The Illinois Department of Health has cited and fined Axiom Healthcare of West Frankfort when, according to state investigators and facility records, a resident with Parkinson’s disease and a long history of falls sustained a closed fracture of the left orbit and left maxilla after the facility failed to consistently implement the fall prevention interventions documented in his care plan. The resident had fallen at least sixteen times in the three months leading up to the injury, and investigators repeatedly observed during the survey that documented fall interventions — including keeping the call light within reach and wrapped with yellow tape — were not being followed.
The resident was a cognitively intact man with Parkinson’s disease, muscle wasting, and a need for assistance with daily care. According to the citation, he had a documented brain bleed from a prior fall before the events described in the survey, and his care plan listed more than two dozen interventions designed to reduce his fall risk over a period of several months. These included keeping the call light within reach and wrapped in yellow tape as a visual reminder, ensuring the bed was kept in the lowest position, moving him closer to the nurses’ station, conducting 15-minute checks, providing grippy socks and proper footwear, and assisting him with all transfers.
Over the course of approximately three months, the facility’s own fall investigation reports documented at least sixteen separate falls — sometimes more than one in a single day. Multiple falls involved the resident leaning forward out of his wheelchair, attempting to retrieve items off the floor on his own, transferring without staff assistance, or being unable to wait for help. After one fall the resident hit his chin on the floor and broke teeth. After another the staff documented they could not locate the resident’s broken teeth in the room.
On the morning that resulted in his serious facial injury, a nurse found the resident on the floor beside his bed without footwear in place. The initial assessment found no injuries and the resident denied hitting his head. The nurse applied grippy socks, returned him to bed, and began neurological checks. Approximately two hours later, a follow-up note documented small swelling to the resident’s left cheek. Several hours after that, the swelling had progressed to left-sided facial and orbital swelling and bruising, and the resident reported head and neck pain. He was sent to the hospital, where imaging confirmed a closed fracture of the left orbit and a closed fracture of the left maxilla. Several days later he was sent to the hospital again after another fall, where imaging incidentally revealed an old thoracic spine fracture of unknown origin.
During the survey, investigators directly observed multiple instances in which the documented fall interventions were not being followed. On separate occasions over several days, investigators observed the resident’s call light placed out of reach — on top of a nightstand, on top of positioning devices, and approximately four feet from where the resident was lying. The yellow tape that was supposed to be wrapped around the call light as a visual reminder was not observed on any of these occasions. The resident’s door was repeatedly observed closed, with no staff in the room. Investigators also witnessed the resident wheel himself out of the dining room with no staff in sight, get his wheelchair caught on a doorway, stand up from his wheelchair, become tangled in his catheter tubing, and walk down the hallway with an unsteady gait pushing his wheelchair from behind — without any staff assistance observed by investigators. A housekeeper was the first to call out for staff to help. It took approximately one minute for three staff members to respond.
A licensed practical nurse told investigators directly that the resident has a lot of falls, especially on the night shift, that he seems like a different person at night, and acknowledged that on some bad nights the 15-minute checks might not all get done. The Assistant Director of Nursing told investigators she was not aware any residents were currently on 15-minute checks, that she would expect the resident’s call light to be in reach when he is in bed, that she would expect his door to be open unless staff were in the room providing care, and that he was supposed to have yellow tape around his call light so he could find it easier. The MDS coordinator stated she was trying to come up with new fall interventions for the resident and other residents, but acknowledged she did not know if the interventions she had put in place were working.
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.
