Recent Amputee Fractures Remaining Leg After Being Left Unattended in Bed at Bella Terra Streamwood

The Illinois Department of Health has cited and fined Bella Terra Streamwood when staff left an 84-year-old resident with dementia and a recent leg amputation unattended on a bed, resulting in a fall and femur fracture that required surgical repair. The facility failed to provide adequate supervision and implement appropriate fall prevention measures for a high-risk resident who had just returned from the hospital following an above-knee amputation.

This case involves an 84-year-old resident with multiple complex medical conditions including dementia, heart failure, severe morbid obesity, and a recent right above-knee amputation. The resident fell while being left unattended in her room, resulting in an “oblique fracture of left femur” that required surgical intervention.

According to hospital records, the resident “fell in facility” and “had pain in the left thigh last couple of days when admitted and x-rays to left femur demonstrate distal third femoral shaft fracture.” The surgeon noted that “she recently had an AKA (Above Knee Amputation) on the right side, so she needed her left side to transfer to wheelchairs therefore decision was made to undergo open reduction intramedullary nailing of the left femur.”

The facility’s Fall and Psychotropic Nurse, who conducted an internal investigation of the incident, stated that a Certified Nursing Assistant (CNA) had left the resident unattended on her bed. When asked if the CNA should have left the resident alone, the nurse acknowledged, “Yes, but she wasn’t left unattended very long.” The nurse further explained that the CNA “should have prepared the supplies prior to propping the resident up to clean her and not leave her unattended.”

When interviewed, the CNA provided conflicting information about the incident. Initially, she stated she was “reaching for a pad” at the doorway when she heard the resident scream, but later admitted, “My linen cart was in the hall outside the door, but you can say I left her unattended, but it was very fast.” The CNA also acknowledged she had limited knowledge about the resident, stating, “When I was working with her, I was not familiar with her at all, and no one told me whether she was a fall risk or not. No one told me anything about her at all.”

An agency nurse who was working that night confirmed that the resident was found “on the floor at the foot of the bed with her head under the footboard part.” The nurse also indicated she had not received proper information about the resident’s condition, stating, “I did not get any endorsement about [the resident] or that she came back with an amputated knee. I just knew she recently got back from the hospital, but I didn’t know for what.”

The resident’s roommate, who was determined to be cognitively intact, reported being “awakened around midnight when [the resident] was screaming loudly.” She confirmed seeing the CNA enter the room to take the resident’s gown off and then seeing the same CNA again when the resident started screaming.
The resident’s attending physician emphasized that the facility should have taken extra precautions due to the resident’s multiple risk factors, stating she “had dementia, severe morbid obesity, and was a recent leg amputee which made her more at risk and unstable (poor trunk control).”

A review of the resident’s fall prevention care plan revealed it had not been updated since nearly a year before the incident, despite her recent hospitalization and amputation. Only after the fall and fracture was her care plan updated to reflect her “recent hospitalization with surgical intervention, right AKA (Above Knee Amputation), recent fall with fracture to left femur.”

The facility’s fall prevention policy specifically states staff should “Pay close attention to residents at high risk for falls” and emphasizes the importance of anticipating residents’ needs and ensuring proper assistance with mobility. However, in this case, the facility failed to adequately communicate the resident’s high-risk status to staff, properly update her care plan following her amputation, and ensure appropriate supervision was maintained during care activities.

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.