Joliet Terrace nursing home fined for resident fall, death

The Joliet Terrace Nursing Home in Joliet, Illinois was fined $30,000 by the Illinois Department of Public Health after a resident suffered a subdural hematoma which resulted in his wrongful death. 

The man had been recently admitted to the facility and was assessed as a fall risk.  The facility developed a fall prevention care plan for him.  However, despite the fall prevention plan, he experienced three falls in the nursing home in less than 2 months.  The facility did not adjust his fall prevention care plan. 

He then had a fourth fall and began to develop neurologic symptoms which were signs of a brain bleed, or subdural hematoma.  The staff did not not promptly recognize these symptoms, and by the time he was transferred to the hospital, it was too late for him to be treated effectively, and he died as a result of the subdural hematoma.

There were two basic areas where the nursing home fell short in caring for this resident: (1) failing to adjust the fall prevention care plan and (2) failing to monitor his condition after the fall.

When someone is admitted to a nursing home, one of the first things that must be done is to develop a care plan for the resident.  The care plan is based on the assessment of the resident's condition.  One thing that is always assessed when someone is admitted to a nursing home is their fall risk.  Falls are a common reason that senior citizens are admitted to a nursing home, and for seniors, injuries from falls are a leading cause of death and major disability.

Once a care plan is developed, it must be implemented, and if it proves ineffective for preventing further falls, it must be adjusted.  The major failure of the nursing home in this case was the failure to adjust the care plan.  There were other steps which could have been taken to prevent additional falls for this man, and the failure of the nursing home to change his care plan to include those additional measures was a likely cause of his fall.  Too often, nursing homes simply rely on the regularly scheduled quarterly care plan meetings and canned care plans to meet the needs of residents who have issues which need prompt, thoughtful attention.  Failing to adjust care plans to meet resident needs is a legitimate basis for a nursing home abuse and neglect suit.

The other area where this nursing home failed the resident was in assessing him after the fall.  Most nursing homes put residents on a 72 hour fall watch after an accident such as this where the resident must be checked regularly by a nurse for changes in condition.  When a resident demonstrates a change in condition, the nurse on duty must notify the doctor so that the doctor can issue new treatment orders or have the resident sent to a nursing home. 

The nursing home staff in this case failed to recognize changes in condition and promptly notify the doctor, resulting in the resident's death.  This is a separate legitimate basis for a nursing home abuse and neglect suit.

The flaws that IDPH identified when it issued this citation is one which we as experienced Chicago nursing home lawyers look for in every case we handle.  Failures in care planning, implementing care plans, adjusting care plans, and notifying doctors of changes in condition are frequent sources of nursing home abuse and neglect lawsuits.