IDPH has cited and fined Chicago Ridge SNF after a resident there suffered potential fluid overload in the lungs and subsequent death only three days after admission.
Nursing home residents who are suffering from kidney failure may require dialysis, and when this is true, families often make the decision to pick one nursing home over another based upon the availability of an in-house dialysis unit in order to spare their loved one from having to be transported to an outside dialysis center. These in-house units are usually operated by a separate company which means that coordination of care between the dialysis unit and the nursing staff is crucial to ensuring that the resident receives the care that is required.
When this doesn’t happen, the results can be catastrophic. When the kidneys are not functioning properly, the body cannot remove excess fluid and toxins. Dialysis takes up that function in the absence of properly working kidneys. When necessary dialysis sessions are missed, excess fluids and toxins can build up and cause serious problems throughout the body, most notably with the heart and lungs.
The resident at issue suffered from end stage renal disease, or kidney failure. On the day that the resident was admitted, the internet was down from approximately 2:30 pm until approximately 1:00 am the following day. While the in-house dialysis center was aware that the resident was arriving, they were never notified via email by the admitting nurse that the patient had actually arrived.
Notes from the investigation highlight that this was most likely due to the initial lack of internet connectivity. To make matters worse, the nursing staff neglected to send the email to the dialysis center once the internet was back up and running later the following morning.
The first signs of trouble appeared two days after the resident was admitted, when a nursing note documented that the resident was having trouble breathing and the blood oxygen level was 93%. A nurse noted that to help the resident the nurse elevated the bed and the blood oxygen level rose back to 97%.
The following afternoon the resident’s condition further deteriorated, with nurses noting that the resident was “coughing a lot and spitting up secretions.” Nurses stated in the investigation that they were “too busy” to listen to the resident with a stethoscope and did not notify any doctors that the resident’s condition had changed for the worse, stating “I didn’t think to call the doctor at that time. I just passed it onto the next nurse.”
Later that night notes indicate that a nurse visited the resident’s room at around 1:21 am. The resident was reported to be talking but sounded upset. While the residen’s breathing sounded congested and was slightly out of breath, the resident refused to be suctioned and was assisted by the nurse to lie back with head elevated. The door was left open so that the nurse could hear if the resident needed assistance.
The resident’s roommate, on the other hand, had a different story to tell. The roommate claims that the resident was “screaming and yelling almost all night” and “coughing to the point of almost choking” screaming aloud “I can’t breathe. Help me!” The roommate claimed that a nurse visited the residence one time that night, telling the resident to “sit up and drink some water.”
Unfortunately, at 6:45 am the morning nurse entered the resident’s room, only to find him without a pulse.
There were a number of shortcomings in the care that this resident received:
- When the resident initially developed shortness of breath and a low blood oxygen level, a doctor should have immediately been informed. Further, there was no attempt to provide him with oxygen or send him to the hospital for further care. It represented a change in condition and a real threat to the health and well-being of the resident.
- There was no effort to regularly monitor the resident on the night before his death. Following the initial change in condition, the resident should have been checked on every two hours. The nurse on duty the night before the resident’s death admitted to not revisiting the resident after 1:21 am due to her busy schedule.
- There was inadequate response to possible fluid overload signs. The resident’s symptoms, such as respiratory distress, were indicative of potential fluid overload, yet no action was taken to address this.
- Finally, when a resident is admitted needing dialysis, certain protocols must be followed. In this case, the admitting nurse was able to order the resident’s medications, but failed to notify the in-house dialysis center, putting the patient in grave danger and contributing to the resident’s death just a few days after admittance.
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