The Illinois Department of Health has cited and fined Heartland Senior Living in Neoga, Illinois when a resident’s bathroom call light was not promptly answered while one staff member stood at the nurses’ station and was not paying attention to the call light panel and another assumed someone else would respond. The resident, who had been identified as a fall risk requiring staff supervision, attempted to stand from the toilet without assistance, lost her balance, fell, and was found unresponsive on the bathroom floor with swelling and bleeding on both sides of her brain.
The resident had been identified as a fall risk and required staff supervision due to an unsteady gait and safety concerns with transfers and ambulation. On the day of the fall, she activated her bathroom call light. A certified nursing aide who was passing meal trays noticed the call light was flashing and sounding. She later told investigators she assumed another aide — who was standing at the nurses’ station at the time — would answer it, so she continued passing trays on a different hall. When she returned to the resident’s hall, the call light was still flashing and sounding. She entered the room and found the resident lying flat on her face on the floor, unresponsive. She estimated that approximately seven minutes had passed from the time she first noticed the call light to the time she finally answered it.
Meanwhile, the aide who had been standing at the nurses’ station told investigators she had not been paying attention to the call light panel because she believed most of the residents were in the dining room eating dinner. After review, staff determined the resident had attempted to stand from the toilet on her own, lost her balance, and fallen. She was bleeding from a skin tear on her left arm. The licensed practical nurse who responded called Emergency Medical Services. When paramedics arrived and tried to move the resident, she complained of pain in her right shoulder. She was transported to the local emergency room, where a head scan documented acute swelling and bleeding on both sides of her brain.
The Director of Nursing told investigators he was aware the resident was a fall risk and that staff would have been as well, since all newly admitted residents are treated as being at risk for falls. He stated his expectation is that any staff member aware of a call light should respond immediately unless actively assisting another resident, in which case the light should be answered within five to eight minutes. He stated specifically that the aide passing trays should have communicated with the aide at the nurses’ station to make sure the call light was being answered, that she should have sought assistance before finishing her tray pass, or that she should have answered the call light herself.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Illinois 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.
