The Illinois Department of Health has cited and fined Prairieview Lutheran Home when a resident died following staff’s failure to adequately assess her injuries after a fall and their improper use of a mechanical sit-to-stand lift. The facility’s neglect in monitoring the resident’s worsening bruising and bleeding, despite her being on blood thinners, resulted in massive blood loss that required emergency surgery and ultimately led to her death.
The resident in question suffered from multiple serious health conditions, including Alzheimer’s disease, morbid obesity, a history of strokes, and severe cognitive impairment. The resident was completely dependent on staff for all daily living activities and was taking blood thinners.
In mid-August, the resident fell while walking to the bathroom with staff assistance. She complained of hip pain and was found to have bruises on her right ear, jawline, and right elbow. However, staff never measured the bruises or conducted a complete baseline assessment of her injuries. Despite the fall, the facility’s restorative nurse updated the resident’s transfer status that same evening to require use of a sit-to-stand lift with two staff members assisting, but no assessment was documented to determine if this lift was appropriate or safe for her condition.
Over the following weeks, the resident’s weekly skin assessments failed to track the progression of her bruising. Some assessments only noted “scattered bruising” without documenting specific locations or measurements. The right elbow bruise was mentioned only once. Meanwhile, multiple staff members observed that the resident disliked the sit-to-stand lift, complained it hurt her, and would tell staff to put her down. She could not stand fully upright in the lift, instead bending her knees and slouching, which caused the sling to bear weight under her armpits. Staff knew she could only tolerate standing in the lift for brief periods and had to be moved quickly, yet none of this was reported to nurses or the restorative staff.
About a month after the fall, in late September, nursing assistants discovered extensive bruising on the resident while preparing her for bed. The bruising extended from her sternum across and under her right breast and under her right arm, matching the pattern of the sit-to-stand lift strap. The resident reported pain and had limited range of motion in her right arm. The nurse contacted the medical director, who was informed the resident was on blood thinners, but he only instructed staff to monitor the area as long as there was no bleeding. Critically, he did not order the blood thinner to be held, and the nurse did not check on the resident again that night or re-measure the bruising.
The next morning, another nurse discovered the bruising had dramatically expanded, now extending from the midline of her chest to her mid-back and down her right arm to her armpit. When the nurse called the medical director, he said he had already stopped the blood thinner and asked what more the nurse wanted him to do. However, the resident had actually received her blood thinner medication that morning before breakfast—the nurse had given it before seeing the full extent of the bruises. The nurse ordered a chest X-ray, but before it could be performed, the resident’s condition deteriorated rapidly. She became very pale, was short of breath, and began dry heaving. The bruising had grown even larger, now extending up her chest along her bra strap line and appearing on multiple areas including her shoulders, neck, and over both ribcages.
The resident was sent to the emergency room, where a CT scan revealed significant soft tissue injury and a large bleeding pocket of blood extending from her right shoulder into her upper arm and right chest wall. Her blood count was critically low—less than half of normal levels—indicating severe blood loss. She received multiple blood transfusions and underwent emergency surgery to stop arterial bleeding in her chest and arm. The interventional radiologist who performed the procedure stated the injury was consistent with blunt force trauma from a sit-to-stand lift and could not have been caused by something minor. He believed if the resident had been sent to the emergency room the night before, when the bruising was first discovered, she would not have died so soon.
The resident returned to the nursing home less than a week later, was placed on hospice care, and died approximately two weeks after being hospitalized. Her death certificate listed the cause of death as metabolic encephalopathy due to blood loss anemia due to chest wall hematoma—meaning her body’s systems failed because of the massive blood loss from the bleeding in her chest wall.
The investigation revealed multiple critical failures. The facility’s restorative nurse admitted she had no assessment process to determine when a sit-to-stand lift was appropriate, and the resident was never evaluated by therapy staff to ensure safe use of the lift. The physical therapist confirmed she had not worked with the resident on sit-to-stand transfers. Staff reported concerns about the resident’s inability to properly use the lift, but these concerns were never communicated to nursing leadership. When contacted, the medical director acknowledged that if he had known the extent of the bruising, he might have held the blood thinner and sent the resident to the emergency room immediately. He stated he expected more than one assessment per shift when he said to “monitor,” but this did not occur.
A housekeeper also came forward during the investigation, stating she had noticed bruising on the resident’s neck, collarbone, face, and wrist on a morning in late August or early September and that an unidentified nursing assistant told her the resident had fallen out of the stand lift that morning. However, the housekeeper did not report this because she was “just a housekeeper.” One nurse speculated the resident may have fallen forward while using the sit-to-stand lift on the day before the severe bruising was discovered, but no fall was ever reported.
The health department determined this constituted an immediate jeopardy—the most serious level of violation—because the
facility’s failures directly caused the resident’s death. The immediate jeopardy began on the date of the initial fall in August and was identified during the survey in early November. After the facility implemented extensive corrective measures, including new assessment protocols, staff education, monitoring policies for residents on blood thinners, and quality assurance programs, the immediate jeopardy was removed, though noncompliance remained because additional time was needed to evaluate whether the changes would be effective.
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.
