IDPH has cited and fined Dobson Plaza when the facility failed to provide proper feeding supervision and assistance as required by the resident’s care plan, resulting in the resident suffering a fall and leg fracture during what should have been a routine breakfast service.
The resident in question had a history of mild cognitive impairment, repeated falls, and dementia.
The resident’s care plan clearly indicated that she required “substantial assistance with eating” and was “totally dependent on staff for bed mobility, transfers, lower body activities, personal hygiene, and toileting activities.” Despite these documented needs, the resident was left unsupervised during breakfast on the day of the incident.
A Certified Nursing Assistant had served the resident breakfast in her bed and then left to prepare for the resident’s shower. The CNA recounted the moment she discovered the resident after the fall: “I was returning to the resident’s room with a shower chair and towels to transfer her to the shower and when I entered the room, I saw the resident sitting on the floor close to her bed with her back leaned on the bed.” This scene was particularly shocking to the CNA, who noted that the resident had two raised bedrails and a bedside table with her breakfast on it when she had last seen her.
The fall resulted in the resident sustaining a fracture to her right shin bone, a serious injury for a woman of her age and condition. What makes this incident even more troubling is that it occurred despite active orders for “bed/chair alarm at all times and fall precautions” for the resident.
Further investigation revealed a series of lapses in care and communication that contributed to this incident. The CNA admitted, “No one had ever told her that the resident had a history of falls” and that she “doesn’t know if the resident was considered a fall risk at the time.” This lack of crucial information left the CNA ill-equipped to provide appropriate care for the resident. Moreover, the CNA stated she “had not been educated or informed of any specific fall prevention interventions for the resident.”
The physical environment of the resident’s room also lacked proper safety measures. The CNA noted, “the resident did not have any floor mats and her bed was at normal height and not lowered all the way to the floor.” These omissions directly contradicted the facility’s Fall Precaution/Safety Intervention Policy, which states, “Safety intervention tools may be implemented to provide safety to the residents and to prevent falls,” including interventions such as a low bed.
This incident underscores the critical importance of following care plans, ensuring proper staff education and communication, and implementing appropriate fall prevention measures for at-risk residents in care facilities. The facility’s Comprehensive Care Plan Policy emphasizes that care plans should “aid in preventing or reducing declines in the resident’s functional status and/or functional levels as is possible.” However, in the resident’s case, this policy was not effectively put into practice.
The failure to adhere to these practices resulted in a serious injury to a vulnerable resident, raising significant concerns about the overall quality of care provided at the facility. This unfortunate event serves as a stark reminder of the potentially severe consequences when established care protocols are not followed and when there is a breakdown in communication among staff regarding resident needs and 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.
