Last week, I wrote about a recent Consumer Product Safety Commission (CPSC) report that analyzed the risks of portable adult bedrails. A recent Illinois Department of Public Health (IDPH) investigation into a nursing home fall experienced by a resident of the Illini Heritage Rehab and Health Care nursing home illustrates how air flow mattresses and side rails in nursing homes can be a dangerous combination.
The investigation began when a woman with dementia, vascular disease, and an amputated leg fell from her bed while a resident of the Illini Heritage Rehab and Health Care nursing home. At the time of the fall, the resident was resting on an air mattress, and the two side bedrails were both fully raised.
Anytime a resident enters a nursing home, a full assessment known as a Minimum Data Set (MDS) is undertaken. In this case, the MDS determined that she was a high risk of nursing home falls. Whenever a resident is determined to be a high risk of nursing home falls, a set of safety precautions is supposed to be determined and implemented to prevent any such fall from taking place. However, there were no implementations recorded for her.
Just four days after being admitted to the Illini Heritage Rehab and Health Care, she was found on the floor of her room with her “left arm pinned under the left side of her body, screaming in pain with any body movement, and head in a pool of blood.”
To a person unfamiliar with nursing home neglect lawsuits, the description of many injuries caused by nursing home neglect make the injures sound completely unpredictable. If, for example, an ambulatory nursing home resident wanders into another resident’s room and is given the wrong medication by a licensed practical nurse (LPN), that sounds like an “honest mistake.” If a nursing home resident falls when a certified nurse aide (CNA) lets go of the gait belt supporting him “just for a second” when opening a door, that seems like simple bad luck.
But it isn’t.
By itself, the failure of the nursing home to prevent this nursing home fall would constitute a strong case for nursing home neglect. But investigators found an additional case for nursing home neglect that was, alarmingly, ignored by nursing home staff and administration for days.
An air flow mattress is designed to reduce the risk of bed sores (also known as pressure ulcers) from forming. The mattress consists of a series of inflatable tubes that inflate and deflate in a sequence to prevent a resident from putting constant pressure on one part of the body. Side rail bedrails, found on most nursing home and hospital beds, can be raised to heights of 6” to 12” inches over the bed frame. The danger of high side rails and a mattress that deflates and inflates should be obvious to any nursing home staff or administrator. Suffocation, bedrail entrapment, and other injuries are possible.
IDPH investigators repeatedly pointed out the dangers to nursing home staff, and also followed up to see if additional safeguards were put in place. They were not.
When similar incidents have occurred, nursing homes have always stated that these injuries were unpredictable and not examples of nursing home neglect. As a nursing home lawyer, I can assure you that unheeded warnings are the hallmarks of nursing home neglect.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary injuries and illnesses 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.