Category Archives: Fall Prevention

The family of Barbara Jones-Davis is suing Wesley Enhanced Living assisted living facility because the facility’s negligence resulted in their loved one’s death. The resident, who was visually impaired and suffered from dementia, was allowed and able to leave the facility unsupervised and was killed after falling from the second floor onto a sidewalk.

The incident happened July 2018 when Jones-Davis opened an unguarded and unlocked door on the side of the facility and wandered outside alone. The door Jones-Davis used to exit allegedly had an alarm, but surveillance video shows no one from the facility responded to the alarm for 25 minutes  She was outside for 23 minutes until she walked to the edge of the property and fell almost two stories onto the sidewalk. An employee allegedly later closed the door without inspecting the property for any residents who may have left.

Jones-Davis was found alive by a passerby and was taken to the hospital where she later died.  The facility allegedly learned of the incident about an hour later when a nurse was notified.

“Wesley Enhanced Living at Stapeley and its security contractor, U.S. Security Associates, were both negligent and grossly negligent for failing to put the appropriate systems, processes, and precautions in place to prevent such an event from happening, especially where similar instances involving unsupervised residents who wandered from the facility had occurred previous to this tragedy,” alleges the suit.

Officials with the Pennsylvania Department of Health and Human Services say there have been three recent incidents where residents have left the facility unsupervised, according to the lawsuit.

McKnight’s reported on the tragic death of a resident in Minnesota.  The assisted living facility was negligent using a mechanical lift and sling to transfer a vulnerable adult from an electric wheelchair to a bed after the resident sustained a head injury and died two days later. GoldPine Home “failed to adequately train staff, failed to determine the appropriate sling size, and failed to maintain the mechanical lift according to manufacturer’s recommendations,” the Minnesota Department of Health said in a 29-page report issued Dec. 26.

According to the health department report, two unlicensed workers were involved in the Aug. 7 evening transfer of a resident (not identified in the report) who had multiple sclerosis and was taking warfarin, a blood thinner, due to a history of a blood clot. During the transfer, the resident reportedly slipped out of the sling opening, hit his or her head on the leg of the lift and began bleeding from the head.

The resident died in a hospital two days later. “The death certificate indicated that as a consequence of falling from the mechanical lift, s/he died of a traumatic subdural hematoma (burst blood vessel). Contributing factors included warfarin therapy,” the report stated.

During a staff interview, it was determined the preventative maintenance of the mechanical lift had not been performed,” the report said. “There was not a system in place to ensure the appropriate size sling. In addition, staff did not sign off when trained on the mechanical lift policy.”



The Telegram reported that Beaumont Rehabilitation & Skilled Nursing Center nursing home has agreed to pay $1 million to settle a wrongful death lawsuit filed after a resident died from injuries she suffered in a fall that should and could have been prevented.

Candilou C Hitchcock filed the lawsuit in 2017 after her mother, Betty “Betsy” (Ford) Crane, fell while residing at the nursing home on July 29, 2015, and died Aug. 7 of blunt force head trauma.  Ms. Crane, who suffered from dementia and had a history of at least 21 falls while at the facility, suffered the fatal fall after an employee forgot to turn on the alarm on the woman’s chair to notify staff when she got up.

The nursing home further failed to notify the physician or nurse practitioner, delaying seeking hospital care; and failed to inform the state Department of Public Health as required, Ms. Hitchcock maintained in the lawsuit


An assisted-living facility has been found negligent in the death of a woman who hit her head after falling out of a mechanical lift in August. The Minnesota Department of Health reported the incident at GoldPine Home after conducting a visit to the facility in September and completing its report in November.  In its findings, the DOH said “the facility failed to adequately train staff, failed to determine the appropriate sling size, and failed to maintain the mechanical lift according to (the) manufacturer’s recommendations.”

A representative with the Department of Health interviewed the workers involved in the incident on Sept. 13. The department held another interview 11 days later with the facility’s director of nursing, who indicated one of the workers involved with the incident was no longer an employee with GoldPine.

According to the report, the resident who died was in a wheelchair when an unlicensed worker attached the sling of the mechanical lift at about 9:30 p.m. on Aug. 7. Another unlicensed worker came to help transfer the resident from the wheelchair to the bed using the lift.

While they were moving the resident from the wheelchair to the bed, the resident slipped out of the sling and hit her head on the leg of the mechanical lift. The report said the lower half of the resident’s body was still in the sling when she struck her head.

The workers applied pressure to the wound and called for assistance. The resident died two days later after being taken to the emergency room and then to a hospital for care.  The woman’s death certificate listed the cause of death as traumatic subdural hematoma (burst blood vessel) that resulted from the fall.


Sonja G. Anderson, as executor of the estate of Delores A. Anderson, filed a complaint in West Virginia against Heritage Center and Genesis Healthcare LLC, alleging violated a nursing home resident’s rights.

According to the complaint, the plaintiff alleges that during Delores Anderson’s residency at defendants’ nursing home facility beginning in Dec. 16, 2017, she suffered multiple falls resulting in nondisplaced left inferior and superior pubic rami fractures, multiple left forearm contusions, skin tears and left frontal scalp hematoma. She passed away on March 14, 2018.

The plaintiff holds Heritage Center and Genesis Healthcare LLC responsible because the defendants allegedly failed to provide an environment free from abuse, neglect and mistreatment and free from accident hazards, and failed to provide adequate and appropriate supervision and assistance.

The plaintiff requests a trial by jury and seeks all damages, attorney’s fees, costs and such other relief that is fit to award.

The Chronicle Herald reported the tragic abuse suffered by Thelma Irene Lake at Haliburton Place.  Lake was forcibly placed and tied into a geriatric chair with a restraint. The Health Department investigated and confirmed the abuse.  Even though it’s been nearly two years since 91-year-old Thelma Irene Lake died, her daughter Marlene Hill tears up remembering what she calls the abuse her mother suffered.

“Her only crime was she wanted to use the bathroom,” says Marlene Hill.  Her mother had dementia and spent the last seven months of her life in the nursing home. She was still walking but unable to talk or ring the call bell in her room.

One November night in 2016, Thelma Lake tried to get out of bed several times to get to the bathroom. She shared the room with a 43-year-old woman named Terri Dean. Dean told Marlene Hill that she rang her mother’s bell looking for assistance because she was concerned Thelma might fall. The investigation found some documentation that said she was “at risk for falls.”

According to Dean, a nurse and a male continuing care assistant arrived but they did not take Thelma to the toilet. Instead, they forcefully removed her diaper and tied her roughly into a geriatric chair using a “posey” restraint — essentially, a rectangular piece of fabric placed around the waist with strings that are tied to the back of the chair. Dean told the investigator she heard one worker say, “We are not allowed to use this,” and another confirming, “No, we aren’t,” while continuing to tie her roommate.  Thelma was crying and continued to cry after being dragged out of the room in the chair shortly before 1 a.m. Notes from staff indicate the woman spent four hours and 15 minutes in the chair next to the nursing station.

Restraining a resident is a safety measure of last resort in consultation with the resident (if competent), or with the family. The report found no care plan or consent on file for the senior. Restraints are also to be used for the shortest time possible. In this case, they included the posey and a table tray similar to a child’s high chair.

Hill says she was told by a nurse her mother sometimes received an antipsychotic drug called Haldol to settle her. Dizziness can be a side effect and Haldol is not usually recommended for geriatric patients.

Staff admitted they took these actions to protect “the safety” of the resident.

The investigator ordered Haliburton Place to provide education on the use of restraints to the staff involved in the Thelma Lake incident and to “any other staff who require it.” The nursing home was told to train staff on the definition of abuse, signs of abuse, and how to report it.

Meanwhile, on Friday March 3, 2017, she and her sister called the attention of the registered nurse and licensed practical nurse to their mother’s leg, which was red and swollen from the knee down. Hill, who had previously worked as certified nurse assistant, wondered if it was related to cellulitis or shingles. Both were ruled out.

On Sunday afternoon, nursing notes show a licensed practical nurse reported Lake was short of breath. The nursing assessment mentions the red area on the leg had decreased, while swelling remained. By the morning of Monday, March 6, notes indicate Lake was still experiencing shortness of breath and was “clearly not herself.” Two phone calls to the attending physician who worked in the same building went unanswered.  Thelma Lake passed away at noon.

Nurses on the Monday shift told the investigator they never received information from nurses on the Friday shift concerning Thelma’s leg, and if they had, they would have summoned the doctor much sooner. It was determined Lake died as the result of a blood clot.

“My mother was a human being,” says Marlene Hill. “Blood clots are treatable. Just because she was 91 years old doesn’t mean she shouldn’t have got the medical attention the problem deserved. I don’t think anyone would have called the doctor to check on Mom if my sister hadn’t happened to drop in that morning.”



Another elderly woman died after suffering from a preventable fall at a nursing home.  Her premature death has been ruled a homicide because she fell during an altercation with another resident, the York County Coroner said. The coroner’s definition of homicide means death at the hands of another person. Law enforcement determines whether such deaths are criminal. The facility failed to properly supervise the residents.

Nancy Young died from a left hip fracture resulting from a fall. She was a resident at the Pleasant Acres Rehabilitation & Nursing Center in Springettsbury Township.  An investigation showed that Young fell sometime after dinner on Dec. 8 during an altercation between another resident and Young. Young fell and broke her hip, resulting in her death a week later, the coroner wrote.

Young had entered another resident’s room, which resulted in a verbal altercation, Gay said. It was not witnessed by anyone else.  Both Young and the other resident have severe dementia. Young walked into the other resident’s room, and the resident screamed and slammed the door shut.  It wasn’t clear if Young fell because the door hit her or because she was startled. The staff heard Young’s call for help and went to her aid, Gay said.

The County of York sold the nursing home to Premier Health Care Management earlier this year for $30.8 million cash.

U.S. News reported that the family of an 86-year-old woman who suffered a wrongful death following a fall is suing a nursing home for $1.27 million. On Dec. 24, 2015, the woman fell while getting out of bed, striking her head on the sink and tile floor.  She died later that night. The Oregon Department of Human Services found in a subsequent investigation that staff acted negligently and failed to provide necessary care and a safe environment.

The lawsuit claims that although the woman’s care plan required at least one person to help her out of bed and to use the restroom, the staff repeatedly didn’t respond in time to help the woman.  This is a violation of the doctor’s orders and safety standards.  The Statesman-Journal reports the wrongful death lawsuit, accuses the staff at Avamere Court of negligence and abuse of a vulnerable person.




A new Labor Department rule, which would ease restrictions on teenagers’ use of mechanical  lifts in nursing homes, has passed presidential review.  Last month, the White House’s Office of Management and Budget completed its initial analysis of the proposed regulation. “Expanding Employment, Training and Apprenticeship Opportunities for 16- and 17-Year-Olds in Healthcare Occupations Under the Fair Labor Standards Act” would drop the age required to operate power-driven lifts in nursing and other healthcare facilities, Bloomberg Law reports.

The proposed rule was first sent to the White House for review July 14, and the OMB has since met with union officials, patient advocates and medical professionals to gather feedback. No draft of the legislation has been made public at this stage.

Members of the provider and business communities have favored the chance to broaden employment opportunities for teens to help fill vacancies, Bloomberg notes. Experts and consumer advocates worry that teenagers do not have the experience, training, or education to provide custodial care to elderly vulnerable residents, and may lead to injuries and even abuse.  But others have worried that the rule change could place young workers in danger. A group of 47 House democrats sent a letter to the heads of the OMB and the Department of Labor last month, urging them to pump the breaks on the idea.

“Weakening protections for young workers could reverse the progress of lowering fatalities among young workers and further jeopardize their health and safety,” representatives wrote in August.

Redwood Springs Healthcare Center nursing home will pay $100,000 to the state’s department of public health after staff caused the death of a resident.  Redwood was given a Class “AA” citation — the most severe penalty under state law.  The patient suffered a preventable fall and injured her head. Doctors at the hospital told the family the fall caused the patient’s brain to swell. The injury resulted in her death.

An investigation into the complaint found there were “deficiencies” that directly led to the death of a patient at the facility.  During the investigation, they discovered that “the facility failed” to provide adequate supervision to an 81-year-old woman while she was using the toilet.

Following the patient’s fall, family said they called the facility to check on the woman. Staff told a family member the woman was “doing great.” However, when family went to visit the woman on Aug. 31 they said the woman wouldn’t wake up and was covered in sweat.

“The nurse said ‘she’s probably just tired from the fall,’” the complaint stated. “My sister called me and said we need to get her back to hospital.”

“They [the facility] shouldn’t have left her,” stated in the complaint. “They knew she couldn’t sit up on her own.”

Staff told CDPH investigators the woman fell when one of the two the Certified Nursing Assistant helping the woman turned around to pick up clothes.

According to the complaint, the patient needed two people when using the toilet.

Ultimately, investigators found that staff “failed to supervise [the woman] while she was using the toilet. This failure resulted in her falling and hitting her head on the floor, causing bleeding inside her skull.”