State fines nursing homes over falls

Injury fatal for one resident, report says

by David C.L. Bauer

Two west-central Illinois nursing homes were among those fined by the Illinois Department of Public Health after one resident was injured and another died, according to the department’s quarterly report released Tuesday.

Aperion Care Jacksonville, a 113-bed skilled care facility at 1021 N. Church St., was fined $25,000 for failure to provide supervision and implement intervention for a resident to prevent multiple falls, according to the state.

Pittsfield Manor, an 89-bed skilled care facility at 610 Lowry St. in Pittsfield, was fined $25,000 for failure to provide supervision to prevent a fall, according to department records.

According to Illinois Department of Public Health documents, policies and requirements were not followed and that resulted in a resident falling, lacerating her head and suffering a fracture that required surgery and the pinning of her hip.

When the woman was admitted to the facility in 2018, it was determined she was at risk for falls, according to the state, but “the facility failed to implement effective interventions and provide supervision to prevent injury for multiple falls.”

At Pittsfield Manor, according to Illinois Department of Public Health documents, the facility also failed to provide supervision to prevent falling for a resident, resulting in her falling, hitting her head and being sent to the emergency room.

The resident suffered “a traumatic skull fracture, subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and subdural hematoma (a pool of blood between the brain and its outermost covering) that caused her death.”

The woman had been admitted to the facility in February and had been diagnosed with Alzheimer’s disease, a history of falls, unsteadiness, anxiety and vertigo.

The state documented a series of falls that occurred although the resident was urged to use a call light to get staff assistance. In the days before the most significant fall, nursing home staff reported she required more assistance and complained more often of headaches and dizziness.

In June, the woman was taken from the facility for a dental appointment, according to the state’s report. A nurse’s aide and bus driver called a few hours later and said the woman had fallen and was taken to the emergency room, where she was diagnosed with a brain bleed. The diagnosis was that the woman would “likely soon pass related to the intracerebral hemorrhage.”

She died about three days later, according to the report. The cause of death was “blunt force trauma” resulting from “falling and striking head on ground.”

Both facilities were cited with type “A” violations of the Nursing Home Care Act and processed between October and December. An “A” violation pertains to a condition in which there is a substantial probability that death or serious mental or physical harm will result or has resulted, according to the Illinois Department of Public Health.


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State fines nursing homes over falls