IDPH has cited and fined Bella Terra Wheeling when a resident fell onto her hip while sitting on the edge of the bed being changed by a CNA. The fall resulted in a fractured hip and raises concerns about the facility’s adherence to fall prevention protocols.
The resident in question was admitted to the facility with various diagnoses including epilepsy, restlessness, agitation, degenerative nervous system disease, severe cognitive impairment and dependence on staff for most activities of daily living (ADLs).
The incident occurred when a CNA was dressing the resident. According to the CNA’s account, “I sat the resident up on the edge of the bed. I was standing on the side of the resident, slipping her arm into the sleeve of the shirt and that’s when the resident started to lean forward.” Despite the CNA’s attempt to prevent the fall, the resident fell onto her right hip from bed height.
Initially, the fall did not appear to cause injury. A Licensed Practical Nurse (LPN) stated, “It did not appear that the resident had any injury at that time, so me, a CNA, and a Wound Care Technician put the resident back into the bed via mechanical lift.” However, several hours later, the resident showed signs of distress and injury. The Director of Nursing reported, “the resident’s injury was discovered at nighttime, several hours after the fall, that’s when the resident started grimacing, pointing to her right hip, and there was a change in the resident’s right leg appearance, it looked displaced.”
The facility’s investigation revealed that the resident had a urinary tract infection at the time of the fall, which may have contributed to the incident. The Former Fall Coordinator stated, “After getting labs done at the hospital, it was discovered that the resident had a urinary tract infection at the time of the fall. The resident had previous falls and had a urinary tract infection around those times.”
The document raises concerns about the facility’s adherence to fall prevention protocols. The resident’s care plan indicated she was at high risk for falls and required extensive assistance with ADLs. However, the CNA’s decision to sit the resident on the edge of the bed for dressing appears to contradict her assessed needs. An Agency CNA commented on this practice, stating, “I would sit them up in the bed while putting on their shirt, not on the edge of the bed. Some CNAs find it more convenient to sit residents on the edge of the bed, but it is too risky.”
This incident highlights potential gaps in staff training, adherence to care plans, and fall prevention strategies at the facility. It underscores the importance of consistent implementation of safety measures for high-risk residents and the need for ongoing staff education on proper care techniques.
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.
