The Illinois Department of Health has cited and fined Sunny Hill Nursing Home of Will County in Joliet, Illinois when a resident fell from her bed during a bed bath performed by a single aide and sustained fractures to both femurs. State investigators determined the facility failed to follow the care plan interventions requiring two-person care.

The resident’s care plan documented a self-care performance deficit related to weakness and limited range of motion, with contractures of both ankles, foot drop, and a prior stroke with left-sided involvement. Its interventions stated that she was totally dependent on two staff for bathing and preferred a bed bath only, and that she required a two-person assist for turning and repositioning in bed. A separate fall-risk care plan intervention directed staff to ensure she was always positioned in the middle of the bed. Facility staff gave differing accounts to investigators of how long the two-person requirement had been in place.

The facility’s initial report to the state agency stated the resident had a fall, complained of pain in her left hip and right knee, and was sent to the hospital, where she was admitted with fractures of both distal femurs.

The resident and the aide gave differing accounts of how the fall occurred. Speaking with investigators a few weeks afterward, the resident said she had been receiving a bed bath from a certified nursing assistant who had no other staff assisting, that she was lying on her left side, and that the aide rolled her too far away, causing her to fall from the bed onto the floor. She stated she was not holding onto the side rail for support. In her written statement, the aide said the resident had a very large bowel movement, was on her left side facing the window, and was holding onto the right bed rail with her right hand. The aide wrote that she was cleaning the resident’s backside with her right hand while her left hand held the resident, and that the resident’s left foot slid off the bed, causing her to fall forward. She wrote, “I tried to grab her to pull her backwards, but she was naked, and her weight was too much,” and that because she was wearing gloves, the resident’s body was slippery and she slid off the bed.

The aide’s written statement concluded, “This is our normal routine, as I reflect on what happened, the only thing that could have changed what has occurred was another person CNA.”

The resident said that while she was on the floor, her feet, hips, leg, and head were hurting, and that she was sent to the hospital, where she had to undergo surgery. The emergency department physician’s report describes her as presenting with a fall out of bed, and records her account that staff were changing her and that she rolled out of bed when they rolled her. The report notes a chin abrasion and that she reported pain in both femurs and both knees.

Imaging at the hospital showed an impacted, comminuted fracture of the right distal femur, described as without angulation or displacement, and a comminuted, impacted fracture of the left distal femoral shaft. Two days after the fall, the resident underwent surgery on both legs. The operative report describes open treatment of the right distal femur fracture using a retrograde femoral rod, noted as without extension into the joint, and open treatment of the left distal femur fracture, which extended between the condyles, using headless compression screws and a retrograde rod.

The facility’s assistant director of nursing, who served as the resident’s restorative nurse, stated the resident required a two-person assist with bed mobility, transfers, and bathing, and that the aide was the only person assisting her with bathing and bed mobility when she rolled out of bed onto the floor. She stated that if the aide had read the resident’s care plan, she would have known two people were required to provide care.

The facility’s administrator stated the aide was alone giving the resident a bed bath when she slid out of bed and fell to the floor. She stated that she reviewed the care plan after the fall and saw that the resident required two people to assist with bed mobility, transfers, and showers. The administrator stated the aide was placed on paid administrative leave pending the investigation and was subsequently terminated for failure to follow the resident’s care plan.

The facility’s director of nursing stated she expects staff to go over a resident’s care plan before the resident is touched for the day, and to follow what the care plan says.

The resident’s physician stated the resident had a fall and sustained fractures to both legs as a result. He stated the fall and the fractures could have been avoided if the aide had followed the care plan and had two staff members giving the bed bath and repositioning the resident rather than one, and said he expects staff to follow care plans.

An assessment completed after the fall found the resident dependent on staff for bathing, toileting, and transferring, and that she required substantial to maximal assistance with rolling from side to side and returning to her back while in bed.

The facility’s written policies require that care plans include measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs. Its policy on nursing assistant assignments directs that duties be based on residents’ assessed needs as identified in the care plan, that staff review the resident care plan daily in the facility’s electronic records system, and that staff follow the care plan and assure all resident needs are met. Its fall prevention policy states that residents determined to be at high risk of falling will be alerted to staff, and that all staff are responsible for reviewing and following individualized resident care plan approaches and interventions.

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

The Illinois Department of Health has cited and fined Pearl of Orchard Valley in Aurora, Illinois when a resident fractured her right tibia and fibula after falling during a transfer that did not use the mechanical lift and two-person assistance her care required. State investigators determined the facility failed to ensure the appropriate lift equipment and staffing were used when the resident was weighed and transferred.

The resident, an 84-year-old woman, had diagnoses including a prior stroke, total occlusion of the arteries of her extremities, atherosclerosis of her left lower extremity, peripheral vascular disease, end-stage renal disease requiring dialysis, muscle disorders, unsteadiness on her feet, dementia, an anxiety disorder, neuropathy, and a history of falls. A standardized assessment on file before the incident found she was severely cognitively impaired and totally dependent on staff for transfers between her bed and chair, and that she required substantial to maximal assistance with other daily activities due to impairment of both legs. Records show she had been formally assessed as requiring transfers using a total mechanical lift with two staff members assisting for a substantial period leading up to the incident.

On the day of the fall, the resident was being transferred from her wheelchair to a weighing scale ahead of a dialysis treatment. The facility’s incident report states that only one certified nursing assistant was performing the transfer. According to the CNA’s statement, she assisted the resident to stand by holding the waistband of her pants while the resident held onto the grab bar on the scale, and the resident’s legs suddenly gave way, causing her to fall to the floor.

The CNA stated she then called a nurse, and the two of them manually lifted the resident off the floor and back into her wheelchair before returning her to her room. The resident continued to complain of right leg pain and was sent to the hospital, where she was admitted and hospitalized for 10 days before returning to the facility. Hospital records confirmed the resident had sustained traumatic fractures of her right tibia and fibula.

The facility’s own incident report initially listed an incorrect date for the fall. The director of nursing stated this was a typographical error and confirmed the fall occurred during the resident’s early-morning transfer to a weighing scale before dialysis, as otherwise described in the report.

The CNA stated that although she had previously used the total mechanical lift to transfer the resident, another certified nursing assistant had told her the resident could be transferred manually without the lift. That certified nursing assistant stated it had been some time since he had cared for the resident, denied giving that instruction, and said the CNA who performed the transfer should have reviewed the resident’s care documentation to determine the appropriate transfer method.

The director of nursing stated that residents assessed as needing a total mechanical lift should have their weight obtained using the facility’s lift, which is equipped with a built-in scale, rather than a separate stand-up scale. When asked why that equipment was not used for the resident, the director of nursing said there was no explanation. The director of nursing also stated that the CNA involved in the transfer received disciplinary action, and that the nurse who helped lift the resident off the floor after the fall was terminated because the resident should not have been manually lifted from the floor following a fall.

The facility’s medical director, who also serves as the resident’s attending physician, stated he was informed that the resident had fallen and sustained fractures of her right tibia and fibula.

During an interview conducted after the fall, the resident — who was alert and responsive — stated that her legs had given way while she was being transferred to the scale, and that she experienced severe pain and was taken to the hospital. She said staff sometimes transferred her manually, sometimes with a mechanical lift, and sometimes with one or two staff members assisting. She reported ongoing pain in her right leg, which she rated an 8 out of 10.

The facility’s Safe Transfer Policy requires staff to use the appropriate mechanical lift device and provide two-person assistance for residents assessed as requiring a total mechanical lift for 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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Miller Health Care Center in Kankakee, Illinois Cited After Resident Suffers Two Fall-Related Fractures With Ordered Alarm Missing
The Illinois Department of Health has cited and fined Miller Health Care Center in Kankakee, Illinois when a resident with a physician-ordered bed and chair alarm suffered two falls resulting in major injury after investigators found the alarm was repeatedly missing or not in use. State investigators determined the facility failed to keep in place the fall-prevention interventions that had been ordered by the resident’s physician, consented to by a family member, and written into his care plan.

The resident, a 76-year-old man, had diagnoses including Parkinson’s disease, dementia with behavioral disturbance, chronic congestive heart failure, urinary tract infections, tremors, and abnormalities of gait and mobility, along with muscle weakness, unsteadiness on his feet, a history of repeated falls, a prior right hip fracture, and an artificial hip joint placed before his admission. According to a family member, he was admitted to the facility for rehabilitation. His admission fall risk assessment identified him as at risk for falls, and his care plan, initiated the following day, identified him as high risk for falls related to deconditioning and balance problems, with an intervention calling for a bed and chair alarm to be in place as needed. A physician’s order for the bed and chair alarm was active from the day of his admission, and a consent for its use was on file.

In the first fall, the resident fell in the bathroom one evening while attempting to transfer without assistance. He was assessed with an abrasion to his elbow and a skin tear at the base of his thumb, with a small amount of blood found on the floor. During the following shift he began complaining of pain in his right leg and was sent to the hospital, where he was diagnosed with an acute fracture of his right femur. The facility’s own fall incident report noted that his motion alarm was not present on the bed at the time. A certified nursing assistant’s statement indicates she had last seen him in bed shortly before the fall, and that he used his bathroom call light minutes later, after which he was found on the bathroom floor. Days after this fall, the resident’s physician order was updated to specify that the alarm be applied whenever he was in his bed or chair.

In a second fall, the resident was found lying on the floor in front of his recliner after attempting to transfer himself to his wheelchair for dinner. He reported increased pain in his right leg and was sent to the hospital, where he was diagnosed with a displacement fracture involving his existing hip replacement. A certified nursing assistant’s statement indicates that when she arrived to take him to dinner, she found him on the floor near the bathroom door, and that his chair alarm had not been turned on.

The resident was hospitalized and underwent an orthopedic surgical procedure. Hospital records reviewed by investigators indicate he reported the second fall occurred as he was returning to bed after using the bathroom on his own. Records show he was later readmitted to the facility with a surgical dressing on his right thigh.

During the state’s on-site survey, investigators observed the resident on three consecutive days. On the first day, he was in his wheelchair wearing a fall-risk bracelet, with large, dark bruises on his arm and the back of his hand. On the second day, he was asleep in bed with no alarm attached; his alarm was sitting on a chair next to the bed. On the third day, he was again asleep in bed with no alarm attached; his alarm was instead attached to his wheelchair, which he was not using.

A family member who said she visits the resident daily stated he has had multiple falls since his admission, and that she had signed consent for the bed and chair alarms when he was admitted. She stated that after each fall, it was determined that the facility had not had the bed alarm or chair alarm in place. She said that on the day she was interviewed, she arrived to find his alarm sitting on a chair near his bed while he sat in his wheelchair on the other side of the room without the alarm attached, and that he had bandages on both legs, one elbow, his shoulder, and a finger.

The facility’s medical director stated that a bed and chair alarm should be implemented once ordered, and said that while anyone who falls can sustain a fracture, it is a concern when an ordered alarm intervention is not in place, as was the case with this resident. A nurse practitioner confirmed the resident’s femur fracture resulted from the first fall and that the second fall further injured his existing hip replacement, requiring surgery, and stated his bed and chair alarm should be on at all times. The facility’s restorative nurse, who has served as its fall coordinator, stated the resident had an active order for the alarm to be connected any time he was in bed or in his chair, that the alarm sounds as soon as pressure is relieved from the pad, and that the sound should give staff time to intervene depending on their proximity. She said staff are expected to round hallways throughout their shifts, and identified the resident as high risk for falls due to his Parkinson’s disease, gait abnormality, weakness, unsteadiness, low blood pressure, and frequent attempts to transfer himself. She said his point-of-care prevention tasks included the bed and chair alarm, bladder prompting every two hours, and hourly safety checks, and confirmed that a fall risk score above 10 indicates a resident is high risk. She also stated that fall interventions are generally expected to begin within 24 hours of a resident’s fall risk assessment, and that she personally initiates related point-of-care tasks, including bed and chair alarms, within 24 hours of a resident’s admission, or by the following Monday for weekend admissions.

The facility’s written fall-prevention policy states that residents at high risk for falls will be placed on fall risk precautions, with an interdisciplinary team initiating a protocol of interventions. Its personal body alarm policy states that nursing staff are to check the placement and proper working order of a resident’s alarm each shift.

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

The Illinois Department of Health has cited and fined Goldwater Care Danville when, according to state investigators and facility records, a certified nursing aide performed a mechanical lift transfer by herself rather than with the two staff members required by facility policy, and without inspecting the lift sling beforehand as the manufacturer and the facility both require. The sling broke while the resident was suspended in the air, and she fell to the floor and struck her head, sustaining a comminuted, displaced and impacted fracture of her left shoulder and a pocket of blood between her skull and scalp.

The facility’s own transfer policy classified mechanical lift transfers as requiring two caregivers and directed that lift equipment undergo routine maintenance checks by nursing and maintenance staff to remain in good working order. The requirement to inspect the sling before each individual use appears in the manufacturer’s manual and was confirmed by the facility’s own nursing leadership. The manufacturer’s instruction manual for the full body sling carried an explicit warning: “Carefully inspect the sling before each use for wear and damage to seams, fabric, straps and strap loops. Torn, cut, frayed, or broken slings can fail, resulting in serious personal injury to the user.” The Director of Nursing confirmed to investigators that staff are required to inspect slings before each use and that two staff members are required to operate the mechanical lift, and that any sling with a problem should be taken out of service and reported to her. The Administrator told investigators that staff are expected to use two assists for mechanical lift transfers and to inspect slings before every use.

According to the citation, the aide was transferring the resident from her wheelchair to her bed using the mechanical lift. The resident’s roommate, who witnessed the transfer, told investigators that both she and the resident told the aide that two staff members were required for mechanical lift transfers, but that the aide insisted she could do the transfer alone. The roommate further told investigators that, after the resident was elevated in the sling, the aide pulled on the sling and the sling then broke.

The sling gave way while the resident was suspended. The facility’s incident report documents that she was found on the floor on top of the mechanical lift legs, lying on her left side with her face pressed against the floor and her legs extended outward, with redness and bruising to the right side of her face and a visible deformity of her left arm. The aide reported that the resident struck her head on the roommate’s table during the fall.

She was transported to the hospital by ambulance. Imaging documented a comminuted, displaced and impacted fracture of the proximal left humerus involving the surgical neck and extending to the greater tuberosity, along with a small subgaleal hematoma — a collection of blood between the skull bone and the scalp — over the right side of her forehead. A CT scan found no underlying skull fracture and no bleeding inside the skull. The hospital record noted she was taking Eliquis, a blood thinner, for atrial fibrillation at the time she struck her head. Her daughter told investigators the resident was dropped from the lift while being transferred by one staff member and sustained a broken shoulder along with cuts and bruises to her face.

The aide acknowledged to investigators that she did not inspect the sling before beginning the transfer and that she was alone in the room. The Assistant Director of Nursing, who was called to the room, said the sling strap had broken while the resident was elevated, and that when she inspected the sling afterward, the hook on it had split in half. She confirmed the resident had been transferred by only one staff member and that facility policy requires two for all mechanical lift transfers.

The day after the fall, the facility held a quality assurance meeting on the incident, audited all slings in service, educated licensed and certified nursing staff on its fall prevention, incident, and mechanical lift transfer policies, educated laundry staff on the mechanical lift sling inspection log, and began auditing whether residents were being transferred with the appropriate equipment and appropriate number of staff.

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

The Illinois Department of Health has cited and fined Casey Rehab and Nursing when, according to state investigators and facility records, a certified nursing aide showering a severely cognitively impaired resident turned her back to reach for a washcloth while the resident was covered in soap, and the resident leaned forward and slid out of the shower chair onto the floor, fracturing her pelvis. A second resident, also severely cognitively impaired and known to stand up from her wheelchair unassisted, fell in the dining room while no staff member was present in the dining room, striking her head and requiring three staples.

The first resident had Alzheimer’s disease, dementia, a disorder of bone density, and a history of prior lumbosacral spine and pelvic fractures. A fall risk assessment completed weeks before the fall classified her as a moderate fall risk. A separate assessment from around the same time documented her as severely cognitively impaired and dependent on staff for total assistance with bathing, transfers, and every other activity of daily living. A fall care plan intervention entered around the same time recorded that she did not understand her mobility limits because of her cognitive limitations and that she would try to get up from a bed or chair unassisted.

The certified nursing aide told investigators she transferred the resident from her wheelchair into a facility shower chair by herself. She had the resident “very soapy” when she turned her back to get a washcloth to cover the resident’s eyes before rinsing. That, she said, is when the resident leaned forward and fell out of the shower chair, landing on her left side on the shower room floor. The aide acknowledged the resident “leans forward in her wheelchair frequently,” that she should not have turned her back knowing the resident was very soapy and leaned forward on her own, and that the resident has Alzheimer’s disease and cannot make safety decisions on her own.

The aide also told investigators the resident should have been placed in the facility’s reclining shower chair, but that she did not realize the facility had a shower chair that reclined. Investigators observed staff using that reclining chair for another resident during the survey. The Administrator told investigators the aide should not have turned her back, that staff “are encouraged to use all the tools needed to ensure every resident is safe,” and that she should have used better judgment caring for a severely cognitively impaired resident. According to the citation, the Administrator confirmed the facility caused the resident’s left pelvic fracture by placing her at risk for falling when the aide turned around and stopped monitoring her. The facility asked the survey team to treat the shower fall as past noncompliance, and that request was denied.

The second resident had vascular dementia, a psychotic disorder with delusions, and encephalopathy, and was likewise assessed as severely cognitively impaired and dependent on staff for most daily care. Her care plan had carried an intervention for months requiring that she eat with supervision, along with a separate intervention directing that staff be educated on her supervision needs while she was up in her wheelchair. A certified nursing aide told investigators the resident was on fifteen-minute checks because she was a high fall risk, that she was supposed to be supervised in the dining room, and that one aide is supposed to be in the main dining room at all times during meals.

On the evening of her fall, she stood from her wheelchair unassisted, lost her balance, and fell. No staff member was in the dining room. The registered nurse on duty told investigators she was in the adjacent living room, did not have visual contact with the resident, was the closest staff member, and that there were no other staff in the dining room at the time. She explained that the facility was holding an event that night that caused “a lot of chaos,” which is why she could not position her medication cart in its normal location where she could see all the residents in the dining room. A cook passing through the dining room found the resident on the floor with blood on the back of her head and called for help.

The cook told investigators the resident had been sitting in the same spot since before supper was served, and may have been sitting there longer. She also said the resident’s right wheel was locked and her left wheel was unlocked. The nurse gave a conflicting account regarding the wheelchair, stating it could not have been locked because the anti-tippers would have prevented the resident from pushing back from the table to where the chair was found. The resident was sent to the emergency room, where a one-centimeter laceration to the back of her skull was closed with three staples and she was diagnosed with a closed head injury. Imaging showed soft tissue swelling to her left posterior scalp.

Other staff described her as a known risk. A unit aide said she “is known to fall a lot” and should not be left alone. A licensed practical nurse said she routinely crawls out of bed, will stand unassisted out of her wheelchair, and “generally tries to do things she shouldn’t,” and that staff should stay in the dining room until all residents have finished eating. The Director of Nursing told investigators the resident was known for pushing herself back from the dining room table, for rocking back and forth in her wheelchair, and for standing up unattended before this fall — and that the fall and the resulting laceration and staples “could have been prevented if staff were monitoring” her. The Administrator confirmed the facility does not have a policy on monitoring the dining room because it is a common area, while stating residents should be monitored during mealtime. The facility’s own Fall Reduction Policy stated that it would provide supervision and assistive devices to prevent or minimize fall-related injuries.

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

The Illinois Department of Health has cited and fined Avantara Park Ridge when, according to state investigators and facility records, a 95-year-old resident documented as high risk for falls fell while trying to get out of bed on a morning when the aide assigned to her had left the unit for more than half an hour to shower a resident in another area without telling the nurse she was going. The resident was emergently hospitalized with a left hip fracture, underwent surgery, and according to the facility’s own restorative director, her physical ability declined afterward.

The resident had been admitted to the facility more than a year earlier, following a hospitalization for recurrent falls. Her diagnoses included cerebral infarction with hemiplegia and hemiparesis affecting her right dominant side, age-related physical debility, and orthostatic hypotension. An assessment completed the month before the fall documented that she required substantial to maximal assistance with sit-to-stand mobility and toilet transfers. A fall risk evaluation in her record identified her as high risk for falls.

On the morning of the fall, according to the citation, the certified nursing aide assigned to the resident left the unit to take another resident to a different unit for a shower. She told investigators the task took her longer than usual — “definitely more than 30-40 min” — that she rarely cared for this resident and was not really familiar with her, and that she did not remember whether she asked anyone to look out for her residents while she was gone. The licensed practical nurse on the unit told investigators the aide never reported that she was leaving and only returned after the incident.

The nurse said she heard the resident’s bed alarm sounding and went to check. She found the resident on her back, holding her left hip, wedged between the wall and the left side of the bed. The nurse called a rapid response, observed that the left leg was displaced, and noted the resident’s vital signs were elevated and she reported being in pain and distress. Staff immobilized her and stayed with her on the floor until paramedics arrived.

The facility’s root cause analysis attributed the fall to the resident’s forgetfulness and concluded she did not call for assistance. The resident told investigators otherwise. In her own words: “I wanted to get out of bed, and I fell. I used a call light, but I didn’t get anybody. They are always so busy in the morning.” A certified nursing aide who regularly cared for her separately told investigators the resident “is very good at using a call light,” and also explained the unit’s morning practice with her: “R9 gets up around 10:00 AM, so we try not to bother her in the morning.” The falls coordinator who conducted the investigation acknowledged she never interviewed the resident, stating she had already been admitted to the hospital and could not recall the incident by the time she returned.

Accounts of what fall interventions were actually in place also diverged. The nurse told investigators that fall prevention measures were in effect at the time — bed in the lowest position, a fall mat, and the call light within reach — though she noted there was no fall mat on the left side of the bed, the side where the resident was found, “because it doesn’t fit.” The facility’s own fall care plan, however, showed no floor mat or lowest-bed-position interventions in place before the fall, and a certified nursing aide told investigators that the interventions now in place — fall mats beside the bed, bed and chair alarms, belongings within reach, and the lowest bed position — “weren’t in place before” the resident fell. The falls coordinator further stated the resident had been assessed at low risk for falls before the incident, which conflicts with the fall risk evaluation in her record identifying her as high risk.

At the hospital, imaging identified a left intertrochanteric femur fracture with mild displacement and angulation. She underwent surgery the following day to place a rod in the left femur. During the admission she developed an acute kidney injury on top of chronic kidney disease, attributed to post-operative low blood pressure and low fluid volume, along with acute blood loss anemia. Hospital records noted her rehabilitation progress was limited by cognitive impairment, decreased activity tolerance, and a need for maximal assistance with transfers and bed mobility. The facility’s restorative director told investigators that the resident had required one-person assistance when she was admitted, that she now requires a gait belt and two-person assistance for transfers, and that her physical ability declined after the fall.

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

The Illinois Department of Health has cited and fined Arc at Bradley when, according to state investigators and facility records, a certified nursing aide transferred a resident from his bed to his wheelchair by herself and without the mechanical lift his care plan required, resulting in an impacted spiral fracture of his left upper arm that required hospitalization. The facility’s own investigation concluded the fracture was caused by the improper transfer, and two other aides told investigators that transferring this resident alone was something staff sometimes did.

The resident was a 70-year-old man who had lived at the facility for several years, with diagnoses including heart disease, chronic atrial fibrillation, hypertension, and a history of traumatic brain injury. His care plan, in place months before the injury, was explicit: he was dependent on two staff members for transfers using a mechanical lift. A subsequent assessment completed after the injury also documented that he was dependent on staff for transferring, and the Director of Nursing told investigators he was dependent on staff for all activities of daily living and unable to get in and out of his bed or chair by himself.

The injury was first brought to staff’s attention by a family member. According to the citation, she came to visit and touched the resident’s left shoulder. He jumped and told her his shoulder hurt. She reported it to his nurse. The nurse examined the shoulder, found it swollen, notified the physician, and an X-ray was ordered. The imaging showed an impacted spiral fracture of the left humerus. He was admitted to the hospital, seen by orthopedics, and discharged three days later with instructions to follow up with an orthopedic physician. When investigators observed the resident nearly two weeks after the injury, his left shoulder and upper arm were still swollen with purple discoloration.

The Administrator told investigators he had investigated the injury and determined that in the early morning hours before it was discovered, a certified nursing aide had transferred the resident by herself and had not used a mechanical lift — and that this was how the fracture occurred. He stated that when he interviewed the aide, she admitted she had transferred the resident by herself without the lift. He stated the resident requires two staff and a mechanical lift for all transfers, and that if the aide had used the lift with two staff, the resident would not have sustained a fracture. The Director of Nursing gave investigators the same account. The facility’s own addendum to its report to the state documented that the cause of the fracture was an improper transfer by facility staff.

The fracture pattern itself was significant. According to the citation, investigators were told that an impacted spiral fracture can only be caused by blunt force trauma, compression, and rotation occurring at the same time. The advanced practice registered nurse who reviewed the injury told investigators that the resident’s fracture was not caused by any medical condition, that it was caused by blunt force trauma, and that the improper transfer caused the fracture. She further stated that if staff had transferred the resident using two staff members and a mechanical lift, he would not have sustained a fracture.

Investigators found the practice was not isolated to a single aide. One certified nursing aide told investigators that the resident is a two-person mechanical lift transfer, but that sometimes staff — including herself — transfer him by themselves. A second certified nursing aide told investigators the same thing, stating that he is a two-person mechanical lift transfer but that sometimes he has had to transfer the resident by himself. The aide who performed the transfer that resulted in the fracture would not make herself available for an interview despite several attempts over two days. The facility’s own transfer policy states that mechanical lifting devices shall be used for any resident needing a two-person assist.

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

The Illinois Department of Health has cited and fined Aliya of Glenwood when, according to state investigators and facility records, a resident identified as high risk for falls with impaired mobility and poor safety awareness was not safely positioned on his bed while a certified nursing aide provided incontinence care, and he rolled off the elevated bed and fell face down onto the floor. The resident sustained a displaced right orbital fracture — a break in the bone surrounding the eye — and a fracture of the second cervical vertebra in his neck.

The resident had been admitted to the facility days earlier with diagnoses including morbid obesity, anemia, and metabolic encephalopathy. His hospital paperwork from just before admission documented weakness, pain, decreased endurance, decreased strength, decreased range of motion, decreased cognition, and impaired gait and balance. His fall risk assessment on admission scored him at high risk, and his care plan identified him as high risk for falls related to impaired mobility, weakness, and high-risk medications. His admission evaluation contained somewhat mixed findings on his mobility: it described him as independent with bed mobility, while also documenting that he was unable to sit on the edge of the bed with little or no support and was not independent in transferring from sitting to standing. A rehabilitation screening completed the day before the fall identified problems with safety concerns, limited range of motion, bed mobility, transfers, and locomotion. A subsequent assessment completed after the fall documented that he required partial to moderate assistance to roll from left to right and was dependent on staff for going from sitting to standing.

On the day of the fall, a nurse saw the resident’s call light on and entered the room with a certified nursing aide. The nurse found the bed sheet was wet and asked the aide to change the resident. According to the nurse’s account to investigators, she intended to assist with the care and stepped out of the room to gather supplies. She said she was only a few feet from the room when the aide came to the door to tell her the resident had fallen.

The certified nursing aide told investigators she assisted the resident onto his side and began providing incontinence care. According to her written statement, while she reached back for a towel, the resident reached for his cell phone and rolled off the bed. She confirmed the bed had been elevated to working height at the time of the fall. She also told investigators she was unsure how much assistance the resident required for care.

The resident was found face down on the floor with a laceration to his right toe and a bump to his forehead. He was sent to the hospital, where imaging documented an acute displaced comminuted blowout fracture of the right orbit with bruising beneath the eye, hemorrhagic contusions to the forehead and scalp, and an acute minimally displaced fracture at the second cervical vertebra. According to the hospital record, the resident reported he was turning in bed and thought a nurse was there to help him turn, but no one was there and he fell out of bed.

The facility’s restorative nurse told investigators what should have happened. She explained that residents are assessed for bed mobility and transfers, and that a care card is placed above the bed documenting whether the resident is a one-person or two-person assist. She stated that if staff are unsure of a resident’s transfer or bed mobility needs, they should use two staff members for safety. She further stated that staff are instructed and expected to gather all supplies before starting care and keep them within reach, that residents should be positioned to the center of the bed when being turned to prevent them from getting too close to the edge, that staff should ensure residents are positioned correctly before rendering care, and that staff should stay with residents while providing care. The facility’s MDS coordinator separately confirmed that a resident coded as requiring partial to moderate assistance would require one to two staff members for the task.

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

The Illinois Department of Health has cited and fined Aliya of Crestwood when, according to state investigators and facility records, an 88-year-old resident at high risk for falls suffered an unwitnessed fall in his room and remained on the floor for a prolonged period before staff discovered him, despite his roommate activating the call light after hearing him fall. The state issued an Immediate Jeopardy citation, the most serious level of violation, and the county medical examiner determined the resident’s cause of death was the fall and complications of his spinal injuries.

The resident had been admitted to the facility roughly a week earlier following a hospitalization for a fall at home with seizure activity. His records documented encephalopathy, generalized muscle weakness, cognitive impairment, seizures, and repeated falls. His admission evaluation classified him as high risk for falls due to impaired memory and judgment, a history of falls, unsteady gait, and incontinence, and his care plan called for rounding at a minimum of every two hours, keeping the call light within reach, and moving him to a room with optimal visual access from the nurses’ station. Investigators later measured the distance from the nurses’ station to his room at 108 feet, and the Director of Nursing acknowledged that no room on that unit could be seen into from the nurses’ station.

The resident’s roommate, who investigators noted was cognitively intact, described what he witnessed. He told investigators he heard a sound, saw the resident on the floor, and pressed his call light — checking the clock and noting it was around four in the morning. He said no one came. In his own words: “My roommate’s head was near my bed, and blood was coming from his head. No one was coming. I did try to yell for help, but I was in a lot of pain. They didn’t come for like 2 hours. I looked at the clock, and it was almost 6:00am.” He added: “How can you let a man just lie there and die.”

According to the citation, the facility’s call light system did not produce an audible alert at the nurses’ station. Multiple staff members told investigators the sound had not been working, in one nurse’s account, for years — meaning staff had to physically walk the halls and visually check each door to see whether a light was on. A certified nursing aide was stationed at the nurses’ station monitoring two other high fall risk residents and told investigators she could not leave those residents to answer call lights. The facility’s maintenance director confirmed there was no system to monitor how long a call light had been active, and the Administrator acknowledged there was no process to verify that rounding was being completed, stating: “That’s what I pay them to do. I mean, I would hope they are doing it.”

The resident was found on the floor unresponsive and bleeding from a head wound. Staff initiated CPR and called 911. The ambulance report documented that staff said the event was unwitnessed, that they had walked into the room and found him pulseless, and that staff were unable to provide an exact time he was last seen alive. Hospital imaging identified a left frontal scalp and periorbital hematoma, an acute L1 vertebral body fracture with mild retropulsion, an acute fracture at C7 with widening of the C7 to T1 disc space concerning for ligamentous injury, and rib fractures. He was resuscitated but never regained consciousness, and his family transitioned him to comfort-focused care. He died that afternoon.

The facility offered differing explanations for the cause of the fall in successive incident reports. Its initial incident report concluded the fall was secondary to cardiac arrest; a later report attributed it to acute bilateral pulmonary embolisms, cardiogenic shock, and a heart attack. Both attributed the spinal and rib fractures to chest compressions and the use of a mechanical CPR device. Investigators found problems with that account. The fire department’s EMS coordinator told investigators the department does not own the mechanical CPR device the facility named, and the ambulance run sheet did not document that any mechanical CPR device was used. More significantly, the county medical examiner — a forensic pathologist who completed the medical review of the death — told investigators the rib fractures were consistent with chest compressions, but that the cervical and lumbar fractures were not. When asked directly whether a CPR machine could have caused those fractures, he stated: “Absolutely not.” He confirmed the cause of death, as stated on the death certificate, was the fall and complications of spinal injuries, and stated he believed there was a chance the resident would be alive today had he not sustained the fall in the facility.

Investigators also documented significant gaps in the facility’s emergency response and its own records. The nursing supervisor who responded to the code told investigators he assessed for a pulse using a pulse oximeter rather than palpating the carotid artery, acknowledged he should have used the carotid artery, and when asked how to assess respirations stated he did not know how. Staff accounts of the timeline conflicted with one another and with the medical record — the nurse’s stated time of last seeing the resident was not documented anywhere in his progress notes, and there was no documentation that certified nursing aides provided any care to him during the entire overnight shift. The last documented care was the prior evening.

The resident’s attending physician told investigators he had not been informed the resident died, saying: “Oh… I did not know. They did not notify me.” The facility’s Medical Director stated he had only learned of the incident days before the survey and had not been involved in any root cause analysis, telling investigators: “I think a delay in assessing the resident is the problem and is a big issue. If it took that long, that’s on the facility. That’s bad.” Investigators separately identified a second resident whose call light was found not working, not attached to the wall, and missing the battery required for it to function.

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

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

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

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

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

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

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

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

The Illinois Department of Health has cited and fined Evercare of Breese when, according to state investigators and facility records, two residents sustained fractures after the facility failed to properly transfer them during incidents involving staff assistance — one when a wheelchair moved during a one-person transfer and the resident fell to the floor, sustaining a fracture of the hip; and another when she lost her balance during a walk to the dining room as the certified nursing aide stepped away to place a chair alarm. Both residents were transferred to the hospital for further evaluation and treatment.

The first resident was a 96-year-old woman with multiple chronic conditions including chronic obstructive pulmonary disease, chronic kidney disease, and significant cognitive impairment. She had been assessed as requiring substantial to maximum assistance for transfers. According to the citation, a certified nursing aide was transferring her from her bed to her wheelchair as a one-person assist with a gait belt. The aide stated she made sure the resident had gripper socks on, used a gait belt, and confirmed the wheelchair was locked. When she stood the resident up, the wheelchair rolled backward, and the resident ended up on the floor on her side. The facility’s progress note documents that the wheelchair did not fully lock on the right side and rolled backward during the transfer.

The resident initially denied pain after the fall, but within the hour began experiencing increased discomfort. An in-house X-ray was ordered, and the results showed a comminuted fracture of the left hemipelvis including a fracture through the acetabulum and a fracture of the inferior pubic ramus. She was sent to the emergency room and returned with a diagnosis of a closed fracture of the left hip.

Approximately two weeks after the hip fracture, the same resident experienced another transfer incident. Two certified nursing aides attempted to transfer her from her bed to her wheelchair using a gait belt as a two-person assist. According to one aide’s account, when they stood the resident up she became “dead weight,” her knees buckled, and the aides slowly lowered her to the floor. No injuries were reported from this incident, but the resident was subsequently downgraded to a mechanical lift for all future transfers.

The second resident was a woman with chronic obstructive pulmonary disease, type 2 diabetes, macular degeneration, blindness in one eye, low vision in the other, and a history of falls. She was assessed as needing substantial to maximal assistance with transfers and was on a care plan calling for one-person assist with a gait belt and assistance any time she ambulated with her walker. On the day of the fall, a certified nursing aide walked her to the dining room using a gait belt and walker. When they reached her seat at the dining table, the aide stepped away to place a chair alarm in the resident’s chair. As the aide did so, the resident lost her balance and fell in the direction away from the aide. The aide reported the resident said “oh, oh” and was already falling before the aide could intervene. She was holding onto her walker at the time of the fall.

The resident was transported to the hospital, where imaging confirmed a comminuted displaced fracture at the distal radial meta-diaphysis with approximately 30 degrees of dorsal angulation, along with a mildly displaced ulnar styloid fracture. The Nurse Practitioner told investigators that she would expect residents to be transferred safely and equipment to be safe.

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

The Illinois Department of Health has cited and fined Axiom Healthcare of West Frankfort when, according to state investigators and facility records, a resident with Parkinson’s disease and a long history of falls sustained a closed fracture of the left orbit and left maxilla after the facility failed to consistently implement the fall prevention interventions documented in his care plan. The resident had fallen at least sixteen times in the three months leading up to the injury, and investigators repeatedly observed during the survey that documented fall interventions — including keeping the call light within reach and wrapped with yellow tape — were not being followed.

The resident was a cognitively intact man with Parkinson’s disease, muscle wasting, and a need for assistance with daily care. According to the citation, he had a documented brain bleed from a prior fall before the events described in the survey, and his care plan listed more than two dozen interventions designed to reduce his fall risk over a period of several months. These included keeping the call light within reach and wrapped in yellow tape as a visual reminder, ensuring the bed was kept in the lowest position, moving him closer to the nurses’ station, conducting 15-minute checks, providing grippy socks and proper footwear, and assisting him with all transfers.

Over the course of approximately three months, the facility’s own fall investigation reports documented at least sixteen separate falls — sometimes more than one in a single day. Multiple falls involved the resident leaning forward out of his wheelchair, attempting to retrieve items off the floor on his own, transferring without staff assistance, or being unable to wait for help. After one fall the resident hit his chin on the floor and broke teeth. After another the staff documented they could not locate the resident’s broken teeth in the room.

On the morning that resulted in his serious facial injury, a nurse found the resident on the floor beside his bed without footwear in place. The initial assessment found no injuries and the resident denied hitting his head. The nurse applied grippy socks, returned him to bed, and began neurological checks. Approximately two hours later, a follow-up note documented small swelling to the resident’s left cheek. Several hours after that, the swelling had progressed to left-sided facial and orbital swelling and bruising, and the resident reported head and neck pain. He was sent to the hospital, where imaging confirmed a closed fracture of the left orbit and a closed fracture of the left maxilla. Several days later he was sent to the hospital again after another fall, where imaging incidentally revealed an old thoracic spine fracture of unknown origin.

During the survey, investigators directly observed multiple instances in which the documented fall interventions were not being followed. On separate occasions over several days, investigators observed the resident’s call light placed out of reach — on top of a nightstand, on top of positioning devices, and approximately four feet from where the resident was lying. The yellow tape that was supposed to be wrapped around the call light as a visual reminder was not observed on any of these occasions. The resident’s door was repeatedly observed closed, with no staff in the room. Investigators also witnessed the resident wheel himself out of the dining room with no staff in sight, get his wheelchair caught on a doorway, stand up from his wheelchair, become tangled in his catheter tubing, and walk down the hallway with an unsteady gait pushing his wheelchair from behind — without any staff assistance observed by investigators. A housekeeper was the first to call out for staff to help. It took approximately one minute for three staff members to respond.

A licensed practical nurse told investigators directly that the resident has a lot of falls, especially on the night shift, that he seems like a different person at night, and acknowledged that on some bad nights the 15-minute checks might not all get done. The Assistant Director of Nursing told investigators she was not aware any residents were currently on 15-minute checks, that she would expect the resident’s call light to be in reach when he is in bed, that she would expect his door to be open unless staff were in the room providing care, and that he was supposed to have yellow tape around his call light so he could find it easier. The MDS coordinator stated she was trying to come up with new fall interventions for the resident and other residents, but acknowledged she did not know if the interventions she had put in place were working.

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

The Illinois Department of Health has cited and fined Montgomery Place, a nursing home in Chicago when, according to state investigators and facility records, a certified nursing aide performed a sit-to-stand mechanical lift transfer alone — without a second staff member present despite the resident being assessed as dependent for transfers requiring two or more helpers — and the 96-year-old resident slid off the bed during the transfer with her legs becoming tangled underneath her, resulting in a right femoral fracture. The resident, who was fully dependent on staff for transfers, was hospitalized following the incident.

The resident had been at the facility for over a year, originally admitted following a fall that resulted in a tibia and fibula fracture. She had a long medical history that included a prior history of falls, generalized muscle weakness, spinal stenosis, polyosteoarthritis, and reduced mobility. Her most recent assessment classified her as dependent for transfers — meaning, per the assessment definition, the assistance of two or more helpers was required. Her fall risk evaluation classified her as high risk for falls. Multiple staff members confirmed she had poor trunk control, could not sit up unassisted for long, and could not bear weight on her legs.

On the morning of the incident, a certified nursing aide working the overnight shift was transferring the resident from her bed to her wheelchair using a sit-to-stand mechanical lift. According to the aide’s own account, she had properly applied the lift’s belt and sling, positioned the resident’s feet on the base, and pressed the up button. As the resident began to lift off the bed, she jerked forward. The aide attempted to lower her back down, but during this process the resident’s buttocks slid off the bed, and her right foot came off the lift’s foot base. The aide lowered the resident toward the floor. By the time the lift had lowered, the resident’s right leg had bent inward and was twisted underneath her body. She came to rest in a seated position on the floor with her right leg folded beneath her.

The aide left the room to find another certified nursing aide to help her. When they returned, they got on either side of the resident and lifted her back into bed. The resident was screaming in pain and complaining repeatedly about her foot, her knee, and her leg. The nurse coming on duty was notified, the resident’s physician was called, and the resident was sent to the hospital by ambulance. The hospital diagnosed her with a right periprosthetic femoral shaft fracture — a fracture of the thigh bone at the site of her artificial knee joint.

Investigators also learned that the aide routinely transferred the resident alone using the sit-to-stand lift. The aide who performed the transfer told investigators that while staff are instructed to use mechanical lifts with two people, she had been using the sit-to-stand on her own because people were not always available to help her, and she had never had a problem doing it on her own before. The second aide who came to help after the fall confirmed in her own interview that this aide routinely got the resident up out of bed by herself using the sit-to-stand lift, stating she knew this because she had never been asked to help with that resident’s transfers.

Multiple staff members agreed the injury may have been prevented if a second person had been present. The aide who performed the transfer told investigators directly: “If there were two CNAs there that morning, it could have prevented the resident from getting injured. Two CNAs could have prevented her from sliding off the bed and with two people we would have been able to get her back onto the bed instead of having to lower her to the floor.” The Director of Nursing acknowledged that under the assessment definition of dependent — which means the resident requires the assistance of two or more helpers — the resident should have had at least two staff members assisting with the sit-to-stand lift. The therapy director, the medical director, the registered nurse, and the Director of Nursing all stated that two staff members should assist during mechanical lift transfers for safety.

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

The Illinois Department of Health has cited and fined Heartland Senior Living in Neoga, Illinois when a resident’s bathroom call light was not promptly answered while one staff member stood at the nurses’ station and was not paying attention to the call light panel and another assumed someone else would respond. The resident, who had been identified as a fall risk requiring staff supervision, attempted to stand from the toilet without assistance, lost her balance, fell, and was found unresponsive on the bathroom floor with swelling and bleeding on both sides of her brain.

The resident had been identified as a fall risk and required staff supervision due to an unsteady gait and safety concerns with transfers and ambulation. On the day of the fall, she activated her bathroom call light. A certified nursing aide who was passing meal trays noticed the call light was flashing and sounding. She later told investigators she assumed another aide — who was standing at the nurses’ station at the time — would answer it, so she continued passing trays on a different hall. When she returned to the resident’s hall, the call light was still flashing and sounding. She entered the room and found the resident lying flat on her face on the floor, unresponsive. She estimated that approximately seven minutes had passed from the time she first noticed the call light to the time she finally answered it.

Meanwhile, the aide who had been standing at the nurses’ station told investigators she had not been paying attention to the call light panel because she believed most of the residents were in the dining room eating dinner. After review, staff determined the resident had attempted to stand from the toilet on her own, lost her balance, and fallen. She was bleeding from a skin tear on her left arm. The licensed practical nurse who responded called Emergency Medical Services. When paramedics arrived and tried to move the resident, she complained of pain in her right shoulder. She was transported to the local emergency room, where a head scan documented acute swelling and bleeding on both sides of her brain.

The Director of Nursing told investigators he was aware the resident was a fall risk and that staff would have been as well, since all newly admitted residents are treated as being at risk for falls. He stated his expectation is that any staff member aware of a call light should respond immediately unless actively assisting another resident, in which case the light should be answered within five to eight minutes. He stated specifically that the aide passing trays should have communicated with the aide at the nurses’ station to make sure the call light was being answered, that she should have sought assistance before finishing her tray pass, or that she should have answered the call light herself.

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

The Illinois Department of Health has cited and fined Fair Oaks Health Care Center in Crystal Lake, Illinois when two certified nursing aides improperly attached a mechanical lift sling, causing the sling to come loose mid-transfer and the resident to fall to the floor, sustaining a subdural hematoma — a bleed on the brain — that required hospitalization. The investigation determined the sling loop came off the hook because one aide had wrapped the excess strap around the end of the lift bar, creating tension that caused the loop to pop free while the resident was being moved over the wheelchair.

The resident was a 75-year-old woman who had been admitted to the facility the previous month. Two certified nursing aides were working together to transfer her from her bed to her wheelchair using a full mechanical lift. One aide hooked her side of the mechanical lift sling onto the lift bar and then wrapped the remaining strap around the end of the lift bar — a step that was not part of correct procedure. When the resident was raised and moved toward the wheelchair, the sling came undone and she fell to the floor.

Both aides described what happened consistently during interviews with investigators. One stated she had hooked the loop of the sling on the lift bar and wrapped the rest around the outer hook of the bar, and that when the resident was lifted and moved toward the wheelchair the sling came undone and the resident fell. The Administrator confirmed that after interviewing both aides they were able to recreate the failure: when the loop strap was wrapped around the end of the transfer bracket it created tension that popped the loop off the hook.

The resident was hospitalized and a CT scan showed she had sustained a 3-millimeter subdural hematoma — a bleed between the brain and the skull — as well as bruising to the scalp. She was discharged from the hospital and readmitted to the facility several days later with a new diagnosis of traumatic subdural hematoma. The facility’s own Safe Resident Handling and Transfers Policy, in place at the time of the incident, required staff to maintain compliance with safe handling and transfer practices. The improper attachment of the sling was inconsistent with that requirement.

Following the incident the facility took corrective action, including providing formal retraining to both aides involved on the day of the incident, conducting facility-wide in-services with video training and return demonstrations for all staff, developing an addendum to the safe handling policy, and requiring agency staff to complete online training and pass a return demonstration with the physical therapy department before being permitted to work on the floor.

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

The Illinois Department of Health has cited and fined Fair Havens Senior Living in Decatur, Illinois when a resident’s wheelchair was improperly secured in the facility’s transport van by a driver who had not been adequately trained on the manufacturer’s wheelchair securement system, causing the resident’s wheelchair to flip forward and the resident to slide onto the floor of the van as it drove down a hill, resulting in multiple leg fractures and a 17-centimeter laceration requiring eight sutures. The state issued an Immediate Jeopardy citation, the most serious level of violation.

The resident at the center of this case used a wheelchair for mobility and required staff assistance for her activities of daily living. She was being transported to a physician appointment in the facility’s transport van. The van driver loaded her into the van, secured her wheelchair, fastened the lap belt, and began driving down the hill in front of the facility. Almost immediately, the resident later told staff, she felt her wheelchair move and called out to alert the driver. The driver told her she would be ok and continued driving.

Within moments the resident was screaming. The driver looked in her rearview mirror and saw the resident leaning forward in the wheelchair, bracing herself against the seat next to her. The driver later said in her own words: “I was pulling away from the building when I heard her screaming. I looked in the rearview mirror and saw her leaning forward in the wheelchair, bracing herself on the seat next to her. I drove back around to get help; she couldn’t hold herself up. Her leg went back underneath her, and blood was everywhere.” Rather than stopping immediately, the driver drove the van around the parking lot back up the hill to the facility’s main entrance to get help.

When the Director of Nursing and a licensed practical nurse reached the van, they found a scene the nurse later described as resembling a car accident. The wheelchair had tipped forward. The resident was on the floor of the van with her left leg bent under her body, blood pooling beneath her. The seatbelt and wheelchair attachments were under such tension from the resident’s body weight that staff had difficulty unlatching them. Once they freed her and placed her flat on the van floor, they discovered a large laceration to the top of her left shin. She was alert and oriented and complained of severe pain in her left leg. Emergency Medical Services arrived and transported her to the hospital. Imaging revealed multiple fractures: a fracture of the upper tibia, a fracture of the fibular head, a fracture of the distal fibula extending to the ankle, and an additional avulsion fracture. The 17-centimeter laceration on her leg was closed with eight sutures.

The investigation revealed that the driver had not been properly trained on the manufacturer’s wheelchair securement system. When investigators observed the driver loading another resident into the van for transport, she attached the securement straps to the wheelchair’s armrests rather than the wheelchair frame, used straps that were twisted, and positioned the straps at a 65-to-75-degree angle. The manufacturer’s manual specifies that the tie-down hooks must be attached to a solid wheelchair frame — explicitly not to spokes, wheels, or movable components — and at an approximate 45-degree angle. The driver acknowledged she had attached the restraints to the armrests and stated this was how she always restrained residents for transport.

When asked about her training, the driver stated she had not been formally trained on driving the van or securing residents and had only received a packet with a safety checklist. The Maintenance Director, who was listed as her trainer, was unable to give an accurate demonstration of the actual securement system used in the transport van, demonstrating instead a different system. He acknowledged the j-hooks should be attached only to the wheelchair frame, not the armrests. The driver’s training records included a form dated the day after the incident that was a photocopy with the trainer’s signature already on it and the driver’s name handwritten in. The driver confirmed she had not actually received the training documented on that form. A third resident interviewed by investigators stated the same driver had restrained his wheelchair using the armrests as the anchoring point on multiple prior occasions. The Administrator confirmed the facility did not have a transportation policy at the time of the incident.

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

The Illinois Department of Health has cited and fined Evercare at Edwardsville when two residents were injured during transfers — one because a certified nursing aide transferred her without the required gait belt, causing her to fall and fracture her left upper arm, and a second because a mechanical lift sling hook was not properly secured, causing the resident to slip out and strike her head. Both injuries were preventable and both violated the facility’s own transfer policies.

The first resident had a below-the-knee amputation on her left leg and significant weakness, making proper transfer technique critically important. Her care plan required extensive assistance for transfers due to her weakness and impaired mobility. During a transfer from wheelchair to bed, the resident shifted her weight to her left side — the side with the amputation — lost her balance, and fell. The certified nursing aide who was performing the transfer stated she had been told by other aides that this resident preferred a “bear hug” transfer method, and on that basis she was not using a gait belt. The resident sustained a fracture of the left humeral neck and was sent to the emergency room. The facility’s transfer policy states explicitly that use of a gait belt for all physical assist transfers is mandatory. The Administrator confirmed she would expect staff to follow that policy.

The second resident had Alzheimer’s disease, muscle weakness, and was fully dependent on staff for all transfers. Her care plan required a full mechanical lift with two staff members for all transfers. On the morning of the incident, the certified nursing aide on duty stated the facility was extremely short-staffed and that she asked multiple staff members to help her with the mechanical lift transfer and no one would assist her. She proceeded to perform the transfer alone. While lifting the resident, the sling hook came unhooked, and the resident slipped out of the sling and struck her head on the floor. The resident sustained a hematoma to the back of her head, complained that her head hurt, and was transported to the emergency room by ambulance. The hospital noted the resident had fallen approximately four feet. The Director of Nursing confirmed the hook was not completely secured before the lift began and that the staff member was performing the transfer by herself — in direct violation of the care plan requirement for two-person assist.

Taken together, both incidents reflect the same core failure: staff did not follow documented transfer requirements, and residents were seriously hurt as a result. The facility’s own policies required mandatory gait belt use for all physical assist transfers and two-person mechanical lift transfers for residents who cannot be safely transferred otherwise. In one case a staff member substituted an informal technique based on secondhand advice from colleagues. In the other, a staff member proceeded with a high-risk transfer alone after being unable to find a second person to assist her.

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

The Illinois Department of Health has cited and fined Elevate Care Country Club Hills when a certified nursing aide transferred a resident who required two-person assist for all transfers without a second staff member present, causing the resident to slide to the floor and sustain a fractured left ankle requiring hospitalization. The resident’s care plan had clearly documented the two-person transfer requirement, and multiple assessments had confirmed she was fully dependent on staff for transfers — but the aide performed the transfer alone.

The resident was a 57-year-old woman with a complex set of diagnoses including cerebral palsy, spastic hemiplegia, vascular dementia, schizophrenia, bipolar disorder, and generalized anxiety, among others. She had been a long-term resident of the facility. Her condition included significant weakness on her left side, and she wore an Ankle Foot Orthosis brace on her left foot to support her mobility. Multiple assessments documented over the preceding months consistently showed she was fully dependent on staff for transfers and required two staff members to assist her safely.

The resident’s care plan was explicit on this point. An entry from over a year before the fall specified moderate to substantial assist with two staff members and a gait belt for all transfers due to increased weakness and behaviors. A later entry directed staff to use a full body mechanical lift with two-person assist for all transfers. These requirements were based on her assessed needs and known fall risk.

On the day of the fall, a single certified nursing aide attempted to transfer the resident from her bed to her wheelchair alone. The resident described what happened clearly when interviewed by investigators: the wheelchair was not positioned correctly, the aide grabbed her from under the arms and stood her up, and then let go of her on her left side. The resident said that is when she slid down to the floor. She was wearing her AFO brace at the time, and when she hit the floor she heard a cracking sound and told staff her leg hurt. She was hospitalized and diagnosed with a closed fracture of the left tibia and fibula.

When investigators interviewed staff, the failures ran deeper than a single aide’s decision. The nurse on duty at the time of the fall said she was unsure what the resident’s transfer status was. Another nurse stated she was not even aware the care plan required a two-person transfer. The Director of Nursing and the Administrator both confirmed that care plan interventions are expected to be followed by all staff — but the documented requirement had not been followed, and at least one nurse did not know it existed. The facility’s own fall prevention policy and transfer policy both required that transfer needs be documented in care plans and that staff follow those documented requirements. Neither happened on the day of the fall.

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

The Illinois Department of Health has cited and fined Arc at Streator in Streator, IL when a resident fell out of a mechanical lift sling during a bed-to-wheelchair transfer, landing on his head and left shoulder while his right leg remained caught in the sling, and sustained a right distal femur fracture and multiple spinal compression fractures requiring surgery. The sling’s upper hook came unlatched during the transfer, and the resident, who had a known tendency to grab at the sling during transfers due to anxiety, fell to the floor before staff could catch him.

The resident had a complex medical history including a prior stroke affecting the left side of his body, epilepsy, anxiety, chronic kidney disease, hypertension, and a prior amputation of toes on his right foot. He required a two-person mechanical lift transfer for all bed-to-chair movements. On the morning of the incident, the resident’s family asked staff to transfer him to his wheelchair for a visit. The assigned certified nursing aide’s usual partner was on lunch break, so she asked a registered nurse to assist her instead.

The two staff members secured the resident into the mechanical lift sling, checking that the loops were attached to the hooks. The CNA then leaned over the bed to move the resident’s catheter bag out of the way. The nurse began pulling the mechanical lift away from the bed. According to the CNA, the lift became caught on a cord under the bed and jerked slightly. The upper left hook of the sling came unlatched, and the resident fell rapidly to the floor, landing on his head and left shoulder. His right leg remained caught in the sling. Staff yelled out, and the CNA rushed toward him trying to catch him, but the fall happened too fast. The resident did not cry out.

The nurse described the scene: “The left upper hook came unhooked, and he went to the floor really fast. She ran and tried to hold his head but his left shoulder and his head hit the floor, and his right leg was still in the sling. We lowered the sling to the floor and got him out of it. He did not yell or call out. He was very startled, we all were.” Staff immediately called for help and called 911. The resident’s family, who had been waiting in the hallway, came into the room. The nurse called the resident’s wife, who was his power of attorney. Paramedics arrived within minutes and transported him to the emergency room.

Despite the severity of the fall, the resident remained alert and communicative throughout. He was talking to staff on the floor, and as the CNA later recalled: “He was talking to me and trying to have a conversation with me.” When interviewed by investigators weeks later, the resident described the incident in his own words, referring to the mechanical lift as a “foyer”: “I have some pain in the back of my head from where they dropped me out of the ‘foyer’ onto the concrete floor.” He also said: “I am not crazy about the ‘foyer’ after that fall, but I got up this morning for breakfast.”

Hospital imaging revealed the full extent of his injuries: a displaced right distal femur fracture requiring surgery, along with acute and subacute compression fractures at multiple levels of the spine, and severe osteopenia throughout the spine. He underwent surgical repair of the femur fracture two days after the fall. The spinal compression fractures were managed with a brace when out of bed, with neurosurgery determining no acute surgical intervention was needed.

The facility’s own investigation identified the resident’s tendency to grab at the sling as a contributing factor, noting he had a known behavior of fidgeting with the sling due to anxiety during transfers. His care plan, updated the day after the incident, reflected this: “I have a behavior of grabbing at the sling due to being anxious while being transferred by the mechanical lift,” with an intervention to give the resident an object to hold to occupy his hands. Notably, this intervention was only added after the fall — not before it, despite the behavior being known to staff. The CNA herself recalled telling him before the lift to put his arms across his chest.

Following the incident the facility took corrective action, including auditing all mechanical lifts and slings, removing three slings with frayed loops or seams from service, reassessing all residents requiring mechanical lifts, and providing additional training to all direct care staff on proper mechanical lift use. Further training from an outside agency on proper transfer techniques and equipment inspection was provided to all nursing and CNA staff in the weeks that followed.

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

The Illinois Department of Health has cited and fined Alden Lincoln Rehab and Healthcare Center when a certified nursing aide left a resident who required supervision alone in the shower room to answer another resident’s call light, and the resident fell and sustained multiple pelvic fractures that required hospitalization and surgery consultation. The resident, who was cognitively intact and able to clearly describe what happened, told investigators he needed help in the shower and that staff normally stayed with him — but on this occasion no one was there when he fell.

The resident had a complex medical history that made his need for supervision during showering especially important. His diagnoses included multiple prior pelvic fractures, heart failure, atrial fibrillation, diabetes, and muscle weakness, among other conditions. His care assessment documented that he required partial to moderate staff assistance during showers. He was cognitively intact and well aware of his own needs. He used a rollator walker and had been functioning with a degree of independence prior to this incident.

On the morning of the fall, a certified nursing aide was accompanying the resident to the shower room. She noticed another resident’s call light going off. Rather than asking a colleague to respond to the call light or waiting until the resident was safely supervised, she instructed the resident to wait and left to answer it herself. The resident, standing in the shower room, leaned over to try to remove a tight sock from his foot and lost his balance. He fell to the floor. No staff member was present.

When the aide returned and found the resident on the floor, she notified the nurse. The resident told staff he thought he had hit his head. Because he was on multiple blood thinners, the nurse practitioner ordered him sent to the hospital immediately. He was transported by ambulance and admitted to the hospital, where imaging revealed multiple fractures to the right hip and pelvis. Surgeons were consulted but determined he was not a candidate for surgery at that time. He was left to heal without surgical intervention.

The resident described the incident clearly to investigators: “I was trying to take a shower, and I could not get my sock off my foot. the certified nursing aide left the shower room and said she would be back. I leaned over and fell on the floor. I do need help in the shower — staff normally stay with me in the shower in case I need help. When I fell, no one was in the shower room with me.” He also shared the lasting impact on his life: “Since I am no longer able to walk around with my rollator, I must depend on staff more for my care. This makes me feel helpless.”

Every staff member interviewed agreed that the resident should not have been left alone. The aide herself acknowledged it: “I don’t think the resident would have fallen if someone was with him.” She stated she could have asked another staff member to answer the call light but believed she could do it quickly and return. The registered nurse on duty said he was never informed the resident was going into the shower — which was itself a protocol violation — and that the aide should have stayed with the resident and asked someone else to handle the call light. The nurse practitioner stated that a staff member should have been with the resident in the shower room to reduce the risk of a fall. The Director of Nursing was direct: staff are required to have everything they need before entering the shower room with a resident, and residents requiring supervision should not be left alone.

The consequences for the resident were significant and lasting. Prior to the fall he had been moving independently with a rollator walker. Afterward, he was restricted to toe-touch weight bearing, could no longer use his rollator, and required a mechanical lift for transfers. He was moved to a higher-acuity unit for increased supervision. He also continued experiencing pain but had stopped taking his prescribed pain medication because it caused constipation — a side effect he found more debilitating than the pain itself. The physical therapist noted that while the resident was progressing, healing from multiple fractures takes time, and diabetes can slow the process further.

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

The Illinois Department of Health has cited and fined Alden Estates of Orland Park when a resident with moderate dementia on a locked memory care unit was left without adequate supervision, fell twice in a short period, and sustained a head laceration requiring staples on the first fall and a fractured femur on the second. Staff were aware the resident was impulsive and prone to attempting to stand and walk unassisted, yet failed to maintain the visual oversight her condition required.

The resident lived on the facility’s locked dementia unit and came with a serious set of risk factors: a diagnosis of dementia with psychotic disturbances, a history of falling, orthostatic hypotension and syncope. Her cognitive assessment documented moderate dementia, with severely impaired decision-making. She frequently tried to get up and walk on her own without calling for help, and staff were well aware of this behavior. Progress notes from the days surrounding the incidents describe her as restless, agitated, crying, yelling at staff, and repeatedly attempting to stand up unassisted despite redirection.

The first fall occurred when the resident, who had been seated in her wheelchair at the nurses’ station, made her way undetected into a staff-only room — a nurses’ closet that required a keypad code to enter and was meant to remain closed at all times for exactly this reason. She apparently entered when a staff member left the door open. Inside, she attempted to use the bathroom, stood up from her wheelchair, lost her balance, and fell. She was found on the floor with bleeding from the back of her head. She was transported to the hospital by ambulance, where a half-centimeter laceration was closed with two staples. A nurse who reviewed the incident said simply: “Someone must have left the door open.”

Shortly after, the resident fell again — this time in the dining room during dinner, with multiple staff present. She had been brought to the dining room in her wheelchair and her wheels were locked. Despite this, according to staff accounts, she pushed herself up from the chair, maneuvered around the wheelchair, and began walking around the table on her own. A staff member noticed her standing and immediately turned to set down a food tray before moving to assist her. By the time she turned back, the resident had already fallen. No staff member witnessed the actual fall. She was found on the floor near her table, with visible swelling to her left leg and pain rated at 8 out of 10. She was transported to the hospital, where an X-ray confirmed a midshaft left femur fracture.

The pattern across both incidents was the same: a resident known to be impulsive, restless, and prone to attempting to stand without assistance was not kept within consistent visual range of staff. The facility’s own memory care coordinator acknowledged that during mealtimes, there was no staff member designated specifically to monitor the dining room — staff were occupied passing out trays and attending to other residents’ needs. A nurse stated that if a resident was trying to get up and ambulate, that would warrant one-to-one monitoring. The nurse practitioner said she would expect staff to be within close visual range and to intervene when this resident exhibited those behaviors. Neither happened.

The facility’s fall management policy required individualized assessment of each resident’s specific risk factors and implementation of preventive interventions tailored to those risks. The care plan did include an intervention added after the first fall to monitor the resident for attempts to get out of her chair and redirect her accordingly. But monitoring and redirection are only effective when staff are close enough to act in time — and on both occasions, they were not.

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

The Illinois Department of Health has cited and fined Alden Courts of Waterford when a newly admitted resident with a documented history of falls, dementia, and a pre-existing neck fracture was left without adequate supervision and fell within his first full day at the facility, sustaining a fractured femur and an acute subdural hematoma that required admission to the intensive care unit. The facility knew he was at high risk for falls from the moment he arrived, but failed to put individualized supervision measures in place to protect him.

The resident arrived at the facility late in the evening and came with a serious medical history: a recent neck fracture from a prior fall, dementia, and a documented history of falls. His admission paperwork flagged him as being at HIGH RISK for falls. Staff who were interviewed confirmed they were well aware of the protocols required for high fall risk residents — keeping them in the line of sight of staff, placing them in common areas when awake, and checking on them every fifteen to thirty minutes when in their rooms. The Assistant Director of Nursing acknowledged that he was agitated when she first met him and that “more frequent rounds could have been done.”

The care plan created after his admission listed generic fall prevention interventions — a low bed, a call light within reach, proper footwear, and a clutter-free environment. Significantly, the Baseline Care Plan identified no cognition problems — yet his cognitive assessment completed that same day showed his cognition was severely impaired. That contradiction meant the care plan failed to account for his actual condition and contained no individualized supervision plan and no increased rounding schedule. For a resident with severely impaired cognition, relying on a call light as a primary safeguard was particularly problematic, as there is a serious question whether he could reliably use one at all. A certified nursing aide who worked with him that day recalled that while his family was present, he was already attempting to get out of bed on his own. Staff toileted him and helped him back into bed — but made no move to bring him to a common area where he could be watched.

After his family left for the evening, the resident was left alone in his room. According to the ambulance report, staff checked on him around 9:00 PM and then did not return for approximately fifty minutes. When they did, they found him sitting on the floor at the foot of his bed. He told them immediately: “My leg is broken.” He was right. He was sent to the hospital by ambulance, where imaging showed a right femur fracture. He was also admitted to the intensive care unit with a diagnosis of acute subdural hematoma — a serious condition involving bleeding near the brain — consistent with the trauma of a fall.

The facility’s own fall management policy required staff to assess each resident’s individual risk factors and develop a care plan with goals and interventions tailored to those specific risks. Multiple staff members confirmed that the standard protocol for high fall risk residents required checks every fifteen minutes when in their rooms and placement in common areas when awake. None of that happened for this resident. The facility’s final incident report attributed the fall to the resident not using his call light and having poor safety awareness — effectively placing the blame on a man with severely impaired dementia for not following instructions he may well have been cognitively unable to follow. The state disagreed, finding instead that the facility failed to provide the supervision this resident’s condition clearly demanded.

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

The Illinois Department of Health has cited and fined Accolade Healthcare of Pontiac in Pontiac, IL when a certified nursing aide performed a mechanical lift transfer alone — without the required second staff member — causing a resident to fracture her left knee. The resident endured weeks of pain, multiple emergency room visits, and an initial misdiagnosis before a CT scan finally confirmed the fracture.

The resident at the center of this case was fully dependent on staff for all transfers and was cognitively intact — meaning she understood exactly what was happening to her and could clearly describe it. In the early morning hours, a certified nursing aide used a total body mechanical lift to transfer her without calling for a second staff member, as the facility’s own policy required. The resident described what happened in her own words: the aide “was pushing on me, then suddenly I heard a pop and a crack.” When she told the aide something was wrong, he responded, “Look, you’re standing up.” The resident replied, “I haven’t stood up in years.” Her feet were touching the floor and her left knee struck the side of the bed during the transfer.

The resident was sent to the hospital that same night complaining of pain above her left knee. She was given powerful pain medications including fentanyl and Norco. The emergency room performed an X-ray, which came back negative for a fracture, and she was discharged with a diagnosis of a sprain. But the pain did not go away. Over the following days she continued to complain, continued to receive pain medication, and continued to tell staff that something was seriously wrong. When the nurse practitioner assessed her days later, the resident stated plainly that the aide had hurt her and that she knew something was wrong and wanted an MRI. The nurse practitioner noted she could be referred to orthopedics — at which point the resident, exhausted and in pain, began demanding that something be done immediately, saying she was “tired of this place.”

It took nearly two weeks and an orthopedic appointment with a CT scan to get the answer the resident already knew: she had a fractured left knee. The initial emergency room X-ray had missed it entirely. Throughout that period she had been living with an undiagnosed fracture, managed with pain medication rather than appropriate orthopedic care.

When investigators spoke to the aide, he confirmed without hesitation that he had performed the mechanical lift transfer alone, without a second staff member. The Director of Nursing confirmed that two staff members were required and that the aide had received disciplinary action. The Assistant Director of Nursing was equally direct: “A two-person transfer is required for all staff when using a total body mechanical lift.” The facility’s own hydraulic lift policy stated explicitly that staff must obtain assistance from a second staff member before performing such a transfer. That policy was ignored, and a dependent, cognitively intact resident paid the price with a fractured knee and weeks of unnecessary suffering.

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

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.