A Quebec coroner has determined that a 97-year-old woman’s death after falling from her bed at a Montreal long-term care facility was accidental. However, the report highlights serious concerns over staff handling of the incident.

Angelina Geraldi passed away at CHSLD LaSalle on December 18, 2024, less than a day after the fall. Classified as high-risk for falls, she relied completely on staff for mobility and bathroom assistance.

Incident Details Emerge from Neighbor’s Account

Between 3:30 a.m. and 4:30 a.m., a neighboring resident heard Geraldi’s cries for help and banging on walls. He activated his alarm, and about 10 minutes later, a nursing assistant arrived. With both doors open, the resident observed the assistant struggling to lift Geraldi and dragging her across the floor by her arms as she groaned in pain.

Protocol requires notifying the head nurse before attempting to move a fallen resident to prevent additional injuries. At the time, the head nurse and an orderly were on breaks but available, leaving only the nursing assistant on the floor.

Delayed Discovery and Faulty Equipment

Geraldi later requested help to sit up, screaming in pain when an orderly tried to transfer her. She mentioned the fall then, surprising the orderly who found her in bed at 5 a.m. Her bed’s SMART sensors, designed to alert staff of movement or falls, showed no activation despite appearing functional during rounds.

The fall went unrecognized until 8:30 a.m., when morning staff arrived and filed an incident report—nearly five hours later. Post-analysis revealed the sensors had failed, leaving uncertainty about whether alarms triggered during the fall.

Autopsy Confirms Severe Injuries

Coroner Geneviève Pépin’s report, released this month, details postmortem findings: fractures in both hips and internal bleeding causing hypovolemic shock, heart failure, and death. Pépin emphasized that such injuries prove a fall occurred, as they could not result from bed rest alone.

Staff Accountability Issues

The nursing assistant initially reported finding Geraldi on the floor to the facility manager but later denied it during internal and police inquiries. She no longer works at CHSLD LaSalle, which referred her to the Ordre des infirmières et infirmiers auxiliaires du Québec (OIIAQ) for negligence.

Pépin noted unresolved questions: why the assistant failed to report the fall, seek help, or follow protocol by moving Geraldi. Her mandate excludes assessing care quality or liability.

Facility Enhances Fall Prevention

No formal recommendations were issued, as CHSLD LaSalle implemented changes post-incident, including team training on fall management, personalized high-risk rounds, standardized risk assessment tools, and mandatory equipment checks at shift starts and ends.

Hélène Bergeron-Gamache, spokesperson for CIUSSS de l’Ouest-de-l’Île-de-Montréal, confirmed these measures aim to respond swiftly to vulnerable residents.

Family Seeks Greater Transparency

Granddaughter Alice Costello expressed frustration over perceived lack of accountability. “What is strange, or at least I don’t understand fully, is that they say it was not [the] fault of anyone. However, someone does not work there anymore,” she said. “Those two things just don’t add up.”

A trained patient care attendant with CHSLD experience, Costello understands panic but stresses protocols exist to minimize harm. She questions if the assistant retains her license or works elsewhere without retraining. The family is reviewing the report before considering legal action.

The OIIAQ has received the report and may pursue disciplinary action if warranted.