IDPH has cited and fined Heather Health Care Center when the facility failed to protect a resident with severe cognitive impairment and visual impairment from a physical attack by another resident with a documented history of aggressive behavior. This failure resulted in the resident being brutally assaulted, suffering severe injuries to his face and head that required hospitalization.
One of the basic expectations that families have when they admit a loved one to a nursing home is that their loved one will be kept safe from violence or what would be criminal behavior elsewhere. In fact, the risk of being exposed to criminal behavior is one of the reasons that IDPH fines nursing homes. Sadly, nursing home residents are at times the victims of criminal behavior by staff or more often, the victims of assaults by fellow residents, as was the case here.
The resident / victim in question was admitted to the facility with diagnoses including Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Schizophrenia, Hypertension, and Presbyopia. He had a BIMS score of 7, indicating severe cognitive impairment. He required supervision and assistance with all functional abilities.
The resident / aggressor was admitted to the facility with diagnoses including Schizoaffective Disorder, Anxiety Disorder, Encephalopathy, and Hypertension. He had a well-documented history of aggression and violence, as evidenced by his Comprehensive Behavioral Health Initial Assessment which noted that he displayed “frequent Hallucinations/Illusions and almost constant Delusions” and coped “through display of anger and hostility.”
Despite these clear risk factors, the facility placed both residents in the same room without implementing adequate monitoring or interventions to prevent potential incidents of abuse.
A resident in the adjacent room provided a chilling account of the assault, stating, “I was awake when the incident happened, around 2:00 AM. The resident / victim was howling: ‘Somebody help!’ while the resident / aggressor was just beating on him. The resident / victim came into my room, he was bleeding from all over his face.”
Staff interviews revealed glaring inconsistencies and lapses in monitoring and reporting of the incident. A Certified Nursing Assistant (CNA) reported that the resident / victim told him “he was punched twice in the face and kicked continuously by the resident / aggressor while he fell to the floor.”
However, the facility’s initial investigation inexplicably concluded that the incident was merely a fall and a sign of the resident / victim’s disease process, despite overwhelming evidence to the contrary.
The resident / victim’s ambulance sheet and hospital records clearly documented an assault, with the resident himself stating that he was hit 15 times by the resident / aggressor’s fists and feet. The police report also corroborated this account, with a Social Worker informing the reporting officer that the resident / aggressor had battered the resident / victim in their shared room.
The facility’s failure to properly assess and monitor the resident’s aggressive behavior, coupled with the ill-advised decision to place the resident / victim, a vulnerable resident, in the same room as the resident / aggressor, directly contributed to this tragic incident. As the Medical Director aptly noted, “If two residents like that are monitored and assisted, their cohorting may be acceptable; however, if there is lack of supervision and monitoring, it would not be appropriate.”
The profound impact of this incident on the resident / victim is hard to overstate.
As a Licensed Practical Nurse (LPN) poignantly described, “the resident / victim was almost blind, but he could walk around. He could also talk and was able to eat independently. He could even go to the bathroom with minimal assistance.” Tragically, after the assault, “the resident / victim was not responding and not talking, he was lethargic.”
This heartbreaking case underscores the critical importance of vigilant abuse prevention, comprehensive resident assessments, and proactive interventions to ensure the safety and well-being of all residents, particularly those with cognitive impairments and a history of aggressive behavior.
The facility’s failure to meet these essential standards resulted in a catastrophic outcome for the resident / victim and serves as a sobering reminder of the grave consequences of inadequate resident protection in long-term care settings.
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.
