The Illinois Department Of Health has cited and fined Alden Lincoln Park Rehab when a resident with Alzheimer’s disease suffered bilateral subdural hemorrhages (bleeding in the brain) after a fall. The incident reveals several failures in following proper care protocols and responding to changes in the resident’s condition.
The situation began when the resident returned from a weekend visit with family, showing an unusual level of anxiety and odd behavior. Early the next morning staff noted that the resident was “walking very fast from room to room” and appeared to be looking for an exit.
The resident’s behavior was notably different from their baseline, including “howling while pacing” and leaning forward while walking.
This would be considered a material change in condition in a nursing home. What’s particularly concerning in this case is how the staff handled this change in condition.
When the night nurse noticed these changes in the resident, she attempted to contact medical staff but failed to fully communicate the severity of the situation. As one staff member noted: “We were worried that she was going to fall, that’s why we were trying to get her to sit down and lay down. Leaning forward was something new for this resident.”
The Nurse Practitioner later stated that had they been properly informed of these changes, they would have taken immediate action: “If her gait is somewhat acute I would have sent her out, ordered a wheelchair, close monitoring… Even without the leaning forward, I feel that anyone that is confused and leaning forward will eventually fall.”
A resident’s gait can be described as “acute” if they experience a sudden, noticeable change in their walking pattern, often due to a recent injury, illness, or neurological event that has caused a new or significantly altered gait abnormality.
The situation culminated in the resident coming out of their room bent forward and falling face first in the hallway, hitting their head. CT scans later revealed “Mixed density right subdural hemorrhage… Another small isodense subdural collection along left frontoparietal convexity… Left frontal scalp hematoma.”
In this case the facility failed to follow their own policies, particularly their “Change of Condition” policy which requires that “Attending physicians or physicians on call /NP and responsible party will be notified of all changes in condition.” Additionally, they failed to complete proper fall risk assessments, as evidenced by incomplete documentation.
This case highlights systemic issues in the facility’s care protocols, particularly in recognizing and responding to changes in a resident’s condition, maintaining proper documentation, and ensuring adequate communication between staff members about resident safety concerns. The resident’s subdural hematomas were a direct result of these failures in care and oversight.
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.
