Nursing Home Abuse and Neglect Archives - The Law Offices of Barry G. Doyle, P.C.

Swansea Rehab resident fractures hip in fall

September 15, 2022 By Barry G. Doyle

IDPH has cited and fined Swansea Rehabilitation & Health Care Center nursing home after a resident there suffered a fractured hip in a fall after she was left unattended while going to the bathroom.

The resident at issue was recognized as being at risk for falls. She suffered from cognitive impairments, was not steady on her feet and only able to stabilize with staff assistance while walking. This combination of physical and cognitive impairments is a leading indicator of fall risk because they are not able to walk safely, but at the same time cannot be counted on to follow instructions or make good decisions for their own safety.

Due to her fall risk, a fall prevention care plan was put into place. The fall prevention measures included one person assist with use of a gait belt for all ambulation.

On the day of this nursing home fall, the resident was brought to the bathroom by an aide to use the toilet before dinner. While the resident was using the toilet, the aide left the resident to get a washcloth. When she returned, she found the resident in a seated position on the floor of her room. The aide admitted to the state surveyor that she knew that she should not have left the resident alone on the toilet. She also admitted to the state surveyor that she told the nurse on duty that she was in the room when the resident fell when actually was not because she did not want to get into trouble.

The aide reported the fall to the nurse who in turn notified the resident’s physician. The doctor ordered x-rays which showed that there was an acute fracture of the hip. The resident was then sent to the hospital for further care.

The cause of this fall and injury to the resident is readily apparent – the aide admitted that the resident should not have been left unattended while on toilet, but she was. The aide told the surveyor that she thought she would be gone for 30 seconds, but it was clearly longer than that, given that the resident finished going to the bathroom, got up from the toilet, and walked into her room where the fall occurred. More troubling than this is the fact that the aide lied to the nurse about what happened, which raises questions as to exactly what was really being done to care for this resident.

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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Resident dies from brain bleed after fall at Elmwood Nursing & Rehab in Maryville

Aperion Care St. Elmo breaks hip in fall

Mar-Ka Nursing Home resident breaks both legs in fall

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Arcadia Care Bloomington resident suffers broken hip and back due to defective wheelchair

September 12, 2022 By Barry G. Doyle

IDPH has cited and fined Arcadia Care Bloomington nursing home after a resident there suffered a broken hip and a fracture to her mid back after she suffered a fall due to a defective wheelchair brake.

Wheelchairs are one of the most commonly used pieces of equipment in a nursing home. However, for them to be used safely, they must be properly maintained and all of the accessories used as well. The brakes on a wheelchair are critical to the safe use of the chair. When residents attempt to get out of the wheelchair, the brakes must hold firmly or the wheelchair will roll out from under them while they are in the process of rising. This will almost certainly result in a fall. In most nursing homes, the maintenance department are the ones called upon the fix and maintain the residents’ wheelchairs.

On the day of this nursing home fall, the physical therapist entered the room only to find that the resident was half-in, half-out of the wheelchair. She summoned an aide who helped get the resident from the floor, but the resident was in too much pain to participate in therapy. The aide noted that the left side brake was loose so that the chair would still move even with the brake on. She was sent to the emergency room where she was diagnosed with a fractured hip and a fracture of the T-12 vertebra (lower middle back) which required the use of a back brace.

The investigation of this incident revealed that there were at least three staff members who were aware that the brake was loose. Two were aides – including the one who helped the therapist. The other was the maintenance man, who found that the brake was “wiggly” when he installed an anti-rollback device but thought it was sufficient to hold and elected to not repair the brake at that time.

Federal regulations require that nursing homes be kept as free of accident hazards as possible. The defective brake on the wheelchair is something that should have been readily recognized as a hazard by staff given that they had doubtless been trained to make sure that the wheelchair was locked in place with the brakes before attempting to transfer a resident. The failure to correct a known hazard was the direct cause of this fall and the resident’s injuries.

Other blog posts of interest:

Good Samaritan at Pontiac resident suffers fracture knee and leg in wheelchair accident

Piatt County Nursing Home resident breaks hip in fall

Resident breaks hip in fall at McLean County Nursing Home

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Odd Fellow-Rebekah Home resident suffers fatal brain bleed due to fall

September 9, 2022 By Barry G. Doyle

IDPH has cited and fined the Odd Fellow-Rebekah Home nursing home in Mattoon after a resident suffered a fatal brain bleed due a fall that occurred after she was left unattended while going to the bathroom.

The resident involved had a complex medical history, including diagnoses of atrial fibrillation, abnormalities of gait and mobility, unsteadiness on her feet, and generalized muscle weakness. The diagnosis of atrial fibrillation was significant because she received a blood thinner commonly known as Eliquis in order to prevent blood clots brought on by the atrial fibrillation. Blood thinners are obviously an important part of preventing blood clots that can lead to stroke and other cardiac and circulatory events. However, one of the risks of the use of blood thinners is the risk of internal bleeding with trauma. In particular, brain bleeds are known to occur after falls, even in the absence of a direct blow to the head.

The resident was also well-recognized as being a fall risk. Her fall risk assessment showed her to be at high risk for falls. The Minimum Data Set (MDS) completed by the nursing home staff showed that she had cognitive impairments, required staff assistance with all activities of daily living, that she was not steady during transitions and while walking, and that she needed the staff with her to stabilize her while toileting. The Minimum Data Set is a form which is completed by the staff and certified under as being an accurate statement of the care the resident requires and is receiving. The reason that is certified under oath is that it forms part of the basis by which the nursing home is paid for the care

In the week prior to the fall at issue, she two other falls. The occurrence of falls is significant because it is well-recognized in the long-term care industry that falls tend to beget more falls. After each of the two prior falls, the staff investigated the fall and determined that the first was caused by her legs becoming weak while walking and that the second was caused by a loss of balance while trying to get to the bathroom unassisted. After each, the staff checked a box for “no” on the form which read, “Independent for Toileting.” After each of the two falls, the resident fall prevention care plan was upgraded.

On the day of this nursing home fall, the aide assigned to the resident was told by another aide who had been in the resident’s room that the resident was on the toilet with clothes on. The aide went into the room and found the resident laying sideways on her bed undressed with resident’s walker turned over on the floor. The aide got the resident positioned in bed and notified the nurse.

The following morning, aides getting the resident from bed saw that the resident had a large (10.5 cm x 12 cm) bruise on her face. The nurse notified the resident’s physician. The doctor happened to be in the nursing home and upon seeing the resident ordered her sent to the emergency room for evaluation. A CT scan at the hospital showed that there was a large (22 cm), acute brain bleed. She was transferred to another hospital where she died a week later. Her cause of death, per her physician, was brain bleed due to the fall.

Following the fall, the director of nursing conducted an investigation and concluded that the cause of the fall was the resident being left unattended on the toilet and attempting to return to bed without assistance.

This was a highly preventable fall. The nursing home staff clearly recognized that she was a fall risk due to her generalized weakness. However, her cognitive impairments were a substantial barrier to her being able to make good decisions for her own safety and to heed warnings and instructions. After each of the two earlier falls (one of which happened when she was on her way to the bathroom unattended), the investigation showed that she was no independent for toileting. Nonetheless, the aide left her on the toilet on her own and left her to get off it and back to bed on her own. In short, her well-recognized care needs were not met. This led directly to her fall and death.

Other blog posts of interest:

Aperion Care St. Elmo resident breaks hip in fall

Charleston Rehab resident suffers fractured hip and brain bleed in fall from bed

Tuscola Health Care Center resident dropped from lift, breaks ankle

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Mishandling of resident results in broken shoulder at Havana Health Care Center

August 29, 2022 By Barry G. Doyle

IDPH has cited and fined Havana Health Care Center nursing home after a resident there suffered a broken shoulder due to being mishandled by staff while she was repositioned in bed.

“Bed mobility” refers to the ability of a resident to change and maintain their position in bed. When a resident has deficits in bed mobility, it is up to the nursing staff to help change their position in bed. When a resident needs to be moved toward the head or the foot of the bed, a lift sheet is used to help reposition the resident.

A lift sheet is laid on top of the fitted sheet and staff lifts the resident up part way and moves them up and down in bed. Besides being helpful in repositioning the resident, the use of a lift sheet reduces the amount of friction and shear to the resident’s skin, something that increases the risk of developing bed sores. Use of a lift sheet in repositioning residents was called for in the nursing home’s policies and procedures.

The resident at issue had a medical history which included chronic lower back pain and a stroke with residual right-sided weakness. Her Minimum Data Set (MDS) certified that she required extensive assistance of staff with bed mobility.

On the day of this resident’s injury, the lift sheet was underneath the resident in a position where the staff could not easily access it. Because it was a busy time with a lot of call lights going off, the aides decided to lift the resident from under her armpits. As they did so, there was a pop heard coming from the resident’s shoulder and she had immediate pain. However, it was not until the next shift that a nurse notified the doctor. An order was placed for an x-ray which showed that she had a fracture of the proximal humerus (the portion of the upper arm which inserts into the shoulder socket).

The treating orthopaedic surgeon confirmed for the state surveyor that this kind of fracture is “a very painful injury, especially initially.” The resident’s physician ordered Norco the following day. However, the resident did not receive the medication due to the nursing home failing to obtain the necessary authorizations for the pharmacy to release a controlled substance, resulting in the resident experiencing unnecessary pain.

There are a number of issues with the care that this resident received. The first level relates to the mishandling of this resident. Use of a lift sheet was called for by facility policies and procedures, but the staff instead mishandled the resident, resulting in the injury. Second, once the injury occurred, she did not receive the prescribed pain medication, resulting in her experiencing unnecessary pain.

These are of course the superficial reasons why. The deeper reason is likely understaffing of the nursing home. This is shown by the fact that the staff took shortcuts in the care of this resident because it was so busy – a sign that there are not enough hands on deck to meet the care needs of the residents. Sadly, understaffing is a core feature of the nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Heritage – Mt. Sterling resident breaks leg in fall

Mason City Area Nursing Home resident suffers broken hip in fall due failure to use gait belt

Fondulac Rehab resident suffers fatal injuries in fall

Mason City Area Nursing Home resident suffers fatal brain bleed in fall

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Symphony of Buffalo Grove resident has catastrophic fall from lift

August 25, 2022 By Barry G. Doyle

IDPH has cited and fined Symphony of Buffalo Grove nursing home after a resident there suffered multiple injuries in a fall from a lift that led to the resident being placed on hospice.

One commonly used piece of equipment in a nursing home setting is a mechanical lift, and used properly, it can be one of the most useful pieces of equipment in the nursing home. It allows the staff to easily move residents with significant mobility deficits from bed to wheelchair, wheelchair to chair, and so forth. Used properly, it minimizes the risk to residents and staff alike during manual transfers.

Of course like any piece of machinery, the risks of injury increase when it is not used properly. Proper use of a mechanical lift has at minimum three main parts: 1) the staff is properly trained in the use of the device, 2) the lift and all of its components parts and accessories are in good condition and used properly, and 3) two staff are used to complete the transfer – one to manage the controls to the lift, the other to supervise and assist the resident through the transfer.

Having one person doing a two-person job is a well-recognized formula for disaster (see here, here, here, here, and here for examples), and this event proved to be no different.

The resident involved had a long list of significant medical conditions, and had been declining since a hospital admission earlier in the year. She was dependent on staff for all care and required the assistance of two staff for all transfers, and her care plan called for use of a mechanical lift with two person assist for all transfers.

On the day of this nursing home fall, the resident was being transferred by a single aide from bed to her wheelchair so that she could receive assistance with eating lunch. The aide admitted to the state surveyor that she knew that there were supposed to be two staff members for all lifts but she did not get a second staff member to assist because they were busy due to it being lunch time.

When the aide went to get the resident up in the lift, she saw that there were six straps to the lift sling, not the four that the aide was accustomed to. She attached the sling to the lift just as she normally would have, ignoring the additional two straps that were a part of the sling. The aide then attempted to maneuver the lift into position, but as she did so, the resident’s foot bumped the arm rest of the wheelchair. The resident began to sway in the sling and then suddenly slid out of the sling onto the floor, landing feet first, but then hitting her head on the floor.

There was immediate bleeding from the back of the resident’s head. The aide got the nurse who tried to bring the bleeding under control and then called for an ambulance. The resident was brought to the hospital, where she was diagnosed with a brain bleed, a fractured skull, a fractured clavicle, and a fractured humerus. Surgery was not attempted and the resident was placed on hospice.

There are a number of causes of this very preventable injury. First the aide was not trained in the use of this lift and this sling, resulting in the sling not being attached to the lift properly. Second, the aide violated the resident care plan which called for two staff with all transfers via lift. Third, the aide attempted to transfer the resident on her own, not with the assistance of a second staff member as required by her training and the facility’s own policies. Had a second staff member been involved in the transfer, there is a reasonable chance that the sling would have been attached properly, but just as importantly, there would have been another staff member to help control the resident so that the contact with the wheelchair would have been avoided, as this is what led to the resident swaying in the sling and eventually being dumped from the lift onto the floor.

These are the obvious reasons for this fall, but there is a second level to this, and it relates to the overall management of the facility. The aide had not been properly trained in the use of the sling and the lift, and then proceeded with the transfer on her own because the staff was busy due to it being lunchtime. Being “too busy” to get the required number of people to provide proper care to a resident is a sign of an understaffed nursing home. Sadly, poor training and understaffing are a result of the nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Addolorata Villa resident fractures hip in fall

Inverness Health & Rehab resident suffers multiple fractures in fall

Glenview Terrace resident suffers multiple fractures when lift topples over during transfer

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Resident suffers broken ankle in unsafe transfer at Loft Rehab of Rock Springs

August 24, 2022 By Barry G. Doyle

IDPH has cited and fined Loft Rehab of Rock Springs nursing home in Decatur after a resident there sustained a fractured ankle while being transferred from her wheelchair to her bed with the assistance of a single aide rather than the two which were required.

Used properly, a mechanical lift is a helpful piece of equipment in a nursing home. It allows residents to be safely transferred from bed to wheelchair, wheelchair to chair, and so forth. It also spares the staff the task of moving residents manually, which reduces the incidence of injury to the staff from lifting injuries and to residents from rough or improper handling while being moved.

The key phrase in the paragraph above is “used properly.” This is because when the lift is not used properly, the potential for disaster lurks. Proper use of the lift includes the staff being properly trained in the use of the lift, two staff involved in the transfer (one to handle the resident, the other to manage the controls), and all of the equipment and accessories on the lift itself being in good working condition. One of the more common types of accidents we see with the use of lift is having one person doing a two-person job (see here, here, and here for examples).

On the day of this nursing home fall, the resident was being transferred from her wheelchair to her bed using a lift. There was only a single aide involved in the transfer. While the resident was being lifted from her wheelchair to her bed, her lower leg became entangled in the foot rests to the wheelchair. The aide completed the completed the transfer and put the resident to bed. The following morning, the resident was complaining of pain, and the nurse on duty found that the resident’s ankle was bruised, swollen, and painful to touch. The resident was sent to the hospital where CT scans showed that there were multiple fractures of the ankle. However, because the resident was nonweight bearing, they elected to proceed without surgery.

This was a highly preventable injury. All that had to be done was for a second aide to participate in the transfer. The very purpose of that second aide is to help handle the resident and this would have likely avoided the entanglement with the wheelchair footrests and the resulting injury. Although the resident was nonweight bearing, this kind of fracture does have serious negative implications for her activity level and her overall quality of life.

The deeper and more important questions is why did the aide skip the step of having a second staff member there? She told the state surveyor that she was in a hurry that evening. Being in too much of a hurry to provide safe care is a hallmark of an understaffed nursing home. Sadly, understaffing a nursing home is a part of the nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Tuscola Health Care Center dropped from lift, breaks ankle

Loft of Rock Springs resident suffers fractured hip in fall

Charleston Rehab resident suffers brain bleed and fractured leg in fall from bed

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Park Place Christian Community resident rolled from bed by staff

August 20, 2022 By Barry G. Doyle

IDPH has cited and fined Park Place Christian Community nursing home in Elmhurst after a staff member there rolled a resident out of bed and onto the floor, resulting in the resident suffering fractures which led to the resident being placed on hospice.

“Bed mobility” in the long-term care industry refers to the ability of the resident to change and maintain position in bed. This includes things like being able to turn to the side and maintain that position. This is something that is important for having the staff provide incontinence care to help prevent the development of bed sores or to get a sling into position for transfers with a mechanical lift.

When residents have deficits in bed mobility, this is something that requires the assistance of staff. The extent of the resident’s deficits and the need for staff assistance should be recorded on the resident’s Minimum Data Set (MDS). The MDS is information which is submitted to the federal government and forms part of the basis by which the nursing home is reimbursed for providing care. Because of the financial implications of this, the data on the MDS is certified as being true and an accurate reflection of the care that the resident is in fact receiving.

This resident had a long medical history and was largely bedbound. Her MDS specified that she had deficits in bed mobility and required the assistance of two staff members with bed mobility. When two staff members are providing help with bed mobility and the resident is being positioned on her side, one should be positioned on each side of the bed. This way, when the resident is turned to one side, one staff member can do what is necessary (e.g., provide incontinence care, position the sling for the lift etc.) while the other assures the position of the resident on the bed and makes sure that the resident does not roll out of bed.

On the day of this nursing home fall, the aide was attempting to position the resident onto the sling for the lift. Even though this was designated on the MDS as a two-person assist, the aide was attempting to do this on her own. Having one person attempt a two-person job is a well-recognized formula for disaster (see here, here, and here for examples). Making the task all the more difficult, the resident was on a low-air loss mattress for the prevention of bed sores. This surface can make the mattress more slippery than it would be otherwise.

As the aide attempted to place the resident into the sling, she moved the resident’s legs away from her. The resident’s legs went over the edge of the bed, pulling the resident with her. The resident landed on her hands and knees. X-rays confirmed that she sustained fractures of the femur (the high bone) and the humerus (the bone of the upper arm). Rather than attempt surgery, the resident’s family elected to have the resident placed on hospice.

This was a highly preventable accident. All that it would have taken is for the resident to receive the care that the nursing home certified was necessary – two persons assisting with bed mobility. Had that been done, the resident’s legs would not have pulled her off the edge of the bed in the way that this happened and she would not have been injured and placement in hospice for necessary pain control would not have been required.

When staff takes shortcuts in the care that a resident needs – such as having one person doing a two-person job – this is an indication that the nursing home may be understaffed. Sadly, understaffing is a core component of the basic nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Grove of St. Charles resident fractures hip after being rolled out of bed by staff

Westmont Manor resident suffers brain bleed after being rolled out of bed

Addolorata Villa resident fractures hip in fall

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Heritage – Mt. Sterling resident breaks leg in fall

August 16, 2022 By Barry G. Doyle

IDPH has cited and fined Heritage of Mt. Sterling nursing home after a resident there suffered a broken leg in a fall which occurred due to the failure to use a gait belt while providing care and failing to provide care with two qualified staff members as required.

One useful tool in the care of nursing home residents is the Minimum Data Set (MDS). The MDS serves as repository of data regarding the abilities and care needs of nursing home residents. One unusual feature of the MDS is that the data contained on it is certified to the federal government as being accurate, as it forms part of the basis by which nursing homes are reimbursed for the care that they provide to residents.

This resident’s MDS included findings that she required extensive physical assistance of two staff with dressing, bed mobility, and transfers. During the care planning process, the resident was assessed as a fall risk due to a history of falls, poor cognition, and overestimating or forgetting her limitations. Her medical history also included a diagnosis of muscle weakness. The care plan called for two staff to assist with all transfers.

The nursing home also had standing policies which the staff was to follow in the care of residents. One of those was a policy regarding the use of gait belts. A gait belt is a woven strap that is applies around the midsection of residents while residents are receiving assistance with transfers or walking. It allows the staff member to better control the balance of the resident and either stop or slow down the rate of falls when the resident loses their balance.

On the day of this nursing home fall, the resident was seated on the edge of the bed while being dressed by an aide. There was no gait belt applied. The resident moved toward the edge of the bed to stand to transfer her from the bed to her wheelchair, but the resident’s legs gave out from underneath her, and she fell to the ground.

At the time of the fall, there was a second staff member called a unit assistant. However, that person was not trained to provide direct patient care to residents and was two feet away when the fall occurred. The administrator and director of nursing both told the state surveyor that a unit assistant did not qualify as a second staff person when the resident required the assistance of two staff with dressing and transfers.

The resident had immediate pain by the knee and was sent to the hospital where she was diagnosed as having a displaced periprosthetic fracture of the distal femur – meaning that there was a fracture of the thigh bone near the resident’s artificial knee where the two sides of the fracture were no longer in alignment. The team at the hospital elected against surgery, and the resident was placed in an immobilizer.

This injury will likely have significant impacts on the well-being of this resident, as her period of immobility will likely result in her no longer having even the limited ability to bear weight on the lower extremities. This in turn can set the stage for issues like the onset of pneumonia or the development of bed sores.

There are two obvious causes of this resident’s injury. One is the failure to use the gait belt as required by the facility’s own internal policies. The second is the failure to have two qualified staff people participating in the transfer as called for in the resident care plan – seeing as the unit assistant was not qualified to participate in helping with the transfer.

There is a deeper level to this, and it likely is that the nursing home was understaffed. When you see shortcuts being taken in the resident care such as not applying a gait belt or there not being two staff available when needed, these are signs of an understaffed nursing home. Sadly, understaffing is a part of the nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Mason City Area Nursing Home suffers fatal brain bleed in fall

Fondulac Rehab resident suffers fatal injuries in fall

Monmouth Nursing Home resident sustains multiple falls leading to brain bleed

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Forest City Rehab fails to send resident to dialysis

August 11, 2022 By Barry G. Doyle

IDPH has cited and fined Forest City Rehabilitation & Nursing Center nursing home in Rockford after a resident had to be sent to the intensive care unit at a local hospital after the nursing home failed to send the resident to dialysis for three consecutive scheduled sessions.

When a nursing home resident suffers from kidney failure and is on dialysis, the resident must receive all of their scheduled sessions. The failure to send a resident to dialysis as ordered can result in the resident suffering high levels of potassium which can cause the death of the resident.

While some nursing homes have in-house dialysis units, other nursing homes have to send residents to outside dialysis centers for their schedules sessions. When this is the case, reliable transportation must be arranged. In this particular instance, the resident was supposed to receive services at an outside center. The contract with the nursing home placed responsibility on arranging for transportation on the nursing home, and there was a staff member who was specifically responsible for arranging for the transportation.

The resident was readmitted to the nursing home after a short hospital admission and was due to get dialysis the following day. Her schedule called for three dialysis sessions per week. However, she was not brought to dialysis that day as scheduled or for the next two sessions either. This meant that the resident did not receive dialysis for a week.

After missing the third session, one nurse noticed that the resident was less alert than normal and appeared puffier – likely because she was retaining fluid due to the missed dialysis sessions. The nurse practitioner was notified and ordered the resident sent to the hospital. There labs showed that the resident had critically high potassium levels. She was admitted to the intensive care unit and received dialysis.

There are three shortcomings in the care that this resident received. First, the nursing home was responsible for arranging transportation, and even if the outside company failed to provide the services it promised, the nursing home was still obligated to get the resident to her scheduled dialysis sessions. Second, when the resident did not receive the care that was ordered, this was a situation where physician notification was required. The failure to get the ordered dialysis is a very serious situation which can have severe adverse health consequences for the resident and the judgment and expertise of a physician as tow to how to address this is necessary. Third, the citation revealed that the staff did not have a good understanding of what dialysis services the resident needed. Because dialysis is so essential to the health and well-being of residents, the dates for dialysis and its completion should be clearly documented in the resident chart. Taken together, these failings led to the unnecessary critical illness of this resident.

Other blog posts of interest:

Forest City Rehab resident murders roommate

Burbank Rehab resident hospitalized due to missed dialysis sessions

Failure to notify doctor of abnormal labs at Momence Meadows

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Mason City Area Nursing Home resident suffers fatal brain bleed in fall

August 10, 2022 By Barry G. Doyle

IDPH has cited and fined Mason City Area Nursing Home after a resident there suffered a brain bleed due to a fall in which the resident was left unattended sitting at the edge of the bed after being transferred there by a single aide using a lift.

Safe use of a mechanical lift requires two staff people. One staff member will operate the lift while the other is responsible for the safety of the resident before, during, and following the transfer. We have written frequently about the predictable accidents that result when one person attempts to do a two-person job (see here, here, here, here, and here for examples).

The Minimum Data Set (MDS) is a part of the nursing home record where the results of various assessments of the resident’s abilities and needs are recorded. The MDS forms part of the basis by which the nursing home is paid, so it must be certified by the nursing home as being accurate. The last MDS completed with regard to this resident documented severe cognitive impairments and the need for extensive assistance with bed mobility and transfers. It further documented that the resident was not steady and only able to stabilize with staff assistance during surface to surface transfers and the need for extensive staff assistance during a lying to sitting on the side of the bed. These findings were largely consistent with the Discharge Summary completed by physical therapy when the resident was discharged from physical therapy four months before the fall having reached maximum potential. There, the resident was documented as not being able to achieve sitting balance. At the time of discharge the resident required total staff assistance with the use of a standing lift and was not expected to improve.

The resident was properly assessed as a fall risk and a fall prevention care plan was put into place. During the care planning process, there is an assessment of the risks to the health and well-being of the resident. There is then a series of steps that are put into place to address those risks which are assigned to the staff who then must implement the care plan on a day-to-day, shift-to-shift basis. Part of this resident’s fall prevention care plan included the use of a mechanical lift with assist of two staff for all transfers.

On the day of this nursing home fall, the resident was being transferred to bed using a standing mechanical lift with a single staff member assisting. The resident was brought to the edge of the bed, and as the aide went to move the lift away, the resident was left unattended sitting on the edge of the bed. The mattress that was in use on her bed was a low air loss mattress intended to help prevent bed sores, so it provided a less firm surface than a traditional mattress. While the aide was putting the lift away, the resident fell to the floor, hitting her head on the floor and cutting her head open.

After the fall, the resident was sent to the hospital to receive sutures. On her return to the nursing home, the staff recognized changes in her baseline mental status, and notified the attending physician who ordered the resident back to the hospital. At the hospital, a CT scan showed that there was a right-sided brain bleed. It was determined that the resident was not surgical candidate and over a 16 day admission to the hospital, her condition continued to decline, and she was discharged in the care of hospice. She died one month after the fall with the cause of death on her death certificate reading intracranial hemorrhage.

There are a number of causes of this nursing home fall. First, the staff failed to follow the care plan which called for two staff to assist with transfers using the lift. Not only is doing this consistent with the care plan, it is what basic industry safety practices require. Incredibly, not only did the staff fail to follow this, the also told the state surveyor that it was the staff’s discretion as to whether to use one or two staff for transfers. This shows poor training on the part of the staff. Secondly, the staff left her unattended at the edge of the bed when they should have known that she was not capable on maintaining that position.

The fact that this was a situation where you had one person doing a two person job is also an indicator that this was an understaffed nursing home. When you have staff that is taking shortcuts in the care of residents, this indicates that they do not have enough people on hand to meet the care needs of the residents. Sadly, this and failing to invest in the training if the staff is consistent with the nursing home business model.

Other blog posts of interest:

Heritage – Mt. Sterling resident breaks leg in fall

Mason City Area Nursing Home resident suffers broken hip in fall due failure to use gait belt

Fondulac Rehab resident suffers fatal injuries in fall

Mishandling of resident results in broken shoulder at Havana Health Center

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Catastrophic brain injury results from medication error at Alden Town Manor

August 6, 2022 By Barry G. Doyle

IDPH has cited Alden Town Manor nursing home in Cicero after a resident there was given glipizide when it was not part of his medication regimen.

Almost all nursing home residents receive medications on a regular basis. To ensure that residents receive medications as ordered, nurses are supposed to follow the five “rights” in administering medications: right patient, right medication, right dose, right time, and right route. Not getting all five “rights” just right can result in a critical nursing home medication error. Sadly, that is what happened here.

The resident was admitted for treatment of a urinary tract infection. While he was a diabetic, glipizide was not a part of his medication regimen. Glipizide is a type of medication known as a sulfonylureas. These medications stimulate the release of insulin from your pancreas, directing your body to store blood sugar. This helps lower your blood sugar levels. However, when taken by someone who does not need this medication, it can drive their blood sugar down to critically low levels. Abnormally low blood sugar levels is known as hypoglycemia. Hypoglycemia can have widespread negative effects on your health and well-being.

When the resident was initially admitted to the nursing home, he was anxious and restless. However, 5 days later when the nurse went to do the afternoon medication pass, she was unable to rouse him. She checked his blood pressure and found that it was normal. She then checked his blood sugar and got a result of 24 (normal range 140-199), which is a critically low result.

When the resident was sent to the hospital where a screening test showed that he had glipizide in his system. The diagnosis was neuroglycopenic injury secondary to hypoglycemia. He had to be intubated in order to protect his airway. When he was extubated, he was still unresponsive. A PEG tube had to be place for long-term nutritional needs due to the brain injury he sustained. He was discharged from the nursing home, where the staff described him as being unresponsive to stimuli.

Investigation at the nursing home showed that there was only one other resident who had an order for glipizide and he was in the room across the hall from the resident. These facts strongly suggest that the resident received the medication which had been ordered for the person across the hall. The system for avoiding just this kind of error was apparently not followed – the check for the right patient was not done – because there is no other way that the resident could have ended up with glipizide in his system.

The simple failure to follow this time-tested system resulted in a very avoidable medication error with catastrophic results. This resident suffered a catastrophic brain injury and is no longer capable of meaningful communication or voluntary movement. Chances are strong that complications from this medication error will result in the wrongful death of this resident, whether from bed sores caused by immobility, pneumonia, feeding tube complications, or any number of other complications that beset a severely medically compromised patient like this resident.

Other blog posts of interest:

Bella Terra Wheeling resident receives roommate’s diabetes medications

Alden Estates of Huntley fails to give antibiotics as ordered

Diabetes medications not given at Alden Estates of Orland Park

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Fondulac Rehab resident suffers fatal injuries in fall

August 5, 2022 By Barry G. Doyle

IDPH has cited and fined Fondulac Rehabilitation & Healthcare Center nursing home in East Peoria after a resident there fell and suffered a fractured hip, resulting in his wrongful death two days later.

The care planning process is the basic tool for delivering routine care in a nursing home setting. There are six basic steps to the care planning process: (1) assessment of the risks to the health and well-being of the resident, (2) development of a care plan which spells out various steps or interventions that are to be taken on a day-to-day, shift-to-shift basis to address those risks and assigning those measures to staff members, (3) communicating the care plan to the staff charged with carrying it out, (4) actual implementation of the care plan, (5) evaluation of the effectiveness of the care plan, and (6) revision of the care plan if it proves in effective in practice or if there are changes in the condition of the resident.

Successful care planning requires all six of these steps, but one thing that is actually required by the federal regulations is that the interventions in the care plan be individualized and suited for the resident. In other words, the steps in the care plan itself should be tailored to the needs of the resident.

The resident involved was recognized as a fall risk. He had a history of falls, had document cognitive impairments with severely impaired decision-making. He used a wheelchair at times and required staff assistance for bed mobility, transfers, and locomotion. The staff was aware that the resident would frequently ambulate within his room and transfer himself. The fall prevention care plan called for assistance as needed when the resident was not feeling well or was weak or dizzy and as needed with change of condition. It further included educating the resident to lock his wheelchair and to ask staff for assistance.

Two days prior to the fall, the resident had been transported to the local hospital because he was drooling, lethargic and not acting appropriately. He was sent back to the nursing home the same day. The following day he was having shortness of breath and below-normal oxygen saturation levels.

On the day of this nursing home fall, the resident got out of bed unassisted at 8:00 a.m. to adjust his pants. In doing so, he lost his balance and fell to the ground, suffering a fractured left hip. Sadly, for persons in this age cohort, hip fractures carry a high mortality rate, and this gentleman was one of those for whom a hip fracture proved fatal. According to the coroner, the fall and hip fracture was one of the causes of this resident’s death.

There are a number of shortcomings with the care that this resident received. First, he was a known fall risk and his behavior of walking and transferring himself in his own room was well-known to the staff. This was a resident for whom walking in his room was a risky endeavor, and to reduce the risk of this kind of fall, he should have been kept in areas where he could be easily observed such as in the dining room or by the nurse’s station. Secondly, his care needs required reassessment after the hospital visit two days before in terms of his strength and cognitive status. Due to this change he likely required closer observation than usual. Third, the steps in the care plan were not suitable. As the nurse appropriately told the state surveyor, “I do not think educating a confused resident to ask for assistance is a good intervention for a fall.” This is completely accurate – one of the reasons that cognitive impairments is a contributing factor for fall risk is that the resident cannot be counted upon to make good decisions for his own safety.

Other blog posts of interest:

Mason City Area Nursing Home resident suffers broken hip in fall due to failure to use gait belt

Pekin Manor resident suffers brain bleed due to fall

Mishandling of resident results in broken shoulder at Havana Health Center

River Crossing of East Peoria resident suffers brain bleed due to fall from unsafe use of lift

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Addolorata Villa resident fractures hip in fall

July 31, 2022 By Barry G. Doyle

IDPH has cited and fined Addolorata Villa nursing home in Wheeling after a resident there fractured a hip in fall that occurred while he was being transferred by a single aide rather than the two staff that he needed for safe transfers.

One key part of a nursing home chart is the Minimum Data Set (MDS). This records a wide array of information about the resident’s condition, activities, abilities, and care needs. The data on the MDS is certified under oath as being true by members of the nursing home staff. The reason that it is completed under oath is that is forms part of the basis by which nursing homes are reimbursed for the care that it provides to the resident. Therefore, the MDS should accurately reflect not only the care that the resident needs, but the care that the nursing home is actually providing.

The resident at issue had a number of chronic conditions including Parkinson’s Disease, muscle weakness, and dementia. His MDS certified that he required the assistance of two staff members to transfer from bed to chair. He was assessed as being at very high risk for falls.

On the day of this nursing home fall, the resident was being transferred from his bed to a wheelchair by a single aide. Having one person doing a two-person job is a well-worn formula for disaster in the nursing home industry (see here, here, here, here, and here for examples). This also happened to be this aide’s first day working with this resident and she advised the state surveyor that she was not instructed on the resident’s care needs.

While the aide was in the process of transferring the resident from his bed to his wheelchair, his feet got tangled in the footrests to his wheelchair. He was too heavy for the aide to control, and she attempted to lower him to the floor, but could not control his descent. He hit the floor and and banged his head against the dresser, resulting in a laceration to the head. Given the resident’s pain in hip and the fact he had head trauma while taking blood thinners, he was sent to the emergency room.

At the hospital, x-rays showed that the resident was suffering from a broken hip. However, the decision was made against surgical repair. The decision to not have surgery done means that the resident will likely lose his ability to ambulate and bear weight on that leg which increases the risk of complications associated with immobility such as the pneumonia and the development of bed sores.

One of the striking features of the citation was how poorly trained the staff were. The surveyor noted falling leaf symbols (used in the nursing home industry as a symbol for fall risk residents – Let’s End Avoidable Falls) by the doorway, but none of the staff was able to explain what it meant. Many of the staff admitted that they received minimal onboard training and were unable to explain why or how certain fall prevention steps were being taken. Sadly, poor training of staff is a common feature of the nursing home business model because properly training staff costs money.

Other blog posts of interest:

Resident suffers jaw, facial fractures in multiple falls at Dimensions Living in Prospect Heights

Resident fractures leg in unsafe transfer at Ascension Nazarethville in Des Plaines

Inverness Rehab resident suffers multiple fractures in fall

Click here to file a complaint about a nursing home with the Illinois Department of Public Health

Monmouth Nursing Home resident suffers multiple falls, resulting in brain bleed

July 30, 2022 By Barry G. Doyle

IDPH has cited and fined Monmouth Nursing Home after a resident experienced multiple falls, resulting in facial fractures and a brain bleed.

The resident at issue was admitted to the nursing home as a sort-term rehab stay after experiencing a urinary tract infection. Her medical history included general physical deconditioning and weakness, a history of falls, and cognitive impairments which affect her safety awareness.

Falls are a special area of focus in the care of nursing home residents, in part because the occurrence of a fall tends to beget more falls and because the injuries sustained in falls have such a negative impact on the health, well-being, and quality of life of nursing home residents. Nursing homes use a number of different tools to assess a resident’s fall risk, but three major factors in determining a resident’s fall risk are: (1) whether the resident has a history of falls, (2) any type of gait or musculoskeletal weakness of dysfunction, and (3) any type of cognitive impairment or lack of safety awareness which makes it less likely that a resident will understand or follow instructions for their own safety or make good decisions regarding their own safety.

When a resident is at risk for falls, a fall prevention care plan is required. A fall prevention care plan sets forth a series of steps that the staff will taken on a day-to-day, shift-to-shift basis to prevent falls.

The first nursing home fall occurred on the fourth day of her admission when the resident was attempting to go from her bed to her chair without assistance and her foot slid out from underneath her. The second fall occurred two days later when she attempted to get of her recliner. The resident was not injured in either of these falls, but the occurrence of two falls in such a short interval should have triggered some revision of the resident’s fall prevention care plan for two reasons. First, one of the truisms in the long-term care industry is that falls tend to beget more falls and the occurrence of two in such a short window should have been a warning sign that additional falls were likely. Secondly, the occurrence of the two falls in such a short period of time should have served as an indication that the fall prevention care plan not not effective and needed to be upgraded.

The third fall occurred the day after the second one. The resident was walking in the hallway unattended carrying a dish with her that she was bringing back to the kitchen. She fell, hitting her face on the floor. There was bleeding and the resident was unresponsive for several minutes. 911 was called, and the resident was sent to the emergency room. Because the resident was on blood thinners and experienced loss of consciousness, a CT scan was ordered. This showed the presence of a brain bleed as well as orbital wall and maxillary fractures. The resident was transferred to a regional trauma center for further care. There, a neurosurgical consult was obtained and the recommendation was to hold the blood thinner medications and follow up in the office. The resident was returned to the nursing home four days after the fall.

When the resident was returned to the nursing home, the plan was to place her in a room closer to the nurse’s station in order to make it easier for the nurses to monitor what the resident was doing. However, the next day the resident fell yet again – the fourth fall in less than 2 weeks. This fall occurred in the morning when the resident tried to get out of bed unassisted. Earlier that night, she had been found out of bed by the staff standing in her room, and the staff felt that she was combative and confused. The staff heard the fall and found the resident on the floor with a small know on the back of her head. Shortly after, she began to complain of severe headache and was dry heaving. The resident was sent to the local hospital where a CT scan showed that there was an increase is the size of the bleed as a well a midline shift of the brain. This is an indication of increased pressure on the brain associated with the bleeding. The resident was transferred to the regional trauma center for further care.

There were a number of shortcomings in the care of this resident which contributed to the serious injuries that she suffered. First, she was well-recognized as being a fall risk because of the history of falls, cognitive impairments, and generalized weakness. Once she experienced the two falls in the facility, the care plan should have been revised to include more frequent rounding and placing the resident at the nurse’s station during waking hours to keep the resident under easy observation. This would have likely prevented the third fall which resulted in the initial brain bleed.

Once the resident returned from the hospital, the care plan should have been upgraded to include a more aggressive schedule of rounding, especially after the resident demonstrated heightened confusion and combativeness. These behaviors should have served as an indicator to the staff that she was not likely to heed instructions and advice for her own safety. Further, use of a bed alarm was called for, but one was not employed even though that was an option at this nursing home.

In short, a series of failures in the delivery of care led to a string of falls with ever-more serious injuries to this resident.

When a resident fails to get the care which is required, it raises a fair question as to whether this was an understaffed nursing home. Residents failing to get needed care is a hallmark of an understaffed and is also a hallmark of the nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Hope Creek resident fractures hip in fall from toilet

Seminary Manor resident suffers fatal brain bleed in fall

Sharon Health Care Elms resident suffers brain bleed in fall while on smoking patio

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Aperion Care St. Elmo resident breaks hip in fall

July 23, 2022 By Barry G. Doyle

IDPH has cited and fined Aperion Care St. Elmo nursing home after a resident there suffered a fractured hip in a fall.

Nursing homes are closely regulated by the federal government, and one of the things that they are required to do is to submit data regarding the care that is being provided to residents on a form known as the Minimum Data Set (MDS). The MDS is certified under oath by the nursing home staff completing it as being an accurate statement of the care that the nursing home is in fact providing. This is because the MDS serves as a basis for the amount of money that the nursing home receives for providing care to the resident.

This resident’s medical history included a history of stroke with residual left-sided weakness. Her MDS certified that the resident required extensive assist of two staff with bed mobility, transfers, walking in the room, walking in the corridor, and for toilet use.

On the day of this nursing home fall, the resident was brought to the bathroom by a single staff member. As they exited the bathroom and began to walk down the hallway, the resident’s left leg became weak, and she was no longer able to bear weight on the left leg. She fell, going down in a seated position abruptly, nearly pulling the staff member who was assisting her down on top of her. She began to experienced pain in the left hip and was brought to the hospital where an x-ray showed that she had a broken hip. She underwent surgery to repair the fractured hip.

Here, the nursing home identified an appropriate level of care for this resident, yet failed to provide it. At the time of this fall, the resident was walking in the corridor assisted by a single aide rather than the two called for in the MDS. Further, this is the kind of injury which was predictable, given her history of left-sided weakness due to her stroke. When her leg gave out on her, the single aide was not able to bring her fall under control, leading to the broken hip.

Other blog posts of interest:

Odd Fellow-Rebekah Home resident suffers fatal brain bleed in fall

Taylorville Skilled resident suffers broken hip after multiple falls

Charleston Rehab resident suffers brain bleed and fractured hip in fall from bed

Piatt County nursing home resident breaks neck in fall from power recliner

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Hope Creek resident fractures hip in fall from toilet

July 23, 2022 By Barry G. Doyle

IDPH has cited and fined Hope Creek Nursing & rehabilitation nursing home in East Moline after a resident there suffered a fractured hip after being left unattended on the toilet.

The resident at issue was recognized as being at high risk for falls, based on a number of factors. These included a history of falls (4 in the six months prior to this nursing home fall), severe cognitive impairments, and musculoskeletal weakness and dysfunction. The overall fall risk was significant enough that she was provided a helmet to wear to prevent brain bleeds in the event that there was a fall. Her fall prevention care plan included the general step of anticipating and meeting the resident’s needs.

However, the resident’s Minimum Data Set (MDS) contained a much more specific set of steps that were to be taken to prevent falls. The Minimum Data Set is submitted to the federal government signed under oath by the nursing home staff and it details what care is in fact being provided to the resident. That affirmation serves as part of the basis by which the nursing home is reimbursed for the care that it provides to the resident. If the nursing home is certifying to the federal government that it is providing a certain level of care to the resident, then that care must be provided. For this resident, the nursing home certified that it was providing two-person assist with toileting.

On the day of this nursing home fall, the resident was brought to the bathroom and seated on the toilet by a single aide who then left the resident unattended. The resident fell from the toilet. When discovered by the staff, she complained of left hip pain. She was brought to the hospital where a CT scan showed that she suffered a fractured hip.

When interviewed by the state surveyor, the MDS Coordinator confirmed that the resident was a two-person assist for toileting, and that the resident should never have been left alone on the toilet. The nurse assigned to the resident also confirmed that the resident should not have been left alone on the toilet due to her being a high fall risk and due to her impulsivity and that fact that the resident was wearing a helmet should have served as a clue to the aide.

The nursing home here clearly identified that the resident was a fall risk and arrived at the appropriate level care that this resident required for toileting. However, that level of care was not provided. While the resident required the assistance of two with toileting, she was brought to the bathroom by a single aide who then left her completely unattended.

The fact that so many shortcuts were taken in the care of this resident raises serious questions as whether this was an understaffed nursing home. Nursing homes are required to have enough properly trained staff on hand to meet the care needs of residents on a 24/7 basis. Sadly, understaffing a nursing home is a feature, not a bug in the nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Failure to use gait belt leads to fall and broken hip at Fair Oaks Rehab in South Beloit

Waverly Place of Stockton resident breaks hip in unsafe transfer

Rochelle Rehab resident breaks leg due to unsafe use of wheelchair

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Sunny Hill resident suffers fractured leg after lift tips over during transfer

May 17, 2022 By Barry G. Doyle

IDPH has cited and fined Sunny Hill Nursing Home of Will County in Joliet after a resident there suffered a fractured femur when a mechanical lift tipped over during a transfer.

The resident at issue was dependent on staff for transfers. She had a medical history which included a prior stroke and a below the knee amputation of the right leg. Transfers were accomplished by way of a mechanical lift. Proper use of a mechanical lift requires the assistance of two staff members – one to operate the controls of the lift, the other to control the movement and positioning of the resident in the sling. We have written many times about the disastrous results which come when one person attempts a two-person job like transferring residents using a lift (see here, here, here, here, and here for examples).

Unfortunately, this was a transfer which was attempted using a single aide. The aide provided incontinence care to the resident on her own (which was itself a violation of the resident care plan), and once finished, placed the resident in the sling for the lift and began to move her to the wheelchair. As the transfer was underway, the lift reportedly jerked and then tipped over, causing the resident to fall to the floor.

The resident was brought to the hospital where she was diagnosed with a displaced, comminuted fracture of the femoral shaft. After being returned to the nursing home, the resident has experienced significant ongoing pain and was largely bed-bound. This is a situation which not only increases the isolation that this resident experiences, but also leaves her at increased risk for developing bed sores and other forms of skin breakdown.

This nursing home fall was the simple product of the aide failing to follow basic safety practices for the use of the mechanical lift. Many times when staff takes shortcuts in the care of a resident, this is due to understaffing of the nursing home. However, the investigation by IDPH into this incident showed that this nursing home was actually reasonably well-staffed.

However, it is clear that this aide (who was agency staff) was not well-trained, and failure to invest in proper training of staff is a feature, not a bug in the nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Villa of South Holland resident breaks back when lift tips over during unsafe transfer

Alden Courts of Shorewood resident breaks both legs during unsafe transfer

Accolade of Pontiac resident fractures hip in fall after call light left out of reach

Click here to file a complaint about a nursing home with the Illinois Department of Public Health

Villa at South Holland resident breaks back when lift tips over during transfer

May 14, 2022 By Barry G. Doyle

IDPH has cited and fined Villa at South Holland nursing home after a resident suffered multiple fractures in his lower back after a lift tipped over during transfer.

Used properly, a mechanical lift is a helpful device for transferring residents in a nursing home setting. Of course, the first phrase of the last sentence is the key – “used properly”. When a lift is not used properly, it places resident at risk of serious harm.

When a transfer is taking place, the resident is suspended from the arm of the lift in a sling. One staff member operates the lift itself while the other staff member keeps the resident steady in the sling and guides the resident in the sling to the final destination.

Because the resident is suspended in the sling, there is a very high center of gravity, which places the lift at risk of tipping over during the transfer. To combat the risk of the lift tipping over, the legs of the lift should be spread as wide open as possible. This helps ensure that the lift has a solid base while the transfer is underway.

On the day of this nursing home fall, the resident was being transferred from bed to wheelchair using the mechanical lift. Two aides were involved in the transfer (which is a good thing – as we have written many times about what happens when one person does a two-person job: see here, here, here, here, and here for examples. Unfortunately, the aide working the controls narrowed the legs as the lift brought the resident in place to be lowered into his wheelchair. As that happened, the lift began to tip over. The aides were unable to bring it under control, and the resident fell to the ground. Her was brought to the hospital where x-rays showed that he had fractures of the spinous processes of three different vertebrae in his lower back.

Obviously, improper use of the lift was the prime culprit in this incident. Sadly, poor training of the staff is often at the root of incidents brought on by the misuse of nursing home equipment. Poor training of of staff is indicative of an unwillingness of the part of nursing home management to make investments in the staff, and failing to invest in the staff is a core part of the nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Grove at the Lake resident suffers multiple injuries in mechanical lift accident

Landmark of Richton Park resident dropped from lift, breaks both legs

Glenview Terrace resident suffers multiple fractures when lift topples over during transfer

Click here to file a complaint about a nursing home with the Illinois Department of Public Heal

Charleston Rehab resident suffers brain bleed and hip fracture in fall from bed

May 12, 2022 By Barry G. Doyle

IDPH has cited and fined Charleston Rehabilitation & Health Care Center nursing home after a resident there suffered a brain bleed and a fractured hip in a fall from bed.

There are two basic means by what care the resident is to receive in a nursing home is determined. First, the are physician orders. If there is an order in place, it is the obligation of the nursing staff to execute those orders. The second is through the care planning process. In the care planning process, the nursing staff makes an assessment of the risks to the health and well-being of residents. Based on that assessment, a series of steps, or interventions, or assigned to various members of the care team to be carried out on a day-to-day, shift-to-shift basis.

The resident at issue here suffered from significant cognitive impairments and his Minimum Data Set (MDS) showed that he needed extensive assist with bed mobility, which includes changing and maintaining position within bed. He was apparently also a restless sleeper as there were physician orders in place for the use of side rails and the care plan called for placement of a body pillow on the edge of the bed as a reminder, with other pillows to be used when the body pillow was not available.

Before the day of this nursing home fall, the resident had side rails as ordered on his bed. However, he contracted covid and had to be moved to another room. When he returned, the side rails had been removed from his bed and were not re-installed. On the day of the fall, the staff heard a loud crashing sound from the resident’s room. The entered the room to find the resident laying face up next to the bed. There was no body pillow is use.

The resident was brought to the hospital where he was diagnosed as having suffered a brain bleed and a fractured right hip.

There were good fall prevention measures in place for this resident: (1) the physician-ordered side rails and (2) the use of the body pillow as incorporated into the care plan. Sadly, neither of these measures were being carried out, and as a result, the resident suffered a very preventable fall with serious injuries resulting.

Other blog posts of interest:

Aperion Care St. Elmo resident breaks hip in fall

Piatt County Nursing Home resident suffers fractured hip in fall

Moweaqua Rehab resident fractures hip in fall

Failure to activate chair alarm leads to fall and brain bleed at Pleasant Meadows Senior Living in Chrisman

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Mason City Area Nursing Home resident suffers broken hip in fall due to failure to use gait belt

May 8, 2022 By Barry G. Doyle

IDPH has cited and and fined Mason City Area Nursing Home after a resident there fell and suffered a fractured hip while being transferred from her bed to her wheelchair by an aide who was not using a gait belt.

Use of a gait belt is a basic fall prevention strategy. A gait belt is a sturdy canvas strap that is applied to the midsection of a resident who is at risk for falls and may require the physical assistance of staff with walking, standing, and transfers. The gait belt allows the staff member assisting the resident help steady the resident in the event that there is a loss of balance or to break a fall or control the descent if there is in fact a fall. Without the use of a gait belt, the staff would have to rely on grabbing onto the clothing or to the resident to try to prevent a fall. Either places both staff and resident at risk for injury. A gait belt is a basic piece of equipment in a nursing home and is provided by the nursing home for staff to use. Its use is often required by the resident care plan and/or facility policies and procedures.

Here, the resident’s Minimum Data Set (MDS) specified that the resident required the assistance of one staff member for transfers, was unable to ambulate, and was unsteady when going from a seated to standing position. The MDS is submitted under penalties of perjury to the federal government and is a statement as to the condition of the resident and the levels of care and assistance that the resident requires. The reason that the MDS is submitted to the federal government under penalties of perjury is that the MDS forms part of the basis by which the nursing home is paid and this is the certification by the nursing home that a) this is the kind of care that the resident requires and b) that the nursing home is in fact providing it.

Here, the facility’s policies and procedures specified that when staff was providing assistance with transfers, a gait belt was required to be in use. Taken together, the MDS and policies and procedures indicated that when this resident was being transferred, there would be physical assistance from one staff member who would be using a gait belt.

On the morning of this nursing home fall, the resident was being transferred from her bed to her wheelchair with the help of a single aide. There was no gait belt in use, as she could not find the one in the resident’s room and someone “stole” hers. As the resident went to turn to get into her wheelchair, her legs crossed over when she attempted to pivot. She lost her balance and began to fall. Had a gait belt been in use then, the aide would have had a chance to either prevent the fall or bring it under control.

However, there was no gait belt in use. As a result, the aide was reduced to trying to bring the fall under control by grabbing at the back of the resident’s pants. This was as ineffective as might be expected and both the resident and the aide fell to the floor. The resident complained of immediate pain to the left hip. She was sent to the hospital where x-rays confirmed a fractured hip. She had to undergo surgery to repair the fractured hip.

Obviously, the most immediate cause of the fall was the failure to use the gait belt. However, when you see staff take shortcuts in the care of a resident such as attempting a transfer without a gait belt rather than taking the time to find this necessary and required piece of equipment, it raises a question of whether the nursing home was understaffed. Sadly, understaffing a nursing home is a feature, not a bug of the nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Mason City Area Nursing Home resident suffers fatal brain bleed in fall

Brain bleed the final result of multiple falls for Monmouth Nursing Home resident

Resident left without gait belt fractures arm in fall at Clayberg Nursing Center

Piatt County Nursing Home resident breaks neck in fall from power recliner

Heritage – Mt. Sterling resident breaks leg in fall

Christian Nursing Home resident suffers severe leg injury in fall

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Grove at the Lake resident suffers multiple injuries in mechanical lift accident

May 4, 2022 By Barry G. Doyle

IDPH has cited the Grove at the Lake nursing home in Zion after a resident there sustained a fractured ankle, an intracranial hemorrhage, and had her dialysis port ripped out when the sling failed while she was being transferred in a mechanical lift by a single aide.

This resident was dependent on staff to transfer her using a mechanical lift. It was well-established that this is an activity which required the assistance of two staff. The resident’s Minimum Data Set (MDS) and care plan called for the assistance of two staff with transfers. The facility policies and procedures also called for assist of two with transfers being done with a mechanical lift. Besides all of those reasons, it is good, safe nursing practice – having two people assist in a transfer using a mechanical lift allows one staff to control the lift itself while the other protects the resident during transfer. We have written many times about how having one person do a two-person job is a formula for disaster (see here, here, here, here, and here for examples).

On the day of this nursing home fall, the resident was being transferred to bed by a single aide using a mechanical lift. During the transfer, one of the loops that attached the sling to the lift itself failed, causing the resident to fall to the ground. As a result of this fall, she suffered a broken ankle, an intracranial hemorrhage, and had her dialysis port ripped out.

In the investigation, the aide involved reported that she had inspected the sling before use and attached the sling properly. The sling was sent to the manufacturer for analysis before it could be inspected by the state surveyor.

During the investigation, the aide acknowledged that the transfer was supposed to be done with two staff, but there were only two aide on duty that night and the other aide was too busy to help. She further acknowledged that she frequently transferred residents on her own – and the resident said as much when asked by the state surveyor.

One of the immediate causes of this fall was the fact that there was a single aide doing the transfer when two were required. However, there is a larger issue, and that is understaffing of the nursing home. When there are facts such having one person doing a two person job, that the staff present were “too busy” to help one another, and that the shortcuts in the care of residents were being routinely taken, these are signs of an understaffed nursing home.

Sadly, understaffing is a feature, not a bug in the nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Grosse Pointe Manor resident breaks leg during improper transfer

Grove of Skokie resident breaks leg due to violation of care plan

Glenview Terrace resident suffers multiple fractures when lift topples over during transfer

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Westmont Manor resident suffers brain bleed after being rolled from bed

May 3, 2022 By Barry G. Doyle

IDPH has cited and fined Westmont Manor Nursing & Rehabilitation Center nursing home after a resident there suffered a brain bleed due to being rolled from bed by the staff during incontinence care.

The resident at issue had a history of having suffered a stroke with resultant left-sided weakness and cognitive deficits. The resident’s Minimum Data Set (MDS) called for the assistance of two staff with bed mobility.

In the long term care industry, the term “bed mobility” refers to the ability of the resident to change and maintain position in bed. This is an important area for assessing a resident’s abilities because the resident’s ability to change positions in bed is crucial for things like incontinence care and turning and repositioning, all of which are important for the prevention of bed sores.

The resident’s abilities with regard to bed mobility are recorded on the Minimum Data Set (MDS) which is a document which is submitted under oath to the federal government and is part of the basis for calculating the payments to the nursing home for the care that the resident receives. When the MDS indicates that a resident requires extensive assist of two staff members for bed mobility, this indicates that the resident has little to no ability to change or maintain position in bed. When two staff are providing care in bed to the resident, one staff member should be on each side of the bed with the staff member on the side of the bed in which the resident is turning being charged with making sure that the resident does not fall from the bed. The resident care plan further called for keeping the resident’s bed in the lowest position.

On the day of this nursing home fall, the resident was receiving incontinence care from a single aide, not the two which were required per the MDS. We have written on multiple occasions about how having one person do a two-person job is a formula for disaster (see here, here, here, here, and here for examples), and that proved again to be the case here. As the aide rolled the resident away from him, the bed was not in the lowest position as called for in the care plan, and the resident rolled over the edge of the bed, hitting his head on the floor. He was brought to the emergency room where it was discovered that he had a brain bleed.

This is a simple case of the resident not receiving the call which was necessary and which the nursing home certified it was providing – it was literally a situation where you had one person doing a two-person job.

The deeper question is of course why did this aide attempt to do a two-person job by herself? The likely answer relates to understaffing of the nursing home.

Federal regulations require that the nursing home have enough staff on hand to meet the care needs of the residents on a 24/7 basis. Unfortunately, nursing home often fail to meet that standard because understaffing is a key component of the nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Prairie Manor resident suffers brain bleed in fall

Failure to supervise Westmont Manor resident leads to fall and broken hip

Resident at Chateau Nursing Home in Willowbrook suffers spinal fractures in wheelchair accident

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Landmark of Richton Park resident dies due to mishandling of tracheostomy

April 22, 2022 By Barry G. Doyle

IDPH has cited and fined Landmark of Richton Park nursing home after a resident there died after a respiratory therapist cut sutures to a fresh tracheostomy without a physician order, leading to the loss of the airway and cardiac arrest.

A tracheostomy is a surgically-created airway. A surgeon cuts a hole, or stoma, in the front of the neck and through the trachea. A tube is then placed in the hole and allows the person to breathe through the hole. A tracheostomy is commonly used for ventilator-dependent patients to reduce complications associated with the use of a ventilator.

The tracheotomy tube actually consists of three parts. One is known as the outer cannula. The outer cannula has a neck plate flange which is stitched into place in the hole (or stoma) in the neck at the time of surgery. There is an inner cannula which fits inside the outer cannula and can be removed and cleaned. Finally, there is an obturator which is used only while the inner cannula is being placed. After it is placed, it is removed and disposed of.

Because the hole (or stoma) is a surgical wound, it must be given time to heal. Premature removal of the stitches can cause subcutaneous emphysema, or leaking of air under the soft tissues. Removal of the tube is not recommended for several days after initial placement because this can lead to rapid loss of the airway.

The resident at issue was admitted to the nursing home the day before the incident with a newly-created tracheostomy. During rounds, the wound care nurse advised the respiratory therapist that dressing wound did not look like it had been cleaned. The respiratory therapist saw that there was some dried blood in the area and decided to clean it. She asked the wound care nurse to borrow a pair of scissors so that she could cut a resident’s sutures. The wound care asked if was okay to do and the respiratory therapist said yes. She then proceeded to cut all of the sutures and clean the area.

Later that day, the alarms to the ventilator went off. The respiratory therapist went in and found that the resident was having a hard time breathing. Believing that the resident had a mucus plug (an accumulation of mucus in the airway which restricts airflow), she attempted to suction out the airway but did not get anything out and was not able to see the plus. She called for help and the rest of the staff responded. According to the respiratory therapist, the staff attempted to remove and replace the tracheostomy tube and ventilate the resident using an ambu-bag. However, there was resistance when they squeezed the bag on the ambu-bag, indicating that there was a loss of the airway. The resident began to turn blue and her face began to swell as they attempted to ventilate the resident.

Paramedics arrived, and they recorded on their report that the staff told them that the respiratory therapist had been the one to remove the tracheostomy tube. The paramedics were unable to re-establish the airway, and the resident went into cardiac arrest. She was brought to the hospital, but did not survive. When the resident arrived at the hospital, the staff noted extensive evidence of subcutaneous emphysema.

There are a number of issues with the care that this resident received. First, the sutures for the tracheostomy were removed prematurely, and done so without a physician order. Second, the tracheostomy tube was removed during the resuscitation effort. This likely contributed to the loss of the airway. It would be critical in any nursing home abuse and neglect lawsuit to determine exactly who removed the tracheostomy tube, as respiratory therapists often work for an outside company. Finally, the nurse provided the scissors to the respiratory therapist when she was likely aware that removing the sutures was inappropriate and that there was no physician order for doing so.

One of our basic 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. Order our FREE report, Built to Fail, to learn more about why. 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.

Other blog posts of interest:

Landmark of Richton Park resident dropped from lift, breaks both legs

Generations at Rock Island cuts respiratory staff, care suffers

Aperion Care Wilmington resident suffers ruptured colon from fecal impaction

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

University Rehab resident breaks hip in fall from bed during incontinence care

April 14, 2022 By Barry G. Doyle

IDPH has cited and fined University Rehab nursing home in Urbana after a resident there suffered a fractured hip in a fall from bed while he was receiving incontinence care.

Doing proper assessments is a basic step to assuring the safety of nursing home residents. Two assessments which are done in well-run nursing homes are bed mobility assessments and side rail assessments. Bed mobility refers to the ability of a nursing home resident to turn, change position, and maintain position in bed. This is important because it helps determine the staff levels and equipment needed to provide proper care to a resident while they are in bed. It is one of the assessments recorded in the Minimum Data Set (MDS) for a resident. Side rails carry some risk of injury or entrapment, and the side rail assessment is used to determine whether the use of a side rail as an aid in bed mobility and/or transfers warrants the risk associated with the use of the side rail.

The resident involved had been a resident at the nursing home, but was relatively new to the room where the incident occurred. In his prior room, the bed was equipped with a side rail. However, in his new room, the bed in his new room did not have side rails.

On the day of this nursing home fall, he was receiving incontinence care form an aide and was positioned on his side, bracing himself with his arm against the wall. The aide removed the brief and was placing a new brief underneath him. As she did so, he rolled out of the bed, suffering a fractured hip which required surgical repair.

When he was in his prior room with the bed with the side rails, he would use the side rails to maintain position while receiving incontinence care. Facility policies called for continuing all interventions which had proven successful in preventing falls. The practice at that nursing home had been to move a resident’s bed with them when they were moved to a new room. This was not done, and the resident was provided with a bed that had no side rails. Had the resident been provided a bed with side rails, he would not have had to be positioned as close to the edge of the bed to reach the wall and would not have had so much weight hanging off the edge of the bed, placing him at greater risk for falling from bed.

Further, investigation showed that there were no assessments of the resident’s bed mobility or side rail assessments in the resident’s chart. Had these been done, it is likely this resident’s care plan would have called for assistance of two staff during incontinence care or the use of side rails for assistance with bed mobility. Either of these steps would have likely prevented this fall and injury.

There were a number of breakdowns in the care of this resident which led to the fall and broken hip. First, there was the lack of proper assessments which led to issues relating to bed mobility not being addressed in the resident care plan. Second, the facility policy of continuing effective fall prevention measures was not followed in that side rails were not incorporated when the resident changed rooms. Finally, the practice of moving the bed with the resident was not followed. Any one of these would likely have prevented the injury to this resident.

Other blog posts of interest:

Westminster Village resident breaks leg in fall from toilet

Failure to activate chair alarm results in fall and brain bleed at Pleasant Meadows in Chrisman

Tuscola Health Care resident dropped from lift, breaks ankle

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Lemont Nursing & Rehab cited for failing to notify doctor of abnormal lab results

March 19, 2022 By Barry G. Doyle

IDPH has cited and fined Lemont Nursing & Rehabilitation Center nursing home in Lemont due to the failure of the staff to notify the resident’s doctor of abnormal lab results.

One of the basic facts of care in a nursing home is that there are not doctors on hand on a 24-7 basis. However, members of the nursing staff are, and one of their functions is to serve as “the eyes and ears of the doctor” when the doctor is not actually in the nursing home. Nurses are required to notify the doctor of significant events in the care of the resident, such as the occurrence of a fall, the development or a bed sore or its decline, abnormal lab or test results, and of any changes in the condition of a resident.

One thing that requires physician notification is the onset of signs and symptoms of infection. Nurses are not required to be able to determine exactly what the infection is or how to treat the infection, but they do need to know when a resident is showing signs and symptoms of infection. When a resident is showing signs and symptoms of an infection, the nurse is required to notify the doctor and the doctor can use that information to decide whether to issue orders for treatment over the phone, come into the nursing home to examine and treat the resident, or to have the resident sent to the emergency room.

The use of an indwelling catheter is something that predisposes nursing home residents to develop urinary tract infections. There are a number of reasons for this, and as a general proposition, nurses working in a nursing home setting are well-schooled on what the signs and symptoms of a urinary tract infection are. These might include: lethargy, confusion or other changes in mental status; fever; back or flank pain; burning while urinating; and changes in the color or appearance of the urine itself such as it becoming cloudy or darker, having pus or blood in it, or having a foul odor. When those signs and symptoms occur, then physician notification is required.

The resident at issue here had an indwelling catheter. He began to show increased confusion and the urine draining from catheter was cloudy. These are signs of a urinary tract infection. The physician was notified and he ordered a urinalysis and urine culture to determine whether the resident was suffering from a urinary tract infection and if so, what antibiotics would be most effective against it.

The resident also had a regularly scheduled Complete Blood Count (CBC) done the next day. When the results of that came back that afternoon it showed that the white blood cell count was significantly elevated. An elevated white blood cell count is an indicator that there is an infection present. This abnormal lab result should have been reported to the doctor. However, it was not. In the context of this resident’s reported confusion and cloudy urine, the failure of the nursing staff to notify the doctor of the abnormal lab results deprived the doctor of a critical piece of information in medical decision-making.

Three days after the CBC test results came back, the results of the urinalysis came back. These showed that the resident did in fact have a urinary tract infection. The doctor was properly notified and started the resident on an antibiotic. However, the following day the resident had to be sent to the hospital due to decreased urine output. The resident was admitted to the intensive care unit with a diagnosis of elevated white blood cell count and sepsis. After the family had the resident placed on comfort care only, the resident died a week later.

Here, there was a simple failure to follow standard nursing practices. The doctor was notified when there was a change in the resident’s condition initially, resulting in the urinalysis being ordered. The doctor was also notified when the results of that test came back with abnormal findings. However, the staff failed to notify the doctor of the blood test showing the elevated white blood cell count. This piece of information would likely have led to early administration of antibiotics and may have yielded a different outcome, as delay in the initiation on effective antibiotics increases ill-effects of infections.

Other blog posts of interest:

Grove of Elmhurst resident dies due to delay in physician notification

Aperion Care of Wilmington resident suffers ruptured colon due to fecal impaction

Resident at Arcadia Care in Danville dies due to improperly treated urinary tract infection

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Swansea Rehab resident fractures hip in fall

Arcadia Care Bloomington resident suffers broken hip and back due to defective wheelchair

Odd Fellow-Rebekah Home resident suffers fatal brain bleed due to fall

Mishandling of resident results in broken shoulder at Havana Health Care Center

Symphony of Buffalo Grove resident has catastrophic fall from lift

Resident suffers broken ankle in unsafe transfer at Loft Rehab of Rock Springs

Park Place Christian Community resident rolled from bed by staff

Heritage – Mt. Sterling resident breaks leg in fall

Forest City Rehab fails to send resident to dialysis

Mason City Area Nursing Home resident suffers fatal brain bleed in fall

Catastrophic brain injury results from medication error at Alden Town Manor

Fondulac Rehab resident suffers fatal injuries in fall

Addolorata Villa resident fractures hip in fall

Monmouth Nursing Home resident suffers multiple falls, resulting in brain bleed

Aperion Care St. Elmo resident breaks hip in fall

Hope Creek resident fractures hip in fall from toilet

Sunny Hill resident suffers fractured leg after lift tips over during transfer

Villa at South Holland resident breaks back when lift tips over during transfer

Charleston Rehab resident suffers brain bleed and hip fracture in fall from bed

Mason City Area Nursing Home resident suffers broken hip in fall due to failure to use gait belt

Grove at the Lake resident suffers multiple injuries in mechanical lift accident

Westmont Manor resident suffers brain bleed after being rolled from bed

Landmark of Richton Park resident dies due to mishandling of tracheostomy

University Rehab resident breaks hip in fall from bed during incontinence care

Lemont Nursing & Rehab cited for failing to notify doctor of abnormal lab results

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