Alden Lincoln Rehab and Healthcare Center Cited After Resident Left Alone in Shower Falls and Sustains Multiple Pelvic Fractures

The Illinois Department of Health has cited and fined Alden Lincoln Rehab and Healthcare Center when a certified nursing aide left a resident who required supervision alone in the shower room to answer another resident’s call light, and the resident fell and sustained multiple pelvic fractures that required hospitalization and surgery consultation. The resident, who was cognitively intact and able to clearly describe what happened, told investigators he needed help in the shower and that staff normally stayed with him — but on this occasion no one was there when he fell.

The resident had a complex medical history that made his need for supervision during showering especially important. His diagnoses included multiple prior pelvic fractures, heart failure, atrial fibrillation, diabetes, and muscle weakness, among other conditions. His care assessment documented that he required partial to moderate staff assistance during showers. He was cognitively intact and well aware of his own needs. He used a rollator walker and had been functioning with a degree of independence prior to this incident.

On the morning of the fall, a certified nursing aide was accompanying the resident to the shower room. She noticed another resident’s call light going off. Rather than asking a colleague to respond to the call light or waiting until the resident was safely supervised, she instructed the resident to wait and left to answer it herself. The resident, standing in the shower room, leaned over to try to remove a tight sock from his foot and lost his balance. He fell to the floor. No staff member was present.

When the aide returned and found the resident on the floor, she notified the nurse. The resident told staff he thought he had hit his head. Because he was on multiple blood thinners, the nurse practitioner ordered him sent to the hospital immediately. He was transported by ambulance and admitted to the hospital, where imaging revealed multiple fractures to the right hip and pelvis. Surgeons were consulted but determined he was not a candidate for surgery at that time. He was left to heal without surgical intervention.

The resident described the incident clearly to investigators: “I was trying to take a shower, and I could not get my sock off my foot. the certified nursing aide left the shower room and said she would be back. I leaned over and fell on the floor. I do need help in the shower — staff normally stay with me in the shower in case I need help. When I fell, no one was in the shower room with me.” He also shared the lasting impact on his life: “Since I am no longer able to walk around with my rollator, I must depend on staff more for my care. This makes me feel helpless.”

Every staff member interviewed agreed that the resident should not have been left alone. The aide herself acknowledged it: “I don’t think the resident would have fallen if someone was with him.” She stated she could have asked another staff member to answer the call light but believed she could do it quickly and return. The registered nurse on duty said he was never informed the resident was going into the shower — which was itself a protocol violation — and that the aide should have stayed with the resident and asked someone else to handle the call light. The nurse practitioner stated that a staff member should have been with the resident in the shower room to reduce the risk of a fall. The Director of Nursing was direct: staff are required to have everything they need before entering the shower room with a resident, and residents requiring supervision should not be left alone.

The consequences for the resident were significant and lasting. Prior to the fall he had been moving independently with a rollator walker. Afterward, he was restricted to toe-touch weight bearing, could no longer use his rollator, and required a mechanical lift for transfers. He was moved to a higher-acuity unit for increased supervision. He also continued experiencing pain but had stopped taking his prescribed pain medication because it caused constipation — a side effect he found more debilitating than the pain itself. The physical therapist noted that while the resident was progressing, healing from multiple fractures takes time, and diabetes can slow the process further.

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. Our experienced Illinois 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.