The U.S. Department of Health and Human Services has cited Magnolia Manor – Inman for the injury of a resident after a CNA tried to operate a two-person lift by herself.
A resident at Magnolia Manor in Inman, South Carolina, required two personnel to operate a Hoyer lift, but on the day of the incident a Certified Nursing Assistant (CNA) attempted a transfer using the Hoyer lift by herself. This meant that while the CNA tried to place the Hoyer lift pad underneath the seated resident, the resident was dropped to the floor and fractured their right ankle.
Later the CNA elaborated on her account, saying that the resident was eased onto the floor and did not fall unassisted. A Licensed Practical Nurse (LPN) on duty came to examine the resident after the incident. This LPN did not see any injury and contacted the resident’s physician, who recommended based on this account that the resident stay in the facility and be assessed by a Nurse Practitioner the next morning.
The resident asked to go to the hospital and immediately complained of pain in their leg. The resident continued to complain of pain and asked for an x-ray, but was told by the LPN that this was not possible without the doctor’s permission. The nurse simply told the resident to let their medications take effect and see the Nurse Practitioner in the morning.
The resident’s family eventually called Emergency Medical Services (EMS) to check on the resident. EMS recommended that the resident go to the hospital, but the resident refused. The resident had the chance to go to the hospital via EMS, but chose to stay. Why did this resident change their mind, even though they had complained of pain and asked earlier to get an x-ray?
Nursing home staff is responsible for caring for a resident, but they also have a considerable amount of power over these vulnerable individuals. It is very possible that the resident did not want to go against the opinion of the nursing staff and ignored their own health needs. This resident did end up returning to the same facility and nursing staff, increasing the chance that they were motivated to avoid upsetting the staff.
After medical treatment outside of the facility the next day, the resident went to the hospital and had a scan done, which revealed a fractured right ankle. The resident returned to the facility with a splint on the right foot and leg.
Records revealed that the Nurse Practitioner never checked on the resident. When five CNA’s were interviewed, all knew how to check a resident’s profile for instructions regarding lift protocol. The nursing home not only made the resident wait for treatment after a fall, but the Nurse Practitioner in the facility never checked on the resident, as the resident’s physician had recommended. Falls for those in a nursing home can often have lasting negative impacts on quality of life, sometimes creating additional health needs and functional limitations.
This resident had proven to be able to make their own decisions when admitted to the facility and was able to clearly communicate the incident in an interview, but not all residents have this ability. Nursing home residents are especially vulnerable and rely completely on nursing staff to care for their needs.
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