The Illinois Department of Health has cited and fined Stearns Nursing & Rehab Center when staff failed to properly assess, monitor, and respond to a resident’s significant medical decline over several days, culminating in the resident being found unresponsive with foam coming from their mouth and nose. The resident suffered cardiac arrest during emergency transport to the hospital, required CPR, and was placed on a ventilator.
The resident in question was documented as cognitively intact, requiring some assistance with daily activities, and had advance directives indicating full code status with a request for all life-sustaining measures. The resident’s care plan confirmed they were “a full code and requests life sustaining measures.”
For approximately 3-4 days prior to the emergency, multiple Certified Nursing Assistants (CNAs) observed significant changes in the resident’s condition and behavior. One CNA stated, “the changes in [the resident] started [several days earlier] and this is when he started notifying the nurses and the Director of Nursing.” Staff consistently reported that these changes were markedly different from the resident’s usual behaviors.
On the morning of the incident, a speech therapist visited the resident around 9:00 AM and found them unresponsive in bed, lying flat with food nearby. The therapist stated, “she called out to [the resident] and no response” and “she performed a sternal rub and [the resident] did not respond.” When the therapist notified a nurse, she “was informed that this was a behavior and not to worry about it.” The therapist provided education to staff about not feeding the resident while lying flat.
The morning nurse recognized the seriousness of the situation and contacted the Nurse Practitioner between 10:30 AM and 12:00 PM, receiving orders to send the resident to the emergency room. However, rather than calling 911 for an immediate emergency response, the nurse called for a regular ambulance transport. When told there would be an hour wait for an ambulance, the nurse informed the oncoming shift nurse and left at the end of his shift.
When staff finally responded to the emergency around 4:30 PM, they found the resident with “respiratory depression. Pulse present, weak and thready… Resident diaphoretic, bilateral pupil dilation, increased oral/nasal secretions. White in color with thick frothy consistency. Resident unresponsive to verbal stimuli, tactile stimuli notes no response.”
During ambulance transport, the resident went into cardiac arrest, requiring CPR. At the hospital, the resident was diagnosed with “Cardiac Arrest and Severe Septic Shock” and required intubation and ventilator support.
In a Root Cause Analysis conducted by the facility, they admitted: “Facility failed to Assess, monitor, and provide timely treatment. Nurse failed to follow up, assess resident and call MD. Nurse thought this was resident behavior. Poor assessment skills by nurse.”
Both the Nurse Practitioner and the resident’s physician stated they were not properly informed of the resident’s deteriorating condition. The physician stated that “if he was notified that [the resident] was unresponsive to a sternal rub and attempts to arouse [the resident] had failed he would consider that an emergency and would have sent [the resident] to the hospital with lights and sirens.”
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.
