The Illinois Department of Health has cited and fined Aperion Care Burbank when a staff member attempted to turn a paralyzed resident alone instead of with the required two-person assistance, resulting in the resident falling to the floor and sustaining a head injury that required a trip to the ER.
The resident in question had diagnoses of Paraplegia, Complete, Dementia, Major Depressive Disorder, Mononeuropathy of Bilateral Lower Limbs, Cataract, Hemiplegia and Hemiparesis Following Cerebral Infarction, Contracture, and Immobility Syndrome (Paraplegic).
The resident’s care assessment indicated cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3. The resident was noted to be “dependent on staff for toileting hygiene, sit to lying or lying to sitting on side of the bed and transfers.”
The resident’s care plan specifically designated that the resident “requires assistance with bed mobility related to weakness” with interventions that include “provide assist of 1-2 staff as needed.” A progress note clearly documented that the resident “is a 2 person assist with bed mobility.”
The incident in question occurred during the early morning hours when a Certified Nursing Assistant (CNA) was attempting to change the resident’s diaper. According to Fire Department records, “the patient was being changed and cleaned in bed when she was rolled out. Patient hit her head on the floor when she fell.” Hospital records confirmed this account, noting that the resident “states nurses were changing her diaper and rolled her over and she kept rolling and fell to the ground.” As a result, the resident sustained “a frontal hematoma and laceration requiring glue to close,” as well as “pain in right knee with hematoma over right tibial tuberosity.”
When interviewed, the resident provided a clear account of the incident: “The girl was turning me and was pushing me, and I kept saying stop, you’re going to push me out. The girl kept pushing, and next thing I knew, I fell to the floor.” The resident added, “It hurt my shoulder and my head.”
Multiple staff members confirmed that the resident required two-person assistance for turning. One CNA stated, “The resident needs 2 persons to turn her. The resident can’t help with positioning and is heavy, and 2 people are needed to turn her.” Another CNA confirmed that the resident “is 2 persons assist for cares” and “can’t roll out of the bed, and she can’t help to turn.” This CNA also noted that when he returned to work after the incident, the resident’s “face was swollen, all on the right side was swollen.”
A Restorative Aid who worked regularly with the resident confirmed, “For the resident’s bed mobility, I go in and I turn her side to side, with another person at all times… The CNA and I are doing all the work to turn her, she is dependent on staff. I have never seen her turn or try to roll. In all the time I have worked with the resident, she has never tried to roll or initiate the roll in bed.”
In this case the facility failed to ensure that two staff members assisted with turning the resident as required by the resident’s care plan. This failure directly resulted in the resident’s fall and subsequent injuries.
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