IDPH has cited and fined Warren Barr Buffalo Grove due to a failure of the staff to correctly obtain timely emergency care for worsening signs of an acute brain bleed, leading to a fall and a trip to the Emergency Room.

One of the basic roles that a nurse in a nursing home setting plays is to serve as the eyes and ears of the resident’s doctor.  When a resident shows signs of a change in condition, has a nursing home fall, or is demonstrating some other condition of ill-being, it is the nurse’s job to notify the doctor.  The doctor then can issue orders over the phone for treatment to be delivered at the nursing home, go into the nursing home to see the resident himself, or order the resident sent to the hospital for examination and treatment there.  Occasionally a situation arises where the nurse does not have time to contact the doctor, and must make a decision as to whether or not to call an ambulance service or 911 when the resident’s condition warrants.  That was the case in this troubling nursing home injury.

The resident at issue was a 66 year old male who had multiple diagnoses including being prescribed blood thinning medications.  The resident suffered an initial fall with head injury around 5PM. Although the resident hit his head and required hospital evaluation, he was returned to the nursing facility by 8:41PM the same night, with some documented complaints of headache but cleared for monitoring with orders to report any changes.

However, the overnight nurse admitted she failed to closely track and report concerning changes in the resident’s condition that developed over her shift between the night of his return from the hospital and his catastrophic re-fall at 5AM the following morning.

Specifically, the nurse shared that the resident became severely restless and agitated overnight, with repeated unproductive calls for assistance going to the bathroom, estimating this happened potentially 6-7 times through the night. She also took his blood pressure multiple times, getting readings as high as 221/97, extremely hypertensive levels that continued uncontrolled for hours without notifying the physician.

Her reasoning for not notifying the physician were documented as “I needed time to figure things out” and worrying doctors “may get upset if it’s not serious,” indicates a neglectful mindset downplaying his unstable vital signs. 

Eventually around 4AM in frustration at his persistent calls she moved him away from his room to sit unattended nearby. 

An hour later he took another devastating fall, now with seizure-like movements. This resulted in prompt hospitalization for an acute brain bleed, likely exacerbated by the unchecked overnight changes signaling a decline in status.

The Assistant DON confirmed the resident’s presentation with headache on blood thinners after a first fall, then subsequent agitation and hypertension without notification, should have indicated probable hemorrhage and been addressed emergently.

Nursing homes are businesses, and well-run businesses have systems in place to carry out their basic functions.  Assuring that patients are not neglected and that they receive timely medical care and attention is one of those basic functions.  Here there was clearly a problem with the system that the nursing home was operating under, as the facility’s failure to implement timely emergency care during the resident’s obvious medical crisis subjected him to a negligent delay in treatment and ultimate second fall and trip to the Emergency Room.

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.

IDPH has cited and fined Bella Terra Schaumburg nursing home after a resident there suffered a hip fracture in a fall in the dining room.

Falls are a major concern in the long-term care industry because of the serious negative effects they have on mortality and the long-term quality of life for nursing home residents.  Because of this, they are a regular focus in the care planning process.

Nursing homes use a variety of tools to assess a resident’s fall risk.  Some of the major factors are a recent history of falls, as it is well-recognized in the long-term care industry that falls tend to beget additional falls; balance, gait, or musculoskeletal dysfunction; and some form of cognitive impairment, dementia, constant or intermittent confusion, or general poor judgment or awareness for one’s own safety or limitations.  The cognitive impairment factor is crucial because this means that a resident cannot be counted on to follow instructions or to make good judgments or decisions for his or her own safety.

Federal regulations pertaining to falls in nursing homes provide that residents must receive supervision and assistance necessary to prevent accidents.  Falls are considered accidents under the regulations.

Close supervision of the resident is a mainstay of any fall prevention strategy in a nursing home.  One of the common ways of providing supervision to residents is to gather them in areas where several residents who require supervision can all be watched at the same time by a limited number of staff people.  Common examples of this would be to gather residents in an activity room, near the nurse’s station, or in the dining room.

The resident at issue had a MDS (minimum Data Set) assessment that  showed he had impaired cognition and required extensive staff assistance for all activities like bed mobility, transfers, and using the toilet. The MDS indicated he was extremely unsteady on his feet and only able to stabilize himself with full staff assistance when moving from seated to standing, walking, getting on and off the toilet, and during transfers. The assessment also documented right-sided paralysis as a result of a previous stroke. Additionally, it showed the resident had impaired decision-making capacity and required complete staff support for daily choices due to his cognitive issues.

He was categorized as having high risk for falls due to these multiple physical and functional limitations and dependencies requiring assistance.

About a week before the fall that resulted in the injury, the resident had a fall in his room while attempting to get out of his wheelchair without the assistance of staff.  After this fall, the resident’s fall prevention care plan was updated to “offer toileting to the resident upon rising in the morning, before and after each meal and at bedtime.”

On the day of this nursing home fall, the resident was last seen unattended, self-propelling his wheelchair in the dining room of the nursing facility. His assigned nursing assistant was busy caring for another resident at the time and was not present to supervise him. At some point, the resident stood up from his chair in the dining room and subsequently lost his balance. A staff member witnessing from across the room saw him fall to the floor, landing on his right side. However, the staff member was too far away to reach him in time to assist or prevent the fall.

Immediately after the fall, the resident complained of significant pain in his right hip area. He was kept immobilized by staff and emergency medical services were called. He was transported to the hospital where he was admitted and diagnosed with a right acute femoral neck fracture requiring urgent surgical intervention.

Critically, Interviews with nursing staff later revealed that the resident had not been assisted to the bathroom following his dinner meal, which was supposed to be an implemented intervention for his toileting needs after the fall less than a week earlier.

Also, the dining room was understaffed.  The lone CNA staff member in the dining room at the time of the fall told the investigator that “there were so many residents in the dining room at that time who were at high risk for falls and could not watch them all.” 

Other staff members concurred that there should have been two staff members present for supervision and assistance in the dining hall instead of just one.

This is a case where the extent to which dementia/confusion plays into fall risk is clearly demonstrated.  The resident was not able to walk independently – he used a wheelchair as a matter of routine – but because of his cognitive impairment, he thought that it was appropriate for him to try to get up on his own when he was clearly not able to do so safely.  This is why close supervision of residents who have cognitive impairments is so crucial – because they cannot be relied upon to follow instructions or make good decisions for their own safety. 

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.

IDPH has cited and fined The Waterford Care Center in Chicago after a resident there suffered a spiral fracture of the right humerus bone requiring hospitalization for surgical repair due to rolling out of bed while receiving incontinence care from a single staff member rather than the two that were needed.

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.  To assist the staff in knowing which residents require the assistance of two staff, the staff is provided with a care card which spells out the requirements for care of that resident.

On the day of this nursing home fall, a certified nursing assistant (CNA) entered the resident’s room alone to provide care. The CNA stated she was going to change the resident’s diaper and instructed the resident to turn onto her side. As the resident attempted to turn, she made an excessive twisting motion and half of her body slid off the bed with her waist down ending up on the floor. The resident was still holding onto the side bed rails with her hands to keep her upper body partially on the bed. According to interviews, The CNA reported she was unable to stop the fall due to the resident’s size. After the fall, the resident stated to the CNA that she had “overturned” herself and fell out of the bed. The CNA left the resident on the floor and went to get a nurse for assistance. The nurse and other CNAs arrived and used a sheet to pull the resident back into the bed, as the mechanical lift could not lower enough to reach the floor.

After being assessed, the resident was noted to have right arm swelling and bruising on her left hand. She complained of pain with any movement and was sent to the emergency room where she was diagnosed with a closed displaced spiral fracture of the right humerus requiring surgery.

The lack of proper two-person assistance during the bed mobility task directly contributed to the resident falling from the bed and suffering this serious injury requiring hospitalization. The nursing assistant’s failure to obtain a second staff member to assist with the turn, as clearly indicated in the care plan, resulted in the preventable fall and subsequent fracture.

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

Unfortunately, understaffing of the nursing home is a feature, and not a bug, in the nursing home business model.  The net effect of understaffing is that it doesn’t give the staff the ability to provide proper care for the residents – and the net result of that is unnecessary injuries such as this one.

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.

IDPH has cited and fined Willow Rose Rehab & Health after a resident experienced multiple falls, the last of which resulted in a right hip fracture.

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 take on a day-to-day, shift-to-shift basis to prevent falls.

The resident in question experienced two back-to-back falls on consecutive days.  The second of the nursing home falls was unwitnessed by any staff members.  The resident was “observed on the floor sitting with her back against the bedside table. Incontinent of urine and shoes next to bed instead of on feet, lighting adequate, no apparent injuries noted at this time other than redness to left upper extremity (bicep) and to left side/back.”

The third fall, approximately a month later, was unwitnessed as well.  According to an internal note, a nurse was called to assess the resident in her room.  The resident was observed sitting on the floor, next to her bed.  She was complaining of severe right hip pain, and her leg was noted to be “extremely rotated and shortened.”  The nurse assisting the resident was unable to move the limb at all. 

The resident was rushed to the emergency room via ambulance, where she was diagnosed with a right hip fracture. 

There were a number of shortcomings in the care of this resident which contributed to the serious injury that she suffered in her third fall.

• The facility failed to properly investigate the root causes of these repeated falls per their own policy. After each fall, the facility conducted a “Quality Assurance Fall Analysis” that contained limited information and no detailed investigation of the root causes of each fall.  

• The resident’s care plan was not updated with new interventions until almost a week after the third fall that resulted in the serious hip injury.  There were no additional fall risk assessments done after the falls, only quarterly.
• After the third fall, some generalized fall interventions were added to the care plan like keeping the call light within reach, but did not include targeted interventions to address the specific circumstances around the resident’s falls.
• Staff interviews revealed a lack of understanding on when and how to update care plans and conduct fall investigations after incidents.  When the investigator interviewed the DON (Director of Nursing), she noted that a relatively brief Quality Assurance Fall Analysis was conducted after each fall, and that “no other investigations occurred after falls.”  The following day, the investigator conducted an additional interview with the DON, where she changed her message to more accurately reflect the facility’s Fall Prevention Policy.  She claimed that she expected Fall Risk Assessments to be performed during admission, quarterly AND after a resident fall.  She also mentioned that there should be fall interventions placed in the resident’s care plan after each fall, and that staff should be following the interventions. 

One can only assume that the serious injury this resident suffered may have been prevented if those caring for the resident had properly investigated the root causes of the falls and updated the care plan in a timely manner with new interventions.

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.

IDPH has cited and fined Addolorata Villa in Wheeling after a resident there was left by the activity staff alone with two dining services staff members.  The resident subsequently tried to rise up from her wheelchair, fell to the ground and suffered a left hip fracture.

Falls are a major issue in the long-term care industry because they have such significant implications for the well-being of residents.  Fall risk is one of the areas which is specifically assessed during resident assessments during the care planning process.  There are a number of tools that are used at different facilities, but the two common threads to assessing a resident’s fall risk are (1) some type of gait, neurologic, or musculoskeletal dysfunction which makes it difficult for a resident to walk, stand, or transfer safely, and (2) some type of cognitive deficit such as dementia, intermittent or constant confusion, or simple poor safety awareness or judgment.

The reason that cognitive deficits contribute to a resident’s fall risk is that the resident cannot be counted on to follow instructions or take basic precautions for their own safety.  Because of this, keeping the resident under close observation is a mainstay of fall prevention.  In fact, federal regulations pertaining to nursing home falls require nursing homes to provide supervision and assistance necessary to prevent accidents.  Usually, this takes the form of keeping residents who are at risk for falls near the nurse’s station, the dining room, the activity area or some other common area where the staff can keep an eye on what the residents are doing.

The resident at issue here had a diagnosis of Dementia, Major Depressive Disorder, Alzheimer’s Disease, and Osteoarthritis.  Importantly, a nurse remarked that if the resident attempted to get up from her wheelchair, she needed both physical cues and physical contact in order to sit back down. She would not just sit down on her own if asked by a staff member.

On the day of this nursing home fall, the resident was left by herself in the dining hall for approximately 20 minutes by the Life Enrichment Aid, who was busy bringing other residents back to their rooms.  The only other staff in the dining hall were dining services members.  

Dining services staff are asked by the facility to keep an eye on residents.  If a resident attempts to get out of their wheelchairs they are instructed to ask the resident to sit down, but since they are not clinically trained, they are not permitted to physically contact the residents.  

The dining staff members claim that they were keeping an eye on the resident in question, but that she “was trying to scoot herself up.” A dining staff member told her to sit down and that someone was coming for her. The resident was lifting her bottom by using the arm rest on the chair to lift herself.  The dining staff member then said that she turned from the resident for a moment, and when she turned back the resident was on the floor.

The resident was rushed off to the hospital, where she was diagnosed with a fractured left hip.    

Whenever there is a report that staff which were required were not present, this raises a question of whether the nursing home is understaffed.  Sadly, understaffing of nursing homes 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.

IDPH has cited and fined Greek American Rehab & Care Center after a resident there was allowed to go to the bathroom without the required help and then fell from the toilet seat, resulting in a fracture to her right hip, which required surgery to fix.

Care planning is a process by which risks to the health and well-being are identified and measures are put into place and carried out on a day-to-day basis to prevent those risks from coming to fruition.  One of the ways that proof of nursing home abuse and neglect is proven is by showing violations of the resident care plan.  Delivery of the care called for in the care plan is fundamental to providing quality care to residents in a nursing home setting.

There are six steps to the care planning process: (1) an assessment of the risks to the health and well-being of the resident; (2) a written care plan is developed which identifies a series of steps or interventions intended to reduce the risks to the resident.; (3) communication of the care plan to the staff who are charged with carrying it out; (4) implementation of the care plan on a day-to-day, sift-to-shift basis; (5) ongoing evaluation of the effectiveness of the care plan; (6) revision of the care plan if it proves to be inadequate in practice or if the care needs of the resident change.

The resident at issue was identified as being a fall risk, and a fall prevention care plan was put into place.  Among the important points in the care plan was the designation of the resident as a 1 person assist to the toilet.  Generally speaking, that means a staff member either stays in the bathroom or just outside the door when a resident toilets.  

On the day of this nursing home fall, the nurse placed the resident on the toilet chair in her bathroom and then left her there unattended to go assist another resident.  The resident subsequently slid off from the toilet onto the floor and threw a bootie she was wearing on her feet out into the room to try to get staff attention.  

The fall resulted in a fracture to her right hip.  The resident was transferred to the hospital where she underwent surgery to fix the injury.  

The basic issue with the care that was provided is that the resident’s care plan called for individual assistance on the toilet.  Residents as fragile and unsteady as this resident cannot be left alone on the toilet.  The decision of the nurse to leave the resident alone with a call button while she was attending to another resident in a different room was a mistake.  Because the resident was left on the toilet unattended, the fall and injury resulted.

When you have staff that is stretched too thin to provide necessary supervision and help to residents to avoid accidents, this raises fair questions as to whether this was an understaffed nursing home.  Unfortunately, understaffing a nursing home is a basic 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.

IDPH has cited and fined The British Home in Brookfield, Illinois after a resident there suffered a right hip dislocation in a fall.  Importantly, the resident’s Minimum Data Set clearly stated that the resident needed two, not one person to assist with movements in bed.  

Much of the routine care that residents receive in a nursing home setting is shaped by the resident care plan.  In the care planning process, an assessment is done to identify the resident’s care needs and risks to the health and well-being of the resident.  A series of steps, or interventions, are then put into place which are intended to meet the resident’s needs.  The staff members assigned to carry out those interventions then must do so on a day-to-day, shift-to-shift basis.

The resident at issue had a Minimum Data Set (MDS), a key part of the care planning process, that indicated the resident required two-person assist for bed mobility, which includes turning side to side and body positioning in bed.

On the day of this nursing home fall, the resident said a male CNA (Certified Nursing Assistant) was helping him get into bed, when he began slipping out of his arms, and almost fell to the floor. The resident added he “kept slipping and sliding out from the male aide’s hold” and was face down when his hands went down to the floor. The resident then said the male aide was trying to hold the rest of his body up, but eventually his whole body ended up on the floor. 

After the fall, the resident was in between the bed and the radiator, almost in a fetal position, screaming “please help me.”  Since the resident was asking to get off the floor, the CNA got the mechanical lift and assisted the resident up off the floor and back into bed.

The resident was emergently sent to a local hospital for further evaluation and treatment per physician’s orders. The resident was admitted to the hospital and diagnosed with “right hip dislocation with no acute fracture.”

The nursing home had a reasonable care plan in place for this resident – the problem was that the staff did not implement it.  Rather than follow this care plan, the staff attempted to help the resident into bed with the assistance of only one CNA, not two as the MDS called for.

The fact that the staff plowed ahead with trying to assist the resident with only one staff member raises a question of whether this is an understaffed nursing home.  This is true anytime you see the staff taking shortcuts which sacrifice resident safety.  Sadly, understaffing a nursing home 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.

IDPH has cited and fined Hillsboro Rehab & Health Care Center after a resident there fell three separate times during her first week at the facility, sustaining a non-operable re-fracture of her left hip.

Falls are a major source of mortality and loss of quality of life for the nursing home population.  They are also addressed in federal regulations which require that nursing home residents receive supervision and assistance necessary to prevent accidents.  A fall is a form of accident.  Because of this, fall prevention is a serious area of focus in the long-term care industry.

There are two major factors that make residents at risk for falls.  These include (1) some form of musculoskeletal, gait, or balance dysfunction which place a resident at risk for losing balance or falling and  (2) some form of cognitive impairment, dementia, confusion, or general poor safety awareness.  Cognitive issues feed into fall risk because the resident cannot be counted on to follow instructions or make good decisions for their own safety.

The resident at issue was severely cognitively impaired, with behaviors such as inattention and disorganized thinking, and required assistance with Activities of Daily Living (ADLs) including bed mobility, transfers, walking in room, dressing, eating and toileting.

The day after the resident was admitted to the facility, the resident was found by a nurse on the ground at the foot of her bed, sitting on her buttocks with her left leg extended forward and right leg bent.  The resident was complaining of pain and discomfort, and was transported to the ER, where all tests for injuries were negative. 

The resident returned to the facility, only to fall again that same evening.  This time the resident was found on the floor in front of the bathroom.  She was lying on her right arm, complaining of right shoulder, back and hip pain.  Before returning to the ER a second time in one day, a nurse at the facility spoke with the ER doctor.  He stressed that he was unable to believe that the resident had fallen a second time, since he had given orders that upon returning to the facility the resident was to receive 1:1 care.  This refers to a specialized level of care provided in nursing homes where one caregiver is assigned to provide individualized care to a single resident. 

The third fall occurred approximately five days later, with the resident found on the floor near her overturned commode.  This fall resulted in another trip to the ER and a diagnosis of a non-operable re-fracture of the left hip.

The citation mentions several interviews with nurses that try to explain how the order for 1:1 care from the doctor was missed after the first fall.  Nurses also honestly confessed that this level of care would have been nearly impossible, as “if you are 1:1 with a resident, no one else would get their care.”

When you have staff that is stretched too thin to provide necessary supervision and help to residents to avoid accidents, this raises fair questions as to whether this was an understaffed nursing home.  Unfortunately, understaffing a nursing home is a basic 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.

The Illinois Department of Health has cited Bella Terra Wheeling after a resident fell from her wheelchair in the dining room and suffered face lacerations and a fractured femur.

Falls are a major concern in the long-term care industry because of the serious negative effects they have on mortality and the long-term quality of life for nursing home residents.  Because of this, they are a regular focus in the care planning process.

Nursing homes use a variety of tools to assess a resident’s fall risk.  Some of the major factors are a recent history of falls, as it is well-recognized in the long-term care industry that falls tend to beget additional falls; balance, gait, or musculoskeletal dysfunction; and some form of cognitive impairment, dementia, constant or intermittent confusion, or general poor judgment or awareness for one’s own safety or limitations.  

The cognitive impairment factor is crucial because this means that a resident cannot be counted on to follow instructions or to make good judgments or decisions for his or her own safety.

Federal regulations pertaining to falls in nursing homes provide that residents must receive supervision and assistance necessary to prevent accidents.  Falls are considered accidents under the regulations.

Close supervision of the resident is a mainstay of any fall prevention strategy in a nursing home.  One of the common ways of providing supervision to residents is to gather them in areas where several residents who require supervision can all be watched at the same time by a limited number of staff people.  Common examples of this would be to gather residents in an activity room, near the nurse’s station, or in the dining room.

On the day of this nursing home fall, the resident in question was in the dining room, in her wheelchair, waiting for breakfast to be served.  The nurse watching over the residents that morning claims that she was helping another resident when she heard the resident “fall hard,” landing on her right side and bleeding onto the floor.  

The resident was assessed, x-rays were ordered and the resident was sent to the hospital for further evaluation.  At the hospital it was determined that the resident had suffered an acute femur fracture.

Falls can be devastating events for seniors, and often they lead to additional falls.  While this fall is certainly a serious and sad occurrence, equally as disturbing in this case are some of the findings that the surveyor found when she went to conduct her investigation at the facility.

– When the surveyor visited the same dining room where the fall occurred, there was a different nurse watching a group of residents.  That nurse commented that “you can see there are a lot of residents here so we can’t get to all of them if they fall.”  When the surveyor counted the number of residents assembled in the dining hall, she counted 41, with just one nurse monitoring the room.  

– When the surveyor visited the nurse that was watching the resident on the day of the incident, the nurse stated that she was “with agency and I had just got there that day and they (facility) assigned me to be in charge of watching the dining room.”  

When the surveyor asked if she had returned to the facility after the day of the accident, she replied that she had not and that she had no idea that the resident was a fall risk.  “No I haven’t been back since that last time and I only was there once.  I didn’t know anything about her fall risk. Is she one because they didn’t tell me anything? All they do like every place is give you the residents and they don’t tell you anything.”

When asked if the agency had received any dementia or fall prevention training, the nurse replied “I’m with agency, they don’t do training.”

When a nursing home is unable to provide residents with the necessary supervision, that is a sign that this is likely an understaffed nursing home.  Even worse, when a nursing home does not train their nurses in fall prevention, it would seem to border on negligence.  Unfortunately, insufficient training of nurses and short-staffing a nursing home is a basic 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.

IDPH has cited and fined Bria of Westmont after a resident fell from her bed,  sustaining a painful pelvic fracture.

Prior to the accident, the resident at issue had a Minimum Data Set (MDS) submitted to the federal government indicating that she required the assistance of two for bed mobility.  For the ability to roll left and right in bed, the resident was coded as “01”.  This code means that the dependent-helper does all of the effort and the resident does none of the effort to complete the activity.  

Importantly, this facility does not use side rails on beds.  Therefore residents that require this much assistance are not able to remain on their side without the risk of rolling over. 

The only way to safely provide incontinence care would be with two staff members, one to hold onto the resident and the other to provide the incontinence care.

At the time of this nursing home fall, an aide was providing incontinence care by herself to the resident. The aide explained that after positioning the resident on her left side, she quickly ran into the bathroom inside of the resident’s room to get more supplies, leaving the resident unattended “for no more than 10 seconds.” The aide acknowledged that she witnessed the resident fall out of the bed as she stepped out of the bathroom, landing onto her right side on the floor.

When the x-ray technician arrived in the room, the technician found the resident “in tremendous pain and screaming.”  

She was diagnosed with a closed nondisplaced fracture of the right acetabulum and a closed fracture of the right pubis.  

This is yet another instance where a resident suffers injury because one person was doing a two-person job (see here, here, here, here, and here for examples).  Generally the root cause of this kind of incident is due to understaffing of the nursing home, which is something that is inherent 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.

IDPH has cited and fined Bria of Belleville after a resident there fell out of bed and was hospitalized due to bed rails that were poorly attached to the frame.

Although the U.S. Food and Drug Administration’s (FDA) warnings on bed rail safety have prompted many manufacturers to design safer beds that minimize the risk of accidents, many nursing homes continue to place their residents in outdated beds with unsafe rail designs.

Nursing homes that do have upgraded beds often still have older models in some rooms, since there is little incentive to rid the facility of any usable bed. Adding to the risk of serious or fatal injury are rental beds from medical supply companies. Not only are the rental beds typically those with more outdated designs, but they are often sent to nursing homes with mismatched parts. In other words, the mattress and bed rails may be from different manufacturers, putting the resident at risk of getting trapped in the space between the mattress and frame.

On the day this resident was admitted to the nursing home she immediately remarked to the admitting nurse that the bed rails felt “loose and wiggly.”  The resident’s husband remarked that his wife showed how loose the bed rails were to “several staff members . . . and no one did anything about it.”  

The citation mentions that the admitting nurse acknowledged that she vaguely remembers someone making a remark about the bed rails as she was checking in the new resident, but that she was new and intensely focused on the computer and her documentation. 

It only took one day for the accident to occur. 

On her second day in the facility, while the new resident was repositioning herself in bed, the bed rail became detached and the resident fell off the bed.  She landed on top of the detached bed rail on the floor.  She was transported to the Emergency Room and was diagnosed with a frontal sinus facial fracture, mildly compressed skull fracture, and a possible subdural hematoma. 

The citation mentions that the bed appeared to be an older model with an air mattress placed on the bed frame.

After the incident, the resident’s husband returned to the facility to examine the bed.  “I got down on the floor to look at how the rails are attached to the bed, and it is only attached by a hand knob that you hand tighten. All anyone had to do was to tighten the black knob and my wife would not be in this condition. Anyone could have done that.  Their negligence is why my wife is like she is now.”

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.