The Illinois Department of Health has cited and fined Clark-Lindsey Village when a certified nursing assistant left a high fall-risk resident unattended on the toilet to fix her bed, resulting in the resident falling and sustaining multiple acute fractures to her left arm. Despite facility policies requiring constant supervision during toileting for fall-risk residents, the nursing assistant admitted he knew the resident should not have been left alone but left her anyway to perform other tasks.
The resident was living at the facility with numerous serious medical conditions including a history of falling, anxiety disorder, difficulty walking, cognitive communication deficit, heart failure, atrial fibrillation, chronic respiratory failure, and pulmonary hypertension. Medical assessments showed the resident had moderate cognitive impairment and was completely dependent on staff for toileting hygiene tasks. Assessments also documented that the resident required substantial to maximal assistance from staff when moving from a sitting to standing position.
The facility had conducted a fall risk evaluation that gave the resident a score of 17.0, and “a score of ten or higher indicates that the resident is at high risk for falls.” The resident’s care plan, recognizing this significant fall risk, documented that the resident “is at risk for falls related to deconditioning” and required staff to “follow facility fall prevention guidelines.” The care plan also specified that certified nursing assistants were to “maintain proactive contact with residents to anticipate needs.”
In the early morning hours, the resident needed to use the toilet. A certified nursing assistant brought her to the bathroom and placed her on the toilet. However, instead of remaining with the resident as required by facility protocols, the nursing assistant left her alone to perform another task. According to the incident report, the nursing assistant “stated that he was just in her room to fix her bed while she was in the bathroom.”
Left unattended on the toilet, the resident attempted to care for herself. The incident report documents that the resident “stated that she voided and was going to get a wipe and stand on her own and fell on her left arm.” The resident, who required maximal assistance to move from sitting to standing and had severe cognitive impairment, tried to stand by herself because no one was there to help her.
The consequences were significant. The incident report describes that when the nursing assistant returned, he found the resident had fallen and her “left arm was bent with obvious signs of deformity and bruising and that the resident could not move it and stated it was painful.” The resident was sent for X-rays, which revealed severe trauma: “Acute comminuted displaced fracture involving the left humeral head/neck with soft tissue swelling. Acute comminuted displaced angulated fracture involving the proximal third shaft of the left humerus with soft tissue swelling.” In simpler terms, the resident sustained multiple broken bones in her upper left arm and shoulder area, with the bones displaced and broken into multiple pieces, accompanied by significant swelling.
When health inspectors visited the facility, they found the resident “lying flat on her back in bed and a brace is on her left arm.” The resident confirmed “she had a fall, broke her arm and it is painful.”
During the investigation, multiple staff members at every level acknowledged that this fall should never have happened. A certified nursing assistant told inspectors that “when a resident has a known fall risk they should never be left unattended when they are sitting on the toilet.” The nursing assistant who left the resident alone admitted his error, stating “he knew the resident was a fall risk and should not have left the resident alone on the toilet.”
The registered nurse on duty confirmed the standard of care, stating “she would expect that all CNAs should not leave a resident unattended on the toilet if they were a fall risk.” A licensed practical nurse emphasized the seriousness of the lapse, noting “it was well known, and it is documented that the resident is at risk for falls and that the resident should not have been left unattended on the toilet.”
Perhaps most telling was the statement from the facility’s former Director of Nursing, who was in that position at the time of the incident. She stated plainly that “the resident’s outcome would have been different if the nursing assistant would have stayed at the resident’s side while she was on the toilet to prevent the resident from falling.” This acknowledgment from the facility’s top nurse confirms that this injury was entirely preventable and resulted directly from the failure to follow basic safety protocols.
This case illustrates a clear failure to implement established care plans and safety protocols. The facility had properly assessed the resident’s fall risk, documented her need for assistance, and created a care plan requiring supervision. However, these safeguards were meaningless when the nursing assistant chose to prioritize making a bed over staying with a vulnerable resident who required constant supervision.
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.
