IDPH has cited and fined Sunset Home nursing home in Quincy after a resident there had to be admitted to the intensive care unit at the hospital due to internal bleeding caused by the use of an improper lift by staff.
There were three key variables in this incident: use of blood thinner medication, a mechanical lift, and violation of the resident care plan.
Blood thinner medications are one of the useful tools in maintaining the health and well-being of nursing home residents. They can be used to help prevent blood clots, strokes, and a host of other circulatory problems. However, one of the risks associated with their use is that of uncontrolled internal bleeding which is a reason why residents are customarily placed on a 72-hour fall watch after experiencing a nursing home fall.
Mechanical lifts are also great tools in a nursing home setting when used properly. They allow residents who have mobility deficits to be transferred from bed to wheelchair, wheelchair to chair, etc. with greatly reduced risk of injury to both the resident and staff. They phrase, though, is “used properly.” This includes using an appropriate type of lift and properly sized, well-maintained, suitable accessories for the lift.
The resident care plan is the tool by which much of the routine care in a nursing home setting is delivered. The care planning process has six steps: (1) a resident assessment where the risks to the health and well-being of the resident are identified, (2) the development of a care plan which identifies steps or interventions to be taken to address the risks to the resident and assigns various staff to carry out those steps, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) evaluation of the effective of the care plan on an ongoing basis, and (6) revision of the care plan if the resident’s needs change or if the care plan proves to be in ineffective in practice.
When a resident uses a mechanical lift, this is covered by the resident care plan. It will specify the reasons why the resident needs the use of a lift, what kind of lift should be used, and how many staff members should be involved in transfers with the lift. (Hint: it should always be two, because having one staff member try to transfer a resident with a mechanical lift is a formula for disaster – see here, here, here, here, and here for examples).
The resident at issue had a medical history which included atrial fibrillation. This is an irregular heart beat which causes the formation of blood clots in the heart which can lead to stroke or heart failure. It is one of the conditions for which a blood thinner is commonly prescribed, and in this case the resident was receiving Elliquis (a blood thinner medication). The resident was also morbidly obese and had significant strength and mobility deficits. The resident also had a documented inability to stand for long. The resident used a full mechanical lift, but a sit-to-stand lift would be used for toileting.
There are differences between a full mechanical lift and a sit-to-stand lift. With a full mechanical lift, the resident has a sling placed underneath them and their whole body is lifted using the lift. With a sit-to-stand lift, the resident’s feet are placed on a plate at the base of the lift, the resident’s shins are placed against a support pad, and a sling is placed under the resident’s armpits and around their chest and the device lifts them up into a standing position. One of the key differences between the two kinds of lifts is that with a sit-to-stand lift, the resident must be able to bear some weight in a standing position, whereas the full mechanical lift requires no physical input from the resident.
On the morning of this incident, two aides went to get the resident out of bed and dressed for the day. Normally this would have been done using the full mechanical lift, but there were no lift slings available for the full mechanical lift. The aides instead elected to use a sit-to stand lift while trying to get the resident dressed. The sling that they used was a regular sized sling, rather than a larger sling which this resident needed. While the aides had the resident in a standing position while trying to get on his pants, the resident was unable to maintain himself in a standing position and his legs gave out. The aides lowered the resident to the floor.
Over the next three days, large, hard, dark bruises appeared under the resident’s armpits and he began to complain of pain especially when the bruised areas were touched. When the bruising began to extend into the back, the resident was transferred to the hospital. At the hospital, the resident was determined to be anemic from acute blood loss to the point that a blood transfusion was required. A CT scan of the chest multiple large hematomas of the left side of the chest. The resident was transferred to the ICU and remained hospitalized as of the time that the state surveyors arrived at the nursing home, some 9 days after the resident was sent to the hospital.
The issue in the care that this resident received is that the aides attempted to use the sit-to-stand lift for a purpose which was not suitable for this resident. The resident was not able to maintain a standing position for a long period of time, yet they elected to use the sit-to-stand lift to attempt to dress him. The key difference between the two kinds of lift is that the sit-to-stand lift does require some physical input from the resident – which this resident was not able to provide.
Compounding the poor decision to use an unsuitable lift, the lift sling (the strap that goes under the armpits) was regular size rather than the large one this resident needed. This likely resulted in there being additional trauma to the resident when the resident’s legs gave out.
These decisions, together with the resident’s use of a blood thinner, caused the serious injuries that this resident suffered.
When you see staff taking shortcuts in the care of residents, this is a mark of a nursing home which is probably short-staffed. Rather than find a sling to use with the full mechanical lift for the resident, they used the sit-to-stand lift. Rather than ask a nurse whether this would be okay, they went ahead anyway. Rather than find a large sling for the sit-to-stand, they used a regular sized sling. These decisions are examples of poor care -and they would have likely avoided serious consequences had this resident not been on a blood thinner. Of course, there could have been other issues that resulted from this – and avoiding those would have been a matter of good luck, not good care.
Sadly, understaffing a nursing home 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.
Other blog posts of interest:
Mishandling of resident results in broken shoulder at Havana Health Care Center
Mason City Area Nursing Home resident suffers fatal brain bleed in fall
Sling breaks during transfer at University Nursing & Rehab
Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
