Nursing Home Fined $100,000 After Resident Died From Brain Injury After Botched Wheelchair Transfer

A nursing home has been fined $100,000 after state officials concluded that poor care led to the injury and death of an elderly resident who fell and injured his head.

The penalty is the state’s most severe, officials said.

The case involved an 83-year-old man, who on the morning of Jan. 4, 2007, lost his balance and struck his head on a bed rail when he was being moved from his bed to a wheelchair. The man had a short-term memory problem and had impaired cognitive skills, and relied on nursing staff for dressing; state officials said the facility failed to provide adequate support for the resident as he was transferred to his wheelchair.

At 8:30 a.m., about half an hour after the blow to the head, nurses' notes documented the man had a bluish discoloration on the left side of his head. Staff monitored the patient’s condition as the attending physician was paged at 8:45 a.m. and 12:30 p.m., but the doctor did not return the call.

His condition continued to deteriorate throughout the day; he refused lunch and dinner and complained of not feeling well. At 8:30 p.m., he was observed as lethargic. Finally, at an unspecified time, an attending physician was reached, and the patient was transferred to a hospital at 9:30 p.m.—more than 13 hours after he had struck his head. The patient had suffered bleeding in the brain and died five days later.

Investigators said the licensed nurses should have called either an alternate physician or the medical director when the attending physician did not respond to pages, or call 911 in an emergency.

“Failure of the facility staff to immediately notify the physician and to provide the necessary care and services to Resident 1 [the patient] ... presented a substantial probability that serious harm would result, and did result to Resident 1 [the patient’s] death,” the report said. For more, read the story.


Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia.