The Illinois Department of Health has cited and fined Prairieview Lutheran Home when a severely cognitively impaired resident with a history of falls died after her chair alarm failed to alert staff when she attempted to get out of her electric lift chair, resulting in a fatal fall and hip fracture. The facility failed to properly maintain safety equipment and implement adequate fall prevention measures despite the resident’s documented high fall risk and previous similar incidents.

The resident in question, who had “severe cognitive impairment” and required “substantial/maximal assistance from staff when moving from sitting to standing, for chair/bed transfers, and when walking,” was supposed to be protected by multiple safety interventions outlined in her care plan. These included a “silent recliner alarm for poor safety awareness,” regular checks of “function and placement of alarm every shift,” and a “nonskid mat in recliner.” However, when she fell, the critical safety systems had failed.

The incident occurred when the resident attempted to get out of her electric lift chair on her own, despite being unable to safely transfer without assistance. A Certified Nursing Assistant discovered the resident “lying on the floor” in front of her recliner, which was found to be “all the way up” in its highest elevated position. Crucially, the staff member later revealed that the resident’s “chair pressure alarm was not plugged into the call light box, so the call light did not activate like it was supposed to.”

This was particularly dangerous because the resident had a known history of attempting unsafe transfers and using the lift chair remote control, which staff tried to keep “out of the resident’s reach.” However, at the time of the fall, “the controls were dangling along the side of the chair within the resident’s reach,” allowing the confused resident to operate the chair and attempt to get out when it was in a dangerous elevated position.

The facility’s investigation revealed multiple systemic failures in safety protocols. Staff members admitted uncertainty about basic safety procedures, with one aide stating she was “unsure how often chair alarms should be checked for functioning” and another being “unsure if the resident’s sensor alarm was connected to the call light box” when the resident was transferred into the chair. When asked what could have been done to prevent the fall, staff simply said “making sure all the cords for the alarm were plugged in” and “checking the alarms.”

The fall resulted in devastating injuries requiring immediate hospitalization. The resident sustained “a hematoma (bruising/swelling) to the left side of her head behind her ear and a skin tear to the left thumb” along with a “nondisplaced left femoral neck fracture.” She underwent surgery for “open reduction internal fixation surgical repair of the left femur fracture” but died shortly after the procedure. Hospital records indicated the “likely etiology is acute cardiopulmonary arrest given her advanced age and underlying heart disease.”

This tragic incident was made worse by the fact that the resident had experienced a very similar fall previously. She had fallen from the same recliner about a year earlier when she was “found sitting on the floor leaning up against the heater in front of the recliner that was in a forward tilt position.” After that earlier fall, physical therapy was recommended as a post-fall intervention, but “the resident’s family declined therapy” and “there were no other interventions that were implemented.”

The facility’s response to the fatal fall was inadequate, with investigators finding that the final incident report “does not identify the root cause of the resident’s fall or any post fall interventions.” There was no documentation about whether “the pressure alarm malfunctioned, that the facility identified the lift chair to be a safety/fall hazard, or if a nonskid mat was in the resident’s recliner.” The Director of Nursing confirmed that “the facility does not do any kind of assessment for the use of electronic lift chairs” and “the facility does not have a policy regarding the use of these chairs.”

The incident highlighted dangerous gaps in the facility’s fall prevention program. Despite having a policy requiring staff to “implement a resident-centered fall prevention plan to reduce fall risk factors for resident’s at risk for falls or with a history of falls,” the facility failed to properly monitor safety equipment, adequately train staff on alarm systems, or develop appropriate policies for managing high-risk residents using electric lift chairs. The tragic result was a preventable death that occurred because basic safety protocols were not followed and essential equipment was not properly maintained.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Pleasant View Luther Home when an 82-year-old resident with Alzheimer’s disease and a history of multiple falls suffered a serious neck fracture after tripping over another resident’s oversized wheelchair in a poorly arranged dining room. The facility failed to provide adequate space for the high fall risk resident to safely navigate around obstacles, despite knowing he was prone to falls and required his walker for safe mobility.

The resident in question, who had experienced multiple previous falls and was described as “impulsive” and someone who “gets up by himself,” was seated at a dining room table in an extremely confined space. Staff described the seating arrangement as problematic, with a wall directly behind the resident’s chair and a large water cooler to the left. To make matters worse, another resident with an oversized wheelchair was positioned next to him, creating a dangerous obstacle course that made safe exit nearly impossible.

Multiple staff members witnessed the incident and described the hazardous conditions that led to the fall. One Certified Nursing Assistant explained that the resident “was trying to leave the table going from the left side and there was not enough room for him to go through, he tripped over the wheelchair.” She noted that the other resident’s “wheelchair wheels are huge when she sits on the side of the table where the wall is there is not enough room to get by.” The space was so narrow that during the investigation, a surveyor “could not walk through the space going forward” and had to “turn her body to the side to fit through the space.”

Another staff member described how the resident “stepped over the other resident’s wheelchair, tripped and fell landing on his right side.” She explained that the other resident’s “wheelchair wheels stick out a lot in the back, her wheels were almost touching the water cooler located behind her. There was not enough room for him to walk through.” The cramped conditions forced the high fall risk resident to attempt dangerous maneuvers to navigate around the obstacles.

The Registered Nurse on duty provided additional details about the dangerous seating arrangement, stating that “the other resident’s wheelchair was positioned at an angle, the resident tried to go over the wheelchair and he was not able to get through without stepping over the wheelchair wheel.” She noted that the resident’s “walker was against the wall, there was not enough space behind his chair for the resident to use his walker,” making it impossible for him to use his required mobility aid safely.

The fall resulted in serious injuries requiring immediate emergency room evaluation. Staff reported that the resident “fell on his right side hitting his head on the floor, he had a good size abrasion to his forehead” and “threw up immediately after falling.” Hospital imaging revealed a C1 fracture, a serious injury to the first cervical vertebra that could have been life-threatening. The resident also sustained a “superficial abrasion to right side of forehead” and complained of “right shoulder pain and head pain.”

This incident was particularly troubling given the resident’s documented fall history and known risk factors. His Fall Risk Assessment showed he was a “HIGH fall risk, has a weak gait and overestimates or forgets limits.” Staff acknowledged that the resident “had numerous falls, he does not pay attention, he shuffles when he walks, is impulsive and gets up by himself” and noted he “had a previous incident of tripping over a chair.” Records showed previous falls on multiple occasions, yet the facility continued to place him in dangerous seating arrangements.

Staff members recognized the problem after the incident, with one noting that the resident “should have been placed at the end of the table where he had room to use his walker when he got up, he used to sit at the end of the table.” Another staff member confirmed that “since the incident we place the other resident on the opposite of the table so she’s not blocking the space,” acknowledging that the dangerous arrangement was preventable.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Goldwater Care Danville when staff failed to implement required fall prevention measures for a severely cognitively impaired resident, resulting in a devastating fall that broke his hip and caused a head laceration requiring five staples. The facility’s Medical Director confirmed the fall was preventable and stated the resident will “most likely be bedbound until he passes away” due to his injuries.

The resident in question, who required maximum assistance with most daily activities and was classified as a fall risk, was found lying on the floor with his head on the bathroom floor and his body in the bedroom area. Staff discovered him after hearing “a loud thud noise” followed by the resident “yelling out ‘Help!'” When found, the resident had pants around his ankles and was bleeding from a head wound, complaining of severe hip pain that he rated as “10 out of 10.”

The fall investigation revealed multiple safety violations that contributed to the incident. The resident’s care plan specifically required several fall prevention interventions including “proper functioning and placement of an electronic bed alarm,” “fall mat next to the resident’s bed,” and ensuring the resident’s “call light is within reach.” However, none of these safety measures were in place at the time of the fall. The resident “was not laying on a personal alarm,” “did not have a fall mat visible in his room,” and his “call light was not activated at the time of the fall.”

Staff members provided conflicting accounts about how the resident came to be wearing pants, which contributed to his fall. The incident report noted that the resident’s “clothing was a predisposing factor” in the fall. One nurse described finding the resident “wearing khaki casual pants around his ankles” and stated “it looked like the resident was laying in bed and had tried to get up and walk over to use the bathroom but tripped because his pants were around his ankles.” However, a Certified Nurse Aide explained that the resident “would not have been able to put his own pants on” due to his cognitive and physical limitations.

The aide revealed that night shift staff had dressed the resident in regular pants as part of a “common practice for the night shift to get some residents up or get some resident half dressed to make it easier on the day shift staff to get everyone up and to breakfast on time.” This practice appears to have contributed to the fall, as the severely impaired resident became entangled in clothing he could not properly manage while attempting to reach the bathroom independently.

The resident sustained serious injuries requiring immediate hospitalization, including “an acute angulated impacted fracture of the Right Subcapital Femoral neck,” “a 3.0 centimeter laceration to the Right Frontotemporal region which required five staples,” and “abrasions to his forearms” with skin tears on both arms. The facility’s Medical Director confirmed that “the resident was sent to the emergency room after his fall and diagnosed with a Right Femoral fracture and Right Temporal lobe laceration.”

Even after the serious fall, the facility continued to fail in providing basic safety measures. During follow-up inspections, investigators repeatedly found the resident’s “call light was laying on the floor next to his bed” and “out of reach,” with no fall mat visible and no personal alarm in use. When asked about this, a Licensed Practical Nurse confirmed that the resident “cannot reach his call light when it is laying on the floor” but staff were not consistently ensuring it remained accessible.

The Medical Director acknowledged the severity of the situation, stating that “the resident’s fall was preventable due to the fall interventions not being in place at the time of the resident’s fall” and that “basic fall precautions typically instituted were not followed resulting in certain facility protocols not being followed.” The doctor noted that the resident’s family “decided to not pursue a surgical option” for the broken hip, meaning the resident “will most likely be bedbound until he passes away” and “has had a general decline since his fall.”

The incident highlighted systemic failures in the facility’s fall prevention program, which requires “measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices.” The Assistant Director of Nursing acknowledged that “staff should know the fall interventions for the residents” and that “fall interventions should be in place to help prevent a fall,” but clearly these protocols were not being followed consistently, resulting in preventable and life-altering injuries to a vulnerable 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. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Serenity Estates of Lincolnshire when a 92-year-old resident with dementia became trapped between her bed rail and mattress, resulting in a broken arm. The facility failed to properly assess entrapment risks and obtain required consent before using bed rails as assistive devices.

The resident, who has dementia with agitation and typically requires partial to moderate assistance with transfers, was discovered in distress by nursing staff responding to a call light. However, the call light had been activated by her roommate, not the resident herself, as staff noted that the resident “never calls for help” and doesn’t remember to use her call light despite repeated reminders. When the Licensed Practical Nurse entered the room, she found the resident kneeling on the floor with her wheelchair positioned behind her and her right arm trapped between the mattress and side rail. The resident was complaining of severe pain and was unable to move her right arm.

The facility’s investigation revealed significant gaps in care and safety protocols. Staff members provided conflicting accounts of the resident’s transfer abilities, with some stating she could “safely transfer herself” while others noted she required “one-person extensive assist” and was “weak and does not ambulate.”

The Director of Nursing acknowledged that the resident was “high fall risk” but was uncertain whether proper consent had been obtained for the use of side rails. Multiple staff members noted that the resident “does not use her call light for assistance” and “needs to be supervised” because “if she is left alone, she will attempt to get up.” One nurse stated that “frequent monitoring and supervision could have prevented the incident.”

An inspection of the bed revealed a dangerous gap between the mattress and side rail that was “wide enough for her arm to fall through to get trapped.” This directly violated the facility’s own bed rail policy, which explicitly states that facilities must “ensure the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident’s head or body.”

The policy also requires informed consent from the resident or representative before installing bed rails, along with a physician’s order specifying the medical reason for their use. The resident’s care plan indicated she was supposed to use “bilateral half side rails to enhance functional independence,” but staff admitted uncertainty about whether proper consent had been obtained.

X-ray results confirmed the resident suffered a “comminuted fracture of the right humeral neck,” meaning her upper arm bone was broken in multiple places. She was hospitalized for treatment of this serious injury.
The resident’s fall risk assessment had previously identified her as having a “weak gait” and tendency to “overestimate or forget her limits,” yet appropriate preventive measures were not consistently implemented. The facility’s own policies required additional interventions for high-risk residents, including “increased frequency of rounds, sitter if needed, low bed, alternate call system access, and scheduled toileting assistance.” However, staff statements suggest these protocols were not adequately followed, with nursing personnel split between multiple units and the resident left unsupervised despite her documented need for constant monitoring due to her dementia and fall risk status.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined The Arc at Bradley when a Certified Nursing Assistant attempted to lift a resident with multiple sclerosis by herself without using the required mechanical lift, causing the resident to fall and suffer a broken leg that required emergency room treatment and orthopedic follow-up.

The resident was admitted to the facility with several serious medical conditions including multiple sclerosis, lack of coordination, abnormal posture, reduced mobility, and chronic obstructive pulmonary disease. Due to these conditions, she had impairments to both her upper and lower extremities and was completely dependent on staff for transfers between her bed and chair.

Because of her physical limitations, the resident’s care plan clearly specified that for “Chair/bed to chair transfer: My usual performance is dependent. I use a mechanical lift for transfer assist.” Her Kardex Report, which is a quick reference guide for staff, also clearly stated “Transferring: Transfer- The resident is totally dependent on 2 staff for transferring.”

Despite these clear instructions, a Certified Nursing Assistant (CNA) attempted to transfer the resident without following proper protocol. When interviewed, the CNA admitted, “I was trying to lift [the resident] without a mechanical lift and with no assistance from another staff member.” The CNA further acknowledged that the resident “became too heavy, and I lowered her onto the floor.”

Most concerning, the CNA fully admitted that she was aware of the proper transfer procedure but chose to ignore it: “I had worked with [the resident] before and knew [she] transferred with a mechanical lift.”

After the fall, the resident immediately “was complaining of pain to her legs.” However, according to the resident, the CNA dismissed her concerns, telling her “Your leg is fine.” Despite this dismissal, the pain persisted, and a nurse practitioner was eventually notified. X-rays were ordered, which revealed an “acute nondisplaced proximal tib-fib fracture” – a break in both the tibia and fibula (the two bones of the lower leg) near the knee.

The resident was then sent to the emergency room for evaluation and treatment. Upon her return to the facility, it was noted that she would need follow-up care with an orthopedic specialist.

When interviewed, the Director of Nursing clearly identified the cause of the injury: “An investigation was done; [the CNA] used the wrong transfer technique.” The Director explained that the CNA “lifted [the resident] for the transfer by herself and did not use a mechanical lift,” while “the correct transfer technique for [the resident] is a mechanical lift with two assistance.” The Director emphasized that the CNA “knew very well that she should have transferred [the resident] with a mechanical lift and two assist,” and acknowledged that “when residents are not transferred appropriately, they could have a fall with injury to both the patient and the staff, adding in this case, the resident had a fall with an injury.”

The Nurse Practitioner who ordered the X-rays confirmed that the fracture “was the result of the CNA transferring the resident inappropriately” and stated that the injury “could have been prevented if the resident was transferred with a mechanical lift and two staff instead on one staff.”

The facility’s policies were clear on this matter. Their “Transfers- Manual Gait Belt and Mechanical Lifts Policy” stated that “Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique.” Similarly, their “Fall Prevention Program” policy specified that “Transfer conveyances shall be used to transfer residents in accordance with the plan of care.”

This incident represents a serious failure to follow established safety protocols that resulted in unnecessary harm to a vulnerable resident. Despite having moderate cognitive impairment, the resident was able to clearly articulate what happened and the pain she experienced as a result of the improper transfer technique. The injury was entirely preventable had the CNA simply followed the resident’s care plan and the facility’s policies regarding safe transfers.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Aliya of Oak Lawn when a certified nursing assistant pushed a resident too hard while turning her during care, causing the resident to fall from the elevated bed and suffer a femur fracture that rendered her non-weight bearing for at least 12 weeks. The facility failed to provide proper safety equipment, including requested side rails, and failed to properly investigate the incident, incorrectly attributing the fall to the resident’s diagnoses rather than the staff member’s actions.

This case involves a resident who sustained a serious injury while receiving care in her room. According to the resident’s account, she was being changed by a certified nursing assistant (CNA) when the CNA “pushed [her] too hard and [she] fell to the floor.” The resident reported that the fall happened so quickly that she “did not have time to put her hands in front of her to prevent face from hitting floor.” She explained that the CNA had “raised the bed up higher before providing care,” which likely increased the risk and severity of the fall.

As a result of this fall, the resident suffered significant injuries, including “bruising to both arms and left leg, bruising and a lump above right eyebrow, and significant pain to left knee.” Hospital records confirmed the extent of her injuries, noting she had “a left condylar fracture with extension to the lateral femur metaphysis” and “a large lipohemarthrosis with hematoma measuring 7.5cm x 3.5cm x 2.2cm” as well as a “hematoma to forehead.” The resident was found to be anemic and required a blood transfusion during her hospitalization.

The resident stated that prior to this incident, she “was able to stand with assistance,” but following the fall, she became “nonweight bearing on left leg for at least 12 weeks.” According to her family member, this injury “has set [her] back at least six months” in terms of her recovery and functioning.

Notably, the resident reported that she had “requested side rails upon admission” months earlier but was told that “someone from therapy would assess her to see if side rails were appropriate for her.” However, she stated that “nobody ever did” conduct this assessment. The resident believed that “if she had side rails she could have possibly prevented or slowed down the fall.” Observations of her room confirmed that she had “no handle on [her] mattress” to hold onto when being turned by staff, despite the CNA reportedly instructing her “to hold onto the bed when turned.”

The facility’s account of the incident differed significantly from the resident’s. According to the facility’s investigation, the CNA stated that while “providing ADL care” and rolling the resident “over to her right side, [the resident] reached for an object on her bedside table and slid off the bed.” This version does not mention the CNA pushing the resident too hard or raising the bed height before providing care.

Further undermining the integrity of the facility’s response, the restorative nurse indicated that the facility had determined the “root cause of [the resident’s] fall was due to diagnoses of adult failure to thrive, anxiety disorder, fluid overload, and the need for extensive assistance with bed mobility.” When asked to clarify this assessment, the nurse responded, “I guess the root cause was determined to be due to [the resident’s] diagnoses and functional abilities” – effectively placing the blame on the resident’s medical conditions rather than examining staff actions.

Medical records indicate the resident has multiple serious health conditions, including “displaced fracture left femur, hemarthrosis left knee, metabolic encephalopathy, moderate protein-calorie malnutrition, liver transplant, critical illness myopathy” and several other conditions. Her Minimum Data Set assessment notes she “is totally dependent on staff for bathing, toileting, and personal hygiene,” highlighting her vulnerability and reliance on proper care.

Interestingly, a side rail review conducted weeks after the incident noted the resident “is appropriate to have 1/4 side rails to aid with bed mobility” – the very accommodation she had requested months earlier but never received.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Ascension Resurrection Life when staff left a 92-year-old resident with severe dementia unattended in an elevated bed, resulting in a fall that caused bilateral subdural hematomas and a subarachnoid hemorrhage requiring hospitalization in intensive care. The facility failed to follow proper safety protocols by leaving the cognitively impaired resident unsupervised with the bed in a raised position while the certified nursing assistant stepped away to get additional supplies.

This case involves a 92-year-old male resident with multiple medical conditions including dementia, osteoarthritis, unsteadiness on feet, lack of coordination, muscle weakness, and difficulty walking. According to his assessments, the resident had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of 01, indicating profound cognitive deficits. He was assessed as being at moderate risk for falls and required extensive assistance with bed mobility from two staff members.

The incident occurred during evening care when a certified nursing assistant (CNA) was providing incontinence care to the resident. According to the facility’s incident report, “The CNA rolled him on his right side and then stepped away to grab more wipes and soap to clean him. The CNA turned back towards and noticed he was leaning towards the edge of the bed. She quickly tried to get to the bed but [the resident] rolled off the bed hitting his head on the floor.”

When interviewed, the CNA admitted, “I put him on the potty, and he took a poo. I needed more material, so I went to the sink to get towels. When I turned around, I seen him falling and tried to catch him.” Critically, she acknowledged, “The bed was still up to about my hip. I did not let it [resident’s bed] back down…Yes, I should have all supplies available when I do care.”

The resident’s family member provided additional context, stating, “The CNA had the bed all the way up because she’s tall. She went to the sink to go get a rag and that’s when he fell. She shouldn’t have left the bed up like that and shouldn’t have left him at the edge of the bed.” The family member also expressed concern that the facility “didn’t fire her” but “just moved her to a different floor,” noting that the resident “has been at this facility for 4 years” and “has Alzheimer’s. They should know better.”

As a result of the fall, the resident sustained serious injuries. Hospital records documented “small acute bilateral cerebral convexity subdural hematomas measuring 5 mm on the left and 3 mm on the right” and “small right parietal subarachnoid hemorrhage measuring 7 mm.” The resident was admitted to the intensive care unit with “bilateral subdural hematomas and small right subarachnoid hemorrhage.”

The Interim Director of Nursing (DON) acknowledged that proper protocols were not followed. “Based off that, I began educating staff when residents are on a low air loss mattress, they should be a 2 person assist because when you’re on air mattresses they are constantly shifting.” The DON further explained what should have happened: “As a one person assist, she should have repositioned him on his back, centered, and lowered the bed. Don’t step away from the bed until lowered and positioned in bed. All those safety checks should have been done. If she would have done the safety checks the fall would likely not have happened.”

While the Administrator was “familiar with the incident,” when asked if the fall was preventable, they responded, “Possibly but I’m not a nurse,” and when asked if it caused harm, claimed, “I don’t feel it changed his condition. He has been declining. I’m not a nurse to assess and clinically cannot make that statement.” This contrasts with the Nurse Practitioner who, when asked if the fall caused harm, responded, “It didn’t help him. In a way yeah.”

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Bella Terra Streamwood when staff left an 84-year-old resident with dementia and a recent leg amputation unattended on a bed, resulting in a fall and femur fracture that required surgical repair. The facility failed to provide adequate supervision and implement appropriate fall prevention measures for a high-risk resident who had just returned from the hospital following an above-knee amputation.

This case involves an 84-year-old resident with multiple complex medical conditions including dementia, heart failure, severe morbid obesity, and a recent right above-knee amputation. The resident fell while being left unattended in her room, resulting in an “oblique fracture of left femur” that required surgical intervention.

According to hospital records, the resident “fell in facility” and “had pain in the left thigh last couple of days when admitted and x-rays to left femur demonstrate distal third femoral shaft fracture.” The surgeon noted that “she recently had an AKA (Above Knee Amputation) on the right side, so she needed her left side to transfer to wheelchairs therefore decision was made to undergo open reduction intramedullary nailing of the left femur.”

The facility’s Fall and Psychotropic Nurse, who conducted an internal investigation of the incident, stated that a Certified Nursing Assistant (CNA) had left the resident unattended on her bed. When asked if the CNA should have left the resident alone, the nurse acknowledged, “Yes, but she wasn’t left unattended very long.” The nurse further explained that the CNA “should have prepared the supplies prior to propping the resident up to clean her and not leave her unattended.”

When interviewed, the CNA provided conflicting information about the incident. Initially, she stated she was “reaching for a pad” at the doorway when she heard the resident scream, but later admitted, “My linen cart was in the hall outside the door, but you can say I left her unattended, but it was very fast.” The CNA also acknowledged she had limited knowledge about the resident, stating, “When I was working with her, I was not familiar with her at all, and no one told me whether she was a fall risk or not. No one told me anything about her at all.”

An agency nurse who was working that night confirmed that the resident was found “on the floor at the foot of the bed with her head under the footboard part.” The nurse also indicated she had not received proper information about the resident’s condition, stating, “I did not get any endorsement about [the resident] or that she came back with an amputated knee. I just knew she recently got back from the hospital, but I didn’t know for what.”

The resident’s roommate, who was determined to be cognitively intact, reported being “awakened around midnight when [the resident] was screaming loudly.” She confirmed seeing the CNA enter the room to take the resident’s gown off and then seeing the same CNA again when the resident started screaming.
The resident’s attending physician emphasized that the facility should have taken extra precautions due to the resident’s multiple risk factors, stating she “had dementia, severe morbid obesity, and was a recent leg amputee which made her more at risk and unstable (poor trunk control).”

A review of the resident’s fall prevention care plan revealed it had not been updated since nearly a year before the incident, despite her recent hospitalization and amputation. Only after the fall and fracture was her care plan updated to reflect her “recent hospitalization with surgical intervention, right AKA (Above Knee Amputation), recent fall with fracture to left femur.”

The facility’s fall prevention policy specifically states staff should “Pay close attention to residents at high risk for falls” and emphasizes the importance of anticipating residents’ needs and ensuring proper assistance with mobility. However, in this case, the facility failed to adequately communicate the resident’s high-risk status to staff, properly update her care plan following her amputation, and ensure appropriate supervision was maintained during care activities.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Ascension Saint Joseph Village when a Certified Nursing Assistant attempted to reposition a physically impaired resident on a specialized air mattress without obtaining required assistance from a second staff member, resulting in the resident falling from the bed and sustaining multiple serious fractures. The facility acknowledged in its own investigation that the fall could have been prevented if staff had followed established safety protocols requiring two-person assistance for residents on air mattresses.

This case involves a severely physically impaired resident who required substantial assistance with mobility. The resident’s care plan clearly specified she needed “assist of two people for all transfers,” and she was using a specialized low air loss mattress due to her physical condition. Despite these documented requirements, a CNA attempted to reposition the resident alone during nighttime care.

According to facility records, “Patient was receiving care by CNA, when she rolled to her right side. She stated she could not hold on and fell onto the floor.” The resident was found “laying partially face down with half her body on the bottom of the bedside table” with “an injury noted to the left lower leg, bruise to the right lower leg and pain to the left upper shoulder.” The resident was sent to the emergency room by ambulance, where hospital records confirmed she had suffered a “humerus shaft fracture, laceration of leg, pubic ramus fracture.”

When interviewed, the resident described the incident in detail, saying the CNA “was in a hurry” and that “it was an unnecessary accident.” She explained that she was on a low air loss mattress when “the girl was throwing me around. I fell on the floor hard… She was on my left side and she pulled the pad up to help me turn and I rolled off of the bed.
They usually use two people to turn me in bed. She was by herself.”

The CNA involved confirmed that she had grabbed the pad underneath the resident to help turn her onto her right side, but the resident “rolled off of the bed onto the floor” and “hit her left side on the bedside table.” The CNA claimed she had “taken care of [the resident] by herself many times before.” However, another CNA contradicted this, stating she had “never seen [the resident] require one person for assistance” and that the resident “has always been a maximum assist with two people, even before her fall out of bed.”

The Assistant Director of Nursing (ADON) confirmed that facility policy required two staff members when repositioning residents on low air loss mattresses, stating: “if a resident is on a low air loss mattress, then two staff should be repositioning the residents.” The ADON acknowledged that the resident’s fall “could have been prevented had there been two staff in [the resident’s] room” and confirmed the CNA “was not aware that if a resident is on a low air loss mattress, then two staff should be repositioning the residents.”

It’s important to recognize that chronic understaffing in nursing homes nationwide often places individual caregivers in difficult positions. Many nurses and nursing assistants are doing their best in challenging circumstances, frequently working short-staffed and caring for more residents than is optimal for safety. CNAs and nurses often work long hours with physically and emotionally demanding responsibilities, sometimes making split-second decisions while juggling multiple urgent resident needs. While safety protocols must be followed, systemic staffing issues in long-term care facilities can create environments where staff feel pressured to complete tasks quickly without adequate support.

The facility’s own investigation through their Safety Event Manager identified the primary factor leading to the incident as “One CNA providing care on an air mattress.” In response to the incident, the facility initiated corrective actions including reviewing and updating the resident’s care plan, monitoring other residents with air mattresses, and re-educating nursing staff on proper procedures for providing care to residents who use air mattresses.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Jerseyville Nursing & Rehab Center when staff failed to properly assess, document, and implement new interventions following multiple falls of a severely cognitively impaired resident, resulting in a delay in diagnosing and treating the resident’s broken hip. The resident suffered for five days with an undiagnosed hip fracture until X-rays were finally ordered, revealing a broken left trochanter that required hospitalization.

The case involves an elderly resident with multiple medical conditions including dementia, tremors, vertigo, and a history of falls. According to facility records, the resident was documented as “severely cognitively impaired” requiring “maximum/substantial assist for activities of daily living (ADLs) and mobility.” The resident’s care plan identified her as “at risk for falls” and included numerous interventions such as toileting assistance every two hours, non-skid socks, standby assistance when ambulating with walker, frequent rest periods, and placement in common areas for increased supervision.

Despite these interventions, the resident experienced a series of falls. On the first documented fall, the resident’s Power of Attorney (POA) brought to staff’s attention that the resident had “abrasion/bruised area to left forehead and an area into left hairline and that the resident complains of pain to head and to left upper hip down into left upper thigh and left foot slightly rotated inwards.” The POA noted that when assisting the resident from the toilet, the resident “started complaining of pain left hip and had a difficult time getting up.” The resident was sent to a local hospital for evaluation, with the hospital reportedly finding “everything was negative” based on CT scans and X-rays.

Four days later, another incident occurred when the resident was “found lying on the bathroom floor on her back with her hands behind her head.” Notes indicated “no new injury” though “bruising continues to right arm and some areas on forehead.” During the process of lifting the resident, staff documented that “she begins to yell and resist care” and “begins to shake all over.” The resident was again transported to the local hospital, with follow-up notes indicating “no injuries and range of motion within normal limits.”

Three days after this second hospital visit, staff documented that the resident was “displaying difficulty with ambulation and transfer this shift as well as bruising to the left hip and thigh area and complaints of pain.” The resident’s daughter expressed concerns that no X-rays had been completed during the previous hospital visit. Only then did the nursing home order X-rays of the left hip, leg, and ankle.
The next day, the resident was found “sitting on wheelchair pedals” with the roommate reporting that “she sat on her pedals hanging onto the arms of the wheelchair.” Again, staff documented “no new bruises” and “no complaints of pain, discomfort, or facial expressions.” However, the following day, progress notes finally acknowledged that the resident “has a broken Trochanter left hip.” The resident’s daughter wanted the resident to see a specific physician who would not be available until a later date, but staff noted the resident was “getting worse, and having more pain.” Later that day, the resident was noted with “increased pain to left hip” and was finally sent to the local hospital for “evaluation and treatment.”

During the investigation, the Director of Nursing (DON) initially stated that she did not think the hip fracture was related to the documented falls, suggesting there might have been an “unknown injury.” Later, the DON acknowledged that “we had been trying to keep her in her chair because she was getting some medication for pain but her daughter kept walking her and would complain of pain so that is why we ordered the x-ray.” The DON confirmed that “there should be an intervention after every fall or incident, and they should be on the care plan,” yet the investigation found no documentation of new interventions for the falls.

Notably, the facility’s own fall policy, which had not been updated since 2017, clearly states that “any change of plane should be considered a fall” and “a fall without injury is still a fall.” The Regional Director confirmed this definition during the investigation. The policy further states that falls should be managed through “prevention, investigation, and implementation, and evaluation of intervention,” yet there was no evidence these steps were properly followed for the resident’s falls.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.