Sharon Healthcare Willows Aide Left Resident Alone Near Water Spill, Causing Fall and Broken Femur

The Illinois Department of Health has cited and fined Sharon Healthcare Willows when a certified nursing assistant left a resident alone in a room with a large water spill on the floor, despite warning the resident not to get up. The resident fell while attempting to get to the bathroom and suffered a severe fractured femur requiring surgery and hospitalization.

The incident involved a 62-year-old female resident with multiple medical conditions including bipolar disorder, chronic obstructive pulmonary disease, metabolic encephalopathy, and kidney absence, who had been living at the facility for over two years. The resident was cognitively intact according to her mental status assessment but had a history of impulsive behavior and delusions. Her care plan noted she “is at risk for falls” and “ambulates independently but has a history of wheelchair use,” requiring supervision for activities of daily living and toileting assistance.

The dangerous situation began when a certified nursing assistant walked past the resident’s room and discovered a significant safety hazard. The aide stated, “I walked past the resident’s room and saw there was water all over the resident’s floor. The resident had a large cup that must have spilled. I don’t know how long the water had been there.” The resident was in her bed, which was positioned in a low setting, when the aide entered the room.

Upon seeing the aide, the resident became agitated about wanting to vape (use electronic cigarettes) and began “rolling in bed like she was trying to get up.” The aide recognized the resident’s impulsive tendencies, noting that “the resident gets adamant about when she wants to vape” and “it depends on the resident’s mood if she listens or not.” Despite these known behavioral patterns, the aide made a critical decision that would lead to serious injury.

The aide told the resident to “stay in bed and not to get up because there was water on the floor” and observed that “the resident was still trying to get up.” However, the aide reasoned that because “the resident needs help to get up from the low bed so I didn’t think the resident could get up.” Based on this assumption, the aide decided to leave the resident alone with the hazardous spill to retrieve cleaning materials from an adjacent room.

The aide explained her decision: “I went through the bathroom that was between the resident’s room and another resident’s room to get some extra pads in the other room to absorb the water.” She emphasized that she “kept telling the resident not to get up” before leaving, but admitted she was only gone “for a few minutes” while speaking with another resident during her brief absence.

The resident’s urgent need to use the bathroom overrode the aide’s instructions. The resident later explained her perspective: “When I fell and broke my leg, I was trying to go to the bathroom in my room. I only have one kidney so as soon when I have to go to the bathroom I have to go. I went to stand up to go to the bathroom and I slipped on water that was on the floor, fell and hurt my right leg.”

When the aide returned, she found the resident had managed to get out of the low bed and was now lying on the floor, having slipped on the water spill. The aide’s witness statement confirmed that “when I returned the resident was on the floor and couldn’t move her leg.” The resident’s own statement corroborated that she “slipped when she got up to use the bathroom.”

The fall resulted in severe injuries. The facility’s incident report noted that “upon assessment the resident was unable to bend her right leg without significant pain and the resident was unable to bear weight.” A nursing note documented that the resident was found “lying on the floor in her bedroom in a supine position” and was “unable to bend her right leg without significant pain which renders her unable to attempt to bear weight.”

Hospital X-rays revealed the extent of the damage: “Acute comminuted and displaced distal femur fracture extending to the articular surface of the knee.” The medical report detailed that the injury involved “acute comminuted fractures involving the distal femoral diaphysis and extending to the articular surface” with “the distal fracture fragment displaced posteriorly by half a shaft width” and “impaction of the fracture fragments.” This complex fracture required surgical intervention, and the resident underwent “ORIF (Open Reduction and Internal Fixation) surgery” to repair the break with metal hardware.

The resident was hospitalized for five days and later showed the surveyor her surgical scar. The incident investigation identified “potential contributing factors” as “wet floor” and noted that the “resident is impulsive – did not wait for staff to clean up floor.”

When questioned about the incident, the aide acknowledged her error in judgment. When asked “if she thought she should have done anything different,” the aide stated, “I would have had someone stay with the resident.” The facility administrator confirmed this was the appropriate response, stating that she “talked to the aide about the resident’s fall and told her that she should have stayed with the resident and put the call light on until someone came to clean up the water so the resident would not have got up and fell.”

The facility’s own fall prevention policy required staff to “assess the patient care environment routinely for extrinsic risk factors and institute appropriate corrective action.” The policy emphasized preventing falls by “recognizing multi-factional risk and causes” and implementing “recommendations for falls prevention and management consistent with clinical practice guidelines and standards of care.” However, in this case, staff failed to follow these safety protocols by leaving a fall-risk resident alone in a room with a known hazard.

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.