IDPH has cited and fined Pleasant Meadows Senior Living when the facility delayed sending a resident to the ER for nearly five hours after a serious fall where the resident hit her head.
The resident in question, who suffered from multiple medical conditions including dementia and a history of falls, experienced a severe fall at around 6:00 AM in the morning. While being assisted to the bathroom by a Certified Nurse Aide (CNA), the resident suddenly “stopped responding to the CNA and fell backwards.” The fall was witnessed, and staff noted that the resident appeared to be in a “postictal like state” and had hit her head. A postictal state is a temporary brain condition that occurs after a seizure and is characterized by an altered state of consciousness.
Instead of immediately sending the resident to the emergency room for evaluation, the facility staff, led by the Director of Nurses (DON), decided to use telehealth services. The DON stated, “I gave the resident a pain pill which she took orally. The resident seemed very drowsy but was able to answer some basic questions. The telehealth doctor was able to see the resident laying in bed with her eyes closed and gave orders to keep monitoring her and return the call if the resident’s mentation (mental activity) changes.”
This decision to use telehealth instead of emergency services proved to be a critical error. Throughout the morning, the resident’s condition deteriorated. Staff members reported that the resident was vomiting, gagging, and showing signs of altered mental status. Despite these concerning symptoms, the resident was not sent to the emergency room until 10:44 AM, nearly five hours after the fall.
An Administrator at the facility later acknowledged that telehealth was not appropriate for this situation, stating, “telehealth is a service that is available to our nursing staff for after hours Physician notification but it is not meant for emergency situations as what happened with this resident.”
The Medical Director emphasized that in cases like this, where there’s a witnessed fall and the resident hits their head hard, they should be “automatically sent to the emergency room.” The Medical Director added, “you don’t need a Physician order to send one of the residents to the emergency room for evaluation. That is left to the nurse’s critical thinking skills.”
The delay in sending the resident to the hospital had severe consequences. When the resident finally arrived at the hospital, she was diagnosed with an “Acute Sub Arachnoid Hematoma” and a “Nondepressed Left Occipital Bone Fracture.” The hospital report grimly stated, “This is a significant brain injury and is not survivable in her condition.”
This incident highlights a critical failure in the facility’s emergency response procedures. The inappropriate use of telehealth services in place of immediate emergency room transfer likely contributed to a delay in the resident receiving the urgent medical care she needed, potentially worsening her already critical condition.
Importantly, a Registered Nurse who had assessed the resident approximately an hour after her fall, stated “I should have sent the resident to the emergency room as soon as I saw her but didn’t because I was too busy.” The RN waited approximately 3 hours until a Licensed Practical Nurse (LPN) came on duty. Once the LPN came on duty the RN asked her to send the resident to the ER.
In this case, an understaffed facility and overworked staff contributed to the delay in care for this resident, with tragic consequences.
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.
