The Illinois Department Of Health has cited and fined Shelbyville Manor when a resident suffered multiple back and neck fractures due to a fall during a shower transfer. The incident resulted in emergency medical evaluation and treatment at two hospitals.
The resident in question had several pre-existing conditions that made them particularly vulnerable, including spastic paraplegia, abnormal posture, difficulty in walking, and muscle wasting and atrophy.
According to the quarterly assessment the resident was “completely dependent on staff for all activities of daily living and utilizes a wheelchair for locomotion.”
On the day of the incident, at approximately 8:50 AM, facility staff were moving the resident on a shower chair from a shower stall when the accident occurred. A Certified Nurse Aide reported that “when I began pulling the resident’s shower chair forward out of the shower stall, a wheel on the chair got caught on the shower curb and the resident began falling forward.” The CNA attempted to prevent the fall by pushing back on the resident and the shower chair, but both the resident and the CNA ended up falling to the ground.
Immediately after the fall, the resident expressed pain and continued to express pain when staff transferred them from the floor to a chair. The facility incident investigation documented that “the resident complained of neck, chest, abdomen, and knee pain after falling to the ground.”
Despite the evident pain, the resident was not immediately sent to the hospital. Progress notes indicate that the resident “stayed in bed during lunch and only ate ‘about six bites’ due to experiencing chest and abdomen pain.” It was only after this that the resident was sent to the local hospital emergency department for evaluation.
At the hospital, the resident reported experiencing pain “everywhere” and was diagnosed with neck and back fractures, necessitating transfer to a regional trauma center. The trauma center report revealed the full extent of the resident’s injuries: “the resident was diagnosed with six back and neck fractures (thoracic vertebrae #11/#12, lumbar vertebrae #1/#2/#3, and cervical vertebrae #3).” The resident required intravenous morphine for pain management and remained hospitalized for just under a week.
Upon returning to the nursing home facility, the resident was prescribed analgesic pain medication and required “a rigid cervical immobilizer (a type of rigid neck brace used to limit movement after surgery or serious injury) to be worn at all times.” The severity of the resident’s injuries is further evidenced by their increased reliance on pain medication. Prior to the fall, the resident had only taken a single dose of acetaminophen over the period of a month. However, after returning from the hospital, the resident was taking acetaminophen “nearly every day” for pain management.
This incident highlights a critical failure in resident safety protocols, particularly in the safe transfer of highly dependent residents during routine care activities. The case underscores the importance of proper equipment maintenance, staff training in transfer techniques, and immediate medical evaluation following falls, especially for residents with pre-existing mobility issues and neurological conditions.
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.
