IDPH has cited and fined Hillview Healthcare Center in Vienna after the facility failed to notify a resident’s family member in a timely manner of their loved ones’ dramatic decline in health. Had the family been notified earlier, they would have acted to send her to the hospital prior to her becoming so ill that she perished in the ambulance.
Failing to follow protocol in notifying family members or Power of Attorney is an unfortunately common nursing home error. (See here, here, and here for examples). This is most often caused by an understaffed nursing home, not following appropriate steps, taking shortcuts, and ignoring the requests of its residents and family members.
In this case, the progress notes from the first night of the incident indicate that the resident was suffering from a high fever. Further, over the nighttime period the resident had remained in a recliner to sleep. When passing her medications the resident was noted to be in a stupor with labored breathing and a temperature of 102.9. It was also noted that the resident was only responsive to painful stimuli of sternal rubs and deep nail press. The resident’s oxygen had dropped to 88% on room air.
The notes from the following day indicate that the resident had a large loose stool while sitting in her recliner and that the stool covered the resident “from head to toe.” That same day the resident was very slow to respond when spoken to and kept her head down while sitting in her recliner.
The facility was unable to provide documentation or reproducible evidence that any emergency contact or family members had been notified of this drastic change in condition.
In the afternoon of the second day a family member made an unannounced visit.
At the time of the family members visit, the resident was observed to be non-responsive, and a staff member attempted a sternal rub with no response. The staff member looked at the resident’s legs, saw the mottling in her lower legs and told the family member “that concerned him.” The family member stated that the caregiver told her, “It just has me baffled. I don’t know what more to do because most of her vital signs were good.”
The staff member stated that it was not clear to him what he was dealing with. At that point he said, “I think we need to send her to the hospital and that maybe it is something an IV could take care of”. When asked if she had spoken to the hospital yet, the staff member stated, “Not really.”
During a post incident interview, the staff stated they did not contact the family because the family had the facility number blocked. When the family contact was interviewed and asked if they had any of the facility phone numbers blocked so the facility would be unable to contact them, they stated, “I did not have my phone off and my phone number is not blocked to receive calls from the facility. Three family members’ contact information were listed in the resident’s record.
Had the facility contacted the numerous numbers available, the resident could have been transferred to the hospital hours earlier, when it was evident the resident’s health was in danger.
Sadly, when the ambulance was finally ordered, the resident was transferred to the ER but died in transit to the hospital. Her cause of death was sepsis due to cellulitis, gastric bleed, and cardiac arrest.
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.
