Resident Suffers Hip Fracture After Being Over-Sedated to Prevent Wandering At Duquoin Nursing & Rehab

The Illinois Department of Health has cited and fined Duquoin Nursing & Rehab when a 92-year-old resident with severe dementia was given excessive doses of sedating psychiatric medications to prevent her from wandering, causing her to become unsteady and fall. The resident suffered a hip fracture requiring surgery after facility staff increased her anti-anxiety medication despite nurses’ warnings that the drugs would make her more likely to fall.

The resident in question entered the nursing facility with severe dementia, anxiety disorder, and major depression. Despite significant cognitive impairment, she was initially able to walk independently around the facility and had no recent history of falls. She was prescribed anti-anxiety medication on an as-needed basis for episodes of anxiety or agitation.

The critical incident occurred when the resident escaped the facility early one morning. Security alarms activated around 6:30 AM, and staff discovered she had left the property. A staff member followed her but when police were called, the resident fled and remained missing for approximately three hours before being found in a garage behind a local business. She was taken to the hospital for evaluation and returned to the facility.

Following this incident, facility staff became concerned about preventing future wandering attempts and contacted the physician to discuss medication changes. The physician initially ordered a powerful antipsychotic medication called Risperidone at 1 milligram for one-time use. However, this medication carries serious FDA warnings that “elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death” and is “not approved for use in patients with dementia-related psychosis.”

When staff attempted to give the resident this medication, she strongly refused, stating “I am not taking that medication; I am a nurse, and you all are not doing that to me.” After various failed attempts, family members arranged for a police officer friend to visit the facility. The officer convinced the resident to take the medication when she wouldn’t take it for anyone else.

Almost immediately after taking the antipsychotic, staff observed alarming changes in the resident’s condition. She appeared “sluggish with her eyes halfway open” and was described as being “sort of out of it” with increased confusion and slurred speech. She reported feeling “really tired” the following day.

Due to these concerning effects, the physician discontinued the antipsychotic the same day but increased the resident’s anti-anxiety medication (Xanax) to three times daily at a higher dose. This occurred despite FDA warnings that elderly patients should receive “the smallest effective dose” to prevent unsteadiness and over-sedation.

Several nurses expressed serious concerns about these medication changes. One licensed practical nurse stated she “told the doctor that [the resident] would end up falling” and explained that “you cannot give those drugs to residents that ambulate because it causes them to be unsteady.” Despite these professional warnings from nursing staff, the medications were continued.

The sedating effects became immediately apparent as the resident became unsteady on her feet. Staff began keeping her in a wheelchair for safety. An activity aide providing one-on-one supervision noted that before the medications, the resident “moved pretty fast” but afterward “became more sluggish” and was “mostly in a wheelchair” due to safety concerns.

On the day of the fall, the resident had been kept in a wheelchair throughout the day due to her medication-induced unsteadiness. While sitting near the nurses’ station wanting to make a phone call, her supervising aide briefly left to retrieve the resident’s cell phone. During this absence, the resident stood up, took a few steps, lost her balance, and fell to the floor. The aide returned just as she was falling but couldn’t prevent it.

The resident landed on her right side and immediately complained of severe hip pain. She was transported to the hospital where X-rays revealed a fractured hip requiring surgical repair with hardware implantation. The facility’s own incident report acknowledged that the root cause was “lack of balance and proprioception” – exactly the side effects nursing staff had warned about.

When questioned, the facility physician acknowledged the dose of antipsychotic was “a dangerous dose” for the resident and admitted he typically starts with one-quarter of that amount. He also stated “I don’t usually use Benzo’s in geriatrics because it can affect their gait” and when asked if the Xanax contributed to the fall, responded “Yes, it is a high probability.”

Family members confirmed they noticed the resident was “sort of out of it and really sleepy” and “more drowsy than normal” after the medication changes. The investigation revealed no evidence that alternative non-drug approaches to managing wandering behavior were attempted before resorting to high-dose psychiatric medications, despite facility policies requiring such approaches. This incident demonstrated the potentially devastating consequences of inappropriate psychiatric medication use in elderly nursing home residents with dementia.

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.