Sunrise Skilled Nursing & Rehab Resident Falls, Suffers Multiple Leg Fractures After Being Left Alone on Side in Elevated Bed

The Illinois Department of Health has cited and fined Sunrise Skilled Nursing & Rehab when staff performing a wound treatment left a dependent resident alone on his side in a bed elevated 36 inches off the floor, telling him to hold onto the side rail while they retrieved supplies. The resident, who was completely dependent on staff for repositioning and had multiple serious medical conditions, could not hold on any longer after waiting for staff to return and fell to the floor, sustaining fractures to both legs including two breaks in one leg.

The resident was living at the facility with extremely serious medical conditions including bone infections in his spine, end stage renal disease requiring dialysis three times per week, diabetes, muscle wasting, stage 3 pressure ulcers, and significant weakness. Medical assessments showed the resident was cognitively intact but completely dependent on staff for most activities of daily living. Critically, assessments documented that for the resident “to roll from left to right he is dependent on staff; helper does all of the work,” meaning he could not reposition himself at all.

During a wound care treatment one morning, staff positioned the resident on his side in an elevated bed to access wounds on his back and buttocks. After the nurse finished the treatment and left the room, another staff member was changing the bed linens. The resident stated the staff member “said she needed a draw sheet because it was dirty from the wound draining on it. She said she would be right back.”

Rather than repositioning the resident safely and lowering the bed, the staff member left him lying on his side in the elevated bed. The resident described what happened: “I was holding on to the bar and was on my left side waiting. The staff left the room, but I waited as long as I could, and I just could not hold on any longer and when I let go, I fell from the bed being up high in the air to the floor. I just couldn’t hold on any longer. I think the staff forgot about me.”
The resident’s wife witnessed the incident and confirmed, “The resident was on his side and was holding on to the bar. The girl left the room, and she said she would be right back but the resident waited and waited and he could not hold on any longer and the bed was up really high, and he fell and broke both of his legs with one leg have two fractures.”

Another nursing assistant stated, “I looked in the room a little later and no staff was in the room. The resident was laying on his left side and the bed was not down and was high up and even then, I knew he was a fall risk. Then I heard a loud help, help and help.”

The facility’s incident report claimed the “resident rolled out of bed,” making no mention of him being left alone on his side in an elevated bed. After the fall, staff gave the resident pain medication and sent him to his scheduled dialysis appointment rather than seeking immediate emergency evaluation. The resident stated, “I feel like they should not have left me like that and should have sent me to the hospital right away.”

The dialysis nurse immediately recognized something was seriously wrong. Her notes documented: “Patient arrived to dialysis with complaints for pain to bilateral lower extremities. Patient stated he fell out of bed prior to coming to the facility and the bed was elevated. Pain too high to do treatment.” She called 911, and emergency services transported the resident to the hospital.

Hospital records revealed serious injuries: acute left distal tibial fracture, acute left distal fibular fracture, acute fracture of the distal right tibial bone, and acute fracture of the neck of the 2nd metatarsal of the right foot. The resident had multiple broken bones in both lower legs and was hospitalized for two weeks.

When the resident returned to the facility, the trauma was evident. Progress notes documented that when staff helped him into bed, the resident “became very agitated and yelled ‘hey watch my legs! Don’t move them!’ The resident hollered ‘no it’s not ok!'” He was fitted with plastic splints and boots extending up to his knees on both legs.

Health inspectors measured the resident’s bed in the elevated position at 36 inches from the floor—three feet high. Multiple staff members confirmed that leaving a resident in this situation violated basic safety standards. The Director of Nursing stated, “I would expect staff to never leave any resident unattended or left laying on their side. I would expect staff to reposition the resident, so they are safe, go and get what they needed and then return. I would not expect staff to leave a resident with the bed up, laying on their side.”

The facility’s investigation was inadequate, failing to address the root cause—lack of supervision and failure to lower the bed. The resident’s care plan also had no fall prevention interventions despite his obvious vulnerability.
This incident represents a fundamental failure in basic nursing care. A completely dependent resident who could not reposition himself was left alone on his side in a bed elevated three feet off the floor, expected to hold himself in position while staff left to retrieve supplies. The result was a catastrophic fall causing multiple fractures to both legs and a two-week hospitalization. The facility compounded this harm by failing to send the resident immediately to the hospital.

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.