IDPH has cited and fined Warren Barr Buffalo Grove due to a failure of the staff to correctly obtain timely emergency care for worsening signs of an acute brain bleed, leading to a fall and a trip 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 injury.
The resident at issue was a 66 year old male who had multiple diagnoses including being prescribed blood thinning medications. The resident suffered an initial fall with head injury around 5PM. Although the resident hit his head and required hospital evaluation, he was returned to the nursing facility by 8:41PM the same night, with some documented complaints of headache but cleared for monitoring with orders to report any changes.
However, the overnight nurse admitted she failed to closely track and report concerning changes in the resident’s condition that developed over her shift between the night of his return from the hospital and his catastrophic re-fall at 5AM the following morning.
Specifically, the nurse shared that the resident became severely restless and agitated overnight, with repeated unproductive calls for assistance going to the bathroom, estimating this happened potentially 6-7 times through the night. She also took his blood pressure multiple times, getting readings as high as 221/97, extremely hypertensive levels that continued uncontrolled for hours without notifying the physician.
Her reasoning for not notifying the physician were documented as “I needed time to figure things out” and worrying doctors “may get upset if it’s not serious,” indicates a neglectful mindset downplaying his unstable vital signs.
Eventually around 4AM in frustration at his persistent calls she moved him away from his room to sit unattended nearby.
An hour later he took another devastating fall, now with seizure-like movements. This resulted in prompt hospitalization for an acute brain bleed, likely exacerbated by the unchecked overnight changes signaling a decline in status.
The Assistant DON confirmed the resident’s presentation with headache on blood thinners after a first fall, then subsequent agitation and hypertension without notification, should have indicated probable hemorrhage and been addressed emergently.
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 him to a negligent delay in treatment and ultimate second fall and trip to the Emergency Room.
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.
