IDPH has cited and fined Accolade of Pontiac nursing home after a resident there suffered a broken leg in a fall while transferring from the toilet to his wheelchair.
The resident at issue was cognitively intact, but required extensive assist with transfer, including the use of a sit-to-stand mechanical lift for transfers. For toileting his care plan (which had not been changed in 6 months before the day of this nursing home fall) called for use of a gait belt and grab bars when transferring from the toilet to the wheelchair. However, when the staff was interviewed by the state surveyor, multiple aides told the surveyor that they regularly used a sit-to-stand lift for the resident when transferring him from the toilet to his wheelchair.
On the day of this fall, there was a single aide attempting to help the resident transfer from the toilet to his wheelchair. No gait belt was in use. The resident was not able to maintain a standing position and attempted to sit down in the wheelchair. However, he was not in the right position to to do and missed the seat, falling to the ground. X-rays were done which showed that he had broken his femur just above the level of his prosthetic knee.
There are two issues here with the quality of care that this resident received.
The first relates to the updating of this resident’s care plan. As written on the day that the resident fell, the care plan called for pivot transfers using a gait belt and grab bars. However, in practice, the staff was often using a sit-to-stand lift to perform this transfer given the weakness of this resident. Part of the care planning process calls for evaluating the effectiveness of the care plan on an ongoing basis and revising the care plan when the care needs of the resident changes or when the existing care plan was proving ineffective in practice. In this case, practical experience was showing that this resident needed the help of the sit-to-stand lift to transfer safely. However, the care plan was not updated to reflect this, and as a result, the resident did not get the help he really needed at the time of this fall.
The second way in which the care was not up to standard is that the existing care plan was not followed. It called for the use of a gait belt. A gait belt is a canvas strap which is applied to the midsection of the resident and allows the staff member to better control the resident during transfers and ambulation and to potentially prevent a fall when the resident begins to lose his balance or fall. Had one been used during this transfer, this resident would have likely not suffered the severe injury he did.
The fact that the resident’s care plan was not revised as needed and the fact that the existing care plan was not being followed speaks to a staff that is struggling to meet the needs of the nursing home’s residents. 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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