Alden Estates of Orland Park nursing home was cited and fined by IDPH after a resident suffered a broken leg during an improper transfer.
The resident at issue was one for who extensive assists with transfer was necessary and the nursing staff had in fact identified that the resident was most safely transferred using a sit-to-stand lift. Use of the sit-to-stand lift was actually incorporated into the resident’s care plan. The nursing home has 3 floors with 4 sit-to-stand lifts available for use: one for each floor and an extra. On the day in question, the resident wanted to return to bed because of pain associated with sitting in his chair. The lift was unavailable, so the CNA’s decided to transfer the resident without the lift.
They attempted to transfer the resident using a pivot transfer technique. In doing so, they heard a loud popping sound from the resident’s leg. The resident was sent to the hospital where he was diagnosed with a fractured tibia and a femoral neck, or hip fracture.
There are two issues which jump out in looking at this situation. First the aides very clearly violated the resident’s care plan, and disaster was the result. The whole point of having a care plan is to minimize the risks to the health and well-being of the resident. This is a resident who likely suffered from osteoporosis and was therefore at increased risk of fractures even with the relatively low additional stresses posed by a pivot transfer. Second, nursing home are required to provide the resources needed for the residents’ care. If there was no lift available, that is a source of concern.
It is also worth noting that this is a resident who did not have surgery done to relieve two fractures, including a fracture of the femoral neck. Hip fractures are one of the common results of nursing home falls and when surgery is not done to repair a hip fracture, the victim is likely doomed to immobility which causes increased risk of developing bed sores, as well as constant pain with even minimal movement. Serious consequences from a serious lapse in judgment.
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