IDPH has cited and fined The Waterford Care Center in Chicago after a resident there suffered a spiral fracture of the right humerus bone requiring hospitalization for surgical repair 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, a certified nursing assistant (CNA) entered the resident’s room alone to provide care. The CNA stated she was going to change the resident’s diaper and instructed the resident to turn onto her side. As the resident attempted to turn, she made an excessive twisting motion and half of her body slid off the bed with her waist down ending up on the floor. The resident was still holding onto the side bed rails with her hands to keep her upper body partially on the bed. According to interviews, The CNA reported she was unable to stop the fall due to the resident’s size. After the fall, the resident stated to the CNA that she had “overturned” herself and fell out of the bed. The CNA left the resident on the floor and went to get a nurse for assistance. The nurse and other CNAs arrived and used a sheet to pull the resident back into the bed, as the mechanical lift could not lower enough to reach the floor.
After being assessed, the resident was noted to have right arm swelling and bruising on her left hand. She complained of pain with any movement and was sent to the emergency room where she was diagnosed with a closed displaced spiral fracture of the right humerus requiring surgery.
The lack of proper two-person assistance during the bed mobility task directly contributed to the resident falling from the bed and suffering this serious injury requiring hospitalization. The nursing assistant’s failure to obtain a second staff member to assist with the turn, as clearly indicated in the care plan, resulted in the preventable fall and subsequent fracture.
The deeper question is of course why did this CNA attempt to do a two-person job by herself? The answer in this case most likely relates to understaffing of the nursing home.
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.
