IDPH has cited and fined Generations Oakton Pavillion after a resident there suffered a fractured leg in a fall which occurred due to staff attempting to manually transfer her from wheelchair to bed without using a lift, in violation of the resident’s care plan.
Much of the routine care that residents receive in a nursing home setting is shaped by the resident care plan. In the care planning process, an assessment is done to identify the resident’s care needs and risks to the health and well-being of the resident. A series of steps, or interventions, are then put into place which are intended to meet the resident’s needs. The staff members assigned to carry out those interventions then must do so on a day-to-day, shift-to-shift basis.
The resident at issue was morbidly obese and had left-sided weakness from having had a stroke in the past. She was unable to bear weight, so her care plan called for transfers with a mechanical lift with the assistance of two staff members.
On the day of this nursing home fall, the sling for the lift that normally would have been left underneath the resident as she sat in her wheelchair was not in place. Because there was no sling readily available, the aides attempted to transfer the resident manually without using a gait belt. As they attempted to pivot to turn from the wheelchair to the bed, the resident’s legs gave out and she fell to the ground, landing on her knees. She was helped from the floor to bed by the aides.
After the fall, the resident had complaints of pain in the knee and swelling and bruising below the knee. The resident was transferred to the hospital where x-rays showed that the resident had a fracture of the upper portion of the tibia, extending into the knee joint, and a patellar tendon avulsion. The resident underwent surgery to repair the injuries from the fall.
The nursing home had a reasonable care plan in place for this resident – the problem was that the staff did not implement it. The care plan called for transfer with a lift, which was appropriate given her inability to bear weight. Rather than follow this care plan, the staff attempted to transfer the resident manually. This was never likely to succeed given her inability to bear weight – and the chances of ensuring an injury-free transfer dropped when they elected to not use a gait belt, either.
The fact that the staff plowed ahead with trying to transfer the resident manually raises a question of whether this is an understaffed nursing home. This is true anytime you see the staff taking shortcuts which sacrifice resident safety and there were two such shortcuts taken – attempting the transfer without the lift and then not using a gait belt. Sadly, understaffing a nursing home is a core feature of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
Other blog posts of interest:
Unsupervised resident falls and fractures hip at Lutheran Home for the Aged
Resident fractures leg in unsafe transfer at Ascension Nazarethville in Des Plaines
Addolorata Villa resident fractures hip in fall
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