The Illinois Department Of Health has cited and fined Pleasant Meadows Senior Living when the facility improperly doubled a resident’s antibiotic dosing for a serious heart infection, then switched to an ineffective antibiotic without understanding the correct diagnosis or consulting specialists. These errors caused the resident to develop kidney failure and worsen to the point of sepsis, ultimately leading to a stroke and death when bacteria from the untreated heart infection spread to the brain.
The resident in question was admitted to the nursing facility after being hospitalized with a serious heart infection called endocarditis, caused by bacteria called Enterococcus. The hospital had placed a special IV line (PICC line) and ordered six weeks of a specific antibiotic treatment – Vancomycin every 48 hours – to treat this life-threatening infection.
However, just one day after admission, something went terribly wrong. Without proper justification or physician approval, the facility changed the resident’s antibiotic schedule from every 48 hours to every 24 hours – effectively doubling the dose. The pharmacist later stated “I believe the change in the Vancomycin order for the resident was not done by pharmacy intentionally… there was no rationale for the order to be changed.”
The consequences were devastating. After receiving four consecutive daily doses instead of the prescribed every-other-day doses, blood tests revealed the resident had toxic levels of Vancomycin (37.4, which was at “panic level”) and had developed kidney failure.
Instead of immediately sending the resident to the hospital, the facility switched the resident to an entirely different antibiotic (Clindamycin) that wasn’t even effective against this type of infection. As the infectious disease doctor later stated, “Enterococcus is not even susceptible to the clindamycin they put the resident on.”
Making matters worse, neither the facility’s medical director nor nurse practitioner were aware the resident had endocarditis in the first place. The medical director admitted: “I was not aware that the resident had Endocarditis. I thought the Clindamycin was appropriate because I believed the resident was being treated for cellulitis.”
Just over three weeks later the resident became severely ill with sepsis and was rushed back to the hospital. The infectious disease physician was blunt about the outcome: “The lack of care for the resident at (the facility) caused the resident to be rehospitalized with Sepsis from Endocarditis. Ultimately the resident had a stroke in my opinion from a bit of vegetation that broke off from the resident’s heart and traveled to the brain. I believe the lack of appropriate care at (the facility) hastened the resident’s death.”
Nearly seven weeks after the initial mistake the resident passed away. The death certificate confirmed the cause as complications from the endocarditis infection. This series of errors – changing the antibiotic dosing without justification, failing to communicate the correct diagnosis, and switching to an ineffective antibiotic – led directly to the resident’s death.
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.
