IDPH has cited and fine Symphony of South Shore nursing home in Chicago after a resident there suffered an open fracture of the leg during a transfer.
In this blog, we spend a great deal of time discussing the care planning process because it is one of the main building blocks for how care is structured in a nursing home. There is a another set of assessments called the Minimum Data Set (MDS). The Minimum Data Set is prepared at regular intervals on admission and then quarterly and with a change in the resident’s condition. The MDS is supposed to be based on the completing nurse’s assessments, information provided by other staff members, and data that is generally tracked by aides and entered into either a piece of software or a tracking sheet and then incorporated into the MDS. When completed, the MDS is supposed to accurately reflect the condition of the resident and the level of assistance needed.
The MDS plays a role in the delivery of care in that it triggers something called a Care Area Assessment (or CAA) which is supposed to prompt care planning for the areas indicated. The MDS also determined the resident’s acuity level which is tied to the amount that the nursing home receives in revenue from the entity that pays for the care. Therefore, it needs to be signed under penalties of perjury by each person participating in completing it.
When the resident at issue went through the MDS process, the nursing home certified to the government that the resident required a two-person assist with transfers. However, when the care plan was completed, it called for the assist of one with transfers.
On the day of the accident, the resident was being transferred from her wheelchair to her bed by a single aide who was using a pivot transfer technique. The resident’s foot slipped during the transfer, and her leg went underneath the bed. The resident sustained an open fracture of the tibia (shin bone), meaning that the bone broke through the surface of the skin. She was taken to the hospital where she underwent a surgical repair of the fracture. On her return to the nursing home, she required a mechanical lift for transfers.
During the investigation by the State, the resident’s nurse practitioner referred the surveyor to the physical therapy department as to whether the resident should have been a one- or two-person transfer. They confirmed that she should have been a two-person transfer. When the surveyor spoke with the Director of Nursing, she was unable to reconcile the discrepancy between the care plan and the MDS and agreed that the care plan should reflect the care levels shown on the MDS.
Many of the nursing home falls we have covered here happened either because the care plan was not followed or because the care was not revised when it needed to be. Here, the care plan was inadequate to begin with in that it did not provide for the levels of care that this resident actually required. Poor care plans beget poor outcomes.
The other thing that is notable about this incident is that there was a variation between the MDS and the care plan. Since the MDS helps determine acuity level which determines payment level, this also means that the nursing home was getting paid for care it wasn’t actually providing. Sadly, this part of how many nursing homes operate. 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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