Amputee’s Surgical Wound Reopens After Fall from Broken Bed at Autumn Meadows at Cahokia

The Illinois Department of Health has cited and fined Autumn Meadows of Cahokia when a recent amputee fell after his bed’s locking mechanism malfunctioned, causing his surgical wound to completely reopen and requiring emergency surgery. Despite the resident reporting that his bed wheels wouldn’t lock, the facility failed to repair or replace the bed, and when he attempted to transfer to his wheelchair, the bed rolled away from him, causing him to fall and tear open his amputation site.

The resident in question had recently undergone amputation of his right leg below the knee and was admitted to the nursing home for rehabilitation. He was assessed as a high fall risk with a score of 50 on the facility’s fall scale, where anything above 45 is considered high risk. The resident was cognitively intact and required assistance with transfers due to his new amputation. His surgical staples had been removed, and the wound had healed over.

One evening, the resident needed to use the bathroom but didn’t want to ask for help because, as he explained, he was “in denial about losing his independence.” He attempted to transfer himself from his bed to his wheelchair positioned beside the bed. However, the bed’s locking mechanism was broken, and when he tried to move, “the bed rolled away from him, and he fell on the floor and busted his stump open.”

The resident said his surgical wound “reopened measuring 15 centimeters in length and 3 centimeters in height.” He described being in severe pain, rating it “an 11” on a scale of 0-10. The resident stated he “put his call light on to get some help, but no one ever came so he crawled out into the hallway and yelled for help.” He said “it still took the CNAs a while to come and help him” even after he crawled into the hallway calling for assistance. When staff finally arrived, he said he “was bleeding all over the place. There was a trail of blood from the bed to the hallway. He said there was so much blood they had to take towels and put on it to stop it from bleeding.”

The resident was transported to the hospital where surgeons discovered the fall had caused “complete dehiscence” (complete reopening) of his amputation closure site. The surgical report documented finding “evidence of some nonviable muscle and traumatized muscle from the fall as well as a hematoma which was evacuated.” There was also “a large amount of fibrous tissue” and exposed bone requiring removal.

Due to the severity of the injury and “depleted venous access” (his veins were too damaged for a regular IV), surgeons had to place a triple lumen catheter in his groin to administer anesthesia. The surgical team performed extensive debridement (removal of dead tissue), excised a portion of the tibial bone using a power saw, irrigated the wound with antibiotics, and reapproximated the skin using interrupted sutures. The resident remained hospitalized for several days before returning to the nursing home.

The maintenance director confirmed the facility knew about the broken bed. When asked why the resident received a new bed after the fall, maintenance staff stated “because the resident complained his bed wouldn’t lock.” The maintenance director explained “the locking mechanism on the bed wasn’t working and when it doesn’t work it will cause the bed to slide.”

However, the facility’s administrator stated she “can’t put a date on it when she was made aware of the resident’s bed not working properly.” When pressed whether she learned about it before or after the fall, she said “she was unable to remember and that is why she can’t put a date on it.” She acknowledged staff should have either fixed it themselves if possible or submitted a work order to maintenance.

Despite the resident being a recent amputee at high risk for falls, his care plan was inadequate. The care plan initiated after the fall simply stated the resident is “at risk for falls” with “gait/balance problems due to a recent below the knee amputation.” The interventions listed were generic: “anticipate and meet the residents needs as needed, ensure the resident’s call light is within reach and encourage the resident to use it for assistance as needed, and follow facility fall protocol.”

An investigation report noted the resident “is a brand-new amputee and has a diagnosis deficit. Resident lack safety awareness and has not come to terms with his most recent amputation. Resident has difficulty with asking for assistance or using his call light because he is in denial about losing his independence.” Despite this documented psychological struggle and high fall risk, no meaningful preventive interventions were implemented.

The facility’s Medical Director stated he would “deem the resident a fall risk and there should be a fall plan of care in place for him.” He said “the fall the resident had has the potential to cause harm and he is sorry it happened.” The Medical Director stated “he thinks the facility failed in preventing the resident’s fall. He said no one was answering his call light, and his bed was broke that’s a lot.” He concluded “yes, this incident has the potential for the resident to experience harm or death.” He said it’s unacceptable and he absolutely agrees the facility failed.

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 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.