IDPH has cited and fined Bridgeway Senior Living when the facility failed to implement adequate fall prevention interventions for a resident at high risk for falls. This failure led to the resident falling out of bed onto a hard floor, sustaining a subdural hematoma, and ultimately passing away approximately two weeks later.
The resident in question suffered from multiple conditions affecting her mobility and cognition, including multiple sclerosis, muscle weakness, lack of coordination, and contractures in both lower legs.
According to the facility’s Final Serious Injury Incident and Communicable Disease Report, “CNA [Certified Nurse Assistant] notified the nurse on duty that the resident was noted on the floor by her bed. The resident stated that she was trying to get something off her table when she tipped over and fell from the bed. The resident was observed with a hematoma and bleeding to the left side of the head.” The report identified the root cause as “the resident possibly hit her head on the bedside table causing the hematoma” but critically did not mention the use of a fall mat at the time of the incident.
The LPN caring for the resident on the night of the fall, stated that upon entering the room, “there was blood all over the floor and the fall mat was either standing up or against the wall.” The LPN believed the fall mat was not in place due to the presence of blood on the floor and not on the mat.
The resident’s family member reported that “there were supposed to be mattresses alongside the bed and if there were, she would not have hit her head and had a brain bleed.”
The resident’s care plan identified her as a fall risk and listed interventions such as placing a floor bed with a floor mat when the resident was in bed, keeping needed items within reach, frequent night checks, and ensuring the call light was accessible. However, the Post Fall Evaluation Assessment indicated that no floor mat was present at the time of the fall.
The resident’s physician confirmed that the resident was at high risk for falls and stated, “the floor mat should have been there as she had previously had a fall” and “if the resident was bed bound, she should have had a fall mattress.”
Unfortunately, the absence of a fall mat and the failure to adhere to the resident’s care plan interventions demonstrate a lack of proper fall prevention measures, ultimately contributing to the resident’s serious injury and subsequent death.
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.
