Avantara Joliet Resident Suffers Broken Femur After Preventable Fall

The Illinois Department of Health has cited and fined Avantara Joliet when a staff member failed to adequately supervise a resident with a known fall risk and physical weight-bearing restrictions, allowing the resident to stand unsupported and fall. The resident sustained a broken femur shaft that extended two-thirds down the bone toward the knee.

The resident was admitted to the facility with a history that included a prior femur fracture, dementia, orthostatic hypotension, anxiety, and difficulty walking. His care plan identified him as a fall risk, and he required one-person assistance for all transfers. Physical therapy records confirmed he was on a partial weight-bearing precaution for his left leg, meaning he was permitted to bear no more than 50% of his weight on that side. A gait belt was required at all times during transfers.

On the day of the incident, a CNA Supervisor — who had not previously worked with the resident — was assigned to his care. The supervisor received a handoff report noting the resident was on oxygen, required assistance with transfers, was a fall risk, and needed to be checked every two hours. When the resident activated his call light and said he wanted to get out of bed, the supervisor used a gait belt to assist him to a wheelchair and brought him to a table in the common area. At that point, the supervisor removed the gait belt.

The resident then became anxious, said “I got to get out of here,” grabbed the table, and pushed himself to a standing position. The supervisor stated that once the resident was standing, he was holding the back of the wheelchair with one hand and had his other hand lightly on the resident’s shoulder — but acknowledged he was not holding or supporting the resident in any meaningful way. The resident pushed back from the table a second time, lost his balance, and fell forward, landing between the supervisor and the table. The resident was taken to the emergency room, where imaging confirmed the femur fracture.

The Therapy Director later stated that a gait belt should have been used at all times, and that if one was unavailable, staff should have supported the resident by holding his arm, hands, or underneath the shoulder to guide him safely to a seated position. The Director of Nursing agreed, stating she expects staff to place their hands on a standing resident’s back and guide them into a locked wheelchair in exactly this kind of situation. Neither intervention was attempted.

The facility’s own orthopedic surgeon confirmed that the fall at the facility was the direct cause of the broken femur.

Nursing homes are built to fail. They are chronically understaffed, and the staff they do have are often undertrained, underpaid, and overworked. When a resident suffers a serious injury like a broken femur because a staff member removed a gait belt and failed to physically support a fall-risk resident, it is not simply a mistake — it is the predictable result of a system that prioritizes cost over care. If your loved one has been injured in a nursing home in Illinois, our attorneys are ready to help. Contact us today for a free consultation.