IDPH has cited and fined Fireside House Of Centralia due to a failure of the staff to correctly obtain timely emergency care for worsening signs of a large gastrointestinal bleed, leading to the death of the nursing home resident en route to the Emergency Room.
One of the basic roles that a nurse in a nursing home setting plays is to serve as the eyes and ears of the resident’s doctor. When a resident shows signs of a change in condition, has a nursing home fall, or is demonstrating some other condition of ill-being, it is the nurse’s job to notify the doctor. The doctor then can issue orders over the phone for treatment to be delivered at the nursing home, go into the nursing home to see the resident himself, or order the resident sent to the hospital for examination and treatment there. Occasionally a situation arises where the nurse does not have time to contact the doctor, and must make a decision as to whether or not to call an ambulance service or 911 when the resident’s condition warrants. That was the case in this troubling nursing home death.
The resident at issue was exhibiting altered mental status, with symptoms including sluggish dilated pupils, difficulty speaking, and abnormally slow responses. Although the LPN (Licensed Practical Nurse) initially stated “she was going to send the resident out to the hospital”, she inexplicably changed course and directed staff to get the resident prepared for her scheduled medical appointment that morning. However, when the resident was found to have a temperature of just 95.7 degrees, the LPN then ordered her back to bed and called the ambulance company at 6:55AM. Crucially though, upon being told no ambulances were currently available, the LPN explicitly stated she would continue to wait rather than contact 911 for emergency assistance.
Over the critical next hour, the facility staff stood by while the resident yelled out in pain, unable to verbally communicate, and even screamed “everywhere!” when asked where she was hurting – clear signs of emergent distress. A CNA reported she kept checking on the resident, who was trying to talk but couldn’t, while the patient continued to deteriorate now that the LPN had decided to delay ambulance transport. Later, another nurse would state “Honestly, if it came down to it, I would push them to the hospital. It is right next door,” indicating the staff were aware they had a duty to act.
Finally at 7:35AM the ambulance arrived, but by then the resident was documented as unresponsive. She went into cardiac arrest en route to the hospital ER, and was pronounced dead shortly thereafter due to complications of a massive gastrointestinal bleed.
Nursing homes are businesses, and well-run businesses have systems in place to carry out their basic functions. Assuring that patients are not neglected and that they receive timely medical care and attention is one of those basic functions. Here there was clearly a problem with the system that the nursing home was operating under, as the facility’s failure to implement timely emergency care during the resident’s obvious medical crisis subjected her to a negligent, hour-long delay in treatment and ultimately resulted in her death.
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. Order our FREE report, Built to Fail, to learn more about why. 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.
