IDPH has cited and fined Aliya On 87th when the facility failed on multiple levels, including failing to keep the resident elevated at mealtime, failing to follow code blue policy, failing to notify the physician in a timely manner, and failing to relay STAT lab results to the physician. These failures resulted in the resident remaining at the facility in place of being rushed to the ER, ultimately leading to the resident’s death.
The resident in question was admitted with multiple medical conditions, including dysphagia, cerebral infarction, and a history of aspiration pneumonia, amongst others.
According to the resident’s care plan and physician orders, staff were to keep the resident’s head elevated 45 degrees during and 30 minutes after tube feeding, provide one-to-one feeding assistance, and monitor for signs of aspiration, reporting any issues to the physician.
However, a certified nurse assistant (CNA) stated ”I made rounds and the resident was resting in bed. Dinner trays came up and I passed out the food trays, and I gave the resident a dinner tray as well. I did not reposition the resident or raise the head of bed up. Approximately around 5:30 PM, I was walking down the hallway picking up the dinner trays. I went into the resident’s room and saw half of his food missing from the food tray and he was making gurgling gasping sounds with vomiting coming from his nose and mouth. The vomit looked like it was his dinner, with food particles. The resident was lying down in bed and leaning on his side, shaking like he was having a seizure, and his eyes was rolled back into his head.”
The CNA further stated “I ran out and got the nurse. The Nurse went into the resident’s room and yelled out for help. The LPN said the resident is aspirating and get the crash cart. A Registered Nurse came running into the room to help with the crash cart. The Registered Nurse called over the speaker system code blue, and other nurses came to help. I passed the resident his dinner tray, I did not know the resident needed one to one feeding assistance. I thought he could feed his self. After the code, the Registered Nurse asked me if I gave the resident a food tray and did the resident feed himself alone. I told the RN I did give the resident his food tray, but I did not know the resident was a one-to-one feed assist. The RN told me that the resident was lying down too far and aspirated on his dinner while eating alone. The RN told me that the resident should have sitting up 90 degrees due to his aspiration precautions, and I needed to feed the resident.”
Even worse, when a Licensed Practical Nurse (LPN) and Registered Nurse responded to the incident, they failed to call 911, despite the resident’s unresponsiveness and difficulty breathing. The Registered Nurse stated, “I did not call 911 when the resident was unresponsive because the resident was left lying down in bed and aspirated, that situation could be managed by nursing interventions.”
Approximately three hours later that evening a Nurse Supervisor called the physician on call service, Third Eye Physician, and failed to provide a complete and accurate report of the resident’s condition. The Third Eye Physician stated, “I was not made aware that code blue was called in the facility for the resident at 5PM, three hours prior to calling me. I was not made aware that the resident was found lying flat in bed, unresponsive, oxygen level in the 70’s percentile, threw up food particles out of his nose and mouth, having difficulty breathing, needed to be suction, started oxygen, and needed continuous oxygen to sustain a blood oxygen of 92%. If the LPN gave me a completely accurate report of the resident’s condition, I would have given an order to send the resident to the hospital.”
Furthermore, the resident’s critical laboratory and diagnostic test results were never relayed to a physician. The Third Eye Physician stated, “I did not know the resident’s labs came back, and his white blood count was 15, and chest Xray showed early infiltrates in the right lung base. No one from the facility notified me or my staff at the Third Eye of the test results. Those results indicated the resident aspirated, and now developing pneumonia. If I would have received the test results, I would have sent the resident to the emergency room.”
The following morning after the incident the resident was found unresponsive in his bed.
While all of these failures are startling, a close read of the investigation report paints a hectic, borderline chaotic situation at the nursing home. The LPN assigned to the resident claims that she was busy with multiple code blues on the same day at the same time. The LPN states “I did not chart on the resident, the RN and Nurse Supervisor help me chart that day because there were a couple of code blues on the same day and same time. I did not call the resident’s physician; we must use Third Eye Physician on call service on the weekends. I did not call the Third Eye Physician, the Nurse Supervisor called third eye and spoke with the physician. I do not know what time the Nurse Supervisor called the physician.
The Nurse Supervisor that did speak with the on-call physician admitted that she had only peaked into the resident’s room and did not assist with the code blue. The Nurse Supervisor stated “I see the documented progress noted dated with my name, but I cannot remember. To access a call with a Third Eye physician, each nurses have their own individual log in and passwords to access the video call. No one could document or call the Third Eye Physician under my name; I must have called the Third Eye Physician. I am so confused, and I do not recall the code for this resident.”
This would explain why the Nurse Supervisor did not communicate all of the resident’s details in a complete and accurate manner to the physician. The three hour delay in calling the physician can also be explained by what appears to be an overworked staff, as there were multiple code blues occurring at the same time.
Another staff member, this time an Agency RN, paints a hectic picture the day of the incident. She states “I was so busy with the other residents and suctioning the resident (with the code blue) that I did not have time to ask another nurse (for help). I did not chart on the resident because I was too busy taking care of the other residents. I took one set of vital signs, but I did not place the vital signs in the resident’s electronic chart, I just ran out of time and forgot to put them into the system.”
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 the one detailed here 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.
