Resident Suffers Brain Hemorrhage After Fall From Bed at Ascension Resurrection Life

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

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

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

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

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

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

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

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

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