Lee Manor Cited When Staff Delay, Take Time To Dress Resident Before Calling 911 After Fatal Fall In Shower

The Illinois Department of Health has cited and fined Lee Manor Rehab & Nursing when a resident suffered a fatal head injury during a shower incident. Staff found the resident unresponsive, but instead of immediately calling emergency services, they first took time to dress the resident, highlighting a critical failure in emergency response procedures.

The resident in question was admitted to the facility in late summer with multiple health conditions including heart failure, dementia, and mobility issues.

A few months after admission, a serious incident occurred during the resident’s shower. According to facility records, a Certified Nursing Assistant (CNA) reported that the resident “was not feeling well after the shower.” They moved the resident to bed, where she was awake but unresponsive to questions, leading staff to call 911.

However, the ambulance report tells a different story. When emergency crews arrived, they found the resident completely unresponsive and not reacting to pain.

Notably, the nursing staff told them that the resident had been found unresponsive in the shower, but instead of calling 911 immediately, staff first got her dressed. The emergency crew found this delay concerning enough to note it in their report. The resident’s normal mental state was described as alert and oriented, and the last time she was normal was approximately 45 minutes before they arrived.

The hospital’s examination revealed a severe situation. As noted in the hospital record, the resident was “unresponsive and does not move to any kind of painful stimuli or verbal stimuli.” A CT scan showed extensive bleeding in the brain, specifically “extensive cortical and subcortical hemorrhage throughout the left cerebral hemisphere with significant edema.”

The Medical Examiner provided crucial insight into the cause of death. They determined that the resident’s death was caused by “intracranial hemorrhage due to probable fall.” The examiner specifically noted that the injuries were consistent with blunt force trauma, likely from hitting a hard surface like the floor. As the examiner stated: “This injury was acute, probably happened quickly within 24 hours, due to resident being unconscious, extent of hemorrhage, and mass effect.” Most importantly, they emphasized that the resident’s “death was directly related to the injury.”

The facility was found to have failed in properly identifying and responding to a blunt force head injury. The delay in calling emergency services – specifically taking time to dress the resident while she was unresponsive – represents a lapse in emergency response protocol, potentially impacting the outcome of this serious medical emergency.

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.