IDPH has cited and fined Havana Health Care Center after a resident there suffered a painful infection of both testicles.
The resident at issue was experiencing ongoing scrotal pain, so he was seen by his primary care physician at the nursing home. After assessing the scrotal pain, the primary care physician ordered an ultrasound of the resident’s testicles and scrotum area to try to determine the underlying cause.
Unfortunately, the facility staff failed to properly schedule and complete the ultrasound as ordered by the physician.
Over a month went by without the diagnostic ultrasound being performed.
The resident’s scrotal pain then significantly worsened to the point that he was crying in pain and had to be sent to the emergency room for evaluation.
The ER doctor found that the ultrasound ordered nearly a month before had never been completed by the nursing facility staff. The ER doctor knew the resident well as a patient and noted this was abnormal behavior for him.
A bedside ultrasound was then urgently completed in the ER, which showed the resident had epididymitis, or inflammation of the testicles.
This would have been detected sooner if the ultrasound had been done when originally ordered by the primary care physician. The ER doctor confirmed that having the earlier ultrasound would likely have allowed them to diagnose and start treating the infection sooner with antibiotics, which could have prevented the resident’s pain from escalating to the point that he was in tears.
Assuring continuity of care is a critical part of helping nursing home residents maintain their health and well-being. Nursing home residents are almost always suffering from some condition of ill-being whether it is acute, as may the case with patients admitted for short-term rehabilitation, or may suffer from long-term chronic medical conditions. The common thread between them is that these conditions are being managed by a physician who is relying upon the nursing home staff to implement the care that they have ordered. When they do not, significant suffering, or worse, can result.
Nursing homes are businesses, and well-run businesses have systems in place to carry out their basic functions. Assuring continuity of care is one of those basic functions. Here there was clearly a problem with the system that the nursing home was operating under, as the sonogram ordered for this resident was not administered when the primary care physician ordered it.
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