IDPH has cited and fined Symphony of Midway nursing home in Chicago after a resident there suffered multiple fractures and died after falling from a fourth floor window.
The resident at issue had multiple issues including a history of alcohol abuse and alcohol induced dementia. As part of the care planning process, he was assessed as being at risk for anxiety related to change in life style, physical and cognitive decline, among other reasons. he was also assessed as being at risk for impaired thought processes related to dementia. He was also assessed as being at risk for elopement (or wandering from the nursing home) to disorientation, aimless wandering, and impaired safety awareness.
When a resident is assessed as being at risk for elopement, there are a series of steps which are regularly taken by the nursing home. These included placing a device called a wanderguard on the resident which will cause an alarm to sound if the resident leaves a designated area; regular visual checks on the resident by the staff; and eliminating means by which the resident can exit the facility. It goes without saying that having the resident leave the nursing home can expose the resident to harm in a wide variety of ways.
In the days leading up to the incident, the resident had been expressing increased levels of anxiety related to a wound on his heel. During the days leading up to the incident, he was seen by the staff with the window open and the screen missing. He told the staff that he just wanted to get some fresh air. Normally, the extent to which a window could be opened was limited by a window lock. The nurse alerted the maintenance staff who replaced the screen and saw that the window lock was in place.
During the days that followed, the resident was seen by a psychiatrist and a nurse practitioner. He denied suicidal ideation to both of them and expressed a desire to be moved to a lower floor where he believed that he would receive better care. His care plan was upgraded to include 15 minute visual checks by the staff as an elopement prevention measure. The psychiatrist and nurse practitioner recommended that resident be moved to a lower floor as a safety measure but this was never done.
On the day of this nursing home fall, the resident was seen by the staff as late at 4:15 p.m. During the investigation that followed, the resident was seen walking on the hall; and then going into his room where no one checked on him after 4:35 p.m. At around 5:30 p.m., a neighbor called the nursing home to tell the staff that they had seen someone falling from a fourth floor window and that they had called 911. The staff went outside and found the resident on the ground.
The resident was brought to the hospital where he was diagnosed as having suffered fractures of the right femur, both ankles, the left heel, an open fracture of the right upper arm, the left radius, and bilateral pelvic bones. He died at the hospital the following day.
There are a host of issues with the care that this resident received. One of the basic steps in preventing resident elopement is securing the physical environment. If the window lock was not in place, this is a serious problem with regard to the resident’s physical environment. Second, there were several checks missed on this resident during the last half hour to an hour before he went out the window – opportunities lost to discover him opening the window. These are violations of the resident’s care plan. Finally, there was a recommendation to put him on a lower floor which was ignored. Part of the purpose this would have served would be to lower his level of anxiety because the resident was upset about his heel wound and believed her would get better care on a different floor. The other purpose that would have been served is to reduce the height of the fall should the resident try to go out the window as he did here. That is something that was likely the difference between an injurious fall and a fatal 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:
Multiple injuries in fall at Symphony at Midway
Breakdown in care results in broken leg at Chalet Living & Rehab
Resident wanders from Aperion Care Forest Park, drowns in river
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