The Illinois Department of Health has cited and fined Warren Barr Orland Park when a nursing assistant improperly turned a 380-pound bedridden resident away from herself during personal care, causing the resident to roll off the bed. The fall resulted in a severe fracture requiring surgical repair with screws and metal hardware.
The resident in question had been living at the facility for nearly three years. She had multiple serious medical conditions including functional quadriplegia, severe obesity with a body mass index between 50-59.9, muscle wasting, and reduced mobility. Her medical history included a severe COVID-19 infection that led to prolonged hospitalization and complete loss of her ability to walk or stand. Hospital records noted she “has not stood or walked in over a year and has since experienced significant weight gain and progressive immobility.”
The resident was completely dependent on nursing staff for all aspects of daily care. Her care plan documented that she required “extensive assistance of 2 staff with mobility and transfers” and noted she was “non ambulatory at this time.” For bed mobility specifically, her care plan stated she “requires extensive assist of 1 staff participation to reposition and turn in bed, and scooting towards head of bed” due to weakness in both legs. However, most recent assessments showed she was actually “dependent” for rolling in bed, meaning “helper does ALL the effort” or “the assistance of 2 or more helpers is required.”
At the time of her fall, the resident weighed 380 pounds and was 5 feet 9 inches tall. She was bedridden and required assistance with all personal care activities including changing incontinence briefs and toileting needs.
The incident occurred during the early morning hours when a nursing assistant was providing personal care to the resident. According to the resident’s account, the nursing assistant was changing her incontinence brief and “was standing on the right side of [the resident’s] bed, and [the nursing assistant] turned [the resident] away from her.” The resident stated she warned the nursing assistant, telling her “her leg is going to fall,” but the staff member “stood there and removed the soiled brief, and her leg slid off the bed.”
The resident described falling “on her knees with her butt sticking up in the air” after her leg went over the side of the bed. She explained that “my leg slid over the bed while the CNA was turning me and I rolled off the bed.”
However, the nursing assistant provided a different account of the incident. She claimed that the resident “turned herself towards the door” and “as [the resident] was turning herself, one of her legs pulled out of the bed and [the resident] was on the floor.” The nursing assistant insisted “she did not touch [the resident]” and denied that the resident warned her about her leg falling.
Multiple facility staff members who were interviewed confirmed that proper procedure was not followed. The facility’s Therapy Director stated unequivocally: “Staff should not roll residents away from them.” She explained that given the resident’s weight of 380 pounds, “if [the resident’s] leg started going off the side of her bed, she couldn’t have stopped it…at 380 pounds the momentum would carry her leg over.”
The Assistant Director of Nursing, who investigated the incident, reinforced this point: “You should not push a resident away from you in bed. You have more control of the patient if you roll them toward you.” She noted that the resident had full range of motion in her arms but “not a whole lot” of range of motion in her legs, and importantly, “nobody was on that opposite side of the bed” to prevent the resident from falling.
After the fall, the resident remained on the floor until six paramedics arrived to assist her onto a stretcher for transport to the hospital. Medical examination revealed she had sustained “a comminuted, supracondylar distal femur fracture with intra-articular extension into the lateral condyle” – a complex break in her thigh bone near the knee that extended into the joint.
The injury required surgical repair, and when surveyors visited the resident after her return to the facility, she reported that her stitches had been removed and “there were three screws in her right knee.” The resident noted the impact on her quality of life, stating her “left leg has arthritis, and now her right knee was broken.”
This incident represents a violation of basic nursing care principles. The facility’s own policies required staff to provide appropriate care to meet residents’ needs, yet the nursing assistant failed to follow established safety procedures for turning a severely mobility-impaired resident.
The resident’s care plan documentation showed she had been assessed as needing either extensive assistance from one staff member or total dependence requiring two staff members for bed mobility, yet she was being turned by a single nursing assistant who used an unsafe technique. The facility’s Restorative Licensed Practical Nurse confirmed that the resident had “never been on a bed mobility program” despite her significant limitations, and had been using a full-body mechanical lift for transfers for approximately two years.
The incident resulted in a preventable injury that caused significant pain and required major surgical intervention for a vulnerable resident who was already dealing with multiple serious health conditions and complete loss of mobility.
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.
