IDPH has cited and fined Illini Restorative Care when a resident suffered a fracture of her left leg when she slid out of her wheelchair. This was directly due to improper positioning and handling of the resident in her wheelchair by the staff.
The resident in question, who suffered from severe cognitive impairment and multiple health issues including dementia, was dependent on staff for most activities of daily living.
On the day of the incident a Certified Nursing Assistant (CNA) reported having to lower the resident to the floor because she was sliding out of her wheelchair. The CNA stated, “She was sliding out and I was unable to get her back in wheelchair, so I lowered the resident to the floor.”
Over the next few days, the resident experienced significant pain, requiring multiple doses of morphine. Despite her obvious discomfort, an x-ray was initially delayed due to family concerns about the resident’s ability to tolerate the x-ray procedure.
When finally performed, the x-ray revealed a “Medial tibial plateau fracture.”
The nursing home failed this resident in several areas.
First, there was improper positioning of the resident in her wheelchair. The CNA admitted that the resident was “sitting close to the edge of her seat” when the incident occurred. Another CNA stated, “We don’t position a resident at the edge of the chair, especially a resident that uses a mechanical lift. They would be at risk for falling out.”
Second, the initial nurse’s assessment after the incident was inadequate, as it did not include a range of motion examination, which might have identified the injury earlier. This contributed to a delayed diagnosis, as several days passed before an x-ray was performed to diagnose the fracture, despite the resident’s persistent pain and need for strong pain medication.
Third, the incident revealed insufficient training or policy adherence among staff. The facility’s Safe Lifting Procedure policy did not specifically address proper body mechanics in a chair prior to transferring a resident. Additionally, the Positioning the Resident policy did not show how a resident was to be safely positioned in a wheelchair.
Lastly, there were inconsistencies in the reporting of the incident and the subsequent care provided, suggesting a lack of clear communication protocols.
This incident highlights significant failures in resident care, safety protocols, and staff training at the nursing home, resulting in serious harm to a vulnerable resident. It underscores the critical importance of proper positioning, prompt and thorough assessments, clear communication, and adherence to comprehensive safety policies in nursing home settings.
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. 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.
