The Illinois Department of Health has cited and fined Prairieview Lutheran Home in Danforth, IL when staff failed to identify and correct environmental hazards and wheelchair safety issues, resulting in two residents suffering serious fractures requiring surgery and emergency hospitalization. In both cases, the dangers were visible and preventable — and staff either walked past them or failed to address them before residents were seriously hurt.

The primary incident involved a resident who used oxygen via nasal cannula and slept in a recliner in her room. Her care plan identified her as a fall risk due to deconditioning, balance problems, a history of falls, and the use of psychotropic medications — and she required staff assistance with transfers and walking. The oxygen tubing ran across the floor from the bathroom to her recliner, and her call light cord stretched across the same path. These cords created an obvious trip hazard directly in the walking path of a resident the facility already knew was at risk for falling. No one moved them. No one rearranged the room. The hazard sat there unaddressed.

In the early hours of the morning, the resident got up on her own to use the bathroom. She tripped on the oxygen tubing, fell, and landed on her back on the floor. Staff found her when they heard her calling for help during routine rounds. She was taken to the hospital by ambulance, where she was found to have a broken hip and a broken arm. She underwent surgery the same day, receiving a partial right hip replacement and a long-arm cast. The Director of Nursing confirmed the root cause: the resident tripped over her oxygen tubing. As one nurse stated plainly during the investigation, “It was not in her best interest to have cords draped across the floor.” The room was rearranged after the fall — something that could and should have been done before it.

Making matters worse, after the fall staff lifted the resident off the floor manually — one person holding her shoulders, one her legs, and one her midsection — rather than using a full mechanical lift or waiting for emergency services. A certified nursing aide who witnessed it said the resident “screamed out in pain” during the transfer. The nurse practitioner stated it “would not be appropriate to arm-and-leg lift” the resident from the floor into bed, and the Director of Nursing confirmed that after any fall, a resident should be moved only with a full mechanical lift or, if the resident can bear weight, with a gait belt and two-staff assist. The resident could not bear weight.

The second incident involved a resident who was taken outside to the facility’s fall festival in her wheelchair by her husband. Before leaving, staff observed him struggling to position the wheelchair’s foot pedals correctly. He tried but could not attach them, and left them folded to the sides with the resident’s legs dangling unsupported in front of her. Multiple staff members walked past and said nothing. Video footage reviewed by the facility’s administrator confirmed this, and the administrator acknowledged that staff should have stepped in before they went outside.

Once outside, the husband pushed the wheelchair from the pavement onto the grass. The wheelchair became stuck, and without foot pedals to support and protect her legs, the resident’s foot caught under the wheelchair. She suffered a fracture of the left shinbone near the knee in two places, confirmed by both X-ray and CT scan. The facility’s own fall prevention policy specifically identified improperly fitted or maintained wheelchairs as an environmental fall risk factor. The Director of Nursing stated that any staff member who saw the situation should have stopped and corrected it before the resident was taken outside.

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.

The Illinois Department of Health has cited and fined Aliya on 87th in Chicago when a resident classified as high fall risk fell in the facility’s dining room when the only staff member present in the dining room at the time became occupied assisting another resident, leaving the high-risk woman unsupervised. The fall resulted in the resident sustaining an acute subdural hematoma to the left frontotemporal region of her head and a right eye hematoma, serious injuries that required hospitalization and were followed by a subsequent emergency transfer when the resident became unresponsive days later.

The resident, a woman with a medical history that included cerebrovascular disease, delirium, difficulty walking, and an unspecified lack of coordination, was admitted to the facility and assessed for fall risk shortly after arrival. She scored a 23 on the facility’s fall risk assessment, where any score of 10 or above is considered high risk. She was assessed as mildly cognitively impaired, with a Brief Interview of Mental Status score of 10. She was also documented as requiring extensive staff assistance with all transfers and used a wheelchair for mobility. Despite this high-risk classification, the resident’s care plan contained only minimal interventions. According to state investigators, the care plan stated only to “keep room free of clutter” and “round at a minimum of 2 hours.” The facility’s own restorative nurse explained that appropriate high fall risk interventions should include “floor mats in place, increased rounding, high staff supervised area such as dining room during activities because the expectation is to monitor them frequently.”

On the day of the fall, the resident was in the dining room during lunch. A certified nursing assistant had been assigned to monitor residents in the dining room but was the only staff member present. While cutting up food for another resident, the CNA heard someone call out that the woman was standing up. The CNA stated that “by the time she got to” the resident, “she had already fallen.” The facility’s Director of Nursing provided a different account of how the monitoring lapse occurred, stating that the resident’s assigned CNA “was asked to help feed a resident” and that “as she went to feed another resident, she took her eyes off” the high-risk woman. Regardless of which account is more precise, both confirm that no staff member was watching the resident when she attempted to get up out of her wheelchair without assistance and fell. A fellow resident who witnessed the fall provided a written statement that read, “I was sitting in the back eating my lunch. I looked over and she was leaning on the side of her wheelchair again after the CNA helped her to scoot back. Next thing I know is she was on the floor.” The resident was found on the dining room floor with mild swelling to both sides of her face.

The resident was sent to the hospital, where she was diagnosed with an acute subdural hematoma overlying the left frontotemporal region of her head and a right eye hematoma. Doctors ordered a repeat CT scan of the head to monitor the injury. The resident was eventually discharged back to the facility about a week later. Upon her return, the facility added her to its “fall star program” as an additional intervention — an acknowledgment that more should have been done from the start, but one that came only after the resident had already suffered a serious brain injury.

Just two days after her return, the resident experienced what staff described as a seizure while sitting in her wheelchair in the cafeteria. A nurse reported that the resident “slumped over in her chair” and was moved to a Geri chair to prevent further slumping. The nurse notified the doctor about the resident’s uncontrolled tremors and was told to monitor her through the night. Her vitals were normal at that time. However, by the following day, the resident’s condition had deteriorated significantly. A nurse practitioner assessed the resident and found that while she was breathing and had a pulse, she “was not responsive to stimuli.” When staff performed a sternal rub, the resident responded only by pushing the hand away. She was sent back to the hospital for further evaluation. The nurse practitioner noted that signs and symptoms of subdural hematoma can include “change in mental status, not responding to physical or verbal stimuli, involuntary muscle movement,” and seizures — symptoms consistent with what the resident had been exhibiting since her return. The nurse practitioner stated that “subdural hematomas are typically caused from some sort of injury” and that while spontaneous cases can occur, “they are usually from some sort of injury.”

The facility’s Director of Nursing confirmed during the investigation that the fall occurred in the dining room, not in the resident’s bedroom as initially reported by some staff. The Director acknowledged that when the assigned CNA left to help another resident, “another staff member or the nurse should have monitored” the high-risk woman, but noted that “the nurse was at her medication cart in the hallway.” A nurse who cared for the resident after her return also told investigators that she did not recall the resident having “floor mats or seizure preventative bed bolsters” in place — basic safety measures that were absent despite the resident’s documented history of falls and now a diagnosed subdural hematoma. The facility’s own fall prevention policy states that the facility “will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible” and that “residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk.”

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.

The Illinois Department of Health has cited and fined Alden Des Plaines Rehab & Health Care when a certified nurse aide transferred an 83-year-old resident from the toilet to a wheelchair alone, despite the resident’s care plan requiring two staff members for all transfers due to his surgical condition and limited mobility. The resident experienced sudden weakness during the transfer, was lowered to the floor, and was subsequently found to have a dislocated right hip prosthesis, requiring hospitalization.

The resident, an 83-year-old man, had been admitted to the facility with a complex medical history that included a periprosthetic fracture around his right hip joint, a history of falling, osteoporosis, and the presence of an artificial right hip. Because of these conditions, the facility conducted multiple assessments upon his admission. A Fall Risk Assessment determined that the resident was at risk for falls. A functional abilities assessment documented him as a “dependent transfer,” meaning he could not transfer between surfaces on his own. A physical therapy evaluation further documented the resident as requiring “max assist out of bed and total dependence assist with transfers.” A restorative nurse confirmed that she assessed the resident’s transfer needs upon admission and that he was classified as a two-person assist “due to surgical site and having a wound vac.” Based on all of these evaluations, the resident’s care plan specified that all bed-to-chair transfers required “2-person assist using rollator walker using good side/left side to transfer.”

Despite these clearly documented requirements, only one certified nurse aide attempted to transfer the resident from the toilet to his wheelchair on the day of the incident. During the transfer, the resident experienced sudden weakness in his right leg and was lowered to the floor. A registered nurse responded after being called to the room and found the resident sitting on the floor. The nurse assessed the resident, who initially denied any pain, and together with the aide assisted him back to bed using a gait belt. However, when the resident was later reassessed for pain, he reported that he was “having pain to the right hip.” The nurse notified the physician and received orders for X-rays. The X-ray results confirmed that the resident’s right hip prosthesis had dislocated, and he was sent to the emergency room for further evaluation.

During the state’s investigation, the facility’s Director of Nursing confirmed that the resident “should have been a 2-person transfer assist” at the time of the incident. The Director also disclosed that the certified nurse aide involved in the incident “is no longer an employee at the facility for multiple reasons including resident safety.” The facility’s Administrator similarly confirmed that the aide “was suspended pending investigation and eventually was let go of the facility due to multiple factors.” The Administrator acknowledged that the fall was reported due to the resulting injury, and the resident was transferred to the hospital because of the hip dislocation and had not returned to the facility.

The facility’s own transfer policy states that “resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe transfers of residents.” The policy requires staff to “assess individual resident’s needs for transfer assistance on an ongoing basis” and to “document resident transferring and lifting needs in the care plan.” The facility’s fall management policy further requires that the facility “assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the residents plan of care in order to minimize the risks for fall incidents and/or injuries to the resident.” In this case, the hazards and risks had been properly assessed and documented, but the interventions were not carried out by the staff member responsible for the resident’s care.

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.

The Illinois Department of Health has cited and fined Addolorata Villa in Wheeling when a resident with Parkinson’s Disease and severe dementia fell and fractured his left hip after staff failed to use a gait belt during ambulation, as required by his care plan. The resident was subsequently transferred to a local hospital for treatment of the hip fracture.

The resident in question was originally admitted to Addolorata Villa with multiple medical conditions including Parkinson’s Disease, Dementia, and Obstructive and Reflux Uropathy. A cognitive assessment scored him at 3 out of 15, indicating severe cognitive impairment, meaning he had very limited ability to understand his surroundings or make decisions about his own safety. Because of these conditions, the facility developed a care plan that included specific safety measures whenever staff helped him walk. The plan stated that he was to ambulate, or walk, with “contact guard in the hallway and a gait belt on for safety with a wheeled walker.” A gait belt is a safety device worn around a resident’s waist that gives staff something secure to hold onto in case the person loses their balance.

On the evening of the incident, a registered nurse observed the resident coming out of his bedroom and walking without his walker. The nurse intervened and asked a certified nurse assistant to stay with the resident while she retrieved the walker. The nurse then walked alongside the resident to a common area near the nurse’s station, gave him ice cream, and seated him in a recliner. However, at no point was a gait belt placed on the resident. About thirty minutes later, after finishing his ice cream, the resident stood up and began walking toward the nurse’s station. The nurse provided the walker, but the resident refused it, “waving his hands to signal ‘no.’” The nurse positioned herself on his right side and walked with him toward his room. After approximately five to six steps, the resident leaned to his left, lost his balance, and fell to the floor. The nurse later acknowledged, “The resident was not wearing a gait belt at the time. Having a gait belt in place would have assisted me in supporting him.”

After the fall, the nurse assessed the resident and, with the help of the certified nurse assistant, transferred him to a wheelchair. She administered pain medication, called the family, and obtained orders from the medical director to send the resident to a local hospital. The hospital confirmed that the resident had sustained a left hip fracture. The certified nurse assistant who was present confirmed that the resident “is very confused, hard to re-direct” and that he “did not have any gait belt on” at the time of the fall.

During the state’s investigation, the facility’s Director of Nursing stated that she expected the nurse to use the gait belt since it was one of the interventions in the care plan. The facility’s own gait belt policy, presented by the Administrator, states that “it is the standard of the community to use a gait belt for all residents in accordance with assessed needs, the care plan and standards of practice in order to provide optimal safety.” The policy further specifies that “gait belts are to be used for all transfers that require staff assistance and when assisting residents to ambulate.”

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.

The Illinois Department of Health has cited and fined The Haven of Paris when a resident with severe dementia and Lewy Body disease fell and fractured his left hip after staff failed to provide the required supervision for high fall-risk residents. Despite facility policies requiring checks every 15 minutes for residents at high risk for falls and elopement, staff were checking on the resident only every two hours or less, resulting in an unmonitored seven-and-a-half-hour period before his fall.

The resident in question had a diagnosis of Neurocognitive Disorder with Lewy Bodies, a form of progressive dementia that affects thinking, movement, behavior, and mood. His mental status assessment showed severe cognitive impairment with a score of five out of 15, indicating he was alert and oriented only to his own name but not to place or time. He had a history of wandering and walking aimlessly without purpose, and was classified as both a high fall risk and at risk for elopement (wandering away from the facility).

In addition the resident had poor safety awareness, a shuffling gait, weakness, and poor balance. Staff noted he “frequently gets up on his own without calling for help” and would often get up to get coffee on his own. His care plan documented he was “at risk for falls related to impaired cognition, poor safety awareness, dementia, shuffling gait, and weakness.”

Just weeks before the hip fracture, the resident had already suffered another unwitnessed fall that resulted in a fracture to his left shoulder, a laceration beside his left eye, and a skin tear to his left elbow. Despite this serious fall and the injuries sustained, the facility’s supervision procedures were not adequately implemented.

On the day of the fall, records show the resident was last checked on and repositioned at 8:22 in the morning. The fall occurred at 3:50 in the afternoon—a gap of approximately seven and a half hours with no documented supervision. A nursing assistant who was at the nurses’ station stated she “was filling out paperwork at the desk and then got up to go to the bathroom and saw that the resident was walking out of his bathroom and begin to lose balance and went down to the floor.”

In a phone interview, the same nursing assistant stated she “looked up and noticed the resident coming out of his neighbor’s room” when he “lost his balance and fell.” When asked for more details, the assistant stated “I don’t know what time the fall happened or the last time I saw the resident, and I don’t have anything else to tell you.”

An x-ray confirmed the resident had sustained an acute intertrochanteric fracture of the left femur (hip) with soft tissue swelling. He was transported to the hospital for treatment and later returned to the facility. When interviewed after his fall, the resident did not remember the fall or that he had broken his hip, and complained of pain in his groin area on the left side.

The facility had clear policies requiring enhanced supervision for high-risk residents. The Director of Nursing stated “staff are responsible for doing rounds every two hours unless a resident is a high fall risk and then they should be checked more frequently (every 15 minutes), and this should be on the Care Plan.” The MDS Coordinator confirmed that “15-minute checks (increased visuals) are implemented for those residents that have been determined to wander or who are at risk for elopement.”

The Assistant Director of Nursing stated “residents that are a high risk for falls or high elopement risk should be checked on every 15 minutes” and acknowledged “the CNAs should have been checking on the resident at minimum every two hours and that it should be documented.” However, she “could not provide documentation showing the resident had been checked on appropriately” on the day of the fall.

The registered nurse caring for the resident that day stated the resident “has dementia, was alert and oriented to person only and frequently would get up on his own” and confirmed “the CNAs should have been checking the resident every two hours if not more frequently.” The Director of Nursing ultimately confirmed that “staff were not checking on the resident every 15-minutes even though he was a high fall risk.”

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.

The Illinois Department of Health has cited and fined Jerseyville Nursing & Rehab Center when a cognitively impaired resident with a history of falls sustained catastrophic head injuries after falling from her bed, dying the next day in the hospital. The facility failed to evaluate, implement, and monitor the effectiveness of fall interventions, resulting in the resident suffering depressed skull fractures, brain bleeds, and facial fractures after three falls in three months.

The resident in question had severe cognitive impairment and dementia with agitation, was rarely or never understood when speaking, and had a history of falling. She required substantial to maximal assistance from staff to stand and used a wheelchair for mobility. She was classified as high fall risk on every assessment conducted at the facility. The resident was also noted to be forgetful and didn’t remember she couldn’t walk by herself.

The resident fell three times during her stay at the facility. After her first fall, when she injured her head, staff added an intervention to have the television on when she was laid down in bed as a distraction. After her second fall, when she again injured her head and arm and was sent to the emergency room, the facility added bed and chair alarms. However, the facility did not adequately assess whether these interventions were actually preventing falls.

The Director of Nursing later acknowledged that bed and chair alarms had already been in place before the second fall, meaning “it would not have been a new intervention.” Similarly, the bed had already been in low position with a fall mat before the third fatal fall, but “it wasn’t added to her care plan interventions until after the fall,” indicating a failure to properly document and monitor existing measures.

The facility failed to evaluate and adjust interventions when they proved ineffective. Staff knew the resident routinely defeated the bed alarm system. The Care Plan Coordinator stated the resident “knew how to turn the bed/chair alarms off, she would grab the box and turn it off.” The Director of Nursing acknowledged “the bed alarm was not an effective intervention for the resident” when she was in bed, admitting “the alarm was only effective when used in her wheelchair.”

Despite knowing the bed alarm wasn’t working, the facility continued to rely on it without implementing alternative strategies or modifications. The facility’s Medical Director stated “he would expect interventions to be progressive and resident centered” and that “if the resident was able to turn off the alarm, he would expect the facility to attempt to prevent her from being able to do so by hiding it.” The Director of Nursing acknowledged after the death that “maybe they could have put the alarm box inside the resident’s bedside table to keep her from turning it off”—but this was never attempted while the resident was alive.

The facility’s own guidelines for Personal Alarms acknowledged that “many reports describe patients deliberately deactivating their alarms and may not be appropriate,” yet staff did not act on this knowledge or seek alternative interventions for this particular resident.

The facility failed to properly document and consistently implement interventions. The Director of Nursing revealed that staff “were doing 15-minute checks on the resident while she was in bed, she was the only one we had to do that on,” but critically admitted “we didn’t have this documented.” Without documentation, there was no way to monitor whether these checks were actually occurring or to hold staff accountable.

After the first fall, staff determined that having the television on for distraction was important “because there weren’t any eyes on her in there.” However, this intervention was not consistently followed. Multiple staff members confirmed the television was not on when the resident was put down for her nap on the day of the fatal fall, despite this being identified as an important fall prevention measure.

The Care Plan Coordinator acknowledged that “a self-release belt as a fall intervention should have been added at the same time her bed and chair alarms were, but she couldn’t see it was actually added,” demonstrating a failure to properly implement and document interventions.

On the day of the fatal fall, nursing assistants put the resident in bed for a nap after lunch. They stated she appeared tired with her eyes closed. One assistant said she placed the resident’s bed alarm and had her fall mat in position, with the call light within reach.

Just 3-5 minutes after staff left the room, another nursing assistant walking down the hall “saw the resident lying on her left side on the floor with a puddle of blood under her head.” The Director of Nursing found the resident “on her left side with half her body on the fall mat, the upper half on the floor.” The bed alarm was still attached but was not going off—consistent with staff’s knowledge that the resident would turn it off, yet no modifications had been made to prevent this.

When paramedics arrived, they found the resident “lying on her left side and had a lot of blood on her, she was moaning and had purposeful movements with her eyes open but was not speaking.” The paramedic stated the resident “was actively bleeding, and her hair was saturated with blood.” No alarms were sounding.

Medical records documented the resident sustained depressed skull fractures, an orbital fracture (eye socket), subdural hematoma (bleeding between brain and skull), subarachnoid hematoma (bleeding around brain), intraparenchymal hematoma (bleeding within brain tissue), maxillary fracture (upper jaw), temporal bone fracture, and a scalp laceration. The resident was flown to a larger hospital for specialized care. Hospital notes documented she was “admitted with severe TBI (Traumatic Brain Injury) and altered mental status” with “concern for impending uncal herniation syndrome,” a life-threatening condition. After discussion with family, care was transitioned to comfort measures. The resident died the following day.

The facility’s Medical Director stated “he would expect staff to be following the fall risk care plan interventions if they were able to do so” and “he would expect interventions to be progressive and resident centered.” He further stated “if the fall risk interventions were not being followed and they were previously working, it could pose a higher risk for the resident to fall”—which is exactly what occurred.

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.

The Illinois Department of Health has cited and fined Richland Nursing & Rehab in Olney when a cognitively impaired resident with severe mobility issues fractured his right arm and elbow after a nursing assistant left him standing alone in the hallway to retrieve his walker. The resident, who was admitted after previous fractures from a fall and required maximum assistance from two people to walk even 10 feet, stumbled and fell into a handrail within seconds of being left unattended.

The resident in question was admitted to the nursing home following fractures to his right hip and back from a previous fall. He had severe cognitive impairment with a mental status score of 7 out of 15, indicating significant dementia. His assessment documented he was “dependent” for mobility, meaning “helper does all of the effort” and he “does none of the effort to complete activity, or the assistance of 2 or more helpers is required.” His physical therapy evaluation showed he required “max assistance x2” (maximum assistance from two people) just to walk 10 feet with a walker. He was classified as high risk for falls due to his history of falls, cognitive impairments, decreased safety awareness, difficulty using his call light, and decreased strength and endurance.

In the early morning hours, the resident was in the hallway in his wheelchair near his room. A nursing assistant was with him when the resident stood up from his wheelchair and grabbed onto the hallway handrail. The assistant stated “he then moved the wheelchair behind the resident and locked the wheels” and then “took 2 steps towards the resident’s room that is a couple of feet away, behind where the resident had been standing to get the resident’s walker.”

The assistant said “when he was a few feet away from the resident, the resident stumbled and hit his right elbow on the handle rail.” Another nursing assistant who witnessed the incident from the nurses’ station stated the assistant “did attempt to get the resident’s walker, but the resident stumbled and fell into the handrail” and the assistant “did reach out to grab the resident after he hit the handrail, so he did not hit the floor.” The resident ended up sitting on the hallway floor with his legs stretched out in front of him.

The resident was complaining of right arm pain with visible swelling. X-rays revealed he had sustained “a comminuted fracture of the proximal humerus and mildly displaced fracture at the base of the olecranon process at the elbow”—meaning multiple fractures in his upper arm and elbow. The resident was transported by ambulance to the emergency room and returned to the facility with a cast on his right arm and orders to follow up with an orthopedic specialist.

Multiple staff members and the facility’s own therapist agreed the resident should never have been left standing alone. The occupational therapy assistant who worked with the resident stated “the resident is not safe to be left to self-ambulate and in her opinion the resident should not be left alone when attempting to stand or while standing.”

A nurse who cared for the resident stated “the resident is unsteady on his feet and very impulsive” and “the resident should not be left unassisted while standing or walking.” The facility’s physician stated “the resident is unsteady on his feet and should not be walking or standing without assistance” and specifically noted the nursing assistant “should have remained at the resident’s side and not left him unassisted.”

The facility’s Administrator stated “it would be her expectation that the nursing assistant remained with the resident and had another staff member bring him the resident’s walker” rather than leaving him standing alone. The facility’s own Fall Management Policy required “necessary supervision” for high-risk residents and specified the use of “gait belts for all non-mechanical lifts and assists with transfers.”

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.

The Illinois Department of Health has cited and fined Autumn Meadows of Cahokia when a recent amputee fell after his bed’s locking mechanism malfunctioned, causing his surgical wound to completely reopen and requiring emergency surgery. Despite the resident reporting that his bed wheels wouldn’t lock, the facility failed to repair or replace the bed, and when he attempted to transfer to his wheelchair, the bed rolled away from him, causing him to fall and tear open his amputation site.

The resident in question had recently undergone amputation of his right leg below the knee and was admitted to the nursing home for rehabilitation. He was assessed as a high fall risk with a score of 50 on the facility’s fall scale, where anything above 45 is considered high risk. The resident was cognitively intact and required assistance with transfers due to his new amputation. His surgical staples had been removed, and the wound had healed over.

One evening, the resident needed to use the bathroom but didn’t want to ask for help because, as he explained, he was “in denial about losing his independence.” He attempted to transfer himself from his bed to his wheelchair positioned beside the bed. However, the bed’s locking mechanism was broken, and when he tried to move, “the bed rolled away from him, and he fell on the floor and busted his stump open.”

The resident said his surgical wound “reopened measuring 15 centimeters in length and 3 centimeters in height.” He described being in severe pain, rating it “an 11” on a scale of 0-10. The resident stated he “put his call light on to get some help, but no one ever came so he crawled out into the hallway and yelled for help.” He said “it still took the CNAs a while to come and help him” even after he crawled into the hallway calling for assistance. When staff finally arrived, he said he “was bleeding all over the place. There was a trail of blood from the bed to the hallway. He said there was so much blood they had to take towels and put on it to stop it from bleeding.”

The resident was transported to the hospital where surgeons discovered the fall had caused “complete dehiscence” (complete reopening) of his amputation closure site. The surgical report documented finding “evidence of some nonviable muscle and traumatized muscle from the fall as well as a hematoma which was evacuated.” There was also “a large amount of fibrous tissue” and exposed bone requiring removal.

Due to the severity of the injury and “depleted venous access” (his veins were too damaged for a regular IV), surgeons had to place a triple lumen catheter in his groin to administer anesthesia. The surgical team performed extensive debridement (removal of dead tissue), excised a portion of the tibial bone using a power saw, irrigated the wound with antibiotics, and reapproximated the skin using interrupted sutures. The resident remained hospitalized for several days before returning to the nursing home.

The maintenance director confirmed the facility knew about the broken bed. When asked why the resident received a new bed after the fall, maintenance staff stated “because the resident complained his bed wouldn’t lock.” The maintenance director explained “the locking mechanism on the bed wasn’t working and when it doesn’t work it will cause the bed to slide.”

However, the facility’s administrator stated she “can’t put a date on it when she was made aware of the resident’s bed not working properly.” When pressed whether she learned about it before or after the fall, she said “she was unable to remember and that is why she can’t put a date on it.” She acknowledged staff should have either fixed it themselves if possible or submitted a work order to maintenance.

Despite the resident being a recent amputee at high risk for falls, his care plan was inadequate. The care plan initiated after the fall simply stated the resident is “at risk for falls” with “gait/balance problems due to a recent below the knee amputation.” The interventions listed were generic: “anticipate and meet the residents needs as needed, ensure the resident’s call light is within reach and encourage the resident to use it for assistance as needed, and follow facility fall protocol.”

An investigation report noted the resident “is a brand-new amputee and has a diagnosis deficit. Resident lack safety awareness and has not come to terms with his most recent amputation. Resident has difficulty with asking for assistance or using his call light because he is in denial about losing his independence.” Despite this documented psychological struggle and high fall risk, no meaningful preventive interventions were implemented.

The facility’s Medical Director stated he would “deem the resident a fall risk and there should be a fall plan of care in place for him.” He said “the fall the resident had has the potential to cause harm and he is sorry it happened.” The Medical Director stated “he thinks the facility failed in preventing the resident’s fall. He said no one was answering his call light, and his bed was broke that’s a lot.” He concluded “yes, this incident has the potential for the resident to experience harm or death.” He said it’s unacceptable and he absolutely agrees the facility failed.

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.

The Illinois Department of Health has cited and fined Alden Estates of Orland Park when a 79-year-old resident with dementia and Alzheimer’s disease fell in the dining room while left unmonitored, suffering a fractured hip that required hospitalization. The facility failed to follow the resident’s care plan which specifically required visual supervision and removal from common areas after meals.

The resident in question had been admitted to the facility in February with multiple serious diagnoses including chronic hepatic failure, hepatic encephalopathy, anemia, Alzheimer’s disease, type 2 diabetes, COPD, depression, anxiety, hypertension, and dementia. Her cognitive functioning was severely impaired, with a Brief Interview for Mental Status score indicating she was “alert and oriented times one to two spheres” and required partial to moderate assistance with activities of daily living. Her fall risk assessment documented multiple concerning factors including an unsteady gait, use of ambulatory devices, confusion, previous falls within the prior three months, and use of medications affecting thought processes and causing hypotensive effects. The assessment clearly identified her as at risk for falls with a score indicating significant danger.

A Licensed Practical Nurse who was covering for the regular nurse during a break stated she had walked past the dining room and observed the resident sitting in her wheelchair at a table with her back to the door, with lunch already concluded and no food trays remaining in the room. The covering nurse then sat down at the nurse station across from the dining room, from which position she acknowledged she could not actually see the resident. A few minutes later, two staff members approached and informed her the resident was on the floor in the dining room. When the nurse assessed the situation, she found the resident lying on her right side between two tables with her head toward the wall and her feet pointed outward. The resident winced and complained of pain when her back was touched during examination.

Emergency services transported the resident to the hospital where X-rays revealed “sclerosis the femoral neck” and “suspicious for an impacted nondisplaced right femoral neck fracture” with the impression of a “probable nondisplaced femoral neck fracture.” Another staff member who discovered the resident described finding her on her back on the floor with no other residents or staff present in the dining room. He reported the resident attempted to get up several times but could not, and he believed she had stood up from her wheelchair causing it to roll backward since the wheels were not locked, which he said “often” happened with this resident.

The resident’s care plan, which had been initiated at admission, specifically documented interventions to prevent falls. The plan stated the goal was the resident “will remain free of falls through next review” and included detailed instructions such as ensuring appropriate use of her wheelchair, monitoring for changes in her ability to navigate the environment, providing proper footwear, and critically, the directive to “remove resident from common areas after completion of her meal” and “do not leave in room in wheelchair without supervision/monitoring.” Multiple staff members confirmed during interviews that the resident frequently needed to be redirected and asked to sit down in her wheelchair because she could fall, and that she often stood up from her chair and sat back down, which would cause the wheelchair to roll backward if the wheels were not locked.

The covering nurse admitted she was not aware the resident was at risk for falls and that the regular nurse had not given her any report before taking her break. She stated there was “no solid rule that someone must be in the dining room to monitor the residents” and that they could be monitored from the nurse station, yet she also acknowledged she did not see the resident fall while supposedly monitoring the dining room.

In contrast, the Director of Nursing acknowledged during her interview that “if the residents are in dining room staff should be there to monitor the residents” and that “the staff should be able to see all the residents when monitoring the dining room.” She stated that if she had to do things differently, she would have staff bring residents out of the dining room after lunch to sit near the nurse station for proper observation. The Director suggested the root cause of the fall was that the resident was likely trying to take herself back to her room after lunch “as she often did,” which was precisely the type of unsupervised activity her care plan was designed to prevent.

Following the incident, the facility implemented corrective measures including reviewing all fall-risk residents and their care plans within days of the fall, conducting in-service training for all nursing staff on fall management and prevention, specifically training staff on resident supervision during and after dining, developing a quality assurance audit tool for dining room supervision, and holding an emergency quality assurance meeting with the interdisciplinary team and Medical Director to approve the corrective action plan.

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.

The Illinois Department of Health has cited and fined Lutheran Care Center Altamont when a hospice resident fell headfirst to the floor after a mechanical lift strap broke during transfer by a single nursing assistant instead of the required two staff members, causing a head injury and rapid decline that led to her death three days later. The facility violated its own policy requiring two staff present during mechanical lift transfers due to weekend staffing shortages.

The resident in question was admitted under hospice care with heart failure, stroke, pneumonia, and respiratory failure. She was completely dependent on staff for all care including transfers. Her care plan required “transfers using mechanical lift and 2 staff assist.”

During a morning transfer, a nursing assistant was alone using a mechanical lift when “the strap broke and the resident fell to the ground headfirst hitting her head.” The incident report documented: “Right blue upper strap broke with resident over the floor. She fell out of sling laying on her right side x 2 raised areas on upper back of head and 1 raised area on upper right side of head.”

The responding nurse found the resident “still alert as her normal” with knots on her head and right arm bruising. Initial vital signs showed respirations 32 and oxygen saturation at 84%.

The resident’s condition rapidly deteriorated. She developed respiratory distress and “had 2 large emesis undigested food” with pulse 130 and oxygen level at 88% even with supplemental oxygen. Hospice ordered comfort medications. By the next midnight, nursing notes documented: “Resident opens both eyes, no verbal response, grimaces with touch. Pupils sluggish. No response when asked to squeeze hands. 7 centimeter round soft area to upper crown of head.”

By afternoon: “Resident non to minimal responsive. Does not open eyes, pupils sluggish.” The following morning, she was “non-responsive, bilateral extremities flaccid.” Early the next morning, a nurse found her “no audible pulse, no audible blood pressure, respirations ceased.” She died three days after the fall.

The hospice nurse stated directly: “Yes definitely” the fall contributed to death. “She had a rapid change in condition that consisted of a change and decrease in her level of consciousness, she began to have vomiting, and inability to eat and keep food down.” When asked if the resident was at end-of-life prior to the fall: “I do not feel like she was at that point prior to the fall. She was not in the condition yet that I would have talked with the resident’s family to inform them that death was near or even a month away.”

The facility physician confirmed: “With a head injury to a resident of her age it is never good.” When told the hospice nurse felt the fall attributed to death, he stated: “I have to agree with Hospice on that statement.”

The administrator stated: “We know the fall caused the change in condition and death of the resident.”
The nursing assistant admitted “using 1 staff member for mechanical lifts was not unusual on the weekends due to staffing shortage but she will never do that again.”

The facility’s policy required “2 staff members to maintain resident’s safety during transfers.” The facility’s report acknowledged: “In our initial report, it was reported that there were 2 CNAs present. During our investigation, it was noted that there was one CNA at the time of the transfer and fall.”

The death certificate listed cause of death as “respiratory failure with hypoxia.” The coroner stated she “was unaware of the resident falling out of a mechanical lift causing a head injury that led to death” and that “the death certificate should have cause of death was accidental.”

The facility violated its policy requiring two staff members during mechanical lift transfers due to weekend staffing shortages. A hospice resident who hospice confirmed was not at the end of life suffered a traumatic head injury when dropped headfirst from a lift and died three days later.

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.

The Illinois Department of Health has cited and fined Bridgeway Senior Living in Bensenville when a nursing assistant propped a thick mat against one side of a severely cognitively impaired resident’s bed and positioned the other side against a wall heater to trap her in bed, causing the resident to crawl out over the footboard and fall, fracturing her hip. The facility failed to investigate how the fall occurred and never interviewed the nursing assistant who had created the dangerous situation.

The resident in question was admitted to the facility with dementia, congestive heart failure, a history of falling, and chronic kidney disease. Her assessment showed she was severely cognitively impaired and needed assistance with activities of daily living including supervision with eating, partial assistance with oral hygiene and dressing, substantial assistance with bathing and transfers, and was dependent on staff for toileting.

The resident’s fall prevention care plan included specific interventions added after previous falls. Following a fall with no injury in February, staff were instructed to “get resident up early in the morning when awake and keep by the nurse’s station.” After another fall in May that resulted in a fractured wrist, an additional intervention was added: “when observed awake keep her engaged in the common area until ready to go back to bed.” The director of nursing explained the resident “liked to be active and move around and when she is awake it is best to keep her in an area where staff can see her.”

During the night shift, at 11:15 PM on her first rounds, the nursing assistant found the resident sitting on a thick mat that was positioned next to the bed. The nursing assistant stated “the height of the mat was almost equal to the height of the bed.” She assisted the resident, who was awake and alert, back into bed. Then she made a dangerous decision.

The nursing assistant explained what she did next: “She then took the thick mat and propped it up, adjacent to the right side of the bed and the left side of the bed was against the heating unit which was attached to the wall with the window.” She stated she “had boxed the resident into the bed so she wouldn’t get up and fall.” The resident was now trapped in bed with a propped-up mat on one side and a wall heater on the other side, with no safe way to get out.

Around 2:15-2:20 AM, the nursing assistant checked on the resident again. The resident was awake but not moving around, and the mat was still propped in place against the right side of the bed. The nursing assistant began her next rounds around 4:20 AM but started on the opposite end of the hall from where the resident’s room was located.

At 5:25 AM, when the nursing assistant finally reached the resident’s room, she found the resident “lying on the floor on her right side in a fetal position with her head at the foot of the bed.” She stated “the propped-up mat was still in place” and explained the resident “must have crawled or scooted out of the end of the bed over the footboard and then fell on the floor.” The resident was complaining of right hip pain and stated she had hit her head.

The nursing assistant summoned the registered nurse, who was passing medications in the hallway. The nurse assessed the resident and found her complaining of right hip pain. The nurse called 911, the physician, and the family to notify them of the fall and the resident’s pain complaints. The resident was transported to the hospital by ambulance at 5:50 AM.

X-rays at the hospital showed the resident had sustained “a mildly comminuted displaced right femoral intertrochanteric fracture” – a right hip fracture where the bone was broken into pieces and displaced. The resident’s physician stated “the likely cause of the resident’s hip fracture was the fall that occurred” that morning.

When interviewed, the nursing assistant acknowledged she “works on all the units in the facility” but stated she “was not sure of what the resident’s care plan interventions to prevent falls were.” The care plan clearly specified the resident should be kept in common areas where staff could see her when she was awake – the exact opposite of trapping her alone in her room with barriers on both sides of her bed.

The nursing assistant also revealed that “no facility staff had interviewed her as of yet as to how the resident had fallen.” The director of nursing confirmed days after the fall that she “had not spoken to the nursing assistant regarding the cause of the resident’s fall” and stated she “was unsure if the restorative nurse had spoken to” her either. This meant the facility failed to investigate the circumstances of the fall despite having a policy requiring staff to identify causes of falls.

The resident’s physician was clear about the danger of what the nursing assistant had done. He stated that “the resident having barriers on both sides of the bed would be an unsafe situation, especially due to the resident being cognitively impaired.”

The facility’s own policy titled “Evaluating Falls and Their Causes” required that “residents must be evaluated for potential causes of falls immediately” and that “within 24 hours of fall, the nursing staff will begin to try to identify possible or likely causes of the incident.” The policy specified staff should evaluate “the chain of events or circumstances proceeding a recent fall” including “the activity the resident was engaged in” and “whether there were environmental factors involved.” Despite this clear policy, the facility never interviewed the nursing assistant who had created the dangerous barrier situation that caused the fall, and failed to conduct a proper investigation into how and why the resident ended up on the floor with a fractured hip.

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.

The Illinois Department of Health has cited and fined Sunrise Skilled Nursing & Rehab when staff performing a wound treatment left a dependent resident alone on his side in a bed elevated 36 inches off the floor, telling him to hold onto the side rail while they retrieved supplies. The resident, who was completely dependent on staff for repositioning and had multiple serious medical conditions, could not hold on any longer after waiting for staff to return and fell to the floor, sustaining fractures to both legs including two breaks in one leg.

The resident was living at the facility with extremely serious medical conditions including bone infections in his spine, end stage renal disease requiring dialysis three times per week, diabetes, muscle wasting, stage 3 pressure ulcers, and significant weakness. Medical assessments showed the resident was cognitively intact but completely dependent on staff for most activities of daily living. Critically, assessments documented that for the resident “to roll from left to right he is dependent on staff; helper does all of the work,” meaning he could not reposition himself at all.

During a wound care treatment one morning, staff positioned the resident on his side in an elevated bed to access wounds on his back and buttocks. After the nurse finished the treatment and left the room, another staff member was changing the bed linens. The resident stated the staff member “said she needed a draw sheet because it was dirty from the wound draining on it. She said she would be right back.”

Rather than repositioning the resident safely and lowering the bed, the staff member left him lying on his side in the elevated bed. The resident described what happened: “I was holding on to the bar and was on my left side waiting. The staff left the room, but I waited as long as I could, and I just could not hold on any longer and when I let go, I fell from the bed being up high in the air to the floor. I just couldn’t hold on any longer. I think the staff forgot about me.”
The resident’s wife witnessed the incident and confirmed, “The resident was on his side and was holding on to the bar. The girl left the room, and she said she would be right back but the resident waited and waited and he could not hold on any longer and the bed was up really high, and he fell and broke both of his legs with one leg have two fractures.”

Another nursing assistant stated, “I looked in the room a little later and no staff was in the room. The resident was laying on his left side and the bed was not down and was high up and even then, I knew he was a fall risk. Then I heard a loud help, help and help.”

The facility’s incident report claimed the “resident rolled out of bed,” making no mention of him being left alone on his side in an elevated bed. After the fall, staff gave the resident pain medication and sent him to his scheduled dialysis appointment rather than seeking immediate emergency evaluation. The resident stated, “I feel like they should not have left me like that and should have sent me to the hospital right away.”

The dialysis nurse immediately recognized something was seriously wrong. Her notes documented: “Patient arrived to dialysis with complaints for pain to bilateral lower extremities. Patient stated he fell out of bed prior to coming to the facility and the bed was elevated. Pain too high to do treatment.” She called 911, and emergency services transported the resident to the hospital.

Hospital records revealed serious injuries: acute left distal tibial fracture, acute left distal fibular fracture, acute fracture of the distal right tibial bone, and acute fracture of the neck of the 2nd metatarsal of the right foot. The resident had multiple broken bones in both lower legs and was hospitalized for two weeks.

When the resident returned to the facility, the trauma was evident. Progress notes documented that when staff helped him into bed, the resident “became very agitated and yelled ‘hey watch my legs! Don’t move them!’ The resident hollered ‘no it’s not ok!'” He was fitted with plastic splints and boots extending up to his knees on both legs.

Health inspectors measured the resident’s bed in the elevated position at 36 inches from the floor—three feet high. Multiple staff members confirmed that leaving a resident in this situation violated basic safety standards. The Director of Nursing stated, “I would expect staff to never leave any resident unattended or left laying on their side. I would expect staff to reposition the resident, so they are safe, go and get what they needed and then return. I would not expect staff to leave a resident with the bed up, laying on their side.”

The facility’s investigation was inadequate, failing to address the root cause—lack of supervision and failure to lower the bed. The resident’s care plan also had no fall prevention interventions despite his obvious vulnerability.
This incident represents a fundamental failure in basic nursing care. A completely dependent resident who could not reposition himself was left alone on his side in a bed elevated three feet off the floor, expected to hold himself in position while staff left to retrieve supplies. The result was a catastrophic fall causing multiple fractures to both legs and a two-week hospitalization. The facility compounded this harm by failing to send the resident immediately to the hospital.

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.

The Illinois Department of Health has cited and fined Clark-Lindsey Village when a certified nursing assistant left a high fall-risk resident unattended on the toilet to fix her bed, resulting in the resident falling and sustaining multiple acute fractures to her left arm. Despite facility policies requiring constant supervision during toileting for fall-risk residents, the nursing assistant admitted he knew the resident should not have been left alone but left her anyway to perform other tasks.

The resident was living at the facility with numerous serious medical conditions including a history of falling, anxiety disorder, difficulty walking, cognitive communication deficit, heart failure, atrial fibrillation, chronic respiratory failure, and pulmonary hypertension. Medical assessments showed the resident had moderate cognitive impairment and was completely dependent on staff for toileting hygiene tasks. Assessments also documented that the resident required substantial to maximal assistance from staff when moving from a sitting to standing position.

The facility had conducted a fall risk evaluation that gave the resident a score of 17.0, and “a score of ten or higher indicates that the resident is at high risk for falls.” The resident’s care plan, recognizing this significant fall risk, documented that the resident “is at risk for falls related to deconditioning” and required staff to “follow facility fall prevention guidelines.” The care plan also specified that certified nursing assistants were to “maintain proactive contact with residents to anticipate needs.”

In the early morning hours, the resident needed to use the toilet. A certified nursing assistant brought her to the bathroom and placed her on the toilet. However, instead of remaining with the resident as required by facility protocols, the nursing assistant left her alone to perform another task. According to the incident report, the nursing assistant “stated that he was just in her room to fix her bed while she was in the bathroom.”

Left unattended on the toilet, the resident attempted to care for herself. The incident report documents that the resident “stated that she voided and was going to get a wipe and stand on her own and fell on her left arm.” The resident, who required maximal assistance to move from sitting to standing and had severe cognitive impairment, tried to stand by herself because no one was there to help her.

The consequences were significant. The incident report describes that when the nursing assistant returned, he found the resident had fallen and her “left arm was bent with obvious signs of deformity and bruising and that the resident could not move it and stated it was painful.” The resident was sent for X-rays, which revealed severe trauma: “Acute comminuted displaced fracture involving the left humeral head/neck with soft tissue swelling. Acute comminuted displaced angulated fracture involving the proximal third shaft of the left humerus with soft tissue swelling.” In simpler terms, the resident sustained multiple broken bones in her upper left arm and shoulder area, with the bones displaced and broken into multiple pieces, accompanied by significant swelling.

When health inspectors visited the facility, they found the resident “lying flat on her back in bed and a brace is on her left arm.” The resident confirmed “she had a fall, broke her arm and it is painful.”

During the investigation, multiple staff members at every level acknowledged that this fall should never have happened. A certified nursing assistant told inspectors that “when a resident has a known fall risk they should never be left unattended when they are sitting on the toilet.” The nursing assistant who left the resident alone admitted his error, stating “he knew the resident was a fall risk and should not have left the resident alone on the toilet.”

The registered nurse on duty confirmed the standard of care, stating “she would expect that all CNAs should not leave a resident unattended on the toilet if they were a fall risk.” A licensed practical nurse emphasized the seriousness of the lapse, noting “it was well known, and it is documented that the resident is at risk for falls and that the resident should not have been left unattended on the toilet.”

Perhaps most telling was the statement from the facility’s former Director of Nursing, who was in that position at the time of the incident. She stated plainly that “the resident’s outcome would have been different if the nursing assistant would have stayed at the resident’s side while she was on the toilet to prevent the resident from falling.” This acknowledgment from the facility’s top nurse confirms that this injury was entirely preventable and resulted directly from the failure to follow basic safety protocols.

This case illustrates a clear failure to implement established care plans and safety protocols. The facility had properly assessed the resident’s fall risk, documented her need for assistance, and created a care plan requiring supervision. However, these safeguards were meaningless when the nursing assistant chose to prioritize making a bed over staying with a vulnerable resident who required constant supervision.

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.

The Illinois Department of Health has cited and fined Manor Court of Rochelle when staff failed to properly monitor a resident with severe dementia after an unwitnessed fall at 3 a.m., neglecting to notify the physician or conduct required neurological checks. The resident remained in severe pain throughout the night without follow-up care, ultimately requiring emergency hospitalization the next morning when staff discovered she had suffered a left hip fracture.

The resident in question was living at the facility with multiple serious conditions including anxiety, arthritis, severe dementia with agitation, and insomnia. Medical assessments confirmed she was severely cognitively impaired. Prior to the incident, the resident walked slowly and steadily with her walker and rarely used a wheelchair.

The facility had established a care plan recognizing the resident’s significant fall risk, documenting that she “has a history of falls prior to admission and is at risk for falling related to poor safety awareness, doesn’t use the call light and has a diagnosis of Dementia.” The care plan specifically required staff to “observe frequently and place in supervised area when out of bed” and indicated the resident “requires assistance of one with walker or ambulation.” A nursing assistant confirmed that the resident “is not supposed to walk around by herself.”

In the early morning hours, the resident was last documented as being in the unit living room with other residents. An hour later, she had somehow made her way to the dining area where she fell while walking alone with her walker. Critically, no documentation was found explaining “why the resident was ambulating unsupervised in the dining room at 3 a.m. in the morning,” despite the care plan requirements for frequent observation and supervision.

When a certified nursing assistant discovered the resident, she called the agency registered nurse on duty. The nurse arrived to find the resident “seated on the floor against a chair which is by the wall.” When asked what happened, the resident explained “she had been walking around with her walker and fell.” The nurse helped the resident into a chair and took her vital signs, which were within normal ranges.

According to the nurse’s documentation, the resident was “alert and oriented” with “skin intact with no wounds or openings. No injuries noted.” However, the resident complained of “pain to back and side.” The nurse’s notes indicated she “gave pain medication to the resident and later escorted to her room,” noting “no limping” as the resident walked with her walker.

The failures in care became apparent during investigation. The nurse supervisor who later reviewed the incident confirmed critical deficiencies: the nurse “did not complete neurological checks and did not notify the physician of the resident’s fall.” Additionally, “there was no follow up documentation of the resident’s complaints of back and side pain and there was no medication administration documentation that pain medication was administered.”

These omissions directly violated the facility’s own written policies, which clearly stated: “If a fall is unwitnessed, notify the physician and initiate neurological checks at least every four hours for twenty four hours, or until stable, or as otherwise ordered by the physician.”

The consequences became clear the following morning. When the day shift licensed practical nurse arrived, certified nursing assistants immediately told her “there was something wrong with the resident.” The nurse recalled they stopped her in the hallway before she had “barely had time to take off my coat.” She went directly to the resident’s room and found her refusing to get up “due to ‘extreme pain’ at left hip/thigh area.” The nurse stated the resident was in “severe pain” and was “most likely in pain all night.”

The day shift nurse quickly recognized the emergency. She stated, “I didn’t know what was wrong with the resident but she needed to be sent out.” She contacted the physician to request X-rays, notified the resident’s power of attorney and the facility administrator, and arranged emergency transport.

Only after making these urgent arrangements did the day shift nurse receive any report about the fall. When she finally spoke with the agency nurse, all she was told was that “the resident fell and was put back in bed. Nothing else.” The day shift nurse stated, “I did not receive any nurse/shift report regarding the resident’s fall until after I was told by my dayshift CNAs that there was something wrong with the resident.”

The resident was transported by ambulance to the hospital where X-rays confirmed she had suffered a left hip fracture from her fall.
After the incident, health inspectors observed the resident sitting in a wheelchair during a church group activity with her head down, appearing to be sleeping—a stark contrast to her previous ability to ambulate with her walker.

This incident represents multiple, compounding failures in resident care. The facility failed to ensure adequate supervision of a resident with severe dementia who required constant observation. When the fall occurred, the nurse on duty failed to follow basic medical protocols including notifying the physician and conducting neurological assessments. The nurse failed to properly document and follow up on the resident’s pain complaints, leaving her to suffer through the night. There was also a breakdown in communication between shifts, as the incoming nurse received very little information about the serious incident that had occurred hours earlier.

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.

The Illinois Department of Health has cited and fined Meadowbrook Manor – Naperville when a resident with severe cognitive impairment and eight previous unwitnessed falls in his room had a ninth unwitnessed fall that caused a brain injury, massive seizure, and ultimately his death. Despite the resident’s care plan requiring increased supervision and monitoring to prevent self-transfers, staff left him alone in his room where he fell again while they were in the dining room.

The resident in question was admitted to the facility with multiple serious conditions including a history of falls, previous traumatic brain bleeding, vascular dementia with moderate agitation, hallucinations, unsteadiness on feet, difficulty walking, and cognitive deficits. His assessment showed he was severely cognitively impaired and required staff assistance with transfers. His medical record did not show any history of seizures.

The resident’s care plan, created shortly after admission, identified him as being at risk for falls related to “confusion, deconditioning, gait and balance problems, poor comprehension, unaware of safety needs, dementia, hallucinations, and recurrent falls.” The care plan included multiple interventions designed to prevent falls, specifically including instructions to “conduct rounds,” “toilet resident and place in dining room, hallways or nurses’ station for more visual supervision,” and “increase supervision in the room. Monitor any attempt of self transfer.”

Despite these care plan requirements, the resident experienced eight unwitnessed falls in his room over a seven-month period. The fall incident reports documented falls occurring regularly, with all incidents showing the resident “was trying to self-transfer in and out of his wheelchair” when he fell. Each time, staff found him on the floor after the fact, meaning no one had been present to supervise him or prevent the fall.

Around 12:35 PM on the day of the incident, the resident had his ninth unwitnessed fall in his room. He was found “sitting on the floor facing his wheelchair with his legs flexed and holding on to his wheelchair” after attempting to stand up from his wheelchair unassisted. His assigned nursing assistant stated in an incident report: “When the incident happened, I did not witness it happening. I was helping in the dining room with passing trays and feeding residents.” His assigned nurse also stated: “At the time of fall, I was at the nurse’s station. Fall not witnessed.”

A nurse assessed the resident after finding him on the floor and initiated neurological checks. The nurse later explained the resident “was at a high risk for falls because he had a known history of falls, was confused, and impulsive.” The neurological assessment appeared normal and the resident “did not appear to have any injury or change in condition.” Staff then assisted him into his wheelchair and transported him to the main dining area for lunch, where he was supervised.

Nearly three hours later, at 3:15 PM, staff noticed a bump on the right side of the resident’s head. The nurse practitioner was notified and gave orders to send the resident to the hospital for further evaluation. Routine paramedics arrived to transfer him. However, as they were moving the resident into the ambulance, he “started to have a massive seizure.” The paramedics immediately contacted emergency paramedics for additional support, and the resident was transported to the hospital.

Hospital notes documented the resident was admitted “post-fall with a suspected significant head trauma likely subdural hematoma, acute encephalopathy, seizures, and dilated left pupil and flaccid left side.” The hospital record showed the resident “remained unresponsive and family elected for hospice care.” The resident died after being admitted to inpatient hospice care without additional diagnostic testing.

The director of nursing acknowledged the resident “was monitored after his fall per protocol, and at 3:15 PM, he was noted with a bump to his head.” She stated the
resident “was admitted for altered mental status, seizure, and traumatic brain injury” and explained “the facility felt they could not determine if the resident’s acute change in medical condition was related to his fall incident because the facility elected to admit the resident into inpatient hospice care and not proceed with additional diagnostic testing.”

The director of nursing stated the resident “had a known history of recurrent falls and head trauma with an intracranial bleed” and claimed “fall incidents were investigated and fall prevention interventions were implemented in the residents’ plan of care.” However, the resident had experienced nine unwitnessed falls in his room over seven months, all involving attempts to self-transfer from his wheelchair – the exact behavior his care plan required staff to monitor and prevent.

The nurse practitioner explained she “expected facility staff to complete a root cause analysis after a resident’s fall to investigate the cause and then implement interventions to prevent reoccurrences.” The facility’s own policy stated that “if falling recurs despite initial interventions, staff will implement additional or different interventions.” Yet despite eight previous unwitnessed falls in his room with the same cause – attempting to self-transfer from his wheelchair – the facility never modified its approach to actually provide the increased supervision and monitoring his care plan required.

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.

The Illinois Department of Health has cited and fined Newman Rehab & Health Care Center when a resident who required assistance with all mobility fell and broke her hip while attempting to take herself to the bathroom because no nursing assistant was available to answer her call light. The facility left an entire hallway without a certified nursing assistant for over an hour and a half during the morning shift when residents typically need bathroom assistance.

The resident in question was admitted to the facility with chronic kidney disease, hypertension, and low back pain. Her admission assessment documented she had a “known history of falling” and was “at risk for fall.” The assessment showed she was not cognitively impaired but “requires assistance with all activities of daily living, bathing, transfers, ambulation and toilet use.” She was continent of bowel and bladder, meaning she could feel when she needed to use the bathroom.

During the night shift, the nursing assistant assigned to the resident had taken her to the bathroom three times. At 5:15 AM, when the resident stated she needed the bathroom again, the nursing assistant asked if she would like to be cleaned up and dressed for the day, and the resident agreed. This was the last time the nursing assistant provided care before her shift ended.

Shortly before 8:45 AM, the resident was heard hollering for help. She was found “on the floor of her room lying on her right side with her right arm underneath her trying to prop herself up.” The resident explained what happened: “I was trying to take myself to the bathroom because I really needed to go. I turned my call light on, but no one came to answer my call light, so I tried to take myself and ended up on the floor.”

A registered nurse was notified of the incident and placed a pillow under the resident’s head, then left to get help to lift her back into bed using a mechanical lift. The resident stated she was having pain in her right side. At 8:55 AM, the nurse gave her Tramadol for pain complaints. The resident continued having pain on her right side and was transported to the hospital by ambulance shortly after noon.

The hospital emergency room examination showed “new fracture across the right femoral neck with moderate displacement and impaction and mild varus angulation” – meaning the resident had broken her hip with the bone fragments displaced and pushed together.

When investigators questioned staff about what happened, they discovered a serious staffing problem that morning. The administrator explained that when she arrived at the facility at 8:00 AM to work as a nursing assistant, “they were having an issue with CNA’s that morning because one of the day CNA’s became sick and had to leave the facility.” The facility had called her and “asked if they could call people in and I told them yes and I would also come in and work.”
The administrator acknowledged the gap in coverage: “The resident’s hall did not have a CNA to answer call lights until 9:30 AM. This is when I was able to work on that hall as a CNA.” This meant that for over an hour and a half during the morning shift – when residents typically need the most assistance with toileting after waking up – an entire hallway of residents who required help had no one available to answer their call lights.

The resident had done exactly what she was supposed to do by turning on her call light when she needed bathroom assistance. However, with no nursing assistant available to respond, she faced an impossible choice: wait indefinitely while needing to urgently use the bathroom, or attempt to get there herself despite requiring assistance for all mobility. She chose to try to take herself and suffered a serious hip fracture as a result of the facility’s failure to ensure adequate staffing coverage during the shift change.

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.

The Illinois Department of Health has cited and fined Warren Barr Orland Park when a nursing assistant improperly turned a 380-pound bedridden resident away from herself during personal care, causing the resident to roll off the bed. The fall resulted in a severe fracture requiring surgical repair with screws and metal hardware.

The resident in question had been living at the facility for nearly three years. She had multiple serious medical conditions including functional quadriplegia, severe obesity with a body mass index between 50-59.9, muscle wasting, and reduced mobility. Her medical history included a severe COVID-19 infection that led to prolonged hospitalization and complete loss of her ability to walk or stand. Hospital records noted she “has not stood or walked in over a year and has since experienced significant weight gain and progressive immobility.”

The resident was completely dependent on nursing staff for all aspects of daily care. Her care plan documented that she required “extensive assistance of 2 staff with mobility and transfers” and noted she was “non ambulatory at this time.” For bed mobility specifically, her care plan stated she “requires extensive assist of 1 staff participation to reposition and turn in bed, and scooting towards head of bed” due to weakness in both legs. However, most recent assessments showed she was actually “dependent” for rolling in bed, meaning “helper does ALL the effort” or “the assistance of 2 or more helpers is required.”

At the time of her fall, the resident weighed 380 pounds and was 5 feet 9 inches tall. She was bedridden and required assistance with all personal care activities including changing incontinence briefs and toileting needs.
The incident occurred during the early morning hours when a nursing assistant was providing personal care to the resident. According to the resident’s account, the nursing assistant was changing her incontinence brief and “was standing on the right side of [the resident’s] bed, and [the nursing assistant] turned [the resident] away from her.” The resident stated she warned the nursing assistant, telling her “her leg is going to fall,” but the staff member “stood there and removed the soiled brief, and her leg slid off the bed.”

The resident described falling “on her knees with her butt sticking up in the air” after her leg went over the side of the bed. She explained that “my leg slid over the bed while the CNA was turning me and I rolled off the bed.”

However, the nursing assistant provided a different account of the incident. She claimed that the resident “turned herself towards the door” and “as [the resident] was turning herself, one of her legs pulled out of the bed and [the resident] was on the floor.” The nursing assistant insisted “she did not touch [the resident]” and denied that the resident warned her about her leg falling.

Multiple facility staff members who were interviewed confirmed that proper procedure was not followed. The facility’s Therapy Director stated unequivocally: “Staff should not roll residents away from them.” She explained that given the resident’s weight of 380 pounds, “if [the resident’s] leg started going off the side of her bed, she couldn’t have stopped it…at 380 pounds the momentum would carry her leg over.”

The Assistant Director of Nursing, who investigated the incident, reinforced this point: “You should not push a resident away from you in bed. You have more control of the patient if you roll them toward you.” She noted that the resident had full range of motion in her arms but “not a whole lot” of range of motion in her legs, and importantly, “nobody was on that opposite side of the bed” to prevent the resident from falling.

After the fall, the resident remained on the floor until six paramedics arrived to assist her onto a stretcher for transport to the hospital. Medical examination revealed she had sustained “a comminuted, supracondylar distal femur fracture with intra-articular extension into the lateral condyle” – a complex break in her thigh bone near the knee that extended into the joint.

The injury required surgical repair, and when surveyors visited the resident after her return to the facility, she reported that her stitches had been removed and “there were three screws in her right knee.” The resident noted the impact on her quality of life, stating her “left leg has arthritis, and now her right knee was broken.”

This incident represents a violation of basic nursing care principles. The facility’s own policies required staff to provide appropriate care to meet residents’ needs, yet the nursing assistant failed to follow established safety procedures for turning a severely mobility-impaired resident.

The resident’s care plan documentation showed she had been assessed as needing either extensive assistance from one staff member or total dependence requiring two staff members for bed mobility, yet she was being turned by a single nursing assistant who used an unsafe technique. The facility’s Restorative Licensed Practical Nurse confirmed that the resident had “never been on a bed mobility program” despite her significant limitations, and had been using a full-body mechanical lift for transfers for approximately two years.

The incident resulted in a preventable injury that caused significant pain and required major surgical intervention for a vulnerable resident who was already dealing with multiple serious health conditions and complete loss of mobility.

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.

The Illinois Department of Health has cited and fined Sharon Healthcare Willows when a certified nursing assistant left a resident alone in a room with a large water spill on the floor, despite warning the resident not to get up. The resident fell while attempting to get to the bathroom and suffered a severe fractured femur requiring surgery and hospitalization.

The incident involved a 62-year-old female resident with multiple medical conditions including bipolar disorder, chronic obstructive pulmonary disease, metabolic encephalopathy, and kidney absence, who had been living at the facility for over two years. The resident was cognitively intact according to her mental status assessment but had a history of impulsive behavior and delusions. Her care plan noted she “is at risk for falls” and “ambulates independently but has a history of wheelchair use,” requiring supervision for activities of daily living and toileting assistance.

The dangerous situation began when a certified nursing assistant walked past the resident’s room and discovered a significant safety hazard. The aide stated, “I walked past the resident’s room and saw there was water all over the resident’s floor. The resident had a large cup that must have spilled. I don’t know how long the water had been there.” The resident was in her bed, which was positioned in a low setting, when the aide entered the room.

Upon seeing the aide, the resident became agitated about wanting to vape (use electronic cigarettes) and began “rolling in bed like she was trying to get up.” The aide recognized the resident’s impulsive tendencies, noting that “the resident gets adamant about when she wants to vape” and “it depends on the resident’s mood if she listens or not.” Despite these known behavioral patterns, the aide made a critical decision that would lead to serious injury.

The aide told the resident to “stay in bed and not to get up because there was water on the floor” and observed that “the resident was still trying to get up.” However, the aide reasoned that because “the resident needs help to get up from the low bed so I didn’t think the resident could get up.” Based on this assumption, the aide decided to leave the resident alone with the hazardous spill to retrieve cleaning materials from an adjacent room.

The aide explained her decision: “I went through the bathroom that was between the resident’s room and another resident’s room to get some extra pads in the other room to absorb the water.” She emphasized that she “kept telling the resident not to get up” before leaving, but admitted she was only gone “for a few minutes” while speaking with another resident during her brief absence.

The resident’s urgent need to use the bathroom overrode the aide’s instructions. The resident later explained her perspective: “When I fell and broke my leg, I was trying to go to the bathroom in my room. I only have one kidney so as soon when I have to go to the bathroom I have to go. I went to stand up to go to the bathroom and I slipped on water that was on the floor, fell and hurt my right leg.”

When the aide returned, she found the resident had managed to get out of the low bed and was now lying on the floor, having slipped on the water spill. The aide’s witness statement confirmed that “when I returned the resident was on the floor and couldn’t move her leg.” The resident’s own statement corroborated that she “slipped when she got up to use the bathroom.”

The fall resulted in severe injuries. The facility’s incident report noted that “upon assessment the resident was unable to bend her right leg without significant pain and the resident was unable to bear weight.” A nursing note documented that the resident was found “lying on the floor in her bedroom in a supine position” and was “unable to bend her right leg without significant pain which renders her unable to attempt to bear weight.”

Hospital X-rays revealed the extent of the damage: “Acute comminuted and displaced distal femur fracture extending to the articular surface of the knee.” The medical report detailed that the injury involved “acute comminuted fractures involving the distal femoral diaphysis and extending to the articular surface” with “the distal fracture fragment displaced posteriorly by half a shaft width” and “impaction of the fracture fragments.” This complex fracture required surgical intervention, and the resident underwent “ORIF (Open Reduction and Internal Fixation) surgery” to repair the break with metal hardware.

The resident was hospitalized for five days and later showed the surveyor her surgical scar. The incident investigation identified “potential contributing factors” as “wet floor” and noted that the “resident is impulsive – did not wait for staff to clean up floor.”

When questioned about the incident, the aide acknowledged her error in judgment. When asked “if she thought she should have done anything different,” the aide stated, “I would have had someone stay with the resident.” The facility administrator confirmed this was the appropriate response, stating that she “talked to the aide about the resident’s fall and told her that she should have stayed with the resident and put the call light on until someone came to clean up the water so the resident would not have got up and fell.”

The facility’s own fall prevention policy required staff to “assess the patient care environment routinely for extrinsic risk factors and institute appropriate corrective action.” The policy emphasized preventing falls by “recognizing multi-factional risk and causes” and implementing “recommendations for falls prevention and management consistent with clinical practice guidelines and standards of care.” However, in this case, staff failed to follow these safety protocols by leaving a fall-risk resident alone in a room with a known hazard.

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.

The Illinois Department of Health has cited and fined Resurrection Place when a certified nurse aide attempted to transfer a resident using a mechanical lift without the required second staff member for assistance. The resident fell from the lift and suffered a displaced fracture of his left femoral neck, requiring surgical intervention and hospitalization.

The incident involved a resident with complex medical needs whose care plan clearly stated he “requires assistance partial to substantial assist with Activities of Daily Living” and specified “transfer with mechanical lift and 2 persons assist.” The resident had been admitted with a history of falls, displaced femur fracture, dementia, left-sided weakness from strokes, and walking difficulties. His functional mobility assessment indicated he needed “dependent assistance with chair/bed-to-chair transfer, sit to stand, toilet transfer.”

On the day of the incident, a certified nurse aide was assigned to care for the resident and was attempting to transfer him to bed using the facility’s mechanical lift. The aide later explained that she “noticed that the resident’s left foot was not on the base of mechanical lift, and she bent over to place it on the base when the resident let go from the grab bar with his right hand and slid off to the floor.” Crucially, the aide admitted she “was the only certified nurse aide in the room with the resident” and acknowledged that she “is aware that the resident is a two person assist and that when using any mechanical lift two-person assist is also required.” When asked why she proceeded alone, the aide explained that “the other staff were busy and could not get any help.”

The violation of protocol had immediate consequences. After the resident fell from the lift, the aide “assisted the resident back to the bed” and initially reported no injuries were observed. However, the next day the resident “complained of pain to his left hip.” X-rays revealed “a fracture to the left femoral neck,” and the resident was transferred to the hospital for emergency treatment and surgical repair.

Hospital records provided additional context about the severity of the incident. The resident “had called his wife and said that he was dropped into his bed and then after that was complaining of hip pain.” Due to his dementia, doctors noted he was “a poor historian,” but his wife confirmed that the resident “has been non ambulatory at the nursing home, they use a mechanical lift for mobility in and out of bed.” The resident underwent surgical intervention and was discharged back to the nursing home for skilled therapy with orders for “no weight bearing to lower left extremity.”

Multiple facility staff members confirmed that proper procedures were not followed. The registered nurse who responded to the incident stated that “when transferring with a mechanical lift the staff are supposed to have a two person assist” and the restorative nurse explained that “when using any Mechanical lift machine for transfers staff should be a two person assist” and confirmed “it is the facility policy when using a mechanical lift that two-person assist is implemented.”

The facility administrator acknowledged the policy violation, stating that “when staff is using a mechanical lift there should always be a two person assist per facility policy.” She admitted she “was unaware that only one certified nurse aide was transferring the resident” but confirmed she knew about the fall incident.

The nursing home’s own policies clearly established the safety requirements that were ignored. The Falls policy emphasized providing “an individualized, person-centered care approach” and stated that “residents who are at risk for falls will have an individualized care plan developed which identifies interventions to reduce fall risk.” The Fall Prevention policy aimed “to provide an environment that is free from accidents hazards” and “provide supervision and intervention to residents to prevent avoidable accidents.”

Despite these clear policies and the resident’s documented need for two-person assistance, a single aide attempted the transfer alone because other staff members were busy, resulting in a preventable fall that caused a serious fracture requiring surgery. The incident highlighted a dangerous gap between written safety protocols and actual practice that put vulnerable residents at risk.

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.

The Illinois Department of Health has cited and fined Oak Park Oasis when a high fall-risk resident with multiple medical conditions fell while attempting to clean up spilled water without proper supervision, resulting in a hip fracture that required emergency surgery. The facility failed to provide adequate oversight despite the resident’s documented need for assistance and known tendency to walk without his required mobility device.

The resident in question, a man in his early sixties, was living at the facility with numerous serious medical conditions including ataxia (loss of muscle coordination), epilepsy, gait and mobility problems, schizoaffective disorder, diabetes with nerve damage, and heart failure. Medical assessments showed he had moderate cognitive impairment and required supervision or assistance when moving from bed to chair and while walking. He used a walker as his primary mobility device and was classified as being at high risk for falls.

The facility had established detailed care plans recognizing the resident’s fall risk, stating he was “at risk for falls related to confusion, gait/balance problems, poor communication/comprehension” and various medications. The plan specifically required staff to “be sure the resident’s call light is within reach and encourage the resident to use it for assistance as needed” and ensure “prompt response to all requests for assistance.” An additional care plan noted his “decreased strength, poor balance, impaired ambulation” and required implementation of “fall precautions per facility protocol.”

On the day of the incident, the resident fell in the hallway near his room while attempting to clean up spilled water. When a registered nurse heard him calling for help, she found him “sitting on the hallway floor, right by his room, leaning against the wall, with one of his legs stretched forward.” The resident told the nurse “he saw spilled water on the floor and was trying to wipe it.” Critically, the resident did not have his required walker with him at the time of the fall.
The nurse who responded noted that the resident “was not able to get up on his own” and observed that he “was not able to move his left leg and it was in extended position.” She found that the resident “was in a lot of pain, especially when trying to move his leg.” Despite these clear warning signs of a serious injury, the facility’s response was inadequate and delayed.

After the fall, the attending physician was contacted and ordered an X-ray, but there were significant delays in obtaining the diagnostic imaging. The responding nurse admitted, “I called the diagnostic company, and I was told they’ll come out to do an x-ray but didn’t say when” and “I didn’t check on the resident nor reassessed the resident’s pain before the end of my shift. The x-ray company didn’t come before I left. I didn’t follow up with the diagnostic company.”

The situation became more concerning the following day when another nurse discovered that the diagnostic company claimed they had “no order for the resident’s x-ray.” This nurse had to place a new STAT X-ray order, and the imaging wasn’t completed until later that day. During this extended period, the resident remained in significant pain and was unable to move his left leg, with nursing notes documenting a “greenish purple bruise noted on the left hip” and “pain level 5/10.”

By the second day after the fall, the facility’s Director of Nursing finally recognized the severity of the situation. When she observed the resident “lying in bed stating, ‘it’s hard for me to stand up it hurts,'” she instructed staff that “when a resident has a change in condition and cannot walk whereas he walked before, nurses should send them out to the hospital.” The resident was finally transported to the hospital, where medical imaging revealed “a moderately displaced and angulated fracture of the left femoral neck.” He required emergency surgery, specifically a “left femoral neck hemi-arthroplasty,” essentially a partial hip replacement.

Several critical factors contributed to this preventable incident. The Director of Nursing explained that the resident had obsessive-compulsive disorder and was “trying to clean and rearrange the room all the time.” She noted that staff “would find him walk without the walker all the time” and that “the resident didn’t use a call light or ask for assistance.” The director explained that “the resident’s fall occurred because the resident was trying to clean up after his roommate and there was spilled water on the floor. The resident has an ‘obsession’ with cleanliness.”

Despite knowing about these behavioral patterns that put the resident at additional risk, the facility failed to provide adequate supervision. On the day of the incident, staffing was inadequate, with only one certified nursing assistant covering an area that normally required two staff members. This assistant was responsible for conducting rounds “at least every two hours” but admitted she didn’t think the resident “was at risk for fall” and didn’t remember “any special interventions that we had to do for the resident,” despite his documented high-risk status.

Even more concerning, the registered nurse who worked the day shift and found the resident after his fall claimed she was unaware of his fall risk status. She stated, “I’m not sure if the resident was at high risk for falls before the incident, so I’m not sure if the resident had any fall prevention interventions.” This statement directly contradicted the resident’s documented care plans and risk assessments that were supposed to be known to all nursing staff.

The attending physician explained that signs of a hip fracture include “complaining of pain, bruising, deformity, and affected range of motion, such as extended leg.” He emphasized that when residents have continuous pain “not managed by over-the-counter medications, they should be sent out to the hospital.” The physician also noted the serious long-term consequences, stating that “a broken hip with subsequent surgery would affect a resident acutely” and “there could also be long lasting effect, such as chronic pain and change in the range of motion.”

When health inspectors later visited the facility, they observed troubling conditions in the resident’s room. They found the resident lying in bed with his “room dark, call light out of the resident’s reach,” violating basic safety requirements outlined in his care plan. The resident told inspectors, “Yeah I fell, I hurt my hip. I’m not sure when or how it happened,” demonstrating his continued confusion and the lasting impact of the incident.

The facility had written policies requiring a comprehensive fall prevention program, stating that “safety interventions will be implemented for each resident identified at risk using a standard protocol” and that “all nursing personnel will be informed of residents who are at risk of falling.” However, the evidence clearly showed these policies were not being followed, as key staff members were unaware of the resident’s risk status and failed to implement required safety measures.

This case represents a clear failure in the facility’s duty to protect a vulnerable resident. Despite having comprehensive knowledge of the resident’s fall risk factors, behavioral patterns, and specific need for supervision, the staff failed to implement adequate safety measures. The delayed medical response compounded the harm, as the resident endured unnecessary pain and delayed treatment for a serious fracture that required surgical intervention and will likely affect his quality of life permanently.

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.

The Illinois Department of Health has cited and fined Midway Neurological & Rehabilitation Center when staff failed to recognize critical signs of a traumatic brain injury and delayed emergency medical care for a resident who had fallen twice. The resident died two days later from a massive brain bleed that could have been detected earlier with proper assessment and immediate medical intervention.

The tragedy began when a nursing home resident fell in her room during the night, causing severe bruising around her left eye and behind her left ear. When a licensed practical nurse discovered these injuries the next morning during breakfast, the resident explained that “she fell last night in her room” and “tripped and hit the left side of her face on her dresser.” The resident admitted she “didn’t report to anyone” because she “thought that she was fine.” The nurse noted that “the skin surrounding the resident’s left eye was black” and also observed “discoloration behind the resident’s left ear” – a critical warning sign known as Battle sign that indicates serious head trauma.

Despite these alarming symptoms, the nursing staff failed to recognize the severity of the situation. The nurse conducted a basic assessment, gave the resident an ice pack, initiated routine neurological checks that appeared normal, and contacted the physician who ordered only a “routine facial x-ray.” The resident was placed on observation and told she “cannot leave the nursing unit without a staff member,” but was otherwise treated as having minor injuries.

Later that same day, the resident went to the facility’s smoking patio where a smoke monitor witnessed her second fall. The monitor observed that when the resident “was finished smoking, she got up, walked over and placed cigarette butt in the discard container” but then “walked around garbage can, staggered and fell to the ground hitting head.” An outside program employee who was visiting the facility saw the resident being brought back in a wheelchair, noting she “had a dark red purple discoloration to left eye and was complaining her head hurt.”

The situation rapidly deteriorated that evening when a nurse “immediately assessed the resident” and discovered she “had a gash to the left side of her head” and “was lethargic.” Most critically, “the resident’s vital signs were abnormal, oxygen saturation level was decreasing to 87% on room air.” The nurse administered oxygen, which improved the resident’s oxygen levels to 95%, but the resident soon became unresponsive, prompting staff to call 911 and begin CPR.

When paramedics arrived, they found nursing home staff performing CPR on the unresponsive resident. The EMS crew noted several critical signs that should have been recognized earlier, including a “hematoma to back of the resident’s head” and confirming that the resident “presented with battle sign behind left ear” along with “swelling with black and blue discoloration to left eye.” The paramedics also observed that the resident “presented with dilated pupils” – another serious neurological warning sign.

At the hospital, medical staff immediately recognized the gravity of the situation. The resident “presented unresponsive to the hospital” with “bruising around left eye and around left mastoid” and “a large scalp hematoma.” Doctors noted the resident’s “pupils are fixed and dilated” and that she “does not respond to pain or voice, does not open eyes.” Given these “signs of trauma to the head, Battle sign, bruising over the mastoid, the resident was emergently taken for CT of head.”

The CT scan revealed the devastating extent of the brain injury that had gone unrecognized for hours. The resident was diagnosed with “a large traumatic subdural with shift causing herniation” – specifically “a large right cerebral convexity acute subdural hematoma measuring up to 3 cm with severe 1.7cm leftward midline shift, subfalcine and uncal herniation.” The neurosurgeon who examined her determined that “the resident’s prognosis was very poor without any chance for any significant functional outcome.” The resident died two days later.

The facility’s director of nursing later acknowledged the critical failure in care, admitting that “given the bruising to the resident’s left eye and posterior left ear, the resident should have been transferred to the hospital when staff first noted injury earlier in the day.” Medical literature confirms that Battle sign – the bruising behind the ear that staff observed – “typically requires significant head trauma and may indicate significant internal injury to the brain” and “takes Battle sign 1-2 days for the sign to appear,” meaning the resident’s initial nighttime fall was far more serious than staff realized.

The facility had clear policies requiring immediate action during medical emergencies. Their “change in resident’s condition or status policy” stated that “during medical emergencies 911 will be notified for transport to the hospital.” However, staff failed to recognize that the combination of Battle sign, facial bruising, and the resident’s reported fall constituted a medical emergency requiring immediate hospital evaluation rather than routine monitoring and X-rays.

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.

The Illinois Department of Health has cited and fined The Loft Rehab of Peoria when staff failed to ensure required foot pedals were on a resident’s wheelchair during transport, resulting in the resident’s leg getting caught in the wheel. The incident caused a severe fracture requiring emergency surgery and hospitalization.

The resident in question was a 77-year-old woman with severe dementia who required total assistance from staff for transfers and wheelchair mobility. Her cognitive impairment was documented as severe, with assessment scores indicating she had extremely limited mental capacity and poor safety awareness.

The facility’s care plans specifically addressed the resident’s mobility needs and fall risks. Her wheelchair locomotion care plan clearly stated that she “requires total assist of one staff with wheelchair locomotion” and emphasized staff must “ensure foot pedals in place prior to propelling wheelchair.” Similarly, her fall prevention care plan reinforced this requirement, documenting that staff should “ensure foot pedals on wheelchair with locomotion.”

Despite these clear care plan requirements, the incident occurred when two nursing assistants were transporting the resident down a hallway. According to witness accounts, the resident was exhibiting behavioral symptoms, becoming agitated and resistant to being moved. One of the nursing assistants described the situation: “I was pushing the resident down the hallway to her room. The resident was sliding down in her wheelchair… was screaming at us. I kept telling the resident I was going to push her, and she needed to put her feet up so I could push her.”

The resident did not have her wheelchair foot pedals attached during this transport. As she became increasingly agitated, she began to slide forward in her wheelchair and attempted to put her feet down on the floor. Her left leg became caught in the wheelchair wheel during this process. A Licensed Practical Nurse who witnessed the incident stated: “The resident’s legs were crossed and the nursing assistant was pushing the resident down the hallway. The resident was having behaviors and did not have wheelchair pedals on her wheelchair… the resident’s left leg got caught in the wheel of the wheelchair.”

When the resident began to fall, a second nursing assistant attempted to help by cradling and lowering her gently to the floor. However, the resident’s left foot remained “bent under and caught in the wheelchair wheel” during this process, causing significant injury.

Initially, facility staff documented that the resident appeared to have no injuries from the incident. The post-fall evaluation completed immediately after the event noted “no injury at time of fall.” However, over the following days, it became clear that the resident had sustained serious damage.

The resident began exhibiting new behaviors, screaming out when touched, which staff noted was unusual for her. When she continued to show signs of severe pain, facility staff ordered emergency X-rays and eventually called 911 when her condition worsened. Hospital records documented that the resident “is clearly in a lot of pain” and was “unable to provide any further history due to dementia.”

Medical examination revealed the resident had suffered an “acute periprosthetic distal left femur fracture” – a serious break in her thigh bone near an existing prosthetic device. The injury required surgical intervention, with the resident undergoing “open reduction internal fixation” to repair the fracture. This type of surgery involves opening the leg and using metal hardware to hold the broken bone pieces in proper position for healing.

Multiple staff members interviewed during the investigation acknowledged that foot pedals were not in place during the incident. One nursing assistant stated: “I do not know why the pedals were not on the resident’s wheelchair.” Another admitted: “Sometimes the resident has wheelchair pedals and sometimes the resident does not have wheelchair pedals. I do not know why.”

The facility’s occupational therapist explained proper protocol, stating that “if a resident is having behaviors and putting their feet on the floor while staff are pushing the wheelchair, then the staff should stop pushing the resident because a fall could occur. They should place foot pedals on the wheelchair and monitor the resident’s behavior.”

Even after the incident, problems with foot pedal compliance continued. During the investigation, surveyors observed the resident in her wheelchair with only the left foot pedal attached while her right foot rested on the floor, demonstrating ongoing inconsistency in implementing the required safety measures.
The resident’s physician confirmed that proper use of foot pedals “could have potentially helped with preventing her fall or getting her leg caught in the wheel” if staff had followed the care plan requirements.

The incident represents a failure to follow established care plans designed to protect a vulnerable resident with severe cognitive impairment, resulting in an injury that caused significant pain and required major surgical intervention.

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.

The Illinois Department of Health has cited and fined HealthBridge of Arlington Heights when a Certified Nursing Assistant failed to use a required safety belt during a bathroom transfer, causing a 69-year-old resident to fall and injure her ankle. The resident ultimately required surgery to repair two fractures, which went undiagnosed for over a week despite her complaints of pain and inability to walk during physical therapy.

The resident in question, who had been admitted with cellulitis of both lower legs, unsteadiness, gait abnormalities, reduced mobility, and morbid obesity, required assistance with transfers and was supposed to have a safety belt used during all mobility assistance.

The incident occurred when the nursing assistant brought the resident into the bathroom to transfer her to the toilet. According to the CNA’s account, “he instructed the resident to hold the grab bar and stand” but “as the resident stood up, she lost her balance and started to fall.” The assistant stated that “he tried to place the wheelchair under her before she fell but was unable to.” When the resident fell, “her right knee hit the floor, but she was still holding onto the grab bar and standing on her left leg.”

The nursing assistant then “guided her to a sitting position on the floor” and had to reposition her leg because “when she was in the sitting position on the floor, her left leg was extended in front of her, and her right leg was under her weight, so he moved her right leg from under her and placed it in front of her.” The assistant had to call for help to get the resident off the bathroom floor.

A critical safety violation emerged during the investigation when the nursing assistant initially admitted that “he did not have a gait belt on the resident when the fall occurred because he did not have one.” However, when another staff member arrived to help, “one was put on her when the staff member came to help get her up off of the floor.” The facility’s policy clearly required that “Staff will use a gait/transfer belt on residents who need limited to total assistance with transfer or walking.”

The Director of Nursing confirmed that “the resident was a one person assist with a gait belt for transfers” and emphasized that “staff should always use a gait belt for the resident’s safety.” This made the nursing assistant’s failure to use the required safety equipment a clear violation of established protocols designed to prevent exactly this type of injury.

When questioned again by supervisors, the nursing assistant changed his story, stating “I do believe I did have a gait belt on before the fall.” However, when confronted with testimony from the staff member who helped lift the resident, who confirmed “they applied a gait belt and lifted her up off the floor and into her wheelchair,” the assistant admitted “To be honest, I don’t remember the scenario whatsoever. I do not remember exactly when the gait belt was put on.”

The resident’s husband discovered her on the bathroom floor when he visited, stating that “he came in and the resident was sitting on the bathroom floor and had fallen.” He observed that “a couple days later, the resident’s right leg was bruised, and her foot was pointed in an abnormal position.”

Despite the resident’s immediate complaints of pain and the inityial signs of injury, the fracture went undiagnosed for over a week. The facility’s own investigation noted that “no localized symptoms or signs of ankle injury were evident immediately following the assisted fall or in the days afterward.” However, this contradicted the resident’s continued pain complaints and her husband’s observations of bruising and abnormal positioning.

The severity of the injury only became apparent when the resident “was in too much pain to ambulate with PT (Physical Therapy)” more than a week after the fall. X-rays finally revealed “an acute fracture of the distal fibula and of the medial malleolus with subluxation of the tibia on the talus medially” along with “soft tissue swelling diffusely.” This meant the resident had broken her ankle in two separate places and the bones had shifted out of their normal position.

The orthopedic surgeon who evaluated the resident documented a “Right ankle bimalleolar fracture subluxation” and determined that surgery was necessary to repair the damage. The resident required “ORIF (Open Reduction Internal Fixation) right ankle” surgery to properly align and stabilize the broken bones.

The facility’s own investigation acknowledged that “the subsequent right ankle fracture confirmed may reflect an initially minor or hairline fracture caused by the assisted fall.” They noted that several factors may have contributed to the delayed diagnosis, including “The resident’s high pain threshold and non-localized chronic lower extremity pain masking early injury” and that “Morbid obesity contributes to mechanical stress and potential progression of injury.”

However, the facility’s explanation did not address the fundamental safety violation that caused the fall in the first place – the failure to use the required gait belt during transfer. The Director of Nursing admitted that “it is likely that the resident received a small fracture during her fall but it worsened due to participation with therapy,” suggesting that proper initial assessment and treatment might have prevented the need for surgery.

This incident represents a failure in basic safety protocols that are specifically designed to prevent falls during transfers. The resident suffered significant injury and required major surgery that could have been prevented if staff had followed the facility’s own safety policies requiring the use of gait belts for residents needing transfer assistance.

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.

The Illinois Department of Health has cited and fined Harmony Palos when staff failed to follow proper fall prevention procedures during routine care, resulting in a 94-year-old resident falling and sustaining a fractured hip. The facility also failed to accurately report the incident, with conflicting accounts from staff about whether the resident actually fell to the floor or was prevented from falling.

The resident in question, who had multiple health conditions including congestive heart failure, chronic kidney disease, lymphedema, and hypertension, was classified as high risk for falls and required assistance with basic movements like rolling in bed.

The incident occurred during morning care when a Certified Nursing Assistant was attempting to reposition the resident in bed. However, the exact details of what happened became the subject of conflicting reports from staff. The initial progress note stated that “the aide witnessed resident attempting to roll off the bed, grabbed her by both legs and pulled her up into the bed.” The resident immediately complained of pain and was given pain medication. A doctor who was in the building ordered X-rays to the right femur and right knee., which revealed “lucency across the intertrochanteric neck and lesser trochanter concerning for an acute intertrochanteric femoral neck fracture.”

However, the facility’s final incident report told a different story, stating that “the CNA inadvertently overturned resident’s right leg which resulted in the resident falling out of bed and on the floor.” This created a significant discrepancy about whether the resident actually fell or was caught before hitting the ground.

When investigators spoke with the resident directly, she provided her own account of what happened. The resident stated “I fell, they (staff) change your diaper and they tell you to roll go ahead keep rolling and that’s when I fell on the floor.” When asked how staff responded, she replied “I think they (staff) just picked me up and put me back in bed, it happened so fast.”

The resident’s family member confirmed ongoing safety concerns, telling investigators “There needs to be 2 people when changing her. She can’t move on her own.” When asked if side rails had been installed after the fall, the family member responded “No, I don’t see any.”

Investigation revealed multiple failures in the facility’s fall prevention protocols. Despite being assessed as high risk for falls, the resident did not have proper assistive devices in place. When investigators observed the resident’s room, “an assistive device (ie: side rails, trapeze) for turning and repositioning was not in place.” Staff members appeared confused about fall prevention measures, with one CNA stating she was “unsure” about the resident’s fall prevention interventions.

The nursing assistant who was allegedly involved in the incident provided yet another version of events through a written statement. She claimed that “during morning care when I was rolling the resident back over, her leg went over the edge. I grabbed her pant leg and the top of her shirt to prevent her from falling. She did touch the oxygen concentrator with her head, and I told the nurse. She never fell when I took care of her.”

The Director of Nursing acknowledged the inconsistencies in the reports, stating that when she initially spoke with the resident, “she was saying that it was taking two people to give her care during the initial contact but only one person was providing care so that didn’t make sense what she was saying at that time.” The Director noted that later, “when we figured out that there was a fracture, that’s when the resident tried to explain everything… she explained that she ended up on the floor and said that it took 2 people to get her off of the floor.”

The resident’s pain level was documented as 5 out of 10, and the fracture was serious enough that surgery was recommended. However, due to the resident’s advanced age of 95, she declined the surgery as it was determined not to be in her best interest.

The Medical Director emphasized the serious consequences of not properly reporting falls, stating “Multiple things can happen if we don’t know about it. They should notify someone that something happened, if they fall they may require x-rays and we need to determine what happened. Falls can get fracture anywhere and if there’s head trauma there’s a risk of bleeding.”

The facility was ultimately cited for multiple violations including failing to follow policy procedures, failing to ensure staff safely turn and reposition residents, failing to ensure staff report resident falls, failing to ensure staff are aware of fall prevention interventions, failing to implement fall prevention interventions, failing to provide adequate supervision, and failing to ensure equipment was functioning properly.

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.

The Illinois Department of Health has cited and fined Caseyville Nursing & Rehab Center when a high-risk resident suffered two serious falls within weeks of each other, including one that resulted in a compound ankle fracture requiring hospitalization. Despite the resident’s documented history of falls and multiple risk factors, facility staff removed essential safety interventions and expressed dismissive attitudes, with the Director of Nursing calling the resident “our problem child” and questioning why safety interventions should be used, as they no longer apply.

The resident in question had been living at the facility for over four years with serious medical conditions including a displaced fracture of her right tibia, chronic obstructive pulmonary disease, acute and chronic respiratory failure, and chronic kidney disease. Her assessment showed she was “moderately cognitively impaired” and required “partial to moderate assist with lying to sitting and sitting to standing.”

The facility had extensively documented the resident’s fall risk. Her care plan identified her as being “at risk for falls related to diagnosis of Chronic Obstructive Pulmonary Disease, Heart Failure, repeated infections, Weakness, Gout, Respiratory Failure, Pain, Obesity, difficulty walking, Rheumatoid Arthritis, visual disturbance, need for assistance with activities of daily living, psychotropic medication use, narcotic medication use, as needed oxygen use, history of falls.” The plan also noted concerning behaviors: she “frequently chooses to sit edge of bed with legs dependent despite education, overestimates limits, declines to use call light at times.”

The facility’s fall risk assessments consistently rated the resident as being at “high risk for falls.” In response to this risk, various safety interventions had been implemented over time, including “anti-slip tape,” a “sign placed in the resident’s room to remind/encourage to call for assist,” and “nonskid to edge of mattress.”

The first serious incident occurred in May when the resident’s “bed alarm heard alerting” and staff found her “on the floor at bedside facing door.” She had sustained a “skin tear noted to left shin” with a “moderate amount of blood noted.” The resident was “unable to state what happened” and “unable to state if she hit head.” Due to her history of taking warfarin, a blood thinner, emergency medical services were called and she was transported to the hospital for evaluation and treatment of a laceration to her left shin.

Following this incident, the facility completed an investigation stating that “appropriate interventions will be put into place and the resident’s plan of care will be updated accordingly.” However, just weeks later, a second and more serious fall occurred.

In the second incident, a registered nurse was “notified by Certified Nursing Assistant that the resident was found lying on the floor next to her bed.” There was a “large amount of blood found pooled under her right lower extremity” and “upon physical assessment, she has a large laceration to the right outer ankle that continues to have active bleeding.” The nurse applied pressure dressings and “held site and controlled bleeding” before emergency medical services transported her to the hospital.

Hospital X-rays revealed devastating injuries: a “comminuted fracture of the distal tibial and fibular metaphysis” and a “small posterior malleolar fracture.” The facility’s investigation noted this was an “open fracture of right ankle” and that “the resident is still in the hospital.” The root cause analysis found that the resident’s bed was noted to be “in highest position” during the fall and identified the “root cause” as “failing to call for assistance.”

Most troubling was what investigators discovered when they visited the resident’s room after the second fall. They found “no call for assist signage posted, no nonskid tape on floor, no nonskid on bedside, and no mat on floor.” The floor mat was “folded up on shelf” rather than being deployed for safety. A nursing assistant explained that the resident “moved into this room about a month ago” and “I think her bed was just changed so the blue piece for sliding is not on the bed. The mat is usually down too.”

The facility’s leadership showed concerning attitudes toward the resident’s care. The Director of Nursing stated that “the resident is our problem child. She refuses to use the call light and ask for help. What else are we supposed to do?” When questioned about the missing safety interventions, the Director responded “None of those interventions apply anymore, so why use them?” The Assistant Director of Nursing claimed “We have all the interventions in place. There’s not much else we can do,” despite clear evidence that safety measures had been removed.

A Certified Nursing Assistant Supervisor acknowledged awareness of the resident’s dangerous behaviors, stating “The last fall the resident had she put her bed up in the air. I tried to tell the staff the resident would do that but with new staff coming in, not everyone knew.” The facility’s Nurse Practitioner provided insight into the resident’s condition, explaining that she “takes her oxygen off a lot and gets hypoxic” and “these are the times she tries to get up and gets hurt.”

When interviewed about the incidents, the resident could only say “I slipped in my room.” During one investigation, she had stated “her legs were restless and she needed to get out of bed,” indicating the ongoing challenges she faced with her medical conditions and mobility limitations.

The case reveals a pattern of inadequate care where a vulnerable resident with documented high fall risk was left without proper safety measures, leading to preventable injuries that required hospitalization and caused significant pain and trauma.

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.