IDPH has cited and fined Westmont Manor Nursing & Rehabilitation Center nursing home after a resident there suffered a brain bleed due to being rolled from bed by the staff during incontinence care.
The resident at issue had a history of having suffered a stroke with resultant left-sided weakness and cognitive deficits. The resident’s Minimum Data Set (MDS) called for the assistance of two staff with bed mobility.
In the long term care industry, the term “bed mobility” refers to the ability of the resident to change and maintain position in bed. This is an important area for assessing a resident’s abilities because the resident’s ability to change positions in bed is crucial for things like incontinence care and turning and repositioning, all of which are important for the prevention of bed sores.
The resident’s abilities with regard to bed mobility are recorded on the Minimum Data Set (MDS) which is a document which is submitted under oath to the federal government and is part of the basis for calculating the payments to the nursing home for the care that the resident receives. When the MDS indicates that a resident requires extensive assist of two staff members for bed mobility, this indicates that the resident has little to no ability to change or maintain position in bed. When two staff are providing care in bed to the resident, one staff member should be on each side of the bed with the staff member on the side of the bed in which the resident is turning being charged with making sure that the resident does not fall from the bed. The resident care plan further called for keeping the resident’s bed in the lowest position.
On the day of this nursing home fall, the resident was receiving incontinence care from a single aide, not the two which were required per the MDS. We have written on multiple occasions about how having one person do a two-person job is a formula for disaster (see here, here, here, here, and here for examples), and that proved again to be the case here. As the aide rolled the resident away from him, the bed was not in the lowest position as called for in the care plan, and the resident rolled over the edge of the bed, hitting his head on the floor. He was brought to the emergency room where it was discovered that he had a brain bleed.
This is a simple case of the resident not receiving the call which was necessary and which the nursing home certified it was providing – it was literally a situation where you had one person doing a two-person job.
The deeper question is of course why did this aide attempt to do a two-person job by herself? The likely answer relates to understaffing of the nursing home.
Federal regulations require that the nursing home have enough staff on hand to meet the care needs of the residents on a 24/7 basis. Unfortunately, nursing home often fail to meet that standard because understaffing is a key component 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.
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