IDPH has cited and fined Bria of Westmont after a resident fell from her bed, sustaining a painful pelvic fracture.
Prior to the accident, the resident at issue had a Minimum Data Set (MDS) submitted to the federal government indicating that she required the assistance of two for bed mobility. For the ability to roll left and right in bed, the resident was coded as “01”. This code means that the dependent-helper does all of the effort and the resident does none of the effort to complete the activity.
Importantly, this facility does not use side rails on beds. Therefore residents that require this much assistance are not able to remain on their side without the risk of rolling over.
The only way to safely provide incontinence care would be with two staff members, one to hold onto the resident and the other to provide the incontinence care.
At the time of this nursing home fall, an aide was providing incontinence care by herself to the resident. The aide explained that after positioning the resident on her left side, she quickly ran into the bathroom inside of the resident’s room to get more supplies, leaving the resident unattended “for no more than 10 seconds.” The aide acknowledged that she witnessed the resident fall out of the bed as she stepped out of the bathroom, landing onto her right side on the floor.
When the x-ray technician arrived in the room, the technician found the resident “in tremendous pain and screaming.”
She was diagnosed with a closed nondisplaced fracture of the right acetabulum and a closed fracture of the right pubis.
This is yet another instance where a resident suffers injury because one person was doing a two-person job (see here, here, here, here, and here for examples). Generally the root cause of this kind of incident is due to understaffing of the nursing home, which is something that is inherent in 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.
