According to nursing home staff, the first resident to suffer a severe injury was simply sitting on the toilet when staff heard her knee “pop” and “crack”. An X-ray revealed a knee sprain and a fracture.
The physician who examined the knee determined that it was due to a twisting injury. The nursing home staff member who was assisting the woman said that there were no other staff members available to help transfer the woman to the toilet. The staff member said that it was common for a single person to transfer the resident even though she was designated as a two-person transfer.
Multiple skin tears were found on the arms of the second resident highlighted in the report. Despite doctors orders that she wear special sleeves to protect her arms during all transfers, the staff at Heartland of Normal failed to supply the special sleeves. A nursing home inspector for the IDPH noticed the bloodstained shirt the resident was wearing. If not for the fact that there was an inspector present, the injury might have gone unreported.
The third resident was able to ambulate by herself using a walker. Staff were instructed to utilize a gait belt anytime she was walking. A gait belt is a device that goes around the waist and provides a way for a nursing home staff member to prevent a nursing home fall if a resident loses balance while walking.
In this case, no gait belt was being used, and the Heartland of Normal resident fell to the floor. As a result of the nursing home fall, she is no longer able to walk on her own.