The Illinois Department of Health has cited and fined Oak Park Oasis when a high fall-risk resident with multiple medical conditions fell while attempting to clean up spilled water without proper supervision, resulting in a hip fracture that required emergency surgery. The facility failed to provide adequate oversight despite the resident’s documented need for assistance and known tendency to walk without his required mobility device.
The resident in question, a man in his early sixties, was living at the facility with numerous serious medical conditions including ataxia (loss of muscle coordination), epilepsy, gait and mobility problems, schizoaffective disorder, diabetes with nerve damage, and heart failure. Medical assessments showed he had moderate cognitive impairment and required supervision or assistance when moving from bed to chair and while walking. He used a walker as his primary mobility device and was classified as being at high risk for falls.
The facility had established detailed care plans recognizing the resident’s fall risk, stating he was “at risk for falls related to confusion, gait/balance problems, poor communication/comprehension” and various medications. The plan specifically required staff to “be sure the resident’s call light is within reach and encourage the resident to use it for assistance as needed” and ensure “prompt response to all requests for assistance.” An additional care plan noted his “decreased strength, poor balance, impaired ambulation” and required implementation of “fall precautions per facility protocol.”
On the day of the incident, the resident fell in the hallway near his room while attempting to clean up spilled water. When a registered nurse heard him calling for help, she found him “sitting on the hallway floor, right by his room, leaning against the wall, with one of his legs stretched forward.” The resident told the nurse “he saw spilled water on the floor and was trying to wipe it.” Critically, the resident did not have his required walker with him at the time of the fall.
The nurse who responded noted that the resident “was not able to get up on his own” and observed that he “was not able to move his left leg and it was in extended position.” She found that the resident “was in a lot of pain, especially when trying to move his leg.” Despite these clear warning signs of a serious injury, the facility’s response was inadequate and delayed.
After the fall, the attending physician was contacted and ordered an X-ray, but there were significant delays in obtaining the diagnostic imaging. The responding nurse admitted, “I called the diagnostic company, and I was told they’ll come out to do an x-ray but didn’t say when” and “I didn’t check on the resident nor reassessed the resident’s pain before the end of my shift. The x-ray company didn’t come before I left. I didn’t follow up with the diagnostic company.”
The situation became more concerning the following day when another nurse discovered that the diagnostic company claimed they had “no order for the resident’s x-ray.” This nurse had to place a new STAT X-ray order, and the imaging wasn’t completed until later that day. During this extended period, the resident remained in significant pain and was unable to move his left leg, with nursing notes documenting a “greenish purple bruise noted on the left hip” and “pain level 5/10.”
By the second day after the fall, the facility’s Director of Nursing finally recognized the severity of the situation. When she observed the resident “lying in bed stating, ‘it’s hard for me to stand up it hurts,'” she instructed staff that “when a resident has a change in condition and cannot walk whereas he walked before, nurses should send them out to the hospital.” The resident was finally transported to the hospital, where medical imaging revealed “a moderately displaced and angulated fracture of the left femoral neck.” He required emergency surgery, specifically a “left femoral neck hemi-arthroplasty,” essentially a partial hip replacement.
Several critical factors contributed to this preventable incident. The Director of Nursing explained that the resident had obsessive-compulsive disorder and was “trying to clean and rearrange the room all the time.” She noted that staff “would find him walk without the walker all the time” and that “the resident didn’t use a call light or ask for assistance.” The director explained that “the resident’s fall occurred because the resident was trying to clean up after his roommate and there was spilled water on the floor. The resident has an ‘obsession’ with cleanliness.”
Despite knowing about these behavioral patterns that put the resident at additional risk, the facility failed to provide adequate supervision. On the day of the incident, staffing was inadequate, with only one certified nursing assistant covering an area that normally required two staff members. This assistant was responsible for conducting rounds “at least every two hours” but admitted she didn’t think the resident “was at risk for fall” and didn’t remember “any special interventions that we had to do for the resident,” despite his documented high-risk status.
Even more concerning, the registered nurse who worked the day shift and found the resident after his fall claimed she was unaware of his fall risk status. She stated, “I’m not sure if the resident was at high risk for falls before the incident, so I’m not sure if the resident had any fall prevention interventions.” This statement directly contradicted the resident’s documented care plans and risk assessments that were supposed to be known to all nursing staff.
The attending physician explained that signs of a hip fracture include “complaining of pain, bruising, deformity, and affected range of motion, such as extended leg.” He emphasized that when residents have continuous pain “not managed by over-the-counter medications, they should be sent out to the hospital.” The physician also noted the serious long-term consequences, stating that “a broken hip with subsequent surgery would affect a resident acutely” and “there could also be long lasting effect, such as chronic pain and change in the range of motion.”
When health inspectors later visited the facility, they observed troubling conditions in the resident’s room. They found the resident lying in bed with his “room dark, call light out of the resident’s reach,” violating basic safety requirements outlined in his care plan. The resident told inspectors, “Yeah I fell, I hurt my hip. I’m not sure when or how it happened,” demonstrating his continued confusion and the lasting impact of the incident.
The facility had written policies requiring a comprehensive fall prevention program, stating that “safety interventions will be implemented for each resident identified at risk using a standard protocol” and that “all nursing personnel will be informed of residents who are at risk of falling.” However, the evidence clearly showed these policies were not being followed, as key staff members were unaware of the resident’s risk status and failed to implement required safety measures.
This case represents a clear failure in the facility’s duty to protect a vulnerable resident. Despite having comprehensive knowledge of the resident’s fall risk factors, behavioral patterns, and specific need for supervision, the staff failed to implement adequate safety measures. The delayed medical response compounded the harm, as the resident endured unnecessary pain and delayed treatment for a serious fracture that required surgical intervention and will likely affect his quality of life permanently.
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.
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