Resident Left Unsupervised, Falls and Suffers Double Fracture at Shelbyville Manor

The Illinois Department of Health has cited and fined Shelbyville Manor when a resident with dementia and a documented history of falls was allowed to walk unsupervised to the bathroom despite requiring substantial assistance with transfers, resulting in a devastating fall that broke both his hip and shoulder. The facility failed to provide adequate supervision and toileting assistance for the high fall risk resident, who had been admitted just six days before the life-altering accident.

The resident in question, who had been admitted to the facility just days earlier with multiple diagnoses including “Dementia,” “Difficulty in Walking,” and “Muscle Wasting and Atrophy,” was assessed as having a “Fall Risk Score of 16 (High Risk)” using the facility’s own scoring system where anything “greater than 13 Total Points equals High Fall Risk.” His physical therapy evaluation confirmed he “required substantial/maximal staff assistance with transfers” and his care instructions directed staff to “transfer the resident with one assist, front wheeled walker and to use a gait belt.”

Despite these clear safety requirements, the resident was found lying on the floor of his room after an unwitnessed fall, complaining of severe pain. The incident report documented that staff found the resident “laying on back on floor, in front of doorway, with head facing doorway and feet facing window” with his “wheelchair noted to be parked at foot of bed, facing window.” The resident told staff “I was trying to go to the bathroom, and I tripped over my heel” and complained of “pain 10/10 to left shoulder and left hip, unable to complete ROM (range of motion).”

The Certified Nursing Assistant who discovered the resident revealed critical information about the facility’s failure to provide adequate supervision. She stated that the resident “always took himself” to the bathroom and “was independent when I worked. He never asked for help.” However, this directly contradicted the resident’s documented need for substantial assistance with transfers. She noted that “the bathroom is pretty far from here, where he laid (approximately 8 feet away)” and admitted “I did not take him to the bathroom before lunch” despite the resident’s obvious toileting needs.

The fall resulted in devastating injuries requiring emergency surgery. Hospital records confirmed the resident “suffered a mechanical fall at his nursing home” and “was found to have left humerus fracture and left femoral neck fracture.” He required surgical repair, with doctors performing “in-situ fixation of left femoral neck fracture” while managing “his humeral fracture non-operatively with a sling.” The injuries left him with severe mobility restrictions, becoming “weight-bearing as tolerated to the left lower extremity, and non-weight bearing to the left upper extremity.”

The facility’s Director of Nursing acknowledged multiple failures in the resident’s care, stating that the resident “was not to ambulate unless he was working with therapy” and admitting “it makes sense that we should have identified why he was trying to self-transfer. He should have had assistance. His intervention should have included increased toileting, in addition to increasing the resident’s supervision.” This admission revealed that staff knew the resident should not have been walking alone but failed to implement proper safeguards.

Perhaps most troubling was the revelation that the facility was aware of the resident’s fall history but failed to act on this knowledge. The resident’s Nurse Practitioner, who had known him before his admission, stated “I have known the resident long before he was a resident in the facility. He had numerous falls when he was at home. He had a very unstable gait. He should have had assistance with ambulation, transfers and toileting. He was somewhat impulsive.” The practitioner noted she was “not surprised when I heard he had the fall with the fractures” but “did not realize staff were not providing him the assistance he needed.”

The facility’s MDS/Care Plan Coordinator admitted that critical fall history information was missing from the resident’s records, explaining “the resident’s MDS did not document that the resident had previous falls, because the facility did not have his history when he was admitted. He is moderately impaired and did not remember falling prior to admission. Now we know his history.” This failure to obtain complete medical history left staff unaware of the resident’s true fall risk, contributing to inadequate safety measures.

The incident highlighted systemic failures in communication and care planning. The Nurse Practitioner confirmed that the resident “was trying to toilet himself, from what I understand, that was the root cause of his fall” and emphasized “yes, he should have been toileted by staff.” The facility’s failure to provide scheduled toileting assistance for a high-risk resident with dementia and mobility issues directly contributed to his attempt to reach the bathroom alone, resulting in life-altering injuries that could have been prevented with proper supervision and assistance.

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.