F0689

G

Failure to Prevent and Adequately Account for Resident’s Multiple Traumatic Injuries of Unknown Origin

Hillside, Illinois Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect and prevent a cognitively intact resident from sustaining injuries of unknown origin, including multiple fractures and intracranial and intra-abdominal hemorrhages. The resident was admitted with significant medical history including an unstable burst fracture of T11–T12, hepatic encephalopathy, cirrhosis, pancytopenia, and a history of falls and alcohol dependence. The resident’s primary language was Spanish, and the most recent MDS documented a BIMS score of 15, indicating intact cognition, with use of a wheelchair for ambulation and a need for supervision or touching assistance for transfers. Therapy records and staff interviews consistently indicated that the resident could not walk independently, could not transfer independently, and required substantial/maximal assistance and a transfer device with two staff for transfers. Despite this, the resident’s fall risk assessments categorized him as low risk for falls, and the physician later stated that the resident should never have been rated low risk and that he was high risk for falls.

On the day of the incident, the resident complained of left shoulder and left leg pain with limited mobility and inability to move the affected extremities. A CNA who spoke Spanish reported that the resident stated he had slept on his left side for a long time and requested help to turn; she assisted by pulling the incontinent pad to reposition him and notified the RN. Another CNA assigned to the resident that morning observed him in pain, with a swollen left arm, and heard him indicate pain in the left arm, again with the explanation that he had been lying on his left side. The RN assessed the resident, noted extreme pain and numbness in the left upper extremity and limited mobility in the left arm and leg, and obtained orders from the NP to send the resident to the ER to rule out stroke. The EMS run sheet documented that the resident complained of left shoulder and hip pain that began the previous night and denied any falls or trauma. The facility’s initial incident report recorded that the resident denied anyone hurting him and stated he felt safe at the facility.

At the hospital, diagnostic imaging revealed multiple acute and chronic fractures, including an acute comminuted and displaced left humeral head fracture, bilateral subcapital femoral neck fractures, sacral fractures, a right L4 transverse process fracture, a small left subdural hematoma, a right parietal subarachnoid hemorrhage, intra-abdominal hemorrhage, and bruising to the anterior chest wall and left shoulder estimated to be 3–4 days old. The ER RN, who spoke Spanish, reported that the resident initially said he did not remember what happened, and hospital documentation noted that at one point he accepted that somebody hurt him but was reluctant to provide details due to fear of police involvement or other social reasons. A facility liaison later interviewed the resident in the hospital; the resident stated he had been doing exercises in bed, felt stronger than normal, attempted to get out of bed, fell toward the window side, and was assisted back to bed by staff, but he reported no pain at that time and said he did not want anyone to get in trouble. During a subsequent in-facility interview with an interpreter, the resident stated he did not know what happened, did not remember falling, and only recalled waking up in pain and being sent to the hospital.

Throughout the facility’s internal investigation, multiple CNAs, LPNs, and RNs who worked with or around the time of the incident denied witnessing any fall or knowing what happened to the resident, and no fall incident report could be produced. Staff interviews consistently described the resident as unable to get out of bed, unable to sit on the edge of the bed or scoot, and requiring two-person assistance with a transfer device for any out-of-bed activity. The physician and NP both stated that the resident had not been able to walk since admission and could not independently get up from bed or dangle his feet to exercise. The physician opined that the resident’s injuries were consistent with a fall and that he was a high fall risk. The administrator and DON maintained that the resident did not fall based on staff interviews, and one CNA who worked the night before the resident’s complaints denied picking the resident up from the floor. However, when shown pictures of night CNAs, the resident identified that CNA as the person who picked him up from the floor. The facility’s abuse prevention policy defined injury of unknown source as an injury not observed and not explainable by the resident, with suspicious extent or location, and the facility concluded that none of the staff knew what happened or the cause of the resident’s injuries.