The Illinois Department of Health has cited and fined The Arc at Streator when staff failed to implement appropriate interventions for a high-fall-risk resident who experienced four falls within a month, resulting in a hip fracture requiring surgical repair.

According to the facility’s Fall Prevention Program, the facility is responsible for “assur[ing] the safety of all residents in the facility, when possible” through “assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices.”

The resident in question was documented as being at risk for falls. Despite this known risk, the resident experienced four falls within a month. The first fall occurred when the resident “was sitting on the floor next to her bed” and stated “she was trying to go to breakfast” but “didn’t realize it was bedtime.” The assessment noted that “safety interventions are already in place” and no new interventions were implemented.

Two days later, the resident fell again and “was sitting on the floor with her back against her roommate’s recliner.” The resident explained she “was walking out of the bathroom without her walker or wheelchair, tripped over the catheter bag.” This fall resulted in “a skin tear 3.7cm (Centimeters) on her right shin and a 5cm by 1.1cm skin tear on her right forearm.” Again, “no new immediate fall interventions were put into place.”

Two days after the second fall, the resident fell a third time. She “was yelling out for help” and found “sitting on her buttocks on the floor.” The resident stated “she was getting up for lunch and fell.” Her “call light was off” and her “wheelchair with her catheter bag was next to” her. This fall caused “a 2cm by 2cm lump and a bruise to her left forehead,” “a 0.5cm by 0.2cm bruise to her left elbow,” and “a 4cm by 4cm skin tear to her left lower extremity.” After this third fall, an intervention was finally implemented: “to keep [the resident] within nurses’ sight.”

However, about two and a half weeks later, the resident fell a fourth time. Three nurses “were at the southwest nurses’ station when they heard a loud yell,” and found the resident “lying on her back on the floor in the middle of the southeast hallway.” The resident indicated “pain to her left hip area with movement.” The resident’s Power of Attorney requested that [the resident] be sent to the emergency room for an evaluation. X-rays revealed an acute minimally displace fracture involving the left femur lesser trochanter with suggestion of extension through the femoral neck. The resident underwent surgery for left hip cephalomedullary nailing.

When interviewed, a Registered Nurse stated that “attempts were made to keep [the resident] within sight while she is up in the chair” but wasn’t sure “why [the resident] was left alone in the hall.” A Certified Nursing Assistant (CNA) reported that the resident “was attempting to get up and down most of the morning” and “was confused, mumbling for a few days prior to her fall.” The CNA explained the staffing challenges: “staff try to sit with [the resident], but it is hard to do when staff are on breaks, and call lights are going off.” The CNA confirmed she “was the only one CNA on the floor at the time of the fall” while the nurses “were at the nurses’ station for report and shift change.”

Another Registered Nurse stated that when the resident “is anxious, attempts are made to keep her at the nurses’ station and within arm’s reach” but verified that the resident “was unable to be redirected.” The Director of Nursing admitted that the resident’s Fall Risk Assessment “is inaccurate” and verified that the resident “was a high risk for falls.” Another CNA confirmed that the resident “was wandering everywhere on the day she fell” and that “during breaks there is only one CNA on the unit to answer call lights and provide care.”

This case highlights the broader issue of chronic understaffing in nursing homes throughout the state of Illinois. When facilities operate with insufficient personnel, residents requiring close supervision—particularly those at high risk for falls—are left vulnerable. As evidenced in this incident, a single CNA was expected to monitor multiple residents while simultaneously responding to call lights and providing essential care. This staffing shortage creates impossible situations where even well-intentioned caregivers cannot implement required safety interventions, leading to preventable injuries that significantly impact residents’ quality of life and create additional healthcare costs.

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.

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.

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.

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.

The Illinois Department of Health has cited and fined Rushville Nursing & Rehab Center when staff failed to use a required gait belt while helping a legally blind resident walk, resulting in a fall that caused multiple severe fractures and required surgery.

The resident in question had a history of muscle weakness and osteoporosis and required substantial assistance with most movements. The resident was also legally blind and was only capable of seeing shadows.

On the day of the incident the resident was being helped to walk when they “went to pivot and tried to sit too soon and fell to the floor.” The fall resulted in multiple severe fractures, including what hospital records described as a “comminuted, displaced distal, femoral shaft/metaphysis fracture.” The injuries were so severe that the resident had to be airlifted to another hospital for specialized treatment.

The hospital surgical report revealed the extent of the injuries, showing the resident required “open reduction, internal fixation, left supracondylar distal femur fracture with intracondylar extension; and intramedullary fixation of a right tibial shaft fracture.” After surgery, facility notes indicated the resident “experienced a decline in her ability to function.”

The Director of Rehabilitation emphasized that the resident required three things for safe walking: one staff member’s assistance, a front-wheeled walker, and a gait belt. They stated firmly that “Everyone should have a gait belt used unless they are independent.” Multiple staff members, including other Certified Nursing Assistants, confirmed these requirements. The resident themselves confirmed they were not wearing a gait belt when the fall occurred.

Facility policy stated, “Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait.”

The facility took decisive action following the incident. The Administrator confirmed that the nursing assistant who failed to use the gait belt “was terminated for not following the facility Gait Belt Policy.”

This case highlights how failing to follow basic safety protocols can result in serious injury to vulnerable residents, particularly those with multiple risk factors such as visual impairment, muscle weakness, and osteoporosis.

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.

The Illinois Department Of Health has cited and fined Elevate Care Waukegan when a resident suffered a significant delay in treatment after experiencing a fall that resulted in a broken hip.

The incident in question began when a nursing supervisor found the resident lying on the floor beside their bed. Although the resident was experiencing pain, showing “facial grimacing and moaning when right leg moved,” the initial response was inadequate.

While the nurse practitioner ordered immediate X-rays due to the resident’s swollen leg, the staff failed to mark the order as urgent (“STAT”), instead entering it as a routine order. This proved to be a critical error. As the Director of Nursing later explained, “the X-ray should have been ordered STAT to ensure the results were received in a timely manner and any injuries could be treated properly and timely.”

The situation worsened overnight. A nursing assistant reported that the resident was “grimacing, wincing, and moaning whenever she had to turn her to provide care,” and it appeared the pain was coming from the right hip. Despite these clear signs of distress, no one checked for the X-ray results, which were actually available that evening and showed “an acute intertrochanteric fracture of the proximal right femur” (a broken hip).

The delay in care was substantial – almost 24 hours passed between the resident’s fall and their transfer to the hospital. The Nurse Practitioner, when later informed about the delay, stated, “If I would have received the results then, the resident would have been sent to the hospital sooner. They didn’t communicate with me.”

Multiple systemic failures contributed to this delay:
– Staff didn’t properly mark the X-ray order as urgent
– No one monitored or followed up on the X-ray results
– Poor communication between shifts
– Failure to properly document the resident’s condition
– Inadequate response to signs of pain and distress

The facility’s own policy required “prompt, appropriate action” for “X-ray or other diagnostic tests reveal suspected findings which may require immediate intervention including but not limited to… new fracture.” Yet in this case, a resident with a broken hip experienced unnecessary pain and delay in treatment due to communication breakdowns and failure to follow proper procedures.

When the resident finally reached the hospital, they were found to be a poor candidate for surgery and had to return to the facility with orders not to put any weight on the injured leg, an outcome that might have been different with prompt medical attention.

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.

The Illinois Department Of Health has cited and fined Allure of Mendota when the facility failed to properly assess, monitor, and communicate about a resident’s fall. This failure led to unnecessary pain and suffering and a two-week delay in treating a broken hip.

The incident in question began when two nursing aides were trying to help the resident transfer from a wheelchair to her bed using a mechanical lift device.

The resident described the frightening incident in her own words: “I don’t know what the problem was, but they were taking too long, and I told them I couldn’t stand anymore… Then my legs just gave out. I was hanging there, by my arms. The sling was pulling under my armpits and shoulder, and I was hanging on to the handles. They tried to sit me on the edge of the bed, but I was slipping. I landed on my butt on the floor.”

After the fall, several critical failures occurred. First, no nurse performed an immediate assessment of the resident’s condition. The nursing aides didn’t even report it as a fall, instead calling it a “rough transfer.” While X-rays were taken two days later, they didn’t show the fracture due to the resident’s body size and positioning, according to an orthopedic surgeon who later explained that more sensitive imaging (MRI) would have been needed.

The resident showed clear signs of injury. She could no longer bear weight on her leg during physical therapy, complained of hip pain, and couldn’t use the mechanical lift anymore. However, these warning signs weren’t properly communicated between staff. As one physical therapy assistant admitted: “I thought since the X-ray didn’t show a fracture that her pain would eventually go away. I was under the assumption that the nurses knew about her right hip pain. That’s my fault.”

A nurse who cared for the resident during this period stated, “If I knew she fell and she was having those problems, I’d assume her hip was broken and call the doctor to send her to the hospital as soon as possible. But no one told me that.”

Finally, two weeks after the fall, the resident was sent to the hospital where an MRI revealed “a greater trochanteric hip fracture.” The resident required surgery to repair the broken hip. The orthopedic surgeon later stated: “It’s very likely that caused her fracture, and the original X-ray missed it. If she was complaining of continued pain and hadn’t returned to baseline physical functioning, they should have sent her to the hospital.”

This case demonstrates how poor communication between staff members and failure to follow proper assessment protocols led to unnecessary suffering and a delay in crucial medical treatment. As the Director of Nursing acknowledged, “The purpose of continued assessments, documentation of findings, and interdisciplinary communication of resident’s change of condition is to ensure the resident is receiving proper care and continuity of care can be maintained.”

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.

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.

The Illinois Department Of Health has cited and fined Manor Court Of Freeport when a staff member attempted to transfer a weakened resident alone using a manual stand aid device, despite the resident lacking the strength to use it safely and facility guidelines requiring two-person assistance. As a result, the resident fell during the transfer and suffered multiple fractures in his arm and elbow, leading to the facility finally changing his care plan to require a full mechanical lift with two staff members – the level of assistance he should have had from the beginning.

The resident in question had been steadily declining in health and required substantial assistance with all movements.

On the day of the incident, at around 5:45 AM, a nursing assistant attempted to transfer the resident from his bed to a wheelchair using a manual stand aid – a device that requires residents to be able to support their own weight and follow directions. According to the nursing assistant’s account, “as the resident was starting to stand up further and she was trying to put the seat flap down behind him, the resident’s legs gave out and he started to fall.”

Several concerning issues emerged about this transfer:
– The aide was working alone, though other staff stated “the resident has not been a one person assist for months”
– No gait belt was used for safety
– Staff had been transferring the resident inconsistently – as his wife noted, “some of the staff would use a gait belt, and some wouldn’t… some staff would just grab the resident by the back of his pants to assist him up”
– Multiple staff members indicated the resident wasn’t strong enough for the manual stand aid and should have been using an electric lift

The manufacturer’s manual specifically warned that to use the stand aid, a resident “must have enough leg and lower body strength to stand up and remain in the standing/sitting position.” For residents lacking this strength, “a sit-to-stand lift such as the electric powered patient lift is preferred and recommended.”

The Director of Nursing later acknowledged the error, stating, “The resident needs to be able to grab onto the bar and bear his own weight to use the stand aid. It was never brought to my attention that they were struggling or were needing assistance with his transfers.” The Nurse Practitioner added that “the resident had been experiencing a steady decline in health and his transfer status should have been reassessed.”

As a result of this improper transfer, the resident suffered multiple serious injuries:
– A comminuted (broken into multiple pieces) fracture of his upper arm
– A fractured elbow
– Significant soft tissue swelling and bruising

After the incident, the facility finally changed the resident’s care plan to require a “full mechanical lift with staff assist of two” – the level of assistance he should have had before the injury occurred.

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.

The Illinois Department Of Health has cited and fined Galena Stauss Nursing Home when a resident suffered a broken neck when staff members dropped her while trying to move her from her bed to a chair.

The resident in question was a cognitively aware person who had partial amputations of both legs and required staff assistance for all transfers.

The incident occurred when two nursing assistants (CNAs) were using a mechanical lift – a device with a sling that cradles the person and lifts them – to move the resident. During the transfer, the resident fell through a gap in the sling, hitting her head, neck, and shoulder on the floor. As one of the CNAs described it: “She fell out the left side of the sling between the head and leg straps.” The other CNA provided more detail, saying “She went through the gap between the head strap and the leg strap, through that hole, over the left arm rest and onto the floor. She hit her head, shoulder, and neck area first.”

What followed was a concerning delay in identifying the severity of the resident’s injury. Though she began complaining of neck pain the very next day, it wasn’t until nine days later that she finally received an X-ray. The scan revealed an “acute nondisplaced fracture of the odontoid process” – in simpler terms, a broken neck.

The resident’s doctor explained his response to the situation: “Cervical fractures present as pain. I was concerned about a fracture, which is why I shot over there right away… My concern with the neck pain was that she had a cervical fracture as a result of her fall, which was the reason I had her sent out.”

When interviewed, the resident was found wearing a neck brace and had visible bruising – “a faint blue/purple color similar to a nearly faded bruise” – on her left temple.

What makes this incident particularly troubling is that it was completely preventable. Multiple staff members confirmed this type of accident shouldn’t happen if proper procedures are followed. As the Director of Nursing stated, “If the CNAs are doing everything correctly, there is no reason that the resident should have fallen out of the sling. The only thing I can think of is that she was not positioned correctly.”

Another nurse who oversees falls prevention was even more direct: “If the [hoist mechanical lift] is used correctly it is our safest way to transfer her. If all the policies and procedures were followed correctly and she was positioned correctly, she should be able to be transferred without falling out of the [hoist mechanical lift]. The fall from the [hoist mechanical lift] caused the cervical fracture.”

In this case, it appears these basic safety requirements were not met, resulting in serious injury to a vulnerable 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.

The Illinois Department Of Health has cited and fined Shelbyville Manor when a resident suffered multiple back and neck fractures due to a fall during a shower transfer. The incident resulted in emergency medical evaluation and treatment at two hospitals.

The resident in question had several pre-existing conditions that made them particularly vulnerable, including spastic paraplegia, abnormal posture, difficulty in walking, and muscle wasting and atrophy.

According to the quarterly assessment the resident was “completely dependent on staff for all activities of daily living and utilizes a wheelchair for locomotion.”

On the day of the incident, at approximately 8:50 AM, facility staff were moving the resident on a shower chair from a shower stall when the accident occurred. A Certified Nurse Aide reported that “when I began pulling the resident’s shower chair forward out of the shower stall, a wheel on the chair got caught on the shower curb and the resident began falling forward.” The CNA attempted to prevent the fall by pushing back on the resident and the shower chair, but both the resident and the CNA ended up falling to the ground.

Immediately after the fall, the resident expressed pain and continued to express pain when staff transferred them from the floor to a chair. The facility incident investigation documented that “the resident complained of neck, chest, abdomen, and knee pain after falling to the ground.”

Despite the evident pain, the resident was not immediately sent to the hospital. Progress notes indicate that the resident “stayed in bed during lunch and only ate ‘about six bites’ due to experiencing chest and abdomen pain.” It was only after this that the resident was sent to the local hospital emergency department for evaluation.

At the hospital, the resident reported experiencing pain “everywhere” and was diagnosed with neck and back fractures, necessitating transfer to a regional trauma center. The trauma center report revealed the full extent of the resident’s injuries: “the resident was diagnosed with six back and neck fractures (thoracic vertebrae #11/#12, lumbar vertebrae #1/#2/#3, and cervical vertebrae #3).” The resident required intravenous morphine for pain management and remained hospitalized for just under a week.

Upon returning to the nursing home facility, the resident was prescribed analgesic pain medication and required “a rigid cervical immobilizer (a type of rigid neck brace used to limit movement after surgery or serious injury) to be worn at all times.” The severity of the resident’s injuries is further evidenced by their increased reliance on pain medication. Prior to the fall, the resident had only taken a single dose of acetaminophen over the period of a month. However, after returning from the hospital, the resident was taking acetaminophen “nearly every day” for pain management.

This incident highlights a critical failure in resident safety protocols, particularly in the safe transfer of highly dependent residents during routine care activities. The case underscores the importance of proper equipment maintenance, staff training in transfer techniques, and immediate medical evaluation following falls, especially for residents with pre-existing mobility issues and neurological conditions.

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.

The Illinois Department Of Health has cited and fined Alden Estates-Courts of Huntley when a resident fell while a staff member was attempting to fix her shoe while she was standing upright. The fall resulted in a fractured hip and the loss of independent mobility.

The resident in question had multiple diagnoses including dementia, Parkinson’s disease, Alzheimer’s, anxiety disorder, and a history of wandering and behavioral disturbances.

Prior to the fall, the resident was able to ambulate with a walker, requiring only verbal cues as reminders. However, the incident dramatically changed her condition. As a RN stated, “Prior to the resident’s fall she was able to ambulate with a walker. The resident only needed verbal cues to remember to use her walker.” After the fall, the resident’s mobility was severely impacted, with the Restorative Nurse noting, “The resident is currently a two persons assist. The resident no longer initiates movement on her own. The resident will not get out of bed independently which is what she did prior to her falling.”

The circumstances of the fall, as described by a CNA, involved a moment of inattention to the resident’s known impulsive behavior: “I provided the resident with a shower on the day the resident fell. I put the resident’s shoes on. The resident became anxious and wanted to get out. The resident stood up as I was trying to finish. The back part of the resident’s shoe was folded over. I tried to get the resident to sit down so I could fix it, she wanted to leave. As I fixed the back of her shoe she stepped away and fell onto the floor.”

This account reveals a failure to properly manage the resident’s known risk factors and behaviors. The resident’s Care Plan clearly indicated she was “At risk for falls” and included instructions to “Encourage appropriate use of walker” and “Provide proper, well-maintained footwear.” The CNA’s actions in attempting to adjust the resident’s shoe while the resident was standing, despite her known impulsivity and fall risk, directly contributed to the incident.

The severity of the consequences is evident in the statement from the resident’s Primary Physician: “after the fall the resident was sent to the hospital. Imaging shows a femur fracture post fall. The resident received surgical intervention to repair the fracture.” This injury not only caused immediate pain and distress but also resulted in a significant decline in the resident’s quality of life and independence.

The facility’s response to the incident, as described by the Director of Nursing (DON), acknowledges the lapse in care: “We have had conversations with the CNA and explained the need to have the resident sit down to adjust shoes.” However, this reactive measure highlights a failure in proactive training and adherence to established care protocols.

The resident’s Power of Attorney aptly summarized the avoidable nature of the incident: “I do not know why they did not have her sit down before messing with her shoe. That contributed to her fall. The resident was able to walk before the fall; she is not able to walk now.”

This case demonstrates a critical failure in providing appropriate Activity of Daily Living (ADL) care to a resident with known dementia-related behaviors. The incident resulted in severe physical harm and a significant decline in the resident’s quality of life, underscoring the importance of strict adherence to care plans and proper training in managing residents with cognitive impairments and fall risks.

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 Lena Living Center when a resident rolled out of bed onto the floor while receiving bed bath care from one staff member instead of the required two staff members. The resident suffered lacerations to her forehead, a chip fracture in her nose, and a fractured hip.

The resident’s medical conditions, as listed in the electronic face sheet, include “intracapsular fracture of right femur, localization-related idiopathic epilepsy and epileptic syndrome with seizures, laceration of head, dementia with agitation, and osteoporosis.” A facility assessment indicated that the resident has “severe cognitive impairment and requires 2+ staff assist for bed mobility.”

The incident in question occurred when a Certified Nursing Assistant (CNA) attempted to provide bed bath care to the resident without the required assistance. According to hospital records, the resident “was getting bed bath done today by staff with bed raised high, patient rolled out of bed resulting in a 3x3cm laceration to forehead, blood from nares, right leg pain with hip flexion.” The injuries were severe, including a “4x4cm linear laceration over the frontal area of the skull,” a “questionable chip fracture of the nasal bone,” and a “displaced sub capital fracture of the right femoral neck.”

In an interview, the CNA responsible admitted to providing care alone despite knowing the resident required two-person assistance: “I was giving the resident cares and washing her buttocks and had her rolled on her side with one of my hands on her hip and cleaning her with the other hand. She had a jerking movement and the momentum flung her forward and she landed on the floor on her stomach.”

The CNA acknowledged, “I know she is supposed to be a 2 person assist for bed mobility but I did it by myself anyway.”

The Director of Nursing and Assistant Director of Nursing confirmed that this was a violation of proper care procedures: “If a resident requires 2 people for bed mobility then it’s obviously not safe to use 1 person because they have been assessed as needing 2 people. This was a bad judgement call for the staff member and we have in-serviced her and the other aides on bed mobility assistance.”

This incident highlights a critical lapse in adhering to established care protocols, resulting in severe consequences for the resident. It underscores the importance of following proper safety procedures and the potential risks when these procedures are not observed.

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 Bella Terra Wheeling when a resident fell onto her hip while sitting on the edge of the bed being changed by a CNA. The fall resulted in a fractured hip and raises concerns about the facility’s adherence to fall prevention protocols.

The resident in question was admitted to the facility with various diagnoses including epilepsy, restlessness, agitation, degenerative nervous system disease, severe cognitive impairment and dependence on staff for most activities of daily living (ADLs).

The incident occurred when a CNA was dressing the resident. According to the CNA’s account, “I sat the resident up on the edge of the bed. I was standing on the side of the resident, slipping her arm into the sleeve of the shirt and that’s when the resident started to lean forward.” Despite the CNA’s attempt to prevent the fall, the resident fell onto her right hip from bed height.

Initially, the fall did not appear to cause injury. A Licensed Practical Nurse (LPN) stated, “It did not appear that the resident had any injury at that time, so me, a CNA, and a Wound Care Technician put the resident back into the bed via mechanical lift.” However, several hours later, the resident showed signs of distress and injury. The Director of Nursing reported, “the resident’s injury was discovered at nighttime, several hours after the fall, that’s when the resident started grimacing, pointing to her right hip, and there was a change in the resident’s right leg appearance, it looked displaced.”

The facility’s investigation revealed that the resident had a urinary tract infection at the time of the fall, which may have contributed to the incident. The Former Fall Coordinator stated, “After getting labs done at the hospital, it was discovered that the resident had a urinary tract infection at the time of the fall. The resident had previous falls and had a urinary tract infection around those times.”

The document raises concerns about the facility’s adherence to fall prevention protocols. The resident’s care plan indicated she was at high risk for falls and required extensive assistance with ADLs. However, the CNA’s decision to sit the resident on the edge of the bed for dressing appears to contradict her assessed needs. An Agency CNA commented on this practice, stating, “I would sit them up in the bed while putting on their shirt, not on the edge of the bed. Some CNAs find it more convenient to sit residents on the edge of the bed, but it is too risky.”

This incident highlights potential gaps in staff training, adherence to care plans, and fall prevention strategies at the facility. It underscores the importance of consistent implementation of safety measures for high-risk residents and the need for ongoing staff education on proper care techniques.

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 Bloomington Rehab & HCC when two serious incidents occurred involving residents falling and sustaining injuries due to inadequate supervision and safety measures. One resident passed away shortly after the fall and the other sustained a broken left foot.

The resident in question had a history of falls and was on anticoagulant therapy.

This first incident involved two separate falls. The initial fall occurred in the bathroom where the resident suffered a subdural hematoma. Despite recommendations from the resident’s physical therapist that the resident “should always have supervision while in bathroom,” the resident was left unsupervised again a few days later, resulting in another fall and a new subdural hematoma.

A nurse aide admitted to leaving the resident alone in the bathroom, stating, “the resident asked for a new gown, so I gave the resident the call light and left the bathroom to get the resident a new gown, and when I came back a nurse said the resident was on the floor.” This incident led to the resident being admitted to hospice care and ultimately passing away approximately five weeks later.

The facility failed to properly update the resident’s care plan with new interventions after the first fall and did not effectively communicate the need for supervision to all staff. The Director of Nursing even admitted that there were issues with staff education and documentation concerning the resident’s care and treatment.

The second incident involves a resident who was allowed to leave the facility unsupervised despite a history of alcohol use and mobility issues.

On the day of this incident the resident fell while walking on a busy road with a faulty walker. A witness reported, “I saw a man with a slate blue wheeled walker going down the road in the left lane of traffic. The walker looked wobbly, like maybe it was broken. I saw the resident stumble and fall.”

The resident admitted to drinking alcohol before the incident, stating, “We drank some alcohol. I was walking to the bus stop. The bus hadn’t come, so I started to walk back to (the facility). It was hot and I fell in the road.” Two days later the resident was diagnosed with a “Nondisplaced Fracture of First Metatarsal Bone Left Foot.”

In this case the facility failed to properly assess the resident’s safety for unsupervised outings and did not maintain the resident’s walker in safe condition. The resident stated, “My walker is broke. I have told the staff, but I still have to use it.”

Both of these incidents highlight significant failures in resident care, including inadequate supervision, poor communication among staff, failure to update and implement care plans, and lack of proper safety assessments. The facility’s responses to these incidents were deemed insufficient, resulting in an Immediate Jeopardy citation by IDPH.

When a resident fails to get the care which is required, it raises a fair question as to whether this was an understaffed nursing home. Residents failing to get needed care is a hallmark of an understaffed and is also a hallmark of the nursing home business model.

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 Illini Restorative Care when a resident suffered a fracture of her left leg when she slid out of her wheelchair. This was directly due to improper positioning and handling of the resident in her wheelchair by the staff.

The resident in question, who suffered from severe cognitive impairment and multiple health issues including dementia, was dependent on staff for most activities of daily living.

On the day of the incident a Certified Nursing Assistant (CNA) reported having to lower the resident to the floor because she was sliding out of her wheelchair. The CNA stated, “She was sliding out and I was unable to get her back in wheelchair, so I lowered the resident to the floor.”

Over the next few days, the resident experienced significant pain, requiring multiple doses of morphine. Despite her obvious discomfort, an x-ray was initially delayed due to family concerns about the resident’s ability to tolerate the x-ray procedure.

When finally performed, the x-ray revealed a “Medial tibial plateau fracture.”

The nursing home failed this resident in several areas.

First, there was improper positioning of the resident in her wheelchair. The CNA admitted that the resident was “sitting close to the edge of her seat” when the incident occurred. Another CNA stated, “We don’t position a resident at the edge of the chair, especially a resident that uses a mechanical lift. They would be at risk for falling out.”

Second, the initial nurse’s assessment after the incident was inadequate, as it did not include a range of motion examination, which might have identified the injury earlier. This contributed to a delayed diagnosis, as several days passed before an x-ray was performed to diagnose the fracture, despite the resident’s persistent pain and need for strong pain medication.

Third, the incident revealed insufficient training or policy adherence among staff. The facility’s Safe Lifting Procedure policy did not specifically address proper body mechanics in a chair prior to transferring a resident. Additionally, the Positioning the Resident policy did not show how a resident was to be safely positioned in a wheelchair.

Lastly, there were inconsistencies in the reporting of the incident and the subsequent care provided, suggesting a lack of clear communication protocols.

This incident highlights significant failures in resident care, safety protocols, and staff training at the nursing home, resulting in serious harm to a vulnerable resident. It underscores the critical importance of proper positioning, prompt and thorough assessments, clear communication, and adherence to comprehensive safety policies in nursing home settings.

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 Pleasant View Lutheran when a resident, who should have been wearing a gait belt, suffered a fall that resulted in a fractured femur. The fracture ultimately contributed to the resident’s decline and death a short period after the fall.

Use of a gait belt is a fundamental fall prevention strategy. A gait belt is a sturdy canvas strap that is applied to the midsection of a resident who is at risk for falls and may require the physical assistance of staff with walking, standing, and transfers. The gait belt allows the staff member assisting the resident to help steady the resident in the event that there is a loss of balance or to break a fall or control the descent if there is in fact a fall. Without the use of a gait belt, the staff would have to rely on grabbing onto the clothing or to the resident to try to prevent a fall. Either places both staff and residents at risk for injury.

The resident in question was diagnosed with Alzheimer’s Disease, General Anxiety Disorder, Chronic Kidney Disease and Muscle Weakness (generalized).

The facility’s Gail Belt / Transfers Policy required that resident’s requiring assistance for ambulation, such as the resident in question, were also required to use a gait belt during assisted ambulation.

On the day of the incident the resident fell while being assisted by a Certified Nursing Assistant (CNA). The incident report states, “Resident was ambulating with CNA and wheeled walker when she tripped over her feet.”

Hospital records confirmed a left hip fracture.

Interviews with staff revealed concerning details about the incident. A Registered Nurse (RN) reported hearing about the fall and assessing the resident afterward. The RN stated, “I saw that the resident did not have a gait belt on. The resident was a one assist with stand-by so the CNA probably should have had one (gait belt) on her.” The RN also mentioned that the resident claimed the CNA was on her phone during the incident.

The CNA involved admitted to not using a gait belt, saying, “I did not have a gait belt on her at that time. I should have, but for the most part she was independent, and she was coming out the door and I didn’t grab it quick enough, and we just kept going.” When asked what could have been done differently, the CNA acknowledged, “Obviously used a gait belt.”

Following the fall and subsequent surgery, the resident’s condition deteriorated rapidly. Progress notes indicate increased confusion and lethargy. The resident was admitted to Hospice and passed away shortly thereafter. The death certificate listed “Aspiration Pneumonia due to Congestive Hypertensive Cardiovascular Disease” as the primary cause of death, with “Fracture of the Femur due to a fall” listed as a significant contributing condition.

The resident’s physician confirmed the impact of the fall on the resident’s decline, stating, “No question about it that (the resident’s) fall with fracture exacerbated her decline and subsequent death. She was so frail.” The Physician also noted the high mortality risk associated with long bone fractures in elderly patients.

This case highlights a significant failure in resident safety protocols, particularly in the proper use of gait belts during assisted ambulation, which directly contributed to a resident’s 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 Dobson Plaza when the facility failed to provide proper feeding supervision and assistance as required by the resident’s care plan, resulting in the resident suffering a fall and leg fracture during what should have been a routine breakfast service.

The resident in question had a history of mild cognitive impairment, repeated falls, and dementia.

The resident’s care plan clearly indicated that she required “substantial assistance with eating” and was “totally dependent on staff for bed mobility, transfers, lower body activities, personal hygiene, and toileting activities.” Despite these documented needs, the resident was left unsupervised during breakfast on the day of the incident.

A Certified Nursing Assistant had served the resident breakfast in her bed and then left to prepare for the resident’s shower. The CNA recounted the moment she discovered the resident after the fall: “I was returning to the resident’s room with a shower chair and towels to transfer her to the shower and when I entered the room, I saw the resident sitting on the floor close to her bed with her back leaned on the bed.” This scene was particularly shocking to the CNA, who noted that the resident had two raised bedrails and a bedside table with her breakfast on it when she had last seen her.

The fall resulted in the resident sustaining a fracture to her right shin bone, a serious injury for a woman of her age and condition. What makes this incident even more troubling is that it occurred despite active orders for “bed/chair alarm at all times and fall precautions” for the resident.

Further investigation revealed a series of lapses in care and communication that contributed to this incident. The CNA admitted, “No one had ever told her that the resident had a history of falls” and that she “doesn’t know if the resident was considered a fall risk at the time.” This lack of crucial information left the CNA ill-equipped to provide appropriate care for the resident. Moreover, the CNA stated she “had not been educated or informed of any specific fall prevention interventions for the resident.”

The physical environment of the resident’s room also lacked proper safety measures. The CNA noted, “the resident did not have any floor mats and her bed was at normal height and not lowered all the way to the floor.” These omissions directly contradicted the facility’s Fall Precaution/Safety Intervention Policy, which states, “Safety intervention tools may be implemented to provide safety to the residents and to prevent falls,” including interventions such as a low bed.

This incident underscores the critical importance of following care plans, ensuring proper staff education and communication, and implementing appropriate fall prevention measures for at-risk residents in care facilities. The facility’s Comprehensive Care Plan Policy emphasizes that care plans should “aid in preventing or reducing declines in the resident’s functional status and/or functional levels as is possible.” However, in the resident’s case, this policy was not effectively put into practice.

The failure to adhere to these practices resulted in a serious injury to a vulnerable resident, raising significant concerns about the overall quality of care provided at the facility. This unfortunate event serves as a stark reminder of the potentially severe consequences when established care protocols are not followed and when there is a breakdown in communication among staff regarding resident needs and risks.

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 Alden Lakeland Rehabilitation & Health Care Center when the facility failed to promptly recognize the severity of a resident’s head injury, neglected to follow their own head injury protocol by not calling 911 immediately, inadequately assessed and communicated the resident’s deteriorating condition, and significantly delayed critical medical intervention. These failures ultimately lead to the resident’s death from complications of a subdural hemorrhage resulting from the fall.

The resident in question, with multiple health conditions including dementia, hemiplegia, and heart failure, fell face-forward from her bed at around 5:30pm. A Certified Nursing Assistant (CNA) witnessed the fall, providing a vivid description: “I was bringing the resident her dinner tray and as I stepped one foot into the room I observed the resident sitting at foot of the bed, at the top of the fold (foot of bed was elevated), as the resident was literally falling forward from the bed onto the floor. The resident was wearing her glasses and hit her face on the floor with a very hard with a loud thud and her glasses remained in place but were broken (right arm flew off).” The CNA emphasized the severity of the impact, calling it “the loudest thud I had ever heard from a fall.”

The fall resulted in a 2cm hematoma and a 1cm abrasion above the resident’s right eye. Despite the obvious severity of the impact, the facility’s response was alarmingly inadequate, revealing multiple critical failures.

Firstly, the facility failed to follow its own Head Injuries policy, which clearly states, “Call paramedics (911) and transfer to hospital if indicated.” Instead of calling 911 immediately, staff called a non-emergency ambulance service with an estimated arrival time of 60 minutes. This decision led to a significant delay in the resident receiving urgent medical attention.

The staff’s assessment of the resident’s condition was also inadequate. They noted elevated blood pressure readings (167/109 and later 181/102) but did not consider these a significant change from the resident’s baseline. The Assistant Director of Nursing (ADN) later admitted, “a blood pressure of 170/100 would warrant a call to 911” and that the elevated readings were “considered a change in condition.” This failure to recognize the severity of the resident’s condition further delayed appropriate intervention.

More than three hours elapsed between the fall and the arrival of paramedics. When they arrived at 8:54 PM, they found the resident in a much worse condition than reported. The lead paramedic stated, “facility staff did not know how critical the resident was when we arrived.” The resident’s blood pressure had risen to 226/110, she was unresponsive, and had a “big hematoma (size of baseball) that was very prominent on the resident’s head.”

The paramedic suspected the facility of trying to conceal the severity of the situation, stating, “I started to question what was really going on and felt that the medications were given to cover the facility.” This suggestion of a potential cover-up adds another layer of concern to the facility’s handling of the incident.

Communication breakdowns were also evident. The paramedic noted that they “were not made aware of anything (about the resident’s status)” upon arrival, indicating a serious failure in relaying critical patient information. Furthermore, despite the paramedic’s recommendation to transfer the resident to a trauma center due to her symptoms, facility staff insisted on transport to a local hospital. The resident was later transferred to the trauma center the paramedic had initially suggested, resulting in further delays in receiving specialized care.

The facility staff’s insistence that the resident was “awake about 15 minutes prior” and able to take medication contradicted the severe symptoms observed by the paramedics, suggesting a critical failure to recognize and respond to a rapidly deteriorating condition.

These compounded failures resulted in critical delays in the resident receiving appropriate medical care. Tragically, the resident died, with the death certificate listing the cause as “complications from subdural hemorrhage and fall.”

This incident exposed systemic failures in the facility’s fall prevention, assessment, and emergency response protocols. It highlighted critical gaps in staff training, decision-making processes, and adherence to established policies, ultimately leading to a preventable tragedy and underscoring the vital importance of prompt, appropriate responses to falls in vulnerable elderly residents. The facility’s multiple shortcomings in this case – from the initial response to the fall, through the assessment and decision-making process, to the communication with emergency services – paint a picture of a system ill-equipped to handle critical incidents, putting residents at severe risk.

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 Pleasant Meadows Senior Living when the facility delayed sending a resident to the ER for nearly five hours after a serious fall where the resident hit her head.

The resident in question, who suffered from multiple medical conditions including dementia and a history of falls, experienced a severe fall at around 6:00 AM in the morning. While being assisted to the bathroom by a Certified Nurse Aide (CNA), the resident suddenly “stopped responding to the CNA and fell backwards.” The fall was witnessed, and staff noted that the resident appeared to be in a “postictal like state” and had hit her head. A postictal state is a temporary brain condition that occurs after a seizure and is characterized by an altered state of consciousness.

Instead of immediately sending the resident to the emergency room for evaluation, the facility staff, led by the Director of Nurses (DON), decided to use telehealth services. The DON stated, “I gave the resident a pain pill which she took orally. The resident seemed very drowsy but was able to answer some basic questions. The telehealth doctor was able to see the resident laying in bed with her eyes closed and gave orders to keep monitoring her and return the call if the resident’s mentation (mental activity) changes.”

This decision to use telehealth instead of emergency services proved to be a critical error. Throughout the morning, the resident’s condition deteriorated. Staff members reported that the resident was vomiting, gagging, and showing signs of altered mental status. Despite these concerning symptoms, the resident was not sent to the emergency room until 10:44 AM, nearly five hours after the fall.

An Administrator at the facility later acknowledged that telehealth was not appropriate for this situation, stating, “telehealth is a service that is available to our nursing staff for after hours Physician notification but it is not meant for emergency situations as what happened with this resident.”

The Medical Director emphasized that in cases like this, where there’s a witnessed fall and the resident hits their head hard, they should be “automatically sent to the emergency room.” The Medical Director added, “you don’t need a Physician order to send one of the residents to the emergency room for evaluation. That is left to the nurse’s critical thinking skills.”

The delay in sending the resident to the hospital had severe consequences. When the resident finally arrived at the hospital, she was diagnosed with an “Acute Sub Arachnoid Hematoma” and a “Nondepressed Left Occipital Bone Fracture.” The hospital report grimly stated, “This is a significant brain injury and is not survivable in her condition.”

This incident highlights a critical failure in the facility’s emergency response procedures. The inappropriate use of telehealth services in place of immediate emergency room transfer likely contributed to a delay in the resident receiving the urgent medical care she needed, potentially worsening her already critical condition.

Importantly, a Registered Nurse who had assessed the resident approximately an hour after her fall, stated “I should have sent the resident to the emergency room as soon as I saw her but didn’t because I was too busy.” The RN waited approximately 3 hours until a Licensed Practical Nurse (LPN) came on duty. Once the LPN came on duty the RN asked her to send the resident to the ER.

In this case, an understaffed facility and overworked staff contributed to the delay in care for this resident, with tragic 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.

IDPH has cited and fined The Arc at Streator when the facility failed to ensure that a resident was assisted to the bathroom in a safe manner, resulting in the resident’s legs giving out and requiring her to be lowered to the floor by staff. This incident led to a right closed displaced spiral distal femoral shaft fracture.

According to the Incident Report an Aide reported that “while walking resident to the restroom- she stated legs/knees were giving out- aide stated she lowered resident to the floor.” The report also noted that the resident denied any new injury or pain but complained of pain to the right shoulder and hip, which she had frequently experienced before.

The resident’s Progress Notes documented her complaints of extreme pain in the right leg, inability to sit up in bed with assistance, and some swelling noted in the right femur. X-rays were ordered, and the resident requested to go to the hospital due to extreme pain without relief. She was transported to the hospital by ambulance.

A Certified Nursing Assistant who was assisting the resident at the time of the incident stated, “As we were walking from the bed to the bathroom, she said her legs felt weak and I told her ‘a couple more steps’ and then she started to go down. I went down first, and my leg hit the floor before she did. I lowered her to the floor.” The CNA also mentioned that when they tried to move the resident to get her up, she complained of pain in her right leg and was unable to roll over to her other side.

The resident’s Orthopedic Consultation confirmed the diagnosis of a “Right closed displaced spiral distal femoral shaft fracture.” The Director of Nursing from the facility called the orthopedic clinic, claiming that the mechanism of the fall could not have resulted in the type of injury that the resident had. However, the orthopedic physician stated that the spiral fracture was from trauma and not pathological in nature, and that the resident’s injury could have been due to a twist-and-fall, leading to the spiral fracture pattern.

The Director of Therapy provided insight into the resident’s condition before the fall, stating that she required a sit-to-stand transfer and was not consistent enough for the therapy team to release her to nursing for ambulation. The Director of Therapy also mentioned that the resident was a “self-limiting individual” who would decide to sit down in the middle of a walk, expecting staff to be there with a chair or to catch her.

After the incident, the facility created a care plan that stated they will place a sign in the resident’s room reminding staff that the resident is a stand/pivot transfer only with no ambulation.

The facility’s failure to ensure that the resident was assisted to the bathroom in a safe manner would be a reasonable basis for a nursing home abuse and neglect lawsuit. The whole point of placing a loved one in a facility such as this is to avoid preventable nursing home falls like this one.

The real question to this though is why did the facility not recognize that the resident was not fit for ambulation prior to the injury? The answer will likely take some form of feeling rushed and with too much work to do and too little time to get it done. This is of course a consequence of understaffing of the nursing home which is a part of the nursing home business model.

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 Forest View Rehab & Nursing Center when the facility failed to use the proper equipment to transfer a resident with a history of fractures, resulting in a left femur fracture that required surgical repair.

The resident in question had diagnoses including diabetes, obesity, anxiety, major depressive disorder, weakness, and Parkinson’s disease. She also had previous documented fractures of the ankle and foot.

In an interview with the resident she stated that she broke her leg while staff were transferring her to bed using a gait belt, instead of the sit-to-stand lift as they were supposed to. Nursing progress notes confirm that the resident was transferred to the hospital emergency department for evaluation and treatment of a left acute femoral neck fracture.

A Licensed Practical Nurse (LPN) recalled the incident, stating that a Certified Nursing Assistant (CNA) asked for assistance in transferring the resident back to bed. They used a gait belt for the transfer, and a few hours later, the resident complained of left hip pain. The LPN admitted, “I did not know the resident was supposed to use the sit-to-stand for transfers until after the occurrence.”

The resident’s physical therapy discharge summary had documented the need for safe transfer techniques using sit-to-stand lift transfers and safety precautions to preserve her current level of function.

The Assistant Director of Nursing (ADON) acknowledged the issue, stating, “If staff are supposed to use the sit-to-stand to transfer it is a problem not using the correct transfer mode. If the pivot is too intense it could contribute to the break. Staff should be following the proper transfer to assure residents are not injured.”

In this case the facility Failed to use the proper sit-to-stand lift equipment, as assessed and documented in the resident’s care plan, which led to a severe left femur fracture requiring surgical repair, highlighting the importance of adhering to individualized transfer protocols to ensure resident safety.

This causes undue suffering for an elderly woman in declining health.

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 St. Paul’s Senior Community when a staff member transferred a resident by herself in violation of the care plan that called for a sit to stand transfer with the assistance of 2 staff members. The failure resulted in the resident sustaining bilateral femur (thigh) fractures which ultimately contributed to her death three days later.

A sit-to-stand lift is a type of lift commonly used in nursing homes. This type of lift should be used only with residents who have some ability to bear weight and who are cognitively intact enough to follow instructions from staff. As with Hoyer lifts, this lift requires the assistance of two staff members to use it safely – one to operate the controls of the lift, the other to assure the safety of the resident.

The resident in question had a care plan that documented “TRANSFER: sit to stand using 2 assist.” However a Certified Nurse’s Aide (CNA) stated that she had been transferring the resident by herself for a while, despite the resident normally requiring a 2-person assist. The CNA admitted that she “lifted her (the resident) with a gait belt and put her own leg between the resident’s legs.” She stated that she (the CNA) “stumbled and the resident fell on top of her.”

A Licensed Practical Nurse (LPN) heard yelling and found the resident with one knee on the floor and the CNA holding the resident up against the dresser. The LPN assessed the resident and noticed a bulging area on her right thigh. Instead of waiting for a mobile x-ray, the LPN called an ambulance to transport the resident to the hospital for a quicker x-ray and additional pain management.

Importantly, the LPN stated that she did not see a gait belt or a sit to stand in the room. She further stated that the CNA never asked her or the other CNA on the unit for help to transfer the resident.

The hospital’s radiology report documented “Acute significantly displaced and comminuted fracture of the mid left femur. Acute significant fracture of the mid right femur.” The resident passed away a few days after the incident.

The Medical Director said that “in his professional opinion the bilateral femur fractures contributed to R2’s death.”

The ER Physician stated that the resident had very severe osteopenia and never would have survived surgery. He further stated that he is unsure if the fractures contributed to her death, but it did not help.

In Summary, the facility failed to ensure the resident’s safe handling during a transfer, ultimately leading to the resident’s significant injury and contributing to the resident’s death a few days later.

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 Macomb Post Acute Care Center after a resident there died from complications of a fall.

The resident in question fell when trying to stand from her recliner and reaching for her walker. The resident fell forward, hitting her head on the nearby bedside table. She sustained two lacerations to her scalp requiring sutures – one 7 cm laceration and one 3 cm vertical laceration between her eyebrows. She also suffered a Grade 3 odontoid fracture which required cervical fusion surgery of C1-C2. She complained of neck pain and pain in her right hip where she had previous surgery.

The resident was transported to the local hospital emergency department then airlifted to a trauma center for subsequent surgery. Unfortunately, the resident’s condition deteriorated and she was moved to the ICU. The resident then passed away, approximately 11 days after the fall. Her death certificate lists pneumonia, the odontoid fracture, and ground level fall as causes of death.

The facility failed this resident in several critical ways. First, the resident’s care plan was woefully deficient. It only included two areas of concern – code status and activity preferences. For a resident deemed high fall risk taking medications that increase falls, having recent surgery, and requiring assistance to transfer, much more should have been documented. Her care plan lacked any details about:

– Fall risk level

– Required supervision or assistive devices for transfers

– Current medications and associated fall risks

– Details of recent physical therapy for her femur fracture

– Cognition status

– ADL assistance needs

Additionally, the facility did not establish appropriate fall interventions for the resident despite her high fall risk. Her unaddressed anxiety on the morning of the fall may have contributed to the incident.

While assistive devices were provided, the level of supervision the resident needed was unclear in her record. Progress notes document her functional ability in conflicting ways. Appropriate supervision and assistance were likely not in place when she attempted to transfer and subsequently fell.

Finally, the resident’s recent hip surgery and spouse’s death two days prior were red flags that should have heightened vigilance. However, the facility still failed to prevent this disastrous fall. Insufficient staffing and procedures likely played a role.

In summary, the facility severely failed the resident by not comprehensively assessing and planning for her fall risk, supervision needs, and emotional/psychological factors. This resulted in an injurious fall with ultimately fatal consequences. More thorough assessment, care planning, supervision, and fall prevention could have protected the resident’s well-being.

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.  Order our FREE report, Built to Fail, to learn more about why.  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 Marigold Rehabilitation & Health Care Center after a resident there fell and suffered a laceration and subdural hematoma due to the failure of an certified nursing assistant (CNA) to properly use a gait belt in transferring a resident from her wheelchair to bed.

The resident in question fell while being transferred to bed by a certified nursing assistant (CNA).  The resident suffered a laceration and subdural hematoma requiring hospitalization. The resident stated that when she tried to stand, her “legs gave out” and she fell, hitting her head on the bedside table. The resident reported that the CNA did not use a gait belt during the transfer, saying “The CNA did not use a gait belt on me. I probably would be ok if she did.” 

The Director of Nurses acknowledged that use of gait belts is an expectation for staff assisting transfers and ambulation.

A Licensed Practical Nurse (LPN) responded after the CNA called for help, finding the resident lying on the floor with a pool of blood under her head. The LPN stated she “did not see a gait belt on the resident.” The CNA admitted to removing the gait belt after the resident’s fall, acknowledging it was only partly applied under one hand at the time of transfer. 

The failure to properly use the gait belt under these circumstances was a violation of the nursing home’s own policies and would be a reasonable basis for a nursing home abuse and neglect lawsuit.  The whole point of the policy is to avoid preventable nursing home falls like this one.  

The real question to this though is why did the aide fail to properly use the gait belt even when the facilities policy was to use one?  The answer will likely take some form of feeling rushed and with too much work to do and too little time to get it done.  This is of course a consequence of understaffing of the nursing home which is a part of the nursing home business model. 

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.  Order our FREE report, Built to Fail, to learn more about why.  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 Sandwich Rehabilitation & Health Care Center after a resident was initially dropped from a mechanical lift and then the facility neglected to ensure the resident was assessed and provided pain management in a timely manner.

The resident in question was being transferred from a shower chair to her bed using a mechanical lift operated by two CNAs. The lift tipped over during the transfer, dropping the resident to the floor and resulting in a right hip fracture.

It was determined that factors contributing to the fall included the lift legs not being fully extended, the wet floor, and the resident’s wheelchair leg pedals obstructing maneuvering of the lift. 

The resident complained of pain but initial nursing assessments, pain assessments, and pain management were neglected for approximately 20 hours until the resident was sent to the emergency department the next evening. The Director of Nursing stated “the resident suffered in pain until medication was administered nearly a full day later.”  

The resident’s son and power of attorney stated the facility has still not clearly explained to him what happened. He said “It is incompetence at all levels. I continue to worry that she is in constant pain, and they can’t get her back to where she was before they dropped her.” This was the second time the resident sustained a fracture during a transfer at the facility. The resident’s son stated his mother was terrified she would be dropped again.

The Regional Clinical Director confirmed neglect occurred due to failure to notify the physician and family immediately, failure to provide adequate assessments and pain management, and failure to send the resident to the emergency department sooner. The Director stated, “the resident should have been sent to the hospital and had her pain treated. Everyone knew there was a fall, that she had pain and her scheduled Tylenol would not be effective.”

To make matters worse, the state investigation highlights that the CNAs operating the mechanical lift had not received adequate training. 

Specifically, the Regional Clinical Director stated she did not have any competencies on file showing that CNAs had received mechanical lift training even though competencies should be completed at time of hire and annually per the facility’s policy. 

One CNA did not have any competencies on file while the other CNAs last competency for using the mechanical lift was dated July 25, 2007, indicating she had not received annual training over her more than 20 years working as a CNA. 

One CNA confirmed during her interview that she has not received yearly mechanical lift training. 

This lack of consistent, comprehensive training for both CNAs and likely other CNAs on proper techniques for operating mechanical lifts appears to be a systemic problem at the facility. 

Properly training staff on use of equipment is fundamental to ensuring safe transfers and preventing injuries.  The lack of training was very likely a preventable contributing factor that led to the lift tipping over and the resident sustaining a serious hip fracture requiring hospitalization. 

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.  Order our FREE report, Built to Fail, to learn more about why.  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.