IDPH has cited and fined Lutheran Home for the Aged nursing home in Arlington Heights after a resident suffered multiple fractures in a fall which was followed by the staff failing to promptly obtain treatment for the resident’s injuries.
This fall has a common theme with many of the nursing home falls and mechanical lift accidents we have described here in this blog: one person doing a two person job and the resident suffering the consequences. For a sampling of incidents which we have addressed see here, here, here, here, and here.
The resident at issue had been assessed as having functional limitations in range of motion on one side and needed the assistance of two with transfers for toileting. On the morning of the accident, the resident was getting out of bed and asked to be taken to the bathroom. The aide knew that the resident needed two people to be transferred to the toilet, so she went and asked a fellow aide to help transfer the resident to the bathroom, but that aide said that she could not help right away because she had other residents to attend to. The resident was insistent about using the toilet so the aide attempted to transfer her to the toilet by herself using a sit to stand lift. However, before they were able to reach the toilet, the resident was no longer able to support any of her own weight and the aide was not able to get her onto the toilet so she gently lowered the resident to the ground.
“Gently lowering the resident to the ground” is a euphemism for a nursing home fall, and given what was found, how “gently” this resident was lowered to the ground should be a subject of fierce debate. A “fall” has a technical definition in the long-term care industry and generally it is considered to be a failure to maintain an appropriate standing, sitting, or lying position, resulting in an individual’s abrupt, undesired relocation to a lower level. Saying that someone was “gently lowered” are words that are used to mask the fact that a fall has occurred.
When an aide is aware that a resident has fallen, it is their job to notify the nurse, who in turn is responsible for assessing the resident, notifying the resident’s doctor, and starting the 72-hour fall watch procedure. The fact that a fall has occurred should be noted on the 24-hour sheets, which are not an official part of the resident’s chart, but which are an important communication tool among the nursing home staff.
Here the aide notified the aide notified the nurse, who claims to have assessed the resident and not found any signs of injury. The nurse did not notify the resident’s doctor, did not report the fall to the nurse coming on duty for the following shift, and did not note the fall in the resident chart. Asked why by the state surveyor, she said, “I don’t know why I didn’t report this as a fall at the time; I just had a lot going on.” The failure to report the fall to the doctor denied the resident the opportunity to get prompt treatment for her injuries. The failure to notify the oncoming nurse denied her the chance to be monitored for injuries which come on more slowly, like a brain bleed.
During the course of the day, the resident complained of increasing pain which was not relived with pain medication, so the nurse on duty called the resident’s doctor. Because shew as unaware of the fall, when she was asked by the doctor if the resident had fallen, she said that there was no fall, so the doctor believed that the resident was suffering from an inflammatory process and not the effects of injuries. It was not until the nurse who had been on duty at the time of the fall came on duty for her next shift and learned that the resident had been experienced increasing, significant pain through out the day was the doctor told that there was fall. The doctor’s reaction: “I’m absolutely appalled by this situation; I feel the whole situation is neglectful and abusive to the resident.”
When the resident was brought to the hospital, x-rays showed that the right leg showed a markedly displaced and overriding impaction fracture of the right distal femoral shaft in respect to the distal femur and condyles. The x-ray of the right arm showed that there was an acute impaction fracture through the right humeral neck. In other words, there were ugly fractures of the right arm and right leg, which raises real questions about just how “gently lowered to the ground” this resident was. Past that, the aide who had been asked to help before the accident came into the room after the accident occurred and told the state surveyor that she saw the resident laying on the floor saying “My shoulder, my shoulder.”
These facts tend to show that this was a much more traumatic fall than the description of someone being “gently lowered to the ground” would ever suggest. Moreover, it wasn’t treated as a fall which resulted in the resident being denied treatment for her injuries for an extended period of time and not being monitored for the onset of more severe problems.
The real question of course is, why did all this happen? The easy answer is that the aide did a two-person job with only one person, but the deeper answer probably lies with the understaffing of the nursing home. Past the fact that the aide felt rushed to get the transfer done by herself, there is also the nurse on duty saying that she didn’t treat this fall as such because she had “a lot going on.” These are the kinds of things that you hear when the nursing home staff simply does not have the help it needs to get the work done.
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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