The Illinois Department of Health has cited and fined The Haven of Paris when a resident with severe dementia and Lewy Body disease fell and fractured his left hip after staff failed to provide the required supervision for high fall-risk residents. Despite facility policies requiring checks every 15 minutes for residents at high risk for falls and elopement, staff were checking on the resident only every two hours or less, resulting in an unmonitored seven-and-a-half-hour period before his fall.
The resident in question had a diagnosis of Neurocognitive Disorder with Lewy Bodies, a form of progressive dementia that affects thinking, movement, behavior, and mood. His mental status assessment showed severe cognitive impairment with a score of five out of 15, indicating he was alert and oriented only to his own name but not to place or time. He had a history of wandering and walking aimlessly without purpose, and was classified as both a high fall risk and at risk for elopement (wandering away from the facility).
In addition the resident had poor safety awareness, a shuffling gait, weakness, and poor balance. Staff noted he “frequently gets up on his own without calling for help” and would often get up to get coffee on his own. His care plan documented he was “at risk for falls related to impaired cognition, poor safety awareness, dementia, shuffling gait, and weakness.”
Just weeks before the hip fracture, the resident had already suffered another unwitnessed fall that resulted in a fracture to his left shoulder, a laceration beside his left eye, and a skin tear to his left elbow. Despite this serious fall and the injuries sustained, the facility’s supervision procedures were not adequately implemented.
On the day of the fall, records show the resident was last checked on and repositioned at 8:22 in the morning. The fall occurred at 3:50 in the afternoon—a gap of approximately seven and a half hours with no documented supervision. A nursing assistant who was at the nurses’ station stated she “was filling out paperwork at the desk and then got up to go to the bathroom and saw that the resident was walking out of his bathroom and begin to lose balance and went down to the floor.”
In a phone interview, the same nursing assistant stated she “looked up and noticed the resident coming out of his neighbor’s room” when he “lost his balance and fell.” When asked for more details, the assistant stated “I don’t know what time the fall happened or the last time I saw the resident, and I don’t have anything else to tell you.”
An x-ray confirmed the resident had sustained an acute intertrochanteric fracture of the left femur (hip) with soft tissue swelling. He was transported to the hospital for treatment and later returned to the facility. When interviewed after his fall, the resident did not remember the fall or that he had broken his hip, and complained of pain in his groin area on the left side.
The facility had clear policies requiring enhanced supervision for high-risk residents. The Director of Nursing stated “staff are responsible for doing rounds every two hours unless a resident is a high fall risk and then they should be checked more frequently (every 15 minutes), and this should be on the Care Plan.” The MDS Coordinator confirmed that “15-minute checks (increased visuals) are implemented for those residents that have been determined to wander or who are at risk for elopement.”
The Assistant Director of Nursing stated “residents that are a high risk for falls or high elopement risk should be checked on every 15 minutes” and acknowledged “the CNAs should have been checking on the resident at minimum every two hours and that it should be documented.” However, she “could not provide documentation showing the resident had been checked on appropriately” on the day of the fall.
The registered nurse caring for the resident that day stated the resident “has dementia, was alert and oriented to person only and frequently would get up on his own” and confirmed “the CNAs should have been checking the resident every two hours if not more frequently.” The Director of Nursing ultimately confirmed that “staff were not checking on the resident every 15-minutes even though he was a high fall risk.”
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.
