The Illinois Department of Health has cited and fined Aliya of Glenwood when, according to state investigators and facility records, a resident identified as high risk for falls with impaired mobility and poor safety awareness was not safely positioned on his bed while a certified nursing aide provided incontinence care, and he rolled off the elevated bed and fell face down onto the floor. The resident sustained a displaced right orbital fracture — a break in the bone surrounding the eye — and a fracture of the second cervical vertebra in his neck.
The resident had been admitted to the facility days earlier with diagnoses including morbid obesity, anemia, and metabolic encephalopathy. His hospital paperwork from just before admission documented weakness, pain, decreased endurance, decreased strength, decreased range of motion, decreased cognition, and impaired gait and balance. His fall risk assessment on admission scored him at high risk, and his care plan identified him as high risk for falls related to impaired mobility, weakness, and high-risk medications. His admission evaluation contained somewhat mixed findings on his mobility: it described him as independent with bed mobility, while also documenting that he was unable to sit on the edge of the bed with little or no support and was not independent in transferring from sitting to standing. A rehabilitation screening completed the day before the fall identified problems with safety concerns, limited range of motion, bed mobility, transfers, and locomotion. A subsequent assessment completed after the fall documented that he required partial to moderate assistance to roll from left to right and was dependent on staff for going from sitting to standing.
On the day of the fall, a nurse saw the resident’s call light on and entered the room with a certified nursing aide. The nurse found the bed sheet was wet and asked the aide to change the resident. According to the nurse’s account to investigators, she intended to assist with the care and stepped out of the room to gather supplies. She said she was only a few feet from the room when the aide came to the door to tell her the resident had fallen.
The certified nursing aide told investigators she assisted the resident onto his side and began providing incontinence care. According to her written statement, while she reached back for a towel, the resident reached for his cell phone and rolled off the bed. She confirmed the bed had been elevated to working height at the time of the fall. She also told investigators she was unsure how much assistance the resident required for care.
The resident was found face down on the floor with a laceration to his right toe and a bump to his forehead. He was sent to the hospital, where imaging documented an acute displaced comminuted blowout fracture of the right orbit with bruising beneath the eye, hemorrhagic contusions to the forehead and scalp, and an acute minimally displaced fracture at the second cervical vertebra. According to the hospital record, the resident reported he was turning in bed and thought a nurse was there to help him turn, but no one was there and he fell out of bed.
The facility’s restorative nurse told investigators what should have happened. She explained that residents are assessed for bed mobility and transfers, and that a care card is placed above the bed documenting whether the resident is a one-person or two-person assist. She stated that if staff are unsure of a resident’s transfer or bed mobility needs, they should use two staff members for safety. She further stated that staff are instructed and expected to gather all supplies before starting care and keep them within reach, that residents should be positioned to the center of the bed when being turned to prevent them from getting too close to the edge, that staff should ensure residents are positioned correctly before rendering care, and that staff should stay with residents while providing care. The facility’s MDS coordinator separately confirmed that a resident coded as requiring partial to moderate assistance would require one to two staff members for the task.
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.
