IDPH has cited and fined the Grove of Fox Valley nursing home in Aurora after a resident there broke both legs in a fall from bed while his sheets were being changed.
The resident at issue had below the knee amputations of both legs. Additionally, she had a contracture of the right hand which limited her use of the right arm. Prior to the accident, the Minimum Data Set (MDS) submitted to the federal government indicated that she required assist of two for bed mobility. “Bed mobility” means moving within the bed, including turning from side to side, which means that in this case two people were required to assist her in moving from side to side. Generally, one aide will be positioned on each side of the bed. Part of the job of the aide who is on the side where the resident is rolling to is to assure the safety of the eresident by keeping the resident from rolling out of bed and hitting the floor.
At the time of this nursing home fall, an aide was changing the resident’s sheets while the resident was still in bed. The aide told the state surveyor that she had been trained that the resident required the assistance of two, and that this was the first time she had repositioned the resident in bed by herself. The resident on the other hand told the state surveyor that repositioning with the assistance of one was common during night shifts and weekends because of a lack of staff.
The accident happened after the aide asked the resident to roll onto her left side. When she did so, her stronger left hand and arm were pinned beneath her body, leaving the weakened right arm to assist in positioning. The head of the bed had been elevated while the changing of sheets was underway and as a result the resident had slid down toward the foot of the bed. Partial side rails were in place on the top half of the bed to assist the resident in moving in bed, but there were no side rails on the bottom half of the bed. When the resident rolled over, she was unable to reach the side rail to steady her position and rolled out of bed onto the floor.
She was taken to the hospital where x-rays showed significant fractures of both femurs. The treating orthopaedic surgeon stated that if the fractures do not heal properly, amputation of the leg(s) above the fracture site may be required. The resident told the state surveyor that she experiences severe muscle spasms in the injured legs which cause her significant pain.
This is yet another instance where a resident suffers injury because one person was doing a two-person job (see here, here, here, here, and here for examples). Generally the root cause of this kind of incident is due to understaffing of the nursing home, which is something that is inherent in the nusing home business model. 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.
What makes this particular citation so interesting is the facility’s response to this fall. Care planning is the basis for much of the care that gets delivered on a day-to-day basis in a nursing home. The first step is a resident assessment to determine what the care needs of the resident and then developing a written care plan to address those care needs. It must be communicated to the staff which then must carry it out on a day-to-day, shift-to-shift basis. Finally, it must be evaluated on an ongoing basis to determine whether the resident’s care needs have changed or if it has proven ineffective in practice. If so, then it must be revised.
The occurrence of a nursing home fall is one thing that usually triggers a revision of the care plan. Falls are a serious issue in the nursing home industry, as falls tend to beget more falls, and residents are at significant risk for injuries such as fractured hips or brain bleeds which can either cause the death of the resident or cause a significant decline in the quality of life.
After this fall, the care plan was indeed revised – but not in the way that you would expect. The care plan was re-written after the fall occurred to authorize assist of one for bed mobility, notwithstanding the fact that the MDS which had already been submitted to federal government under oath stated that this resident required the assist of two with bed mobility. Past that, an assist of one had already proven ineffective in practice – that was how this resident ended up on the floor with two broken legs! Perhaps there is a legitimate reason for re-writing the care plan this way, but it seems like the most likely motivation for this was to paper up the chart in anticipation of the State coming in after this resident’s injuries. Some people might use the term “cover-up” to describe that.
If you have had a loved one injured in an accident at a nursing home, 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.
Other blog posts of interest: