The Illinois Department of Health has cited and fined Alden Estates of Orland Park when a resident with moderate dementia on a locked memory care unit was left without adequate supervision, fell twice in a short period, and sustained a head laceration requiring staples on the first fall and a fractured femur on the second. Staff were aware the resident was impulsive and prone to attempting to stand and walk unassisted, yet failed to maintain the visual oversight her condition required.
The resident lived on the facility’s locked dementia unit and came with a serious set of risk factors: a diagnosis of dementia with psychotic disturbances, a history of falling, orthostatic hypotension and syncope. Her cognitive assessment documented moderate dementia, with severely impaired decision-making. She frequently tried to get up and walk on her own without calling for help, and staff were well aware of this behavior. Progress notes from the days surrounding the incidents describe her as restless, agitated, crying, yelling at staff, and repeatedly attempting to stand up unassisted despite redirection.
The first fall occurred when the resident, who had been seated in her wheelchair at the nurses’ station, made her way undetected into a staff-only room — a nurses’ closet that required a keypad code to enter and was meant to remain closed at all times for exactly this reason. She apparently entered when a staff member left the door open. Inside, she attempted to use the bathroom, stood up from her wheelchair, lost her balance, and fell. She was found on the floor with bleeding from the back of her head. She was transported to the hospital by ambulance, where a half-centimeter laceration was closed with two staples. A nurse who reviewed the incident said simply: “Someone must have left the door open.”
Shortly after, the resident fell again — this time in the dining room during dinner, with multiple staff present. She had been brought to the dining room in her wheelchair and her wheels were locked. Despite this, according to staff accounts, she pushed herself up from the chair, maneuvered around the wheelchair, and began walking around the table on her own. A staff member noticed her standing and immediately turned to set down a food tray before moving to assist her. By the time she turned back, the resident had already fallen. No staff member witnessed the actual fall. She was found on the floor near her table, with visible swelling to her left leg and pain rated at 8 out of 10. She was transported to the hospital, where an X-ray confirmed a midshaft left femur fracture.
The pattern across both incidents was the same: a resident known to be impulsive, restless, and prone to attempting to stand without assistance was not kept within consistent visual range of staff. The facility’s own memory care coordinator acknowledged that during mealtimes, there was no staff member designated specifically to monitor the dining room — staff were occupied passing out trays and attending to other residents’ needs. A nurse stated that if a resident was trying to get up and ambulate, that would warrant one-to-one monitoring. The nurse practitioner said she would expect staff to be within close visual range and to intervene when this resident exhibited those behaviors. Neither happened.
The facility’s fall management policy required individualized assessment of each resident’s specific risk factors and implementation of preventive interventions tailored to those risks. The care plan did include an intervention added after the first fall to monitor the resident for attempts to get out of her chair and redirect her accordingly. But monitoring and redirection are only effective when staff are close enough to act in time — and on both occasions, they were not.
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 Illinois 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.
