The Illinois Department of Health has cited and fined Villa Health Care East when staff left a resident with severe dementia and high fall risk alone on the toilet despite her inability to safely transfer herself or use a call light. The resident attempted to return to bed without assistance, fell, and suffered a left hip fracture that was not properly identified for two days.

The resident in question had been recently admitted to the facility with diagnoses including dementia, Lewy Body Dementia, and high risk for injury related to falls. Her facility assessment documented that she was a high fall risk with severely impaired cognition, occasionally incontinent of urine, and required substantial to maximum assistance with toilet transfers.

The resident’s care plan specifically noted, “Anticipate and meet the resident’s needs” and “Be sure my call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.”

According to the facility’s fall investigation, a Certified Nursing Assistant (CNA) summoned a nurse after finding the resident “lying on (Right) side in front of toilet.” When asked what happened, the resident stated, “I tried to get up.” The facility documented the root cause as: “Resident new to facility and attempted to walk back to her bed from her toilet without calling for assistance.”

Two days after the fall, hospital records show the resident was diagnosed with a “mildly displaced intertrochanteric fracture with resultant varus angulation” of the left hip. The hospital history noted that the day after her fall, the resident “worked with physical therapy she was able to [do a] few steps she was hunched over but still was able to do some therapy” before her condition worsened the next morning when “she was having difficulty with legs.”

Staff interviews revealed significant inconsistencies in care practices. A Licensed Practical Nurse (LPN) from the day shift stated, “we did not leave her on the toilet alone because they all knew she was a high fall risk.” This nurse also mentioned there was a white board in the resident’s room noting her high fall risk status.

The nurse who assessed the resident after her fall stated she found the resident “lying on her right side on the floor” with “a scrape above her right eyebrow.” The nurse performed range of motion tests of her arms and legs and found “no issues.” Notably, this nurse admitted she “did not know why [the CNA] put her on the toilet and then left the room, maybe to help another resident.” The nurse also stated she did not think the resident “knew how to use the call light or what it was for because of her dementia.”

Another CNA who cared for the resident the day after the fall observed that the resident “was having pain in both of her hips and in her back” and had “facial grimacing when she transferred.” This CNA emphasized that she “would not leave [the resident] unattended on the toilet nor would she never depended on [the resident] using her call light when she needed to get off of the toilet and that she would stay with her until she was finished.”

The nurse who ultimately identified the hip fracture described finding the resident’s “left leg was rotated outward and shortened,” classic signs of a hip fracture. This nurse immediately called the doctor and the resident was sent to the emergency room. The nurse stated the resident “should have never been left alone on the toilet” and that “with [the resident’s] dementia she would not know when or how to use the call light.”

A Licensed Physical Therapy Assistant who worked with the resident the day after her fall confirmed the resident “could not safely transfer herself on or off of the toilet” and while she “could hold a call light,” the therapist “did not think she would understand how to use it.” The therapist stated that “from a safety standpoint someone should have stayed in the bathroom with her.”

The Director of Nursing, when asked if the resident should have been left unattended on the toilet given her high fall risk, simply answered “no.” When asked how staff, including agency staff, would know who is at high risk for falls and what interventions are needed, the Director stated “agency should check the residents care plan and also when they get report from the previous shift, they should be let known.”

The facility’s Fall Assessment and Management Policy states, “It is the policy of this facility to assess each resident’s fall risk on admission, quarterly and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned.”

Despite the clear policy, the resident’s documented high fall risk, and her severe cognitive impairment, staff failed to provide the supervision necessary to prevent this serious injury.

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 Nature Trail Health & Rehab when staff failed to properly implement fall prevention interventions for a high-risk resident with dementia, resulting in two falls within six days of admission that caused a hip fracture requiring surgery, after which the resident never returned to the facility and died while in hospice care.

The resident in question was admitted to the facility with several serious health conditions, including unspecified dementia, weakness, and atrial fibrillation. With moderately impaired cognition, he was immediately identified as a “high fall risk.” The facility developed a care plan with interventions including bed and chair alarms from admission day, and later added precautions such as “assist to toilet prior to laying down” and “mat at bedside when in bed” after his first fall.

Despite these documented precautions, the resident experienced two falls within just six days of being admitted to the facility. The first fall occurred while he was eating dinner in his room. A Certified Nursing Assistant reported hearing “a loud noise and ran to his room and found him on the floor.” The resident’s roommate stated he witnessed the resident hit his head when he fell. The CNA observed that “there was no fall mat observed in the room and the resident did not have an alarm sounding,” even though bed and chair alarms had been ordered for him.

Following this first fall, the resident was sent to the emergency room for evaluation, particularly because he was on blood thinners, which increased his risk of internal bleeding from any trauma. The root cause of the fall was identified as the resident attempting “to stand up out of bed unassisted and fell, hitting his head.”

Just two days later, the resident experienced a second fall. A nursing note documented that he “slid out of his bed onto his bedroom floor” at 6:30 in the morning. Initially, the resident didn’t report any pain after this fall and was moved to his wheelchair with the assistance of two staff members. However, by 11:00 AM, he began “complaining of pain to left hip.” Later that same day, he also reported shoulder pain. The facility physician ordered X-rays of both areas.

The X-ray results, received in the early morning hours of the following day, revealed a left intertrochanteric fracture—a serious break near the top of the femur (thigh bone). The resident was transferred to the hospital, where a CT scan ruled out head and spine injuries, but an orthopedic surgeon confirmed the hip fracture and recommended surgical repair. A “Brief Operative Note” documents that the resident underwent an “Open Reduction Internal Fixation of the left hip” (surgical procedure to repair the broken bone using metal hardware).

Tragically, the facility administrator later stated that after the second fall and subsequent hospitalization, the resident “never returned to the facility as planned due to going on hospice and expiring at the hospital.” This suggests the resident’s condition deteriorated significantly after the hip fracture, ultimately leading to his death.

When investigators interviewed the resident’s roommate, who was alert and oriented, he stated “the alarm did not sound for either of the falls.” He remembered seeing the resident getting up and being “all wobbly” but was unable to help because he himself couldn’t walk.

The Director of Nursing explained that Certified Nursing Assistants are supposed to “check placement and function at the start of each shift of resident’s bed/chair alarms.” She stated she was “unsure why the alarm did not sound after each of the falls” and confirmed the alarm “should have been placed both in the chair and in the bed.” Multiple CNAs confirmed they were responsible for checking “placement and function every shift for alarms.”

The circumstances of both falls suggest serious lapses in the implementation of the resident’s care plan. Despite being identified as a high fall risk with orders for alarms, the alarms either weren’t properly installed or weren’t functioning during critical moments. The resident was able to attempt transfers independently despite his cognitive impairment and physical weakness, without the alarm system alerting staff in time to intervene.

These failures ultimately contributed to life-changing injuries for the resident, who sustained a serious hip fracture requiring surgery, and never returned to the facility before his 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.

The Illinois Department of Health has cited and fined Bethany Rehab & Health Care Center when a staff member failed to properly assist a resident during a transfer from wheelchair to bed, resulting in a fall that caused multiple fractures to the resident’s knee and changed her mobility status.

The resident in question had been admitted just days earlier, a woman with a history of falls and notable weakness, particularly in her legs. Despite these challenges, she maintained her cognitive sharpness—alert, aware, and able to advocate for herself.

On the night of the incident, the resident had stayed up later than usual. “I should not have stayed up so late,” she would later recall. As the hour grew late, she needed to get into bed. According to the resident’s assessment, she required maximum assistance for mobility and transfers due to the weakness in her knees. Her care plan specifically indicated she needed significant help to move from sitting to standing positions.

A young Certified Nursing Assistant (CNA) entered the room to help with the bedtime routine. What happened next would become a matter of conflicting accounts.

The resident’s story was clear and unwavering: “While transferring myself into bed, my knees gave out and I fell forward onto my knees,” she explained. “The CNA was in the room but was just standing there and did not help me in any way.” According to the resident, no safety belt was used, and no proper assistance was provided.

The CNA, however, told a different tale. “I was advised by other aides to transfer the resident with a gait belt, and she was a one-person assist,” the aide insisted. “I had the gait belt around her and was transferring her from the wheelchair to the bed. During the transfer, the resident did not want to stand up so I was standing behind her holding onto the gait belt and helped her stand up, then moved the wheelchair out of the way. As she was pivoting her knees gave out and I lowered her to the ground on her buttocks.”

The nurse who responded to the scene added another perspective. Upon entering the room with the CNA, she found the resident sitting on the floor, alert and oriented. Notably, the nurse “did not recall seeing the gait belt around the resident” when she entered the room. Only after the assessment did she observe the CNA place a gait belt around the resident to help get her into bed.

Initially, there appeared to be no injury. The resident had no complaints of pain at the time. But days later, when the resident returned from a scheduled orthopedics appointment for an unrelated matter, she mentioned right knee pain. A diagnostic scan revealed the hidden damage: a fracture to the right knee.

Further imaging confirmed “age-indeterminate fractures of the distal femur just proximal to the knee prosthesis and at the superior aspect of the patella (kneecap).” The report specifically noted that these injuries “correlate with timing of trauma and pain”—connecting them directly to the fall incident.

The Director of Nursing at the facility was forthright in her assessment of the situation. After speaking with the resident and reviewing the evidence, she stated she “did believe the resident, and the transfer occurred without a gait belt, resulting in the resident falling and fracturing her leg.” She found the CNA’s statement “to be untruthful regarding the events that took place.”

The consequences for the resident were significant. Because of the fracture, she became non-weight bearing and required a mechanical lift for all transfers—a much more restrictive intervention than her previous level of care. When asked about the facility’s policy on gait belt transfers, the Director of Nursing admitted there was no formal policy, saying only that “the facility follows best practice when doing gait belt transfers.”

As the resident sat in her wheelchair weeks later, now wearing a brace on her right leg and with a mechanical lift sling positioned beneath her, the lasting impact of that night’s events was evident. A preventable accident had resulted in increased dependency and a painful fracture—all because proper transfer techniques and safety precautions weren’t followed.

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 Aperion Care Niles when staff failed to provide proper supervision and safety measures for a fall-risk resident who was left alone in her room without proper footwear and with her walker out of reach, resulting in a fall that caused a subdural hematoma requiring hospitalization.

The resident in question suffered from multiple health conditions including diabetes, difficulty walking, malnutrition, and a history of falling. This resident had moderately impaired cognition and needed assistance with basic activities like eating and moving between bed and chair.

On the day of the incident, the resident had gone out for a medical appointment with her son. When they returned to the nursing home, it was later than usual. Instead of taking the resident to the dining room where she typically ate under supervision, staff served her dinner in her room. The resident was seated in her wheelchair with the call button within reach, and she was instructed to call for help if she needed anything.

What happened next would prove critical – the Certified Nursing Assistant assigned to watch over the resident went on break. During this time, the resident attempted to stand up from her wheelchair. There were several factors working against her safety: her walker had been placed far away by the closet where she couldn’t reach it, she was wearing only socks without proper shoes, and there was no staff member present to supervise or assist her.

The resident lost her balance and fell face-first onto the floor. Another nursing assistant heard moaning coming from the room and discovered the resident lying on her stomach with a bruise on her forehead and blood on the floor. Staff quickly notified the nurse, who was working on a different floor at the time.

When the nurse arrived and assessed the situation, he found the resident on the floor with food still sitting on the table, indicating she had fallen while trying to move around during or after her meal. The resident had suffered a visible injury to her forehead. Following facility protocol, the nurse contacted the doctor, who ordered the resident to be transferred to the hospital.

At the hospital, doctors performed a CT scan that revealed an acute subdural hematoma – bleeding between the brain and its outer covering. The hospital physician noted that the resident was drifting in and out of consciousness, complaining of neck pain, and unable to answer questions coherently. After several days of hospitalization, the resident was returned to the nursing facility.

In the aftermath of this serious incident, nursing home leaders acknowledged that the fall could have been prevented through proper supervision. Multiple staff members admitted that if the resident had been placed in the dining room or near the nurses’ station for closer monitoring, if her walker had been kept within reach, or if she had been wearing proper footwear instead of slippery socks, the fall might not have occurred.

The facility’s own fall prevention policy emphasized the importance of keeping assistive devices like walkers within reach and ensuring residents wear proper non-skid footwear. Yet in this case, both of these basic precautions were overlooked.

The nursing home’s failures in this case represent a troubling pattern seen in many long-term care facilities – basic safety protocols that exist on paper but aren’t consistently followed in practice. Despite knowing the resident’s high fall risk and having documented a history of previous falls, staff made a series of critical errors: serving her in an isolated location rather than a supervised common area, leaving assistive devices out of reach, failing to ensure proper footwear, and not providing adequate supervision when the assigned caregiver went on break.

These shortcomings point to potential issues with staffing levels, training effectiveness, and the facility’s culture of safety. While corrective measures were implemented after the incident, they came too late to prevent a potentially life-threatening brain injury to a vulnerable resident who depended on the facility for protection.

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 Aperion Care Burbank when a staff member attempted to turn a paralyzed resident alone instead of with the required two-person assistance, resulting in the resident falling to the floor and sustaining a head injury that required a trip to the ER.

The resident in question had diagnoses of Paraplegia, Complete, Dementia, Major Depressive Disorder, Mononeuropathy of Bilateral Lower Limbs, Cataract, Hemiplegia and Hemiparesis Following Cerebral Infarction, Contracture, and Immobility Syndrome (Paraplegic).

The resident’s care assessment indicated cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3. The resident was noted to be “dependent on staff for toileting hygiene, sit to lying or lying to sitting on side of the bed and transfers.”

The resident’s care plan specifically designated that the resident “requires assistance with bed mobility related to weakness” with interventions that include “provide assist of 1-2 staff as needed.” A progress note clearly documented that the resident “is a 2 person assist with bed mobility.”

The incident in question occurred during the early morning hours when a Certified Nursing Assistant (CNA) was attempting to change the resident’s diaper. According to Fire Department records, “the patient was being changed and cleaned in bed when she was rolled out. Patient hit her head on the floor when she fell.” Hospital records confirmed this account, noting that the resident “states nurses were changing her diaper and rolled her over and she kept rolling and fell to the ground.” As a result, the resident sustained “a frontal hematoma and laceration requiring glue to close,” as well as “pain in right knee with hematoma over right tibial tuberosity.”

When interviewed, the resident provided a clear account of the incident: “The girl was turning me and was pushing me, and I kept saying stop, you’re going to push me out. The girl kept pushing, and next thing I knew, I fell to the floor.” The resident added, “It hurt my shoulder and my head.”

Multiple staff members confirmed that the resident required two-person assistance for turning. One CNA stated, “The resident needs 2 persons to turn her. The resident can’t help with positioning and is heavy, and 2 people are needed to turn her.” Another CNA confirmed that the resident “is 2 persons assist for cares” and “can’t roll out of the bed, and she can’t help to turn.” This CNA also noted that when he returned to work after the incident, the resident’s “face was swollen, all on the right side was swollen.”

A Restorative Aid who worked regularly with the resident confirmed, “For the resident’s bed mobility, I go in and I turn her side to side, with another person at all times… The CNA and I are doing all the work to turn her, she is dependent on staff. I have never seen her turn or try to roll. In all the time I have worked with the resident, she has never tried to roll or initiate the roll in bed.”
In this case the facility failed to ensure that two staff members assisted with turning the resident as required by the resident’s care plan. This failure directly resulted in the resident’s fall and subsequent injuries.

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 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.