Ascension Saint Anne Resident Suffers Two Falls and Fractures Due to Inadequate Assistance

The Illinois Department of Health has cited and fined Ascension Saint Anne Place when a resident with maximum assistance needs for standing and toileting fell twice, resulting in hip and wrist fractures. Despite the resident’s documented need for staff help and his use of the call light system, he reports to have been left unattended for extended periods and left to attempt dangerous tasks independently.

The resident in question was admitted to Ascension Saint Anne Place with multiple health conditions including adult failure to thrive, Type 2 diabetes, chronic kidney disease, and low back pain. His facility assessment showed he had no cognitive problems but needed maximum assistance from staff for standing and using the toilet. The assessment also classified him as having a moderate risk for falls.

The first fall occurred in April when the resident was found on the floor lying on his right side. A registered nurse discovered him after hearing someone yelling for help. The resident explained that “he was moving around in his chair and slid out of the wheelchair” and had “rolled onto his other side” after falling. He told staff he “broke his fall by putting down his left hand so he wouldn’t hit his head,” which likely contributed to his wrist injury. Hospital records confirmed he had sustained “an acute mildly displaced left hip fracture” and also had a fracture to his left wrist. Surgery to repair his hip was performed the day after his hospital arrival.

Following the first incident, the facility updated the resident’s care plan to include interventions such as keeping personal items within his reach due to his “risk for falls, repeated falls, weakness and malnutrition.” The plan continued to specify that he “required one staff assistance for toileting.”

Despite these documented needs and previous fall, a second incident occurred in June. The resident described being “standing up at the foot of his bed reaching for his urinal” when “his legs gave out and he fell.” He explained that he “had his call light on because he could not reach his urinal” but “after half an hour he tried to do it himself and fell.” The resident reported that he “felt his hip break when he fell” and “had to yell for help from the staff.” He expressed frustration that “because he is younger and has his wits about him, the staff thinks he is independent.”

A registered nurse who was passing medications in the hallway heard someone yelling “help me” and had to walk up and down the hall trying to locate the source of the calls. She eventually heard the resident yell out his room number and found him “on the floor at the foot of his bed near the bathroom door.” The nurse noted that “the resident’s urinal was on the other side of the bed from where the resident had been sitting” and assessed that “due to the pain level, he probably had a fracture to his hip.” Emergency services were called and the resident was transported to the hospital.

The facility’s investigation into the June fall revealed inconsistencies in staff understanding of the incident. The Director of Nursing stated that “during the facility investigation into the fall they determined the resident did not have his call light on” and believed “the resident was in his wheelchair when the fall happened but wasn’t sure.” However, this contradicted the resident’s detailed account of having his call light activated and waiting thirty minutes for assistance before attempting to reach his urinal independently.

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