The Illinois Department of Health has cited and fined Alden Estates of Orland Park when a 79-year-old resident with dementia and Alzheimer’s disease fell in the dining room while left unmonitored, suffering a fractured hip that required hospitalization. The facility failed to follow the resident’s care plan which specifically required visual supervision and removal from common areas after meals.

The resident in question had been admitted to the facility in February with multiple serious diagnoses including chronic hepatic failure, hepatic encephalopathy, anemia, Alzheimer’s disease, type 2 diabetes, COPD, depression, anxiety, hypertension, and dementia. Her cognitive functioning was severely impaired, with a Brief Interview for Mental Status score indicating she was “alert and oriented times one to two spheres” and required partial to moderate assistance with activities of daily living. Her fall risk assessment documented multiple concerning factors including an unsteady gait, use of ambulatory devices, confusion, previous falls within the prior three months, and use of medications affecting thought processes and causing hypotensive effects. The assessment clearly identified her as at risk for falls with a score indicating significant danger.

A Licensed Practical Nurse who was covering for the regular nurse during a break stated she had walked past the dining room and observed the resident sitting in her wheelchair at a table with her back to the door, with lunch already concluded and no food trays remaining in the room. The covering nurse then sat down at the nurse station across from the dining room, from which position she acknowledged she could not actually see the resident. A few minutes later, two staff members approached and informed her the resident was on the floor in the dining room. When the nurse assessed the situation, she found the resident lying on her right side between two tables with her head toward the wall and her feet pointed outward. The resident winced and complained of pain when her back was touched during examination.

Emergency services transported the resident to the hospital where X-rays revealed “sclerosis the femoral neck” and “suspicious for an impacted nondisplaced right femoral neck fracture” with the impression of a “probable nondisplaced femoral neck fracture.” Another staff member who discovered the resident described finding her on her back on the floor with no other residents or staff present in the dining room. He reported the resident attempted to get up several times but could not, and he believed she had stood up from her wheelchair causing it to roll backward since the wheels were not locked, which he said “often” happened with this resident.

The resident’s care plan, which had been initiated at admission, specifically documented interventions to prevent falls. The plan stated the goal was the resident “will remain free of falls through next review” and included detailed instructions such as ensuring appropriate use of her wheelchair, monitoring for changes in her ability to navigate the environment, providing proper footwear, and critically, the directive to “remove resident from common areas after completion of her meal” and “do not leave in room in wheelchair without supervision/monitoring.” Multiple staff members confirmed during interviews that the resident frequently needed to be redirected and asked to sit down in her wheelchair because she could fall, and that she often stood up from her chair and sat back down, which would cause the wheelchair to roll backward if the wheels were not locked.

The covering nurse admitted she was not aware the resident was at risk for falls and that the regular nurse had not given her any report before taking her break. She stated there was “no solid rule that someone must be in the dining room to monitor the residents” and that they could be monitored from the nurse station, yet she also acknowledged she did not see the resident fall while supposedly monitoring the dining room.

In contrast, the Director of Nursing acknowledged during her interview that “if the residents are in dining room staff should be there to monitor the residents” and that “the staff should be able to see all the residents when monitoring the dining room.” She stated that if she had to do things differently, she would have staff bring residents out of the dining room after lunch to sit near the nurse station for proper observation. The Director suggested the root cause of the fall was that the resident was likely trying to take herself back to her room after lunch “as she often did,” which was precisely the type of unsupervised activity her care plan was designed to prevent.

Following the incident, the facility implemented corrective measures including reviewing all fall-risk residents and their care plans within days of the fall, conducting in-service training for all nursing staff on fall management and prevention, specifically training staff on resident supervision during and after dining, developing a quality assurance audit tool for dining room supervision, and holding an emergency quality assurance meeting with the interdisciplinary team and Medical Director to approve the corrective action plan.

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.

The Illinois Department of Health has cited and fined Lutheran Care Center Altamont when a hospice resident fell headfirst to the floor after a mechanical lift strap broke during transfer by a single nursing assistant instead of the required two staff members, causing a head injury and rapid decline that led to her death three days later. The facility violated its own policy requiring two staff present during mechanical lift transfers due to weekend staffing shortages.

The resident in question was admitted under hospice care with heart failure, stroke, pneumonia, and respiratory failure. She was completely dependent on staff for all care including transfers. Her care plan required “transfers using mechanical lift and 2 staff assist.”

During a morning transfer, a nursing assistant was alone using a mechanical lift when “the strap broke and the resident fell to the ground headfirst hitting her head.” The incident report documented: “Right blue upper strap broke with resident over the floor. She fell out of sling laying on her right side x 2 raised areas on upper back of head and 1 raised area on upper right side of head.”

The responding nurse found the resident “still alert as her normal” with knots on her head and right arm bruising. Initial vital signs showed respirations 32 and oxygen saturation at 84%.

The resident’s condition rapidly deteriorated. She developed respiratory distress and “had 2 large emesis undigested food” with pulse 130 and oxygen level at 88% even with supplemental oxygen. Hospice ordered comfort medications. By the next midnight, nursing notes documented: “Resident opens both eyes, no verbal response, grimaces with touch. Pupils sluggish. No response when asked to squeeze hands. 7 centimeter round soft area to upper crown of head.”

By afternoon: “Resident non to minimal responsive. Does not open eyes, pupils sluggish.” The following morning, she was “non-responsive, bilateral extremities flaccid.” Early the next morning, a nurse found her “no audible pulse, no audible blood pressure, respirations ceased.” She died three days after the fall.

The hospice nurse stated directly: “Yes definitely” the fall contributed to death. “She had a rapid change in condition that consisted of a change and decrease in her level of consciousness, she began to have vomiting, and inability to eat and keep food down.” When asked if the resident was at end-of-life prior to the fall: “I do not feel like she was at that point prior to the fall. She was not in the condition yet that I would have talked with the resident’s family to inform them that death was near or even a month away.”

The facility physician confirmed: “With a head injury to a resident of her age it is never good.” When told the hospice nurse felt the fall attributed to death, he stated: “I have to agree with Hospice on that statement.”

The administrator stated: “We know the fall caused the change in condition and death of the resident.”
The nursing assistant admitted “using 1 staff member for mechanical lifts was not unusual on the weekends due to staffing shortage but she will never do that again.”

The facility’s policy required “2 staff members to maintain resident’s safety during transfers.” The facility’s report acknowledged: “In our initial report, it was reported that there were 2 CNAs present. During our investigation, it was noted that there was one CNA at the time of the transfer and fall.”

The death certificate listed cause of death as “respiratory failure with hypoxia.” The coroner stated she “was unaware of the resident falling out of a mechanical lift causing a head injury that led to death” and that “the death certificate should have cause of death was accidental.”

The facility violated its policy requiring two staff members during mechanical lift transfers due to weekend staffing shortages. A hospice resident who hospice confirmed was not at the end of life suffered a traumatic head injury when dropped headfirst from a lift and died three days later.

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.

The Illinois Department of Health has cited and fined Bridgeway Senior Living in Bensenville when a nursing assistant propped a thick mat against one side of a severely cognitively impaired resident’s bed and positioned the other side against a wall heater to trap her in bed, causing the resident to crawl out over the footboard and fall, fracturing her hip. The facility failed to investigate how the fall occurred and never interviewed the nursing assistant who had created the dangerous situation.

The resident in question was admitted to the facility with dementia, congestive heart failure, a history of falling, and chronic kidney disease. Her assessment showed she was severely cognitively impaired and needed assistance with activities of daily living including supervision with eating, partial assistance with oral hygiene and dressing, substantial assistance with bathing and transfers, and was dependent on staff for toileting.

The resident’s fall prevention care plan included specific interventions added after previous falls. Following a fall with no injury in February, staff were instructed to “get resident up early in the morning when awake and keep by the nurse’s station.” After another fall in May that resulted in a fractured wrist, an additional intervention was added: “when observed awake keep her engaged in the common area until ready to go back to bed.” The director of nursing explained the resident “liked to be active and move around and when she is awake it is best to keep her in an area where staff can see her.”

During the night shift, at 11:15 PM on her first rounds, the nursing assistant found the resident sitting on a thick mat that was positioned next to the bed. The nursing assistant stated “the height of the mat was almost equal to the height of the bed.” She assisted the resident, who was awake and alert, back into bed. Then she made a dangerous decision.

The nursing assistant explained what she did next: “She then took the thick mat and propped it up, adjacent to the right side of the bed and the left side of the bed was against the heating unit which was attached to the wall with the window.” She stated she “had boxed the resident into the bed so she wouldn’t get up and fall.” The resident was now trapped in bed with a propped-up mat on one side and a wall heater on the other side, with no safe way to get out.

Around 2:15-2:20 AM, the nursing assistant checked on the resident again. The resident was awake but not moving around, and the mat was still propped in place against the right side of the bed. The nursing assistant began her next rounds around 4:20 AM but started on the opposite end of the hall from where the resident’s room was located.

At 5:25 AM, when the nursing assistant finally reached the resident’s room, she found the resident “lying on the floor on her right side in a fetal position with her head at the foot of the bed.” She stated “the propped-up mat was still in place” and explained the resident “must have crawled or scooted out of the end of the bed over the footboard and then fell on the floor.” The resident was complaining of right hip pain and stated she had hit her head.

The nursing assistant summoned the registered nurse, who was passing medications in the hallway. The nurse assessed the resident and found her complaining of right hip pain. The nurse called 911, the physician, and the family to notify them of the fall and the resident’s pain complaints. The resident was transported to the hospital by ambulance at 5:50 AM.

X-rays at the hospital showed the resident had sustained “a mildly comminuted displaced right femoral intertrochanteric fracture” – a right hip fracture where the bone was broken into pieces and displaced. The resident’s physician stated “the likely cause of the resident’s hip fracture was the fall that occurred” that morning.

When interviewed, the nursing assistant acknowledged she “works on all the units in the facility” but stated she “was not sure of what the resident’s care plan interventions to prevent falls were.” The care plan clearly specified the resident should be kept in common areas where staff could see her when she was awake – the exact opposite of trapping her alone in her room with barriers on both sides of her bed.

The nursing assistant also revealed that “no facility staff had interviewed her as of yet as to how the resident had fallen.” The director of nursing confirmed days after the fall that she “had not spoken to the nursing assistant regarding the cause of the resident’s fall” and stated she “was unsure if the restorative nurse had spoken to” her either. This meant the facility failed to investigate the circumstances of the fall despite having a policy requiring staff to identify causes of falls.

The resident’s physician was clear about the danger of what the nursing assistant had done. He stated that “the resident having barriers on both sides of the bed would be an unsafe situation, especially due to the resident being cognitively impaired.”

The facility’s own policy titled “Evaluating Falls and Their Causes” required that “residents must be evaluated for potential causes of falls immediately” and that “within 24 hours of fall, the nursing staff will begin to try to identify possible or likely causes of the incident.” The policy specified staff should evaluate “the chain of events or circumstances proceeding a recent fall” including “the activity the resident was engaged in” and “whether there were environmental factors involved.” Despite this clear policy, the facility never interviewed the nursing assistant who had created the dangerous barrier situation that caused the fall, and failed to conduct a proper investigation into how and why the resident ended up on the floor with a fractured hip.

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.

The Illinois Department of Health has cited and fined Sunrise Skilled Nursing & Rehab when staff performing a wound treatment left a dependent resident alone on his side in a bed elevated 36 inches off the floor, telling him to hold onto the side rail while they retrieved supplies. The resident, who was completely dependent on staff for repositioning and had multiple serious medical conditions, could not hold on any longer after waiting for staff to return and fell to the floor, sustaining fractures to both legs including two breaks in one leg.

The resident was living at the facility with extremely serious medical conditions including bone infections in his spine, end stage renal disease requiring dialysis three times per week, diabetes, muscle wasting, stage 3 pressure ulcers, and significant weakness. Medical assessments showed the resident was cognitively intact but completely dependent on staff for most activities of daily living. Critically, assessments documented that for the resident “to roll from left to right he is dependent on staff; helper does all of the work,” meaning he could not reposition himself at all.

During a wound care treatment one morning, staff positioned the resident on his side in an elevated bed to access wounds on his back and buttocks. After the nurse finished the treatment and left the room, another staff member was changing the bed linens. The resident stated the staff member “said she needed a draw sheet because it was dirty from the wound draining on it. She said she would be right back.”

Rather than repositioning the resident safely and lowering the bed, the staff member left him lying on his side in the elevated bed. The resident described what happened: “I was holding on to the bar and was on my left side waiting. The staff left the room, but I waited as long as I could, and I just could not hold on any longer and when I let go, I fell from the bed being up high in the air to the floor. I just couldn’t hold on any longer. I think the staff forgot about me.”
The resident’s wife witnessed the incident and confirmed, “The resident was on his side and was holding on to the bar. The girl left the room, and she said she would be right back but the resident waited and waited and he could not hold on any longer and the bed was up really high, and he fell and broke both of his legs with one leg have two fractures.”

Another nursing assistant stated, “I looked in the room a little later and no staff was in the room. The resident was laying on his left side and the bed was not down and was high up and even then, I knew he was a fall risk. Then I heard a loud help, help and help.”

The facility’s incident report claimed the “resident rolled out of bed,” making no mention of him being left alone on his side in an elevated bed. After the fall, staff gave the resident pain medication and sent him to his scheduled dialysis appointment rather than seeking immediate emergency evaluation. The resident stated, “I feel like they should not have left me like that and should have sent me to the hospital right away.”

The dialysis nurse immediately recognized something was seriously wrong. Her notes documented: “Patient arrived to dialysis with complaints for pain to bilateral lower extremities. Patient stated he fell out of bed prior to coming to the facility and the bed was elevated. Pain too high to do treatment.” She called 911, and emergency services transported the resident to the hospital.

Hospital records revealed serious injuries: acute left distal tibial fracture, acute left distal fibular fracture, acute fracture of the distal right tibial bone, and acute fracture of the neck of the 2nd metatarsal of the right foot. The resident had multiple broken bones in both lower legs and was hospitalized for two weeks.

When the resident returned to the facility, the trauma was evident. Progress notes documented that when staff helped him into bed, the resident “became very agitated and yelled ‘hey watch my legs! Don’t move them!’ The resident hollered ‘no it’s not ok!'” He was fitted with plastic splints and boots extending up to his knees on both legs.

Health inspectors measured the resident’s bed in the elevated position at 36 inches from the floor—three feet high. Multiple staff members confirmed that leaving a resident in this situation violated basic safety standards. The Director of Nursing stated, “I would expect staff to never leave any resident unattended or left laying on their side. I would expect staff to reposition the resident, so they are safe, go and get what they needed and then return. I would not expect staff to leave a resident with the bed up, laying on their side.”

The facility’s investigation was inadequate, failing to address the root cause—lack of supervision and failure to lower the bed. The resident’s care plan also had no fall prevention interventions despite his obvious vulnerability.
This incident represents a fundamental failure in basic nursing care. A completely dependent resident who could not reposition himself was left alone on his side in a bed elevated three feet off the floor, expected to hold himself in position while staff left to retrieve supplies. The result was a catastrophic fall causing multiple fractures to both legs and a two-week hospitalization. The facility compounded this harm by failing to send the resident immediately to the hospital.

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.

The Illinois Department of Health has cited and fined Clark-Lindsey Village when a certified nursing assistant left a high fall-risk resident unattended on the toilet to fix her bed, resulting in the resident falling and sustaining multiple acute fractures to her left arm. Despite facility policies requiring constant supervision during toileting for fall-risk residents, the nursing assistant admitted he knew the resident should not have been left alone but left her anyway to perform other tasks.

The resident was living at the facility with numerous serious medical conditions including a history of falling, anxiety disorder, difficulty walking, cognitive communication deficit, heart failure, atrial fibrillation, chronic respiratory failure, and pulmonary hypertension. Medical assessments showed the resident had moderate cognitive impairment and was completely dependent on staff for toileting hygiene tasks. Assessments also documented that the resident required substantial to maximal assistance from staff when moving from a sitting to standing position.

The facility had conducted a fall risk evaluation that gave the resident a score of 17.0, and “a score of ten or higher indicates that the resident is at high risk for falls.” The resident’s care plan, recognizing this significant fall risk, documented that the resident “is at risk for falls related to deconditioning” and required staff to “follow facility fall prevention guidelines.” The care plan also specified that certified nursing assistants were to “maintain proactive contact with residents to anticipate needs.”

In the early morning hours, the resident needed to use the toilet. A certified nursing assistant brought her to the bathroom and placed her on the toilet. However, instead of remaining with the resident as required by facility protocols, the nursing assistant left her alone to perform another task. According to the incident report, the nursing assistant “stated that he was just in her room to fix her bed while she was in the bathroom.”

Left unattended on the toilet, the resident attempted to care for herself. The incident report documents that the resident “stated that she voided and was going to get a wipe and stand on her own and fell on her left arm.” The resident, who required maximal assistance to move from sitting to standing and had severe cognitive impairment, tried to stand by herself because no one was there to help her.

The consequences were significant. The incident report describes that when the nursing assistant returned, he found the resident had fallen and her “left arm was bent with obvious signs of deformity and bruising and that the resident could not move it and stated it was painful.” The resident was sent for X-rays, which revealed severe trauma: “Acute comminuted displaced fracture involving the left humeral head/neck with soft tissue swelling. Acute comminuted displaced angulated fracture involving the proximal third shaft of the left humerus with soft tissue swelling.” In simpler terms, the resident sustained multiple broken bones in her upper left arm and shoulder area, with the bones displaced and broken into multiple pieces, accompanied by significant swelling.

When health inspectors visited the facility, they found the resident “lying flat on her back in bed and a brace is on her left arm.” The resident confirmed “she had a fall, broke her arm and it is painful.”

During the investigation, multiple staff members at every level acknowledged that this fall should never have happened. A certified nursing assistant told inspectors that “when a resident has a known fall risk they should never be left unattended when they are sitting on the toilet.” The nursing assistant who left the resident alone admitted his error, stating “he knew the resident was a fall risk and should not have left the resident alone on the toilet.”

The registered nurse on duty confirmed the standard of care, stating “she would expect that all CNAs should not leave a resident unattended on the toilet if they were a fall risk.” A licensed practical nurse emphasized the seriousness of the lapse, noting “it was well known, and it is documented that the resident is at risk for falls and that the resident should not have been left unattended on the toilet.”

Perhaps most telling was the statement from the facility’s former Director of Nursing, who was in that position at the time of the incident. She stated plainly that “the resident’s outcome would have been different if the nursing assistant would have stayed at the resident’s side while she was on the toilet to prevent the resident from falling.” This acknowledgment from the facility’s top nurse confirms that this injury was entirely preventable and resulted directly from the failure to follow basic safety protocols.

This case illustrates a clear failure to implement established care plans and safety protocols. The facility had properly assessed the resident’s fall risk, documented her need for assistance, and created a care plan requiring supervision. However, these safeguards were meaningless when the nursing assistant chose to prioritize making a bed over staying with a vulnerable resident who required constant supervision.

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.

The Illinois Department of Health has cited and fined Manor Court of Rochelle when staff failed to properly monitor a resident with severe dementia after an unwitnessed fall at 3 a.m., neglecting to notify the physician or conduct required neurological checks. The resident remained in severe pain throughout the night without follow-up care, ultimately requiring emergency hospitalization the next morning when staff discovered she had suffered a left hip fracture.

The resident in question was living at the facility with multiple serious conditions including anxiety, arthritis, severe dementia with agitation, and insomnia. Medical assessments confirmed she was severely cognitively impaired. Prior to the incident, the resident walked slowly and steadily with her walker and rarely used a wheelchair.

The facility had established a care plan recognizing the resident’s significant fall risk, documenting that she “has a history of falls prior to admission and is at risk for falling related to poor safety awareness, doesn’t use the call light and has a diagnosis of Dementia.” The care plan specifically required staff to “observe frequently and place in supervised area when out of bed” and indicated the resident “requires assistance of one with walker or ambulation.” A nursing assistant confirmed that the resident “is not supposed to walk around by herself.”

In the early morning hours, the resident was last documented as being in the unit living room with other residents. An hour later, she had somehow made her way to the dining area where she fell while walking alone with her walker. Critically, no documentation was found explaining “why the resident was ambulating unsupervised in the dining room at 3 a.m. in the morning,” despite the care plan requirements for frequent observation and supervision.

When a certified nursing assistant discovered the resident, she called the agency registered nurse on duty. The nurse arrived to find the resident “seated on the floor against a chair which is by the wall.” When asked what happened, the resident explained “she had been walking around with her walker and fell.” The nurse helped the resident into a chair and took her vital signs, which were within normal ranges.

According to the nurse’s documentation, the resident was “alert and oriented” with “skin intact with no wounds or openings. No injuries noted.” However, the resident complained of “pain to back and side.” The nurse’s notes indicated she “gave pain medication to the resident and later escorted to her room,” noting “no limping” as the resident walked with her walker.

The failures in care became apparent during investigation. The nurse supervisor who later reviewed the incident confirmed critical deficiencies: the nurse “did not complete neurological checks and did not notify the physician of the resident’s fall.” Additionally, “there was no follow up documentation of the resident’s complaints of back and side pain and there was no medication administration documentation that pain medication was administered.”

These omissions directly violated the facility’s own written policies, which clearly stated: “If a fall is unwitnessed, notify the physician and initiate neurological checks at least every four hours for twenty four hours, or until stable, or as otherwise ordered by the physician.”

The consequences became clear the following morning. When the day shift licensed practical nurse arrived, certified nursing assistants immediately told her “there was something wrong with the resident.” The nurse recalled they stopped her in the hallway before she had “barely had time to take off my coat.” She went directly to the resident’s room and found her refusing to get up “due to ‘extreme pain’ at left hip/thigh area.” The nurse stated the resident was in “severe pain” and was “most likely in pain all night.”

The day shift nurse quickly recognized the emergency. She stated, “I didn’t know what was wrong with the resident but she needed to be sent out.” She contacted the physician to request X-rays, notified the resident’s power of attorney and the facility administrator, and arranged emergency transport.

Only after making these urgent arrangements did the day shift nurse receive any report about the fall. When she finally spoke with the agency nurse, all she was told was that “the resident fell and was put back in bed. Nothing else.” The day shift nurse stated, “I did not receive any nurse/shift report regarding the resident’s fall until after I was told by my dayshift CNAs that there was something wrong with the resident.”

The resident was transported by ambulance to the hospital where X-rays confirmed she had suffered a left hip fracture from her fall.
After the incident, health inspectors observed the resident sitting in a wheelchair during a church group activity with her head down, appearing to be sleeping—a stark contrast to her previous ability to ambulate with her walker.

This incident represents multiple, compounding failures in resident care. The facility failed to ensure adequate supervision of a resident with severe dementia who required constant observation. When the fall occurred, the nurse on duty failed to follow basic medical protocols including notifying the physician and conducting neurological assessments. The nurse failed to properly document and follow up on the resident’s pain complaints, leaving her to suffer through the night. There was also a breakdown in communication between shifts, as the incoming nurse received very little information about the serious incident that had occurred hours earlier.

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.

The Illinois Department of Health has cited and fined Meadowbrook Manor – Naperville when a resident with severe cognitive impairment and eight previous unwitnessed falls in his room had a ninth unwitnessed fall that caused a brain injury, massive seizure, and ultimately his death. Despite the resident’s care plan requiring increased supervision and monitoring to prevent self-transfers, staff left him alone in his room where he fell again while they were in the dining room.

The resident in question was admitted to the facility with multiple serious conditions including a history of falls, previous traumatic brain bleeding, vascular dementia with moderate agitation, hallucinations, unsteadiness on feet, difficulty walking, and cognitive deficits. His assessment showed he was severely cognitively impaired and required staff assistance with transfers. His medical record did not show any history of seizures.

The resident’s care plan, created shortly after admission, identified him as being at risk for falls related to “confusion, deconditioning, gait and balance problems, poor comprehension, unaware of safety needs, dementia, hallucinations, and recurrent falls.” The care plan included multiple interventions designed to prevent falls, specifically including instructions to “conduct rounds,” “toilet resident and place in dining room, hallways or nurses’ station for more visual supervision,” and “increase supervision in the room. Monitor any attempt of self transfer.”

Despite these care plan requirements, the resident experienced eight unwitnessed falls in his room over a seven-month period. The fall incident reports documented falls occurring regularly, with all incidents showing the resident “was trying to self-transfer in and out of his wheelchair” when he fell. Each time, staff found him on the floor after the fact, meaning no one had been present to supervise him or prevent the fall.

Around 12:35 PM on the day of the incident, the resident had his ninth unwitnessed fall in his room. He was found “sitting on the floor facing his wheelchair with his legs flexed and holding on to his wheelchair” after attempting to stand up from his wheelchair unassisted. His assigned nursing assistant stated in an incident report: “When the incident happened, I did not witness it happening. I was helping in the dining room with passing trays and feeding residents.” His assigned nurse also stated: “At the time of fall, I was at the nurse’s station. Fall not witnessed.”

A nurse assessed the resident after finding him on the floor and initiated neurological checks. The nurse later explained the resident “was at a high risk for falls because he had a known history of falls, was confused, and impulsive.” The neurological assessment appeared normal and the resident “did not appear to have any injury or change in condition.” Staff then assisted him into his wheelchair and transported him to the main dining area for lunch, where he was supervised.

Nearly three hours later, at 3:15 PM, staff noticed a bump on the right side of the resident’s head. The nurse practitioner was notified and gave orders to send the resident to the hospital for further evaluation. Routine paramedics arrived to transfer him. However, as they were moving the resident into the ambulance, he “started to have a massive seizure.” The paramedics immediately contacted emergency paramedics for additional support, and the resident was transported to the hospital.

Hospital notes documented the resident was admitted “post-fall with a suspected significant head trauma likely subdural hematoma, acute encephalopathy, seizures, and dilated left pupil and flaccid left side.” The hospital record showed the resident “remained unresponsive and family elected for hospice care.” The resident died after being admitted to inpatient hospice care without additional diagnostic testing.

The director of nursing acknowledged the resident “was monitored after his fall per protocol, and at 3:15 PM, he was noted with a bump to his head.” She stated the
resident “was admitted for altered mental status, seizure, and traumatic brain injury” and explained “the facility felt they could not determine if the resident’s acute change in medical condition was related to his fall incident because the facility elected to admit the resident into inpatient hospice care and not proceed with additional diagnostic testing.”

The director of nursing stated the resident “had a known history of recurrent falls and head trauma with an intracranial bleed” and claimed “fall incidents were investigated and fall prevention interventions were implemented in the residents’ plan of care.” However, the resident had experienced nine unwitnessed falls in his room over seven months, all involving attempts to self-transfer from his wheelchair – the exact behavior his care plan required staff to monitor and prevent.

The nurse practitioner explained she “expected facility staff to complete a root cause analysis after a resident’s fall to investigate the cause and then implement interventions to prevent reoccurrences.” The facility’s own policy stated that “if falling recurs despite initial interventions, staff will implement additional or different interventions.” Yet despite eight previous unwitnessed falls in his room with the same cause – attempting to self-transfer from his wheelchair – the facility never modified its approach to actually provide the increased supervision and monitoring his care plan required.

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.

The Illinois Department of Health has cited and fined Newman Rehab & Health Care Center when a resident who required assistance with all mobility fell and broke her hip while attempting to take herself to the bathroom because no nursing assistant was available to answer her call light. The facility left an entire hallway without a certified nursing assistant for over an hour and a half during the morning shift when residents typically need bathroom assistance.

The resident in question was admitted to the facility with chronic kidney disease, hypertension, and low back pain. Her admission assessment documented she had a “known history of falling” and was “at risk for fall.” The assessment showed she was not cognitively impaired but “requires assistance with all activities of daily living, bathing, transfers, ambulation and toilet use.” She was continent of bowel and bladder, meaning she could feel when she needed to use the bathroom.

During the night shift, the nursing assistant assigned to the resident had taken her to the bathroom three times. At 5:15 AM, when the resident stated she needed the bathroom again, the nursing assistant asked if she would like to be cleaned up and dressed for the day, and the resident agreed. This was the last time the nursing assistant provided care before her shift ended.

Shortly before 8:45 AM, the resident was heard hollering for help. She was found “on the floor of her room lying on her right side with her right arm underneath her trying to prop herself up.” The resident explained what happened: “I was trying to take myself to the bathroom because I really needed to go. I turned my call light on, but no one came to answer my call light, so I tried to take myself and ended up on the floor.”

A registered nurse was notified of the incident and placed a pillow under the resident’s head, then left to get help to lift her back into bed using a mechanical lift. The resident stated she was having pain in her right side. At 8:55 AM, the nurse gave her Tramadol for pain complaints. The resident continued having pain on her right side and was transported to the hospital by ambulance shortly after noon.

The hospital emergency room examination showed “new fracture across the right femoral neck with moderate displacement and impaction and mild varus angulation” – meaning the resident had broken her hip with the bone fragments displaced and pushed together.

When investigators questioned staff about what happened, they discovered a serious staffing problem that morning. The administrator explained that when she arrived at the facility at 8:00 AM to work as a nursing assistant, “they were having an issue with CNA’s that morning because one of the day CNA’s became sick and had to leave the facility.” The facility had called her and “asked if they could call people in and I told them yes and I would also come in and work.”
The administrator acknowledged the gap in coverage: “The resident’s hall did not have a CNA to answer call lights until 9:30 AM. This is when I was able to work on that hall as a CNA.” This meant that for over an hour and a half during the morning shift – when residents typically need the most assistance with toileting after waking up – an entire hallway of residents who required help had no one available to answer their call lights.

The resident had done exactly what she was supposed to do by turning on her call light when she needed bathroom assistance. However, with no nursing assistant available to respond, she faced an impossible choice: wait indefinitely while needing to urgently use the bathroom, or attempt to get there herself despite requiring assistance for all mobility. She chose to try to take herself and suffered a serious hip fracture as a result of the facility’s failure to ensure adequate staffing coverage during the shift change.

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.

The Illinois Department of Health has cited and fined Warren Barr Orland Park when a nursing assistant improperly turned a 380-pound bedridden resident away from herself during personal care, causing the resident to roll off the bed. The fall resulted in a severe fracture requiring surgical repair with screws and metal hardware.

The resident in question had been living at the facility for nearly three years. She had multiple serious medical conditions including functional quadriplegia, severe obesity with a body mass index between 50-59.9, muscle wasting, and reduced mobility. Her medical history included a severe COVID-19 infection that led to prolonged hospitalization and complete loss of her ability to walk or stand. Hospital records noted she “has not stood or walked in over a year and has since experienced significant weight gain and progressive immobility.”

The resident was completely dependent on nursing staff for all aspects of daily care. Her care plan documented that she required “extensive assistance of 2 staff with mobility and transfers” and noted she was “non ambulatory at this time.” For bed mobility specifically, her care plan stated she “requires extensive assist of 1 staff participation to reposition and turn in bed, and scooting towards head of bed” due to weakness in both legs. However, most recent assessments showed she was actually “dependent” for rolling in bed, meaning “helper does ALL the effort” or “the assistance of 2 or more helpers is required.”

At the time of her fall, the resident weighed 380 pounds and was 5 feet 9 inches tall. She was bedridden and required assistance with all personal care activities including changing incontinence briefs and toileting needs.
The incident occurred during the early morning hours when a nursing assistant was providing personal care to the resident. According to the resident’s account, the nursing assistant was changing her incontinence brief and “was standing on the right side of [the resident’s] bed, and [the nursing assistant] turned [the resident] away from her.” The resident stated she warned the nursing assistant, telling her “her leg is going to fall,” but the staff member “stood there and removed the soiled brief, and her leg slid off the bed.”

The resident described falling “on her knees with her butt sticking up in the air” after her leg went over the side of the bed. She explained that “my leg slid over the bed while the CNA was turning me and I rolled off the bed.”

However, the nursing assistant provided a different account of the incident. She claimed that the resident “turned herself towards the door” and “as [the resident] was turning herself, one of her legs pulled out of the bed and [the resident] was on the floor.” The nursing assistant insisted “she did not touch [the resident]” and denied that the resident warned her about her leg falling.

Multiple facility staff members who were interviewed confirmed that proper procedure was not followed. The facility’s Therapy Director stated unequivocally: “Staff should not roll residents away from them.” She explained that given the resident’s weight of 380 pounds, “if [the resident’s] leg started going off the side of her bed, she couldn’t have stopped it…at 380 pounds the momentum would carry her leg over.”

The Assistant Director of Nursing, who investigated the incident, reinforced this point: “You should not push a resident away from you in bed. You have more control of the patient if you roll them toward you.” She noted that the resident had full range of motion in her arms but “not a whole lot” of range of motion in her legs, and importantly, “nobody was on that opposite side of the bed” to prevent the resident from falling.

After the fall, the resident remained on the floor until six paramedics arrived to assist her onto a stretcher for transport to the hospital. Medical examination revealed she had sustained “a comminuted, supracondylar distal femur fracture with intra-articular extension into the lateral condyle” – a complex break in her thigh bone near the knee that extended into the joint.

The injury required surgical repair, and when surveyors visited the resident after her return to the facility, she reported that her stitches had been removed and “there were three screws in her right knee.” The resident noted the impact on her quality of life, stating her “left leg has arthritis, and now her right knee was broken.”

This incident represents a violation of basic nursing care principles. The facility’s own policies required staff to provide appropriate care to meet residents’ needs, yet the nursing assistant failed to follow established safety procedures for turning a severely mobility-impaired resident.

The resident’s care plan documentation showed she had been assessed as needing either extensive assistance from one staff member or total dependence requiring two staff members for bed mobility, yet she was being turned by a single nursing assistant who used an unsafe technique. The facility’s Restorative Licensed Practical Nurse confirmed that the resident had “never been on a bed mobility program” despite her significant limitations, and had been using a full-body mechanical lift for transfers for approximately two years.

The incident resulted in a preventable injury that caused significant pain and required major surgical intervention for a vulnerable resident who was already dealing with multiple serious health conditions and complete loss of mobility.

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.

The Illinois Department of Health has cited and fined Sharon Healthcare Willows when a certified nursing assistant left a resident alone in a room with a large water spill on the floor, despite warning the resident not to get up. The resident fell while attempting to get to the bathroom and suffered a severe fractured femur requiring surgery and hospitalization.

The incident involved a 62-year-old female resident with multiple medical conditions including bipolar disorder, chronic obstructive pulmonary disease, metabolic encephalopathy, and kidney absence, who had been living at the facility for over two years. The resident was cognitively intact according to her mental status assessment but had a history of impulsive behavior and delusions. Her care plan noted she “is at risk for falls” and “ambulates independently but has a history of wheelchair use,” requiring supervision for activities of daily living and toileting assistance.

The dangerous situation began when a certified nursing assistant walked past the resident’s room and discovered a significant safety hazard. The aide stated, “I walked past the resident’s room and saw there was water all over the resident’s floor. The resident had a large cup that must have spilled. I don’t know how long the water had been there.” The resident was in her bed, which was positioned in a low setting, when the aide entered the room.

Upon seeing the aide, the resident became agitated about wanting to vape (use electronic cigarettes) and began “rolling in bed like she was trying to get up.” The aide recognized the resident’s impulsive tendencies, noting that “the resident gets adamant about when she wants to vape” and “it depends on the resident’s mood if she listens or not.” Despite these known behavioral patterns, the aide made a critical decision that would lead to serious injury.

The aide told the resident to “stay in bed and not to get up because there was water on the floor” and observed that “the resident was still trying to get up.” However, the aide reasoned that because “the resident needs help to get up from the low bed so I didn’t think the resident could get up.” Based on this assumption, the aide decided to leave the resident alone with the hazardous spill to retrieve cleaning materials from an adjacent room.

The aide explained her decision: “I went through the bathroom that was between the resident’s room and another resident’s room to get some extra pads in the other room to absorb the water.” She emphasized that she “kept telling the resident not to get up” before leaving, but admitted she was only gone “for a few minutes” while speaking with another resident during her brief absence.

The resident’s urgent need to use the bathroom overrode the aide’s instructions. The resident later explained her perspective: “When I fell and broke my leg, I was trying to go to the bathroom in my room. I only have one kidney so as soon when I have to go to the bathroom I have to go. I went to stand up to go to the bathroom and I slipped on water that was on the floor, fell and hurt my right leg.”

When the aide returned, she found the resident had managed to get out of the low bed and was now lying on the floor, having slipped on the water spill. The aide’s witness statement confirmed that “when I returned the resident was on the floor and couldn’t move her leg.” The resident’s own statement corroborated that she “slipped when she got up to use the bathroom.”

The fall resulted in severe injuries. The facility’s incident report noted that “upon assessment the resident was unable to bend her right leg without significant pain and the resident was unable to bear weight.” A nursing note documented that the resident was found “lying on the floor in her bedroom in a supine position” and was “unable to bend her right leg without significant pain which renders her unable to attempt to bear weight.”

Hospital X-rays revealed the extent of the damage: “Acute comminuted and displaced distal femur fracture extending to the articular surface of the knee.” The medical report detailed that the injury involved “acute comminuted fractures involving the distal femoral diaphysis and extending to the articular surface” with “the distal fracture fragment displaced posteriorly by half a shaft width” and “impaction of the fracture fragments.” This complex fracture required surgical intervention, and the resident underwent “ORIF (Open Reduction and Internal Fixation) surgery” to repair the break with metal hardware.

The resident was hospitalized for five days and later showed the surveyor her surgical scar. The incident investigation identified “potential contributing factors” as “wet floor” and noted that the “resident is impulsive – did not wait for staff to clean up floor.”

When questioned about the incident, the aide acknowledged her error in judgment. When asked “if she thought she should have done anything different,” the aide stated, “I would have had someone stay with the resident.” The facility administrator confirmed this was the appropriate response, stating that she “talked to the aide about the resident’s fall and told her that she should have stayed with the resident and put the call light on until someone came to clean up the water so the resident would not have got up and fell.”

The facility’s own fall prevention policy required staff to “assess the patient care environment routinely for extrinsic risk factors and institute appropriate corrective action.” The policy emphasized preventing falls by “recognizing multi-factional risk and causes” and implementing “recommendations for falls prevention and management consistent with clinical practice guidelines and standards of care.” However, in this case, staff failed to follow these safety protocols by leaving a fall-risk resident alone in a room with a known hazard.

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.

The Illinois Department of Health has cited and fined Resurrection Place when a certified nurse aide attempted to transfer a resident using a mechanical lift without the required second staff member for assistance. The resident fell from the lift and suffered a displaced fracture of his left femoral neck, requiring surgical intervention and hospitalization.

The incident involved a resident with complex medical needs whose care plan clearly stated he “requires assistance partial to substantial assist with Activities of Daily Living” and specified “transfer with mechanical lift and 2 persons assist.” The resident had been admitted with a history of falls, displaced femur fracture, dementia, left-sided weakness from strokes, and walking difficulties. His functional mobility assessment indicated he needed “dependent assistance with chair/bed-to-chair transfer, sit to stand, toilet transfer.”

On the day of the incident, a certified nurse aide was assigned to care for the resident and was attempting to transfer him to bed using the facility’s mechanical lift. The aide later explained that she “noticed that the resident’s left foot was not on the base of mechanical lift, and she bent over to place it on the base when the resident let go from the grab bar with his right hand and slid off to the floor.” Crucially, the aide admitted she “was the only certified nurse aide in the room with the resident” and acknowledged that she “is aware that the resident is a two person assist and that when using any mechanical lift two-person assist is also required.” When asked why she proceeded alone, the aide explained that “the other staff were busy and could not get any help.”

The violation of protocol had immediate consequences. After the resident fell from the lift, the aide “assisted the resident back to the bed” and initially reported no injuries were observed. However, the next day the resident “complained of pain to his left hip.” X-rays revealed “a fracture to the left femoral neck,” and the resident was transferred to the hospital for emergency treatment and surgical repair.

Hospital records provided additional context about the severity of the incident. The resident “had called his wife and said that he was dropped into his bed and then after that was complaining of hip pain.” Due to his dementia, doctors noted he was “a poor historian,” but his wife confirmed that the resident “has been non ambulatory at the nursing home, they use a mechanical lift for mobility in and out of bed.” The resident underwent surgical intervention and was discharged back to the nursing home for skilled therapy with orders for “no weight bearing to lower left extremity.”

Multiple facility staff members confirmed that proper procedures were not followed. The registered nurse who responded to the incident stated that “when transferring with a mechanical lift the staff are supposed to have a two person assist” and the restorative nurse explained that “when using any Mechanical lift machine for transfers staff should be a two person assist” and confirmed “it is the facility policy when using a mechanical lift that two-person assist is implemented.”

The facility administrator acknowledged the policy violation, stating that “when staff is using a mechanical lift there should always be a two person assist per facility policy.” She admitted she “was unaware that only one certified nurse aide was transferring the resident” but confirmed she knew about the fall incident.

The nursing home’s own policies clearly established the safety requirements that were ignored. The Falls policy emphasized providing “an individualized, person-centered care approach” and stated that “residents who are at risk for falls will have an individualized care plan developed which identifies interventions to reduce fall risk.” The Fall Prevention policy aimed “to provide an environment that is free from accidents hazards” and “provide supervision and intervention to residents to prevent avoidable accidents.”

Despite these clear policies and the resident’s documented need for two-person assistance, a single aide attempted the transfer alone because other staff members were busy, resulting in a preventable fall that caused a serious fracture requiring surgery. The incident highlighted a dangerous gap between written safety protocols and actual practice that put vulnerable residents at 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.