A failure to follow their own written policy on resident transfers resulted in a resident suffering a fractured leg at the Avenue Care Nursing and Rehab Center in Chicago. According to the Avenue Care administration, the resident requires total assistance with all Activities of Daily Living (ADLs) and at least two people as well as a mechanical lifting device to transfer her from her bed to her chair and vice versa.
Her diagnoses, and the need for two people and a mechanical lift to effect a transfer was confirmed by the Assistant Director of Nursing as well as a Restorative Aide.
In spite of this, two Avenue Care Nursing and Rehab Center certified nurses aides (CNA) attempted to transfer the woman from her recliner to her bed without the use of the required assistive lifting devices.
These assistive lifting devices can encompass a variety of equipment. For a resident who requires total assistance with all ADLs, a Hoyer Lift may be required. Using a set of slings and straps, a Hoyer Lift, when used correctly, can be very effective in creating a safe environment for residents who need assistance.
Predictably, the CNAs lost their balance and the resident suffered a nursing home fall that resulted in a fractured leg. Compounding this error, the CNAs did not report the incident to their superior claiming that “I did not make anything out of it because [the resident] normally cries for attention.”
It was several hours before the Avenue Care Nursing and Rehab resident was able to attract attention to her plight and was sent to a local hospital where her broken leg was diagnosed and treated. By failing to report the incident, the CNA ensured that the effects of the nursing home neglect were magnified.