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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.