The Illinois Department of Health has cited and fined Pleasant View Luther Home when an 82-year-old resident with Alzheimer’s disease and a history of multiple falls suffered a serious neck fracture after tripping over another resident’s oversized wheelchair in a poorly arranged dining room. The facility failed to provide adequate space for the high fall risk resident to safely navigate around obstacles, despite knowing he was prone to falls and required his walker for safe mobility.
The resident in question, who had experienced multiple previous falls and was described as “impulsive” and someone who “gets up by himself,” was seated at a dining room table in an extremely confined space. Staff described the seating arrangement as problematic, with a wall directly behind the resident’s chair and a large water cooler to the left. To make matters worse, another resident with an oversized wheelchair was positioned next to him, creating a dangerous obstacle course that made safe exit nearly impossible.
Multiple staff members witnessed the incident and described the hazardous conditions that led to the fall. One Certified Nursing Assistant explained that the resident “was trying to leave the table going from the left side and there was not enough room for him to go through, he tripped over the wheelchair.” She noted that the other resident’s “wheelchair wheels are huge when she sits on the side of the table where the wall is there is not enough room to get by.” The space was so narrow that during the investigation, a surveyor “could not walk through the space going forward” and had to “turn her body to the side to fit through the space.”
Another staff member described how the resident “stepped over the other resident’s wheelchair, tripped and fell landing on his right side.” She explained that the other resident’s “wheelchair wheels stick out a lot in the back, her wheels were almost touching the water cooler located behind her. There was not enough room for him to walk through.” The cramped conditions forced the high fall risk resident to attempt dangerous maneuvers to navigate around the obstacles.
The Registered Nurse on duty provided additional details about the dangerous seating arrangement, stating that “the other resident’s wheelchair was positioned at an angle, the resident tried to go over the wheelchair and he was not able to get through without stepping over the wheelchair wheel.” She noted that the resident’s “walker was against the wall, there was not enough space behind his chair for the resident to use his walker,” making it impossible for him to use his required mobility aid safely.
The fall resulted in serious injuries requiring immediate emergency room evaluation. Staff reported that the resident “fell on his right side hitting his head on the floor, he had a good size abrasion to his forehead” and “threw up immediately after falling.” Hospital imaging revealed a C1 fracture, a serious injury to the first cervical vertebra that could have been life-threatening. The resident also sustained a “superficial abrasion to right side of forehead” and complained of “right shoulder pain and head pain.”
This incident was particularly troubling given the resident’s documented fall history and known risk factors. His Fall Risk Assessment showed he was a “HIGH fall risk, has a weak gait and overestimates or forgets limits.” Staff acknowledged that the resident “had numerous falls, he does not pay attention, he shuffles when he walks, is impulsive and gets up by himself” and noted he “had a previous incident of tripping over a chair.” Records showed previous falls on multiple occasions, yet the facility continued to place him in dangerous seating arrangements.
Staff members recognized the problem after the incident, with one noting that the resident “should have been placed at the end of the table where he had room to use his walker when he got up, he used to sit at the end of the table.” Another staff member confirmed that “since the incident we place the other resident on the opposite of the table so she’s not blocking the space,” acknowledging that the dangerous arrangement was preventable.
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.