IDPH has cited and fined GreenFields of Geneva after a resident there was allowed to go to the bathroom without the required help and then fell while trying to transfer herself from the commode to the wheelchair, resulting in a fracture to her left femur, which required surgery and a 4-day hospital stay.
Nursing homes track a great deal of data concerning their residents. Much of it is strictly for internal use, but one piece – the Minimum Data Set, or MDS – is reported outside the facility. It is submitted under penalties of perjury to the federal government because the information that is in there forms part of the basis by which nursing homes are paid. It tracks information concerning the physical abilities and deficits of residents, as well as the levels of care that the nursing home is in fact providing to the resident.
For this resident, the MDS showed that the resident required extensive assistance with toileting and transfers from the toilet. The MDS also showed that she had severe cognitive impairments. This is a resident who was clearly at high risk for falls – she had well-documented issues with balance and mobility and also had severe cognitive impairments where she could not be counted on to follow instructions or make good decisions for her own safety.
The resident’s progress notes indicated that in the last 12 months she had been found on the bathroom floor after falling while attempting to self-transfer no less than 8 separate times.
On the day of this nursing home fall, the resident told a nurse that she needed to be toileted. The nurse placed her on the commode chair in her bathroom and then left her there unattended to go assist another resident. The nurse claimed in the citation that a separate nurse told her that it would be okay to leave the resident unattended. The resident was alone and subsequently fell while attempting to self-transfer back to her wheelchair.
The fall resulted in a fracture to her left femur. The resident was transferred to the hospital where she had a four day stay and underwent surgery to fix the injury.
The basic issue with the care that was provided is that the resident required assistance with transfers, toileting, and walking. She was also unsteady when moving off and on the toilet. The nurse had a feeling that she should not leave the resident alone while toileting, but needed to attend to another resident. When the nurse asked one of her co-workers if it was okay to leave the resident unattended on the toilet, the nurse said that it was okay. This turned out to be very bad advice. Because the resident was left on the toilet unattended, the fall and injury resulted.
When you have staff that is stretched too thin to provide necessary supervision and help to residents to avoid accidents, this raises fair questions as to whether this was an understaffed nursing home. Unfortunately, understaffing a nursing home is a basic feature 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.
