IDPH has cited and fined Bria of Elmwood Park when the facility failed to respond urgently and quickly to a resident’s respiratory distress and need for suctioning, resulting in a delay of care and ultimately the resident’s death.
Around 9:00 AM on the morning of the incident, a LPN (Licensed Practical Nurse) noticed the resident gesturing and pointing to his tracheostomy, indicating a need for suctioning. The LPN informed the Respiratory Therapist, who was working with another patient next door. Critically the LPN did not ensure that suctioning was provided immediately.
The Respiratory Therapist stated that she provided routine morning tracheostomy care, including suctioning, around 9:25 AM – 9:30 AM, noting that the resident was agitated before, during, and after the care.
At approximately 10:30 AM, a CNA found the resident unresponsive and notified the LPN, who initiated a code blue. During the resuscitation efforts, it was discovered that the resident’s tracheostomy tube was dislodged. Despite the staff’s efforts and the arrival of EMS, the resident was declared deceased at 11:07 AM.
One of the most significant shortcomings in the resident’s care was the nursing home staff’s inadequate response to his clear signs of respiratory distress. When the resident was observed gesturing and pointing to his tracheostomy, indicating an urgent need for suctioning, the LPN (Licensed Practical Nurse) failed to recognize the severity of the situation and did not take immediate action to ensure that the resident received the necessary care. This lack of urgency was a contributing factor to the delay in the resident’s treatment.
Furthermore, the Respiratory Therapist failed to prioritize the resident’s needs when informed of his distress. Instead of immediately attending to the resident, the RT continued with routine tracheostomy care for other residents, only reaching the resident nearly 30 minutes later. This delay in providing crucial suctioning support was problematic given the resident’s agitated state and the well-known risks associated with inadequate airway clearance in tracheostomy-dependent patients.
The nursing home’s substandard policies and insufficient staff training regarding respiratory care and suctioning also played a significant role in the suboptimal care the resident received. The inconsistencies in staff members’ understanding of their roles and responsibilities in responding to respiratory emergencies highlight the facility’s failure to ensure that its staff was adequately prepared to handle such critical situations. This lack of proper education and clearly defined protocols directly contributed to the confusion and delay in the resident’s care.
Moreover, the nursing home’s inadequate staffing levels and lack of proper monitoring equipment for residents with tracheostomies not connected to ventilators further compromised the resident’s safety. The facility’s decision to prioritize cost-cutting measures over resident well-being, by failing to provide sufficient respiratory therapists and neglecting to install necessary alarm systems to alert staff of potential tracheostomy dislodgement, created an environment in which the resident’s deteriorating condition went unnoticed until it was too late.
The culmination of these shortcomings in the resident’s care – the lack of urgency in care, the delay in providing necessary suctioning, the inadequate policies and staff training, and the insufficient staffing levels and monitoring equipment – resulted in the resident suffering from prolonged respiratory distress, ultimately leading to cardiac arrest and death. This tragic outcome could have been avoided had the nursing home fulfilled its fundamental duty to provide timely, competent, and attentive care to its residents.
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.
