IDPH has cited and fined Heritage Health nursing home in Jacksonville after a resident fell forward out of specialized postural positioning chair, suffered a fractured hip, and died.
One of the factors that contributes to fall risk in residents who are bedbound or chairfast is poor trunk control. Lack of having even minimal core strength can lead to the resident not being able to control their own torso when in a seated position or in bed. This can lead to rapid loss of control when the resident is being moved and result in the resident falling from bed or from a chair.
That was what happened in this situation. The resident at issue had poor trunk control and part of her care plan called for the use of a specialized postural positioning chair which would tilt back while the resident was being moved. Tilting the resident back in the chair would have the effect of preventing the resident from suddenly leaning forward and falling forward out of the chair.
Of course, for that care plan to work properly, the staff charged with carrying out needed to be trained in the use of this specialized piece of equipment. Sadly, that was not the case here.
On the day of this nursing home fall, the resident was being brought back from the bathroom seated in the postural positioning chair. However, the chair was not tilted back and the resident fell forward from the chair. She was brought to the hospital where she was diagnosed as having suffered a fractured hip. She died two days later, apparently from complications from the broken hip.
During the inspection by the state surveyor, the aide told the surveyor that she had never been trained on how to use the chair. The state surveyor also determined that there were no facility policies in place regarding the use of this piece of equipment. Bottom line: a reasonable care plan which could not be effectively carried out because the staff did not know how to use the equipment needed to deliver the care this resident needed.
The net result: a fall with a fractured hip leading to the wrongful death of this nursing home resident.
Nursing homes are required to have staff on hand with the necessary competencies to deliver the care required to meet the resident’s needs on a 24/7 basis. When the staff is not trained on how to use the equipment specified in the resident care plan, that is a violation of federal regulations.
The real question is of course, why was the staff not properly trained? That comes down to time, attention, and money, and the nursing home business model cuts away at all of those things when it comes to delivery of care to the 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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