The Illinois Department of Health has cited and fined Manor Court of Rochelle when staff failed to properly monitor a resident with severe dementia after an unwitnessed fall at 3 a.m., neglecting to notify the physician or conduct required neurological checks. The resident remained in severe pain throughout the night without follow-up care, ultimately requiring emergency hospitalization the next morning when staff discovered she had suffered a left hip fracture.
The resident in question was living at the facility with multiple serious conditions including anxiety, arthritis, severe dementia with agitation, and insomnia. Medical assessments confirmed she was severely cognitively impaired. Prior to the incident, the resident walked slowly and steadily with her walker and rarely used a wheelchair.
The facility had established a care plan recognizing the resident’s significant fall risk, documenting that she “has a history of falls prior to admission and is at risk for falling related to poor safety awareness, doesn’t use the call light and has a diagnosis of Dementia.” The care plan specifically required staff to “observe frequently and place in supervised area when out of bed” and indicated the resident “requires assistance of one with walker or ambulation.” A nursing assistant confirmed that the resident “is not supposed to walk around by herself.”
In the early morning hours, the resident was last documented as being in the unit living room with other residents. An hour later, she had somehow made her way to the dining area where she fell while walking alone with her walker. Critically, no documentation was found explaining “why the resident was ambulating unsupervised in the dining room at 3 a.m. in the morning,” despite the care plan requirements for frequent observation and supervision.
When a certified nursing assistant discovered the resident, she called the agency registered nurse on duty. The nurse arrived to find the resident “seated on the floor against a chair which is by the wall.” When asked what happened, the resident explained “she had been walking around with her walker and fell.” The nurse helped the resident into a chair and took her vital signs, which were within normal ranges.
According to the nurse’s documentation, the resident was “alert and oriented” with “skin intact with no wounds or openings. No injuries noted.” However, the resident complained of “pain to back and side.” The nurse’s notes indicated she “gave pain medication to the resident and later escorted to her room,” noting “no limping” as the resident walked with her walker.
The failures in care became apparent during investigation. The nurse supervisor who later reviewed the incident confirmed critical deficiencies: the nurse “did not complete neurological checks and did not notify the physician of the resident’s fall.” Additionally, “there was no follow up documentation of the resident’s complaints of back and side pain and there was no medication administration documentation that pain medication was administered.”
These omissions directly violated the facility’s own written policies, which clearly stated: “If a fall is unwitnessed, notify the physician and initiate neurological checks at least every four hours for twenty four hours, or until stable, or as otherwise ordered by the physician.”
The consequences became clear the following morning. When the day shift licensed practical nurse arrived, certified nursing assistants immediately told her “there was something wrong with the resident.” The nurse recalled they stopped her in the hallway before she had “barely had time to take off my coat.” She went directly to the resident’s room and found her refusing to get up “due to ‘extreme pain’ at left hip/thigh area.” The nurse stated the resident was in “severe pain” and was “most likely in pain all night.”
The day shift nurse quickly recognized the emergency. She stated, “I didn’t know what was wrong with the resident but she needed to be sent out.” She contacted the physician to request X-rays, notified the resident’s power of attorney and the facility administrator, and arranged emergency transport.
Only after making these urgent arrangements did the day shift nurse receive any report about the fall. When she finally spoke with the agency nurse, all she was told was that “the resident fell and was put back in bed. Nothing else.” The day shift nurse stated, “I did not receive any nurse/shift report regarding the resident’s fall until after I was told by my dayshift CNAs that there was something wrong with the resident.”
The resident was transported by ambulance to the hospital where X-rays confirmed she had suffered a left hip fracture from her fall.
After the incident, health inspectors observed the resident sitting in a wheelchair during a church group activity with her head down, appearing to be sleeping—a stark contrast to her previous ability to ambulate with her walker.
This incident represents multiple, compounding failures in resident care. The facility failed to ensure adequate supervision of a resident with severe dementia who required constant observation. When the fall occurred, the nurse on duty failed to follow basic medical protocols including notifying the physician and conducting neurological assessments. The nurse failed to properly document and follow up on the resident’s pain complaints, leaving her to suffer through the night. There was also a breakdown in communication between shifts, as the incoming nurse received very little information about the serious incident that had occurred hours earlier.
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.
