The Illinois Department Of Health has cited and fined Odd Fellow-Rebekah Home when a resident with dementia and on blood thinners died after experiencing multiple falls. The facility failed in several ways to protect this resident from falls and to properly respond when falls occurred.
The resident had several medical conditions including dementia, unsteadiness on feet, difficulty walking, and was taking two blood thinners (Aspirin and Rivaroxaban). The facility assessed them as “severely cognitively impaired” and needing significant help with daily activities like toileting, bathing, and moving around.
The resident experienced a series of falls over a short period of time. On the day in question the resident fell twice – first at 12:45 PM, causing a cut near their eye, and again at 7:00 PM, complaining of hip pain. Despite being on blood thinners and hitting their head, the facility didn’t notify a doctor after the first fall, which was against medical best practices. As the Medical Director later stated, “the resident should have been sent to the emergency room after the 12:45 PM fall due to being severely cognitively impaired, having a fall with a head injury and on anticoagulants.”
Five days later, the situation became critical. A nursing aide found the resident on the floor in the hallway, bleeding from a reopened cut on their temple. The resident was saying “I’m going to pass out!” and was rushed to the emergency room. Hospital records showed the resident had developed a large blood clot in their brain (described as a “Large Left Frontal and Temporal mixed density Subdural Hematoma”). Tragically, the resident passed away the next day.
A certified nursing aide (CNA) provided a heartbreaking account: “It was awful. I found her in the hallway outside her room. She was bleeding. I sat there with her. She bled all over my pants. I’ll never forget that. I felt so bad for her but I don’t know what else we could have done besides putting her on a one to one.”
The facility had multiple failures in their care:
– They didn’t properly implement a walking program that was ordered for the resident
– They couldn’t prove they were doing required 15-minute safety checks
– They lacked proper policies for monitoring residents on blood thinners who hit their head
– They failed to thoroughly investigate the falls
The Medical Director summed up these failures, stating “the resident’s falls were missed opportunities resulting in her major injuries.” He noted that while he doesn’t usually recommend constant observation, this resident “would have been a great candidate due to her poor awareness of instability.”
This case highlights how a breakdown in proper safety protocols and failure to respond appropriately to falls, especially for a resident on blood thinners, can have devastating consequences.
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.
