IDPH has cited and fined Aliya of Homewood when the facility failed to follow the instructions of the resident’s care plan, which called for a 2 person assist during bed turning and hygiene activities. As a result, a single caregiver was unable to stop the resident from falling from her bed onto the hard floor as the resident was being changed.

Care planning is a process by which risks to the health and well-being of a resident are identified and measures are put into place and carried out on a day-to-day basis to prevent those risks from coming to fruition. One of the ways that proof of nursing home abuse and neglect is proven is by showing violations of the resident care plan. Delivery of the care called for in the care plan is fundamental to providing quality care to residents in a nursing home setting.
In this nursing home case the resident in question suffered from numerous health challenges, including chronic obstructive pulmonary disease, dementia, heart failure, and hypertension.

The resident was also identified as being a fall risk, and a fall prevention care plan was put into place. Importantly, the care plan called for the assistance of two staff members during bed turning and hygiene activities. The plan also included interventions such as keeping the bed in a low position and encouraging the resident to transfer and change positions slowly.
While the resident had many health challenges, her family would regularly visit, bringing her favorite candies to enjoy.

On the day of the incident, while a CNA was changing the resident by herself, the resident started asking for the candy her family had brought. The CNA, focused on the task at hand and wearing gloves, asked the resident to wait until she finished before giving her the candy. However, the resident, eager for her treat, started reaching towards the drawer that held the candy. As the resident’s weight shifted towards the candy drawer, the CNA was unable to stop her from falling off the bed and onto the hard floor.

The fall was a turning point for the resident.

She was sent to the hospital, where a CT scan revealed a small traumatic subdural hematoma. When she returned to the nursing home, she had a neck collar, a new feeding tube, and was no longer able to eat by mouth.

Multiple staff members confirmed that the resident required two-person assistance for ADLs due to her condition and weight. A RN stated, “staff always need assistance to turn and hold her, will say that the resident requires 2-person assistance for ADLs to be on the safe side.”

The CNA who was caring for the resident on the day of the fall admitted to not following the care plan, stating, “she was a total care, incontinent of bowel and bladder and she had always taken care of her by herself, never called anyone to assist her with the resident.” The CNA acknowledged being told that the resident required two-person assistance as per the care plan but claimed she was unaware of this at the time of the incident.
There was a care plan in place which was intended to prevent just this kind of injury. The failure to follow the care plan led directly to this injury and to a sad outcome for the resident.

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.

IDPH has cited and fined Bridgeway Senior Living when the facility failed to implement adequate fall prevention interventions for a resident at high risk for falls. This failure led to the resident falling out of bed onto a hard floor, sustaining a subdural hematoma, and ultimately passing away approximately two weeks later.

The resident in question suffered from multiple conditions affecting her mobility and cognition, including multiple sclerosis, muscle weakness, lack of coordination, and contractures in both lower legs.

According to the facility’s Final Serious Injury Incident and Communicable Disease Report, “CNA [Certified Nurse Assistant] notified the nurse on duty that the resident was noted on the floor by her bed. The resident stated that she was trying to get something off her table when she tipped over and fell from the bed. The resident was observed with a hematoma and bleeding to the left side of the head.” The report identified the root cause as “the resident possibly hit her head on the bedside table causing the hematoma” but critically did not mention the use of a fall mat at the time of the incident.

The LPN caring for the resident on the night of the fall, stated that upon entering the room, “there was blood all over the floor and the fall mat was either standing up or against the wall.” The LPN believed the fall mat was not in place due to the presence of blood on the floor and not on the mat.

The resident’s family member reported that “there were supposed to be mattresses alongside the bed and if there were, she would not have hit her head and had a brain bleed.”

The resident’s care plan identified her as a fall risk and listed interventions such as placing a floor bed with a floor mat when the resident was in bed, keeping needed items within reach, frequent night checks, and ensuring the call light was accessible. However, the Post Fall Evaluation Assessment indicated that no floor mat was present at the time of the fall.

The resident’s physician confirmed that the resident was at high risk for falls and stated, “the floor mat should have been there as she had previously had a fall” and “if the resident was bed bound, she should have had a fall mattress.”

Unfortunately, the absence of a fall mat and the failure to adhere to the resident’s care plan interventions demonstrate a lack of proper fall prevention measures, ultimately contributing to the resident’s serious injury and subsequent death.

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.

IDPH has cited and fined Aperion Care Midlothian when the nursing home failed to ensure the safe transfer of a resident using a mechanical lift, as required by the resident’s care plan and the facility’s transfer policy. This failure resulted in the resident being transferred to the local hospital and treated for a fractured right hip.

Much of the routine care that residents receive in a nursing home setting is shaped by the resident care plan. In the care planning process, an assessment is done to identify the resident’s care needs and risks to the health and well-being of the resident. A series of steps, or interventions, are then put into place which are intended to meet the resident’s needs. The staff members assigned to carry out those interventions then must do so on a day-to-day, shift-to-shift basis.

The resident in question had a care plan that clearly stated that the resident was “totally dependent with transfers related to generalized weakness” and required “transfer from bed to chair with two persons using the mechanical lift device, using safe technique and verbal cues.”

Despite these clear directions in the care plan, multiple staff members, including two CNA’s, admitted to manually lifting the resident under the arms during transfers, disregarding the care plan and the facility’s policy.

Further, when the interviews were conducted at the facility, the State was unable to get a clear picture of exactly how the resident was injured due to the staff’s unwillingness to discuss the incident. The Director of Nursing acknowledged the lack of transparency among staff, stating, “I asked staff what happened but the staff stick together and cover for each other and would not tell me anything.”

There were also inconsistencies in the documentation and statements provided by staff members. A Nurse initially stated that the resident required only one person to assist with transfers, contradicting the resident’s functional assessment and care plan. The Nurse also denied documenting false information on the resident’s transfer form, despite the hospital receiving a copy noting the reason for transfer as a fall.

The nursing home’s failure to follow the resident’s care plan and the facility’s transfer policy, coupled with the lack of transparency and inconsistent documentation among staff, directly contributed to the resident’s injury and subsequent hospitalization.

The facility failed to prioritize resident safety and adhere to established guidelines, resulting in preventable harm to the resident.

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.

IDPH has cited and fined Dixon Rehab & Health Care Center when a resident there tripped and fell over a towel left on the bathroom floor, resulting in a fractured nose and brain hemorrhage.

When a nursing home agrees to accept a resident, they are agreeing that they will meet the care needs of the resident on a 24/7 basis. That’s the promise they make to the resident and his or her family. More than just being a promise to the resident, it is what federal regulations require. When the facility fails to provide the care that is needed, they don’t just break their promise to the resident and his/her family, they break the law.

The resident in question, who has a history of falls and requires moderate assistance with showering, was walking into the shower room with her walker when she tripped over a wrinkled blanket on the floor.

The CNA that was accompanying the resident to the shower explained that she had placed the blanket on the floor to absorb water and had asked the resident to stop so she could get next to her, but the resident did not stop and continued walking towards the shower.

The Director of Nursing stated that a gait belt should be used but the resident refuses to wear one. The Administrator acknowledged that it is not a safe practice to have a blanket on the floor of the shower room and later discovered that the shower was leaking water onto the floor, which is why a towel was being used.

It is the responsibility of the facility to provide a safe environment for its residents, and in this case it appears that a leaky shower was at the root of the problem. If the facility had maintained the bathroom correctly, the CNA would not have felt inclined to put a towel on the floor to soak up the water, and the resident would have had a clear, safe path to the shower.

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.