Jerseyville Nursing & Rehab Resident Dies After Catastrophic Fall As Ineffective Fall Prevention Monitoring Cited As Contributing Factor

The Illinois Department of Health has cited and fined Jerseyville Nursing & Rehab Center when a cognitively impaired resident with a history of falls sustained catastrophic head injuries after falling from her bed, dying the next day in the hospital. The facility failed to evaluate, implement, and monitor the effectiveness of fall interventions, resulting in the resident suffering depressed skull fractures, brain bleeds, and facial fractures after three falls in three months.

The resident in question had severe cognitive impairment and dementia with agitation, was rarely or never understood when speaking, and had a history of falling. She required substantial to maximal assistance from staff to stand and used a wheelchair for mobility. She was classified as high fall risk on every assessment conducted at the facility. The resident was also noted to be forgetful and didn’t remember she couldn’t walk by herself.

The resident fell three times during her stay at the facility. After her first fall, when she injured her head, staff added an intervention to have the television on when she was laid down in bed as a distraction. After her second fall, when she again injured her head and arm and was sent to the emergency room, the facility added bed and chair alarms. However, the facility did not adequately assess whether these interventions were actually preventing falls.

The Director of Nursing later acknowledged that bed and chair alarms had already been in place before the second fall, meaning “it would not have been a new intervention.” Similarly, the bed had already been in low position with a fall mat before the third fatal fall, but “it wasn’t added to her care plan interventions until after the fall,” indicating a failure to properly document and monitor existing measures.

The facility failed to evaluate and adjust interventions when they proved ineffective. Staff knew the resident routinely defeated the bed alarm system. The Care Plan Coordinator stated the resident “knew how to turn the bed/chair alarms off, she would grab the box and turn it off.” The Director of Nursing acknowledged “the bed alarm was not an effective intervention for the resident” when she was in bed, admitting “the alarm was only effective when used in her wheelchair.”

Despite knowing the bed alarm wasn’t working, the facility continued to rely on it without implementing alternative strategies or modifications. The facility’s Medical Director stated “he would expect interventions to be progressive and resident centered” and that “if the resident was able to turn off the alarm, he would expect the facility to attempt to prevent her from being able to do so by hiding it.” The Director of Nursing acknowledged after the death that “maybe they could have put the alarm box inside the resident’s bedside table to keep her from turning it off”—but this was never attempted while the resident was alive.

The facility’s own guidelines for Personal Alarms acknowledged that “many reports describe patients deliberately deactivating their alarms and may not be appropriate,” yet staff did not act on this knowledge or seek alternative interventions for this particular resident.

The facility failed to properly document and consistently implement interventions. The Director of Nursing revealed that staff “were doing 15-minute checks on the resident while she was in bed, she was the only one we had to do that on,” but critically admitted “we didn’t have this documented.” Without documentation, there was no way to monitor whether these checks were actually occurring or to hold staff accountable.

After the first fall, staff determined that having the television on for distraction was important “because there weren’t any eyes on her in there.” However, this intervention was not consistently followed. Multiple staff members confirmed the television was not on when the resident was put down for her nap on the day of the fatal fall, despite this being identified as an important fall prevention measure.

The Care Plan Coordinator acknowledged that “a self-release belt as a fall intervention should have been added at the same time her bed and chair alarms were, but she couldn’t see it was actually added,” demonstrating a failure to properly implement and document interventions.

On the day of the fatal fall, nursing assistants put the resident in bed for a nap after lunch. They stated she appeared tired with her eyes closed. One assistant said she placed the resident’s bed alarm and had her fall mat in position, with the call light within reach.

Just 3-5 minutes after staff left the room, another nursing assistant walking down the hall “saw the resident lying on her left side on the floor with a puddle of blood under her head.” The Director of Nursing found the resident “on her left side with half her body on the fall mat, the upper half on the floor.” The bed alarm was still attached but was not going off—consistent with staff’s knowledge that the resident would turn it off, yet no modifications had been made to prevent this.

When paramedics arrived, they found the resident “lying on her left side and had a lot of blood on her, she was moaning and had purposeful movements with her eyes open but was not speaking.” The paramedic stated the resident “was actively bleeding, and her hair was saturated with blood.” No alarms were sounding.

Medical records documented the resident sustained depressed skull fractures, an orbital fracture (eye socket), subdural hematoma (bleeding between brain and skull), subarachnoid hematoma (bleeding around brain), intraparenchymal hematoma (bleeding within brain tissue), maxillary fracture (upper jaw), temporal bone fracture, and a scalp laceration. The resident was flown to a larger hospital for specialized care. Hospital notes documented she was “admitted with severe TBI (Traumatic Brain Injury) and altered mental status” with “concern for impending uncal herniation syndrome,” a life-threatening condition. After discussion with family, care was transitioned to comfort measures. The resident died the following day.

The facility’s Medical Director stated “he would expect staff to be following the fall risk care plan interventions if they were able to do so” and “he would expect interventions to be progressive and resident centered.” He further stated “if the fall risk interventions were not being followed and they were previously working, it could pose a higher risk for the resident to fall”—which is exactly what occurred.

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.