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Glenview Terrace resident suffers multiple fractures when lift topples over during transfer

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IDPH has cited and fined Glenview Terrace nursing home after resident sustained multiple fractures to her back and sacrum when a mechanical lift toppled over during a transfer.

Used properly, a mechanical lift is a useful tool for caring for residents in a nursing home setting.  It allows residents to be transferred safely from one place to the other with minimal risk of injury.  It also reduces the risk of injury to staff members by eliminating the lifting that has to be done by staff in manual transfers.  However, the key to this is that the lift must be used properly, and proper use of a mechanical lift requires two staff members to assist in transferring a resident from one place to the other.  Having on person do a two-person job when it comes to transfers is a formula for disaster, as we have written about many times on this blog (see here, here, here, here, and here for examples).

The resident at issue was wheelchair bound and had a medical history which included a stroke with residual weakness on one side.  Her care plan called for transfers to be done with a mechanical lift with the assistance of two staff members.  Two staff members are needed for transfers with a lift because one staff member is needed to operate the lift while the other staff member keeps the resident steady in the sling.

On the day of this nursing home fall, the resident was being transferred from wheelchair to bed by a single aide using the mechanical lift.  After the resident was placed in the sling to the lift and was lifted up from the chair, the resident began to sway in the sling.  This resulted in the center of gravity shifting and the lift itself toppling over.  The resident landed on the floor on her back.  She was brought to the hospital where she was diagnosed with multiple fractures to the vertebrae in her lower back as well as to her sacrum.

The obvious cause of this mechanical lift accident was the aide failing to follow the terms of the care plan and failing to follow generally recognized safe practices regarding the use of the lift.  The deeper question is, why did he not get assistance before attempting the transfer.  The answer to this likely relates to the understaffing of the nursing home – he was too rushed to get the extra help needed to accomplish a safe transfer of this resident.  Alternatively, it could simply be poor training of the aide.

Either option – understaffing or poor training of the staff – implicates the choices made regarding the management of this nursing home.  Sadly, failing to invest in the staff so as to help assure that residents receive the care they need and deserve is part of the nursing home business model.   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.  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.

Other blog posts of interest:

Violation of care plan at Generations Oakton Pavillion leads to fall and fracture

Avantara Lake Zurich resident suffers lower leg wound during unsafe transfer

Grove at the Lake resident suffers multiple injuries in mechanical lift accident

Resident suffers jaw, facial fractures at Dimensions Living in Prospect Heights

Niles Nursing & Rehab resident suffers fatal brain bleed in fall

Failure to provide needed assistance leads to fall at Generations of Elmwood Park

Resident suffers broken hip in unsafe transfer at Pearl of Rolling Meadows

Grove of Skokie resident breaks leg due to violation of care plan

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Victorian Village resident develops pressure ulcer from orthotic boot

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IDPH has cited and fined Victorian Village Health & Wellness nursing home in Homer Glen after a resident there developed a pressure ulcer on her heel from her orthotic boot.

“Pressure ulcers” are commonly referred to as bed sores because they frequently develop on persons who are unable to get out of bed and are caused by pressure from the weight of the body against the bony prominences.  This is why some of the most common parts of the body for bed sores to develop are the buttocks, hips, sacrum, and heels.

However, pressure from the weight of the body is not the only way that pressure ulcers can develop.  One common way for bed sores to develop is pressure against the body from medical devices and equipment such as casts, catheters, immobilizers.  The risk associated with the use of these devices is well-known in long-term care industry and should be addressed in the care planning process.  The risk from these devices can be mitigated by frequent skin inspections; checking the device for fit, condition, and positioning; and obtaining doctor orders permitting removal when appropriate.

The resident at issue was admitted to the nursing home for rehabilitation after suffering a fall at home.  One of the complications that she had as a result of the surgery was that she had a drop foot on one side for which she was given an orthotic boot to wear.  On admission to the nursing home, she underwent a full skin inspection and there were no pressure ulcers.

After being admitted to the nursing home, she would periodically complain of a burning sensation in the heel.  However, no one would take the boot off to inspect the underlying skin or the condition of the boot; they would simply loosen  the boot for a period of time.  Further, no one notified the doctor that the resident was complaining of a burning sensation in the heel.

The pressure ulcer was not discovered until the resident had been admitted to the nursing home for about 10 days, at which point a staff member removed it to clean the foot.  At this point, the wound was considered an unstageable pressure ulcer which is by definition at least a Stage 3 or possibly a Stage 4 pressure ulcer.  According to the citation, the wound had extended up to the Achilles tendon of the resident.

Why did the resident develop the pressure ulcer?  Inspection of the boot revealed that even though it was lined, a portion of the lining had worn away so that the heel of the resident was laying directly on the frame of the boot.  This is exactly the kind of thing that causes pressure ulcers to develop with the use of medical devices and equipment – prolonged pressure from an inadequately padded device.

What should the nursing home have done?  For starters, the regular inspections of the skin and the device were not done.  Had the boot been removed and the condition of the skin and the boot been observed, the relationship between the resident’s complaints about a burning sensation in her heel would have been readily apparent.  Beyond that, the frequent appearance of a burning sensation in the heel also should have resulted in physician notification.  This was not done.

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.  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.

Other blog posts of interest:

Moweaqua Rehab resident develops pressure ulcer from fracture brace

Resident at Christian Nursing Home in Lincoln develops pressure ulcer from brace

Oak Brook Care Center resident develops pressure ulcer from immobilizer

Pressure ulcer from surgical boot at Amberwood Care Center

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Resident at Hickory Point Christian Village in Forsyth suffers multiple fractures in fall

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IDPH has cited and fined Hickory Point Christian Village in Forsyth after a resident there suffered a fractured arm and fractured hip in a fall.

The resident at issue had a history of repeated falls, including two falls within a 24 hour period, the last of which resulted in a fractured right hip which brought about the admission to the nursing home.  On admission the resident was noted to have strength and mobility deficits and suffered from dementia and confusion.  Having a history of falls is a significant fall risk factor, as are strength and mobility deficits and dementia/confusion.

On the day of this nursing home fall, the resident was brought to the bathroom by an aide.  The aide did not consult the Kardex for the resident and was unaware of the resident’s history of falls and fall risk status. He requested some privacy so she closed the door to leave him in the bathroom.  When he was done, she realized that she did not have supplies for cleaning him up, so she left him unattended in the bathroom while she went to get them.  While she was gone, the resident got up from the toilet and fell, suffering fractures to the left arm and left hip.

This was a fall that likely would have been avoided had the aide checked the Kardex for the resident’s fall risk status and/or had the aide brought the necessary supplies to clean up after the resident.  Neither of these things occurred, and as a result, a very preventable fall occurred.

Given that this resident had a fracture to the right hip from which he was recovering, an additional fracture to the left hip will make recovery from the two injuries much more difficult.  These fractures were compounded by the fact that the resident suffered a fracture of the left arm as well, which would complicate any effort to have the resident engage in any form weight bearing using a walker or in the parallel bars in physical therapy.  If the resident does not regain his ability to walk, this has serious negative consequences for his quality of life as well as his risk of developing additional complications such as bed sores.

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.  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.

Other blog posts of interest:

Charleston Rehab resident suffers brain bleed and fractured hip in fall from bed

Cumberland Rehab resident suffers brain bleed due to fall from toilet

Hilltop Skilled resident breaks leg in fall from bed

Piatt County Nursing Home resident fractures hip in fall

Heritage Health Pana staff violates care plan leading to fall and fractured hip

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Cedar Ridge resident breaks both legs in fall from bed

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IDPH has cited and fine Cedar Ridge Health & Rehabilitation Center nursing home in Lebanon after a resident suffered fractures to both legs in a fall from bed.

The resident at issue had an extensive medical history which included a below the knee amputation, morbid obesity, and a host of other medical issues.  Her Minimum Data Set (MDS) reflected that she required the extensive assistance of two persons with transfers and bed mobility.  The entry of that information on the MDS is significant because the MDS is completed under oath since it forms part of the basis of payment for the nursing home.  The resident care plan also called for assist of two with bed mobility.  The resident was regularly transferred with the use of a Hoyer lift, which requires two staff for safe operation.

On the day of this nursing home fall, the resident was getting ready to be transferred from bed to her wheelchair using the Hoyer lift.  As part of the transfer process the sling of the lift had to be placed underneath the resident, requiring her to roll from side to side while the sling is positioned underneath her.

During the process of getting the sling positioned underneath her, the resident rolled to one side.  Once the sling was positioned beneath her she rolled to the other side, but rolled off the edge of the bed, landing on her knees.  She felt and heard a pop in both knees.  X-rays showed that there were fractures to both femurs which required her to be transferred to a teaching hospital for further care.

We frequently write on this blog about mishaps that occur when you have one person doing a two person job, as that is often a formula for disaster (see here, here, here, here, and here for examples).  Here it was unclear whether there was one or two staff people in the room at the time of the fall.  The resident quite clearly described there being only a single aide involved.  The aide claimed that there was agency staff in the room at the time but that the agency staff was not near the bed at the time of the fall.  Whether there was one or two staff people on the room, if only one was involved in repositioning this resident, then the resident was not receiving the level of assistance required to keep her safe – a violation of federal regulations and a violation of the resident care plan.

While the care plan violations was most clearly the cause of this resident’s fall, there is potentially a deeper level to this: the understaffing of the nursing home.  The resident related here that there would normally be only a single aide involved in getting her on to the sling for transfers even though two was required.  When there is one person doing a two person job, that raises a fair question about understaffing.  Sadly this is a feature and not a bug in the nursing home business model.  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.  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.

Other blog posts of interest:

Use of improper lift at Sunset Home leads to admission to intensive care unit

Vandalia Rehab cited for understaffing

Sling breaks during transfer at University Nursing & Rehab

Hitz Memorial resident dropped from lift

Resident dies from brain bleed after fall at Elmwood Rehab in Maryville

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Oak Brook Care resident develops bed sore from immobilizer

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IDPH has cited and fined Oak Brook Care Center nursing home after resident there developed a Stage 4 bed sore from an immobilizer.

“Bed sores” are also known as “pressure ulcers” because one of the main factors that cause these wounds is pressure.  Most often the pressure that causes them is pressure brought about by immobility which is why you normally see bed sores develop on the bony prominences such as the hips, buttocks, sacrum, or heels.  However, immobility-related pressure is not the only type of pressure which can cause skin breakdown as pressure from medical devices and equipment such as braces, immobilizers, catheters, casts, bed pans, and other devices and equipment can cause bed sores or pressure ulcers to develop as well.

Because the risks of developing pressure ulcers from medical devices and equipment is well-recognized, interventions such as regular skin checks should be included as part of the care-planning process and should be incorporated into the nursing home’s policies and procedures.  When early signs of a skin breakdown are identified, physician notification is required so that the physician can determine whether there are suitable alternatives to the device that is causing the pressure, whether the use of the device is necessary, or whether there are ways in which the use of the device can be modified so as to eliminate or reduce the pressure caused by the device.  It also allows the physician to enter orders for treatment.

The resident at issue was admitted to the nursing home with an immobilizer in place for treatment of a fractured kneecap.  At the time that the resident was admitted to the nursing home, there were no bed sores present, according to her Minimum Data Set (MDS).  Federal regulations provide that when a resident is admitted to a nursing home with no pressure ulcers present, they must receive care consistent with standards or professional practice such that the resident does not develop pressure ulcers unless they were unavoidable.

Within two weeks of her admission to the nursing home, the resident developed some redness to the calf, likely caused by some rubbing by the brace.  The nursing staff noticed the wound and referrals for treatment by a wound care nurse and a wound care physician were obtained.  However, the family was not notified and the treating orthopaedic surgeon was not notified for over a week.

When the treating orthopaedic surgeon was notified of the presence of the wound, he gave instructions that the immobilizer could be removed when the resident was in bed but that it needed to be left on during transfers and while the resident was in her wheelchair.  Limiting the time that the resident was in the immobilizer would have helped with healing the wound on the calf by reducing the exposure of skin to the pressure from the use of the immobilizer.  However, compliance with this order was not tracked in any meaningful way.

By the time that the wound care physician saw the resident for the first time over a week after when the wound was first seen, the wound was characterized as a full thickness wound and was much larger in size.  It also had slough and necrotic tissue, indicating that there was dead tissue from the wound.  This represented a significant decline in the condition of the wound from when the wound was detected.  There was no notification to the family of the decline in the wound.

The wound care physician issued orders for the treatment of the wound.  However, there were multiple days when those treatment orders were not carried out.  The wound continued to decline and worsened to a Stage IV pressure ulcer with exposed tendon.  Additionally, the facility failed to keep multiple telehealth appointments with the treating orthopaedic surgeon who was also unaware of the continued decline in the condition of the wound.

Approximately 8 weeks after the wound on the calf was first detected, the resident was transferred to the hospital for a urinary tract infection.  The hospital recognized that the wound had a cellulitis infection and began to treat it with a bedside debridement and use of a wound vac.  The care of the wound was being managed by a plastic surgeon.  The treating orthopaedic surgeon told the state surveyor that the nursing home did not advise him of the decline in the condition of the wounds and that the wound would not have declined to the point that it did had his instructions to remove the brace been followed.

For their part, the administrator and Director of Nursing blamed agency staff for failing to complete ordered wound treatments and stated that it had been an ongoing issue with agency staff.  Of course, the nursing home remains responsible for the provision of care and the administration of the nursing home is responsible for the operation of the nursing home.  The failure to hire or retain qualified staff or get agency staff in who will get the job done will inevitably have consequences for the health and well-being of the residents. 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.  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.

Other blog posts of interest:

Resident at Christian Nursing Home in Lincoln develops pressure ulcer from brace

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

Victorian Village resident develops pressure ulcer from orthotic boot

Pressure ulcer from surgical boot at Amberwood Care Center

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

 

 

 

 

University Rehab Northmoor resident suffers fractured hip in fall from bed

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IDPH has cited and fined University Rehab Northmoor nursing home in Peoria after a resident there suffered a fractured hip as a result of a fall from bed.

The resident at issue here suffered from cerebral palsy, cognitive deficits, and paraplegia.  This is someone who would have had a great deal of difficulty assisting in her care due to her physical and cognitive challenges.  There was a care plan put into place which called for assist of two with bed mobility, keeping the bed in the lowest position, and use of bilateral floor mats.  When a care plan is put into place, it falls to the staff charged with caring for the resident to implement it on a day-to-day, shift-to-shift basis.

On the day when this nursing home fall, there was a single aide who was providing incontinence care to the resident. While doing so, the aide had raised the bed and moved one of the floor mats to get better access to the bed. In the process of providing incontinence care to the resident, the aide recognized that she needed a bed pan. She left the room with the bed still in a raised position, the resident unattended, and one of the floor mats moved out of position. When she returned to the room, she found that the resident had fallen from bed.

X-rays were done, which showed that the resident suffered a fractured hip requiring surgical repair.

There were at least three violations of the care plan that took place that resulted in the fall. First, the aide was providing incontinence care to the resident by herself instead of with two people.  The care plan called for the assist of two with bed mobility. Bed mobility refers to the ability to change and maintain a position in bed, something that is necessary when a resident is receiving incontinence care. Two people should have been assisting with this rather the one who was actually providing this care.  Having one person do a two-person job is a well-recognized formula for disaster (see here, here, here, here, and here for examples).  Second, the care plan called  for the bed to be in a low position. The bed was in a raised position when the resident fell. Third, it also called for floor mats on both sides of the bed, and the floor mats had been removed so that the aide could get at the resident to provide care, but then the aide left the resident unattended with a floor mats out of position. As a result, we have the resident falling, hitting the floor and suffering a broken hip.

At one level, those violations of the care plan are the cause of this resident’s injuries. However, there is a deeper level to that, and that relates to the understaffing of the nursing home. When the aide was questioned by the state surveyor as to what happened, the aide explained to the surveyor that she just didn’t have time to ask for help in providing this care. When you have a staff that is describing not having time to ask for help, when you have staff that are taking shortcuts in the care that’s being provided to the resident, then that’s a sign of a nursing home which is understaffed, and that’s a nursing home which places residents at increased risk for adverse events, such as falls, bedsores,  nursing home choking accidents, medication errors, and so forth.

Unfortunately, understaffing is part of how nursing homes are run. 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.  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.

Other blog posts of interest:

Farmington Country Manor resident breaks leg due to failure to follow care plan

Resident at The Clayberg breaks arm due to failure to use gait belt

Fondulac Rehab resident suffers fatal injuries in fall

River Crossing of East Peoria resident suffers brain bleed due to unsafe transfer

Aperion Spring Valley resident suffers fatal brain bleed in fall

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Sharon Health Care Elms in Peoria fails to give anti-seizure medication to resident

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IDPH has cited and fined Sharon Health Care Elms nursing home in Peoria after a resident there suffered seizures due to not receiving anti-seizure medications as ordered.

Treating seizures is a difficult task but must be done.  Prolonged seizures can cause brain damage but even shorter seizures can cause injury and have lasting effects.  The most effective way to prevent seizures is through the use of medication, often given in combination.  Nursing home medication errors which result in residents not receiving their medications as ordered can result in significant seizures with serious resulting injuries.

The resident at issue had a diagnosis of epilepsy as well other neurologic disorders which affected the brain.  She was prescribed multiple medications, including Keppra and Depakote to help prevent seizures.

Over a period of approximately 6 hours, the resident experienced four seizures.  The shortest of these was 90 seconds, the longest approximately 5 minutes.  Two occurred in the nursing home, one in the ambulance on the way to the hospital, and the last in the emergency room.

When the resident arrived in the emergency room, labs were drawn.  These showed that the resident’s Depakote levels were 13 mcg/ml (normal range 50-100) and that Keppra could not be detected at all.  The conclusion was that the resident’s seizures were due to subtherapeutic (below normal) levels of these anti-seizure medications.

Investigation into this incident showed that the Keppra had been discontinued due to a clerical error by a member of the nursing staff.  An error had been made in entering the order for the Keppra.  The wrong order was discontinued; however the correct order was not entered.  The net result was that no Keppra was being given to the resident.  This is of course consistent with lab results showing that Keppra could not be detected at all.

The issue with the Depakote is more difficult to determine how the resident ended up with subtherapeutic levels of the medication.  However, the last delivery of Depakote was made to the nursing home from the pharmacy a little less than a month and a half prior to the date that the seizures occurred.  However, the container only had enough medication to last 18 days.  Clearly there was not enough medication on hand for the resident to be receiving the medication as ordered, resulting in the below-normal levels of this medication as well.

Giving medications as ordered is one of the basic tasks in a nursing home, and this incident demonstrated two clear but critical breakdowns in the delivery of medication to this resident.  One, relating to the Keppra, was the result of simple clerical error.  However, in well-run nursing homes, entries as to medication orders are normally double checked after the order is entered by a nurse on the floor.  The other medication error, relating to the Depakote, was likely multi-factorial but likely involves some element of false charting by the nursing home staff.

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.  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.

Other blog posts of interest:

Medication error at Sunset Rehab in Canton

Failure to give anti-coagulant medication at H&J Vonderlieth Living Center

Resident given wrong medication at Villa Health Care East

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Rochelle Rehab resident breaks leg due to unsafe use of wheelchair

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IDPH has cited and fined Rochelle Rehabilitation & Health Care Center nursing home after a resident there suffered a broken leg in a fall caused by the failure of the staff to use footrests while pushing the resident in a wheelchair.

On the surface, a wheelchair is a safe, simple piece of equipment to use.  However, like all equipment in a nursing home setting it must be used properly.  When it is being pushed by staff, that includes the use of foot rests.  Foot rests are required when the wheelchair is being pushed by staff because the failure to use foot rests requires residents to keep their feet up off the ground while they are being pushed forward.  If residents are unable to do so because of physical or cognitive limitations, one of two things happen when the residents are no longer able to keep their feet up: (1) the resident’s feet get pulled underneath the wheelchair, resulting in twisting injuries to the leg which can cause fractures or torn ligaments and cartilage or (2) the resident can be thrown forward out the wheelchair, resulting in injuries such as a brain bleed, facial fractures, or broken collarbones, or wrists.

Sometimes, a fall from a wheelchair causes both.  And that was the case here.

The resident involved had cognitive impairments and was wheelchair bound.  She was being pushed by an aide in a wheelchair with no foot rests.  According to the aide, the resident stomped her foot job and sprang out of her seat “like a jack in the box.”  She landed on the floor and had a large laceration to the forehead that was immediately apparent.  She was sent to the hospital where she was also diagnosed with a fractured femur and additional scans showed two fractured vertebrae in the neck which were age indeterminant.

This is exactly the kind of nursing home fall which is going to result from pushing a nursing home resident in a wheelchair with no foot rests.  The failure to take these very simple steps raises a couple of questions about the operation of the nursing home, specifically with regard to the training of the staff and whether this was an understaffed nursing home.  Either one of these speaks to the investment that nursing home management is making in ensuring that the care needs of the residents are being met.  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.  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.

Other blog posts of interest:

Good Samaritan of Pontiac nursing home resident fractures leg and ankle in wheelchair accident

Resident breaks leg in wheelchair accident at Heritage Health in Dwight

Fall from wheelchair at LaSalle County Nursing Home

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Sling breaks during transfer at University Nursing & Rehab

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IDPH has cited and fined University Nursing & Rehabilitation Center nursing home in Edwardsville after a resident there suffered a broken hip and broken shoulder after falling during a transfer with a mechanical lift when the sling to the lift broke during transfer.

Used properly, a mechanical lift is a very beneficial piece of equipment for use in a nursing home.  It allows residents who have significant strength and mobility issues to be transferred from bed to wheelchair, wheelchair to chair, and so forth safely while at the same time reducing the risk of injury to residents and staff.

The key part of that statement is of course, the “used properly” part.  Proper use of a mechanical lift includes making sure that there are two staff members involved in all transfers because having on person do a two-person job is a formula for disaster (see here, here, here, here, and here for examples).  The other part of “proper use” is that the lift itself and all of the associated equipment is in condition for safe use and is used properly in accordance with manufacturer specifications.

The resident at issue here required the use of a mechanical lift for all transfers.  On the day of this nursing home fall, she was being transferred from a shower chair to her bed.  There were two staff present, but during the course of the transfers, the loop that attaches the sling to the lift device itself tore, causing the resident to fall to the ground.  The staff member who was assisting the resident during the transfer kept the resident’s head from hitting the floor, but the resident complained of leg pain and back pain.  The resident was sent to the hospital where she was diagnosed as suffering from a fractured hip and fractured shoulder.

The investigation into this mechanical lift accident revealed two things.  First is that the type of sling in use at the time of the accident was manufactured by a different company than the lift itself.  Neither the manufacturer of the lift nor the manufacturer of the sling recommended mixing their products with those made by other companies.  Second, the sling had been in use for two years and five months, and the sling manufacturer recommended that its product be replaced after a year.  The bottom line is that the sling was being used well past the end of its useful life in a manner that neither the manufacturer of the lift or the manufacturer of the sling recommended.

Past that, there was no set protocol for inspecting the slings to ensure that they were in good condition for use.  The administrator told the state surveyor that there was a laundry aide who was good about inspecting the slings but they did not have a protocol for inspecting the slings otherwise.  If the laundry aide did not do an inspection, there was no one who regularly did one or was trained to do so.  Without having enough trained eyes on the condition of the sling, this was allowed to fall into disrepair, leading to the failure of the sling and injury to this resident.

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.  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.

Other blog posts of interest:

Use of improper sling leads to resident being dropped from lift at Carlinville Rehab

Fall from mechanical lift at Hillcrest Retirement Village

Cornerstone Rehab resident falls from lift, breaks leg

Hitz Memorial resident dropped from lift

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Resident at Aspen Rehab in Silvis chokes to death due to violation of care plan

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IDPH has cited and fined Aspen Rehabilitation & Health Care nursing home in Silvis after a resident there choked to death on a sandwich due to a violation of the resident care plan.

The resident involved in this nursing home choking accident was a long-term resident of the nursing home.  He suffered from schizophrenia, anxiety, and dementia.  Some people afflicted with this set of conditions tend to eat very quickly, shoving food into their mouth and swallowing without chewing.

This is something that places the resident at risk for choking, and this had proven to be the case for this resident.  Prior to being admitted to the nursing home, the resident had a choking incident which led to an admission to the hospital intensive care unit.  He also had at least three other known choking incidents at the nursing home before the fatal one.  This was a resident who was clearly at risk for choking.

When there are threats to the health and well-being of nursing home residents, this must be addressed in the care planning process.  There are six basic steps to the care planning process: (1) an assessment of the risks to the well-being of the resident, (2) development of a written care plan consisting of a series of steps or interventions that must be taken to address those risks, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) ongoing evaluation of the effectiveness of the care plan, and (6) revision of the care plan if there are changes in the resident’s condition or if it proves to be ineffective in practice.

The nursing home recognized that that the resident was at risk for choking, and consulted with a speech therapist for recommendations to help ensure that the resident was able to eat safely.  These steps included obtaining an order for a modified diet to mechanical soft and mositening bread before serving.  It also included supervision of the resident while eating, cutting food into small pieces, cueing the resident to eat nore slowly and to take sips of water in between bites.  These steps were all incoporated into the resident care plan.

The resident’s family was permitted to bring food in for the resident periodically, but it had to be prepared and served by the staff.  On the day of the incident, the resident’s family brought in a tuna melt sandwich.  The sandwich was microwaved in the kitchen but not moistened.  Due to the pandemic, the residents were all eating in their individual rooms.  The resident’s meal was brought to him in his room by an aide who then left the room to pass additional meals.  She returned to the room about 5 minutes later to assist the resident’s roommate.

When she got to the room, she heard a gasping sound coming from the resident and realized that he was choking.  She called for help and began resuscitation efforts.  However, the resident’s airway was filled with food which they were not able to successfully clear.  The resident’s heart beat was lost and they were not able to regain it.  An emergency room physician instructed the paramedics and staff to cease resuscitation efforts and the resident was declared deceased.  Cause of death per the death certificate was anoxia due to choking on food.

There were a number of failures that led to the death of this resident.

First is that the resident was not being supervised while he was eating.  The nursing home properly recognized that he was at risk for choking and took reasonable steps to identify a number of steps which could be taken to mitigate that risk.  The key one here was supervision of the resident while eating – and this was not done here and was a violation of the resident care plan.

Why was there a violation of the care plan?

The simple answer is that the aide who served the meal did not know that he was supposed to be supercised while eating.  She did not know this because no one told her.  The resident care plan is more than paperwork – it is the game plan for the delivery of routine but necessary care for the resident.  If the staff charged with carrying out the care plan doesn’t know what they are supposed to be doing, the effort in coming up with the care plan is wasted.  More than that it represents a breakdown in the basic system that is intended to assure the safety of residents throughout the facility.  It is a major systems failure.

The second reason was that the kitchen staff failed to follows the orders for mositening of the bread.  The mechanical soft diet is supposed to help residents who have swallow difficulties and the moistening of the bread is intended to reduce the choking risk associated with bread.  This step which was intended to mitigate the risk of choking was also not followed.

In the end, these failures resulted in the very preventable death of this resident.

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.  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.

Other blog posts of interest:

Fondulac Rehab resident chokes to death

Aperion of Spring Valley resident chokes to death

Fatal choking accident at River Bluff nursing home

Heartland of Moline resident develops pneumonia due to failure to follow diet orders

Sunset Rehab resident chokes to death

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Resident at Christian Nursing Home in Lincoln develops pressure ulcer from brace

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IDPH has cited and fined Christian Nursing Home in Lincoln after a resident there developed an infected pressure ulcer from an immobilizer that was being used to treat a broken leg.

Bed sores are also known as pressure ulcers because one of the main factors that lead to the development of these wounds is pressure.  Most often that pressure is caused by immobility associated with some form of debility.  However, that pressure can also be produced by the use of medical devices and equipment such as braces, casts, tubing, or catheters.

When residents are at risk for developing pressure ulcers due to the use of medical devices or equipment, this must be addressed through the resident care plan.  Most often, this would include the use of padding on pressure points, periodic removal of the device to check the condition of the skin, and regular assessments of the fit and positioning of the device.

The resident here was admitted as a short-term rehab patient after breaking the lower end of his femur (thigh bone) in a fall.  He was placed in an immobilizer for the fracture and was supposed to be receiving care and therapy in the nursing home.

When the resident was admitted to the nursing home, he was assessed as being at risk for developing bed sores, which makes sense because he was suffering from immobility related to the fractures.  A care plan was put into place which addressed the risk of the resident developing the usual kind of bed sores that you see with nursing home residents who suffer from immobility.  There was no part of the care plan that specifically addressed the risk of developing pressure ulcers related to the use of the immobilizer.

The failure to care plan specifically for the development of pressure ulcers related to the use of the immobilizer was substandard care.  Done properly, care planning addresses the risks of harm specific to that resident.  Here, the resident faced a specific risk of harm related to the use of the immobilizer.  However, that risk was never addressed in the care plan.  The point of care planning is to help ensure that the risks of harm to the resident are addressed in a thought-out, systematic way and that the care needed is delivered on day-to-day, shift-to-shift basis and not left to the random decisions of nurses who may have varying levels of skill, knowledge, and work loads.

Within a week of the resident’s admission to the nursing home, there were reports made to the nursing staff by occupational therapy and physical therapy about concerns regarding the condition of the resident’s skin.  The resident was finally assessed at the end of that first week as having developed deep tissue injuries to the leg where the immobilizer was applied.  He alose had developed multiple bed sores on his hips and sacrum,

After the pressure ulcers developed, the care plan was revised to account for the presence of the immobilizer and the presence of the wounds.  Revision of the care plan to account for the presence of the bed sores was appropriate, but at that point, the damage from poor care planning had been done.   Making matters worse, the resident here also had peripheral vascular disease or poor circulation to the lower extremities which would make recovery from the wounds all the more difficult.

The resident was sent to the hospital within two weeks of admission to the nursing home suffering from sepsis related to the pressure ulcers from the immobilizer.  Poor care planning all too often leads to poor outcomes and that proved to be the case here.

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.  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.

Other blog posts of interest:

Moweaqua Rehab resident develops pressure ulcer from fracture brace

Sharon Health Care Elms resident develops bone deep bed sore

Christian Nursing Home resident suffers severe leg injury in fall

Flanagan Rehab resident suffers infection from bed sore

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

Pressure ulcer from surgical boot at Amberwood Care Centre

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Good Samaritan of Pontiac resident suffers fractured leg and knee in wheelchair accident

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IDPH has cited and fined Good Samaritan nursing home of Pontiac after a resident there suffered a fractured kneecap and femur due to being pushed in a wheelchair with no foot rests.

Wheelchairs are one of the basic pieces of equipment in use in nursing homes, and when used properly, they are very safe things to use for nursing home residents.  However, the key is safe use – and when wheelchairs are being pushed by staff, this includes using the foot rests.  It is acceptable for wheelchairs to be used without foot rests when residents are propelling themselves by walking their feet forward.  However, when staff is pushing a resident, use of foot rests is required for safe use. The facts of this incident demonstrate why.

The resident at issue was admitted to the nursing home after suffering a fall at home in which she suffered a fractured pelvis.  The resident’s Minimum Data Set (MDS) indicated that she was wheelchair bound and required assist of one staff members with transfers.

On the day of the incident, the resident was brought to the dentist’s office using the facility’s transportation van.  The transportation aide did not place the foot rests on the wheelchair before leaving the facility.  When they arrived outside the dental office, there was a handicapped ramp available to push the wheelchair up.

As the aide was pushing the resident up the ramp, her feet dropped and her legs got pulled underneath her.  The resident experienced immediate pain at the knee.  They got into the dentist’s office where the resident asked the staff for Tylenol.  The aide told the staff that they could not give the resident the medication.  The aide reported the incident and after the appointmenet was done, brought the resident back to the nursing home.

The staff obtained orders for x-rays which showed that the resident suffered a fracture to the knee cap and a fracture to the femur which extended down the through end plate of the bone.  The resident was placed in a cast, but some two months after the incident, the resident was still in an immobilizer and she told the state surveyor that her doctor said that she would likely never be able to walk again.

The failure to use foot rests while pushing a wheelchair leads to a very predictable accident: the resident is not able to keep their feet elevated off the floor while being pushed forward.  When their feet drop to the floor, the wheelchair keeps moving forward, pulling the resident’s legs underneath.  Once that happens, one of two things happens:  (1) there is a twisting mechanism which results in fractures to the legs or tears to the cartilage and ligaments; or (2) the resident is thrown forward out of the wheelchair.

Federal regulations pertaining to nursing home falls require that nursing home residents receive supervision and assistive devices necessary to prevent accidents.  And while those regulations most commonly pertain to nursing home falls, they also apply to this set of circumstances.  The failure to use the foot rests at the time of this accident led to this resident’s injury and was a violation of federal regulations.

The failure of the aide to know that this was necessary for safe use of the wheelchair speaks to poor training of the staff.  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.  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.

Other blog posts of interest:

Rochelle Rehab resident suffers multiple injuries in fall from wheelchair

Assisi at Clare Oaks resident breaks neck in fall from wheelchairs

Resident breaks leg in wheelchair accident at Heritage Health in Dwight

Fall from wheelchair at LaSalle County Nursing Home

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Bella Terra Streamwood resident suffers multiple fractures after falling out of bed

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IDPH has cited and fined Bella Terra Streamwood nursing home after a resident there sustained a fractured tibia and femur after falling from bed.

One piece of information that our firm looks at very closely in investigating nursing home abuse and neglect cases is the Minimum Data Set (MDS).  The MDS is a summary of the results of a series of assessments done as to the care needs of the resident.  It is supposed to reflect the levels of care that the resident requires.  It forms part of the basis by which the nursing home is paid for providing care to the resident and must be signed under oath by the staff members completing it.

The results of the MDS trigger a process called the Care Area Assessment which is essentially a prompt for the nursing home staff to initiate the care planning process for various areas.  Because the MDS triggers the Care Area Assessment, there should be a high degree of congruency between the MDS and what is reflected on the resident care plan.

Here, the resident’s MDS indicated that she required a two-person assist to turn and reposition in bed.  Her care plan also called for assist of two with bed mobility.

On the day of this nursing home fall, the resident was receiving incontinence care from a single aide.  She was in a position lying on her side and asked the aide to apply some additional lotion before turning her back from her side.  As the aide reached for the lotion, the resident rolled off the side of the bed and landed on the floor.  The resident was sent to the hospital where she was diagnosed with fractures of the tibia (shin bone) and the femur (thigh bone).

Here, the resident was properly assessed as requiring a two-person assist with bed mobility.  This was because she had strength and mobility deficits which made it hard for her to maintain position in bed.  There was a care plan in place which called for the proper level of care – two staff with bed mobility – but that care plan was not followed because you had one person doing a two-job with predictably disastrous results.

When you have staff taking shortcuts in the care of residents, it raises questions about three larger questions than the immediate shortcomings in care.  One is the possibility that the this is an understaffed nursing home – did the aide feel that she did not have time to wait for extra help to keep the resident safe?  Second, is this a poorly trained staff given that the aide did not know to follow the care plan?  Third, is there a breakdown in the delivery of care where the staff on the floor is not properly instructed as to the contents of the care plan?  All of these possibilities deserve a closer look.

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.  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.

Other blog posts of interest:

Niles Nursing & Rehab resident suffers fatal brain bleed in fall

Warren Barr North Shore resident rolled from bed, suffers fractured ankle

Alden Valley Ridge resident rolled from bed, breaks both legs

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

 

 

 

Heartland of Moline resident develops pneumonia due to failure to follow diet orders

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IDPH has cited and fined Heartland of Moline nursing home after a resident there developed aspiration pneumonia due to the failure of the staff to follow orders for a modified diet.

One common condition that nursing home resident suffer from is dysphagia, or a swallowing dysfunction.  This condition is commonly associated with the residual effects of a stroke, some neurological condition, generalized weakness, or advanced dementia.  Swallow dysfunction can be a deadly condition in that it places the resident at risk for having a nursing home choking accident or developing aspiration pneumonia.  Aspiration pneumonia occurs when foreign materials such as food, liquids, or saliva enter the lungs and cause an infection in the lungs.

When a resident is recognized as having a swallow dysfunction, evaluation by a speech therapist is necessary.  The speech therapist will then make recommendations regarding the resident’s eating and diet.  These recommendations are intended to combat the risks to the health and well-being of the resident, and will often include supervision and assistance with eating as well as modifications to the diet such as a puree or mechanical soft diet and/or thickened liquids.  The recommendations of the speech therapist should be incorporated into an order by the physician and into the resident care plan.

The resident at issue suffered from dysphagia and was referred to a speech therapist.  The speech therapist confirmed the presence of the swallow dysfunction and determined that a puree diet and moderately thickened liquids was necessary for the safety of the resident.  Those recommendations were accepted by the resident’s doctor who issued the appropriate order.

However, shortly after these recommendations were made, the resident was seen with a half finished glass of regular water at lunch.  Regular water is considered a thin liquid and giving this to the resident would be a violation of the recommendations of the speech therapist and of the doctor’s orders.

The following day, the resident was running a fever, was disoriented, and had crackling sounds in the lungs.  The physician was notified, and he was sent to the hospital where x-rays confirmed the diagnosis of aspiration pneumonia.  The resident was suffering from sepsis due to the pneumonia and was placed on comfort care measures only by his family.

This horrific outcome could have been easily prevented.  The whole point of having a speech therapy evaluation done is to find out what has to be done to keep the resident safe while eating.  When those recommendations (and the corresponding physician orders and care plan) are ignored, this subjects the resident to unnecessary risks of harm.  In this case, the recommendation for thickened liquids was not followed by the staff, with a deadly pneumonia being the end result.

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.  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.

Other blog posts of interest:

Aperion of Spring Valley resident chokes to death

Fatal choking accident at River Bluff nursing home

Feeding tube error puts Burgess Square resident into heart failure

Fatal choking accident at Spring Creek in Joliet

 

Click here to file a complaint about a nursing home with the Illinois Department of Public

Alden Valley Ridge resident breaks leg in fall

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IDPH has cited and fined Alden Valley Ridge nursing home in Bloomingdale after a resident there suffered a broken leg in a fall due to an aide’s failure to use a gait belt.

Properly run nursing homes invest significant effort into determining what kind of help and assistance residents require to assure their safety and well-being.  When the required levels of care are properly identified but then not provided, unnecessary injuries are the very predictable result.

The resident at issue had weakness associated with a prior stroke and was considered a fall risk.  Her Minimum Data Set indicated that she required extensive one person assist with ambulation, transfers, and toileting.  “Extensive assist” includes actually physically assisting and supporting the resident during the activity.

When a resident requires extensive physical assist, use of a gait belt is required to perform the activity safely.  A gait belt is a canvas strap which is applied to the midsection of the resident and used by the aide while assisting the resident.  It allows the aide to effectively provide physical support to the resident and to either help the resident maintain and upright position or control the fall should a resident begin to fall or lose their balance.  The nursing home’s policies and procedures required the use of a gait belt on residents who required physical assistance.

On the day of this nursing home fall, the aide had brought the resident to the bathroom and was assisting her in getting an adult brief on.  The resident was standing by the toilet holding onto a grab bar.  The aide had a gait belt, but it was not on the resident.  It was in the aide’s pocket.  The aide explained to the state surveyor that it was a matter of judgment as to whether to use the gait belt, and that it was her judgment that this resident did not need one.

The resident told the aide that she could not maintain her standing position and that her legs were giving out.  The aide tried to get the resident to the toilet or to get a wheelchair over to help the resident, but the resident fell to the floor.  She later complained of leg pain and when x-rays were done, they showed a fractured femur.

The whole point of performing assessments and determining the level of care that a resident receives is so that it is not left to random chance.  The same would be true of having policies and procedures.  When staff decides that providing the level of care that a resident truly needs is a matter of judgment, the residents’ care is left to random chance – what did a particular staff member see and what did they think about what they saw on a particular day?  When a staff member provides substandard care but avoids injury, that becomes part of the basis for judgments made down the line – not realizing that the lack of a catastrophic outcome was a matter of good luck, not good care.  And having gotten lucky once, that becomes a tempting option in providing care going forward.  The net result though is that residents are exposed to unnecessary risk of harm.

Unfortunately, that was what happened here.  A staff member disregarded what the assessments had said about the resident’s care needs, disregarded the facility’s policies and procedures, and substituted her own judgment, much to the detriment of the resident.

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.  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.

Other blog posts of interest:

Inverness Health & Rehab resident suffers multiple fractures in fall

Alden Valley Ridge resident rolled from bed, breaks both legs

Failure to use gait belt leads to fall and fractured kneecap at Friendship Village in Schaumburg

Assisi at Clare Oaks resident breaks neck in fall from wheelchair

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

River Bluff nursing home in Rockford resident suffers multiple fractures in fall

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IDPH has cited and fined River Bluff nursing home in Rockford after a resident there suffered multiple fractures in a fall.

Here, the resident at issue was involved in a nursing home fall in which she suffered a fractured pelvis and a fractured humerus.  There was a care plan in place which called for the use of a bed alarm and a chair alarm, both of which were in place when the fall occurred.  However, the resident had shut the chair alarm off when she got up to go to the bathroom and was returning from the bathroom when the fall occurred.

You may be asking yourself how this is the nursing home’s fault?  The answer goes to the fundamentals of the care planning process.

Care planning is an ongoing process.  It is not something that is done once and then forgotten about.  There are in fact six steps to the care planning process: (1) the assessment of the risks to the health and well-being of the resident, (2) the development of a written care plan, (3) communication of the care plan to the members of the staff charged with carrying it out, (4) implementation of the care plan on a day-to-day, shift-to-shift basis, (5) evaluation of the effectiveness of the care plan, and (6) revision of the care plan if it proves to be ineffective in practice or if the care needs of the resident change.

The breakdown here occurred in the sixth and final step of the care planning process.  The point of the fall prevention care plan was to prevent falls by avoiding having the resident up and about unattended which was when she was at highest risk for falls.  However, this resident had a known behavior of disarming the alarm when she wanted to get up on her own.  The nursing home staff was aware of this, but did not make any changes even though what they were doing was being shown to be ineffective in practice.

What should have been done instead?

A chair alarm or bed alarm essentially consist of two main components: the alarm box and the alarm device.  The alarm device is either a pressure-sensitive pad (which was what was in use here) or a clip which is affixed to the resident’s clothing, usually between the shoulder blades where it is difficult to remove with a short cord which goes to the alarm box.  If the pressure alarm is in use, the alarm sounds when the resident gets up off the pad; if the clip is used, the alarm sounds when the cord is pulled away from the alarm box.

Here the staff placed the alarm box in easy reach of the resident who simply shut it off before getting up.  This was a known behavior on the part of the resident which had been shown on a number of occasions before this nursing home fall.  All that would have been required to prevent this fall would have been to modify the resident care plan to include placing the alarm box out of the reach of the resident and making sure that this was communicated to the staff charged with caring for this resident.  However, due to a lack of effort and critical thought, this change was never made.  A care plan which is ineffective in practice is not one that meets the care needs of the resident.  Making that simple change would likely have prevented this injury.

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.  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.

Other blog posts of interest:

Hope Creek resident breaks hip in fall from toilet

River Bluff resident fractures elbow in fall from wheelchair

Fall from toilet at Alden Park Strathmoor

Resident left unattended in dining room at Ascension Saint Anne Place falls and fractures hip

Waverly Place of Stockton resident breaks hip in unsafe transfer

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

 

 

Psych med usage leads to bed sores at Eastview Terrace

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IDPH has cited and fined Eastview Terrace nursing home in Sullivan after a resident there suffered significant weight loss and developed bed sores due to lethargy associated with the use of psychotropic medications.

The use of restraints is strongly discouraged in the long-term care industry for a number of reasons, but most particularly, they pose a serious risk of harm to nursing home residents and are also an affront to their right to dignity.  Tying a resident into a bed or chair is something which is generally not acceptable nursing practice.  Use of a chemical restraint – that is medicating a resident in such a way that the resident is so sedated to the point that their movement or freedom is restricted – also carries serious risks to the health and well-being of nursing home residents and is an affront to their right to dignity.

Certain medications especially psychotropic medications carry a high risk of becoming chemical restraints by sedating nursing home residents to the point that they are unable to move.  Federal regulations limit the use of psychotropic medications to the extent necessary to treat the symptoms and prohibit the use of unnecessary drugs.  Regulations also require monitoring for the presence of side effects.

The resident at issue was initially admitted to the nursing home with a diagnosis of dementia with behavioral disturbances.  He weighed 184 pounds and was ambulatory.  Ten days after admission, he was transferred to a geripsych facility after attacking a staff member.

When he returned there were dramatic changes in the resident’s condition.  He was no longer ambulatory, required extensive assist of two staff members for activities of daily living, and was largely nonverbal.  He was on a regimen of six psychotropic medications, including receiving some more than once daily.  A week after admission, the staff called the doctor with concern about the resident’s lethargy.  The nurse practitioner came to the facility and ordered a lab check for levels of one medication and ordered that the medication be held if the resident appeared sleepy.  It did not appear as though the medication was ever held.

The resident continued to demonstrate lethargy, requiring extensive assistance from the staff with activities of daily living including eating.  He did not demonstrate much appetite, and when he did try to eat independently, he often missed his mouth.  He was discharged from both physical and occupational therapy due to inability to participate.  he was wheelchair bound and was using a high-backed wheelchair to aid in positioning.

There was nothing in the citation that suggested that his behaviors were being tracked or monitored for the side effects of the psychotropics, even though the care plan called for monitoring of somnolence and to notify the doctor if the side effects outweigh the benefits.  There was no further notification to the resident’s doctor even though he was seen twice via telehealth during which the staff advised that there were no concerns.  There was no apparent referral to a psychiatrist to modify the drug regimen.

What was done with this resident is a near classic example of a chemical restraint.  While the resident’s behavior was absolutely a source of concern, there was no meaningful attempt to monitor for side effects to eliminate potentially unnecessary medications.  The net result of this was that the resident was so sedated that he was unable to move independently to the point that he was unable to feed himself, unable to participate in therapy, unable to care for himself, and unable to stand and move independently.

There are a number of dangers associated with chemically restraining a resident, including having nursing home falls and developing bed sores.  There are three main risk factors for developing bed sores: (1) incontinence, (2) immobility, and (3) poor nutritional status.

The citation demonstrated two of the three factors clearly.  The resident had immobility based on the inability to participate in the therapy, the well-documented lethargy, and the change from being ambulatory to needing a high-backed  wheelchair for positioning.  He also had poor nutritional status in that poor appetite and an inability to eat were explicitly documented.  He also had documented significant weight loss in that his weight decreased from 185 pounds when he was initially admitted to 172 pounds after being readmitted from the geripsych unit to 159 pounds a month later.  He also likely had some element incontinence given that he was dependent on staff for activities of daily living and would have been dependent upon them for toileting.

It should be small surprise then that this resident ended up developing bed sores.  He developed a deep tissue injury on his coccyx and pressure ulcers on his sacrum and on his left and right buttocks.

These injuries are the predictable results of employing a chemical restraint on a resident.  Lethargy with an inability to move and loss of appetite with associated weight loss predictably led to the development of multiple bed sores.  Recovering from them will be very difficult without any modification of his psychotropic medication regimen.

While the staff was rightly concerned about the resident’s aggressive behavior, the solution to that is not to sedate the resident into total inactivity without making any effort to minimize the side effects of the psychotropics that the resident was receiving,  Yet, that is what occurred here.

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.  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.

Other blog posts of interest:

Resident undergoes electroconvulsive therapy after staff at Palm Terrace fails to give antipsychotic medication

Resident develops bed sore at Nokomis Rehab

Moweaqua Rehab resident suffers worsening bed sores

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Resident fractures leg in unsafe transfer at Ascension Nazarethville in Des Plaines

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IDPH has cited and fined Ascension Nazarethville Place nursing home in Des Plaines after a resident there sustained a fractured leg as a result of an unsafe transfer.

Nursing homes are required to periodically complete a document called the Minimum Data Set (MDS) which spells out the level of care that a resident requires.  This document forms part of the basis by which the the nursing home is reimbursed for the care that it provides, so it is signed under penalties of perjury by the people completing it.

The results of the MDS may trigger a process known as the Care Area Assessment (or CAA) which is an indicator to the nursing staff that it should be considering care planning for the various areas where the MDS triggers the CAA.  The net result of this is that there should be some congruency between what is shown as the resident care plan and the resident’s documented care needs on the MDS.

The resident here was coded on the MDS as requiring two-person physical assist with transfers.  However, the resident care plan did not provide any instruction to staff as to how the transfers should be accomplished.  A properly completed care plan would have included instructions for two-person physical assist with transfers and use of a gait belt.

On the day of this nursing home fall, the resident was being transferred from her wheelchair to bed.  A single aide was involved in attempting the transfer.  The resident asked for a second staff member to help with the transfer because she was nothing but dead weight, but the aide said that she was in a hurry and did not have much time and that she would be able to complete the transfer on her own.

Rather than use a gait belt, she held the resident under her arms and attempted to lift her from wheelchair to bed.  As the resident predicted, she proved to be “dead weight” during the transfer and depending on who you are asking, she was either “lowered safely to the floor” (per the aide) or “dropped” (per the resident).  Regardless, the resident sustained a fracture of the thigh bone just above her prosthetic knee which required surgical repair.  She now requires transfers to be accomplished by way of a mechanical lift.

There are a number of shortcomings with the care that this resident received:

  • The MDS showed that she required a two-person assist with transfers but a) that was not incorporated in the care plan and b) was not provided to her when the fall occurred.
  • No gait belt was used for the transfer so it was next to impossible for the aide to perform any kind of transfer properly, leading to the resident being dropped (and given the kind of injury sustained, a controlled lowering to the floor is an unlikely scenario).  Purportedly there was only a single gait belt for each floor rather than one for each staff member.
  • The aide ignored the resident request to have two staff help with the transfer because the aide was in a hurry.

All of the above are the most immediate causes of this nursing home fall, but the fact that shortcuts were taken in the care of the resident which sacrificed resident safety is a hallmark of an understaffed nursing home.  The fact that the aide was not trained how to do proper transfers and that each aide did not have a gait belt (a necessary piece of equipment) speaks to a lack of investment in the staff and facility which is also a management issue.   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.  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.

Other blog posts of interest:

Symphony of Buffalo Grove resident suffers catastrophic injuries in fall from lift

Grove of St. Charles resident suffers fractured hip after being rolled from bed

Glenview Terrace resident suffers multiple fractures when lift topples over during transfer

Resident breaks hip in unsafe transfer at the Pearl of Rolling Meadows

Failure to use gait belt results in fall and fractured knee at Friendship Village in Schaumburg

Grove of Skokie resident breaks leg due to violation of care plan

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

 

Grove of Skokie resident breaks leg due to violation of care plan

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IDPH cited and fined the Grove of Skokie nursing home after a resident there suffered a broken leg due to an unsafe transfer which was also a violation of the resident’s care plan.

The basic purpose of a care plan is to outline a series of steps that the nursing home staff can take on a day-to-day, shift-to-shift basis to reduce the risks of harm to the resident.  The nursing home staff will almost always agree when asked that it is part of their job to implement the care plan.

The resident at issue here suffered from multiple sclerosis and as a result had significant mobility deficits.  Therefore, her care plan called for the assist of two staff and the use of a mechanical lift for all transfers – meaning that any time she was being moved from bed to wheelchair or wheelchair to chair and so forth that two staff members would use a mechanical lift to accomplish the transfer.

On the day of the injury, the resident was getting a shower and needed to be transferred from her wheelchair to the shower chair.  Rather than use the mechanical lift as called for in the care plan, two aides attempted to transfer the resident to the shower chair with a two person manual transfer.  During the transfer, the resident was not able to continue to bear any portion of her own weight and the staff lowered her to the floor.

When a nursing home chart describes a resident being “lowered to the floor,”  that is actually a nursing home fall.  A fall is generally considered to have occurred when there is an unplanned change in the vertical level of the resident.  And despite the benign description of being “lowered to  the floor,”  this is something that can and frequently does produce injury to the resident.

Following this incident the resident began to complain of leg pain.  X-rays showed that the resident suffered a comminuted fracture of the leg, meaning that it was broken in multiple places.

Here, the resident’s injury was clearly produced by the violation of the care plan.  The care plan was in place to prevent just this kind of injury, but the staff chose to not follow it, and a very predictable and preventable injury was the result.

The violation of the resident care plan was the obvious cause of the resident’s injury, but a deeper look at the circumstances surrounding this injury raises questions as to whether this was an understaffed nursing home.  Use of the mechanical lift was called for by the resident care plan, but the staff chose to not follow it, likely because it would have taken more time than attempting the manual transfer.  Any time you see information which indicates that the staff is taking shortcuts which sacrifice resident safety, understaffing should be a consideration.

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.  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.

Other blog posts of interest:

Violation of care plan at Generations Oakton Pavillion leads to fall and fracture

Resident falls and fractures hip and Lutheran Home for Aged in Arlington Heights

Brain bleed from fall at Landmark of Des Plaines

Failure to provide needed assistance leads to fall at Generations of Elmwood Park

Multiple fractures from fall at Lutheran Home for the Aged

Grosse Pointe Manor falls and breaks hip after being left unattended

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Medication error at Sunset Rehab in Canton

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IDPH has cited and fined Sunset Rehabilitation and Health Care Center nursing home in Canton after a resident there had to be hospitalized in the intensive care unit after a medication error in which the the nurse gave medications to the wrong resident.

Many nursing home residents are on multiple medications.  One of the basic tasks for members of the nursing staff is to give the medications to the resident as ordered by the doctor.

To safely do this, and avoid nursing home medications errors, nurses are supposed to check the 5 “rights” before giving medications to the resident: (1) is this the right resident, (2) is this the right medication, (3) is this the right dose, (4) is this the right route (pill, oral, etc.), and (5)  is this the right time?  Checking each of the 5 rights is a simple, but proven and effective way to avoid preventable medication errors.

The resident at issue was a known choking risk.  When the nurse went to pass medications to her, the resident was in bed.  To reduce the risk of aspiration, the nurse asked the aides to get the resident out of bed.  The aides did so, placed the resident in her wheelchair, and brought her to the nurse’s station.

When the resident arrived at the nurse’s station, the nurse was preparing medications for other residents.  There were other residents surrounding the nurse’s station asking for their medications.

Because the resident at issue was a choking risk, she would normally receive her medications in pudding.  The nurse placed medications into the pudding cup and gave it to the resident. Unfortunately, when she put the medication into the pudding cup, she put medications for another resident into the pudding cup.  The resident swallowed the medications before the nurse realized that she made a medication error by giving the resident the wrong medications.  Among the wrong medications that the resident received were two diabetes medications and two antipsychotic medications.

To her credit, the nurse realized the medication error almost immediately and notified the resident’s doctor and the nursing home administration.  The doctor instructed the nurse to do blood sugar testing on the resident and monitor for lethargy.  Within a couple of hours, the resident began to demonstrate significant lethargy.  The nursing staff notified the doctor of the changes in the resident’s condition and he ordered her sent to the hospital.

The resident was admitted to the hospital into the intensive care unit suffering from hypoglycemia, or low blood sugar, associated with the effects of being the other resident’s diabetes medications.  She also experienced a couple of seizures.  The resident further reported to the state surveyor that she was feeling the ill effects of the medication error even after being discharged back to the nursing home.

This was a highly preventable medication error.  Giving one resident medications that were intended for another resident is the kind of medication error which should never occur – that is one of the basic “5 rights” that should be verified before giving medication.  However, the nurse got distracted, and a serious and highly avoidable medication error 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 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.

Other blog posts of interest:

Aperion Care Capitol fails to give medication to resident suffering from bacterial meningitis

Failure to give anticoagulant medication at H&J Vonderlieth Living Center

Failure to give diabetes medications at Bridge Care Suites

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Burbank Rehab resident hospitalized due to missed dialysis sessions

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IDPH has cited and fined Burbank Rehabilitation Center nursing home after a resident there had to be hospitalized for fluid overload after not being brought to dialysis as ordered.

Nursing home residents who are suffering from kidney failure may require dialysis, and when this is true, families often make the decision to pick one nursing home over another based upon the availability of an in-house dialysis unit in order to spare their loved one from having to be transported to an outside dialysis center.  These in-house units are usually operated by a separate company which means that coordination of care between the dialysis unit and the nursing staff is crucial to ensuring that the resident receives the care that is required.  When this doesn’t happen, the results can be catastrophic.   When the kidneys are not functioning properly, the body cannot remove excess fluid and toxins.   Dialysis takes up that function in the absence of properly working kidneys.  When necessary dialysis sessions are missed, excess fluids and toxins can build up and cause serious problems throughout the body, most notably with the heart and lungs.

The resident at issue suffered from end stage renal disease, or kidney failure.  She was admitted to the nursing home from the hospital with orders to receive dialysis three days a week (Tuesday, Thursday, and Saturday).  The orders are also called for the nursing staff to checks vitals after dialysis and to check the dialysis access site for signs of redness, bleeding, or swelling. The nursing home staff documented that the resident received dialysis as ordered for the first three scheduled sessions and that the post-sessions checks of vitals and of the access site were all done.

However, on the same day as the scheduled third session, the nursing staff noted that the resident was suffering from pitting edema, required supplemental oxygen, and was lethargic.  The staff could not obtain her vital signs.  Due to this change in condition, the nursing staff notified the resident’s doctor who ordered the resident sent to the hospital.

At the hospital, based on the resident’s presentation and abnormal labs, the resident was diagnosed as suffering from volume overload due to missed dialysis sessions.  She was hospitalized for twelve days in order to resolve the condition.

The investigation into this incident revealed that the facility had policies and procedures in place for coordinating the care between the nursing home and the dialysis center for new admissions to the nursing home who required dialysis.  However, even with the policy in place, the resident was not added to the list of residents who would be receiving dialysis on the days on which it was ordered.  This breakdown in the process led to the missed dialysis sessions and the resident not receiving the care as ordered.

Beyond that, the nursing staff on the floor signed off on the resident as receiving dialysis on the days when it was ordered when it was in fact not done.  Had the nursing staff realized that the care ordered had not been provided instead on simply checking off that it had been done, this situation would not have escalated to the point that it did.

One of the things that out firm does very carefully in prosecuting nursing home abuse and neglect cases is go through the chart very carefully for evidence of false charting – that is, documenting care that was never provided.  We have seen examples of where the staff was documenting care being provided when the resident was in the hospital or in one case, after the resident was dead.  When we find this evidence, it undermines the credibility of the other entries made on the chart and makes it very difficult for the nursing home to defend the care that was provided.

This is a situation where there were clear breakdowns in the basic operations of the nursing home.  The process that was in place wasn’t followed and the staff was documenting care that was never provided.  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.  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.

Other blog posts of interest:

Landmark of Richton Park resident dies due to mishandling of tracheostomy tube

Failure to notify doctor leads to resident death at Alden Estates of Barrington

Failure to obtain treatment for congestive heart  failure at Avantara Long Grove

Dialysis patient bleeds to death at Warren Barr North Shore

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Hillside Rehab resident suffers brain bleed due to failure to obtain lab work

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IDPH has cited and fined Hillside Rehabilitation and Care Center in Yorkville after the nursing home failed to obtain lab tests for a resident who was taking blood thinner medication.

Many nursing home residents take anticoagulant or “blood thinner” medications.  Used for a variety of purposes such as a history of blood clots, atrial fibrillation, stroke prevention, and management of other circulatory and cardiac conditions, this class of medication can be crucial for maintaining the health and well-being of the resident for whom the medication was ordered.

However, the use of this medication has to be carefully managed.  If the blood is considered “too thick,” or subtherapeutic, it can lead to blood clots which can have catastrophic consequences; if the blood is “too thin,” or supratherapeutic, this can lead to uncontrolled bleeding.

To ensure that the resident remains in the desired or therapeutic range, the resident must receive regular blood testing called a PT/INR test which is measures whether the blood is in the therapeutic range.  If the blood is outside the therapeutic range, then the nurse must contact the doctor to notify him that the resident had an abnormal lab result.  From there, it would be up to the doctor to make adjustments in the dosing of the blood thinner medication or to take other steps to treat the condition.

The resident at issue had a history of blood clots and had peripheral vascular disease (poor circulation to the extremities) and was receiving blood thinner medications to treat this.  As part of his treatment regimen, there was also an order in place for regular blood draws for PT/INR testing.

When lab work is ordered for nursing home residents, this is performed by an outside laboratory who will send a technician to the nursing home to do the blood draw and then take the sample back to the lab to have the test done.  Results will then be forwarded to the nursing home who in turn will notify the doctor of any abnormal results.

Here, the nursing home had a contract with a single lab to perform the testing.  However, the technician did not show up to perform the testing, so no test was performed.  The following day the resident was sent to the hospital suffering from a brain bleed.  In the emergency room a PT/INR test was performed.  The result was a score of 7.5 when the normal range is 0.8-3.5.  The conclusion at the hospital was that the brain bleed was due to supratherapeutic INR.  In other words, the resident’s blood was too thin, leading to the brain bleed.  Had the ordered lab work been performed, the doctor could have acted on the elevated INR and prevented the brain bleed from occurring.

There are a number of issues with the care that this resident received.  First, the lab that had contracted with the nursing home did not provide the services that were required, raising questions of its liability for failing to provide the ordered testing. Second, the nursing home staff was aware that over the past few months leading up to this incident, the quality of the lab’s performance had dropped and that there had been problems getting ordered tests performed.  However, nursing home management had a contract with a single lab and did not have options available for the staff to look elsewhere for testing.  Third, the nursing home staff failed to notify the doctor that the tests he ordered had not been done.  All of these issues led to a very preventable injury to this nursing home resident.

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.  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.

Other blog posts of interest:

Bethany Rehab resident suffers brain bleed due to medication error

Lemont Nursing & Rehab staff fails to notify doctor of abnormal labs

Alden Valley Ridge fails to give resident anti-seizure medications

Aperion Care Wilmington resident suffers ruptured colon due to fecal impaction

Pearl Pavilion resident dies of pulmonary embolism after not receiving blood thinners

Failure to monitor anticoagulant levels at Greentree of Bradley

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Winston Manor resident chokes on peanut butter sandwich

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IDPH has cited and fined Winston Manor nursing home in Chicago after a resident there choked to death on a peanut butter sandwich.

One of the frightening possibilities that families face when they admit a loved one to a nursing home is that they could be the victim of a nursing home choking accident.  Some nursing home residents suffer from dysphagia which is a swallow dysfunction.  At times this is the result of a stroke, other neuromuscular condition, advanced dementia, or just generalized weakness.  When a swallow dysfunction is present, the resident is at increased risk for choking.  Customarily, this risk is addressed through a modified diet given per physician orders, treatment with a speech therapist, and through the care planning process.

The resident here was someone who was known to at risk for choking.  In fact, this resident had experienced a choking incident about a year before the choking incident at issue and had also been admitted to the hospital for aspiration pneumonia.  Aspiration pneumonia occurs when someone inhales a foreign substance whether it is food or a fluid into the lungs with an infection being the net result.  The fact that this resident had this history demonstrated that he was at risk for choking.

The resident’s choking risk was addressed in the care plan where it called for the resident to receive extensive assistance while eating.  Facility policies further called for residents who are at risk for choking to be monitored during meals.

On the day of the incident the resident was passed a peanut butter sandwich by one of the aides who then left him unattended.  Shortly thereafter, the resident approached a staff member holding his hands to his throat, obviously choking.  The staff member did the Heimlich.  911 was called and the resident was brought to the hospital where a large quantity of peanut butter was suctioned from his airway in the emergency room.  He required intubation and was hospitalized for two weeks thereafter.

This was a very preventable accident which could have easily resulted in the death of this resident.  The resident was a known choking risk, yet the staff handed him a peanut butter sandwich (something that is not always easy to swallow) and then left him unattended.  The resident clearly had difficulty swallowing this given the large amount of peanut butter that was suctioned from his airway.  Simply monitoring him as called for in the facility policies would likely have averted this choking incident from reaching the point where hospitalization was required.

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.  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.

Other blog posts of interest:

Chicago Ridge Nursing & Rehab resident chokes to death on sandwich

Alden Poplar Creek resident chokes to death

Fatal choking accident at Spring Creek in Joliet

Bella Terra Wheeling resident chokes to death

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

 

Resident breaks leg in wheelchair accident at Heritage Health in Dwight

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IDPH has cited and fined Heritage Health nursing home in Dwight after a resident there suffered a broken leg in a wheelchair accident.

Wheelchairs are one of the most common pieces of equipment used in a nursing home setting and at first blush are very simple to use safely.  However, even these simple devices can prove dangerous when not used properly.

On the day of the injury, the resident was being pushed back to her room by an aide.  There were no foot pedals on the wheelchair at the time.  Her feet dropped to the floor as the chair was being pushed forward, resulting in her legs being pulled underneath the wheelchair.  As this happened, there was a cracking sound that came from her thigh.  She was brought to the hospital where she was diagnosed with a fractured femur.

Like all pieces of equipment in a nursing home, a wheelchair is a safe piece of equipment – when used properly.  This includes using the footrests – the use of which would have prevented this kind of accident.  The misuse of the wheelchair was the immediate cause of this accident.

The fact that such an obvious safety measure was not taken raises serious questions as to whether this is an understaffed nursing home.  When the facts of an accident show that the staff was taking a shortcut which placed the safety of the resident at risk, it could be an indicator that the staff was not trained properly or that the staff simply did not have time to do things properly.  Either way, this raises questions about how the nursing home is being operated.  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.  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.

Other blog posts of interest:

Good Samaritan of Pontiac resident suffers fractured knee and leg in wheelchair accident

Assisi at Clare Oaks resident breaks neck in fall from wheelchair

Wheelchair accident at Avanti Wellness

Lack of wheelchair footrests leads to broken leg at Lexington of Orland Park

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Flanagan Rehab resident develops infection from bed sore

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IDPH has cited and fined Flanagan Rehabilitation and Health Care Center nursing home after a resident there suffered an infected bed sore which required surgery.

Bed sores are a major focus of patient care in nursing homes.  There are specific federal regulations regarding bed sores and they are a specific area of focus in the care planning process.

The Braden scale is the most common tool used to assess a resident’s risk of developing bed sores.  The resident was who the subject of this citation was assessed as being at high risk for skin breakdown when her Braden score was completed.  When a resident is at risk or high risk for developing bed sores, then the usual next step is to put a specific care plan into place to address that risk.  However, despite the fact that she was assessed as being at high risk, no care plan to prevent bed sores was put into place.

The nursing home’s policies and procedures called for daily skin inspections when a resident was at high risk for skin breakdowns.  However, during the two month period between when the resident was assessed and when she was finally sent to the hospital, only weekly skin checks are documented.

A few weeks after the initial assessment was done, the resident developed a skin breakdown over the sacrum.  The CNA who found it reported it to the nurse who notified the doctor and received orders for treatment.  Medihoney was applied to the wound and it was dressed, but there was no further documentation of the condition of the wound or of any further treatment being provided during the next month up until the resident was sent to the hospital.

The only other time there was any record of the condition of the resident’s wound was when a CNA noted the presence of a wound on a shower sheet.  The nurse on duty signed off on the shower sheet, but there was no documentation of the condition of the wound or of further physician notification.

Three and a half weeks later, the nurse found the resident unresponsive.  The physician was notified and the resident was sent to the hospital.  There, they found that she was suffering from a urinary tract infection and there was an abscess on the buttocks which was infected with MRSA.  She was diagnosed as suffering from metabolic encephalopathy due to sepsis.  The resident was brought to surgery where the wound was debrided and the abscess drained.  The surgeon described the extensive infection that was present and said that it would have been present for several days causing the resident significant pain.

There are a number of failures in the care that this resident received.  First, despite the fact that she was assessed as being at high risk for developing bed sores, no care plan to address that risk was put into place.  Second, the facility’s own policies and procedures were not followed in that the daily skin checks were not done.  Third, there was no further care provided to the bed sore once it was discovered other than the initial treatment and dressing.  Getting bed sores to heal is a lengthy process.  Fourth, there was no follow up to the wound that observed and documented in the shower sheet.  Finally, the declining condition of the wound as shown in the emergency room was not ever discovered by the staff.  Besides the skin checks that were supposed to be done daily per facility policy, the skin checks that were done during showers, the staff would have been providing incontinence care to this resident which would have offered additional opportunities to discover the decline in the condition of the resident’s skin and notify the doctor.  In short, there was a long list of failures in the care that this resident received, resulting in a serious, infected wound which required surgery.

These kinds of failures reflect poorly on the training levels of the staff and are indications that management is unwilling to invest in training the staff.  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.  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.

Other blog posts of interest:

Failure to follow orders leads to infected bed sore at Generations Oakton Pavillion

Untreated pressure ulcer at Aperion Care Bradley

Resident develops bed sores on both heels at McLean County Nursing Home

Resident suffers from pressure ulcers at Parker Rehab

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

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