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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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