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

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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

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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

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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. 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: 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

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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: 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 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

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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

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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

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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

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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. 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: 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

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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. 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: 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.  

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

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IDPH has cited and fined Dimensions Living nursing home in Prospect Heights after a resident there was involved in two falls in four days – the first resulting in a broken jaw, the second resulting in facial fractures. One of the basic truisms in the long-term care industry is that if a nursing home is unable to meet the care needs of a resident, the only proper course is for the nursing home to decline the admission of that resident.  In fact, federal regulations require that nursing homes have enough properly trained staff on had to meet the care needs of its residents on a 24/7 basis. This resident was admitted to the nursing home from an assisted living facility.  The reason that the transfer was made was that the resident was having frequent falls in the assisted living facility, and one of the well-recognized truths about falls in a long-term care setting is the falls tend to beget more falls.  A history of recent falls is a factor that is accounted for in almost all fall risk assessment tools. And this resident was in fact a fall risk – in addition to the history of falls, she also suffered from cognitive impairments with diminished safety awareness.  She also had generalized weakness and and required extensive assistance with transfers and mobility.  Her assessment concluded with a statement which stated that she required one-on-one care. The first nursing home fall occurred approximately a month after the resident was admitted.  She was seated in a wheelchair doing an activity.  The activity aide assigned to run the activity was passing out to drinks to other residents when the resident fell forward from her wheelchair and hit the ground, suffering a fractured jaw. The second fall occurred four days later.  The resident was again brought to the dining room for activities being conducted by an activity aide.  The resident again had another fall, this time hitting her head, resulting in significant bleeding and a lost tooth.  The resident was sent to the hospital due to complaints of pain and having a hard time breathing.  There a CT scan showed that she sustained facial fractures. The resident’s assessment showed that she required a significant degree of supervision.  She was an obvious fall risk in light of her history of falls, cognitive impairments, poor safety awareness, and generalized weakness.  The assessment recited that she required one-on-one assistance, which is a level of care that nursing homes generally claim is impossible.  The facts here show not only did the nursing home fail to provide the care which they recognized in the assessment that she required, but they failed to provide the adequate supervision called for by federal regulations.  The activity aide was charged with not only conducting the activity, but also supervising the multiple residents who had been brought to the activity without the help of additional staff.  Inadequate supervision leads to fall, and did so here. 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: Grove of Skokie resident breaks leg due to violation of care plan Grosse Pointe Manor resident falls and breaks hip after being left unattended Resident breaks both legs in unsafe transfer at Symphony of Buffalo Grove   Click here to file a complaint about a nursing home with the Illinois Department of Public Health.    

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

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IDPH has cited and and fined Fair Oaks Rehabilitation & Health Care Center in South Beloit after a resident there fell and suffered a broken hip due to the failure of a therapist to use a gait belt while walking with the resident. Use of a gait belt is a fundamental 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. The resident at issue was considered at risk for falls and had been assessed as not being steady during transitions and walking and required the extensive assist of one staff member with walking in the corridor.  Extensive assist has a particular technical meaning – it means that the staff member is providing some physical assistance with the weight bearing.  Doing this properly requires the use of a gait belt. On the day of this nursing home fall, the resident was being walked back from therapy by a COTA (certified occupational therapy aide).  There was no gait belt in use.  The aide later told the state surveyor, “[The resident] should have had a gait belt on for a security belt because she was unsteady.  I should have had a gait belt on her.  I don’t know why I didn’t use one.”  As they walked down the hall, a nurse sitting at the nurse’s station observed the resident and the aide, later telling the surveyor that it looked like the aide was not paying attention.  The resident began to tire and reached back to sit in a wheelchair, but instead fell to the ground, suffering a fractured left hip which required surgical repair. Here, there was a failure in the fundamentals which led to this fall.  And it was not for a lack of equipment – the rehab director told the state surveyor that there was a drawer full of gait belts available in the therapy department.  Simple failures lead to very preventable accidents. It is worth noting that the primary culprit in this incident was the therapy aide.  Frequently in nursing homes, therapy services are provided by an outside contractor.  However, the therapy aide was not the sole person bearing some responsibility for this fall as the nurse saw the aide walking with the resident and failed to act to correct the dangerous situation of walking the resident with no gait belt. 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: Pleasant View Rehab resident fractures hip in fall Bethany Rehab resident breaks arm in fall Multiple falls leads to fall with broken hip at Tower Hill   Click here to file a complaint about a nursing home with the Illinois Department of Public Health.    

Prairie Manor resident suffers broken leg in fall

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IDPH has cited and fined Prairie Manor Nursing & Rehabilitation Center nursing home in Chicago Heights after a resident there suffered a fractured leg after falling eight times in just over a year, with seven of the falls (including the last) being caused by her attempting to go to the bathroom unassisted. One of the common situations where falls occur in nursing homes is when the resident attempts to go to the bathroom.  Nursing home residents are adults and when they are able to control their bowel and bladder and have sufficient cognitive wherewithal to recognize this, the desire to maintain their dignity takes over and they will attempt to make it to the bathroom unassisted, often leading to disastrous outcomes. Before the fall at issue, this resident had 8 prior falls in just over a year’s time.  After each fall, the staff did the right thing and performed a root cause analysis in an effort to determine why the fall occurred.  When there is a root cause found, then there should be changes to the fall prevention care plan to take steps to prevent further falls.  The net result of the root cause analysis for 6 of the prior falls is that the root cause was the resident attempting to go to the bathroom unassisted.  Further to the nursing home’s credit, the care plan was upgraded five times to include getting a urinalysis, use of floor mats, a referral to physical therapy, rounding every 2 hours, and then finally rounding frequently and keeping resident in area where she could be supervised. On the day of this nursing home fall, the resident was attempting to go to the bathroom unassisted and fell again.  This time, she suffered a fracture of the femur which resulted in her being wheelchair bound. The nursing home did many things right in the care of this resident.  She was clearly a fall risk and was treated as such.  When she sustained falls, there was an effort made to determine the cause of those falls and to try to prevent further falls.  However, there was a common theme among almost all the falls in that she was attempting to go to the bathroom unassisted.  One means of addressing the behavior would be to put the resident on a toileting schedule.  This would involve the staff tracking the resident’s bathroom habits over  period of several days so that the patterns could be discovered, and once those are identified, the staff would be scheduled to bring the resident to the bathroom when the need was expected.  This was never tried for this resident, leading to repeat falls with changes in the care plan of dubious value. 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: Symphony at Palos Park suffers brain bleed in fall from toilet Prairie Manor resident suffers brain bleed after being rolled out of bed Mechanical lift accident at South Holland Manor   Click here to file a complaint about a nursing home with the Illinois Department of Public Health.    

Symphony of Palos Park resident suffers brain bleed in fall from toilet

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IDPH has cited and fined Symphony of Palos Park nursing home after a resident there suffered a brain bleed as a result of a fall which occurred due to him being left unattended while seated on a toilet. Federal regulations pertaining to nursing home falls call for residents to receive supervision and assistance as needed to prevent accidents.  Falls are a form of accident, and the regulations require nursing homes to take the required measures to prevent this kind of accidental injury.  How does the staff know what has to be done to prevent falls?  The basic answer to that is the care planning process. During the care planning process, there is an assessment done of the risks to the health and well-being of the resident.  This results in a care plan being developed which sets forth a specific set of measure which staff members are assigned to carry out on a day-to-day, shift-to-shift basis.  The care plan must be communicated to the staff charged with carrying it out and then it must actually be implemented.  Finally, its effectiveness must be evaluated on an ongoing basis and then revised if there are changes in the resident’s needs or it proves to be ineffective in practice. The resident at issue had a number of medical conditions which placed him at risk for falls, including a history of epilepsy, cognitive impairments, and generalized weakness.  The resident was assessed on multiple occasions using the facility’s fall risk assessment tool which scored him consistently as 18 or higher.  On the fall risk assessment tool used at this nursing home, any score 10 or higher indicated a high risk of falls and required that the resident be placed in the “red leaf” fall prevention program.  Staff were trained that residents who were in the red leaf program were not to be left unattended on toilets. On the day of this nursing home fall, the resident was brought to the toilet by an aide.  The aide who brought the resident to the toilet then left to get a beverage for the resident, telling him to pull the call light when he was finished.  When the aide returned to the room, she found the aide on the floor.  The resident was sent to the hospital where he was diagnosed as suffering from a brain bleed. There was clearly a break down in the care that this resident received.  He was assessed as a fall risk and the nursing home had a reasonable procedure in place to address that fall risk: that residents should not be left unattended while seated on a toilet.  One reason for this is that it actually requires a significant amount of trunk control to maintain position on the toilet.  Unfortunately, either the risk level for this resident was not communicated to the aide involved, or she was not properly trained on the red leaf fall prevention program.  In either event, this breakdown in the care led to this resident’s fall and injury. 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: Westmont Manor resident suffers brain bleed after being rolled from bed AHVA Care of Stickney resident breaks hip 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.

Failure to obtain treatment orders leads to infection of surgical wound at Loft of Canton

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IDPH has cited and fined the Loft Rehab & Nursing of Canton nursing home after a resident there developed a surgical wound infection due to the failure of the staff to obtain orders for the care of the wound. Many persons who undergo surgery are sent to nursing homes for post-operative rehabilitation.  Often part of the care is actual rehabilitation – therapy that is needed to get them “back on their feet” so that they can go home.  However, a crucial part of the care that residents receive is directed toward making sure that residents receive necessary medications and lab work, that the surgical incisions are healing and free of signs of infection, and other aspects of care that are directed to making sure that nothing goes awry. When residents are admitted to the nursing home from a hospital, there are transfer orders that go with the resident.  Typically these will include things like the medications the resident is supposed to receive, treatments that the resident requires, labs that must be completed, and so forth.  This assures continuity of care.  When the resident is being admitted the nurse at the nursing home is supposed to review the orders with a nurse from the transferring hospital. Additionally, when the resident is admitted to the nursing home, they undergo a number of assessments, one of which is a head-to-toe skin inspection.  One of the reasons for the skin inspection is to check for the existence and condition of any bed sores or pressure ulcers.  However, in the context of a post-surgical admission, this inspection is to check to see if there are signs and symptoms of infection to any of the wounds and to make sure that there are appropriate orders for care of the surgical wounds. The resident at issue here was initially admitted to the nursing home after undergoing the removal of her parotid glands and a resection of her neck due to malignancy.  However, she developed a post-surgical infection and had to be readmitted to the hospital. When she returned to the nursing home, there were four surgical wounds present, including one which under her left breast but which was recorded in the chart as being a “chest” wound.    That “chest” wound included a drain, staples, and a surgical dressing.  However, there were no orders for the care of that surgical wound, and no one called the doctor or the hospital get orders for care. As a result, the resident was in the nursing home for a week with no care being provided for the wound under her left breast.  This continued until the surgical wound developed an odor, was red and inflamed, and was draining yellow and green fluid.  The resident was also lethargic, said that she was not feeling good and having nausea.  These are all signs of infection.  The resident was brought to the hospital where the dressings were changed and the resident was placed on antibiotics.  The surgeon also ordered a culture of the wound.  When the cultures were completed, they showed that the wound to the breast as well as wound on her clavicle were infected with MRSA.  The resident was sent back to the hospital for management of the new wound infections. There were a number of shortcomings in the care that this resident received:
  • It is unclear from the citation whether the “chest” wound recorded on the admitting assessment referred to the clavicle wound or breast wound.  If the breast wound was missed all together, that is a complete failure on the skin inspection;
  • There were very clearly no orders for the breast wound.  When the skin inspection revealed that there was a breast wound for which there were no treatment orders, it was incumbent upon the nursing home staff to contact the doctor for treatment orders, just as physician notification is required when a resident develops a bed sore;
  • After the resident was admitted, there were multiple shifts where no one seemed to recognize that there were no orders for the treatment of the breast wound.  Multiple opportunities missed.
  • Typically, the condition of a post-operative wound is recorded on a per shift basis.  This is because a surgical wound infection is a serious matter which needs to be addressed promptly.  The condition of the dressing when the nurses first noted the odor was described as being filthy, which means that there had likely been multiple shifts where either no one paid any attention to the breast wound or to the fact the dressing had not been changed.
In short, there were several levels of failure at the nursing home in the care of this resident, all of which led to a serious infection of the surgical wound.  The resident had been admitted to the hospital for care for this, but this will likely require extensive use of antibiotics and likely surgical excision of the infected tissues.  This is a situation which was made worse, not better by the care that this resident 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.  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: Heartland of Galesburg resident dies due to untreated urinary tract infection Rushville Nursing & Rehab resident suffers untreated surgical wound infection Failure to notify physician leads to resident death at Alden Estates of Barrington   Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Failure to provide needed assistance leads to fall at Generations of Elmwood Park

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IDPH has cited and fined Generations at Elmwood Park nursing home after a resident there suffered a broken hip in a fall. Nursing homes are required to complete a series of documents called the Minimum Data Set (MDS).  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 requiring it. The resident at issue was 101 years old and was wheelchair bound, but was largely independent.  However, her MDS certified that she required assistance of one staff member with getting her pants on.  This was confirmed by the nursing home’s occupational therapist who confirmed that she needed at least supervision with getting her clothes on her lower body.  However, most staff members charged with her care believed that she was independent in all aspects of daily living, including dressing herself. On the morning of this nursing home fall, the resident was seated in her wheelchair in her room getting ready for the day.  Staff present in her room knew that she was getting dressed but no one waited to provide supervision and assistance with her getting her pants on.  She attempted to do so herself but lost her balance while standing to pull her pants up and fell.  She landed to one side and was assisted back to bed by staff.  However, the fact that a fall occurred was not communicated to the resident’s doctor so it was not until the following day that she was sent to the hospital after staff heard her telling her family about the fall and that she was having pain in the side.  There, the fractured hip was diagnosed and treated. Nursing homes are businesses, and well-run businesses have processes that must be followed to ensure that necessary services are provided as a matter of routine.  This should include incorporating care called for in the MDS into the resident care plan, having the contents communicated to the staff charged with carrying it out, and then having that care actually delivered.  Here there were multiple breakdowns in the delivery of care.  The care called for in the MDS was no incorporated into the care plan, communicated to the staff, or actually delivered.  The assessments clearly called for supervision and assistance with putting on pants but that was not done.  As a result, this resident fell and suffered a fractured hip. Past that, a fall is something that requires physician notification.  This was not done until the following day leaving the resident with no care of relief from pain from the fractured hip.  When asked, most nurses working in a nursing home setting will agree that subjecting a resident to unnecessary pain is a form of nursing home abuse. 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: Inverness Rehab resident suffers multiple fractures in fall Tower Hill resident suffers fractured hip in fall Assisi at Clare Oaks resident breaks neck in fall from wheelchair   Click here to file a complaint about a nursing home with the Illinois Department of Public Health.  

Westminster Village resident suffers broken leg in fall from toilet

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IDPH has cited and fined Westminster Village nursing home in Bloomington after a resident there suffered a broken leg in a fall while getting up from the toilet. Falls are a major source of concern in the long-term care industry.  Falls are associated with increased mortality rates, steep declines in the quality of life when there is significant injury, and increased risk of falls in the future.  For these reasons, and because of the requirements of federal regulations, fall risk is a specific area of focus in the care planning process. When fall risk assessments are done, the nursing home will use its assessment tool to evaluate the resident’s fall risk.  Two factors that are in in all well-done fall risk assessment tools are (1) some form of gat/balance/musculoskeletal dysfunction and (2) some form of cognitive impairment such as intermittent or constant confusion, dementia, poor safety awareness or judgment, and/or impulsivity.  These combine to make the resident a fall risk because the physical issues leave the resident at risk for falls or loss of balance and the cognitive deficits increase the chances that the resident will not follow instructions, ask for assistance, or make good decisions for their own safety. This resident had many of the factors that made her a fall risk.  Her Minimum Data Set (MDS) indicated that the resident had moderate cognitive impairments, that she required extensive assist of staff with transfers, toileting, and personal hygiene, and that she was unsteady when rising from a seated to standing position and was only able to stabilize with staff assistance.  The resident had a known history of attempting to rise from the toilet unassisted – something which could result ion a fall. At the time of this nursing home fall, the facility had in place a policy which stated residents who are i9dentified as being at risk for falls if left unattended on the toilet should not be left unattended while on the toilet. On the day that the fall occurred, the resident was brought to the toilet by an aide who then left the resident to go get hair rollers.  While she was doing that the resident attempted to rise from the toilet unassisted and fell.  She was brought to the hospital where a broken femur was diagnosed. This is a resident who was at risk for just this kind of fall based on the documented findings of cognitive impairments and difficulty with standing from a seated position – all documented on her MDS,  as well her known history of attempting to get up unassisted from the toilet.  Based upon prevailing standards pf practice as well as the facility’s own policy, this resident should not have been left unattended.  The administration of the nursing home agreed with this, writing the aide up. 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 fractured hip in fall due to failure to use gait belt Westminster Village resident suffers multiple fractures in fall Resident breaks hip in fall at McLean County Nursing Home 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.    

Elmwood Nursing & Rehab resident fractures and dislocates hip in two falls

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IDPH has cited and fined Elmwood Nursing & Rehabilitation Center nursing home in Maryville after a resident fractured his left hip in a fall, underwent surgery to repair that fracture, and then dislocated that same hip in a fall occurring five days after his return to the nursing home. The initial nursing home fall occurred for a simple reason: the resident was wearing two different shoes which were of different heights leading to a loss of balance and the fall which resulted in the hip fracture. The citation issued by IDPH does not mention whether this resident was considered a fall risk prior to the fall where the hip was initially fractured.  It appears that he was walking independently when the fall occurred, but the citation also references a statement from a nurse who described the resident as being some degree of confusion before the fall occurred.  Regardless of whether the resident was considered a fall risk, having residents in proper footwear is considered a basic fall prevention measure that should be employed for all residents.  Having shoes of different height contributing to loss of balance falls short of that standard, and if the resident was demonstrating confusion even before the initial fall, simple checks on the resident were likely in order. After the initial fall occurred, the resident was brought to the hospital where he underwent surgical repair of the fracture.  Three days after the fall occurred, he was returned to the nursing home for further care and rehabilitation. Upon his return to the nursing home, he would definitely be considered a fall risk based upon his history of a recent fall, together with the weakness and general musculoskeletal dysfunction from the original injury.  The fall prevention care plan included monitoring per facility protocol and reminding the resident to use a call light.  The nurse referenced earlier also advised the state surveyor that after returning from the hospital following the hip fracture, the resident demonstrated increased confusion.  Constant or intermittent confusion, dementia, poor safety awareness, or other cognitive impairments can be a major fall risk factor because the resident can no longer be counted on to follow instructions or make good decisions for their own safety. The second fall occurred when the resident was found on the floor of his room five days after returning from the hospital.  He could not be supervised at the nurse’s station because he was required to be quarantined due to COVID restrictions.  The inability to supervise the resident along with the increased confusion that followed his readmission to the facility rendered the care plan ineffective because the regular pattern of supervision was not practicable and the resident could not be relied upon to use the call light.  Poor care plans here led to poor results, and that is what happened here. The resident was brought to the hospital where it was discovered that the recently repaired hip had been dislocated.  Care for this injury will complicate the recovery from the initial injury and diminish the chances that the resident will ever be able to walk again.  Immobility increases the risk of further complications such as the onset of pneumonia, the development of blood clots, and/or the development of bed sores. 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: Red Bud Regional Care resident breaks hip and leg in bathroom fall Pittsfield Manor resident suffers fatal 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.

Vandalia Rehab cited for understaffing

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IDPH has cited Vandalia Rehabilitation & Health Care Center for failing to have enough staff on hand to meet the care needs of the residents. Nursing homes are regulated by both the federal government and the State of Illinois.  Both have regulations regarding minimum staffing levels.  The state regulation sets a mathematical formula for the minimum number of staff required, and it is rare to see nursing homes out of compliance with that regulation.  The federal regulation is a more flexible but demand standard.  It requires nursing homes to have enough trained staff on hand to meet the care needs of the residents on a 24/7 basis. One of our core beliefs is that the root cause of many of the catastrophes that befall nursing home residents is actually due to understaffing of the nursing home – the staff simply does not have the ability to provide the care and critical thought the residents require because they are stretched so thin due to the choices that management made in how to staff the nursing home. With that said, it is exceedingly rare for a nursing home to be explicitly for understaffing a nursing home, but that is what happened here.  The local ombudsman received a call from the residents complaining that there was only one nurse and one CNA on duty caring for twenty-five residents.  Upon arriving at the facility, the ombudsman found that the complaints from the residents were accurate.  The appearance and odor of the residents demonstrated that they were not being showered on any regular basis or provided incontinence care in a timely way. Proving good care in a nursing home is a labor-intensive business, and without having adequate staff on hand, residents get placed at risk of harm in multiple ways:
  • Residents who require the help of a mechanical lift for transfers might receive manual transfers rather than with the use of the lift or have a single staff member operate the lift when doing so is a two-man job;
  • Residents who are risk for nursing home falls due to musculoskeletal issues and some degree of cognitive impairment will not receive the supervision called for under federal regulations to prevent falls;
  • Residents who suffer from incontinence will not receive timely incontinence care, placing them at higher risk for developing bed sores;
  • Residents who have a care plan which calls for turning and repositioning as means of preventing bed sores will not get the necessary turning and repositioning, increasing the chances of getting bed sores;
  • Residents who already have bed sores will not receive dressing changes and other care necessary to promote healing and prevention of infection;
  • Residents who are experiencing some change in condition are less likely to have the staff recognize it.  The staff are the eyes and ears of the doctor and understaffing can lead to a delay in notifying the doctor of a change in condition;
  • It increases the chance that medication errors will occur;
  • Residents may not receive their meal trays and needed fluids in a timely way, increasing the odds that residents will suffer from malnutrition and dehydration, with all of the complications that follow from that;
  • Residents are unlikely to receive the care called for in their care plans;
  • Residents who are risk of choking may not receive the supervision they need while eating, increasing the risk of a nursing home choking accident;
  • And the list goes on ….
None of this is to serve as a criticism of the staff who stayed on trying to provide care for the residents in that nursing home.  When the nursing home is chronically understaffed, they are really fighting a losing battle and deserve more help from management to provide the residents with the care that they are entitled to. COVID has obviously made operating a nursing home harder than it used to be, but management must find a way to provide the necessary care to residents.  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: Sharon Health Care Elms resident suffers brain bleed in fall while on smoking patio Cedar Ridge resident breaks both legs in fall from bed Understaffing at Generations at Rock Island leads to fall and hip fracture   Click here to file a complaint about a nursing home with the Illinois Department of Public Health.    

Resident at Park Pointe in Morris suffers multiple fractures down unlocked stairwell

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IDPH has cited and fined Park Pointe Healthcare and Rehab nursing home in Morris after a resident there suffered multiple fractures due to falling down a stairwell. The resident involved in this fall down the stairwell had a care plan for wandering. Wandering is also known as elopement in the long-term care industry and is a serious risk of harm to the resident. Residents who wander can find themselves in situations where they are faced with hazards which due to physical or cognitive limitations, they are unable to safely face or address. This resident was also a fall risk because she was wheelchair-bound and had musculoskeletal deficits as well as significant cognitive deficits. For residents which are at risk of harm due to wandering/elopement or falls, there are a number of steps that can be taken to mitigate that risk.  One of the principal steps is to keep the resident under close supervision.  Doing this reduces the risk from injury for both falls and wandering, and is consistent with the requirements of federal regulations. On the day of this nursing home fall, the staff noticed that a plastic curtain, which went to an otherwise-empty COVID unit, had been disturbed. The staff checked the rooms in the COVID unit for  residents but did not find any. They returned to their own unit and discovered that the resident involved in this incident was missing. They looked throughout the facility but were unable to locate her and returned to the COVID unit.  Upon return to the COVID unit, they re-inspected all of the rooms and were unable to find the missing resident. Coming to the end of the hallway, they noticed that the door to the stairwell was closed, but the green light for alarm was flashing. This was an indication that the alarm was not armed. The staff opened the door and found the resident down at the bottom of the stairwell, with her wheelchair two or three steps down the stairwell. She apparently had begun to fall down the stairs. The wheelchair stopped, and she was ejected from the wheelchair. An ambulance was called. The resident was brought to the hospital where she was diagnosed as having a fracture to her clavicle, as well as broken ribs. There were two major shortcomings in the care that this resident received. First, any resident who is at risk for falls and is also known as a wanderer and at risk for elopement should be a resident who is closely supervised. The citation issued by IDPH indicates that the staff was well aware of her history of wandering and that she wandered actively throughout the facility, often looking for her husband, who is in fact, not a resident at the facility.  Keeping her under close observation would have likely prevented this injury, especially given the amount of time that it would have taken her to travel that distance and open not only the door to the stairwell, but also the curtain to the COVID unit. The other major shortcoming in the care that this resident received is that the stairwell was not secured with either a lock or an alarm. Stairwells pose a special risk of harm to nursing home residents.  This is partially due to the fact that many are simply not able to negotiate them safely as well as the fact that stairwells are an area where they are out of view of the staff.  Once a fall occurs in a stairwell, it is likely that the resident will endure a prolonged period of time before the fall is discovered and care for any injuries from the fall can be offered. In this particular case, the practice at the nursing home was that the maintenance staff would check the alarms throughout the facility during weekdays, but there was no one specifically assigned to check the alarms on weekends – which is when this fall occurred. As a result, the stairwell was not secured with locks or alarm leading to the fall and injuries sustained by 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: Warren Park Health & Living Center resident suffers brain bleed in fall down stairwell Accolade of Pontiac resident fractures hip in fall after call light left out of reach Resident breaks both legs in fall from bed at Grove of Fox Valley   Click here to file a complaint about a nursing home with the Illinois Department of Public Health.  

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

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IDPH has cited and fined Prairie Manor Nursing & Rehabilitation Center in Chicago Heights after a resident there suffered a brain bleed due to being rolled 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, the resident was receiving incontinence care from a single aide.  As the aide turned resident away from her, the resident slid off the edge of the bed, hitting her head on the floor.  She had immediate bleeding and was sent to the hospital where scan showed that she suffered a brain bleed. Besides this being a situation where you had one person doing a two-person job – which is almost always a formula for disaster (see here, here, here, here, and here for examples), the aide compounded the problem by rolling the resident away from her instead of bringing her toward her while positioning the resident. 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.  The aide explained to the supervising nurse that she could not find anyone to help her.  Not having staff available to meet the care needs of the resident is characteristic of an understaffed 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. Other blog posts of interest: Prairie Manor resident suffers broken leg in fall Landmark of Richton Park resident dropped from lift, breaks both legs Manorcare of Palos Heights East resident breaks hip in fall Resident rolled from bed at South Suburban Rehab   Click here to file a complaint about a nursing home with the Illinois Department of Public Health.  

Piatt County Nursing Home resident breaks hip in fall

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IDPH has cited and fined Piatt County Nursing Home after a resident there fractured a hip in a fall due to the failure of an aide to provide needed supervision and assistance. Falls are a major issue in the long-term care industry due to the serious negative effects that they have on the mortality and quality of life of nursing home residents.  Therefore, fall prevention is always a specific area of focus in the care planning process. The care planning process begins with an assessment of the resident’s fall risk.  Nursing homes use a variety of tools to assess fall risk, but one common feature in almost all tools is that (1) some form of musculoskeletal weakness, balance issue, or gait dysfunction and (2) some form of dementia, forgetfulness, intermittent or constant confusion, poor safety awareness or judgment, or some other form of cognitive impairment are major factors in weighing the resident’s fall risk.  The reason that cognitive impairment contributes to fall risk is that the resident cannot be counted on to follow instructions or make good decisions for their own safety.  Where cognitive impairments are a contributing factor to fall risk, close supervision is a mainstay of fall prevention – consistent with the requirements of federal regulations. The resident at issue was properly assessed as being a fall risk.  Among the factors that made the resident a fall risk were having mobility impairments, poor balance, an unsteady gait, a history of falls, and according to the resident’s Minimum Data Set (MDS) he required extensive assist of the staff with transfers and to stabilize.  On the cognitive side, he was noted to have long and short term memory problems.  He further had a known history of attempting to self-transfer and forgetting to use the call light.  He was considered a fall risk because of his impaired gait and forgetting and/or overestimating his limits. On the day of this nursing home fall, the resident activated the call light for assistance to use the commode.  The aide arrived to assist the resident.  He provided the resident his walker and then turned and went to close the privacy curtain for the resident.  As the aide was closing the privacy curtain, the resident attempted to stand using the walker.  As he did so, he lost his balance and fell to the floor.  The resident’s leg was rotated outward with a leg length discrepancy – obvious signs of a fractured hip. The resident was brought to the hospital where the fractured hip was confirmed.  The resident was transferred to a larger hospital where he underwent surgery to repair the fractured hip. The facts of this fall show how quickly small failures in the care that the resident is provided can have catastrophic consequences.  The aide responded to the call light (something that does not always happen) and attempted to provide the resident with a measure of dignity by closing the privacy curtain.  However, he did so after providing the resident with the walker.  He was not in a position to provide the resident with the needed assistance with transferring and stabilizing when he rose from the position seated at the edge of the bed.  Further, he had his back turned to a resident whose known history and behaviors spoke to a need for close supervision.  The Director of Nursing admitted as much, telling the state surveyor that simply closing the privacy curtain when he entered the area could have prevented this fall. 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: Piatt County Nursing Home resident breaks neck in fall from power recliner Westminster Village resident suffers multiple fractures in fall Moweaqua Rehab resident fractures hip in fall Mason City Area Nursing Home resident suffers fractured hip in fall due to failure to use gait belt   Click here to file a complaint about a nursing home with the Illinois Department of Public Health.    

Inverness Health & Rehab resident suffers multiple fractures in fall

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IDPH has cited and fined Inverness Health & Rehabilitation nursing home after a resident there suffered multiple fractures in a fall due to violations of the resident care plan. The resident care plan is one of the building blocks by which much of the routine care a resident in a nursing home requires is provided.  Once a care plan is put into place, it falls the to the staff charged with carrying out the various steps in the care plan to actually implement the care plan on a day-to-day, shift-to-shift basis. For the resident at issue, her Minimum Data Set (MDS) showed that she required the extensive assistance of two staff members with all transfers.   This means that the resident required the hands-on help from two people to move from bed to wheelchair, wheelchair to chair or toilet, and so forth.  The data in the MDS is certified under penalties of perjury to the federal government and the care needs shown on the MDS should be reflected in the resident care plan. On the day of this nursing home fall, the resident was being transferred to the toilet by a single aide, not two staff members as called for by the resident care plan.  Having one person do a two-person job is a formula for disaster, as we have written about many times on this blog  (see here, here, here, here, and here for examples).  In attempting to complete the transfer, the resident fell to the floor.  As a result of the fall, the resident suffered fractures to the kneecap and to the tibia and fibula (the long bones of the lower leg) – but these injuries would not be discovered or treated for over a day. When an aide is involved in a resident fall, it must be reported to the nurse so that the nurse can do an assessment on the resident.  It then falls to the nurse to report the fall to the resident’s  family and the resident’s doctor so that he can make orders about further care for the resident. However, after this fall the aide simply helped the resident from the floor before reporting the fall to the nurse, exposing the resident to risk of injury from being moved when it was not safe to do so.  Further the failure to report the nurse delayed the onset of care because nothing was done about the injuries until the following morning when the resident refused to get out of bed due to the pain she was experiencing. The nursing staff then called the physician and the doctor’s physician’s assistant ordered STAT x-rays.  The portable x-ray company advised that it could not make it the facility in a timely way, so the staff called the PA back and were advised to send the resident to the hospital.  However, that did not actually happen for nearly 9.5 hours.  Most nursing home staff members would agree that subjecting a resident to unnecessary pain is a form of nursing home abuse. The immediate cause of the injuries to this resident was a violation of the resident care plan.  The deeper question is why this occurred the way that it did.  It likely relates to understaffing of the nursing home and the training of the staff.  Having staff take dangerous shortcuts in the care of the resident (such as attempting a transfer with one when two are required) is a sign of an understaffed nursing home.  Failing to invest in training of the staff so that the staff knows to follow the care plan and report falls when they occur is also something that reflects the choices that management makes regarding the nursing home.  Sadly, understaffing the nursing home and failing to invest in the staff is consistent with the core features 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 of St. Charles resident suffers fractured hip after being rolled out of bed by staff Glenview Terrace resident suffers multiple fractures after lift topples over during transfer Assisi at Clare Oaks resident suffers broken neck in fall from wheelchair   Click here to file a complaint about a nursing home with the Illinois Department of Public Health.  

Pekin Manor resident suffers brain bleed due to fall

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IDPH has cited and fined Pekin Manor nursing home after a resident there sustained a brain bleed in a fall. Falls are a significant issue in the long term care industry because of the serious adverse effects they have on the mortality rate and overall quality of life for nursing home residents.  Because of this, falls are a specific area of focus in the care planning process.  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) development of a care plan which spells out specific steps (or interventions) to be taken to address the risks to the resident’s health and well-being, (3) communication of the care plan to the staff members charged with carrying it out, (4) implementation of the care plan on a day-to-day, shift-to-shift basis, (5) evaluation of the effectiveness of the care plan on an ongoing basis, and (6) revision of the care plan if proves to be ineffective in practice of if changes in the resident’s condition warrant it.  An effective care plan is one that meets the risks of resident and are tailored to that particular resident. When it comes to falls there is no “gold standard” risk assessment tool similar to the Braden Scale used for assessing the risk of developing bed sores.  However, there are two major fall risk factors which appear in just about every well-designed fall risk assessment tool.  The first of these is some form of balance or musculoskeletal dysfunction which leaves the resident at risk of falling.  The second major fall risk factor is some form of cognitive deficit such as constant or intermittent confusion, dementia, forgetfulness, or general poor safety awareness or judgment.  The reason that cognitive deficits contribute to fall risk is that the resident cannot be counted on to follow instructions or make good decisions for their own safety.  When the cognitive deficits are significant contributors to fall risk, the care plan should reflect this. The resident was admitted to the nursing home as a short-term admission for rehabilitation and strengthening.  Her preliminary care plan assessed her as being a fall risk.  The care plan called for “call light education” as an intervention to address her fall risk.  During the days that followed, the full extent of her cognitive impairments became apparent.  Her Minimum Data Set (MDS), which is submitted under oath to the federal government, documented her as having severe cognitive impairments.  The nursing home social worker told the state surveyor after the fall that she suffered from cognitive impairments to the point that she was unable to recognize family members.  Her roommate told the state surveyor that she would forget things that she had been told five minutes earlier. In light of this, call light education was an inadequate care plan.  She simply could not be relied upon to use the call light, completely undermining that as a fall prevention strategy.  Federal regulations call for residents to receive supervision and assistance as necessary to prevent accidents, and falls are a form of accident.  As the extent of her cognitive impairments became apparent, her care plan should have been revised to include supervision as a primary means of fall prevention, rather than depending on her to use the call light. On the day that this nursing home fall occurred, the resident was found on the floor of her room with bruising to the back of her head.  She was sent to the emergency room where a CT scan showed that she suffered a brain bleed as a result of the fall. Sadly, the basic step of having an adequate care plan was not taken in this case.  Both her doctor and the director of nursing told the state surveyor that the care plan was not proper in light of her cognitive impairments.  Without an adequate care plan, fall prevention was left to random chance. Pointing to an inadequate care plan providers an easy answer as to why this resident fell and was injured, but the deeper question is why this happened.  The real answer to that question probably relates to the management of the nursing home – the staff was so stretched and stressed that they did not have the time or ability to give this resident’s needs to the critical thought and attention they required.  Unfortunately, that is typical of how nursing homes are operated.   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 at Westminster Village suffers broken leg in fall from toilet Accolade of Pontiac resident suffers fractured hip in fall after call light left out of reach Christian Nursing Home resident suffers severe leg injury in fall University Rehab Northmoor resident suffers broken hip in fall from bed   Click here to file a complaint about a nursing home with the Illinois Department of Public Health.  

Chicago Ridge Nursing & Rehab resident chokes to death

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IDPH has cited and fined Chicago Ridge Nursing & Rehab nursing home after a resident there choked to death on a sandwich. One thing that families almost never envision being a possible outcome when they admit a family member to a nursing home is the possibility that their loved one could choke to death on food.  However, there are residents in nursing homes who are at risk of choking and sadly for some, that possibility comes to pass with deadly results. There are two main factors that place residents at risk for having a nursing home choking accident.  The first of these is physical; the other is psychiatric or behavioral.  The kinds of physical issues that place residents at risk for choking would include things like poor dentition or some form of chewing or swallow dysfunction – often associated with neuromuscular issues such as movement disorders or the residual effects of strokes.  The kinds of psychiatric issues that may place a resident at risk for may include dementia or some form of behavioral disorder which results in compulsive or uncontrolled behaviors with regard to food. When a resident is at risk for choking, this should be addressed in the care planning process.  This may include having a swallow evaluation done by a speech therapist to come up with modified diet orders or other approaches to eating which can serve to reduce the risk of choking.  The recommendations of the speech therapist should be incorporated into physician orders and/or the resident care plan, which then must be carried out on a day-to-day, shift-to-shift basis. One of the kinds of records that are unique to the nursing home industry is the Minimum Data Set, or MDS.  The MDS collects information regarding the resident’s condition, care needs, and the levels of assistance needed.  The MDS forms part of the basis by which the reimbursement (or payment) levels for the nursing home are set, so there is a requirement that the MDS be completed under oath.  Because the MDS is certifying that the resident needs and is receiving a given level of care, the care shown on the MDS is usually incorporated into the resident care plan. The resident at issue had a number of medical issues, including suffering from dementia and having had a history of stroke.   There was a physician order in place for a puree diet.  The resident had a series of know n behaviors, including frequently goin into other resident’s rooms and stealing food from other residents.  Her care plan included one person assistance and supervision while eating and supervision related to her dementia. The staff interviewed after this choking incident however told the state surveyor that she was able to eat without supervision and was alert and oriented to person, time, and place. Her Minimum Date Set (MDS), however, told a different story.  It described her as having severe cognitive impairments.  With regard to eating, it stated that she required supervision of one while eating,  that she experienced loss of food or liquid from the mouth while eating, and that she showed signs of a swallowing disorder in the form of pocketing while eating.  This is very clearly the picture of a resident who was at risk for choking and required supervision.  This is also consistent with the care plan. On the day of this nursing home choking accident, the resident was found unresponsive in bed with a piece sandwich in her mouth.  She was not breathing.  Paramedics were called, but since she was a DNR, they did not attempt to resuscitate her and did not bring her to the hospital.  Case of death per the death certificate was asphyxia due to choking on a food bolus. There were a number of shortcomings in the care that this resident received which led to her death:
  • The staff was not aware of what the care plan called for – they believed that the she was capable of eating independently when she required supervision due to her swallow difficulties and cognitive impairments.  Communicating the contents of the care plan to the staff charged with carrying it out is a basic part of the delivery of care via the care planning process;
  • The care plan did not address her known behavior of taking food from other residents.  The physician’s order called for a puree diet and consumption of anything that was not pureed would be a violation of that order.  As part of the care planning process, the care plan must be revised when it prove inadequate in practice.  If the resident was taking food from other residents which placed her at risk for choking, this is a risk to the health and well-being of the resident which must be addressed in the care plan.  Sadly, it was not.
  • The care plan called for supervision of the resident, but we know that leading up to the choking incident, she obtained a sandwich from somewhere, began to eat it, and choked on it – all without the knowledge of the staff.  As noted above, the staff should have been monitoring this resident specifically for the taking of food which she was not supposed to have, but that was not being done – and it also appears that the more general supervision was lacking as well.
Together, all of these failures led to the very preventable death of 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: Winston Manor resident chokes on peanut butter sandwich Bella Terra Wheeling resident chokes to death Alden Poplar Creek resident chokes to death   Click here to file a complaint about a nursing home with the Illinois Department of Public Health.  

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

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IDPH has cited and fined Accolade Healthcare of Pontiac nursing home after a resident there suffered a hip fracture in a fall. Fall prevention is a major focus of care in nursing homes because falls have such a devastating effect on the mortality and overall quality of life for nursing home residents.  One mainstay of fall prevention is encouraging the use of a call light and leaving personal items such as books, glasses, phones, and so forth in easy reach of the resident.   The basic idea of having things in easy reach is that residents don’t have to get up and down from a seated position and walk across the room to get anything. Another mainstay in fall prevention is use of a call light.  Call lights can be effective in summoning the staff for assistance.  However, for that to happen, the call light must also be left in easy reach of the resident – just as with personal items. The resident at issue was a very clear fall risk.  She suffered from moderate cognitive impairments (and thus could not be relied upon to consistently make good judgments for her own safety) and had difficulty walking, using a walker or a wheelchair for mobility. On the day of this nursing home fall, the resident was found on the floor.  Her left leg was rotated, a common sign of a hip fracture.  The resident did not have on nonskid footwear and had not activated her call light.  However, the nurse on duty noted that the call light was hanging on the call light box on the wall.  The resident was brought to the hospital where she was diagnosed as suffering from a hip fracture. This fall was due to the failure to take the simple step of leaving the call light in a place where the resident could easily reach it without getting up.  However, the call light had been placed on top of the call light box, out of reach.  Besides being a common-sense failure in care, it was also a violation of the facility’s own policies and procedures which called for the call light to be in easy reach of the 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: University Rehab resident falls from bed during incontinence care and breaks hip Westminster Village resident suffers multiple fractures in fall Resident breaks hip in fall at McLean County Nursing Home 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.      
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