The Two-Week Wait: How Poor Communication Led to an Undiagnosed Broken Hip At Allure of Mendota

The Illinois Department Of Health has cited and fined Allure of Mendota when the facility failed to properly assess, monitor, and communicate about a resident’s fall. This failure led to unnecessary pain and suffering and a two-week delay in treating a broken hip.

The incident in question began when two nursing aides were trying to help the resident transfer from a wheelchair to her bed using a mechanical lift device.

The resident described the frightening incident in her own words: “I don’t know what the problem was, but they were taking too long, and I told them I couldn’t stand anymore… Then my legs just gave out. I was hanging there, by my arms. The sling was pulling under my armpits and shoulder, and I was hanging on to the handles. They tried to sit me on the edge of the bed, but I was slipping. I landed on my butt on the floor.”

After the fall, several critical failures occurred. First, no nurse performed an immediate assessment of the resident’s condition. The nursing aides didn’t even report it as a fall, instead calling it a “rough transfer.” While X-rays were taken two days later, they didn’t show the fracture due to the resident’s body size and positioning, according to an orthopedic surgeon who later explained that more sensitive imaging (MRI) would have been needed.

The resident showed clear signs of injury. She could no longer bear weight on her leg during physical therapy, complained of hip pain, and couldn’t use the mechanical lift anymore. However, these warning signs weren’t properly communicated between staff. As one physical therapy assistant admitted: “I thought since the X-ray didn’t show a fracture that her pain would eventually go away. I was under the assumption that the nurses knew about her right hip pain. That’s my fault.”

A nurse who cared for the resident during this period stated, “If I knew she fell and she was having those problems, I’d assume her hip was broken and call the doctor to send her to the hospital as soon as possible. But no one told me that.”

Finally, two weeks after the fall, the resident was sent to the hospital where an MRI revealed “a greater trochanteric hip fracture.” The resident required surgery to repair the broken hip. The orthopedic surgeon later stated: “It’s very likely that caused her fracture, and the original X-ray missed it. If she was complaining of continued pain and hadn’t returned to baseline physical functioning, they should have sent her to the hospital.”

This case demonstrates how poor communication between staff members and failure to follow proper assessment protocols led to unnecessary suffering and a delay in crucial medical treatment. As the Director of Nursing acknowledged, “The purpose of continued assessments, documentation of findings, and interdisciplinary communication of resident’s change of condition is to ensure the resident is receiving proper care and continuity of care can be maintained.”

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.