IDPH has cited and fined Aperion Care Marseilles when staff members were embroiled in confusion, refusing to follow a physician’s order for a resident in seriously declining health. This failure resulted in a delay of treatment, leading to continued decline and eventual admission to the local hospital’s intensive care unit with multiple comorbidities, including Sepsis and Pneumonia.
On the day of the incident the Dialysis RN documented that the resident in question had been ill for a few days and was getting worse. The RN further noted that the resident had “rales in upper lobes per auscultation,” was unresponsive, had a temperature of 100.4°F, cloudy and brown urine with a strong odor, and oxygen saturation of 81% on room air.
Despite these concerning symptoms, the floor nurse believed it was due to “fluid overload” and that the resident “just needs dialysis.”
When the Dialysis Nurse received push back from the facility RN, she contacted the resident’s Nephrologist, who agreed that the resident should be evaluated in the emergency room.
The Dialysis Nurse wrote an order at 4:15 pm stating, “Please have nursing home send patient to emergency room for evaluation of elevated temperature, decreased O2 (oxygen) saturation, MS (mental status) changes, rales upper lobes.”
However, this order was scanned into the miscellaneous tab of the resident’s electronic health record and was not processed into the Physician Order tab.
Despite the fact that the order was scanned into the incorrect tab on the electronic health record, the Dialysis Nurse did give the order to the floor nurse at the facility. The facility RN then began to argue with the Dialysis Nurse and “basically refused to send the resident out.”
The Dialysis Nurse then spoke with the Director of Nursing (DON). The DON responded that “my staff got different vitals than you did and that the resident seems ok.”
The situation is a complex one, as the resident was also suffering from a UTI, and there was some belief on the facility’s part that if the resident received an antibiotic, she would be better in 24 hours.
The facility then went ahead and proceeded with dialysis treatment despite the resident’s condition.
After the dialysis treatment, the resident’s condition remained poor. The Dialysis Communication Report noted that the resident was “Moaning, confused, labored respirations” with a temperature of 99.5°F.
Despite the continued poor condition of the resident, she was not sent to the hospital until the next day.
The resident was admitted to the hospital ICU “with sepsis and very high troponin level.” The hospital discharge paperwork revealed multiple serious conditions, including “Sepsis related to MRSA infection, Pneumonia, ESBL UTI, MRSA bacteremia leading to acute endocarditis suspected related to catheter associated infection, Acute on chronic systolic heart failure with pulmonary edema,” and several other complications.
Multiple staff members, including a LPN, a RN, and a second RN, confirmed that there was confusion and disagreement about sending the resident to the hospital. When questioned, the DON even said that “If there was an order for her to be sent to the hospital (I) would not have, not sent her.”
It was later explained by the Dialysis Nurse that the facility staff members did not fully comprehend the risk involved with sending the resident out to dialysis. If there had been infection in the resident’s blood stream the infection could have been spread throughout the body during dialysis, making it worse for the resident. This is why the dialysis team was concerned about moving forward with the treatment and why the Physician felt the resident should be sent to the ER to be examined.
This incident highlights significant issues in the facility’s communication processes, order management, and decision-making regarding resident care, particularly in emergent situations. The delay in following the physician’s order resulted in a potentially preventable decline in the resident’s condition and subsequent intensive care hospitalization.
Nursing homes are businesses, and well-run businesses have systems in place to carry out their basic functions. Assuring that patients are not neglected and that they receive timely medical care and attention is one of those basic functions. Here there was clearly a problem with the system that the nursing home was operating under, as the facility’s failure to implement timely emergency care during the resident’s obvious medical crisis subjected her to a negligent delay in treatment.
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.
