IDPH has cited and fined Alden Lakeland Rehabilitation & Health Care Center when the facility failed to promptly recognize the severity of a resident’s head injury, neglected to follow their own head injury protocol by not calling 911 immediately, inadequately assessed and communicated the resident’s deteriorating condition, and significantly delayed critical medical intervention. These failures ultimately lead to the resident’s death from complications of a subdural hemorrhage resulting from the fall.
The resident in question, with multiple health conditions including dementia, hemiplegia, and heart failure, fell face-forward from her bed at around 5:30pm. A Certified Nursing Assistant (CNA) witnessed the fall, providing a vivid description: “I was bringing the resident her dinner tray and as I stepped one foot into the room I observed the resident sitting at foot of the bed, at the top of the fold (foot of bed was elevated), as the resident was literally falling forward from the bed onto the floor. The resident was wearing her glasses and hit her face on the floor with a very hard with a loud thud and her glasses remained in place but were broken (right arm flew off).” The CNA emphasized the severity of the impact, calling it “the loudest thud I had ever heard from a fall.”
The fall resulted in a 2cm hematoma and a 1cm abrasion above the resident’s right eye. Despite the obvious severity of the impact, the facility’s response was alarmingly inadequate, revealing multiple critical failures.
Firstly, the facility failed to follow its own Head Injuries policy, which clearly states, “Call paramedics (911) and transfer to hospital if indicated.” Instead of calling 911 immediately, staff called a non-emergency ambulance service with an estimated arrival time of 60 minutes. This decision led to a significant delay in the resident receiving urgent medical attention.
The staff’s assessment of the resident’s condition was also inadequate. They noted elevated blood pressure readings (167/109 and later 181/102) but did not consider these a significant change from the resident’s baseline. The Assistant Director of Nursing (ADN) later admitted, “a blood pressure of 170/100 would warrant a call to 911” and that the elevated readings were “considered a change in condition.” This failure to recognize the severity of the resident’s condition further delayed appropriate intervention.
More than three hours elapsed between the fall and the arrival of paramedics. When they arrived at 8:54 PM, they found the resident in a much worse condition than reported. The lead paramedic stated, “facility staff did not know how critical the resident was when we arrived.” The resident’s blood pressure had risen to 226/110, she was unresponsive, and had a “big hematoma (size of baseball) that was very prominent on the resident’s head.”
The paramedic suspected the facility of trying to conceal the severity of the situation, stating, “I started to question what was really going on and felt that the medications were given to cover the facility.” This suggestion of a potential cover-up adds another layer of concern to the facility’s handling of the incident.
Communication breakdowns were also evident. The paramedic noted that they “were not made aware of anything (about the resident’s status)” upon arrival, indicating a serious failure in relaying critical patient information. Furthermore, despite the paramedic’s recommendation to transfer the resident to a trauma center due to her symptoms, facility staff insisted on transport to a local hospital. The resident was later transferred to the trauma center the paramedic had initially suggested, resulting in further delays in receiving specialized care.
The facility staff’s insistence that the resident was “awake about 15 minutes prior” and able to take medication contradicted the severe symptoms observed by the paramedics, suggesting a critical failure to recognize and respond to a rapidly deteriorating condition.
These compounded failures resulted in critical delays in the resident receiving appropriate medical care. Tragically, the resident died, with the death certificate listing the cause as “complications from subdural hemorrhage and fall.”
This incident exposed systemic failures in the facility’s fall prevention, assessment, and emergency response protocols. It highlighted critical gaps in staff training, decision-making processes, and adherence to established policies, ultimately leading to a preventable tragedy and underscoring the vital importance of prompt, appropriate responses to falls in vulnerable elderly residents. The facility’s multiple shortcomings in this case – from the initial response to the fall, through the assessment and decision-making process, to the communication with emergency services – paint a picture of a system ill-equipped to handle critical incidents, putting residents at severe risk.
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.
