IDPH has cited and fined Continental Nursing & Rehab Center when a resident died after it took over four hours for the resident to be transported to an emergency room.
The resident in question had multiple medical diagnoses including asthma, cerebral infarction, type 2 diabetes, dysphagia, and dementia. The resident experienced an acute change in condition at the care facility. A registered nurse observed that the resident was lethargic, had continuous hiccups, and had oxygen saturation levels ranging from 82% to 90% on room air. The nurse administered oxygen at 4 liters per nasal cannula, which increased the resident’s oxygen saturation to 96%. However, the resident’s skin color was not good and slightly moist.
The nurse contacted the resident’s physician, who gave a telephone order to send the resident to the hospital for an emergency room evaluation. The nurse completed the necessary paperwork and called the facility’s contracted ambulance company around 9:20 PM, requesting transport to the emergency room. The ambulance company informed the nurse that there would be a two-to-three-hour estimated time of arrival. The nurse did not notify the physician or the Director of Nursing about the delay in transport.
According to the ambulance company’s “Patient Care Report,” the facility staff nurse called dispatch at 10:26 PM, not 9:20 PM. The ambulance arrived at the facility at 12:25 AM and made direct contact with the resident at 12:30 AM. The ambulance left the facility at 1:02 AM, and the resident arrived at the hospital emergency room at 1:38 AM, approximately 4 hours after the initial physician’s order to send the resident to the hospital.
Upon arrival at the facility, the ambulance crew, consisting of two Basic Emergency Medical Technicians, assessed the resident and found him to be lethargic, incoherent, unable to speak clearly, with an increased heart rate and wheezing in bilateral lungs. The nurse informed the crew that this was the resident’s baseline orientation and vital signs, with the exception of the newly administered oxygen. The nurse did not disclose to the crew that the resident’s oxygen saturation had earlier dropped to 82%. The EMT stated, “If I would have received that information in report, I would have called our advanced life support, if they were too far out the I would have called 911 and stayed with the resident until 911 arrived.”
At the hospital, the resident was diagnosed with acute respiratory failure with hypoxemia, altered mental status, hiccups, systemic inflammatory response syndrome, and elevated lactic acid. Despite receiving treatment, the resident passed away.
The resident’s family member expressed concerns about the delay in transport and the facility’s decision to send the resident to a hospital 19 miles away, bypassing several closer hospitals. The family member stated, “If the resident was stable, then why did the physician give the order to send a stable resident to the hospital emergency department. From the nursing home facility which is located on the north side of Chicago and transported the resident to a south side of Chicago hospital which was 19 miles away from each other, bypassing several closer hospitals that was terrible. The resident arrived at the hospital over 4 hours later in respiratory failure. The Administrator and the Director of Nursing seem not to understand, a delay in transport means a delay in receiving medical treatment, just maybe the resident would still be alive, all the nurse had to do was call 911.”
The facility’s Change in Resident’s Condition or Status policy states that during medical emergencies such as unstable vital signs or respiratory distress, 911 will be notified for transport to the hospital. However, the facility failed to follow this policy and did not immediately call 911 when the resident’s condition worsened.
The Director of Nursing, however, stated, “I understand the policy, however, once the resident was receiving 4 liters of oxygen he became stable, and the nurse should not have phoned 911. The change of condition policy was not followed in terms of calling 911, that was because the resident became stable, there was no reason to call 911.”
The resident’s physician, when informed of the details in the nurses’s progress note, stated, “Oh my goodness, the nurse absolutely did not tell me that the resident was lethargic, continues hiccups, elevated heart rate, oxygen saturation in the 80’s, skin color was not good, and skin was moist. I would have called 911 myself. I would have told the nurse to call 911 for immediate care, treatment, and transport. The nurse did not notify me that the ambulance service was going to be two-to-three hours getting to the facility. The nurse should have called 911 for this resident, he was not stable. I am so sorry that the resident expired. The nurse did not tell me all the information stated in her progress note, the nurse should have called 911.”
The facility’s failure to follow their change of condition policy, assess the resident properly, and call 911 when his condition worsened resulted in a delay in receiving a higher level of care and ultimately contributed to the resident’s death. The facility has since implemented corrective actions, including staff education and audits, to ensure compliance with the change of condition policy and prevent similar incidents from occurring in the future.
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 such as this one 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.
