The Illinois Department of Health has cited and fined Alden Lakeland Rehab & Health Care Center when staff failed to administer two out of three prescribed antibiotics to a resident returning from hospitalization, resulting in the resident developing life-threatening sepsis that required emergency rehospitalization.
The resident in question was returning from a hospital stay. The hospital’s discharge instructions were clear: the resident needed to continue taking three powerful antibiotics – vancomycin, metronidazole, and cefepime – for six more days to fight a serious infection.
When the resident arrived back at the nursing home, an agency nurse was responsible for reviewing the discharge papers and setting up the medication orders in the facility’s system. The nurse later claimed to have properly transcribed all the orders and even spoke with a nurse practitioner to confirm them. “I transcribed the orders and called the nurse practitioner, and no orders were changed from the discharge paperwork,” the agency nurse insisted.
But something went terribly wrong. Despite the clear instructions, only one of the three antibiotics – cefepime – was ever administered to the resident. The other two medications, crucial for fighting the resident’s infection, were neither ordered from the pharmacy nor given to the resident.
The nursing home had a system designed to catch such errors. After an admission nurse enters medication orders, a quality assurance nurse is supposed to double-check everything. The Clinical Support Nurse who was responsible for this review later admitted her mistake: “I did not catch the medication errors. I must have missed it.”
For three days, the resident received inadequate antibiotic treatment. The Consultant Pharmacist who reviewed the case explained the serious nature of this error: “Cefepime would not have had enough coverage to effectively treat all of what grew in the resident’s cultures.” In simple terms, the single antibiotic being given wasn’t strong enough to fight all the bacteria causing the infection.
The resident’s condition deteriorated rapidly. In the middle of the night, a nurse observed alarming vital signs: a temperature of 100.4°F, racing heart rate of 135 beats per minute, elevated breathing rate, dangerously low blood pressure of 87/55, and oxygen levels that had plummeted to just 55%.
The telehealth physician who evaluated the resident recognized the seriousness of the situation immediately. The doctor diagnosed sepsis – a life-threatening condition where infection overwhelms the body – and ordered the resident to be transferred to the emergency department due to “hypotension and sepsis.”
When questioned about the incident, the facility’s physician reviewed the resident’s vital signs and confirmed, “The resident met sepsis criteria.” The doctor further acknowledged that the missing antibiotics “certainly could have contributed to the resident developing sepsis. I mean, the resident clearly needed the medication.”
The telehealth physician who had ordered the emergency transfer was even more direct about the seriousness of the situation: “Sepsis and septic shock is life-threatening.”
Remarkably, when the Administrator of the facility was asked about the definition of neglect, they replied, “I would have to google it to give you the definition, I don’t want to give you something wrong.” The Administrator also downplayed the severity of the resident’s condition, stating, “I wouldn’t say sepsis is a life-threatening condition but that would be more of a question for a clinician.”
This statement directly contradicted not only medical facts but also the facility’s own abuse policy, which defines neglect as “the failure of the facility, its employees or service providers to provide goods and services needed to avoid physical harm, pain, mental anguish or emotional distress.”
The Director of Nursing, when confronted with the evidence, admitted that if antibiotics are not given as prescribed, a resident’s health status “could get worse or develop a serious infection.” She confirmed that the facility’s expectation is that “all orders are transcribed accurately and are carried out” – an expectation that clearly wasn’t met in this case.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
