IDPH has cited and fined Heartland Nursing & Rehabilitation in Casey after a resident there suffered a fractured hip due to falling from the commode as a nurse was attempting to care for two residents at the same time.
Juggling is a skill I very much admire, but if you are juggling something like fine china and let one drop, it is going to shatter into a thousand pieces. When you are juggling the care of two nursing home residents at the same time, there is a chance that you are going to let something drop, and due to their delicate condition, the result could be a nursing home fall that results in a fractured hip. That is bascially what this citation from IDPH describes.
The nurse caring for the resident at the time of the fall described the work load – they had about 50 residents spread over 4 halls with 2 CNA’s (sometimes 3) and one nurse, and she told the state surveyor that “most of the time that is enough” … more on that later.
The night that fall occurred, the two CNA’s were on one hall, leaving the nurse to care for two separate residents. Resident number 1 was a high fall risk due to a series of diagnoses relating to musculoskeletal weakness and cognitive deficits. She also had a history of 7 separate falls before that day. Resident number 2 was in the room across the hall. She was also a high fall risk with a history of prior falls – in this case, 11 prior falls.
What happened is that Resident 2 sounded her call light to go to the bathroom and was placed on a commode stool in her room. While she was seated on the commode, Resident 1 also needed to be toileted. The nurse brought Resident 1 to the toilet and was attending to her while she was on the toilet when she saw across that hall that Resident 2 was getting up from the commode stool on her own. The nurse left Resident 1 on the toilet and rushed across the hall and helped resident 2 to the edge of the bed of the bed. When she turned around to attend to Resident 1, she fell from the toilet.
There were obvious skin tears, and the nurse attended to these, helped Resident 1 back to bed with the help of an aide, and then helped resident 2 back to bed.
The next morning, when the aide assigned to Resident 1 attempted to get her dressed, she complained of pain in the left leg. Ultimately, she was sent to the emergency room where a fractured hip was diagnosed. This fractured hip will require surgical repair.
Providing continence care to residents is an important task for members of the nursing staff. It helps promote the dignity and comfort of the residents, and is an important step in preventing bed sores. However, there was a series of gambles that were taken with the safety of the residents – and not just Resident 1. When she took Resident 1 to the bathroom while Resident 2 was seated on the commode stool, there was a risk that Resident 2 would fall from the commode stool or would get up unattended, which is of course what happened. When she reacted to Resident 2 getting up unattended, there was a risk that Resident 1 would fall from the toilet which is of course exactly what happened. When she left Resident 2 on the edge of the bed to take care of Resident 1, there was a risk that Resident 2 would fall from the edge of the bed (such as happened here).
To say the least, the nurse here made a poor choice to try to juggle the needs of two residents at the same time. Gambling with the safety of nursing home residents is never acceptable.
The real question is why the nurse felt compelled to take that gamble. The answer to that question is found in the statement that the nurse made to the state surveyor – that “most of the time” the staffing was adequate to meet the needs of the residents. “Most of the time” is not what is required – federal regulations require the nursing home to have enough staff on hand to meet the care needs of the residents on a 24/7 basis. The work load of this crew (50 residents over 4 halls) was likely high enough that this crew was stretched to the breaking point on a nightly basis. My guess: that the nurse involved in this incident took gambles like this more often than she would have liked because caring for the residents sequentially (finishing toileting Resident 2 before dealing with Resident 1) would have resulted in Resident 1 having an episode of incontinence that would have had to be cleaned up which would have put her behind in caring for other residents, all in a vicious cycle.
This kind of nursing home fall is exactly the kind of accident that understaffing a nursing home causes.
The choice of staffing levels lies with the management of the nursing home, not the nurses charged with the care of 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 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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