Care plan violation at Central Nursing Home

IDPH has cited and fined Central Nursing Home in Chicago after a resident was rolled out of bed by an aide and suffered a fractured elbow.

The resident at issue had a number of diagnoses, including a history of stroke, quadraplegia, and epilepsy.  She was assessed as being a high fall risk and required the total assistance of two for side positioning.   Her care plan called for the assistance of two with activities of daily living, which would include incontinence care.

On the day of the accident, a single aide was providing incontinence care to the resident.  The resident’s body weight caused her to begin to slide out of bed, and the aide could not stop the fall.  She fell to the floor.  X-rays taken later at the hospital showed that she had a fractured elbow.

This is a classic scenario (as shown here, here, here, and here as well as elswhere on this blog) of how doing something simple like providing incontinence care can result in a nursing home fall.  The resident here was clearly at risk for falls due to her underlying medical conditions.  There was a care plan in place which called for two aides to provide incontinence care to the resident, but that care plan was not being followed that night as the aide was working on the resident alone.  This kind of fall could have easily had more significant consequences such as a fractured hip or a brain bleed.

Past the obvious care plan violation, there were two fascinating statements in the citation issued by IDPH:

1.  The aide told the state surveyor that she always provided incontinence care to this resident alone.  This means the care plan was being violated not just that day, but on a routine basis.  The whole point of a care plan is to set out the care that a resident is supposed to be receiving day-to-day, shift-to-shift.  It isn’t just some piece of paper in the chart, and when it is being ignored on a routine basis, having an acceptable outcome (incotinence care provided without injury to the resident) is a matter of getting luck rather than providing quality care.
2. The nurse on duty told the state surveyor that they were short-staffed that night.  This kind of nursing home falls is the kind of thing that results when a nursing home is understaffed because the staff feels the need to cut corners to keep up with the pace of the residents’ needs.  Yet … the aide told the surveyor that this was done all the time.  Looking into the issue of understaffing would be a critical issue in any civil lawsuit arising from this fall.

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:

Brain injury from being rolled from bed at Bria of Palos Hills

Resident rolled from bed at Warren Barr – Lincolnshire

Niles Nursing & Rehab resident suffers fatal brain bleed in fall

Fall from bed at Landmark of Des Plaines results in brain bleed

 

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