Unsupervised Walk Leads to Fall & Brain Hemorrhage At Serenity Estates Of Lincolnshire

The Illinois Department of Health has cited and fined Serenity Estates of Lincolnshire when staff failed to supervise a resident with dementia walking to their room after dinner, resulting in an unwitnessed fall that caused severe brain bleeding. The resident, who had a documented history of falls and required supervision for walking, was found on the floor with a head injury and had to be admitted to the Intensive Care Unit for treatment of subdural and subarachnoid hemorrhages.

According to facility records, the resident “was seen walking towards her room with her rolling walker” and “was later found lying flat on her back on the floor” with “a bump on the back of her head.” The situation was particularly concerning because the resident had clear care instructions requiring supervision for all walking activities, especially after meals, due to previous falls and multiple risk factors.

The resident’s care plan explicitly outlined significant fall risks, including “confusion and impaired memory,” “abnormalities of gait and mobility,” and “unsteadiness on feet.” The facility’s own assessment showed the resident required “Supervision or Touching assistance” for even basic movements like standing up, transferring between surfaces, and walking any distance.

Particularly troubling was that this incident occurred despite enhanced safety measures put in place after a previous fall. The facility had specifically added a requirement to “Assist the resident to walk to her bedroom before and after meals.” When investigating the incident, staff noted that “drawers were still open” in the resident’s room, leading them to assume the resident had attempted to retrieve something and lost their balance.

The Director of Nursing’s comments revealed a serious lapse in care protocols, as staff were aware the resident had been walking alone – they reported the resident “was last seen walking toward her room after dinner.” This admission suggests a troubling gap between documented care requirements and actual practice, as staff apparently observed the resident walking unassisted but did not intervene as required by the care plan.

This incident highlights multiple failures in the nursing home’s duty of care: failure to follow established care plan requirements, failure to implement supervision protocols despite known fall risks, and failure to provide necessary assistance during a high-risk activity (walking after meals) that had been specifically identified as requiring staff support. The severity of the resulting injuries – brain hemorrhages requiring ICU admission – underscores the critical importance of following safety protocols for vulnerable residents with cognitive impairment and mobility issues.

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.