The Illinois Department of Health has cited and fined Aliya on 87th in Chicago when a resident classified as high fall risk fell in the facility’s dining room when the only staff member present in the dining room at the time became occupied assisting another resident, leaving the high-risk woman unsupervised. The fall resulted in the resident sustaining an acute subdural hematoma to the left frontotemporal region of her head and a right eye hematoma, serious injuries that required hospitalization and were followed by a subsequent emergency transfer when the resident became unresponsive days later.
The resident, a woman with a medical history that included cerebrovascular disease, delirium, difficulty walking, and an unspecified lack of coordination, was admitted to the facility and assessed for fall risk shortly after arrival. She scored a 23 on the facility’s fall risk assessment, where any score of 10 or above is considered high risk. She was assessed as mildly cognitively impaired, with a Brief Interview of Mental Status score of 10. She was also documented as requiring extensive staff assistance with all transfers and used a wheelchair for mobility. Despite this high-risk classification, the resident’s care plan contained only minimal interventions. According to state investigators, the care plan stated only to “keep room free of clutter” and “round at a minimum of 2 hours.” The facility’s own restorative nurse explained that appropriate high fall risk interventions should include “floor mats in place, increased rounding, high staff supervised area such as dining room during activities because the expectation is to monitor them frequently.”
On the day of the fall, the resident was in the dining room during lunch. A certified nursing assistant had been assigned to monitor residents in the dining room but was the only staff member present. While cutting up food for another resident, the CNA heard someone call out that the woman was standing up. The CNA stated that “by the time she got to” the resident, “she had already fallen.” The facility’s Director of Nursing provided a different account of how the monitoring lapse occurred, stating that the resident’s assigned CNA “was asked to help feed a resident” and that “as she went to feed another resident, she took her eyes off” the high-risk woman. Regardless of which account is more precise, both confirm that no staff member was watching the resident when she attempted to get up out of her wheelchair without assistance and fell. A fellow resident who witnessed the fall provided a written statement that read, “I was sitting in the back eating my lunch. I looked over and she was leaning on the side of her wheelchair again after the CNA helped her to scoot back. Next thing I know is she was on the floor.” The resident was found on the dining room floor with mild swelling to both sides of her face.
The resident was sent to the hospital, where she was diagnosed with an acute subdural hematoma overlying the left frontotemporal region of her head and a right eye hematoma. Doctors ordered a repeat CT scan of the head to monitor the injury. The resident was eventually discharged back to the facility about a week later. Upon her return, the facility added her to its “fall star program” as an additional intervention — an acknowledgment that more should have been done from the start, but one that came only after the resident had already suffered a serious brain injury.
Just two days after her return, the resident experienced what staff described as a seizure while sitting in her wheelchair in the cafeteria. A nurse reported that the resident “slumped over in her chair” and was moved to a Geri chair to prevent further slumping. The nurse notified the doctor about the resident’s uncontrolled tremors and was told to monitor her through the night. Her vitals were normal at that time. However, by the following day, the resident’s condition had deteriorated significantly. A nurse practitioner assessed the resident and found that while she was breathing and had a pulse, she “was not responsive to stimuli.” When staff performed a sternal rub, the resident responded only by pushing the hand away. She was sent back to the hospital for further evaluation. The nurse practitioner noted that signs and symptoms of subdural hematoma can include “change in mental status, not responding to physical or verbal stimuli, involuntary muscle movement,” and seizures — symptoms consistent with what the resident had been exhibiting since her return. The nurse practitioner stated that “subdural hematomas are typically caused from some sort of injury” and that while spontaneous cases can occur, “they are usually from some sort of injury.”
The facility’s Director of Nursing confirmed during the investigation that the fall occurred in the dining room, not in the resident’s bedroom as initially reported by some staff. The Director acknowledged that when the assigned CNA left to help another resident, “another staff member or the nurse should have monitored” the high-risk woman, but noted that “the nurse was at her medication cart in the hallway.” A nurse who cared for the resident after her return also told investigators that she did not recall the resident having “floor mats or seizure preventative bed bolsters” in place — basic safety measures that were absent despite the resident’s documented history of falls and now a diagnosed subdural hematoma. The facility’s own fall prevention policy states that the facility “will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible” and that “residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize 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.
