IDPH has cited and fined Waverly Place of Stockton nursing home after a resident there suffered a broken hip as a result of failing to follow the resident care plan for safe transfers.
The resident who was involved in this incident was weak on the left side, likely as a result of a stroke. Her care plan called for assist of two with a mechanical lift for all transfers.
However, on the day of this nursing home fall, the resident was being transferred from bed to wheelchair by a single aide and without the use of a mechanical lift. A pivot transfer can be done with a single aide. It involves applying a gait belt around the midsection of the resident and the helping them to a standing position and then pivoting them from where they are to their destination (for example, from the bed to the wheelchair). However, for this to be done safely, the resident must be able to bear weight well enough to truly participate in the transfer process. Unfortunately, when the aide attempted this transfer, the wheelchair locks were not applied, and the chair rolled away as the resident was moving into a seated position. As a result, she fell to the ground and suffered a fractured hip which required surgery.
There are a number of levels of failure that led to this very preventable injury. First the resident care plan was not followed. A care plan is designed specifically to address the risks to the health and well-being of the resident, and failing to follow it subjects the resident to an unnecessary risk of harm. Here the resident called for the assist of two, not one, and the use of a mechanical lift. None of these elements were followed. Second the locks to the brakes to the wheelchair were not applied when the transfer was attempted. Setting aside the fact that the pivot transfer should never have been attempted, applying the brakes for a wheelchair is a basic safety step when a resident is getting into a wheelchair. Sadly, this is a familiar result of what happens when you have one person doing a two-person job (see here, here, here, here, and here for other examples).
Past that, the basic fact pattern present here and the information in the citation give strong indicators that this is an understaffed nursing home. The citation contains an interview from the resident’s roommate that the mechanical lift was seldom used for transfers. This means that the staff was violating the resident’s care plan on other instances rather than just that day. Unfortunately doing so was taking a gamble with the safety and well-being of the resident. Good luck is not a substitute for good care.
Fractured hips are a serious issue for nursing home residents. Besides the risks of dying during surgery of during the immediate post-operative period, the immobility associated with the hip fractures places resident at risk for other health complications such as pneumonia or bed sores, in addition to the significant, unnecessary pain from the underlying injury.
Unfortunately, understaffing a nursing home is really a part of the nursing home business model, and 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:
Rochelle Rehab resident suffers multiple injuries in fall from wheelchair
Understaffing at Generations of Rock Island leads to fall and hip fracture
Fall during transfer leads to broken ankle at Sandwich Rehab
Resident falls from lift during transfer at Oregon Living & Rehab
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