IDPH has cited and fined Bloomington Rehab & HCC when two serious incidents occurred involving residents falling and sustaining injuries due to inadequate supervision and safety measures. One resident passed away shortly after the fall and the other sustained a broken left foot.
The resident in question had a history of falls and was on anticoagulant therapy.
This first incident involved two separate falls. The initial fall occurred in the bathroom where the resident suffered a subdural hematoma. Despite recommendations from the resident’s physical therapist that the resident “should always have supervision while in bathroom,” the resident was left unsupervised again a few days later, resulting in another fall and a new subdural hematoma.
A nurse aide admitted to leaving the resident alone in the bathroom, stating, “the resident asked for a new gown, so I gave the resident the call light and left the bathroom to get the resident a new gown, and when I came back a nurse said the resident was on the floor.” This incident led to the resident being admitted to hospice care and ultimately passing away approximately five weeks later.
The facility failed to properly update the resident’s care plan with new interventions after the first fall and did not effectively communicate the need for supervision to all staff. The Director of Nursing even admitted that there were issues with staff education and documentation concerning the resident’s care and treatment.
The second incident involves a resident who was allowed to leave the facility unsupervised despite a history of alcohol use and mobility issues.
On the day of this incident the resident fell while walking on a busy road with a faulty walker. A witness reported, “I saw a man with a slate blue wheeled walker going down the road in the left lane of traffic. The walker looked wobbly, like maybe it was broken. I saw the resident stumble and fall.”
The resident admitted to drinking alcohol before the incident, stating, “We drank some alcohol. I was walking to the bus stop. The bus hadn’t come, so I started to walk back to (the facility). It was hot and I fell in the road.” Two days later the resident was diagnosed with a “Nondisplaced Fracture of First Metatarsal Bone Left Foot.”
In this case the facility failed to properly assess the resident’s safety for unsupervised outings and did not maintain the resident’s walker in safe condition. The resident stated, “My walker is broke. I have told the staff, but I still have to use it.”
Both of these incidents highlight significant failures in resident care, including inadequate supervision, poor communication among staff, failure to update and implement care plans, and lack of proper safety assessments. The facility’s responses to these incidents were deemed insufficient, resulting in an Immediate Jeopardy citation by IDPH.
When a resident fails to get the care which is required, it raises a fair question as to whether this was an understaffed nursing home. Residents failing to get needed care is a hallmark of an understaffed and is also a hallmark of the nursing home business model.
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.
