Casey Rehab and Nursing Cited After Two Residents Fall While Unsupervised, One Fracturing Her Pelvis in the Shower

The Illinois Department of Health has cited and fined Casey Rehab and Nursing when, according to state investigators and facility records, a certified nursing aide showering a severely cognitively impaired resident turned her back to reach for a washcloth while the resident was covered in soap, and the resident leaned forward and slid out of the shower chair onto the floor, fracturing her pelvis. A second resident, also severely cognitively impaired and known to stand up from her wheelchair unassisted, fell in the dining room while no staff member was present in the dining room, striking her head and requiring three staples.

The first resident had Alzheimer’s disease, dementia, a disorder of bone density, and a history of prior lumbosacral spine and pelvic fractures. A fall risk assessment completed weeks before the fall classified her as a moderate fall risk. A separate assessment from around the same time documented her as severely cognitively impaired and dependent on staff for total assistance with bathing, transfers, and every other activity of daily living. A fall care plan intervention entered around the same time recorded that she did not understand her mobility limits because of her cognitive limitations and that she would try to get up from a bed or chair unassisted.

The certified nursing aide told investigators she transferred the resident from her wheelchair into a facility shower chair by herself. She had the resident “very soapy” when she turned her back to get a washcloth to cover the resident’s eyes before rinsing. That, she said, is when the resident leaned forward and fell out of the shower chair, landing on her left side on the shower room floor. The aide acknowledged the resident “leans forward in her wheelchair frequently,” that she should not have turned her back knowing the resident was very soapy and leaned forward on her own, and that the resident has Alzheimer’s disease and cannot make safety decisions on her own.

The aide also told investigators the resident should have been placed in the facility’s reclining shower chair, but that she did not realize the facility had a shower chair that reclined. Investigators observed staff using that reclining chair for another resident during the survey. The Administrator told investigators the aide should not have turned her back, that staff “are encouraged to use all the tools needed to ensure every resident is safe,” and that she should have used better judgment caring for a severely cognitively impaired resident. According to the citation, the Administrator confirmed the facility caused the resident’s left pelvic fracture by placing her at risk for falling when the aide turned around and stopped monitoring her. The facility asked the survey team to treat the shower fall as past noncompliance, and that request was denied.

The second resident had vascular dementia, a psychotic disorder with delusions, and encephalopathy, and was likewise assessed as severely cognitively impaired and dependent on staff for most daily care. Her care plan had carried an intervention for months requiring that she eat with supervision, along with a separate intervention directing that staff be educated on her supervision needs while she was up in her wheelchair. A certified nursing aide told investigators the resident was on fifteen-minute checks because she was a high fall risk, that she was supposed to be supervised in the dining room, and that one aide is supposed to be in the main dining room at all times during meals.

On the evening of her fall, she stood from her wheelchair unassisted, lost her balance, and fell. No staff member was in the dining room. The registered nurse on duty told investigators she was in the adjacent living room, did not have visual contact with the resident, was the closest staff member, and that there were no other staff in the dining room at the time. She explained that the facility was holding an event that night that caused “a lot of chaos,” which is why she could not position her medication cart in its normal location where she could see all the residents in the dining room. A cook passing through the dining room found the resident on the floor with blood on the back of her head and called for help.

The cook told investigators the resident had been sitting in the same spot since before supper was served, and may have been sitting there longer. She also said the resident’s right wheel was locked and her left wheel was unlocked. The nurse gave a conflicting account regarding the wheelchair, stating it could not have been locked because the anti-tippers would have prevented the resident from pushing back from the table to where the chair was found. The resident was sent to the emergency room, where a one-centimeter laceration to the back of her skull was closed with three staples and she was diagnosed with a closed head injury. Imaging showed soft tissue swelling to her left posterior scalp.

Other staff described her as a known risk. A unit aide said she “is known to fall a lot” and should not be left alone. A licensed practical nurse said she routinely crawls out of bed, will stand unassisted out of her wheelchair, and “generally tries to do things she shouldn’t,” and that staff should stay in the dining room until all residents have finished eating. The Director of Nursing told investigators the resident was known for pushing herself back from the dining room table, for rocking back and forth in her wheelchair, and for standing up unattended before this fall — and that the fall and the resulting laceration and staples “could have been prevented if staff were monitoring” her. The Administrator confirmed the facility does not have a policy on monitoring the dining room because it is a common area, while stating residents should be monitored during mealtime. The facility’s own Fall Reduction Policy stated that it would provide supervision and assistive devices to prevent or minimize fall-related injuries.

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.