Newman Rehab & Health Care Center Cited After Resident Broke Hip Trying to Get to Bathroom When No One Answered Call Light

The Illinois Department of Health has cited and fined Newman Rehab & Health Care Center when a resident who required assistance with all mobility fell and broke her hip while attempting to take herself to the bathroom because no nursing assistant was available to answer her call light. The facility left an entire hallway without a certified nursing assistant for over an hour and a half during the morning shift when residents typically need bathroom assistance.

The resident in question was admitted to the facility with chronic kidney disease, hypertension, and low back pain. Her admission assessment documented she had a “known history of falling” and was “at risk for fall.” The assessment showed she was not cognitively impaired but “requires assistance with all activities of daily living, bathing, transfers, ambulation and toilet use.” She was continent of bowel and bladder, meaning she could feel when she needed to use the bathroom.

During the night shift, the nursing assistant assigned to the resident had taken her to the bathroom three times. At 5:15 AM, when the resident stated she needed the bathroom again, the nursing assistant asked if she would like to be cleaned up and dressed for the day, and the resident agreed. This was the last time the nursing assistant provided care before her shift ended.

Shortly before 8:45 AM, the resident was heard hollering for help. She was found “on the floor of her room lying on her right side with her right arm underneath her trying to prop herself up.” The resident explained what happened: “I was trying to take myself to the bathroom because I really needed to go. I turned my call light on, but no one came to answer my call light, so I tried to take myself and ended up on the floor.”

A registered nurse was notified of the incident and placed a pillow under the resident’s head, then left to get help to lift her back into bed using a mechanical lift. The resident stated she was having pain in her right side. At 8:55 AM, the nurse gave her Tramadol for pain complaints. The resident continued having pain on her right side and was transported to the hospital by ambulance shortly after noon.

The hospital emergency room examination showed “new fracture across the right femoral neck with moderate displacement and impaction and mild varus angulation” – meaning the resident had broken her hip with the bone fragments displaced and pushed together.

When investigators questioned staff about what happened, they discovered a serious staffing problem that morning. The administrator explained that when she arrived at the facility at 8:00 AM to work as a nursing assistant, “they were having an issue with CNA’s that morning because one of the day CNA’s became sick and had to leave the facility.” The facility had called her and “asked if they could call people in and I told them yes and I would also come in and work.”
The administrator acknowledged the gap in coverage: “The resident’s hall did not have a CNA to answer call lights until 9:30 AM. This is when I was able to work on that hall as a CNA.” This meant that for over an hour and a half during the morning shift – when residents typically need the most assistance with toileting after waking up – an entire hallway of residents who required help had no one available to answer their call lights.

The resident had done exactly what she was supposed to do by turning on her call light when she needed bathroom assistance. However, with no nursing assistant available to respond, she faced an impossible choice: wait indefinitely while needing to urgently use the bathroom, or attempt to get there herself despite requiring assistance for all mobility. She chose to try to take herself and suffered a serious hip fracture as a result of the facility’s failure to ensure adequate staffing coverage during the shift change.

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.