The Illinois Department Of Health has cited and fined Alden Estates-Courts of Huntley when a resident fell while a staff member was attempting to fix her shoe while she was standing upright. The fall resulted in a fractured hip and the loss of independent mobility.
The resident in question had multiple diagnoses including dementia, Parkinson’s disease, Alzheimer’s, anxiety disorder, and a history of wandering and behavioral disturbances.
Prior to the fall, the resident was able to ambulate with a walker, requiring only verbal cues as reminders. However, the incident dramatically changed her condition. As a RN stated, “Prior to the resident’s fall she was able to ambulate with a walker. The resident only needed verbal cues to remember to use her walker.” After the fall, the resident’s mobility was severely impacted, with the Restorative Nurse noting, “The resident is currently a two persons assist. The resident no longer initiates movement on her own. The resident will not get out of bed independently which is what she did prior to her falling.”
The circumstances of the fall, as described by a CNA, involved a moment of inattention to the resident’s known impulsive behavior: “I provided the resident with a shower on the day the resident fell. I put the resident’s shoes on. The resident became anxious and wanted to get out. The resident stood up as I was trying to finish. The back part of the resident’s shoe was folded over. I tried to get the resident to sit down so I could fix it, she wanted to leave. As I fixed the back of her shoe she stepped away and fell onto the floor.”
This account reveals a failure to properly manage the resident’s known risk factors and behaviors. The resident’s Care Plan clearly indicated she was “At risk for falls” and included instructions to “Encourage appropriate use of walker” and “Provide proper, well-maintained footwear.” The CNA’s actions in attempting to adjust the resident’s shoe while the resident was standing, despite her known impulsivity and fall risk, directly contributed to the incident.
The severity of the consequences is evident in the statement from the resident’s Primary Physician: “after the fall the resident was sent to the hospital. Imaging shows a femur fracture post fall. The resident received surgical intervention to repair the fracture.” This injury not only caused immediate pain and distress but also resulted in a significant decline in the resident’s quality of life and independence.
The facility’s response to the incident, as described by the Director of Nursing (DON), acknowledges the lapse in care: “We have had conversations with the CNA and explained the need to have the resident sit down to adjust shoes.” However, this reactive measure highlights a failure in proactive training and adherence to established care protocols.
The resident’s Power of Attorney aptly summarized the avoidable nature of the incident: “I do not know why they did not have her sit down before messing with her shoe. That contributed to her fall. The resident was able to walk before the fall; she is not able to walk now.”
This case demonstrates a critical failure in providing appropriate Activity of Daily Living (ADL) care to a resident with known dementia-related behaviors. The incident resulted in severe physical harm and a significant decline in the resident’s quality of life, underscoring the importance of strict adherence to care plans and proper training in managing residents with cognitive impairments and fall risks.
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.
