IDPH has cited and fined South Holland Manor after a resident there suffered a fractured femur due to being rolled out of bed by a staff member.
The resident at issue suffered from multiple health conditions, was morbidly obese, and was largely bed-bound. Her assessment showed that she required the extensive assist of two with bed mobility, meaning that she required the assistance of two aides to be turned and repositioned in bed. This was incorporated into the resident care plan, which was communicated to aides using a tool known as the Kardex, which was a summary of what care had to be provided to the resident.
On the day of the accident, an aide was in the resident’s room providing incontinent care to the resident. She called for another aide to help her, but that aide was slow in responding, so the aide decided to proceed to try to finish rolling the resident onto her side on her own. As she did so, the resident rolled off the edge of the bed, landing on the floor. She had a laceration to her head and was complaining of pain in the leg, so she was sent to the emergency room where x-rays showed that she had a comminuted fracture of the femur.
The aide here was doing a truly crucial task – providing incontinent care for this resident is a key measure for preventing bed sores. The facility had a care plan in place for doing it safely, one which called for the help of two aides with this task. There was a specific safety concern for the resident that motivated this item to be in the care plan: the risk that the resident would be rolled out of bed in the process if there wasn’t another aide on the other side of the bed. A reasonable care plan, communicated to the staff, not carried out – it seems like a simple enough scenario to result in this nursing home fall.
Look the next level deeper, and ask the question “why” – why did this aide proceed to try to turn this debilitated resident on her side without any help. The citation describes the aide involved waiting for a prolonged period of time for the other aide to arrive to help her, and then deciding to go it alone. It is not hard to imagine the aide waiting, hearing additional call lights going off, knowing all of the other scheduled tasks she had to complete … and then taking the risk, a risk that sadly came back to haunt the resident. But why take risk? The answer is likely understaffing of the nursing home – there just weren’t enough hands on deck to meet the care needs of the resident, and that came back to bite one of the residents.
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 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:
Prairie Manor resident suffers brain bleed after being rolled from bed
Resident rolled from bed at South Suburban Rehab
Resident breaks in leg in failed mechanical lift transfer at South Holland Manor
Understaffing results in fall at Manorcare of Libertyville
Lack of footrests on wheelchair leads to broken ankle at South Holland Manor
Brain bleed from being rolled out of bed at Bria of Palos Hills
Staff rolls resident out of bed at Generations of Applewood
Brain bleed from fall at Landmark in Des Plaines
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