Richland Nursing & Rehab Resident Fractures Arm and Elbow After Being Left Standing Unattended

The Illinois Department of Health has cited and fined Richland Nursing & Rehab in Olney when a cognitively impaired resident with severe mobility issues fractured his right arm and elbow after a nursing assistant left him standing alone in the hallway to retrieve his walker. The resident, who was admitted after previous fractures from a fall and required maximum assistance from two people to walk even 10 feet, stumbled and fell into a handrail within seconds of being left unattended.

The resident in question was admitted to the nursing home following fractures to his right hip and back from a previous fall. He had severe cognitive impairment with a mental status score of 7 out of 15, indicating significant dementia. His assessment documented he was “dependent” for mobility, meaning “helper does all of the effort” and he “does none of the effort to complete activity, or the assistance of 2 or more helpers is required.” His physical therapy evaluation showed he required “max assistance x2” (maximum assistance from two people) just to walk 10 feet with a walker. He was classified as high risk for falls due to his history of falls, cognitive impairments, decreased safety awareness, difficulty using his call light, and decreased strength and endurance.

In the early morning hours, the resident was in the hallway in his wheelchair near his room. A nursing assistant was with him when the resident stood up from his wheelchair and grabbed onto the hallway handrail. The assistant stated “he then moved the wheelchair behind the resident and locked the wheels” and then “took 2 steps towards the resident’s room that is a couple of feet away, behind where the resident had been standing to get the resident’s walker.”

The assistant said “when he was a few feet away from the resident, the resident stumbled and hit his right elbow on the handle rail.” Another nursing assistant who witnessed the incident from the nurses’ station stated the assistant “did attempt to get the resident’s walker, but the resident stumbled and fell into the handrail” and the assistant “did reach out to grab the resident after he hit the handrail, so he did not hit the floor.” The resident ended up sitting on the hallway floor with his legs stretched out in front of him.

The resident was complaining of right arm pain with visible swelling. X-rays revealed he had sustained “a comminuted fracture of the proximal humerus and mildly displaced fracture at the base of the olecranon process at the elbow”—meaning multiple fractures in his upper arm and elbow. The resident was transported by ambulance to the emergency room and returned to the facility with a cast on his right arm and orders to follow up with an orthopedic specialist.

Multiple staff members and the facility’s own therapist agreed the resident should never have been left standing alone. The occupational therapy assistant who worked with the resident stated “the resident is not safe to be left to self-ambulate and in her opinion the resident should not be left alone when attempting to stand or while standing.”

A nurse who cared for the resident stated “the resident is unsteady on his feet and very impulsive” and “the resident should not be left unassisted while standing or walking.” The facility’s physician stated “the resident is unsteady on his feet and should not be walking or standing without assistance” and specifically noted the nursing assistant “should have remained at the resident’s side and not left him unassisted.”

The facility’s Administrator stated “it would be her expectation that the nursing assistant remained with the resident and had another staff member bring him the resident’s walker” rather than leaving him standing alone. The facility’s own Fall Management Policy required “necessary supervision” for high-risk residents and specified the use of “gait belts for all non-mechanical lifts and assists with transfers.”

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.