IDPH has cited and fined Grove of St. Charles nursing home after a resident there became injured in a wheelchair accident.

Wheelchairs are one of the most common pieces of equipment used in a nursing home setting and at first blush are very simple to use safely.  However, even these simple devices can prove dangerous when not used properly.

On the morning of the injury, aides were escorting three residents on a morning walk around the facility through the parking lot.  The residents were walking side by side when the left rear wheel of one of the resident’s wheelchairs caught the edge of a manhole cover. Unfortunately for the resident, the aide had neglected to attach the foot pedals to the resident’s wheelchair.  

The use of leg pedals on a wheelchair helps to position the hips back if there is a sudden “jerk” while in motion. They keep the knees up and the person back in their seat. 

As the chair became stuck in the manhole cover, the resident lurched forward and fell out of the chair, landing on the pavement.  

The resident suffered a progression of an existing neck fracture, a shoulder dislocation, and a hematoma on her forehead.

Sadly, the resident had been mobile prior to the fall and had been able to wheel herself around the hallways but has subsequently become primarily bed bound after the injury.

A janitor, examining the manhole cover after the accident, noted that it was painted yellow and was set down three-quarters of an inch below the surrounding asphalt.  The janitor also noted that there was ample room on either side of the manhole cover and that the aide should have been able to wheel the resident around the cover, not over it.

Like all pieces of equipment in a nursing home, a wheelchair is a safe piece of equipment – when used properly.  This includes using the footrests – the use of which would have helped to prevent this kind of accident.  The misuse of the wheelchair was the immediate cause of this accident.

The fact that such an obvious safety measure was not taken raises serious questions as to whether this is an understaffed nursing home.  When the facts of an accident show that the staff was taking a shortcut which placed the safety of the resident at risk, it could be an indicator that the staff was not trained properly or that the staff simply did not have time to do things properly.  Either way, this raises questions about how the nursing home is being operated.  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.

IDPH has cited and fined Arcadia Care Bloomington nursing home after a resident there suffered a broken hip and a fracture to her mid back after she suffered a fall due to a defective wheelchair brake.

Wheelchairs are one of the most commonly used pieces of equipment in a nursing home.  However, for them to be used safely, they must be properly maintained and all of the accessories used as well.  The brakes on a wheelchair are critical to the safe use of the chair.  When residents attempt to get out of the wheelchair, the brakes must hold firmly or the wheelchair will roll out from under them while they are in the process of rising.  This will almost certainly result in a fall.  In most nursing homes, the maintenance department are the ones called upon the fix and maintain the residents’ wheelchairs.

On the day of this nursing home fall, the physical therapist entered the room only to find that the resident was half-in, half-out of the wheelchair.  She summoned an aide who helped get the resident from the floor, but the resident was in too much pain to participate in therapy.  The aide noted that the left side brake was loose so that the chair would still move even with the brake on.  She was sent to the emergency room where she was diagnosed with a fractured hip and a fracture of the T-12 vertebra (lower middle back) which required the use of a back brace.

The investigation of this incident revealed that there were at least three staff members who were aware that the brake was loose.  Two were aides – including the one who helped the therapist.  The other was the maintenance man, who found that the brake was “wiggly” when he installed an anti-rollback device but thought it was sufficient to hold and elected to not repair the brake at that time.

Federal regulations require that nursing homes be kept as free of accident hazards as possible.  The defective brake on the wheelchair is something that should have been readily recognized as a hazard by staff given that they had doubtless been trained to make sure that the wheelchair was locked in place with the brakes before attempting to transfer a resident.  The failure to correct a known hazard was the direct cause of this fall and the resident’s injuries.

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:

Failure to follow care plan leads to fall, fractured hip at Piatt County Nursing Home

Good Samaritan at Pontiac resident suffers fracture knee and leg in wheelchair accident

Piatt County Nursing Home resident breaks hip in fall

Resident breaks hip in fall at McLean County Nursing Home

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

 

 

 

 

 

IDPH has cited and fined Chateau Nursing & Rehabilitation Center nursing home in Willowbrook after a resident there suffered spinal fractures due to falling from her wheelchair after being pushed forward by the staff when there were no leg rests on her wheelchair.

Wheelchairs are a common sight in nursing homes, and as long as they are used properly, they are generally safe, helpful equipment for the care of nursing home residents who need that level of assistance.  The key of course is that they are used properly, and proper use of a wheelchair requires that the leg rests to the wheelchair be applied when the wheelchair is being pushed by staff.

The reason that leg rests are required to be used when the resident is being pushed forward in the wheelchair is that without the leg rests in use, there is a chance that the resident’s feet will drop to the floor while the wheelchair is being pushed forward.  When this happens, one of two things are likely to occur: (1) that the resident’s legs will get pulled underneath the chair, resulting in a twisting mechanism which can produce fractures or tears to ligaments and cartilage or (2) that the resident can be thrown forward out of the chair, resulting in the kinds of injuries you might see if a resident falls forward while walking – except that this fall will happen at a higher speed.

The resident at issue was wheelchair bound.  She suffered from Parkinson’s which left one arm contracted against her body.  However, she was able to self-propel in her wheelchair using her feet, meaning that she was able to move throughout the nursing home in her wheelchair by walking her feet forward.  For many wheelchair-bound residents, this is an important part of maintaining some degree of independence.

This resident experienced not one, but two nursing home falls due to staff pushing her in her wheelchair with no leg rests applied.  The first occurred two months before the fall at issue.  In that fall, she was being pushed forward by staff with no leg rests on the wheelchair.  She dropped her feet to the floor and was thrown forward out of the wheelchair.  Fortunately, there were no injuries from this fall.

After the fall, there was a care planning meeting held with the family.  The family agreed to obtain leg rests for the wheelchair and a bag for them to be kept on the back of the wheelchair.  The resident’s care plan was updated to include using leg rests while pushing the resident in her wheelchair and the staff was given in-service training on the use of leg rests while pushing the resident in her wheelchair.  The change in the care plan was noted on the care card which advises staff of the contents of the care plan.

On the day of the fall, the resident was being pushed forward into the dining room by an activity aide.  There were no foot rests applied to the wheelchair even though they were in the bag that was hanging on the back of the chair.  Even though she attended the in-service training, the aide explained to the state surveyor that she did not know that the leg rests needed to be applied according to the care plan and that she could not see the bag because the resident was seated on top of a mechanical lift sling and the bag with the leg rests was was hidden by the sling.

While the resident was being pushed into the dining room, the resident’s feet dropped to the floor and the resident was thrown forward out of the wheelchair, and hit her head on the floor.  This is of course a near-replay of the fall two months earlier.  It is also one of the truly predictable mechanisms of injury when a nursing home resident is pushed in a wheelchair that has not foot rests.

Sadly, in this fall the resident did not escape injury.  She was brought to the hospital where it was determined that she suffered a fracture of the C1 vertebra, the bone at the top of the spinal column.  She had a previous compression fracture of the T4 vertebra, located in the upper portion of the mid-back.  It was decided that she was not a good surgical candidate, so she was placed in a hard cervical collar.  Because she actively tried to remove it while in the hospital, restraints were used.  Once she was discharged to the nursing home, she received supervision from a 1:1 sitter whose job was to keep her from removing the hard collar and causing further injury to herself.

The obvious and basic cause of this fall is the failure to place the foot rests on the wheelchair while pushing her forward.  It resulted in a very predictable injury to the resident.  Even though the staff and this aide specifically were in-serviced to use the foot rests, this should be a basic part of the training that staff receives in caring for every resident in the facility.  This resident was not the only one put at risk from being pushed in a wheelchair with no footrests.

Past that, the aide explained to the state surveyor that the care card which indicated that foot rests were required was in the resident’s room, and as an activity aide, she did not go into resident rooms.  However, part of the care planning process is communicating the contents of the care plan to the staff charged with carrying it out.  The care plan is supposed to guide the actual provided, and if the staff delivering the care does not know what is required, the plan is nothing more than paperwork.

These breakdowns, especially the failure to train staff, are sadly common in the long-term care industry.  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:

Good Samaritan of Pontiac nursing home resident suffers multiple fractures in wheelchair accident

Wheelchair accident at Avanti Wellness

Assisi at Clare Oaks resident suffers broken neck in fall from wheelchair

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Rochelle Rehabilitation & Health Care Center nursing home after a resident there suffered a broken leg in a fall caused by the failure of the staff to use footrests while pushing the resident in a wheelchair.

On the surface, a wheelchair is a safe, simple piece of equipment to use.  However, like all equipment in a nursing home setting it must be used properly.  When it is being pushed by staff, that includes the use of foot rests.  Foot rests are required when the wheelchair is being pushed by staff because the failure to use foot rests requires residents to keep their feet up off the ground while they are being pushed forward.  If residents are unable to do so because of physical or cognitive limitations, one of two things happen when the residents are no longer able to keep their feet up: (1) the resident’s feet get pulled underneath the wheelchair, resulting in twisting injuries to the leg which can cause fractures or torn ligaments and cartilage or (2) the resident can be thrown forward out the wheelchair, resulting in injuries such as a brain bleed, facial fractures, or broken collarbones, or wrists.

Sometimes, a fall from a wheelchair causes both.  And that was the case here.

The resident involved had cognitive impairments and was wheelchair bound.  She was being pushed by an aide in a wheelchair with no foot rests.  According to the aide, the resident stomped her foot job and sprang out of her seat “like a jack in the box.”  She landed on the floor and had a large laceration to the forehead that was immediately apparent.  She was sent to the hospital where she was also diagnosed with a fractured femur and additional scans showed two fractured vertebrae in the neck which were age indeterminant.

This is exactly the kind of nursing home fall which is going to result from pushing a nursing home resident in a wheelchair with no foot rests.  The failure to take these very simple steps raises a couple of questions about the operation of the nursing home, specifically with regard to the training of the staff and whether this was an understaffed nursing home.  Either one of these speaks to the investment that nursing home management is making in ensuring that the care needs of the residents are being met.  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:

Good Samaritan of Pontiac nursing home resident fractures leg and ankle in wheelchair accident

Resident breaks leg in wheelchair accident at Heritage Health in Dwight

Fall from wheelchair at LaSalle County Nursing Home

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

IDPH has cited and fined Assisi Health Care Center at Clare Oaks nursing home in Bartlett after a resident suffered a broken neck in a fall from a wheelchair.

Wheelchairs are like every other piece of equipment in a nursing home setting – usually safe, helpful, and beneficial if well-maintained and used properly.  For a wheelchair, this includes things such as having the wheels working properly, functioning wheel locks, a properly fitting seat cushion, and foot rests in place.  Without all of those things being true, something as simple as a wheelchair can add an extra level of hazard for a nursing home resident.

The resident at issue here was wheelchair bound, but was able to eat independently, and needed only limited assistance with her activities of daily living.  She was able to wheel herself about the facility, something which gave her some degree of independence and added to the quality of her life.

On the day of this nursing home fall, the resident was being wheeled out of the shower.  The aide pushing the wheelchair had noticed that the seat cushion was too long for the seat.  The foot rests were also not being used.  As the resident was being pushed forward, the resident slid forward out of the seat onto the floor.  There was immediate bleeding, and the aide left to get a nurse.

The resident was brought to the hospital where she was diagnosed with a fracture of the C2 vertbera (the second one from the base of the skull).  She successfully underwent cervical fusion surgery to stabilize and repair the fracture and returned the to the nursing home.  However, where she was able to feed herself, wheel herself about the facility, and needed only minimal assistance with her activities of daily living, now she is a total assist with everything.

There were two notable shortcomings in the care that this resident received.  First, she was being wheeled about in a chair with a cushion that was too large.  How the too-large cushion got there was not addressed in the citation, but the fact is that it was recognized as such before the resident was taken from the shower.  Having an ill-fitting cushion leads to an unstable seating surface which creates the potential for this kind of accident to occur.  Second, the resident was being pushed without the foot rests in place.  Use of footrests would  have helped stabilize the resident in the wheelchair and likely prevented the fall.  It is also impossible based on the contents of the citation to exclude the possibility that the resident’s feet dropped to the floor, resulting in her being propelled forward out of the chair.  Lack of footrests is far more dangerous than would appear at first glance.

The failure to recognize the danger which was which being created here is an indication of a poorly trained staff.  Having a poorly trained staff shows a lack of investment in the personnel working at the nursing home.  Sadly, this is consistent with 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:

Resident at Chateau nursing home in Willowbrook suffers spinal fractures in wheelchair accident

Rochelle Rehab resident suffers multiple injuries in fall from wheelchair

Wheelchair accident at Avanti Wellness

Symphony of Buffalo Grove resident suffers catastrophic injuries in fall from lift

Failure to use gait belt results in fall and fractured kneecap at Friendship Village

Alden Valley Ridge resident rolled from bed and breaks both legs

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined the LaSalle County Nursing Home in Ottawa after a resident fell from his wheelchair due to the absence of a slip-resistant cover for the seat cushion, and as a result suffered fractures to the elbow and hip.

Wheelchairs are one of the basic pieces of equipment in a nursing home and where you have a resident who is wheelchair-bound, there is more to using a wheelchair than just plopping them into the seat and pushing them where they need to go.  The wheelchair must be properly maintained and have the right pieces accessories such as footrests, anti-tipping bars, and a proper cushion.  Residents must still be repositioned within the chair every two hours at a minimum to provide pressure relief to prevent the development of bed sores.  If the resident is going to be taken somewhere outside the nursing home in a van, the wheechair needs to be properly loaded and secured in the transport vehicle before the driver starts to pull away.  Not having all of these things in place anytime the wheelchair is in use places the resident using it at risk for unncessary injury.

This nursing home fall was brought about by the failure to equip the wheelchair with a proper cushion.  Wheelchair cushions besides providing pressure relief must be covered with a non-slip material to prevent the cusion with the resident on top of it from sliding forward out of their chairs and getting hurt as a result of the fall.  The resident’s family bought a new cushion which was put into use right away.  However, the cover with the non-slip surface on the bottom which was intended to keep the cushion from sliding out of the chair was not in use.

The usual practice when a new piece of equipment for a wheechair is put into use is that the therapy department evaluates it to ensure that the chair is still safe for use.  That evaluation was never done – a crucial breakdown in the system.

As a result, the resident was leaning forward while brushing his teeth and the cushion slipped forward out of his wheelchair, causing the resident to fall to the floor.  He suffered a broken hip and and elbow, and at 97 years of age, he is unlikely to recover fully from his injuries.

Well-run nursing homes operate on systems which make help ensure that routine items of care get delivered as required.  When those systems are not actually implemented, then there are crucial breakdowns in the delivery of care such as this one which result in needless injuries to the resident.  Here, there was a well-defined system of what was supposed to happen – therapy was supposed to check the cushion to make sure that it was safe to use.  They would have recognized that the absence of the cover with the nonslip surface was a safety hazard and brought that to the attention of family and staff so that issue could have been corrected.

Past that, a more basic question is why was the family providing a wheelchair cushion to begin with.  Federal regulations regarding nursing home falls require nursing homes to provides supervision and assistive devices necessary to prevent falls.  In this context, the wheelchair cushion is as much an assistive device as the wheelchair itself.  If the old cushion needed to be replaced because it was worn, soiled, or needed to be replaced for any other reason, it was the responsibility of the nursing home, not the family to provide that cushion.

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:

Resident suffers unexplained broken arm at Oregon Living & Rehab

Wheelchair accident at Generations of Lincoln

Accolade of Pontiac resident fractures femur in fall

Resident breaks hip in fall from wheelchair at Meadowbrook Manor in Naperville

Fatal fall from wheelchair at Rosewood of Elgin

Good Samaritan of Pontiac resident suffers fractured knee and leg in wheelchair accident

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

The Illinois Department of Public Health cited and fined Hillcrest Retirement Village in Round Lake Beach after a resident there fell forward from her wheelchair and suffered a broken neck.

The resident at issue was a stroke survivor with right sided hemiplegia. During the care planning process, she was assessed as being a high fall risk. She was given a wheelchair with a reclined back to help reduce her fall risk. A family member and a friend who visited the resident separately earlier on the day of the accident both saw the resident lean forward in her chair to the point that they were concerned that she would fall from her wheelchair.

The friend who visited told the nurse on duty on her way out of the facility that she was worried about the resident’s leaning forward and possibly falling out of her wheelchair. The nurse went into check on her, adjusted her in her wheelchair and left her to watch TV. A few minutes later a visitor to the nursing home informed the nurse that the resident had fallen.

The resident was brought to the hospital where scans showed that she had fractures at the C1 and C2 levels – the highest levels up on the neck. Due to the resident’s age, surgery would not be pursued, meaning that she would have to remain in a cervical collar for the rest of her life. These are very dangerous injuries, according to the resident’s neurosurgeon and can in fact be fatal injuries.

The Director of Nursing at the nursing home told state inspectors that the resident had been trying to get out of the chair from Day 1 and that she should have been placed in a well-supervised area.

Many times, when families come to see us after a nursing home fall, one of the concerns that they have is that their family member should have been restrained so that the accident could not have happened. That is actually the wrong tack to take because restraints can result in even more serious accidents.

Rather, the right approach is what the Director of Nursing indicated: that the resident should have been brought in an area where she could be closely supervised, especially given the concerns voiced by the resident’s friend. Not only would this provide her with the right kind of supervision in the moment, it would also give the nursing staff better data with which to revise the resident fall prevention care plan if that was called for.

It was interesting to see that a reclined wheelchair was in use. These can be effective for helping to prevent falls in residents with poor trunk control (as was apparently the case here), but they also carry the risk of developing bed sores. The use of this kind of wheelchair needs to be a carefully considered nursing judgment.

Our law firm serves nursing home residents who have been injured in falls and their families. Contact our experienced Chicago nursing home lawyers to learn more about what can be done after a fall and what your rights are. There is no charge for contacting us, and you are not obligated to hire us if you do call.

Other blog posts of interest:

Fall from mechanical lift at Hillcrest Retirement Village

Fatal injuries in fall from wheelchair at Rosewood of Elgin

Poor trunk control leads to fall at Charleston Rehab

Fatal consequences from fall at Forest Villa

Wheelchair accident at Avanti Wellness

Resident falls from wheelchair at Meadowbrook Manor

 

Click here to file a complaint against a nursing home with the Illinois Department of Public Health

Heartland of Galesburg nursing home was cited and fined by IDPH after a resident suffered a broken neck in a fall involving the facility’s transport van.

The resident was a long-term resident who was known as being impulsive and having poor safety awareness.  A staff member was taking him to the local hospital for a CT scan after a previous fall.   After arriving at the hospital, the staff member released the securing restraints for the wheelchair and told the resident to wait while he adjusted the lift gate.  While the staff member was doing that, the resident released the wheelchair brakes and the wheelchair rolled backward and tipped over backwards resulting in the resident suffering a fracture of the C5 vertebra.

While at first blush, this nursing home fall may seem to be the “fault” of the nursing home resident.  After all, he was the one who released the brake to the wheelchair.  However, one recurrent theme in our nursing home fall cases is that residents who demonstrate impulsive behaviors or poor judgment for their own safety should not be counted on to do the things that are necessary to assure their own safety.  That is the reason why things like bed alarms should be part of the arsenal of fall prevention tools.

In this case, there was a resident who was known to be impulsive and have poor judgment for his own safety.  Under these circumstances, relying upon him to leave the brake in place was a mistake by the staff.  The securing restraints should not have been released until the staff member was ready to take the resident off the transport.  This simple mistake in judgment cost the resident a broken neck.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary injuries and illnesses 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:

Heartland of Galesburg resident dies due to untreated urinary tract infection

Unsafe transfer at Heartland of Galesburg results in dislocated hip

Brain bleed from fall at Good Samaritan Home in Quincy

Medication error at Bloomington Rehab

Wheelchair accident at Avanti Wellness

Improper use of restraints at Paris Healthcare Center

Urinary catheter injury at Marigold Rehab in Galesburg

 

Click here to file a complaint against a nursing home with the Illinois Department of Public Health