The Centers for Medicare and Medicaid Services have cited Southgate Healthcare Center of Illinois with violations after interviews and records uncovered that the facility failed to provide prescribed oxygen therapy during a resident’s shower, leading to the residents death.
Noncompliance in following prescribed orders is an all-too-common reason for nursing home error. (See here, here, and here for examples).
Errors of noncompliance are most often caused by lack of training, disorganization, and failing to follow changes in the prescribed orders for the resident. This incident demonstrates that incidents occur when the staff are not properly trained and are noncompliant.
In this case, the resident was admitted to Southgate facility with diagnoses including Pulmonary fibrosis, chronic respiratory failure, COPD (chronic obstructive pulmonary disease), and continuous dependence on supplemental oxygen. The resident required 2-2.5L of oxygen continuously at the time of admission. Additionally, he was determined to require the physical assistance of one person for bathing activity due to his impaired balance, limited mobility, and the necessity of supplemental oxygen.
During his stay, therapy notified nursing that the resident’s oxygen levels had been dropping in the 80’s when trying to work with him. The nurse checked resident tubing for kinks. The resident appeared to be anxious and holding his breath, causing his oxygen to drop into the high 80’s.
Medication records showed that the resident had been prescribed Buspirone 10 mg. for anxiety, three times daily. Physical therapy asked if the resident could be prescribed anything additional for his anxiety. The resident’s Primary Care Physician’s office was notified of the request. The physician placed a new order for an increase to 3L of oxygen by nasal canula, active on every shift.
During interview the CNA stated she went to the resident’s room and told him it was his shower day and stated, “I asked if he wanted a bed bath or shower. He looked at me and stated, you know I haven’t had a shower since I’ve been here, I’m sticky. I want a shower.” CNA said she then took the resident from his room without his oxygen to the shower room. She estimated that the time from his room to the time he became unresponsive in the shower room was about 10 minutes. “I did a quick one for him because I know the oxygen situation. He wanted his head washed really good. He was greasy. I know oxygen patients can’t be off of oxygen long. I’m terrified to take the oxygen machine into the shower because of electrical concerns. I monitored his 02 stats the whole time and they were “high” (mid to high 90’s). I don’t do that kind of paperwork, but I used the 02 sat monitor on his finger. He was talking with me the whole time and he said, Baby, are we about done? I told him yes and we were drying off and getting dressed. I had him out of the shower, he was in the shower chair. I turned to my left to grab his shirt and went to put his shirt on, and he had his arms up to put the sleeve holes, I got his arms in and then his arms fell into his lap. I called for help immediately. I stuck my head in the hall and a CNA was right there in the hall (we were using that shower room because they were working on skilled back shower room water). I told him to get the nurse STAT that the resident was unresponsive I never left him alone in the shower. Not even a minute later the nurse came in. I’m pretty sure someone took his vital signs, but I don’t remember. I think that someone could stay off oxygen for 10 minutes, but in my experience, I didn’t think 10 minutes would be that long. What scared me was that he had been talking to me.”
When asked what electrical concerns one might have with portable oxygen, the staff member said she was not aware she could take a portable with her to the shower and stated, “I did not know that this resident was required to be on continuous oxygen. We have residents who take their oxygen off to go to the dining room, but I was assuming he was the same way. This was the second time I had ever worked with him, and it was never conveyed to me he was continuous oxygen.” When asked if the resident had ever sustained a fall, the CNA stated not that she was aware of.
Facility notes read, “This nurse was on hall passing medicines when a CNA came to get me telling me they need a nurse. I went into the hall shower room and found the resident non-responsive. I immediately called 911. The LPN stated when she entered the shower room the resident was sitting in the shower chair just outside the shower itself. His dentures were protruding from his mouth. The CNA relayed to the nurse that she was drying the resident off, and he started not breathing very well. It was noted that the resident’s oxygen was not in the shower room and the nurse immediately instructed “the male staff” to go and get his oxygen, then called 911.
When asked if the resident had experienced a fall at any time, the LPN said she was told he had not, that he remained in the shower chair. LPN continued that she asked what the resident’s code status was, but that the CNA did not know how to read the board. At this time the nurse was able to confirm the code status was DNR. 2-3 minutes later, the male staff returned with resident’s portable oxygen. The resident’s oxygen per nasal cannula was administered at 2L and, according to records, his color returned. LPN stated she kept calling the resident’s name and he would gasp but did not speak. “He was still in distress, and I was praying the ambulance would get there quick.” She added that prior to this incident, the resident was cognitive with confusion, but could hold a conversation with her and could tell her exactly how he liked his pills. When asked if any vitals were taken during the incident, she stated no, she had been on the phone with 911. She said EMS took vitals on arrival. “Had I realized he was being taken down to the shower room, I would have suggested he have his 02 with him. I would have rather he stayed in bed and had a bed bath because he gets out of breath with movement, but he has that right to a shower.
The nurse confirmed if a resident requires a continuous 02 you would take the portable to the shower and work around it. You would never not take the 02 with them to the shower, stating, “they could meet Jesus on the way.” When asked how a CNA would determine whether a resident required oxygen and whether it would be intermittent, as needed, or continuous, both the CNA and nurse stated the easiest thing would be to ask the nurse and that’s what they would do. When asked how they would handle a situation in which a resident who was ordered continuous oxygen for all activities asked for a shower, both nurses stated they would take the portable oxygen tank. The portable tanks do not need to be plugged in.
EMS facility notes staff state that they were told the patient went to go take a shower and the staff found him unresponsive on the shower floor. According to EMS the CNA sat him up and then noticed that he was still unresponsive, so they called 911.
Upon arrival to Southgate, the staff brought EMS to the bathing room where they found the patient sitting in shower chair with CNA holding patient up with nasal cannula with oxygen delivered at 2L.
Staff stated patient had been taking a shower and talking with no problem. CNA stated she turned around to grab a towel and turned back and patient head was slumping down and not responding to stimuli. Resident was transported and the family notified.
Based on interview and record review the facility failed to ensure this resident received continuous oxygen therapy as required during a shower. This failure resulted in the resident becoming unresponsive requiring emergent care with subsequent hospitalization.
Upon admission to the ER the patient was found unresponsive but had a pulse. Patient was in acute respiratory failure requiring intubation. Upon reassessment after treatment, the resident began to become more awake and started pulling at his tube. He was left on the ventilator to reduce carbon dioxide levels. The patient was extubated to a non-invasive high-flow respiratory support system and ultimately the decision to extubate and provide comfort measures was made. He remained in the company of family and passed away two days later. The cause of death was determined to be Acute Chronic Respiratory Failure with a duration of two days and Community Acquired Pneumonia.
The interview and review of records concluded that post incident, the resident suffered an elevated troponin level, indicating heart muscle damage not due to acute coronary syndrome, weakness, pulmonary fibrosis but from respiratory failure due to the lack of oxygen (hypoxia) and subsequently developed pneumonia.
When the Director of Nursing was asked about the resident’s hospital records documenting his history that was taken by EMS indicating that the resident was found on the floor unresponsive. The director reiterated that the resident never sustained a fall, especially on the date of the shower incident and that the information obtained was either misunderstood or recorded incorrectly in the report.
During the interview the director stated if a resident required continuous oxygen, you would make sure to take the portable 02 with the resident in the shower and only remove while washing the face to ensure the oxygen was off as short a time as possible because some residents have COPD and “things like that”.
The facility stated that access resident information is available at the kiosk or tablet Kardex where charting is performed but was not sure if their information would define whether a resident required continuous 02, but that most CNAs would ask the nurse. The facility confirmed if a resident required continuous oxygen for all activities, a portable tank would be taken to the shower room. The male staff member stated they would be afraid to take a resident out of their room for the fear they may become short of breath, but if they requested a shower, he would not take them without some form of 02.
This facility estimated the resident was without his oxygen for approximately 10 minutes from the time he left his room for the shower until the time he became unresponsive, and oxygen was started again 2-3 minutes later. When asked if he felt being off oxygen during this time would have contributed to an acute respiratory distress event, the staff member stated, “In my mind the main thing with the resident was he had end stage lung disease/pulmonary fibrosis and if he was without oxygen longer than 10 minutes, he would definitely think that could trigger an event and that anything less than 10 minutes would not contribute to acute respiratory distress. When asked if he thought this could have contributed to the resident’s death while in the hospital, the facility did not think the incident would directly relate to his death. He reiterated the time frame involved and stated the resident was oxygen dependent, and he had a terminal illness.
Unfortunately, noncompliance with physician orders and poor training is the standard level of care for many nursing homes. 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.
Other blog posts of interest:
Failure to supervise Westmont Manor resident results in fall with hip fracture
Park Place Christian Community resident rolled from bed by staff
Sunny Hill resident suffers fractured leg after lift tips over
Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
