The Illinois Department of Health has cited and fined Bridgeway Senior Living in Bensenville when a nursing assistant propped a thick mat against one side of a severely cognitively impaired resident’s bed and positioned the other side against a wall heater to trap her in bed, causing the resident to crawl out over the footboard and fall, fracturing her hip. The facility failed to investigate how the fall occurred and never interviewed the nursing assistant who had created the dangerous situation.
The resident in question was admitted to the facility with dementia, congestive heart failure, a history of falling, and chronic kidney disease. Her assessment showed she was severely cognitively impaired and needed assistance with activities of daily living including supervision with eating, partial assistance with oral hygiene and dressing, substantial assistance with bathing and transfers, and was dependent on staff for toileting.
The resident’s fall prevention care plan included specific interventions added after previous falls. Following a fall with no injury in February, staff were instructed to “get resident up early in the morning when awake and keep by the nurse’s station.” After another fall in May that resulted in a fractured wrist, an additional intervention was added: “when observed awake keep her engaged in the common area until ready to go back to bed.” The director of nursing explained the resident “liked to be active and move around and when she is awake it is best to keep her in an area where staff can see her.”
During the night shift, at 11:15 PM on her first rounds, the nursing assistant found the resident sitting on a thick mat that was positioned next to the bed. The nursing assistant stated “the height of the mat was almost equal to the height of the bed.” She assisted the resident, who was awake and alert, back into bed. Then she made a dangerous decision.
The nursing assistant explained what she did next: “She then took the thick mat and propped it up, adjacent to the right side of the bed and the left side of the bed was against the heating unit which was attached to the wall with the window.” She stated she “had boxed the resident into the bed so she wouldn’t get up and fall.” The resident was now trapped in bed with a propped-up mat on one side and a wall heater on the other side, with no safe way to get out.
Around 2:15-2:20 AM, the nursing assistant checked on the resident again. The resident was awake but not moving around, and the mat was still propped in place against the right side of the bed. The nursing assistant began her next rounds around 4:20 AM but started on the opposite end of the hall from where the resident’s room was located.
At 5:25 AM, when the nursing assistant finally reached the resident’s room, she found the resident “lying on the floor on her right side in a fetal position with her head at the foot of the bed.” She stated “the propped-up mat was still in place” and explained the resident “must have crawled or scooted out of the end of the bed over the footboard and then fell on the floor.” The resident was complaining of right hip pain and stated she had hit her head.
The nursing assistant summoned the registered nurse, who was passing medications in the hallway. The nurse assessed the resident and found her complaining of right hip pain. The nurse called 911, the physician, and the family to notify them of the fall and the resident’s pain complaints. The resident was transported to the hospital by ambulance at 5:50 AM.
X-rays at the hospital showed the resident had sustained “a mildly comminuted displaced right femoral intertrochanteric fracture” – a right hip fracture where the bone was broken into pieces and displaced. The resident’s physician stated “the likely cause of the resident’s hip fracture was the fall that occurred” that morning.
When interviewed, the nursing assistant acknowledged she “works on all the units in the facility” but stated she “was not sure of what the resident’s care plan interventions to prevent falls were.” The care plan clearly specified the resident should be kept in common areas where staff could see her when she was awake – the exact opposite of trapping her alone in her room with barriers on both sides of her bed.
The nursing assistant also revealed that “no facility staff had interviewed her as of yet as to how the resident had fallen.” The director of nursing confirmed days after the fall that she “had not spoken to the nursing assistant regarding the cause of the resident’s fall” and stated she “was unsure if the restorative nurse had spoken to” her either. This meant the facility failed to investigate the circumstances of the fall despite having a policy requiring staff to identify causes of falls.
The resident’s physician was clear about the danger of what the nursing assistant had done. He stated that “the resident having barriers on both sides of the bed would be an unsafe situation, especially due to the resident being cognitively impaired.”
The facility’s own policy titled “Evaluating Falls and Their Causes” required that “residents must be evaluated for potential causes of falls immediately” and that “within 24 hours of fall, the nursing staff will begin to try to identify possible or likely causes of the incident.” The policy specified staff should evaluate “the chain of events or circumstances proceeding a recent fall” including “the activity the resident was engaged in” and “whether there were environmental factors involved.” Despite this clear policy, the facility never interviewed the nursing assistant who had created the dangerous barrier situation that caused the fall, and failed to conduct a proper investigation into how and why the resident ended up on the floor with a fractured hip.
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.
