IDPH has cited and fined Ignite Medical Resorts McHenry when a resident died after the staff failed to recharge the resident’s left ventricular assist device.
The resident in question was admitted to the facility in a weakened condition, recovering from a recent brain bleed. His left ventricular assist device (LVAD) had been supporting his limited heart function, pumping blood to his vital organs. However, the facility nursing staff did not identify, monitor, or properly maintain the device.
Specifically, they failed to plug the device into a power source. No monitoring of battery life or function occurred, despite audible alarms. Over the span of several days, the resident’s LVAD batteries became depleted to non functioning levels. The device stopped assisting the resident’s faltering cardiovascular system, with his native heart unable to compensate.
The resident descended into shock due to ineffective blood flow and oxygenation. When he was finally transported to the emergency department, the LVAD was noted to be non operational.
The facility’s neglect thus directly allowed the resident’s LVAD to fail, resulting in shock, cardiac arrest, end organ damage, and ultimately the resident’s death – merely 8 days after his admission and 3 days after his LVAD’s failure.
The facility failed this resident in several critical ways. Upon his admission nursing staff were unaware of this critical device supporting the resident’s heart function. The resident’s care plan made no mention of the LVAD initially. With no identification of the LVAD, there was subsequently no staff competency or training conducted on monitoring LVAD function and battery life – critical to prevent failure of the device. Documentation on appropriate device settings, battery function checks, and alarm responsiveness was totally lacking in the records from time of admission.
Facility staff also failed to communicate the resident’s device and needs between shifts, with multiple accounts noting they were told only “the resident was not oriented” in shift reports. Potential issues with the resident or the LVAD during the overnight were thus unlikely to be flagged or met with any understanding when staff arrived to care for the resident.
Finally, the facility made no attempt to coordinate care with the resident’s LVAD clinic or note clinic contact information – key resources, as specialists that could educate on appropriate handling or troubleshoot device alarms and problems. Thus, gaps in assessment, monitoring, coordination, documentation, communication, and competencies fundamentally impacted the ability to intervene before sudden catastrophic failure of the resident’s LVAD occurred.
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 such as this one 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.
