Nursing Home Abuse Blog - The Law Offices of Barry G. Doyle, P.C.

Neglected for 11 Days: The Shocking Story of a Patient Left to Manage His Own Surgical Drain At Alden Long Grove Rehab & Health Care Center

January 17, 2025 By Barry G. Doyle Leave a Comment

IDPH has cited and fined Alden Long Grove Rehab & Health Care Center when surveyors discovered a patient managing his own post-surgical drain care – a task that should have been performed by trained medical staff.

The patient in question had recently had gallbladder surgery and had a Jackson Pratt (JP) drain, a tube with a collection bulb, protruding from his stomach area.

When asked about the care he was receiving, the patient revealed a startling truth: “No one does anything with it. They don’t change the dressing or empty it. I empty it myself.” The dressing on his drain hadn’t been changed for eleven days, according to the date written on it.

When the Wound Care Nurse finally examined the site the following day, the situation was grim. The old dressing was saturated with blood, and the skin around the drain tube showed clear signs of problems: dried, crusted blood, redness, tenderness, and an unpleasant odor. This neglect directly violated the facility’s care requirements, as the nurse confirmed that dressings were supposed to be changed daily by staff nurses.

The documentation of care painted a very different picture from reality. The treatment records showed signatures indicating daily dressing changes and assessments, yet there was no record of the patient refusing care or any explanation for why the same dressing remained in place for eleven days.

By the third day of the investigation, the situation had deteriorated further. The Wound Care Nurse found the area around the drain was red and swollen, requiring intervention from a doctor. A Nurse Practitioner, when asked if the lack of care led to the need for antibiotics, responded “yes, possibly.” New orders were written for antibiotic ointment and special dressing materials to address the developing infection.

The facility’s own policy on JP drain care states simply that drains “will be cared for to prevent incision complications.” Yet in this case, complications occurred precisely because this basic standard of care wasn’t met. The patient’s medical record contained no documentation of him refusing care or any other explanation for this extended lapse in basic wound care.

This case reveals a troubling gap between documented care and actual practice, raising serious concerns about patient safety and the accuracy of medical records Alden Long Grove. What began as a routine post-surgical drain requiring simple daily care evolved into a situation requiring additional medical intervention – all due to basic care protocols being ignored for nearly two weeks.

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.

Broken Hip Goes Untreated for 24 Hours Due to Failure to Check X-Rays At Elevate Care Waukegan

January 13, 2025 By Barry G. Doyle Leave a Comment

The Illinois Department Of Health has cited and fined Elevate Care Waukegan when a resident suffered a significant delay in treatment after experiencing a fall that resulted in a broken hip.

The incident in question began when a nursing supervisor found the resident lying on the floor beside their bed. Although the resident was experiencing pain, showing “facial grimacing and moaning when right leg moved,” the initial response was inadequate.

While the nurse practitioner ordered immediate X-rays due to the resident’s swollen leg, the staff failed to mark the order as urgent (“STAT”), instead entering it as a routine order. This proved to be a critical error. As the Director of Nursing later explained, “the X-ray should have been ordered STAT to ensure the results were received in a timely manner and any injuries could be treated properly and timely.”

The situation worsened overnight. A nursing assistant reported that the resident was “grimacing, wincing, and moaning whenever she had to turn her to provide care,” and it appeared the pain was coming from the right hip. Despite these clear signs of distress, no one checked for the X-ray results, which were actually available that evening and showed “an acute intertrochanteric fracture of the proximal right femur” (a broken hip).

The delay in care was substantial – almost 24 hours passed between the resident’s fall and their transfer to the hospital. The Nurse Practitioner, when later informed about the delay, stated, “If I would have received the results then, the resident would have been sent to the hospital sooner. They didn’t communicate with me.”

Multiple systemic failures contributed to this delay:
– Staff didn’t properly mark the X-ray order as urgent
– No one monitored or followed up on the X-ray results
– Poor communication between shifts
– Failure to properly document the resident’s condition
– Inadequate response to signs of pain and distress

The facility’s own policy required “prompt, appropriate action” for “X-ray or other diagnostic tests reveal suspected findings which may require immediate intervention including but not limited to… new fracture.” Yet in this case, a resident with a broken hip experienced unnecessary pain and delay in treatment due to communication breakdowns and failure to follow proper procedures.

When the resident finally reached the hospital, they were found to be a poor candidate for surgery and had to return to the facility with orders not to put any weight on the injured leg, an outcome that might have been different with prompt medical attention.

Untreated Bedsore Leads To Serious Bone Infection Requiring Surgery At Paul House & Health Care Center

January 8, 2025 By Barry G. Doyle Leave a Comment

The Illinois Department Of Health has cited and fined Paul House & Health Care Center when the facility failed to provide proper wound care to a resident that led to the development of a severe, infected pressure ulcer (bedsore) that went all the way to the bone.

The resident in question, who needed extensive help with daily care due to muscle weakness and other health conditions, was identified as “high risk” for skin problems when first admitted to the facility and required staff assistance for repositioning and toileting.

The facility first noticed a skin issue in the resident’s sacral area (lower back/tailbone), documenting it as moisture-associated skin damage. The resident was supposed to receive daily treatment with a special honey-based medication (Medihoney) covered with a foam dressing. However, records show this treatment wasn’t documented as being performed for five consecutive days.

The situation became critical when the resident had to be transferred to the emergency room. Hospital records revealed a disturbing discrepancy – while the facility had prescribed Medihoney (a clear substance), the ER noted “white substance and dressing on arrival,” suggesting improper treatment. The resident reported pain in their “butt,” and doctors discovered a “large sacral decubitus” (pressure ulcer).

Further medical examination revealed the severity of the wound. A surgical consultation noted the wound “appears likely to involve muscle and likely periostium (membranous tissue that covers the surface of bone).” The situation was so serious that an MRI confirmed bone infection (osteomyelitis) of the sacrum and coccyx, requiring surgical debridement. The wound was also infected with multiple types of bacteria.

An investigation revealed several systemic problems at the facility:
– The main wound care nurse lacked proper certification despite working there for over a year
– Staff members without wound care certification were performing treatments
– Required treatments weren’t being performed or documented properly
– Poor communication about wound care responsibilities

The Medical Director explained the severity of improper wound care: “there is potential for serious harm, the wound can become infected, and the resident can become septic.” He further explained how such wounds progress: “the deeper the wound goes there’s muscle and fascia. The deeper the wound goes; it can involve the bone and it can be an infection which is osteomyelitis.”

This case highlights how failure to provide proper wound care and follow prescribed treatments can lead to severe complications. The resident, who was mentally alert enough to report their discomfort, suffered unnecessary progression of a preventable condition that ultimately required surgery and resulted in a bone infection.

The Two-Week Wait: How Poor Communication Led to an Undiagnosed Broken Hip At Allure of Mendota

January 6, 2025 By Barry G. Doyle Leave a Comment

The Illinois Department Of Health has cited and fined Allure of Mendota when the facility failed to properly assess, monitor, and communicate about a resident’s fall. This failure led to unnecessary pain and suffering and a two-week delay in treating a broken hip.

The incident in question began when two nursing aides were trying to help the resident transfer from a wheelchair to her bed using a mechanical lift device.

The resident described the frightening incident in her own words: “I don’t know what the problem was, but they were taking too long, and I told them I couldn’t stand anymore… Then my legs just gave out. I was hanging there, by my arms. The sling was pulling under my armpits and shoulder, and I was hanging on to the handles. They tried to sit me on the edge of the bed, but I was slipping. I landed on my butt on the floor.”

After the fall, several critical failures occurred. First, no nurse performed an immediate assessment of the resident’s condition. The nursing aides didn’t even report it as a fall, instead calling it a “rough transfer.” While X-rays were taken two days later, they didn’t show the fracture due to the resident’s body size and positioning, according to an orthopedic surgeon who later explained that more sensitive imaging (MRI) would have been needed.

The resident showed clear signs of injury. She could no longer bear weight on her leg during physical therapy, complained of hip pain, and couldn’t use the mechanical lift anymore. However, these warning signs weren’t properly communicated between staff. As one physical therapy assistant admitted: “I thought since the X-ray didn’t show a fracture that her pain would eventually go away. I was under the assumption that the nurses knew about her right hip pain. That’s my fault.”

A nurse who cared for the resident during this period stated, “If I knew she fell and she was having those problems, I’d assume her hip was broken and call the doctor to send her to the hospital as soon as possible. But no one told me that.”

Finally, two weeks after the fall, the resident was sent to the hospital where an MRI revealed “a greater trochanteric hip fracture.” The resident required surgery to repair the broken hip. The orthopedic surgeon later stated: “It’s very likely that caused her fracture, and the original X-ray missed it. If she was complaining of continued pain and hadn’t returned to baseline physical functioning, they should have sent her to the hospital.”

This case demonstrates how poor communication between staff members and failure to follow proper assessment protocols led to unnecessary suffering and a delay in crucial medical treatment. As the Director of Nursing acknowledged, “The purpose of continued assessments, documentation of findings, and interdisciplinary communication of resident’s change of condition is to ensure the resident is receiving proper care and continuity of care can be maintained.”

Resident Dies After Missing Six Doses Of Medication At Forest City Rehab & Nursing

January 4, 2025 By Barry G. Doyle Leave a Comment

The Illinois Department Of Health has cited and fined Forest City Rehab & Nursing Center when the facility failed to ensure a resident received a critical medication for several days after admission, which ultimately resulted in a stroke and the resident’s death.

The resident in question had a history of strokes caused by blood clots and was prescribed a blood-thinning medication called Xarelto to be taken twice daily to prevent future strokes.

Due to a combination of insurance authorization delays and facility communication failures, the medication wasn’t delivered until four days after admission. During this gap, the resident missed six doses of this crucial medication.

The situation became critical when family members noticed concerning symptoms. As documented in the progress notes, “Resident’s niece states ‘I’m scared my uncle might have had a stroke earlier when we were talking to him, but I really don’t know.'” Although staff checked the resident at that time and found no obvious signs of stroke, the next day the resident “started having a seizure in the dining room that lasted 2 minutes” and was rushed to the hospital, where they were diagnosed with another stroke.

The Nurse Practitioner explained the severity of the situation, stating that “missing 6 doses of the Xarelto could have contributed to having an acute embolic stroke.” She also noted that she “didn’t order an alternative blood thinner because she was under the understanding that the insurance issue was addressed promptly.”

The investigation revealed several systemic problems at the facility:
– A complicated medication storage system that staff couldn’t easily access
– Many nurses didn’t have access to the automated medication dispensing system
– Poor communication about medication availability
– Inadequate follow-up on delayed medications

The Director of Nursing demonstrated these problems while trying to locate Xarelto in their storage system, stating “Look at this. There isn’t even a label on this to tell me what is inside. I just have to look at each separate medication. This system is ridiculous. I hate it.”

Tragically, the resident remained hospitalized until they passed away several days later. The death certificate listed the cause of death as “recurrent embolic strokes.”

The Pharmacy Consultant confirmed that “Xarelto was not a medication stocked in the automated medication dispensing system” and that residents could be “at an increased risk of stroke if multiple doses were missed.” Only after this incident did the facility decide to start stocking this critical medication in their automated system.

Missed Warning Signs Lead to Fatal Fall At Odd Fellow-Rebekah Home

January 2, 2025 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Odd Fellow-Rebekah Home when a resident with dementia and on blood thinners died after experiencing multiple falls. The facility failed in several ways to protect this resident from falls and to properly respond when falls occurred.

The resident had several medical conditions including dementia, unsteadiness on feet, difficulty walking, and was taking two blood thinners (Aspirin and Rivaroxaban). The facility assessed them as “severely cognitively impaired” and needing significant help with daily activities like toileting, bathing, and moving around.

The resident experienced a series of falls over a short period of time. On the day in question the resident fell twice – first at 12:45 PM, causing a cut near their eye, and again at 7:00 PM, complaining of hip pain. Despite being on blood thinners and hitting their head, the facility didn’t notify a doctor after the first fall, which was against medical best practices. As the Medical Director later stated, “the resident should have been sent to the emergency room after the 12:45 PM fall due to being severely cognitively impaired, having a fall with a head injury and on anticoagulants.”

Five days later, the situation became critical. A nursing aide found the resident on the floor in the hallway, bleeding from a reopened cut on their temple. The resident was saying “I’m going to pass out!” and was rushed to the emergency room. Hospital records showed the resident had developed a large blood clot in their brain (described as a “Large Left Frontal and Temporal mixed density Subdural Hematoma”). Tragically, the resident passed away the next day.

A certified nursing aide (CNA) provided a heartbreaking account: “It was awful. I found her in the hallway outside her room. She was bleeding. I sat there with her. She bled all over my pants. I’ll never forget that. I felt so bad for her but I don’t know what else we could have done besides putting her on a one to one.”

The facility had multiple failures in their care:
– They didn’t properly implement a walking program that was ordered for the resident
– They couldn’t prove they were doing required 15-minute safety checks
– They lacked proper policies for monitoring residents on blood thinners who hit their head
– They failed to thoroughly investigate the falls

The Medical Director summed up these failures, stating “the resident’s falls were missed opportunities resulting in her major injuries.” He noted that while he doesn’t usually recommend constant observation, this resident “would have been a great candidate due to her poor awareness of instability.”

This case highlights how a breakdown in proper safety protocols and failure to respond appropriately to falls, especially for a resident on blood thinners, can have devastating consequences.

How a Single Missed Lab Report Led to a Devastating Bone Infection At Elevate Care South Holland

January 2, 2025 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Elevate Care South Holland when they failed to administer antibiotics to a resident when lab results indicated a bedsore infection. As a result of the failure to communicate the results to the resident’s doctor and nurses, the wound was left untreated for two weeks and progressed to a stage 4 bedsore and bone infection requiring hospitalization.

The resident in question was admitted to the facility with multiple conditions including a stage three pressure ulcer, quadriplegia (paralysis of all four limbs), and other health issues.

The incident began when a wound care specialist noted concerning changes in the resident’s pressure ulcer, including an unpleasant odor and greenish drainage. They ordered a wound culture (a test to check for bacteria) and requested an infectious disease consultation. The wound at this time measured 5 centimeters by 4 centimeters with a depth of 0.1 centimeters.

The lab results, which came back four days later, showed a serious infection: “high amount of bacteria greater than 100,000 of pseudomonas aeruginosa.”

Unfortunately, these results weren’t properly communicated to the necessary medical staff. As noted in the report: “the facility failed to follow their physician notification of laboratory/radiology/diagnostic results policy by not notifying the physician/nurse practitioner of a sacral wound culture results.”

The wound continued to worsen. An additional four days after the lab results were received it had significantly deteriorated, with the documentation showing it had grown to “8 centimeters length x 8.5 cm width x 2 cm depth” – a substantial increase in size and depth. The wound was now classified as stage 4, which is more severe than its previous stage 3 classification.

Due to the lack of communication about the lab results, the resident did not receive any antibiotic treatment. The report notes that “the resident’s medication administration record and physician orders did not document any new antibiotic treatment after the lab results were received.”

Two weeks after the culture results came back, the wound remained untreated and the resident had to be hospitalized with a diagnosis of sacral osteomyelitis (an infection in the bone).

Multiple healthcare providers interviewed stated they were unaware of the culture results. The Infectious Disease Nurse Practitioner stated “he was not aware of the resident’s wound culture results and would have ordered antibiotics for the resident.”

Another physician noted that “there should have been intervention sooner in relation to the wound culture results.” The facility’s own care plan had specifically called for staff to “monitor for signs and symptoms of infection (redness, warmth, swelling, pain, excessive drainage, odor) and notify provider.”

Unfortunately for this resident the wound monitoring and notification process at Elevate Care South Holland appears to have broken down.

Alzheimer’s Resident Suffers Fall, Brain Bleeding After Staff Mishandles Change In Behavior

December 27, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Alden Lincoln Park Rehab when a resident with Alzheimer’s disease suffered bilateral subdural hemorrhages (bleeding in the brain) after a fall. The incident reveals several failures in following proper care protocols and responding to changes in the resident’s condition.

The situation began when the resident returned from a weekend visit with family, showing an unusual level of anxiety and odd behavior. Early the next morning staff noted that the resident was “walking very fast from room to room” and appeared to be looking for an exit.

The resident’s behavior was notably different from their baseline, including “howling while pacing” and leaning forward while walking.

This would be considered a material change in condition in a nursing home. What’s particularly concerning in this case is how the staff handled this change in condition.

When the night nurse noticed these changes in the resident, she attempted to contact medical staff but failed to fully communicate the severity of the situation. As one staff member noted: “We were worried that she was going to fall, that’s why we were trying to get her to sit down and lay down. Leaning forward was something new for this resident.”

The Nurse Practitioner later stated that had they been properly informed of these changes, they would have taken immediate action: “If her gait is somewhat acute I would have sent her out, ordered a wheelchair, close monitoring… Even without the leaning forward, I feel that anyone that is confused and leaning forward will eventually fall.”

A resident’s gait can be described as “acute” if they experience a sudden, noticeable change in their walking pattern, often due to a recent injury, illness, or neurological event that has caused a new or significantly altered gait abnormality.

The situation culminated in the resident coming out of their room bent forward and falling face first in the hallway, hitting their head. CT scans later revealed “Mixed density right subdural hemorrhage… Another small isodense subdural collection along left frontoparietal convexity… Left frontal scalp hematoma.”

In this case the facility failed to follow their own policies, particularly their “Change of Condition” policy which requires that “Attending physicians or physicians on call /NP and responsible party will be notified of all changes in condition.” Additionally, they failed to complete proper fall risk assessments, as evidenced by incomplete documentation.

This case highlights systemic issues in the facility’s care protocols, particularly in recognizing and responding to changes in a resident’s condition, maintaining proper documentation, and ensuring adequate communication between staff members about resident safety concerns. The resident’s subdural hematomas were a direct result of these failures in care and oversight.

Pavilion of Logan Square Resident Breaks Neck In Van Accident

December 26, 2024 By Barry G. Doyle

IDPH has cited and fined the Pavilion of Logan Square nursing home in Chicago after a resident suffered a broken neck when the nursing home van he was riding in stopped short, causing him to fall from his wheelchair because he was not properly belted in.

Many nursing homes have vans which are used to shuttle residents to and from hospitals and doctor’s offices or on outings in the community. When this is the case, the whole operation must be safe for residents – from the way in which the van is driven to the way in which residents are gotten on or off the van to the way in which they are secured in the van.

The resident at issue was wheelchair bound and was being taken in a nursing home van from the facility to a local hospital to have testing done with an aide accompanying him. The resident was loaded onto the van by the driver who was also responsible for making sure that the resident was safely secured within the van. Doing this involves not only making sure that the wheelchair is locked into place so that it doesn’t move, but also securing the resident in place as well.

After leaving the facility, the driver came to an abrupt stop. The aide and the driver heard a crashing sound behind them and turned around to see that the resident had been thrown from his wheelchair. The driver had not applied a seatbelt to the resident and as a result he was thrown forward out of the wheelchair when the van stopped short.

They got him back into his wheelchair and upon arrival at the hospital, the accident was reported to the hospital staff as well as the resident’s complaints of neck and shoulder pain. A CT scan was done which showed fractures at the level of the C6-7 vertebrae. The resident was transferred to another hospital for further care.

One of our core beliefs is that many unnecessary injuries and deaths of nursing home residents occur as a consequence of the nursing home business model. Unfortunately, not investing in adequate training of the staff is a feature, not a bug, of the way in which too many nursing homes operate. This kind of accident is characteristic of accidents that are the result of an inadequately trained staff.

Elevate Care South Holland Resident Develops Infection In Bone From Bedsore

December 18, 2024 By Barry G. Doyle

IDPH has cited and fined Elevate Care South Holland nursing home after a resident there developed sacral osteomyelitis from a bed sore which was not properly treated.

The resident suffered from a Stage 3 bedsore. Bed sores are rated or “staged” on a 1-4 scale, with a Stage 4 being the worst. A Stage 3 bedsore is one where the deeper tissues beneath the skin are exposed, but there is no exposure of muscle, tendon, or bone. One of the functions of intact skin is that it serves as a barrier to infectious bacteria, and a Stage 3 bedsore is an interruption in the integrity of the skin.

Federal regulations require that nursing home residents who have a bed sore receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new bedsores.

When a resident develops a bedsore, management of care of the bedsore is often assigned to a wound care doctor or wound care nurse who oversees the care of the bedsore. However, nurses on the floor are still required to provide day-to-day care and to monitor the condition of the bedsore, including monitoring for signs of infection.

When the wound care doctor was providing care, he saw signs of infection, including malodor and greenish drainage. The wound care doctor ordered a culture of the wound. The wound culture was obtained and sent to the lab.

One of the ways in which care provided in a nursing home is different from care provided in a hospital setting is that doctors are not on site 24/7. Therefore, when doctors are not present in the facility, it is up to the nursing staff to act as the “eyes and ears” of the doctor, including notifying the doctor of any changes in condition or any abnormal lab results. This allows the doctors to make decisions regarding the treatment of residents under their care.

Four days after the culture was obtained, the lab faxed the results of the culture back to the nursing home. It showed that the wound was indeed infected with multiple strains of bacteria. Despite the abnormal lab results, none of the responsible health care providers – the wound care doctor, the attending physician, or the infectious disease nurse practitioner – were notified of the abnormal lab results. Each told the IDPH surveyor that had they been advised of the culture results, antibiotics would have been ordered for this resident.

Because the antibiotics were not ordered, the infection was allowed to progress, and a little over three weeks later, the resident was sent to the hospital where the diagnosis was sacral osteomyelitis. Osteomyelitis is an infection of the bone which can be intensely painful.

Nursing homes are businesses, and well-run businesses have systems in place which ensure that the regular functions of the business (and notifying doctors of abnormal lab results is one) are carried out on a day-to-day basis. There was clearly a breakdown of that system here, and led to a serious infection for this resident. One of our core beliefs is that the nursing home business model too often results in unnecessary injuries, illnesses, and deaths for nursing home residents, and the failure to invest in the training necessary to ensure that systems are implemented is a part of the nursing home business model.

Alden Estates Courts Of Huntley Resident Chokes To Death – Second Choking Incident In 2 Days

December 18, 2024 By Barry G. Doyle

IDPH has cited Alden Estates Court of Huntley nursing home after a resident died due
to choking on food. Unbelievably, this was the second time this particular individual
choked on food being served to him in 2 days. While he managed to avoid serious
complications from the first choking incident, the second ultimately proved fatal.

This resident suffered from a variety of long-term conditions and had diagnoses of
dysphagia (difficulty swallowing), Parkinson’s disease, and dementia. All of these
conditions can place a nursing home resident at risk for choking.

The resident recently had his diet upgraded from a mechanical soft diet to a general
diet, but still required distant supervision while eating. The facility speech therapist
explained that “distant supervision” meant that the resident had to eat in the dining room with staff present.

On the day of the first choking incident, the resident began to choke while eating dinner. A resident called for help an aide entered the dining room and saw that the resident was choking. She saw that there was no other staff members in the dining room and did not know what to do. A nurse entered the dining room and said, “That’s not my resident, I’ll go get his nurse.” By the time that the resident’s nurse made it into the dining, the resident had coughed up the food he was choking on.

His nurse practitioner saw him that day, and entered a number of orders for an
evaluation by speech therapy and 1:1 assistance with feeding at a low rate. The nurse
did not enter the orders into the resident chart and while she told the oncoming nurse at change of shifts about the “coughing” incident, she did not tell the oncoming nurse
about the orders given by the nurse practitioner. She told the IDPH surveyor that she
was “too busy” to enter the orders into the resident chart or advise the CNA’s about the
need for 1:1 supervision.

Further, while she told the IDPH surveyor that there was not enough staff to do 1:1
feeding as ordered by the nurse practitioner, she did not tell the nurse practitioner that.
The nurse also believed that she had the ability to downgrade the diet to mechanical
soft but did not do so.

Federal regulations require that nursing homes provide supervision and assistance
necessary to prevent accidents, and a choking incident such as this is an accident in the meaning of the federal regulations. To comply with the federal regulations, nursing
homes must provide the necessary supervision to residents at risk of choking such as
this gentleman.

The following morning at breakfast, the resident began to choke again, this time on a
sausage. The nurse assigned to him heard calls for help. The nurse entered the dining
room and saw that the resident was blue and appeared lifeless. There was no other
staff in the dining room. The nurse began to do the Heimlich and was able to get some
food from the airway. The resident’s oxygen saturation levels were in the 60s, when
they should be in the high 90s, indicating significant oxygen deprivation.

911 was called and the resident was brought to the hospital where he died 10 days later due to aspiration pneumonia (likely caused by food particles entering the lungs) and complications from the choking incident.

There were a number of immediately apparent breakdowns in the care that this resident received. The most obvious is the failure to implement the orders of the nurse
practitioner to provide 1:1 supervision while eating. Past that, the oncoming nurse
should have been advised of the choking incident (not a “coughing incident”) and of the orders that had been given by the nurse practitioner. These failures led directly to the death of this resident.

While there are obvious shortcomings of the staff, it is apparent that management
choices also contributed to the death of this resident:

– The nurse told the IDPH surveyor that there was not enough staff to do 1:1
supervision while eating. Federal regulations require nursing homes to provide
enough staff to meet the care needs of residents on a 24/7 basis. Whether this
perception on the part of the nurse contributed to her decision to not enter the
orders of the nurse practitioner or communicate them to the oncoming nurse is a
question worth pursuing.

– There was no staff present in the dining room during either choking incident even though both happened during regularly scheduled mealtimes.

– The aide on duty during the first choking incident did not know how to handle a
choking resident. This speaks to a lack of investment in training the staff on the
part of facility management.

One of our core beliefs is that many of the unnecessary injuries and deaths that occur in nursing homes happen due to choices that are made in the management of the facility, and understaffing and failing to invest in training staff are a core part of the nursing home business model. Sadly, those choices can have tragic outcomes as was the case here.

Resident Suffers Multiple Arm Fractures After Improper Solo Transfer At Manor Court Of Freeport

November 18, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Manor Court Of Freeport when a staff member attempted to transfer a weakened resident alone using a manual stand aid device, despite the resident lacking the strength to use it safely and facility guidelines requiring two-person assistance. As a result, the resident fell during the transfer and suffered multiple fractures in his arm and elbow, leading to the facility finally changing his care plan to require a full mechanical lift with two staff members – the level of assistance he should have had from the beginning.

The resident in question had been steadily declining in health and required substantial assistance with all movements.

On the day of the incident, at around 5:45 AM, a nursing assistant attempted to transfer the resident from his bed to a wheelchair using a manual stand aid – a device that requires residents to be able to support their own weight and follow directions. According to the nursing assistant’s account, “as the resident was starting to stand up further and she was trying to put the seat flap down behind him, the resident’s legs gave out and he started to fall.”

Several concerning issues emerged about this transfer:
– The aide was working alone, though other staff stated “the resident has not been a one person assist for months”
– No gait belt was used for safety
– Staff had been transferring the resident inconsistently – as his wife noted, “some of the staff would use a gait belt, and some wouldn’t… some staff would just grab the resident by the back of his pants to assist him up”
– Multiple staff members indicated the resident wasn’t strong enough for the manual stand aid and should have been using an electric lift

The manufacturer’s manual specifically warned that to use the stand aid, a resident “must have enough leg and lower body strength to stand up and remain in the standing/sitting position.” For residents lacking this strength, “a sit-to-stand lift such as the electric powered patient lift is preferred and recommended.”

The Director of Nursing later acknowledged the error, stating, “The resident needs to be able to grab onto the bar and bear his own weight to use the stand aid. It was never brought to my attention that they were struggling or were needing assistance with his transfers.” The Nurse Practitioner added that “the resident had been experiencing a steady decline in health and his transfer status should have been reassessed.”

As a result of this improper transfer, the resident suffered multiple serious injuries:
– A comminuted (broken into multiple pieces) fracture of his upper arm
– A fractured elbow
– Significant soft tissue swelling and bruising

After the incident, the facility finally changed the resident’s care plan to require a “full mechanical lift with staff assist of two” – the level of assistance he should have had before the injury occurred.

Neglected Wound Care At Imboden Creek Leads To E. Coli Infection And Emergency Surgery

November 12, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Imboden Creek Senior Living when the facility failed to provide basic daily wound care for a resident’s back surgery incision, skipping required cleanings and dressing changes on multiple days. As a result, the resident developed a severe E. coli infection from fecal contamination, requiring emergency hospitalization, a second surgery to clean out the infected tissue, and an extended course of powerful antibiotics.

A nursing home resident suffered a severe infection requiring additional surgery because staff failed to properly care for her surgical incision. The resident in question was admitted to the facility following back surgery (a lumbar laminectomy) that had been performed five days earlier.

The doctor’s orders were clear: staff needed to clean the resident’s surgical incision daily with normal saline, dry it, and apply a fresh dressing. They were also supposed to check the incision every shift for signs of infection. However, records show the staff failed to provide this basic wound care on multiple days.

The consequences were severe. When the resident went for her follow-up appointment, her surgeon immediately sent her to the emergency room. Hospital tests revealed a shocking discovery – her surgical incision was infected with E. coli, a bacteria found in fecal matter. As her surgeon noted, this was “a result of fecal contamination and not from surgery, consistent with the resident’s statements of poor quality care” at the facility.

The resident’s daughter described the poor care her mother received: “The nurses at the facility did not do the cleanings of her incisions like they were supposed to, the dressings they had would never stick in place, they left her on the bedpan for over an hour, she was left laying on her back almost all the time.” As a result, the resident developed “rashes under her breast and in her groin, and bed sores on her backside.”

The infection was so severe that the resident needed another surgery. The hospital records detail a gruesome procedure where the surgeon had to:
– Remove staples
– Clean out “a large amount of brown purulent material and liquid”
– Cut away infected tissue
– Perform deep cleaning through separated muscle layers
– Use multiple rounds of sanitizing solutions
– Place antibiotics directly in the wound before reclosing it

The resident required intensive antibiotic treatment, including medications that needed careful monitoring due to their strength. She had to remain in the hospital until the full course of antibiotics was completed.

This entire ordeal could have been prevented with proper wound care and basic hygiene practices. As hospital records confirmed, the bed sores and rashes the resident developed weren’t present when she was first discharged to the nursing home, highlighting how quickly her condition deteriorated under their care.

Critical Medication Oversight Results In Resident Experiencing 10 Seizures In Nine Days At The Grove Health & Rehab Center

November 9, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined The Grove Health & Rehab Center when a resident with a history of seizures experienced a serious medical crisis when staff failed to give her prescribed seizure medication for nearly a month. As a result, the resident began experiencing multiple seizures, ultimately needing to be transferred to the hospital for further care.

The incident in question began when the resident’s neurologist ordered a new seizure medication (Trileptal/oxcarbazepine). The plan was specific: start with 300 mg twice a day for one week, then increase to 600 mg twice a day. However, due to a critical error, a nurse misread the order and simply discontinued the medication entirely after the first seven days, ignoring the instruction to increase the dose.

As a result, the resident went without this crucial medication and began experiencing multiple seizures. The timeline of events was devastating:

– Day 1: She had “seizures back to back” and was so weak she needed to go to the emergency room
– Day 2: She experienced three more seizures
– Day 8: Another seizure in the dining room
– Day 9: Multiple seizures, including one during breakfast and another during dinner

The situation became so severe that the resident was eventually transferred to a regional hospital. When hospital neurologists reviewed her case, they were alarmed by what they found. As noted in the hospital records, “It appears that her seizures were likely due to sub-optimal management of her medications while she was in the nursing home.” The hospital staff had to specifically ask “why she was not taking the oxcarbazepine 600 mg bid prescribed to her.”

When questioned about this serious error, the facility’s Director of Nurses explained, “I have looked into how the oxcarbazepine was discontinued. I reached out to pharmacy and when [the nurse] looked at the order she only read the first part of 300 mg for seven days and went into the computer and discontinued the medication.”

The Medical Director acknowledged the severity of the error, stating “Any medication ordered should be given as ordered.” However, he was hesitant to directly link the medication error to the resident’s deterioration, saying “the resident is a very complicated case not getting the oxcarbazepine did not help her but I am unable to say if it harmed her because she was such a complicated case.”

The situation ultimately resulted in the resident having to transfer to a different facility closer to Springfield, after experiencing at least 10 documented seizures over a nine-day period – seizures that might have been prevented had she received her prescribed medication.

Mistakenly Doubling Antibiotic Dose Leads To Death Of Resident At Pleasant Meadows Senior Living

November 5, 2024 By Barry G. Doyle

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.

Maggot Infestation Found In Resident’s Leg At Belleville Health Center

October 30, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Belleville Healthcare Center when a nursing home resident there developed maggots in her leg wound after staff failed to properly care for her dressing changes.

The resident in question was a mentally alert woman who had an open wound on her right lower leg and needed dressing changes three times a week (Monday, Wednesday, and Friday).

The tragedy unfolded over several days. The last documented dressing change was on a Wednesday. The staff claimed they then changed the dressing two days later, on Friday, however there was no documentation to prove this, and the resident insisted it wasn’t done.

Over the following weekend, the resident repeatedly told staff something was wrong. She could actually feel movement in her wound, describing it as “creepy crawlies in her leg.” The dressing was visibly saturated with drainage, yet staff refused to help. Another resident even tried to advocate for her, telling the nurse “the dressing was saturated” and that the resident “could feel something crawling in the wound.” The nurse’s response was shocking – she told him to “mind his own business” and, according to this resident, said “it’s not due to be changed until Monday, I am not changing it” before slamming the door.

The situation came to a horrifying conclusion early Monday morning when “maggots were found in the sheets” and upon inspection, staff found “maggots within the wound bed.” The resident was immediately sent to the emergency room.

At the hospital, the situation was found to be even worse than initially apparent. X-rays showed the wound had deteriorated significantly, with “severe soft tissue swelling” that now “extends through to the underlying fibula” (leg bone). The resident had developed osteomyelitis (bone infection) and her wound tested positive for multiple serious infections including MRSA.

As a result of this negligence, the resident required:
– Hospitalization
– Treatment for maggot infestation
– 42 days of intravenous antibiotics for multiple infections
– Treatment for bone infection

The Director of Nursing later admitted that staff should have responded when the resident complained: “she would have expected her nurse to remove the dressing and assess the wound when the resident complained of discomfort.” The facility eventually moved the resident to a different room, as her previous room’s location near the smoking area meant there were “more flies in the resident’s previous room.”

This incident violated the facility’s own policy which required staff to check dressings for drainage and the presence of possible complications. As the hospital notes stated, the resident “states dressing is to be changed every MWF (Monday, Wednesday, Friday), but staff hadn’t changed since last Wednesday.” The consequences of this negligence led to a serious deterioration in the resident’s condition and weeks of intensive medical treatment.

Resident Falls From Mechanical Lift, Breaks Neck At Galena Stauss Nursing Home

October 29, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Galena Stauss Nursing Home when a resident suffered a broken neck when staff members dropped her while trying to move her from her bed to a chair.

The resident in question was a cognitively aware person who had partial amputations of both legs and required staff assistance for all transfers.

The incident occurred when two nursing assistants (CNAs) were using a mechanical lift – a device with a sling that cradles the person and lifts them – to move the resident. During the transfer, the resident fell through a gap in the sling, hitting her head, neck, and shoulder on the floor. As one of the CNAs described it: “She fell out the left side of the sling between the head and leg straps.” The other CNA provided more detail, saying “She went through the gap between the head strap and the leg strap, through that hole, over the left arm rest and onto the floor. She hit her head, shoulder, and neck area first.”

What followed was a concerning delay in identifying the severity of the resident’s injury. Though she began complaining of neck pain the very next day, it wasn’t until nine days later that she finally received an X-ray. The scan revealed an “acute nondisplaced fracture of the odontoid process” – in simpler terms, a broken neck.

The resident’s doctor explained his response to the situation: “Cervical fractures present as pain. I was concerned about a fracture, which is why I shot over there right away… My concern with the neck pain was that she had a cervical fracture as a result of her fall, which was the reason I had her sent out.”

When interviewed, the resident was found wearing a neck brace and had visible bruising – “a faint blue/purple color similar to a nearly faded bruise” – on her left temple.

What makes this incident particularly troubling is that it was completely preventable. Multiple staff members confirmed this type of accident shouldn’t happen if proper procedures are followed. As the Director of Nursing stated, “If the CNAs are doing everything correctly, there is no reason that the resident should have fallen out of the sling. The only thing I can think of is that she was not positioned correctly.”

Another nurse who oversees falls prevention was even more direct: “If the [hoist mechanical lift] is used correctly it is our safest way to transfer her. If all the policies and procedures were followed correctly and she was positioned correctly, she should be able to be transferred without falling out of the [hoist mechanical lift]. The fall from the [hoist mechanical lift] caused the cervical fracture.”

In this case, it appears these basic safety requirements were not met, resulting in serious injury to a vulnerable resident.

Resident Bleeds To Death When Staff Fail To Adjust Blood Thinner At Goldwater Care Gibson City

October 24, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Goldwater Care Gibson City when a resident died because the staff made two critical mistakes with their blood-thinning medication: they gave the wrong dose and failed to properly monitor how the medication was affecting the resident’s blood.

The resident in question had several health conditions, including heart problems that required them to take blood thinners. Initially, they were on a medication called Plavix, but they were eventually switched to a different blood thinner called Warfarin.

Three days prior to the fatal mistake blood tests showed dangerously high levels of the blood thinner in the resident’s system. The doctor specifically ordered the facility to:
– Stop giving Warfarin for three days
– Do blood tests on specific dates
– Then restart Warfarin at a lower dose (2.5mg instead of 3mg)

However, the facility ignored these orders. They continued giving the resident the higher 3mg dose for 24 more days and didn’t do the required blood tests. As the Director of Nursing later admitted, “the facility was not administering the Warfarin as ordered and not monitoring the resident’s labs as they should have done.”

The consequences were devastating. When the resident was finally tested, their blood was dangerously thin. They were rushed to the hospital with “lethal bleeding.” The hospital found severe internal bleeding, including:
– Bleeding into the space around their lungs
– Bleeding in their right lung
– A large blood collection in their hip area measuring about 3 inches by 2 inches by 3 inches

Sadly, the resident passed away shortly thereafter. The Medical Director was direct about the cause, saying “the resident clearly died from the hemothorax” (bleeding around the lungs).

What makes this particularly tragic is that these kinds of problems are preventable with proper monitoring. The medication’s guidelines clearly state that patients need frequent blood tests to ensure the medication isn’t making their blood too thin. Staff should also watch for warning signs of bleeding, such as unusual bruising or bloody stools.

The facility’s pharmacist revealed a complete breakdown in safety measures, admitting she “was unaware that the resident had out of target range or critical” blood test results. Another pharmacist emphasized that this level of oversight was unacceptable, stating that given the resident’s concerning test results, “closer laboratory monitoring should have been done. Failure to do so could result in increased bleeding and possibly death.”

Maggot Infestation Found In Resident’s Leg At La Bella Of Danville

October 21, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined La Bella Of Danville when a resident experienced recurring infestations of maggots in his leg wounds due to inadequate wound care and dressing changes.

The resident in question was admitted to the facility with multiple diagnoses including acute kidney failure, type II diabetes mellitus, morbid obesity, and various wounds. Despite being cognitively intact, the resident was dependent on staff for proper wound care.

The resident’s wounds were initially evaluated by a Wound Physician, who documented multiple large wounds on the resident’s legs and ordered a specific wound care regimen. This included the application of “0.1% Triamcinolone cream to both legs with 4-layer compression wraps from ankle to knee, twice a week.”

The first incident of maggot infestation occurred approximately five days later. The Wound Nurse reported that “a Licensed Practical Nurse notified her she found maggots in the resident’s leg dressing and in his wheel chair.” This led to a new wound care order from the Wound Physician, including washing the resident’s legs with Betadine and applying new dressings every other day for 30 days.

Despite this intervention, a second maggot infestation was discovered approximately one week later. During an examination, “the Director of Nursing (DON) removed the resident’s right lateral and medial leg wound dressings and the dressing pulled away from the wound contained 7 adult size (length of a diameter of a dime) live maggots.” The DON acknowledged the severity of the situation, stating, “this is the second time the resident has gotten maggots in the facility, as he was notified the resident had maggots in his wounds last Monday. The DON said this is unacceptable care.”

The investigation revealed that prescribed dressing changes were not being performed as ordered. A Registered Nurse had documented completing the dressing changes but later admitted, “we only had three Certified Nursing Assistants (CNAs) and the nurses were having to help pass trays and feed and I just got busy and forgot to do it after I charted it.”

The consequences of this neglect were severe. The resident’s wounds deteriorated significantly. One wound evaluation showed that the resident’s right anterior medial leg wound had increased from 8cm x 5cm to 16cm x 14cm in just six days.

The resident experienced considerable pain due to this neglect. The resident reported that “he had terrible pain in his legs and feet and behind his eye” and that “the pain in his legs had been worse recently, but he didn’t know why, and he needed someone to address it.”

The severity of the situation was acknowledged by multiple healthcare professionals. A Nurse Practitioner stated, “This has to be dealt with immediately. It could have been prevented and it could certainly have made the wound worse causing infection. This is unacceptable care.” The Wound Physician expressed concern about the frequency of dressing changes, saying “based on the size of the maggot, he questioned whether the dressings were being changed as ordered.”

This case highlights a critical failure in providing basic wound care, resulting in unnecessary suffering for the resident, potential for serious infection, and deterioration of existing wounds. It underscores the importance of adhering to prescribed care routines and maintaining adequate staffing levels to ensure proper patient care.

Resident At Shelbyville Manor Falls From Chair In Shower, Suffers Six Back And Neck Fractures

October 18, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Shelbyville Manor when a resident suffered multiple back and neck fractures due to a fall during a shower transfer. The incident resulted in emergency medical evaluation and treatment at two hospitals.

The resident in question had several pre-existing conditions that made them particularly vulnerable, including spastic paraplegia, abnormal posture, difficulty in walking, and muscle wasting and atrophy.

According to the quarterly assessment the resident was “completely dependent on staff for all activities of daily living and utilizes a wheelchair for locomotion.”

On the day of the incident, at approximately 8:50 AM, facility staff were moving the resident on a shower chair from a shower stall when the accident occurred. A Certified Nurse Aide reported that “when I began pulling the resident’s shower chair forward out of the shower stall, a wheel on the chair got caught on the shower curb and the resident began falling forward.” The CNA attempted to prevent the fall by pushing back on the resident and the shower chair, but both the resident and the CNA ended up falling to the ground.

Immediately after the fall, the resident expressed pain and continued to express pain when staff transferred them from the floor to a chair. The facility incident investigation documented that “the resident complained of neck, chest, abdomen, and knee pain after falling to the ground.”

Despite the evident pain, the resident was not immediately sent to the hospital. Progress notes indicate that the resident “stayed in bed during lunch and only ate ‘about six bites’ due to experiencing chest and abdomen pain.” It was only after this that the resident was sent to the local hospital emergency department for evaluation.

At the hospital, the resident reported experiencing pain “everywhere” and was diagnosed with neck and back fractures, necessitating transfer to a regional trauma center. The trauma center report revealed the full extent of the resident’s injuries: “the resident was diagnosed with six back and neck fractures (thoracic vertebrae #11/#12, lumbar vertebrae #1/#2/#3, and cervical vertebrae #3).” The resident required intravenous morphine for pain management and remained hospitalized for just under a week.

Upon returning to the nursing home facility, the resident was prescribed analgesic pain medication and required “a rigid cervical immobilizer (a type of rigid neck brace used to limit movement after surgery or serious injury) to be worn at all times.” The severity of the resident’s injuries is further evidenced by their increased reliance on pain medication. Prior to the fall, the resident had only taken a single dose of acetaminophen over the period of a month. However, after returning from the hospital, the resident was taking acetaminophen “nearly every day” for pain management.

This incident highlights a critical failure in resident safety protocols, particularly in the safe transfer of highly dependent residents during routine care activities. The case underscores the importance of proper equipment maintenance, staff training in transfer techniques, and immediate medical evaluation following falls, especially for residents with pre-existing mobility issues and neurological conditions.

Bria Of River Oaks Fails To Quickly Address Critical Changes In Resident Health, Contributing To Death Of Two Residents

October 11, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Bria of River Oaks when two separate residents both experienced critical changes in their conditions that were not appropriately addressed by staff and ultimately contributed to their deaths.

The first resident in question was a male with a history of cerebral infarction, type II diabetes, and dementia.

He was found vomiting in his room one afternoon. The nurse on duty assessed the resident and found abnormal vital signs, including high blood pressure (177/94) and low oxygen saturation (87%). The Nurse documented that the resident “had four episodes of vomiting within the hour, looked pale and was confused.” Despite these concerning symptoms, emergency services were not called until two hours after the initial assessment.

When paramedics arrived, they found the resident alert but “complaining of shortness of breath with no relief from O2 (oxygen) via nursing home.” They increased his oxygen support, which improved his saturation. At the emergency room, the resident was diagnosed with a “large subdural hematoma (blood in brain) with midline shift,” a critical condition requiring “emergent neurosurgical consultation.” The resident was airlifted to another hospital for advanced care but unfortunately passed away.

The resident’s physician emphasized the seriousness of the situation, stating, “If a patient is experiencing an increase of blood pressure such as the 170’s or higher, it is important to assess mental status. If the mental status has decreased from baseline, it is an emergency and the patient should be rushed to the emergency room via 911 to rule out a stroke, brain bleed or hypertensive encephalopathy.” The delay in seeking emergency care for the resident potentially contributed to the severity of his condition and subsequent death.

The second case involved a resident with type II diabetes, chronic kidney disease, and hypertension.

On the day of this second incident, at around 9:15 PM, the resident was assessed by a Nurse with symptoms of low blood sugar, including “sweating and slow with speech.” His blood sugar was measured at 73. Despite attempts to raise his blood sugar with sugar packets and orange soda, a subsequent check at 9:40 PM showed it had dropped to 62. The Nurse administered an emergency glucagon injection, and at 10:00 PM, the resident’s blood sugar had risen to 107.

However, the situation took a dramatic turn less than an hour later. At 10:56 PM, the Nurse observed the resident “slow to respond” in bed. By 11:00 PM, the resident was found “unresponsive, not breathing and without a pulse.” CPR was initiated, and 911 was called at 11:02 PM. When paramedics arrived at 11:11 PM, they found the resident in cardiac arrest with a critically low blood sugar of 45.

The resident was revived and taken to the hospital, where he was treated for “hypoglycemia (low blood sugar), respiratory distress, and cardiac arrest.” He was later discharged to home hospice and passed away shortly thereafter, with the cause of death listed as “Hypoxic Brain Injury.”

The second resident’s physician highlighted the critical nature of managing low blood sugar, stating, “the resident should have quickly gone out to the emergency room after the nurse determined the blood sugar was critically low and a glucagon injection was needed in order to prevent further lowering of the blood sugar. If the blood sugar gets too low, as in the case of this resident and the patient can stop breathing, the brain loses oxygen and can lead to fatality.”

These cases illustrate significant failures in recognizing and responding to medical emergencies in a timely manner. The delays in seeking emergency care for both of these residents likely contributed to the severity of their outcomes, underscoring the critical importance of prompt assessment, intervention, and escalation of care in nursing facilities.

Botched Lift Leaves Resident “Hanging From The Lift Sling With Her Arms Raised High And Legs Dangling” At Radford Green

October 11, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Radford Green when a resident suffered a left hip fracture due to improper handling during a mechanical lift transfer. It took the facility nearly a week to finally discover the full extent of the injury and transport the resident to the emergency department for evaluation and treatment.

The resident in question is described as having severe cognitive impairment and requiring maximum assistance with bed mobility and transfers. Her diagnoses include fibromyalgia, atrial fibrillation, congestive heart failure, and dementia.

The incident in question occurred during a shower transfer using a sit-to-stand lift. According to a Certified Nursing Assistant, the resident became agitated and resistive while he was attempting to place the lift sling under her arms. Despite this, the CNA proceeded with the transfer alone, violating the facility’s policy requiring two staff members for mechanical lift transfers. During the transfer, the resident began to slide out of the lift sling.

A separate CNA provided a more alarming account of the incident. She reported hearing yelling from the shower room and upon investigation, found the resident “hanging from the sit to stand lift sling with her arms raised high and her legs dangling near the ground.” This CNA stated that the resident “was not bearing any weight on her legs at the time” and that the original CNA manipulating the lift “was just standing there looking at the resident with a shocked look on his face.”

The intervening CNA instructed the Aide to support the resident’s weight from behind while she lowered the lift arm and detached the sling. They then lowered the resident to the ground. Notably, the intervening CNA mentioned that the leg band was not secured around the resident’s legs, which is a critical safety measure for this type of transfer.

The facility failed in several key areas following this incident:

1. Timely Assessment: The facility did not ensure the resident was assessed immediately after being lowered to the ground. An Advanced Practice Nurse stated, “when the resident was lowered to the ground on the day of the incident, it should have been reported to the nurse right away so an assessment for injuries could have been performed.”

2. Physician Notification: The facility failed to notify the resident’s physician in a timely manner about the incident.

3. Ongoing Assessments: There was a lack of ongoing nursing assessments from the time of the incident through the following week, when the resident was finally transported to the emergency department.

4. Delayed Medical Evaluation: An Orthopedic Surgeon emphasized the severity of the situation, stating, “the resident had a bad injury, and she should have been sent out to the emergency department after the incident for x-rays and treatment.”

The consequences of these failures were severe. The resident’s left hip fracture went undiagnosed for a week, potentially causing unnecessary pain and complicating her recovery. The hospital emergency department report noted that the resident’s “left leg was swollen with tenderness and bruising noted to the back of the leg and painful range of motion.”

This case highlights critical failures in resident care, safety protocols, and post-incident procedures. It underscores the importance of adherence to transfer protocols, immediate incident reporting, thorough assessments, and timely medical evaluations in ensuring the safety and well-being of vulnerable residents in care facilities.

Resident Falls, Loses Ability To Walk When Staff Attempt To Adjust Shoe While Resident Is Standing At Alden Estates-Courts Of Huntley

October 2, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Alden Estates-Courts of Huntley when a resident fell while a staff member was attempting to fix her shoe while she was standing upright. The fall resulted in a fractured hip and the loss of independent mobility.

The resident in question had multiple diagnoses including dementia, Parkinson’s disease, Alzheimer’s, anxiety disorder, and a history of wandering and behavioral disturbances.

Prior to the fall, the resident was able to ambulate with a walker, requiring only verbal cues as reminders. However, the incident dramatically changed her condition. As a RN stated, “Prior to the resident’s fall she was able to ambulate with a walker. The resident only needed verbal cues to remember to use her walker.” After the fall, the resident’s mobility was severely impacted, with the Restorative Nurse noting, “The resident is currently a two persons assist. The resident no longer initiates movement on her own. The resident will not get out of bed independently which is what she did prior to her falling.”

The circumstances of the fall, as described by a CNA, involved a moment of inattention to the resident’s known impulsive behavior: “I provided the resident with a shower on the day the resident fell. I put the resident’s shoes on. The resident became anxious and wanted to get out. The resident stood up as I was trying to finish. The back part of the resident’s shoe was folded over. I tried to get the resident to sit down so I could fix it, she wanted to leave. As I fixed the back of her shoe she stepped away and fell onto the floor.”

This account reveals a failure to properly manage the resident’s known risk factors and behaviors. The resident’s Care Plan clearly indicated she was “At risk for falls” and included instructions to “Encourage appropriate use of walker” and “Provide proper, well-maintained footwear.” The CNA’s actions in attempting to adjust the resident’s shoe while the resident was standing, despite her known impulsivity and fall risk, directly contributed to the incident.

The severity of the consequences is evident in the statement from the resident’s Primary Physician: “after the fall the resident was sent to the hospital. Imaging shows a femur fracture post fall. The resident received surgical intervention to repair the fracture.” This injury not only caused immediate pain and distress but also resulted in a significant decline in the resident’s quality of life and independence.

The facility’s response to the incident, as described by the Director of Nursing (DON), acknowledges the lapse in care: “We have had conversations with the CNA and explained the need to have the resident sit down to adjust shoes.” However, this reactive measure highlights a failure in proactive training and adherence to established care protocols.

The resident’s Power of Attorney aptly summarized the avoidable nature of the incident: “I do not know why they did not have her sit down before messing with her shoe. That contributed to her fall. The resident was able to walk before the fall; she is not able to walk now.”

This case demonstrates a critical failure in providing appropriate Activity of Daily Living (ADL) care to a resident with known dementia-related behaviors. The incident resulted in severe physical harm and a significant decline in the resident’s quality of life, underscoring the importance of strict adherence to care plans and proper training in managing residents with cognitive impairments and fall risks.

Mentally Ill Resident Left Lying In Urine, Contracts Sepsis At Shawnee Senior Living

October 2, 2024 By Barry G. Doyle

The Illinois Department Of Health has cited and fined Shawnee Senior Living when staff failed to accurately assess, treat, and prevent a significant both mental and physical decline in condition for a resident. This failure resulted in the resident, who has a history of confusion with infections, experiencing altered mental status and refusing overall care after being diagnosed with a urinary tract infection. The resident’s refusals of care additionally led to the resident developing a Stage 3 pressure ulcer with sepsis secondary to skin and soft tissue infection, subsequently requiring an 11-day hospitalization for IV antibiotic therapy.

When a resident is being considered for admission to a nursing home, one of the judgments that the admissions staff must make is whether the resident has care needs which would make him unsuitable for the facility or has care needs which cannot be met at the facility. This is an especially critical judgment where a resident has a demonstrated history of psychiatric and behavioral issues which demonstrate a pattern of aggressive or threatening behaviors because a nursing home is often filled with residents who due to physical or mental infirmities may not be able to fend off an aggressor.
The nursing home administration here made a poor decision to readmit this resident and then compounded the problem by failing to train or empower the staff as their proper role in protecting residents and then failing to provide the care this mentally ill patient needed, despite the very difficult situation staff members were presented with.

The story is a troubling account on many levels. For the resident, it is a sad account of unmet psychiatric needs and neglect of physical needs at a nursing facility.

The individual was a long-term resident with a history of suffering mental confusion during infections. He was readmitted to the facility following a hospital stay for treatment of a urinary tract infection (UTI) with extended spectrum beta-lactamase (ESBL) bacteria. Upon return, the resident had orders for Augmentin 875-125 mg twice daily for 10 days to treat the UTI.
From the moment of readmission, signs of trouble were apparent. The progress note from the day of admittance noted that the resident was “alert and oriented to person, place, and time, refused a skin evaluation and was refusing to take medications as ordered.”

Over the next few days, the resident’s condition rapidly deteriorated. Just two days after readmission, a progress note at 5:11 PM documented, “referral information faxed to a behavioral hospital for possible placement related to the resident’s delusions, refusal of care, and verbal behaviors.” Another note from the same day at 3:08 PM painted a concerning picture: “Resident refused to get up out of bed. He is mumbling to himself unable to understand what he is saying. He refused to take all meds. He would not allow writer to take his vitals.”

The situation continued to worsen. On the fourth day after readmission, a progress note at 5:27 PM stated, “Resident has been in room talking to people that are not there all day he was heard telling people to get out of his room and mumbling under his breath. He refused to get up this shift has refused all meds. He did allow (blood glucose monitoring) but not insulin.”

Approximately a week after readmission, the severity of the resident’s condition was clear. A progress note at 4:13 AM documented, “refused meds and meals for past 1-2 weeks.” The next day a particularly disturbing note at 3:26 PM read, “CNA (Certified Nursing Assistant) states that resident has been incontinent of stool and is lying in his bed with genitals exposed and refusing to be changed.”

The neglect reached a critical point several days later. A progress note at 2:55 AM described a horrifying scene: “All shift resident has refused to let staff change him. Resident’s bed is saturated in urine and dripping into the floor. Resident has a puddle of urine under his bed and was trailing to the door. Resident let staff clean the urine from his bed to the door but refused to let staff change him or clean under the bed.”

Throughout this period, the resident was consistently refusing medications. The Medication Administration Record (MAR) showed that the resident refused Augmentin 16 out of 20 offered dosages. He also refused another antibiotic, Levaquin, 5 out of 7 offered doses.

The neglect culminated a day or so later when the resident became physically aggressive towards another resident. The aggressor entered the other resident’s room and attempted to pull the resident out of bed, claiming he was “shooting him with black stuff.” This incident finally prompted the facility to send the resident to the emergency room.

Upon arrival at the hospital, the full extent of the physical issues the resident had suffered became apparent. The emergency room record documented the resident as having “wounds on his bottom.” Further examination on the following day revealed the resident had developed severe pressure ulcers: a Stage 3 pressure injury on his left buttock measuring 4 cm in length, 2.5 cm in width, and 0.3 cm in depth, and a Deep Tissue Pressure Injury (DTPI) on his right buttock. The resident was diagnosed with sepsis secondary to skin and soft tissue infection.

The resident’s case highlights a systemic failure to provide appropriate care, with staff seemingly more concerned with documenting refusals than finding ways to provide necessary medical treatment and hygiene care. The facility’s approach to the resident’s declining condition could demonstrate a lack of understanding of the interplay between infections, mental status changes, and the need for persistent attempts to provide care even when a resident is initially refusing.

At the same time, when a resident is victimized in a resident-on-resident assault, it is incumbent upon the administration to determine whether that resident should remain in their facility. On this point it would seem that the administration made the correct decision in sending the resident out to the ER. Whether the resident should have been initially admitted to the facility, or sent out to the ER at an earlier date, is another question.

It could be argued that the resident was allowed to stay in the facility for too long, ultimately resulting in the resident assaulting another resident. It should have been obvious to the administration that this was not a proper resident to have in the facility in the first place. A nursing home is a “home” for many residents where they live full time. They do not deserve to be terrorized in their own home. And the resident that was assaulted was not provided with the level of protection he deserved.

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 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.

Facility’s Failure To Adequately Care For Bruise Sends Resident To Hospital With Septic Shock And Left Foot Abscess

September 21, 2024 By Barry G. Doyle

IDPH has cited and fined Accolade Healthcare Danville when the facility failed to properly assess, monitor, and report a bruise/hematoma on a resident’s left foot, which ultimately led to a serious infection requiring hospitalization and surgical intervention.

The incident in question began when a “fresh, purple bruise” measuring 3 cm by 1 cm was discovered on the resident’s left foot. The resident reported that it likely occurred during a mechanical lift transfer the previous day.

Initial documentation and monitoring of the bruise were inconsistent and inadequate. While a Weekly Skin Assessment noted the bruise had grown to 5 cm by 2.5 cm, subsequent assessments on the following two consecutive weeks failed to mention the bruise at all, stating only that there were “no new or worsening skin conditions.”

The facility’s failure to properly monitor and report the worsening condition led to severe consequences. Approximately two and a half weeks after the initial reporting of the wound, the resident was hospitalized with “left foot swelling, fluctuance (boggy feeling due to buildup of fluid), redness and warmth.” The hospital diagnosed the resident with septic shock and a left foot abscess. The situation was so severe that a few days later, “purulence was expressed from the resident’s abscessed hematoma and a large hematoma was operatively removed.”

Upon the resident’s readmission to the facility, further lapses in care were evident. The readmission assessment noted “multiple stage one pressure ulcers on the right outer foot” without providing crucial details such as the number of wounds, their characteristics, or measurements. Subsequent assessments continued to lack necessary detail and consistency.

The facility’s staff, including nurses and wound care specialists, acknowledged these failures in care. A RN stated that “the area stayed the same from when it was first identified until the resident was hospitalized, and the area had not shown any signs of improvement.” The same RN also noted that “there should be documented monitoring and assessments for this area recorded on the Treatment Administration Record or progress notes,” which were clearly lacking.

A Nurse Practitioner emphasized the severity of the oversight, stating that “the facility staff should have been monitoring and assessing the resident’s hematoma, including characteristics, measurements/assessments, and monitoring for fever.” The Nurse Practitioner added that “it is a ‘strong possibility’ that the resident’s hospital incision and drainage may have been prevented if the resident was evaluated by the Wound Physician and antibiotics were ordered.”

The Wound Physician corroborated this assessment, stating that had the facility properly monitored and reported the hematoma, he “would have lanced and drained the hematoma at the facility, which could have prevented the resident’s hospital incision and drainage.”

This case highlights a systemic failure in wound care protocols, communication, and adherence to established policies, resulting in unnecessary suffering and complications for the resident.

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