IDPH has cited and fined Lakeshore Rehab & Healthcare nursing home in Joliet after an aide rolled a resident out of bed while providing incontinent care causing the resident to suffer a broken femur.
The resident at issue was described as a “larger lady” whose medical history included a stroke with residual left-sided weakness and a below the knee amputation on the right side. This medical history is significant because it would significantly impact her bed mobility, or her ability to move around in bed and told keep a position in bed. Because of this, she regularly received incontinent care with two aides – one to provide the care, the other to assure safe positioning in bed.
The resident’s care plan called for her to be provided with a valet bar which would give her something to hold onto grab to help her maintain position in bed. However, this was never provided to her.
When the therapy staff was interviewed by the state surveyor, they were clear that one or the other – two staff or a valet bar – had to be provided to the resident to assure her safety and prevent her falling out of bed during incontinent care. Sadly, neither was – with predictable results.
The aide who was assigned to care for the resident was a male who believed that he was strong enough to handle the resident on his own and had in fact done so before. Interestingly, there were several staff members who knew that the resident did not want to be cared for by this aide because she considered him unprofessional because he would frequently sing, dance, and talk on his phone while caring for residents.
On the day of this nursing home fall, the resident was positioned onto her side, and when the aide went to pull the incontinent brief out from underneath her, she rolled from the bed and hit the floor. The resident complained of immediate pain to the leg and was sent to the emergency room.
At the hospital, the resident was diagnosed as suffering from a fractured femur. The family elected to not have surgery done, and the resident was placed in a cast which would be on for 6-8 weeks. According to the citation, she complained of significant pain every time she was moved. Past that, the immobility associated with the fractures places her at increased risk of developing additional problems such as bed sores or developing pneumonia.
This was a highly preventable injury. There was a clear violation of the resident’s fall prevention care plan in that she was never provided with the valet bar that was called for. Past that, providing incontinent care to a resident like this is always a two-person job regardless of how “big and strong” the aide is because there is still need for someone to help the resident maintain position in bed. The results of having one person do a two-person job have been seen in this blog over and over (see here, here, here, here, and here for examples).
These failures – a long-running violation of the resident care plan, untrained and unprofessional staff delivering care to the resident speaks to systemic issues in the management of this nursing home. 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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