Lakeside Health & Rehab Center Cited After Resident’s Fall Went Unreported, Resulting in Delayed Assessment Before Pelvic Fractures Were Diagnosed

The Illinois Department of Health has cited and fined Lakeside Health & Rehab Center in Carlinville, Illinois when, according to state investigators and facility records, a certified nursing aide found a resident on the floor after a fall, assisted her from the floor before a nurse could assess her, and did not immediately report the fall until the resident later reported significant pain. The resident was ultimately hospitalized with multiple pelvic fractures that required surgery.

The resident was a cognitively intact woman with diagnoses including atrial fibrillation, anemia, and age-related osteoporosis. She was assessed as requiring substantial to maximal assistance for toilet transfers and for going from sitting to standing. According to the citation, on the morning of the fall she was helped to the restroom by a certified nursing aide and told to pull the call string when she was done. She later told investigators she waited for a while and no one came, that she was unsure whether she should get up or keep waiting, and that as she waited she became uncomfortable and began having pain. She decided to get up on her own and fell just outside the bathroom door.

According to investigators, the certified nursing aide found the resident on the floor after the fall. According to the facility’s own corrective action documentation, when the resident reported that she had fallen, the aide responded, “I won’t tell if you don’t,” and did not report the fall to the nurse until after the resident began complaining of pain. According to the investigation, the aide assisted the resident back to bed before a nurse assessed her. The resident later told investigators that what really bothered her was that the aide told her not to tell anybody what had happened.

According to investigators, the fall was not promptly reported, and family members later discovered that nursing staff were unaware the resident had fallen when a family member visited later that morning. The resident told the family member she had fallen and was in pain. The family member alerted the nurse, who according to the account knew nothing about a fall, and the Director of Nursing then came to assess the resident. The resident was found to have pain and redness on her right side and difficulty moving or bearing weight on her right leg. She was sent to the hospital by ambulance, where imaging showed fractures of the right superior and inferior pubic rami. Orthopedic notes documented two, possibly three, pelvic fractures and recommended surgery to stabilize the pelvis with an implant. The resident was later hospitalized for the fracture and underwent surgery.

The facility issued the certified nursing aide a final warning for not following safety procedures and unsatisfactory job performance. When interviewed, the aide gave an account that differed in some respects from the resident’s — he stated he found her on the floor while walking past her room, that she asked him to help her up but not to tell anyone because she was doing so well in therapy, and that she did not complain of pain at the time. He acknowledged he did not report the fall until the resident pressed her call light about an hour later and told him she was in pain. He stated he was the only aide working that hall at the time.

The Medical Director told investigators that he expects a fall to be reported at the time it occurs and that ideally a resident should not be moved before a nurse assesses them, in case of a head or neck injury. He confirmed the resident sustained fractures and required surgery, stated he expects staff to follow the facility’s incident and accident policy, and stated he did not consider the resident to have been neglected. Investigators also observed during the survey that the resident’s call light was not within her reach — it was found buried under sheets on the opposite side of her bed from where she was sitting in her wheelchair. The resident stated that when a staff member had come by earlier, she left the call light somewhere and could not find it, and that the staff member did not make sure she had it before leaving.

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.