IDPH has cited and fined Warren Barr North Shore nursing home in Highland Park after a resident there was rolled out of bed while receiving incontinence care, suffering multiple fractures of the tibia and fibula.
Bed mobility is a term that generally refers to a resident’s ability to move and change position in bed. Some residents, due to musculoskeletal issues, need the assistance of one or more staff members with bed mobility. This is important for changing positions to prevent bed sores, for example. It also is important when a resident needs incontinence care so that they can get into a side-lying position to allow staff members to clean them and apply barrier cream.
When a resident requires assistance with bed mobility, this is something that should be addressed in the care plan and recorded in the Minimum Data Set. Depending on the degree to which assistance is needed in safely positioning the resident, this may require the help of two staff members.
Having two staff members on hand for assistance with bed mobility is critical for the safety of the resident in order to prevent injuries from rough handling, or as here, being rolled out of bed.
The resident at issue had significant musculoskeletal deficits and had been care planned as requiring the extensive assistance of two staff members with bed mobility. On the day of this nursing home fall, there was a single aide providing incontinence care to the resident. While this was happening the resident rollled over the edge of the bed. The aide attempted to slow the descent of the resident, but she still landed on her ankle. She was brought to the hospital where a CT scan showed that there were four separate fractures of the tibia and fibula (bones of the lower leg).
For regular readers of this blog, it is part of the familiar story of what happens when you have one person doing a two-person job (see here, here, here, and here for examples) with predictably disastrous results.
One person doing a two-person job is also consistent with a understaffed nursing home, something that was a specific issue raised in a citation involving a fall at this nursing home last year. Sadly, understaffing is a part of the nursing 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. 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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