IDPH has cited and fined Morgan Park Healthcare (formerly Symphony of Morgan Park) in Chicago after a resident there suffered a large hematoma to the left side of her forehead due to rolling out of bed while receiving incontinence care from a single staff member rather than the two that were needed.
In the long term care industry, the term “bed mobility” refers to the ability of the resident to change and maintain position in bed. This is an important area for assessing a resident’s abilities because the resident’s ability to change positions in bed is crucial for things like incontinence care and turning and repositioning, all of which are important for the prevention of bed sores.
The resident’s abilities with regard to bed mobility are recorded on the Minimum Data Set (MDS) which is a document which is submitted under oath to the federal government and is part of the basis for calculating the payments to the nursing home for the care that the resident receives. When the MDS indicates that a resident requires extensive assist of two staff members for bed mobility, this indicates that the resident has little to no ability to change or maintain position in bed. When two staff are providing care in bed to the resident, one staff member should be on each side of the bed with the staff member on the side of the bed in which the resident is turning being charged with making sure that the resident does not fall from the bed. To assist the staff in knowing which residents require the assistance of two staff, the staff is provided with a care card which spells out the requirements for care of that resident.
On the day of this nursing home fall, the resident was receiving incontinence care from a single CNA (Certified Nursing Assistant). As the CNA turned away from the resident to gather her care items, the resident slid off the edge of the bed, hitting her head on the floor. She suffered a large hematoma on the left side of her forehead and was sent to the hospital.
The deeper question is of course why did this CNA attempt to do a two-person job by herself? The answer in this case relates to understaffing of the nursing home. The CNA explained to the investigator that on the day of the incident there were five CNA’s scheduled to cover the floor, however four of them had called off. While the facility did assign one aide to assist the sole CNA that day, the floor was significantly understaffed. Even worse, the Director of Nursing explained that the facility had made a policy decision to not use a staffing agency when a floor is understaffed.
Unfortunately, understaffing of the nursing home is a feature, and not a bug, in the nursing home business model. The net effect of understaffing is that it doesn’t give the staff the ability to provide proper care for the residents – and the net result of that is unnecessary injuries such as this one.
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.
