A resident of the Benton Rehab and Health Care Center in Benton, Illinois, fractured her knee as a result of a failed transfer. The resident was being lifted from the toilet to her wheelchair when, she reports, her “good leg gave out and I hit my knee on the floor.”
The plan of care developed by Benton Rehab and Health Care Center called for “two or more” staff members to assist in any transfers including those to a wheelchair. In spite of this, only a single certified nurses aide (CNA) was present to attempt the transfer.
This resident was designated to be at a high risk for nursing home falls because she suffered from decreased muscle coordination, loss of balance while standing and walking, and prior nursing home falls.
Nursing home falls are some of the most dangerous injuries for two reasons. First, the fall itself can be devastating and can produce catastrophic injuries. Broken legs, ribs, and hips can require months of rehabilitation.
These periods of convalescence, sadly, are the second reason why nursing home falls are so deadly. For many elderly people, a fractured knee can mean the permanent end to all mobility. That, in turn, means half of the day in a chair, and the other half in a bed. Not only can that lead to pneumonia and other infections, it can also lead to bed sores.
This resident was clearly a high risk of nursing home falls. The staff and administration at the Benton Rehab nursing home should have ensured that there were two staff members available to make the necessary transfers and ensure the safety of the residents in their care.