IDPH has cited and fined Pearl Pavilion nursing home in Freeport after a resident died when his wound vac machine became disconnected, resulting in him bleeding to death.
The resident at issue was found unresponsive in a wheelchair in his room by a nursing assistant around 7:11AM. There was blood all over the floor. The assistant alerted the nurse on duty about the situation. When the nurse came to assess, she saw that the resident was nonverbal, saturated in blood, with more blood on the floor. But she did not identify where the bleeding was coming from or monitor the resident continuously.
Approximately 27 minutes went by before the Assistant Director of Nursing was told at 7:38AM. When she came to the resident’s room, his wound vac machine was laying on the floor disconnected and he was bleeding out. The resident could only say “ugh” before he slumped over unresponsive in his wheelchair. The Assistant Director of Nursing decided to leave him with the nurse while she left to get paperwork. Neither checked him fully or applied pressure to stop the bleeding.
Soon after, 911 was called. But when EMTs arrived, they found that the staff had not monitored the resident or given any care. EMTs discovered that the resident had a large, actively bleeding wound on his right groin area which led to severe blood loss and heart stoppage. They had to start CPR and aggressively resuscitate him while transporting to the hospital ER. Tragically, the blood loss was too severe and he passed away in the ER later that morning despite receiving many rounds of CPR.
Interviews with nurses on staff showed concerning gaps in emergency training and clinical judgment. One said she assumed care was being handled so she “just moved on.” Another admitted she may have had to cut his clothes off to find the wound and wasn’t sure where the blood was coming from when EMTs arrived. The Assistant Director stated “it all happened pretty fast” and care wasn’t prioritized over paperwork.
This startling lack of care and compassion speaks to a lack of investment in the facility staff which is a hallmark of the for-profit business model that most nursing homes follow. It also makes one think that these nurses may just be overworked, and have lost respect for the residents they care for on a daily basis.
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.
