The Illinois Department of Public Health issued a citation to Village at Victory Lakes nursing home in Lindenhurst after a resident suffered a broken leg in a nursing home fall when she was rolled out of bed by an aide.
The resident in question was bed bound and had next to no movement on her left side due to the effects of a stroke. Her care plan called for assist of two with bed mobility, which includes rolling and turning in bed. The resident needed this level of assistance because of the deficits she had from the stroke.
On the day of the accident, a new aide was providing incontinence care to the resident by herself. Providing incontinence care is a desirable things, as it help prevent the development of bed sores and provides residents with some degree of comfort and dignity. The resident was rolled on to her right side in the process of receiving the care, but due to her left sided weakness from the stroke, once she began to be rolled, she just continued to roll until she fell from the bed. The aide tried mightily to stop her form falling further, but a femur fracture was still the result.
There are at least three issues with the care that was provided here:
First, the aide violated the care plan. The care plan called for assist of two with bed mobility for a reason: to help make sure that the resident was not injured while being turned, rolled, or handled by a single aide working on their own. The failure to carry out the care plan as developed is a legitimate basis for holding the nursing home liable for the resident’s injuries.
Secondly, there was a failure to properly communicate the care plan to the aide. Having a great care plan is useless if no one knows what they are supposed to do, and this aide was a new aide who simply did not know what was supposed to be done. This is evidence of a huge systems failure at this nursing home.
Third, nursing homes are required to provide necessary equipment to prevent accident injuries to residents such as this one. There is a type of mattress called a scoop mattress which has raised edges which are intended to reduce the chances of residents falling from bed. Given her weakness on the one side, it was a reasonable safety measure which should have been part of the care plan.
The bottom line is that this was a very preventable injury from the way that the care plan was developed, to the process by which it was communicated to the staff charged with carrying it out, to what was actually done at the time of the accident.
Other bog posts on nursing home falls: