Resident At Aliya Of Homewood Falls and Suffers Head Injury Due to Lack of Required Toileting Assistance

The Illinois Department of Health has cited and fined Aliya of Homewood when staff failed to provide proper toileting assistance to a high-risk resident with dementia, resulting in two falls with the second causing a head injury requiring hospitalization.

The resident in question suffers from diagnoses including history of falling, altered mental status, unspecified dementia, psychotic disturbance, and muscle wasting. She scored 3 on the Brief Interview for Mental Status (BIM) and 20 on the falls risk assessment, putting her at high risk for falls.

The resident had experienced two falls at the facility. The facility’s care plan for the resident noted her high fall risk related to cognitive deficit and impaired mobility, and was revised after her first fall to include “Staff to provide prompt toileting assist before and after meals and PRN [as needed].”

The Progress notes for the resident documented that she was found sitting on the bathroom floor with a wet brief, and later was observed on the floor with a head injury.
Multiple staff members provided accounts of the incidents. A Certified Nursing Assistant (CNA) stated she wasn’t assigned to the resident but helped return the resident to bed, noting she had seen the resident in bed about half an hour before the incident. Another CNA who was assigned to the resident stated that when she checked on the resident early morning, the resident wasn’t in her room because she was in therapy. When she returned around 7:00am, the resident was in bed, and the CNA informed her she would return with breakfast. This CNA admitted she didn’t offer toileting assistance because the resident was “an incontinent resident.” She later helped put the resident back to bed after the fall and discovered the resident’s diaper was soiled with both urine and feces.

A Registered Nurse reported finding the resident sitting on the floor with a head injury. The resident couldn’t explain what happened. After assessment, the nurse notified the family and doctor, who ordered the resident be sent to the hospital. An Occupational Therapy Assistant confirmed taking the resident to therapy early morning and bringing her back to her room.
The Assistant Director of Nursing stated the expectation that “staff to offer toileting and incontinence care whenever they round on the residents.” Sadly, in this case, the resident suffered a serious injury when proper toileting assistance, as required by her care plan, was not provided.

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