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Nurse Fails To Complete Report, Notify Doctor & Family In Timely Manner After Resident Falls At Fairhaven Christian Retirement Center

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IDPH has cited and fined Fairhaven Christian Retirement Center after staff members failed to assess and provide adequate pain medications in a timely manner to a resident after a fall that resulted in multiple pelvic fractures and that required hospitalization and surgery.

Maintaining continuity of care from the staff members of the night shift to the staff members of the day shift is critical for the safety and well-being of a resident.  When a nurse or an aide fail to communicate the status of a resident, or fail to complete the work they are responsible for prior to leaving for the day, residents can suffer. 

On the day of this nursing home fall, the resident was in the common area sitting in a recliner with her feet up from about 5:00 AM so staff members could keep a closer eye on her. A nurse reported to the investigator that around 6:15 AM or 6:30 AM she was at the other end of the hallway finishing her rounds when she saw the resident standing at the recliner holding the alarm box in her hands. The nurse said that the resident was taking stumbling steps forward and backward and was very unsteady. The nurse further said she yelled to the resident and ran toward her but could not get there in time. When she did get to the resident she was moaning and groaning in pain on the floor.

After assessing the resident, a night shift nurse made the decision that there were no major injuries and that the resident could be assisted from the floor back into the recliner. 

This same nurse then proceeded to complete one half of an incident report, before handing off the report to a nurse that had arrived for the morning shift.  Importantly, the night shift nurse did not complete the incident report, did not complete any charting, and did not notify the resident’s family or doctor of the fall. 

Nearly three hours passed before a LPN (Licensed Practical Nurse) notified the DON (Director of Nursing) and the family of the fall.  The DON instructed the nurse to order an x-ray, which subsequently showed multiple pelvic fractures.  The resident was then sent to the ER with subsequent hospitalization and surgery.

The reason that this delay in treatment occurred was the failure to follow the system for completing incident reports that was in place.  In this facility the nurse that begins an incident report is usually responsible for completing it in full and making the appropriate notifications to other doctors, family and staff members.  The deeper question is why the system wasn’t followed.  Investigation by IDPH revealed that the nurse who failed to complete the incident report and make the appropriate notifications was an agency nurse, or a temp.  We tend to see a lot of agency nurses in facilities where they have hiring and retention problems, generally due to low pay and heavy work loads.  Temporary staff can help address this, but there is little chance to ensure that they are trained in the systems and processes that must be followed for the consistent delivery of routine care.

In the end, this was an injury that was a product of the nursing home business model, where understaffing of the nursing home and lack of investment in the staff are cardinal features – and this is because those kinds of expenses cut into the bottom line.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Resident Falls From Bed, Suffers Large Hematoma At Morgan Park Healthcare

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IDPH has cited and fined Morgan Park Healthcare (formerly Symphony of Morgan Park) in Chicago after a resident there suffered a large hematoma to the left side of her forehead due to rolling out of bed while receiving incontinence care from a single staff member rather than the two that were needed.

In the long term care industry, the term “bed mobility” refers to the ability of the resident to change and maintain position in bed.  This is an important area for assessing a resident’s abilities because the resident’s ability to change positions in bed is crucial for things like incontinence care and turning and repositioning, all of which are important for the prevention of bed sores.

The resident’s abilities with regard to bed mobility are recorded on the Minimum Data Set (MDS) which is a document which is submitted under oath to the federal government and is part of the basis for calculating the payments to the nursing home for the care that the resident receives.  When the MDS indicates that a resident requires extensive assist of two staff members for bed mobility, this indicates that the resident has little to no ability to change or maintain position in bed.  When two staff are providing care in bed to the resident, one staff member should be on each side of the bed with the staff member on the side of the bed in which the resident is turning being charged with making sure that the resident does not fall from the bed.  To assist the staff in knowing which residents require the assistance of two staff, the staff is provided with a care card which spells out the requirements for care of that resident.

On the day of this nursing home fall, the resident was receiving incontinence care from a single CNA (Certified Nursing Assistant).  As the CNA turned away from the resident to gather her care items, the resident slid off the edge of the bed, hitting her head on the floor.  She suffered a large hematoma on the left side of her forehead and was sent to the hospital.

The deeper question is of course why did this CNA attempt to do a two-person job by herself?  The answer in this case relates to understaffing of the nursing home.  The CNA explained to the investigator that on the day of the incident there were five CNA’s scheduled to cover the floor, however four of them had called off.  While the facility did assign one aide to assist the sole CNA that day, the floor was significantly understaffed.  Even worse, the Director of Nursing explained that the facility had made a policy decision to not use a staffing agency when a floor is understaffed.  

Unfortunately, understaffing of the nursing home is a feature, and not a bug, in the nursing home business model.  The net effect of understaffing is that it doesn’t give the staff the ability to provide proper care for the residents – and the net result of that is unnecessary injuries such as this one.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Resident Left Alone In Bathroom Slips From Toilet, Fractures Hip At Greek American Rehab & Care Center

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IDPH has cited and fined Greek American Rehab & Care Center after a resident there was allowed to go to the bathroom without the required help and then fell from the toilet seat, resulting in a fracture to her right hip, which required surgery to fix.

Care planning is a process by which risks to the health and well-being are identified and measures are put into place and carried out on a day-to-day basis to prevent those risks from coming to fruition.  One of the ways that proof of nursing home abuse and neglect is proven is by showing violations of the resident care plan.  Delivery of the care called for in the care plan is fundamental to providing quality care to residents in a nursing home setting.

There are six steps to the care planning process: (1) an assessment of the risks to the health and well-being of the resident; (2) a written care plan is developed which identifies a series of steps or interventions intended to reduce the risks to the resident.; (3) communication of the care plan to the staff who are charged with carrying it out; (4) implementation of the care plan on a day-to-day, sift-to-shift basis; (5) ongoing evaluation of the effectiveness of the care plan; (6) revision of the care plan if it proves to be inadequate in practice or if the care needs of the resident change.

The resident at issue was identified as being a fall risk, and a fall prevention care plan was put into place.  Among the important points in the care plan was the designation of the resident as a 1 person assist to the toilet.  Generally speaking, that means a staff member either stays in the bathroom or just outside the door when a resident toilets.  

On the day of this nursing home fall, the nurse placed the resident on the toilet chair in her bathroom and then left her there unattended to go assist another resident.  The resident subsequently slid off from the toilet onto the floor and threw a bootie she was wearing on her feet out into the room to try to get staff attention.  

The fall resulted in a fracture to her right hip.  The resident was transferred to the hospital where she underwent surgery to fix the injury.  

The basic issue with the care that was provided is that the resident’s care plan called for individual assistance on the toilet.  Residents as fragile and unsteady as this resident cannot be left alone on the toilet.  The decision of the nurse to leave the resident alone with a call button while she was attending to another resident in a different room was a mistake.  Because the resident was left on the toilet unattended, the fall and injury resulted.

When you have staff that is stretched too thin to provide necessary supervision and help to residents to avoid accidents, this raises fair questions as to whether this was an understaffed nursing home.  Unfortunately, understaffing a nursing home is a basic feature of the nursing home business model. 

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Resident Falls, Dislocates Hip As Only One Aide, Instead Of Two, Assists Him Into Bed

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IDPH has cited and fined The British Home in Brookfield, Illinois after a resident there suffered a right hip dislocation in a fall.  Importantly, the resident’s Minimum Data Set clearly stated that the resident needed two, not one person to assist with movements in bed.  

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

The resident at issue had a Minimum Data Set (MDS), a key part of the care planning process, that indicated the resident required two-person assist for bed mobility, which includes turning side to side and body positioning in bed.

On the day of this nursing home fall, the resident said a male CNA (Certified Nursing Assistant) was helping him get into bed, when he began slipping out of his arms, and almost fell to the floor. The resident added he “kept slipping and sliding out from the male aide’s hold” and was face down when his hands went down to the floor. The resident then said the male aide was trying to hold the rest of his body up, but eventually his whole body ended up on the floor. 

After the fall, the resident was in between the bed and the radiator, almost in a fetal position, screaming “please help me.”  Since the resident was asking to get off the floor, the CNA got the mechanical lift and assisted the resident up off the floor and back into bed.

The resident was emergently sent to a local hospital for further evaluation and treatment per physician’s orders. The resident was admitted to the hospital and diagnosed with “right hip dislocation with no acute fracture.”

The nursing home had a reasonable care plan in place for this resident – the problem was that the staff did not implement it.  Rather than follow this care plan, the staff attempted to help the resident into bed with the assistance of only one CNA, not two as the MDS called for.

The fact that the staff plowed ahead with trying to assist the resident with only one staff member raises a question of whether this is an understaffed nursing home.  This is true anytime you see the staff taking shortcuts which sacrifice resident safety.  Sadly, understaffing a nursing home is a core feature of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Resident Falls Three Times In One Week, Fractures Hip At Hillsboro Rehab & Health Care Center

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IDPH has cited and fined Hillsboro Rehab & Health Care Center after a resident there fell three separate times during her first week at the facility, sustaining a non-operable re-fracture of her left hip.

Falls are a major source of mortality and loss of quality of life for the nursing home population.  They are also addressed in federal regulations which require that nursing home residents receive supervision and assistance necessary to prevent accidents.  A fall is a form of accident.  Because of this, fall prevention is a serious area of focus in the long-term care industry.

There are two major factors that make residents at risk for falls.  These include (1) some form of musculoskeletal, gait, or balance dysfunction which place a resident at risk for losing balance or falling and  (2) some form of cognitive impairment, dementia, confusion, or general poor safety awareness.  Cognitive issues feed into fall risk because the resident cannot be counted on to follow instructions or make good decisions for their own safety.

The resident at issue was severely cognitively impaired, with behaviors such as inattention and disorganized thinking, and required assistance with Activities of Daily Living (ADLs) including bed mobility, transfers, walking in room, dressing, eating and toileting.

The day after the resident was admitted to the facility, the resident was found by a nurse on the ground at the foot of her bed, sitting on her buttocks with her left leg extended forward and right leg bent.  The resident was complaining of pain and discomfort, and was transported to the ER, where all tests for injuries were negative. 

The resident returned to the facility, only to fall again that same evening.  This time the resident was found on the floor in front of the bathroom.  She was lying on her right arm, complaining of right shoulder, back and hip pain.  Before returning to the ER a second time in one day, a nurse at the facility spoke with the ER doctor.  He stressed that he was unable to believe that the resident had fallen a second time, since he had given orders that upon returning to the facility the resident was to receive 1:1 care.  This refers to a specialized level of care provided in nursing homes where one caregiver is assigned to provide individualized care to a single resident. 

The third fall occurred approximately five days later, with the resident found on the floor near her overturned commode.  This fall resulted in another trip to the ER and a diagnosis of a non-operable re-fracture of the left hip.

The citation mentions several interviews with nurses that try to explain how the order for 1:1 care from the doctor was missed after the first fall.  Nurses also honestly confessed that this level of care would have been nearly impossible, as “if you are 1:1 with a resident, no one else would get their care.”

When you have staff that is stretched too thin to provide necessary supervision and help to residents to avoid accidents, this raises fair questions as to whether this was an understaffed nursing home.  Unfortunately, understaffing a nursing home is a basic feature of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Fall Investigation Reveals Startling Lack Of Training And Understaffing At Bella Terra Wheeling

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The Illinois Department of Health has cited Bella Terra Wheeling after a resident fell from her wheelchair in the dining room and suffered face lacerations and a fractured femur.

Falls are a major concern in the long-term care industry because of the serious negative effects they have on mortality and the long-term quality of life for nursing home residents.  Because of this, they are a regular focus in the care planning process.

Nursing homes use a variety of tools to assess a resident’s fall risk.  Some of the major factors are a recent history of falls, as it is well-recognized in the long-term care industry that falls tend to beget additional falls; balance, gait, or musculoskeletal dysfunction; and some form of cognitive impairment, dementia, constant or intermittent confusion, or general poor judgment or awareness for one’s own safety or limitations.  

The cognitive impairment factor is crucial because this means that a resident cannot be counted on to follow instructions or to make good judgments or decisions for his or her own safety.

Federal regulations pertaining to falls in nursing homes provide that residents must receive supervision and assistance necessary to prevent accidents.  Falls are considered accidents under the regulations.

Close supervision of the resident is a mainstay of any fall prevention strategy in a nursing home.  One of the common ways of providing supervision to residents is to gather them in areas where several residents who require supervision can all be watched at the same time by a limited number of staff people.  Common examples of this would be to gather residents in an activity room, near the nurse’s station, or in the dining room.

On the day of this nursing home fall, the resident in question was in the dining room, in her wheelchair, waiting for breakfast to be served.  The nurse watching over the residents that morning claims that she was helping another resident when she heard the resident “fall hard,” landing on her right side and bleeding onto the floor.  

The resident was assessed, x-rays were ordered and the resident was sent to the hospital for further evaluation.  At the hospital it was determined that the resident had suffered an acute femur fracture.

Falls can be devastating events for seniors, and often they lead to additional falls.  While this fall is certainly a serious and sad occurrence, equally as disturbing in this case are some of the findings that the surveyor found when she went to conduct her investigation at the facility.

– When the surveyor visited the same dining room where the fall occurred, there was a different nurse watching a group of residents.  That nurse commented that “you can see there are a lot of residents here so we can’t get to all of them if they fall.”  When the surveyor counted the number of residents assembled in the dining hall, she counted 41, with just one nurse monitoring the room.  

– When the surveyor visited the nurse that was watching the resident on the day of the incident, the nurse stated that she was “with agency and I had just got there that day and they (facility) assigned me to be in charge of watching the dining room.”  

When the surveyor asked if she had returned to the facility after the day of the accident, she replied that she had not and that she had no idea that the resident was a fall risk.  “No I haven’t been back since that last time and I only was there once.  I didn’t know anything about her fall risk. Is she one because they didn’t tell me anything? All they do like every place is give you the residents and they don’t tell you anything.”

When asked if the agency had received any dementia or fall prevention training, the nurse replied “I’m with agency, they don’t do training.”

When a nursing home is unable to provide residents with the necessary supervision, that is a sign that this is likely an understaffed nursing home.  Even worse, when a nursing home does not train their nurses in fall prevention, it would seem to border on negligence.  Unfortunately, insufficient training of nurses and short-staffing a nursing home is a basic part of the nursing home business model. 

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Resident Breaks Pelvis In Fall From Bed At Bria Of Westmont

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IDPH has cited and fined Bria of Westmont after a resident fell from her bed,  sustaining a painful pelvic fracture.

Prior to the accident, the resident at issue had a Minimum Data Set (MDS) submitted to the federal government indicating that she required the assistance of two for bed mobility.  For the ability to roll left and right in bed, the resident was coded as “01”.  This code means that the dependent-helper does all of the effort and the resident does none of the effort to complete the activity.  

Importantly, this facility does not use side rails on beds.  Therefore residents that require this much assistance are not able to remain on their side without the risk of rolling over. 

The only way to safely provide incontinence care would be with two staff members, one to hold onto the resident and the other to provide the incontinence care.

At the time of this nursing home fall, an aide was providing incontinence care by herself to the resident. The aide explained that after positioning the resident on her left side, she quickly ran into the bathroom inside of the resident’s room to get more supplies, leaving the resident unattended “for no more than 10 seconds.” The aide acknowledged that she witnessed the resident fall out of the bed as she stepped out of the bathroom, landing onto her right side on the floor.

When the x-ray technician arrived in the room, the technician found the resident “in tremendous pain and screaming.”  

She was diagnosed with a closed nondisplaced fracture of the right acetabulum and a closed fracture of the right pubis.  

This is yet another instance where a resident suffers injury because one person was doing a two-person job (see here, here, here, here, and here for examples).  Generally the root cause of this kind of incident is due to understaffing of the nursing home, which is something that is inherent in the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.

Communication Failure Leads To Fall And Death At The Arc At Normal

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IDPH has cited and fined The Arc At Normal after a resident fell and died after attempting to toilet on his own.

There is a framework for providing the vast majority of routine care in a nursing home setting.  This is referred to as the care planning process.  When it is done properly, the risk of residents suffering unnecessary injuries, falls  and wrongful deaths is greatly reduced.  However, oftentimes there are serious deficiencies in the care-planning process which sets the stage for disaster.

When the resident in question was admitted to the nursing home, the initial assessment listed the resident at a moderate risk for falls.  The only fall prevention intervention documented at that time was to make sure the call light was within reach.

The resident’s family, on the other hand, informed the admitting nurse that their loved one was a high fall risk with frequent intermittent confusion and requested that he not take the ordered Eliquis (blood thinner) due to his frequent falls and prolonged bleeding. Importantly, they communicated to the admitting nurse that their loved one be toileted at 1:00 am and 4:00 am, as that is what he was accustomed to when they were caring for him at home.

When the family was leaving the facility later that night they communicated to another nurse that they were concerned about their loved one.  The nurse assured them that residents are checked on every 2 hours and toileted at those times.  Further, since the resident was confused and often tried to get up, the nurse assured the family that a nurse would check on the resident every hour to see if he needed anything.   

Critically, the admitting nurse never communicated to other nurses, including the night staff, that this particular resident needed to be toileted at 1:00 am and 4:00 am.  

Without this critical information, tragedy struck.  

An aide did stop to toilet the resident sometime between 9:00 pm and 10:00 pm, but did not return again until midnight.  When the aide saw that the resident was sleeping, she decided to let the resident sleep without toileting him.

The next interaction anyone had with the resident was at 1:15 am when the aide found the resident lying face down on the floor, behind the door and bleeding from his head. 

The resident was rushed to the hospital but passed that same night.  Cause of death was Intracranial Hemorrhage with anticoagulant used for AFib (Atrial Fibrillation).

In this case the major breakdown in the care planning process was with communication.  Once the care plan has been developed, it must be communicated to the members of the nursing home staff charged with carrying it out.  This should be a simple enough process, but in practice, nurses and other staff members often have a hard time explaining how that occurs which leaves the issue in doubt as to whether the contents of the care plan are ever communicated to the people charged with doing the work.

These systemic failures are often a sign of an understaffed nursing home.  Sadly, that is a basic part of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Aide Neglects To Attach Foot Pedals To Wheelchair, Resident Falls & Suffers Neck & Shoulder Injuries At Grove Of St. Charles

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IDPH has cited and fined Grove of St. Charles nursing home after a resident there became injured in a wheelchair accident.

Wheelchairs are one of the most common pieces of equipment used in a nursing home setting and at first blush are very simple to use safely.  However, even these simple devices can prove dangerous when not used properly.

On the morning of the injury, aides were escorting three residents on a morning walk around the facility through the parking lot.  The residents were walking side by side when the left rear wheel of one of the resident’s wheelchairs caught the edge of a manhole cover. Unfortunately for the resident, the aide had neglected to attach the foot pedals to the resident’s wheelchair.  

The use of leg pedals on a wheelchair helps to position the hips back if there is a sudden “jerk” while in motion. They keep the knees up and the person back in their seat. 

As the chair became stuck in the manhole cover, the resident lurched forward and fell out of the chair, landing on the pavement.  

The resident suffered a progression of an existing neck fracture, a shoulder dislocation, and a hematoma on her forehead.

Sadly, the resident had been mobile prior to the fall and had been able to wheel herself around the hallways but has subsequently become primarily bed bound after the injury.

A janitor, examining the manhole cover after the accident, noted that it was painted yellow and was set down three-quarters of an inch below the surrounding asphalt.  The janitor also noted that there was ample room on either side of the manhole cover and that the aide should have been able to wheel the resident around the cover, not over it.

Like all pieces of equipment in a nursing home, a wheelchair is a safe piece of equipment – when used properly.  This includes using the footrests – the use of which would have helped to prevent this kind of accident.  The misuse of the wheelchair was the immediate cause of this accident.

The fact that such an obvious safety measure was not taken raises serious questions as to whether this is an understaffed nursing home.  When the facts of an accident show that the staff was taking a shortcut which placed the safety of the resident at risk, it could be an indicator that the staff was not trained properly or that the staff simply did not have time to do things properly.  Either way, this raises questions about how the nursing home is being operated.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Resident’s Requests To Fix Bed Rails Go Unheeded, Falls From Bed At Bria Of Belleville

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IDPH has cited and fined Bria of Belleville after a resident there fell out of bed and was hospitalized due to bed rails that were poorly attached to the frame.

Although the U.S. Food and Drug Administration’s (FDA) warnings on bed rail safety have prompted many manufacturers to design safer beds that minimize the risk of accidents, many nursing homes continue to place their residents in outdated beds with unsafe rail designs.

Nursing homes that do have upgraded beds often still have older models in some rooms, since there is little incentive to rid the facility of any usable bed. Adding to the risk of serious or fatal injury are rental beds from medical supply companies. Not only are the rental beds typically those with more outdated designs, but they are often sent to nursing homes with mismatched parts. In other words, the mattress and bed rails may be from different manufacturers, putting the resident at risk of getting trapped in the space between the mattress and frame.

On the day this resident was admitted to the nursing home she immediately remarked to the admitting nurse that the bed rails felt “loose and wiggly.”  The resident’s husband remarked that his wife showed how loose the bed rails were to “several staff members . . . and no one did anything about it.”  

The citation mentions that the admitting nurse acknowledged that she vaguely remembers someone making a remark about the bed rails as she was checking in the new resident, but that she was new and intensely focused on the computer and her documentation. 

It only took one day for the accident to occur. 

On her second day in the facility, while the new resident was repositioning herself in bed, the bed rail became detached and the resident fell off the bed.  She landed on top of the detached bed rail on the floor.  She was transported to the Emergency Room and was diagnosed with a frontal sinus facial fracture, mildly compressed skull fracture, and a possible subdural hematoma. 

The citation mentions that the bed appeared to be an older model with an air mattress placed on the bed frame.

After the incident, the resident’s husband returned to the facility to examine the bed.  “I got down on the floor to look at how the rails are attached to the bed, and it is only attached by a hand knob that you hand tighten. All anyone had to do was to tighten the black knob and my wife would not be in this condition. Anyone could have done that.  Their negligence is why my wife is like she is now.”

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Resident’s 9th Fall From Toilet Results In Left Femur Fracture And Surgery At GreenFields Of Geneva

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IDPH has cited and fined GreenFields of Geneva after a resident there was allowed to go to the bathroom without the required help and then fell while trying to transfer herself from the commode to the wheelchair, resulting in a fracture to her left femur, which required surgery and a 4-day hospital stay.

Nursing homes track a great deal of data concerning their residents.  Much of it is strictly for internal use, but one piece – the Minimum Data Set, or MDS – is reported outside the facility.  It is submitted under penalties of perjury to the federal government because the information that is in there forms part of the basis by which nursing homes are paid.  It tracks information concerning the physical abilities and deficits of residents, as well as the levels of care that the nursing home is in fact providing to the resident.

For this resident, the MDS showed that the resident required extensive assistance with toileting and transfers from the toilet.  The MDS also showed that she had severe cognitive impairments.  This is a resident who was clearly at high risk for falls – she had well-documented issues with balance and mobility and also had severe cognitive impairments where she could not be counted on to follow instructions or make good decisions for her own safety.

The resident’s progress notes indicated that in the last 12 months she had been found on the bathroom floor after falling while attempting to self-transfer no less than 8 separate times. 

On the day of this nursing home fall, the resident told a nurse that she needed to be toileted.  The nurse placed her on the commode chair in her bathroom and then left her there unattended to go assist another resident.  The nurse claimed in the citation that a separate nurse told her that it would be okay to leave the resident unattended.  The resident was alone and subsequently fell while attempting to self-transfer back to her wheelchair.

The fall resulted in a fracture to her left femur.  The resident was transferred to the hospital where she had a four day stay and underwent surgery to fix the injury.  

The basic issue with the care that was provided is that the resident required assistance with transfers, toileting, and walking.  She was also unsteady when moving off and on the toilet.  The nurse had a feeling that she should not leave the resident alone while toileting, but needed to attend to another resident.  When the nurse asked one of her co-workers if it was okay to leave the resident unattended on the toilet, the nurse said that it was okay.  This turned out to be very  bad advice.  Because the resident was left on the toilet unattended, the fall and injury resulted.

When you have staff that is stretched too thin to provide necessary supervision and help to residents to avoid accidents, this raises fair questions as to whether this was an understaffed nursing home.  Unfortunately, understaffing a nursing home is a basic feature of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Bella Terra Elmhurst resident fractures hip, dislocates knee in fall

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IDPH has cited Bella terra Elmhurst nursing home after a resident there suffered a fractured femur and dislocated knee in a fall.

One of the well-worn paths for injury to nursing home residents is having one person do a two-person job (see here, here, here, here, and here for examples).  Most often, this occurs because the staff member involved is taking a shortcut in the care of the resident, usually because the nursing home is understaffed.  This incident shows that this can also happen when there is a breakdown in the process by which the care needs of the residents are communicated to the staff on the floor.

The resident at issue suffered a dislocated shoulder and underwent a course of physical therapy.  At the time the resident was discharged from physical therapy, there was a recommendation by the therapy for the resident to have transfers with the assistance of two staff members using a gait belt.  The nursing home incorporated that recommendation into the resident’s care instructions which were kept in a binder at the nurse’s station.

On the day of this nursing home fall, there was an aide from a staffing agency who was assigned to care for the resident at issue.  It was that aide’s first time caring for the resident, so she asked the nurse assigned to the resident what her transfer status was, and was told that the resident required assist of one with a gait belt.  The aide was unaware of the existence of the binder.  The nurse, who was caring for the resident for only the second time, claims that she was told during the nurse-to-nurse report during change of shifts that the resident was assist of one with transfers.  However, she did not verify this in the binder.

Acting on the information provided, the aide attempted to transfer the resident from her bed to her wheelchair without the assistance of another staff members.  Immediately after the resident stood up from the bed, her legs gave out from underneath her, and the resident was lowered to the floor using the gait belt.  The aide  got a nurse who helped the resident get back into bed using a lift.

The resident had persistent complaints of pain before she was sent to the hospital where x-rays showed a subcapital femur fracture (a type of hip fracture) and a dislocated knee as a result of the fall.

One of the interesting points about this is that the aide and nurse who were charged with caring for this resident were both agency staff, meaning that they were not necessarily people who regularly worked in the facility.  When agency staff is brought on board, they must be trained sufficiently in how things are done in the nursing home.  The aide did the right thing by asking what the transfer status was of the resident, but was unaware that there was a clear answer in the binder – because she did not know that the binder existed.

The use of agency staff and the failure to invest the minimal time necessary to properly train them is a sign of a nursing home that takes shortcuts in the care of the resident.  Sadly, this is consistent with the basic nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Failure to supervise Westmont Manor resident results in fall with hip fracture

Park Place Christian Community resident rolled from bed by staff

Sunny Hill resident suffers fractured leg after lift tips over

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Violation of care plan at Generations Oakton Pavillion leads to fall and fracture

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IDPH has cited and fined Generations Oakton Pavillion after a resident there suffered a fractured leg in a fall which occurred due to staff attempting to manually transfer her from wheelchair to bed without using a lift, in violation of the resident’s care plan.

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

The resident at issue was morbidly obese and had left-sided weakness from having had a stroke in the past.  She was unable to bear weight, so her care plan called for transfers with a mechanical lift with the assistance of two staff members.

On the day of this nursing home fall, the sling for the lift that normally would have been left underneath the resident as she sat in her wheelchair was not in place.  Because there was no sling readily available, the aides attempted to transfer the resident manually without using a gait belt.  As they attempted to pivot to turn from the wheelchair to the bed, the resident’s legs gave out and she fell to the ground, landing on her knees.  She was helped from the floor to bed by the aides.

After the fall, the resident had complaints of pain in the knee and swelling and bruising below the knee.  The resident was transferred to the hospital where x-rays showed that the resident had a fracture of the upper portion of the tibia, extending into the knee joint, and a patellar tendon avulsion.  The resident underwent surgery to repair the injuries from the fall.

The nursing home had a reasonable care plan in place for this resident – the problem was that the staff did not implement it.  The care plan called for transfer with a lift, which was appropriate given her inability to bear weight.  Rather than follow this care plan, the staff attempted to transfer the resident manually.  This was never likely to succeed given her inability to bear weight – and the chances of ensuring an injury-free transfer dropped when they elected to not use a gait belt, either.

The fact that the staff plowed ahead with trying to transfer the resident manually raises a question of whether this is an understaffed nursing home.  This is true anytime you see the staff taking shortcuts which sacrifice resident safety and there were two such shortcuts taken – attempting the transfer without the lift and then not using a gait belt.  Sadly, understaffing a nursing home is a core feature of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Unsupervised resident falls and fractures hip at Lutheran Home for the Aged

Resident fractures leg in unsafe transfer at Ascension Nazarethville in Des Plaines

Addolorata Villa resident fractures hip in fall

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Fairhaven Christian Retirement Center resident dropped from lift, breaks hip

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IDPH has cited and fined Fairhaven Christian Retirement Center nursing home in Rockford after a resident there suffered a fractured hip when she was dropped from a lift during a transfer.

Used properly, a mechanical lift is a great tool for providing care for nursing home residents with severe mobility deficits.  They allow residents to be moved safely from bed to wheelchair, wheelchair to chair or toilet, etc.  They allow residents to be moved safely while being bathed.  They also prevent injuries from being twisted while being moved manually.  They save wear and tear on the backs, knees, shoulders, and so forth of the staff and help prevent injury to staff as well.

Of course, the key phrase in that first sentence of the paragraph above is “used properly.”  When not used properly, they set the stage for serious injury to the resident.  Proper use includes having two staff members operate the lift (see here, here, here, here, and here for examples of what happens when one person does a two-person job); it includes safe operation of the lift itself (see here and here for examples of what happens when the lift isn’t used properly); and it includes making sure that the lift itself is in good condition and that all of the slings and accessories are in good condition and appropriate for use (see here, here, and here for examples for when that is not true).

This incident shows what happens when you have one person doing a two-person job.

The resident at issue had significant cognitive and mobility impairments such that she required assistance of two staff members with transfers.  Further, the resident care plan called for the use of a mechanical lift with two staff assist.  Having the care plan call for two staff members to participate in transferring the resident with a lift is consistent with prevailing safety practices in the long term care industry, as safe operation of a lift requires one staff member to operate the controls of the lift while the other staff member keeps the resident safe and properly positioned in the sling.

On the morning of this nursing home fall, an aide was walking down the hallway when she heard a loud noise come from the resident’s room.  She entered the room to find the resident on the floor lying on the top of the legs of the lift with blood coming from her head.  The only other person in the room was another aide.  The aide explained that she was transferring the resident from her wheelchair to bed by herself.  While the transfer was in progress, the resident rolled to the right and fell from the sling.  Because there was only a single staff member involved in the transfer, there was no one who was able to help keep the resident in the sling.

The resident was transferred to the hospital where she was diagnosed with a fractured hip.  Surgical repair was attempted, but the fracture was complicated and proved to be nonrepairable.  The resident was returned to the nursing home for comfort measures, including pain management.

This is another example of the disaster that results when one person attempts to do a two-person job.  Not only was this a violation of the resident care plan, there were also facility policies in place which required the use of two staff for transfers with a mechanical lift.  And the nursing home not only had a policy in place, but also provided the staff with radios to call for help with transfers.  The aide involved clearly knew that this was not something she should be doing, as she told the first person to enter the room, “I always ask for help.”  Sadly she didn’t do so this time, and the resident paid the price.

When you have staff taking shortcuts in the care of residents, this raises the question as to whether this is an understaffed nursing home.  Unfortunately, understaffing a nursing home is a feature of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Staff at Bella Terra Schaumburg knowingly uses broken lift, resulting in brain bleed for resident

Waverly Place of Stockton resident breaks hip in unsafe transfer

Resident left unattended in dining room at Ascension Saint Anne Place suffers fractured hip in fall

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Resident dropped from lift due to use of improper sling at Carlinville Rehab

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IDPH has cited and fined Carlinville Rehabilitation & Health Care Center nursing home after a resident there suffered a fractured humerus after being dropped from a lift because the staff used a sling which should not have been used with that lift – in violation of manufacturer’s specs.

Used properly, a mechanical lift is a very beneficial piece of equipment for use in a nursing home.  It allows residents who have significant strength and mobility issues to be transferred from bed to wheelchair, wheelchair to chair, and so forth safely while at the same time reducing the risk of injury to residents and staff.

The key part of that statement is of course, the “used properly” part.  Proper use of a mechanical lift includes making sure that there are two staff members involved in all transfers because having on person do a two-person job is a formula for disaster (see here, here, here, here, and here for examples).  The other part of “proper use” is that the lift itself and all of the associated equipment is in condition for safe use and is used properly in accordance with manufacturer specifications.

The resident involved suffered from muscle wasting and atrophy and had a care plan which called for mechanical lift transfers with two staff.  On the day of this nursing home fall, two aides were transferring the resident to bed when the sling came off the arm to the lift, causing the resident to fall to the floor.  he was taken to the hospital where he was diagnosed as having suffered a fractured humerus.

The cause of this nursing home fall was not readily apparent, as the lift was brand new and the sling itself was in good shape.  However, further investigation revealed that the owner’s manual for the lift stated that only slings made by that manufacturer should be used with that lift.  The manual went on to warn that use of slings made by a different manufacturer was unsafe and may result in injury to the resident or caregiver.  The sling in use was not made by that manufacturer, and in fact, the nursing home did not have any slings made by that manufacturer.

Very clearly, the warning contained in the owner’s manual was not heeded, and the very outcome predicted in the owner’s manual came to pass.  There are several levels of failure to this, including the failure to obtain the necessary accessories to the lift; failure to review the owner’s manual, and the failure to train the staff on the proper use of the new lift.

Sadly, failure to invest time in training the staff and in proper equipment is one of the hallmarks of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Use of improper lift at Sunset Home leads to admission to intensive care unit

Mishandling of resident results in broken shoulder at Havana Health Care Center

Sling breaks during transfer at University Nursing & Rehab

Farmington Country Manor resident breaks leg in unsafe transfer

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Michaelsen Health Center resident rolled from bed, suffers brain bleed

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IDPH has cited and fined Michaelsen Health Center nursing home in Batavia after a resident there suffered a brain bleed after being rolled out of bed.

In the nursing home industry, the term “bed mobility” refers to the ability of a resident to change and maintain position in bed.   Bed mobility is one of the areas which is assessed during the process of preparing the Minimum Data Set (MDS).  The MDS form records the resident’s physical abilities and deficits and records the amount of assistance that a resident requires.  The information on the MDS form is submitted to the federal government under penalties of perjury because that information forms part of the basis by which the nursing home is paid for the care it provides.

Beyond that the information gathered during the MDS process is often incorporated directly into the resident care plan.  The care planning process has six steps: (1) a resident assessment where the risks to the health and well-being of the resident are identified, (2) the development of  a care plan which identifies steps or interventions to be taken to address the risks to the resident and assigns various staff to carry out those steps, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) evaluation of the effective of the care plan on an ongoing basis, and (6) revision of the care plan if the resident’s needs change or if the care plan proves to be in ineffective in practice.

The resident at issue here had a cervical collar on due to a cervical spine fracture.  She also had right-sided weakness which was a residual from having had a previous stroke.  Her bed had a low air loss mattress, likely as a means of preventing bed sores.

On the day of this nursing home fall, the resident was receiving a bed bath from a single aide.  The aide had the resident move onto her left side and cross her right leg over her body so that the aide could clean her back.  At the time that was happening the aide was on the side of the bed where the resident was turning away from her.  When the resident crossed her leg over her body, the momentum from that movement carried her leg over the edge of the bed.  Due to her weakness from her stroke, the resident was not able to stop that momentum and this carried her over the edge of the bed.  Because the aide was positioned such that the resident was moving away from her, the aide was unable to stop the fall as well.  The resident crashed to the floor, hitting her head and leaving a bump on the back of the right side of her head.

The resident was brought to the hospital where a CT scan was performed which showed that she had a subdural hematoma of the left temporal lobe (the front front side of her brain).  The doctor described this a contrecoup injury – a type of brain injury which occurs when the brain strikes the inside of the skull opposite the direction of a blow to the head.  The resident was eventually returned to the facility where her care plan was upgraded to include assist of two with activities of bed mobility.

There were a number of shortcomings in the care of this resident.  First, the aide turned the resident away from her so that the aide was in a position to stop the momentum which carried the resident over the edge of the bed.  This is a fundamental skill which aides should have and exercise of this was necessary especially since the resident was on a low air loss mattress which can be a difficult support surface for bed mobility activities.  Second, to the extent that the aide did not know that the resident should be turned toward her, this is an issue with staff training.  Third, the care plan was revised upon the resident’s return to include two staff with bed mobility activities.  An effective care planning process includes ongoing review of the effectiveness of the care plan and revision if it proves to be ineffective in practice.  The fact that the care plan had to be revised after the fall suggests that a revision may have been required earlier but no critical thought was given to the actual care needs of this 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.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Bella Terra Elmhurst resident fractures hip, dislocates knee is fall

Staff at Bella Terra Schaumburg knowingly uses broken lift, leading to fall and brain bleed for resident

Park Place Christian Community resident rolled from bed

Westmont Manor resident suffers brain bleed after being rolled from bed

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Violation of care plan and orders leads to broken leg at Meadowbrook Manor in Bolingbrook

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IDPH has cited and fined Meadowbrook Manor nursing home in Bolingbrook after a resident there suffered a broken leg while being transferred to bed manually by a CNA rather than with a lift as called for by the resident care plan and by the orders from her doctor.

In a nursing home, the Minimum Data Set (MDS) is a tool which assesses the overall function of the resident and the care needs of the resident.  One of its uses is that it forms part of the basis by which the nursing home is paid for services so it must be completed under penalties of perjury when it is submitted to the federal government.  For this resident, her MDS stated that she was cognitively intact but that she needed extensive assist of two staff with all activities involving transfers, likely due to a history of past strokes.  The resident care plan was reflective of this in that it called for assist of two using a mechanical lift for transfers, as did the orders from her physician.

On the night of this nursing home fall, the resident was being transferred to bed by a single aide from an agency, rather than being transferred to bed with a lift being operated by two aides.  During the transfer, the resident tripped and the aide fell on top her.  The aide got the resident into bed and then reported to the nurse on duty that the resident had lower extremity pain after being transferred to bed using a mechanical lift with the assistance of another aide from that same agency.  However, when that second aide was questioned about the incident she denied having transferred any resident with a lift, denied having been asked to help with a transfer by the first aide, and stated that she worked on a different hallway that evening.

Following the incident, the resident remained in bed for three days before being sent to the hospital due to discoloration of her lower leg.  There, an x-ray showed an acute comminuted fracture of the proximal tibia (a new fracture of the shin bone closer to the knee with the fracture having many fragments).  Her physician told the state surveyor that it was a recent fracture and was the kind of fracture that was caused by an impact and did not just happen spontaneously.

During the hospitalization, the resident experienced a hypotensive event (a drop in blood pressure) which in turn led to increased confusion due to encephalopathy.  Her family elected against aggressive treatment and she returned to the nursing home to be placed on hospice.

The obvious cause of this fall was the failure of the aide to follow the care plan and the physician orders to transfer the resident with two staff members using a mechanical lift rather than transferring her manually by himself.  A likely deeper cause would be the use of agency staff and the failure to adequately train them and orient them to the care needs of the residents.  And while the staffing agency and the nursing home are directly responsible for this fall and injury, the management choices made at the nursing home are a likely culprit as well.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Promedica Skilled Homewood resident falls and breaks hip

Park Place Christian Community resident rolled from bed by staff

Westmont Manor resident suffers brain bleed after being rolled from bed

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

 

Multiple falls leads to fractured hip and brain bleed at Monmouth Nursing Home

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IDPH has cited and fined Monmouth Nursing Home after a resident there experienced eight (8) falls in a two and half month period, the last resulting in a fractured hip and a brain bleed, both of which required surgical intervention.  This is the second citation that IDPH has written to this nursing home for a resident who experienced significant injuries after having multiple falls in the nursing home.

Falls are a major cause of death and diminished quality of life for nursing home residents.  They are also addressed in the federal regulations, so the issue of fall prevention is a major area of focus in the long-term care industry.

Fall prevention is an area which is addressed in the care planning process.  Most of the routine care that is provided in nursing homes is addressed through the care planning process.  This process has six steps: (1) a resident assessment where the risks to the health and well-being of the resident are identified, (2) the development of  a care plan which identifies steps or interventions to be taken to address the risks to the resident and assigns various staff to carry out those steps, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) evaluation of the effective of the care plan on an ongoing basis, and (6) revision of the care plan if the resident’s needs change or if the care plan proves to be in ineffective in practice.

There is no tool for assessing fall risk that is considered “gold standard” the way that the Braden scale is for assessing the risk of developing bed sores.  However, any decent fall risk tool will account for the two main factors which place a resident at risk for having falls.  These are:  These include (1) some form of musculoskeletal, gait, or balance dysfunction which place a resident at risk for losing balance or falling and  (2) some form of cognitive impairment, dementia, confusion, or general poor safety awareness.  Cognitive issues feed into fall risk because the resident cannot be counted on to follow instructions or make good decisions for their own safety.  Further, it is also well-recognized that falls tend to beget additional falls – so a history of falls tends to be a precursor for additional falls.

The resident at issue had all of these factors at play.  She had a history of multiple falls at home which preceded her admission to the nursing home, the last of which resulted in compression fractures in her thoracic spine.  Further, she had a history of stroke with residual left-sided weakness as well as Parkinson’s.  Her Minimum Data Set showed that she required assist of two staff members for most mobility activities.  She further had a diagnosis of dementia and the staff recognized that she experienced confusion and was impulsive.  In short, this resident was at high risk for falls and was properly assessed at the start of her admission as being at high risk for falls.

Having assessed her as being at high risk for falls, the care plan consisted of placing a “Call, Don’t Fall” sign in her room, placing the call light and personal items within reach, use of appropriate footwear and/or gripper socks, and a referral to physical therapy and occupational therapy.

Prior to the fall at issue, the resident experienced seven falls without serious injury.  Additionally, there were at least three times where the staff found her transferring herself without assistance.  Havin incidents such as these where there are falls and residents self-transferring without help but with no injury resulting is good luck, not good care.  Reliance on good luck to assure the safety and well-being of nursing home residents is not a formula for success.

When a nursing home resident sustains a fall this should trigger some additional steps: a 72-hour fall watch, physician notification, and revision of the fall prevention care plan.  Only one of these falls resulted in an updating of the care plan, and this consisted of placing additional “Call, Don’t Fall” signs within her room.  Needless to say, this was not an effective measure, given her level of confusion and impulsivity.

On the morning of this nursing home fall, the resident was woken up by a nurse who was passing medication.  The nurse told the resident to open her eyes because breakfast was coming soon.  The nurse went on to the room next door.  While she was there, she heard screaming coming from the resident’s room.  The resident had gotten out of bed to go to the bathroom.  Urine was found soaking the bed and the floor nearby.  The resident told staff that she was trying to get clothes from her closet.

The resident was brought to the hospital where she was diagnosed with a fractured hip and a brain bleed.  The fractured hip required an open reduction and internal fixation surgery, and the brain bleed required the placement of a drain to remove the blood which was putting pressure on the brain.

The overall picture here shows a failure of the nursing home to respond in an effective way to the falls that occurred.  The final steps of the care planning process are evaluating the effectiveness of the care plan and revising it if it proves ineffective in practice.  When a resident has seven falls and three other incidents where they were known to self-transfer when they required higher levels of assistance, this is a sign that the care plan in place was not working and the only revision made to the care plan was to place additional signage which the resident was not heeding anyway.

Further, waking the resident up and then not being in a position to assist with one of the basic needs one has upon waking up in the morning (going to the bathroom) was foolish and likely led directly to the resident’s fall and injuries.  Effective rounding on residents includes not only checking on them, but assuring that their needs are met.  This was clearly not done in this instance.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Staff at Lutheran Home in Peoria drops resident from lift, resulting in fractured hip

Heritage – Mt. Sterling resident leg in fall

Mason City Area Nursing Home resident suffers fatal brain bleed in fall

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Pleasant Meadows Senior Living resident fractures hip and wrist in fall

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IDPH has cited and fined Pleasant Meadows Senior Living nursing home in Chrisman after a resident there was allowed to go to the bathroom without the required help and then fell while trying to get dressed, resulting in fractures to her eye orbit, her hip, and her wrist and a laceration to her head.

Nursing homes track a great deal of data concerning their residents.  Much of it is strictly for internal use, but one piece – the Minimum Data Set, or MDS – is reported outside the facility.  It is submitted under penalties of perjury to the federal government because the information that is in there forms part of the basis by which nursing homes are paid.  It tracks information concerning the physical abilities and deficits of residents, as well as the levels of care that the nursing home is in fact providing to the resident.

For this resident, the MDS showed that the resident required the assistance of one staff member with transfers, walking, dressing, and toileting.  It further reflected that the resident was not steady, used a walker, and was only able to stabilize with the assistance of staff while turning around, moving off/on the toilet, and for surface to surface transfers.  The MDS also showed that she had severe cognitive impairments.  This is a resident who was clearly at high risk for falls – she had well-documented issues with balance and mobility and also had severe cognitive impairments where she could not be counted on to follow instructions or make good decisions for her own safety.

On the day of this nursing home fall, the resident was walking to the dining room for lunch with an aide.  The resident told the aide that she needed to use the bathroom.  The aide allowed her to go the restroom unattended and unassisted.  Shortly thereafter, a scream was heard and the resident was found on the floor of a different resident’s room with another resident’s pants half on.  The resident’s own pants were found on the floor of the bathroom.  Apparently the resident needed to change pants after using the bathroom and went into an adjoining room and took another resident’s pants and fell while putting them on.

When she was discovered on the floor, there was blood pooling on the floor from a cut to the head.  The resident was sent to the hospital where she was diagnosed with a fractured orbital bone, a fractured hip, and a fractured wrist.

The basic issue with the care that was provided is that the resident required assistance with transfers, toileting, and walking.  She was also unsteady when moving off and on the toilet.  She required assistance with getting dressed.  The aide knew that she was going to the bathroom – a time when she needed help getting on and off the toilet.  She also needed help with dressing – something that was necessary after she apparently got her pants dirty or was otherwise unable to get them back on after going to the bathroom.  Because the resident was left to handle all of these tasks without help when she needed, the fall and injury resulted.

When you have staff that is stretched too thin to provide necessary supervision and help to residents to avoid accidents, this raises fair questions as to whether this was an understaffed nursing home.  Unfortunately, understaffing a nursing home is a basic feature of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Failure to follow care plan leads to fall and fractured hip at Piatt County Nursing Home

Unlocked furniture causes fall and broken leg at Mt. Vernon Countryside Manor

Unsupervised resident at Odd Fellow Rebekah Home in Mattoon suffers brain bleed in fall

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Unsupervised resident falls and fractures hip at Lutheran Home for Aged in Arlington Heights

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IDPH has cited and fined Lutheran Home for the Aged nursing home in Arlington Heights after a resident there suffered a fractured hip in a fall.

Falls are a major source of mortality and loss of quality of life for the nursing home population.  They are also addressed in federal regulations which require that nursing home residents receive supervision and assistance necessary to prevent accidents.  A fall is a form of accident.  Because of this, falls prevention is a serious area of focus in the long-term care industry.

There are two major factors that make residents at risk for falls.  These include (1) some form of musculoskeletal, gait, or balance dysfunction which place a resident at risk for losing balance or falling and  (2) some form of cognitive impairment, dementia, confusion, or general poor safety awareness.  Cognitive issues feed into fall risk because the resident cannot be counted on to follow instructions or make good decisions for their own safety.

The resident at issue was wheelchair bound and had a history which included cognitive impairments due to developmental delay.  He had a history of falls and it is well-recognized in the long term care industry that falls tend to beget additional falls.  It was also well-known to the staff that reminding the resident to use the call light, to not try to stand unassisted, or to ask for help did not work due to his cognitive impairments, as there had been multiple incidents where he did not heed reminders which did not result in falls.

On the day of this nursing home fall, the staff heard the resident screaming in room.  When they responded, they found him on his floor in obvious pain.  The medical record notes he either slid from his wheelchair trying to get his mask off the floor or he stood to get the mask.  In either event, he fell to the floor.  He was sent to the emergency room where he was diagnosed with a fractured hip and underwent surgery.

The basic shortcoming in the care that this resident received was an issue of inadequate supervision.  It was well-known to the staff that he resident could not be relied upon to ask for assistance, use a call light, or otherwise follow instructions.  Despite this, the resident was placed in a room far from the nurse’s station when placing residents who need closer levels of supervision are customarily placed in rooms closer to the nurse’s station.  Further, residents who need closer supervision are commonly placed in common areas such as the hallway adjacent to the nurse’s station, the dining room, or a activity/common room where one staff member can watch several residents at once.  Short of that a rigorously followed rounding schedule is the fallback.  Without these measures being taken, the safety of the resident is at the mercy of the cognitive impairments of the resident, as they cannot be counted on to make good decisions for their own safety.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Addolorata Villa resident suffers fractured hip in fall

Resident suffers jaw, facial fractures in fall at Dimensions Living in Prospect Heights

Inverness Rehab resident suffers multiple fractures in fall

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Staff at Bella Terra Schaumburg knowingly uses broken lift, resulting in brain bleed for resident

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IDPH has cited and fined Bella Terra Schaumburg nursing home after the staff there knowingly used a mechanical lift with a broken attachment to the sling.  This led to a resident being dropped from the lift during transfer and suffering a brain bleed.

Used properly, a mechanical lift is a useful tool for caring for nursing home residents.  They allow residents to be moved safely from bed to wheelchair, wheelchair to chair or toilet, etc.  They allow residents to be moved safely while being bathed.  They also prevent injuries from being twisted while being moved manually.  They save wear and tear on the backs, knees, shoulders, and so forth of the staff and help prevent injury to staff as well.  Useful tools indeed!

The key phrase in that first sentence of the paragraph above is “used properly.”  When not used properly, they set the stage for serious injury to the resident.  Proper use includes having two staff members operate the lift (see here, here, here, here, and here for examples of what happens when one person does a two-person job); it includes safe operation of the lift itself (see here and here for examples of what happens when the lift isn’t used properly); and it includes making sure that the lift itself is in good condition and that all of the slings and accessories are in good condition and appropriate for use (see here, here, and here for examples for when that is not true).

The only proper course of action when the lift and all of its equipment is not in proper shape is to take it out of service.  This is what happens when the staff decides to soldier on using equipment it knows was defective.

The resident at issue had multiple long term conditions and required all transfers to be done with a mechanical lift.  One week before this nursing home fall, the staff on the third floor (where this resident was housed) saw that the clip which attached the sling to the lift arm was broken.  They notified the Director of Nursing who inexplicably told them to continue using the lift.

According to the citation, there were 13 residents on the third floor who required mechanical lift transfers.  Each of these residents likely required several transfers each day.  And for each transfer, the staff made a choice to continue using equipment which it should have recognized as being unsafe for use with the residents.  And for a time, they got away with it.

But good luck is no substitute for good care, and eventually the luck ran out, and it was this resident who paid the price.

The resident was being transferred when the slings lipped loose from the lift arm, causing the resident to fall to the ground.  She was taken to the hospital where a head wound was closed with staples and the resident was diagnosed as having suffered a brain bleed.

This injury was highly preventable, and worse the hazard which caused the injury here was known not just to staff, but management as well.  And management ordered the lift to continue to be used.  This is utterly inexcusable.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Bella Terra Elmhurst resident fractures hip, dislocates knee is fall

Resident falls and fractures hip and Lutheran Home for Aged in Arlington Heights

Symphony of Buffalo Grove resident has catastrophic fall from lift

Glenview Terrace resident suffers multiple fractures when lift topples over during transfer

Grove of Skokie resident breaks leg due to violation of care plan

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

 

Resident left unattended in dining room at Ascension Saint Anne Places suffers fractured hip in fall

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IDPH has cited and fined Ascension Saint Anne Place  nursing home in Rockford after a resident there suffered a fractured hip in a fall after he was left unattended in the dining room.

Falls are a major concern in the long-term care industry because of the serious negative effects they have on mortality and the long-term quality of life for nursing home residents.  Because of this, they are a regular focus in the care planning process.

Nursing homes use a variety of tools to assess a resident’s fall risk.  Some of the major factors are a recent history of falls, as it is well-recognized in the long-term care industry that falls tend to beget additional falls; balance, gait, or musculoskeletal dysfunction; and some form of cognitive impairment, dementia, constant or intermittent confusion, or general poor judgment or awareness for one’s own safety or limitations.  The cognitive impairment factor is crucial because this means that a resident cannot be counted on to follow instructions or to make good judgments or decisions for his or her own safety.

Federal regulations pertaining to falls in nursing homes provide that residents must receive supervision and assistance necessary to prevent accidents.  Falls are considered accidents under the regulations.

Close supervision of the resident is a mainstay of any fall prevention strategy in a nursing home.  One of the common ways of providing supervision to residents is to gather them in areas where several residents who require supervision can all be watched at the same time by a limited number of staff people.  Common examples of this would be to gather residents in an activity room, near the nurse’s station, or in the dining room.

The resident at issue was admitted to the nursing home after suffering a subdural hematoma in an earlier fall.  Once at the facility, he was assessed as a fall risk due to cognitive impairments, and the need for extensive assistance of staff with transfers and the use of a wheelchair and a walker for ambulation.

After arriving in the nursing home, he had two unwitnessed falls, both of which occurred in his room.  The circumstances surrounding each of these falls suggested that the resident got up from his wheelchair unassisted while left in his room alone.  After the second of the two falls, the resident’s fall prevention care plan was updated to include, “resident should not be left alone in his room in his wheelchair.”

On the day of this nursing home fall, one of the nurses was looking for the resident in order to check his blood sugar.  She was initially unable to locate the resident on his unit, but was able to determine that he had been brought down to the dining room.  She checked his blood sugar levels and found that they were 269 (elevated blood sugar levels – above 140 – are known to be a potential cause of confusion.  The nurse told the aide in the dining room to not leave the resident alone because he was a fall risk.

Shortly after this, the resident’s wife and son entered the facility.  His wife went to use the public restroom while his son went to the resident’s room.  On her way to the resident’s room, the wife passed by the dining room and saw a man laying on the floor and she recognized that it was her husband.  He later told her that he got up because everyone else in the dining room had left, so he thought that he should too.

A dietary aide discovered that the resident was on the floor and called for help.  The facility dietician responded and upon entry to the dining room discovered that there were no aides in the dining room.  The nurse was summoned to the dining room and encountered the aide that she had spoken to earlier.  That aide explained that he had taken another resident to their room and left the resident unattended in the dining room.

Paramedics were called to the facility and the resident was brought to the hospital where it was revealed that the resident had a fractured hip.

This is a case where the extent to which dementia/confusion plays into fall risk is clearly demonstrated.  The resident was not able to walk independently – he used a walker of a wheelchair as a matter of routine – but because of his cognitive impairment, he thought that it was appropriate for him to try to leave the dining room on his own when he was clearly not able to do so safely.  This is why close supervision of residents who have cognitive impairments is so crucial – because they cannot be relied upon to follow instructions or make good decisions for their own safety.  Sadly, the admonition from the burse to the aide to not leave the resident alone was not followed, and this fall and injury was the result.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Addolorata Villa resident fractures hip in fall

Failure to use gait belt leads to fall and fractured hip at Fair Oaks rehab in South Beloit

Rochelle Rehab resident breaks leg sue to unsafe use of wheelchair

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

 

 

Promedica Skilled Homewood resident falls and breaks hip

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IDPH has cited and fined Promedica Skilled Homewood nursing home after a resident there suffered a fractured hip in a fall.

Federal regulations pertaining to falls in nursing homes provide that residents are entitled to receive supervision and assistive devices necessary to prevent accidents.  Falls are a type of accident.

Because falls are addressed in the regulations this way and because falls have such a detrimental affect on the quality of life and well being of nursing home residents, they are a specific point of focus in the the care planning process.  There are a six basic steps to the care planning process: (1) an assessment of the risks to the health and well-being of the resident, (2) development of a written care plan, (3) communication of the contents of the care plan to those members of the care team charged with carrying it out, (4) actual implementation of the care plan, (5) evaluation of the effectiveness of the care plan on an ongoing basis, and (6) revision of the care plan if it proves to be ineffective in practice or if the resident’s care needs change.

Nursing homes use various tools to assess a resident’s fall risk, but there are two main factors that feed into fall risk: (1) some form of musculoskeletal weakness or gait, strength, or balance dysfunction and (2) intermittent or constant confusion, dementia, or general poor safety awareness or judgment.  These type of cognitive deficits feed into fall risk because the resident cannot be  counted on to follow instruction or make good decisions for their own safety.  A third, important risk factor is the occurrence of falls in the recent past, as it is well-recognized in the long-term care industry that falls tend to beget additional falls.

The resident at issue here was one who was clearly at risk for falls – she had well-documented musculoskeletal strength deficits, had significant cognitive deficits, and had another fall just days before the one at issue here.  Further, on the day of this fall, she was telling the staff that she wanted to leave.

The fall prevention care plan did include a number of interventions or steps intended to prevent falls, but none of them specifically addressed the issue of supervision of the resident.  Further, when asked by the state surveyor what steps were in place to prevent falls for this resident, the staff was unable to9 explain what interventions were actually in place.  For a care plan to work, it must have steps which are specifically tailored for the resident and the staff must know what those steps are.  Unless this is true, the staff is left to improvise what care is being provided to the resident where the care plan process is designed to provide the necessary care  is a systematic, routine manner.  Poor care plans lead to poor outcomes, and that was the case here.

On the night of this nursing home fall, the resident was given dinner and placed in bed by an aide who left the resident in her room with the TV on.   Normally, a sitter would be present, but the sitter was a no-show the night of this fall.  There was no provision for that added level of supervision, especially in light of the resident’s earlier comments that evening that she wanted to leave

The aide left to provide care to other residents.  While she was providing care to other residents, she was notified that the resident had fallen and was in the hallway.  The resident had apparently left her room by the nurse’s station and walked halfway down the hallway before her legs gave out from her, as had happened in her earlier fall and as has been seen during physical therapy earlier. The resident was brought to the hospital where she was diagnosed with a fractured hip.

There were a number of shortcoming in the care that this resident received.  First the care plan did not provide for the regular, systematic supervision and observation that was necessary for a resident who this set of known behaviors and risks.  Second, the fact that this resident had been verbalizing a desire to leave the nursing home was a warning sign that she was likely to get up and try to act on that, but nothing was done to mitigate the risks that were present that night.  Third, the sitter who was a regular part of the care team was not present.  Fourth, even minimal supervision was not provided as this resident was able to get up out of bed, walk out of her room, and then go halfway down the hallway before she was discovered – to say nothing of how long she was on the floor before she was actually discovered.

When a nursing home is unable to provide residents with the necessary supervision, that is a sign that this is likely an understaffed nursing home.  Unfortunately, short-staffing a nursing home is a basic part of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Landmark of Richton Park resident dropped from lift, breaks both legs

Failure to provide required assistance leads to fall and broken arm at Bria of Palos Hills

Prairie Manor resident suffers brain bleed after being rolled out of bed by staff

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Unsupervised resident at Odd Fellow Rebekah Home falls and suffers brain bleed

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IDPH has cited and fined Odd Fellow Rebekah Home in Mattoon after a resident there was left unsupervised and fell, suffering a brain bleed.

Federal regulations pertaining to falls in nursing homes provide that resident must receive supervision and assistive devices necessary to prevent falls.  Supervision is a key factor because one of the main factors that place nursing home residents at risk of falling and suffering injury is dementia, cognitive deficits, or general poor safety awareness.  This leads to falls because residents with these issues cannot be counted on to follow instructions or make good decisions for their own safety.

One of the basic strategies for providing the necessary supervision is to keep the resident in an area where their actions can be easily monitored.  Often this is by the nurse’s station or in a dining room or activity room where one or more staff members may be assigned to watch over several residents at once.  This strategy is often incorporated into the resident’s fall prevention care plan.  However for this strategy to be effective, the supervision must in fact be provided.

The resident involved was recognized as a fall risk due to a number of factors, including cognitive impairments, unsteadiness of his feet, gait and mobility abnormalities, and muscle weakness.  He used a wheelchair.  The resident’s Minimum Data Set (MDS) recorded that the resident was unsteady when rising from a seated to a standing position.  The resident also had two falls in the first week of his admission to the nursing home, and one well-recognized fact about nursing home falls is that falls tend to beget more falls. In short, this resident was at serious risk for having a fall.

To address this risk, the staff moved the resident in his wheelchair to the nurse’s station.  This was a solid strategy for fall prevention.  In this facility, the nurse’s station was across the hall from the physical therapy gym, which has a window.  The physical therapist on duty at the time saw the resident’s head pop into view through the window and disappear rapidly.  Concerned that there was a nursing home fall, the therapist went out into the fall and saw the resident on the floor, bleeding from a wound on the head.  There was no staff at the nurse’s station or anywhere nearby.

The resident was sent to a local hospital where scans showed that he had a brain bleed.  He was immediately transferred to another hospital to receive a higher level of care.

Here, the staff took the right first steps in recognizing that the resident was a fall risk and bringing him to be watched at the nurse’s station.  However, there was no one actually watching him when he fell.  This is a violation of federal regulations which require that the resident receive supervision necessary to prevent falls.  Sadly because the necessary supervision was not in fact being provided, this resident had a very predictable fall with serious injuries resulting.

This is all the more unfortunate because this is the second time in the last few months that a resident at this facility has suffered a fall with a brain bleed as a result.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Unlocked furniture causes fall and broken leg at Mt. Vernon Countryside Manor

Moweaqua Rehab resident fractures hip in fall

Charleston Rehab resident suffers brain bleed and fractured hip in fall

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Unlocked furniture causes fall and broken leg at Mount Vernon Countryside Manor

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IDPH has cited and fined Mount Vernon Countryside Manor after a resident there suffered a fall with a fractured leg after he leaned against his bed which rolled away from him due to the wheel locks not being applied.

The resident at issue was admitted to the nursing home  after falling and suffering a fractured hip at home.  He underwent surgical repair of the fracture and entered the nursing home as a short-term rehab patient with the expectation that he would be returning home after recovering from his injury and the surgery.

During the course of his admission, he became ill and was also diagnosed with covid.  He was sent to the hospital and upon discharge was assigned to a new room where he was under quarantine due to the recent hospital admission and the covid diagnosis.

In preparation for this, the housekeeping staff was instructed to move a bed into the resident’s new room.  However, after the bed was put into place, the wheel locks were not applied.

Having furniture in a nursing home setting locked into place is a key safety measure as many nursing home residents with strength, gait, or other mobility deficits will use pieces of furniture to support themselves and maintain balance.  Further, nursing home resident are far less likely to recover their balance if it is lost when a piece of furniture they were relying on for balance rolls away from them.

Not only is keeping furniture locked and in place a common-sense safety measure, it is also consistent with federal regulations.  Federal regulations pertaining to falls require that nursing homes be kept as free of accident hazards as possible, and unlocked wheels on a piece of furniture represents a significant safety hazard.

On the day of this nursing home fall, the resident had just returned that day from the hospital admission.  He was alone in his room in a wheelchair.  he got up from the wheelchair to put his mail on the nightstand and leaned on the bed as he did so.  Because the wheels were not locked, the bed rolled away from him and he fell.

Initially he refused to go to the hospital, so x-rays were done at the nursing home which showed that he had a fracture of the femur just below the prosthesis from his recent hip fracture.  The resident refused to have additional surgery on it and elected to be admitted to the nursing home for comfort care.

This was a highly preventable injury with devastating consequences.  Keeping wheels locked in place is a basic, common-sense safety measure, but this was not done here.  As a result, the resident suffered a fracture which was especially significant due to his recent injury at home as well as its location.  Its location near the prosthesis meant that the surgery to repair the fracture would be complex and difficult.  It is unlikely that this resident will ever bear weight again in any meaningful way and will be subject to a host of complications that are associated with immobility including a general acceleration of his decline, pneumonia, and bed sores.

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.

Other blog posts of interest:

Aperion Care Fairfield resident injured by falling television set

Resident rolled from bed, breaks leg at Stonebridge Nursing & Rehab in Benton

Odd-Fellow Rebekah Home resident suffers fatal brain bleed due to fall

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

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