The Illinois Department of Health has cited and fined Aliya of Crestwood when, according to state investigators and facility records, an 88-year-old resident at high risk for falls suffered an unwitnessed fall in his room and remained on the floor for a prolonged period before staff discovered him, despite his roommate activating the call light after hearing him fall. The state issued an Immediate Jeopardy citation, the most serious level of violation, and the county medical examiner determined the resident’s cause of death was the fall and complications of his spinal injuries.
The resident had been admitted to the facility roughly a week earlier following a hospitalization for a fall at home with seizure activity. His records documented encephalopathy, generalized muscle weakness, cognitive impairment, seizures, and repeated falls. His admission evaluation classified him as high risk for falls due to impaired memory and judgment, a history of falls, unsteady gait, and incontinence, and his care plan called for rounding at a minimum of every two hours, keeping the call light within reach, and moving him to a room with optimal visual access from the nurses’ station. Investigators later measured the distance from the nurses’ station to his room at 108 feet, and the Director of Nursing acknowledged that no room on that unit could be seen into from the nurses’ station.
The resident’s roommate, who investigators noted was cognitively intact, described what he witnessed. He told investigators he heard a sound, saw the resident on the floor, and pressed his call light — checking the clock and noting it was around four in the morning. He said no one came. In his own words: “My roommate’s head was near my bed, and blood was coming from his head. No one was coming. I did try to yell for help, but I was in a lot of pain. They didn’t come for like 2 hours. I looked at the clock, and it was almost 6:00am.” He added: “How can you let a man just lie there and die.”
According to the citation, the facility’s call light system did not produce an audible alert at the nurses’ station. Multiple staff members told investigators the sound had not been working, in one nurse’s account, for years — meaning staff had to physically walk the halls and visually check each door to see whether a light was on. A certified nursing aide was stationed at the nurses’ station monitoring two other high fall risk residents and told investigators she could not leave those residents to answer call lights. The facility’s maintenance director confirmed there was no system to monitor how long a call light had been active, and the Administrator acknowledged there was no process to verify that rounding was being completed, stating: “That’s what I pay them to do. I mean, I would hope they are doing it.”
The resident was found on the floor unresponsive and bleeding from a head wound. Staff initiated CPR and called 911. The ambulance report documented that staff said the event was unwitnessed, that they had walked into the room and found him pulseless, and that staff were unable to provide an exact time he was last seen alive. Hospital imaging identified a left frontal scalp and periorbital hematoma, an acute L1 vertebral body fracture with mild retropulsion, an acute fracture at C7 with widening of the C7 to T1 disc space concerning for ligamentous injury, and rib fractures. He was resuscitated but never regained consciousness, and his family transitioned him to comfort-focused care. He died that afternoon.
The facility offered differing explanations for the cause of the fall in successive incident reports. Its initial incident report concluded the fall was secondary to cardiac arrest; a later report attributed it to acute bilateral pulmonary embolisms, cardiogenic shock, and a heart attack. Both attributed the spinal and rib fractures to chest compressions and the use of a mechanical CPR device. Investigators found problems with that account. The fire department’s EMS coordinator told investigators the department does not own the mechanical CPR device the facility named, and the ambulance run sheet did not document that any mechanical CPR device was used. More significantly, the county medical examiner — a forensic pathologist who completed the medical review of the death — told investigators the rib fractures were consistent with chest compressions, but that the cervical and lumbar fractures were not. When asked directly whether a CPR machine could have caused those fractures, he stated: “Absolutely not.” He confirmed the cause of death, as stated on the death certificate, was the fall and complications of spinal injuries, and stated he believed there was a chance the resident would be alive today had he not sustained the fall in the facility.
Investigators also documented significant gaps in the facility’s emergency response and its own records. The nursing supervisor who responded to the code told investigators he assessed for a pulse using a pulse oximeter rather than palpating the carotid artery, acknowledged he should have used the carotid artery, and when asked how to assess respirations stated he did not know how. Staff accounts of the timeline conflicted with one another and with the medical record — the nurse’s stated time of last seeing the resident was not documented anywhere in his progress notes, and there was no documentation that certified nursing aides provided any care to him during the entire overnight shift. The last documented care was the prior evening.
The resident’s attending physician told investigators he had not been informed the resident died, saying: “Oh… I did not know. They did not notify me.” The facility’s Medical Director stated he had only learned of the incident days before the survey and had not been involved in any root cause analysis, telling investigators: “I think a delay in assessing the resident is the problem and is a big issue. If it took that long, that’s on the facility. That’s bad.” Investigators separately identified a second resident whose call light was found not working, not attached to the wall, and missing the battery required for it to function.
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.
