The Illinois Department Of Health has cited and fined Shawnee Senior Living when staff failed to accurately assess, treat, and prevent a significant both mental and physical decline in condition for a resident. This failure resulted in the resident, who has a history of confusion with infections, experiencing altered mental status and refusing overall care after being diagnosed with a urinary tract infection. The resident’s refusals of care additionally led to the resident developing a Stage 3 pressure ulcer with sepsis secondary to skin and soft tissue infection, subsequently requiring an 11-day hospitalization for IV antibiotic therapy.
When a resident is being considered for admission to a nursing home, one of the judgments that the admissions staff must make is whether the resident has care needs which would make him unsuitable for the facility or has care needs which cannot be met at the facility. This is an especially critical judgment where a resident has a demonstrated history of psychiatric and behavioral issues which demonstrate a pattern of aggressive or threatening behaviors because a nursing home is often filled with residents who due to physical or mental infirmities may not be able to fend off an aggressor.
The nursing home administration here made a poor decision to readmit this resident and then compounded the problem by failing to train or empower the staff as their proper role in protecting residents and then failing to provide the care this mentally ill patient needed, despite the very difficult situation staff members were presented with.
The story is a troubling account on many levels. For the resident, it is a sad account of unmet psychiatric needs and neglect of physical needs at a nursing facility.
The individual was a long-term resident with a history of suffering mental confusion during infections. He was readmitted to the facility following a hospital stay for treatment of a urinary tract infection (UTI) with extended spectrum beta-lactamase (ESBL) bacteria. Upon return, the resident had orders for Augmentin 875-125 mg twice daily for 10 days to treat the UTI.
From the moment of readmission, signs of trouble were apparent. The progress note from the day of admittance noted that the resident was “alert and oriented to person, place, and time, refused a skin evaluation and was refusing to take medications as ordered.”
Over the next few days, the resident’s condition rapidly deteriorated. Just two days after readmission, a progress note at 5:11 PM documented, “referral information faxed to a behavioral hospital for possible placement related to the resident’s delusions, refusal of care, and verbal behaviors.” Another note from the same day at 3:08 PM painted a concerning picture: “Resident refused to get up out of bed. He is mumbling to himself unable to understand what he is saying. He refused to take all meds. He would not allow writer to take his vitals.”
The situation continued to worsen. On the fourth day after readmission, a progress note at 5:27 PM stated, “Resident has been in room talking to people that are not there all day he was heard telling people to get out of his room and mumbling under his breath. He refused to get up this shift has refused all meds. He did allow (blood glucose monitoring) but not insulin.”
Approximately a week after readmission, the severity of the resident’s condition was clear. A progress note at 4:13 AM documented, “refused meds and meals for past 1-2 weeks.” The next day a particularly disturbing note at 3:26 PM read, “CNA (Certified Nursing Assistant) states that resident has been incontinent of stool and is lying in his bed with genitals exposed and refusing to be changed.”
The neglect reached a critical point several days later. A progress note at 2:55 AM described a horrifying scene: “All shift resident has refused to let staff change him. Resident’s bed is saturated in urine and dripping into the floor. Resident has a puddle of urine under his bed and was trailing to the door. Resident let staff clean the urine from his bed to the door but refused to let staff change him or clean under the bed.”
Throughout this period, the resident was consistently refusing medications. The Medication Administration Record (MAR) showed that the resident refused Augmentin 16 out of 20 offered dosages. He also refused another antibiotic, Levaquin, 5 out of 7 offered doses.
The neglect culminated a day or so later when the resident became physically aggressive towards another resident. The aggressor entered the other resident’s room and attempted to pull the resident out of bed, claiming he was “shooting him with black stuff.” This incident finally prompted the facility to send the resident to the emergency room.
Upon arrival at the hospital, the full extent of the physical issues the resident had suffered became apparent. The emergency room record documented the resident as having “wounds on his bottom.” Further examination on the following day revealed the resident had developed severe pressure ulcers: a Stage 3 pressure injury on his left buttock measuring 4 cm in length, 2.5 cm in width, and 0.3 cm in depth, and a Deep Tissue Pressure Injury (DTPI) on his right buttock. The resident was diagnosed with sepsis secondary to skin and soft tissue infection.
The resident’s case highlights a systemic failure to provide appropriate care, with staff seemingly more concerned with documenting refusals than finding ways to provide necessary medical treatment and hygiene care. The facility’s approach to the resident’s declining condition could demonstrate a lack of understanding of the interplay between infections, mental status changes, and the need for persistent attempts to provide care even when a resident is initially refusing.
At the same time, when a resident is victimized in a resident-on-resident assault, it is incumbent upon the administration to determine whether that resident should remain in their facility. On this point it would seem that the administration made the correct decision in sending the resident out to the ER. Whether the resident should have been initially admitted to the facility, or sent out to the ER at an earlier date, is another question.
It could be argued that the resident was allowed to stay in the facility for too long, ultimately resulting in the resident assaulting another resident. It should have been obvious to the administration that this was not a proper resident to have in the facility in the first place. A nursing home is a “home” for many residents where they live full time. They do not deserve to be terrorized in their own home. And the resident that was assaulted was not provided with the level of protection he deserved.
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 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.
