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Alden Valley Ridge fails to give resident anti-seizure medications

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IDPH has cited and fined Alden Valley Ridge Nursing Home in Bloomingdale after a resident there had to be hospitalized after experiencing grand mal seizures brought on by a failure to give prescribed anti-seizure medications.

The resident at issue had a history of epilepsy with seizures.  When he was discharged from the hospital to the nursing home, there were orders in place and prescriptions written for at least three anti-seizure medications which were to be given twice per day: dilantin, onfi, and keepra.  When the resident arrived at the facility, these medications were not on hand and had to be obtained from the pharmacy.  These medications were not obtained during the first 36 hours of the resident’s admission to the facility, and as a result, he did not receive his anti-seizure medications.

As a result, the resident experienced two grand mail seizures.  The doctor was not notified about the first, and as a result, was not sent to the hospital.  After the second occurred, the doctor was notified and the resident was sent to the hospital where labs showed that he had critically low levels of dilantin.  He was admitted to to the hospital for several days to stabilize his condition.

Before a resident is accepted for admission to a nursing home, the facility receives a package of materials about the resident which includes a medication list.  This is so that the nursing home can determine whether it can meet the care needs of the resident and if they decide to accept the resident, they can order necessary medications.  Well-run nursing homes have processes in place to ensure that routine items such as this get handled properly so that critical medications such as this are on hand when the resident arrives.  Past that, when there is a critical medication like an anti-seizure medication that is unavailable for a resident, there are processes in place to ensure that  the medication is delivered in a timely fashion.

Past that, there were events during this admission which required physician notification.  The first of these was the fact that there was a medication error because these was no medication available and that there were multiple missed doses of medication.  Had the doctor been notified, the doctor would have had the option of ordering other medications or taking other steps to help the resident maintain his dilantin levels to prevent the seizures.  The second of these was the occurrence of the first seziure.  When a resident experiences a significant event like that, it requires care regardless.  It is also an indication that the missed doses of the anti-seziure medication are having adverse effects on the health and well-being 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:

Catastrophic brain injury from medication error at Alden Town Manor

Grove of Elmhurst resident dies due to delay in physician notification

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

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

Failure to obtain anti-seizure medication at Gilman Healthcare Center

Failure to notify resident physician leads to death at Alden Estate of Barrington

Failure to give anti-seizure medication at Lexington of Orland Park

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

 

Heritage Health Pana staff violates care plan, resident falls and breaks hip

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IDPH has has cited and fined Heritage Health – Pana nursing home after a resident there was left unattended in her wheelchair in violation of her care plan.  The resident tried to get up from her wheelchair on her own and fell, breaking her hip.

The care planning process is the foundation for much of the routine care that gets delivered in a nursing home setting.  Fall prevention is a special area of emphasis in the nursing home setting because falls tend to beget additional falls and any fall tends to have serious long-term consequences for nursing home residents.

The care planning process starts with an assessment of the resident’s fall risk.  The tools that nursing homes use to measure fall risk vary widely, but there are a number of factors that tend to be given weight: balance, gait, or musculoskeletal dysfunction; dementia or intermittent or constant confusion; incontinence; and a history of prior falls.  If the resident is assessed as being a fall risk, then a fall prevention care plan must be developed which includes a series of steps or interventions that should be performed .  That care plan must be communicated to the staff charged with carrying it out, and then it must in fact be implemented on a day-to-day, shift-to-shift basis.  The care plan must be evaluated for effectiveness on an ongoing basis and then revised if it is either ineffective or there are changes in the resident’s condition.

Of course, it all comes down to the care plan being carried out on a day-to-day, shift-to-shift basis.  The best assessments and the best care plans have no value if they are not actually implemented, and that was the source of this nursing home fall.

This resident had a history of a prior fall with a broken left hip.  The Minimum Data Set (MDS) showed that the resident required extensive assistance from two staff members for transfers and had severe cognitive impairments.  The assessment also noted a behavior of getting up unassisted.  In short, she was a clear fall risk and was assessed as such.  Part of her care plan was that when the resident was up in her wheelchair, she should be placed in a high traffic/highly visible area (in the common room or by the nurses’ station would be examples).  This is a very common intervention to address this form of fall risk.  The care plan was recorded on the kardex which was stored on the back of the door to the resident’s room.

On the day of this nursing home fall, the staff reported finding the resident trying to crawl from her bed to her wheelchair.  They assisted her into her wheelchair.  Then, rather than bring her out to an area where she could be kept under observation, she was left unattended in her room.  Shortly after being left in the room, the resident attempted to get up unassisted, and fell.  She was brought to the emergency room, where x-rays showed that she had fractured her left hip – the same one which had been broken before.

The obvious cause of this nursing home fall and the injury sustained by this resident was the failure of the aide to care out the care plan.  The resident was left unattended in her room in her wheelchair.  This was a violation of the care plan, and the Director of Nursing conceded as much to the state surveyor.  For her part, the aide told the state surveyor that she did not know that the resident needed to be supervised.

In situations such as this, where the staff cannot take the time to access readily available information to know how to properly care for a resident, this is a strong indicator that this is an understaffed nursing home.  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 suffers fractured hip in fall

Taylorville Skilled nursing home resident falls and breaks hip

Piatt County Nursing Home resident fractures hip in fall

Pleasant Meadows Senior Living resident breaks hip and wrist in fall

Repeated resident falls at Heritage Health in Springfield ends with broken arm and brain bleed

Failure to train staff leads to broken hip and death at Heritage in Jacksonville

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

 

Southpoint Nursing & Rehab resident breaks leg in improper transfer

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IDPH has cited and fined Southpoint Nursing & Rehab nursing home in Chicago after a resident there suffered a broken leg as a result of an improper transfer.

The Minimum Data Set (MDS) is a report which is submitted under oath to the federal government and describes the level of care that a resident is receiving.  It is supposed to be based upon the information in the resident chart, discussions with staff members and the resident and family, and on the assessment of the individuals signing off on it.

The reason that the MDS is completed under oath per federal regulations is that the response in the MDS can change the acuity level for the resident which in turn can affect the payment that the nursing home receives for caring for the resident.  In short, there is money involved, so honest reporting on the MDS is required.

The responses on the MDS in turn trigger something called a Care Area Assessment (CAA) which is an indication to the care planning staff that particular areas should be considered in the care planning process.  This helps assure that the resident is receiving the care he or she needs on a day-to-day basis.

The resident at issue was coded on the MDS as requiring extensive assistance with transfers and bed mobility from two staff members.  She was totally dependent on staff members for activities of daily living.  Given that was how she was coded, per facility policies, this should have been reflected in the care plan and in the care that the resident was receiving on a day-to-day, shift-to-shift basis.

On the day of this nursing home fall, the resident was being transferred from her bed to a wheelchair by a single aide using a gait belt.  The resident’s leg buckled and the aide was forced to lower her to the edge of the wheelchair and then after obtaining some additional help, to lower her to the floor.  The resident was brought to the hospital where x-rays showed that she had a broken femur.  She underwent surgery to repair the fracture.

At first blush, this appears to be a common case of one person doing a two-person job, as we have often discussed on this blog (see here, here, for examples).  While this is true, it is also not the whole story.

When the state surveyor interviewed the staff at the facility, the aide explained that she regularly cared for the resident and knew that the resident was a one-person transfer because there was a note above the resident’s bed that said “B-1” which meant that the resident was a one-person transfer.  The surveyor then went and interviewed the floor nurse, who is supposed to be supervising the aide, and the nurse told her she followed along with what the aides told her because they know what to do for each resident.  Finally, the surveyor was told by the restorative nurse that “B-1” meant one person assist for bed mobility – which is of course not what the MDS indicated.

To summarize: the MDS and the care plan called for two-person extensive assist with transfers.  The aide charged with providing that care had not been providing that care as a matter of routine because she misunderstood the significance of the sign over the resident’s bed.  That sign did not even track the level of care that the resident was supposed to receive.  Topping it all off, the nurse who was supposed to be supervising the aide simply relied on the aide to know what to do – an assumption that was not borne out by what was happening all around her.

Having this many levels of breakdowns in care might be called a comedy of errors – if it were not for the fact that a resident suffered a significant injury which will likely have longer term consequences which will place her at risk of a premature death.

Sadly, having a staff that has not been properly trained and having a nursing home claiming to be providing a higher level of care than is actually being delivered is all too typically a 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:

Resident fractures leg in improper transfer at Woodbridge Nursing Pavillion

Broken ankle from unsafe transfer at Aperion Care International

Multiple injuries from fall at Symphony of Midway

 

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

 

Stephenson Nursing Center resident undergoes surgery for bed sore

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IDPH has cited and fined Stephenson Nursing Center nursing home in Freeport after a resident from that nursing home had a bed sore decline due to bad care that the resident required surgery to treat it.

There are three main factors which place a resident at risk for developing bed sores:  immobility, incontinence, and poor nutritional status.  A resident’s risk of developing bed sores is supposed to be addressed through the care planning process.  Once a resident develops bed sores, this is an event which requires physician notification and a revision of the resident care plan, as federal regulations relating to bed sores require that once a resident develops a bed sore that the nursing home provide care, treatment, and services necessary to promote healing, prevent  infection, and prevent the development of new sores.

When this resident was admitted to the nursing home, he did not have bed sores.  This meant that he was entitled to receive the care necessary to prevent the development of bed sores unless they were clinically unavoidable.  Although the citation does not recite what his Braden score was, he was very clearly at risk for developing bed sores, as he suffered from quadriplegia and neurogenic dysfunction of the bladder, which means that he was immobile and incontinent.  When the care planning process is implemented properly, a resident such as this would have had a care plan put into place once the resident was determined to be at risk for developing bed sores.  However, this was not done until four and a half months after the resident’s admission and over a month and a half after the first bed sore developed.

The first bed sore, located on the left buttocks, was noted approximately 3 months after the resident entered the nursing home and about two months before he was eventually sent to the hospital.  The resident’s doctor was notified but the care plan was not changed to reflect the fact the resident’s had greater care needs due to the onset of this new bed sore.  Over the course of the next month and a half, the wound continued to decline, growing larger in diameter and gaining additional depth with necrotic tissue appearing in the wound bed.  The continuing decline of the bed sore is also something that called for physician notification, as that indicates that the care which was being provided was not successful in resolving the bed sore.  The treatment orders were not changed at all until about two and half weeks before the resident went to the hospital.

At the same time that the condition of the bed sore was declining, the resident was experiencing significant weight loss.  This means in addition to having immobility and incontinence as risk factors for bed sores, he also now had poor nutrition to go along with this.  Having good nutrition is important for preventing bed sores but is really crucial when attempting to heal a pressure ulcer.  How significant was the weight loss?  According to the citation, during period beginning just over two months before he was admitted to the hospital up through the date he went to the emergency room, the resident’s weight dropped from 240 pounds t0 212 pounds.  Part of that was due to the loss of a tooth and difficulty eating associated with that, but the bottom line is that this resident was not receiving the intake of nutrients necessary to recover, and contrary to facility policies, his intake was not tracked for the vast majority of the meals that he was served.

It is also worth noting that the nursing home recorded his weight as being 235 pounds only four days before he went to the hospital.  Obviously, that is an example of false charting.  Being able to pinpoint examples of false charting in a nursing home chart is valuable in nursing home abuse and neglect lawsuits because the presence of false chart entries undermines the reliability of other chart entries which tend to reflect that care was provided in the right way and undermines the credibility of the individual staff members.

On the day the resident was sent to the emergency room, he told the staff that he was dying and asked to go to the hospital.  Permission was given by the attending doctor, and he was brought to the hospital.  There, his blood sugar level was taken and it was 407, a severely elevated blood sugar level.  Elevated blood sugar levels are often associated with the presence of an infection.  Inspection of the skin revealed a second bed sore, this one on his sacrum, which measured approximately 2 cm in diameter but was bone deep.  The left buttocks wound was 10×13 cm with 2 cm of depth.  About half of the surface area of the buttocks ulcer was necrotic.  He underwent surgery to debride both of the bed sores.   He was diagnosed with osteomyelitis at the location of the sacral wound.  This ordinarily would have been addressed surgically, but he was not a surgical candidate, so the doctors were going to try to bring the infection under control with antibiotics.

The level of failure in the care of this resident is staggering.  Here is a short rundown of the failure of the care that this resident endured:

  • He was on obvious risk for developing bed sores based on his immobility and incontinence.  Yet, there was never a pressure ulcer prevention care plan developed for him.
  • Once he did develop the left buttocks wound, the care plan was never revised to include the care needs associated with attempting to heal an existing pressure ulcer.
  • The resident suffered significant weight loss during the period of his residency at this nursing home.  At a time when his nutritional needs were at their maximum level to sustain wound healing, he was likely suffering from malnutrition.
  • The left buttock wound continued to decline, but the doctor was not notified that the treatments he ordered for the resident were not effective and the wound was getting worse, not better.  Similarly, there was nothing done until the very end with regard to care planning for pressure ulcer healing.
  • The facility staff failed to recognize the presence of the sacral wound at all.  As a result there were no treatment orders obtained and no revisions made to the care plan to account for this new bed sore.
  • The wounds became infected, but the staff failed to recognize signs and symptoms of the infection and failed to notify the doctor, delaying the start of care allowing the infection to progress.
  • The family was not notified about the declines in the resident’s condition.

These are only the very high-level failures in the care that this resident received.  A detailed review of the resident chart would likely show dozens of individual failures of the care 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:

St. Anthony’s nursing home resident requires surgery for bed sore

Bed sore requires surgery for Timbercreek resident

Resident suffers pressure ulcers to both knees at Royal Oak Care Center

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

 

 

St. Anthony’s nursing home resident requires surgery for bed sore

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IDPH has cited and fined St. Anthony’s Nursing & Rehabilitation Center in Rock Island after a resident there was required to undergo surgery due to worsening in the condition of the sore.

Bed sores or pressure ulcers are a major focus of care in the long-term care industry.  The development and/or decline of a bed sore is a serious health event in the course of care for a nursing home resident, often leading to other complications.

Federal regulations relating to be sores provide that when a resident enters the nursing home, they should receive care consistent with professional standards necessary to prevent the development of bed sores.  The regulations further provide that once a resident develops bed sores, they must receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new wounds.

Once a resident develops a bed sore or a bed sore declines, two things must happen.  First, the doctor must be notified so that new treatment orders must be carried.  Second, the care plan must be evaluated and likely revised.   Both the doctor’s orders and the steps outlined in the care plan must be carried out on a day-to-day, shift-to-shift basis.

The resident at issue was admitted to the nursing home with a Stage 4 bed sore measuring 3×3.5 cm with a depth of 1.7 cm.  Over the course of a month, the wound declined in that it grew in size to 10×8 cm with a depth of 3.5 cm with necrotic tissue in the wound bed and involvement of the fascia.  At that point the resident was transferred to the hospital to undergo surgery to remove the dead tissue.

How did things go so badly for this resident?  The answer, as is often true with bed sores, was in many ways:

  • The Stage 4 bed sore that he was admitted with was not addressed in the resident care plan.  In addition to physician orders, there are a number of nursing interventions that can be taken to improve the resident’s chances of healing.  Without having those steps included in the resident care plan, having those things done is left to chance.
  • The physician orders were not followed.  The initial orders were for dressing changes once per day, but then were changed early in the second week that the resident was there to twice daily.  The changed orders were not reflected on the Treatment Administration Record, so the resident only got dressing changes daily – on the days that there were dressing changes at all – and there were days when there were no dressing changes at all.  Skin audits that were ordered were not done.  Measurements were not taken regularly of the wound.

Bed sores are a different kind of injury than those that might be sustained in a nursing home fall or a nursing home choking accident in that there is usually not a clearly defined time when the injury took place.  Instead this is an injury which really reflects the cumulative effects of breakdowns in the delivery of care.  The records here show that there are small breakdowns in the care happening over and over – and as a result this resident’s bed sore decline swiftly to the point that surgery was needed.

The real question is of course why these breakdowns happen, and the answer frequently comes back to this being an understaffed nursing home.  The staff in understaffed nursing homes have a hard time keeping up with basic needs of the residents, and this has a direct impact on the residents.  Unfortunately, understaffing the nursing home is a key component 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:

St. Anthony’s fails to treat resident’s pain during wound care

Bed sore requires surgery for Timbercreek resident

Resident suffers pressure ulcers to both knees at Royal Oak Care Center

Resident suffers flesh-eating disease due to untreated skin tear at Regency of Sterling

Stephenson Nursing Center resident requires surgery for bed sore

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

 

Champaign-Urbana Nursing & Rehab resident breaks hip in fall

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IDPH has cited and fined Champaign-Urbana Nursing & Rehabilitation nursing home in Savoy after a resident there suffered a fractured hip after being left unattended in the courtyard.

Assessing fall risk is one of the standard assessments which is completed as part of the care planning process.  For assessing fall risk, there are few standardized scales similar to the Braden scale (which is used to assess risk of developing bed sores), so nursing home use a variety of standardized tools.  However, virtually all of them give major weight to two factors: (1) musculoskeletal weakness of dysfunction and (2) cognitive impairment  which renders the resident unable to comply with safety instructions or make good decisions for their own safety.

While musculoskeletal dyfunction is obviously an important factor in determining fall risk, cognitive impairment is at least as significant, if not more.  A resident with really significant musculoskeletal issues is not terribly likely to suffer injury in a fall, if they can understand and follow instructions that must be followed to keep themselves safe.  On the other hand, a resident with relatively minor musculoskeletal issues but with real issues with intermittent or constant confusion which renders them unable to follow instructions or make good decisions regarding their own safety may have really significant risks of sustaining a catastrophic fall.

The resident at issue here has well-recognized cognitive impairments.  She had in fact been assessed by the speech therapist (in addition to doing swallow assessments which play such an important role  in keeping residents safe from choking accidents, they also do assessments and treatment of residents suffering from cognitive issues) shortly before this injury and found to have deficits in reasoning and judgment with impulsive, unsafe confused behaviors.  She also had a history of falls – another key factor for determining whether a resident was a fall risk.

On the day of this nursing home fall, the resident walked out to the courtyard unassisted and began to pick dead flowers out of a flower pot.  Staff saw her out in the courtyard, and brought her wheelchair to her, locked the wheelchair in place, and placed it next to a bench where they placed the flower pot.  Staff then left the resident unattended in the courtyard.  About ten minutes later a family member of another resident came in and reported that the resident at issue was on the ground.

She was brought to the hospital where x-rays showed that she had sustained a broken hip in the fall.  She underwent surgical repair of the fracture.

So what did the nursing home do wrong?  The basic answer is that this resident was left unattended.  She was very clearly a fall risk with a history of falls, musculoskeletal issues, and documented cognitive impairments.  If there was no fall prevention care plan in place, that would be a serious shortcoming in the care that this resident received.  If the care plan did not call for keeping the resident under close observation, that is equally problematic.  If the care plan called for that and the resident was left alone in the courtyard, that would be a violation of the care plan.  The bottom line with residents who have cognitive impairments which leave them unable to be counted on to make good decisions for their own safety is that they must be kept under observation.  That was not done here, with catastrophic results.

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:

University Rehab resident falls from bed during incontinence care and breaks hip

Gardenview Manor resident suffers broken hip during unsafe transfer

Fall results in fractured kneecap at Country Health in Gifford

Accolade of Pontiac resident suffers fractured hip in fall after call light left out of reach

Tuscola Health Care Center resident dropped from lift, suffers fractured ankle

Brain bleed from fall at Gibson Community Hospital Annex

 

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

 

Assisi at Clare Oaks resident breaks neck in fall from wheelchair

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IDPH has cited and fined Assisi Health Care Center at Clare Oaks nursing home in Bartlett after a resident suffered a broken neck in a fall from a wheelchair.

Wheelchairs are like every other piece of equipment in a nursing home setting – usually safe, helpful, and beneficial if well-maintained and used properly.  For a wheelchair, this includes things such as having the wheels working properly, functioning wheel locks, a properly fitting seat cushion, and foot rests in place.  Without all of those things being true, something as simple as a wheelchair can add an extra level of hazard for a nursing home resident.

The resident at issue here was wheelchair bound, but was able to eat independently, and needed only limited assistance with her activities of daily living.  She was able to wheel herself about the facility, something which gave her some degree of independence and added to the quality of her life.

On the day of this nursing home fall, the resident was being wheeled out of the shower.  The aide pushing the wheelchair had noticed that the seat cushion was too long for the seat.  The foot rests were also not being used.  As the resident was being pushed forward, the resident slid forward out of the seat onto the floor.  There was immediate bleeding, and the aide left to get a nurse.

The resident was brought to the hospital where she was diagnosed with a fracture of the C2 vertbera (the second one from the base of the skull).  She successfully underwent cervical fusion surgery to stabilize and repair the fracture and returned the to the nursing home.  However, where she was able to feed herself, wheel herself about the facility, and needed only minimal assistance with her activities of daily living, now she is a total assist with everything.

There were two notable shortcomings in the care that this resident received.  First, she was being wheeled about in a chair with a cushion that was too large.  How the too-large cushion got there was not addressed in the citation, but the fact is that it was recognized as such before the resident was taken from the shower.  Having an ill-fitting cushion leads to an unstable seating surface which creates the potential for this kind of accident to occur.  Second, the resident was being pushed without the foot rests in place.  Use of footrests would  have helped stabilize the resident in the wheelchair and likely prevented the fall.  It is also impossible based on the contents of the citation to exclude the possibility that the resident’s feet dropped to the floor, resulting in her being propelled forward out of the chair.  Lack of footrests is far more dangerous than would appear at first glance.

The failure to recognize the danger which was which being created here is an indication of a poorly trained staff.  Having a poorly trained staff shows a lack of investment in the personnel working at the nursing home.  Sadly, this is consistent with 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:

Resident at Chateau nursing home in Willowbrook suffers spinal fractures in wheelchair accident

Rochelle Rehab resident suffers multiple injuries in fall from wheelchair

Wheelchair accident at Avanti Wellness

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

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

Alden Valley Ridge resident rolled from bed and breaks both legs

 

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

Taylorville Skilled fails to obtain anti-convulsant medication for resident

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IDPH has cited and fined Taylorville Skilled nursing home after a resident there went six days without his anticonvulsant medication, resulting in seizures that led to the resident being admitted to hospice.

Fundamentally, nursing homes are businesses, and well-run businesses have systems in place to ensure that the routine delivery of necessary services occurs, and those services are critical, that there are back-up or fail safe systems that can kick in when things break down to avert catastrophe.  Giving medications is one of those routine services that nursing home provides.  But in order for that to happen, the prescribed medications must be on hand.

Nursing home medication errors like this are what happens when the medication prescribed for a resident is not on hand and nothing is done to address the situation.

The resident at issue had a complex medical history including epilepsy.  His neurologist prescribed a medication called Vimpat to be twice daily to control seizures.  Epileptic seizures in adults can have long-term serious effects.

Nursing homes rely on pharmacies to supply medication to the facility.  These medications are delivered on a regular basis to the nursing home, and the nursing home relies on timely delivery of the medications to ensure the health and well-being of the residents.  The nursing home here switched pharmacies, and in the process of making the switch, the new pharmacy did not deliver the medication because it wanted a new prescription from the doctor.

In the meantime, over a 6-day period the resident did not receive the anticonvulsant medication.  The staff duly noted on the resident chart that the resident did not get the medication because they were awaiting delivery from the pharmacy.  However, they did not notify the doctor, the director of nursing or the administrator, or the resident’s family.  As a result, the resident experienced significant seizures which were difficult to bring under control even in a hospital setting.  Due to the consequences of the seizures, the resident has been placed on hospice.

There are a number of breakdowns in the care that this resident received.  A large part of that relates to the breakdown in the delivery of medications and the failure to resolve the issue once it occurred.  This is a staff training issue since apparently among multiple staff members who cared for the resident over that 6-day window, none of them knew what to do when the medications were not being delivered.  At a minimum the doctor and resident’s family needed to be notified that his patient was not receiving critical medications. This is a critical issue of which the nursing home administration should have been notified.

The failure to properly train the staff is consistent with a lack of investment in the staff.  Failing to make investment in the personnel on the floor is consistent with how the nursing home business model operates.  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:

Taylorville Skilled resident sustains fractured hip after multiple falls

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

Flora Gardens staff fails to give antibiotic, leading to death of resident

Resident given wrong medication at Villa Health Care East

Taylorville Skilled nursing home resident falls and breaks hip

 

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

Aperion of Spring Valley resident chokes to death

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IDPH has cited and fined Aperion of Spring Valley nursing home after a resident there choked to death on a peanut butter and jelly sandwich.

Having their mom or dad choke to death in a nursing home is one of those things that is too horrible for children to imagine happening when their loved one is admitted to a nursing home.  Sadly, given declining physical and mental conditions, it is a risk that some nursing home residents face.

The basic tool for addressing known risks to the health and safety of nursing home residents is the care planning process.  The care planning process is a series of steps which must be taken to address the risks to the safety and well-being of nursing home residents. Choking risk can be addressed in the care planning process.

There are six basic steps to the care planning process: (1) an assessment of the threats to the safety and well-being of the resident, (2) development of the care plan which is an actual written document which outlines the steps or interventions that must be taken to address those threats, (3) communication of the care plan to the staff members charged with carrying it out, (4) implementation of that care plan on a day-to-day, shift-to-shift basis, (5) evaluation of the effectiveness of the care plan on an ongoing basis, and (6) revision of the care plan in the event that there are changes in the resident’s condition or needs or if the care plan as written proves to be ineffective.

When it comes to choking risk, the person who customarily evaluates the resident’s risk of choking is the speech therapist.  There are a number of conditions which can place a resident at risk of choking.  Dysphagia is the medical term for difficulty swallowing.  Regardless of the medical condition which produced the difficulty with the swallow function, this is a prime driver of increased risk of choking.  When combined with dementia, this can result in a high risk of choking because the resident may not be able to adjust his/her behavior in a way to minimize choking risk.

Besides outright choking, difficulty with swallowing can lead to aspiration pneumonia as food particles entering the airway and make their way into the lungs.  The body’s reaction to having food enter the lungs is to cough in an effort to expel the foreign substance.  Observation of coughing while eating may be a sign that the resident has swallow deficits.

When the speech therapist determines that a resident is at increased risk of choking, there are a number of recommendations that are normally a part of the care plan.  These include therapy, supervision while eating, behavioral cues, and modifications to diet.

The resident at issue had a diagnosis of dysphagia and suffered from dementia.  She had a history of multiple episodes of aspiration pneumonia.  She was well-known to the staff to someone who could not follow swallow strategies to take small bites and eat at a slow pace.  While she was being fed, she could often be heard coughing.   Her care plan included supervision while eating, to serve the resident a prescribed diet, and to monitor the resident while eating for difficulties with swallowing.

On the day of this nursing home choking accident, the residents were not able to eat in common areas due to COVID restrictions, so they would be brought to their doorways while being fed.  Each resident had a specific snack that was supposed to be provided to them.  This resident was supposed to receive a pudding snack, but the aide passing the snacks did not see that the resident had been provided with a designated snack, so she provided the resident with a peanut butter and jelly sandwich per the resident’s request.

After passing the peanut butter and jelly sandwich to the resident, the aide continued to pass snacks to other residents, leaving the resident unattended and unsupervised.  About 10-15 minutes after the resident was given the sandwich, a physical therapy assistant working with a resident across the hall looked out the door and saw that there was something wrong with the resident.  He went over to the resident and asked what was wrong, and she said, “I am choking.”

The physical therapist pounded the resident on the back and went and got the aide, who in turn summoned a nurse.  A code was called, and efforts were made at clearing the airway and doing the Heimlich.  The resident lost consciousness and was placed on the floor while CPR was performed.  However, she lost her pulse, and by the time that paramedics arrived, she could not be revived.  She was declared deceased without being brought to the hospital.  Cause of death per the death certificate was asphyxiation and choking on a sandwich.

There are a couple of shortcomings in the care that this resident received.

The first is that she was not given the snack that had been selected for her by the dietary staff.  Pudding (the selected snack) is much less thick than a peanut butter and jelly sandwich and is less likely to cause an airway obstruction.  Instead of verifying what should be given to the resident, the aide left that in the hands of the resident who likely never understood what her needs were.

Second, the resident was not supervised while consuming the snack.  This resident had a well-known risk of choking starting with her dementia and dysphagia, her history of having episodes of aspiration pneumonia, her well-known behavior of not following safe eating practices, and her documented history of coughing while eating.  This was a resident who required close supervision while eating and that level of supervision called for in her care plan was simply not provided.  No doubt that COVID made this more difficult, but it needed to be done to assure the safety of this resident.

Delivery of good care in a nursing home isn’t always easy, but it is possible.  However, it is that much harder when there is not enough staff on hand to get the job done.  Sadly understaffing a nursing home is a feature and not a bug 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:

Aspen of Silvis resident chokes to death due to care plan violation

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

Resident chokes to death at River Bluff nursing home

Sunset Rehab resident chokes to death

Fatal choking accident at Spring Creek in Joliet

Aperion of 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.

 

 

Grosse Pointe Manor resident falls and breaks hip after being left unattended

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IDPH has cited and fined Grosse Point Manor nursing home in Niles after a resident there fell and suffered a fractured hip after being left unattended in the dining room.

Falls are a major focus in the long-term care industry because as a whole nursing home residents are more susceptible to suffering serious injuries in falls which can easily prove fatal or have serious adverse effects on the resident’s quality of life.

Because falls are a focus, they are specifically addressed in the care planning process.  There is no commonly adapted tool for measuring fall risk the same way the Braden Scale is used to measure risk of developing bed sores.  However, there are two major factors that are used in just about every fall risk assessment tool I have seen.  The first of these is some form of musculoskeletal, gait, or balance dysfunction or deficit.  This contributes to fall risk for obvious reasons.  The other is some degree of dementia, impaired judgment, or intermittent or constant confusion.  This is because the resident then cannot be counted on to follow instructions, heed safety precautions, or make good decisions about their own safety.

When a resident is considered a fall risk, there are a couple of mainstay interventions or steps that can be taken to address fall risk.  The first of these is to keep the resident under observation in the common areas or by the nurse’s station during hours when the resident is awake.  The other is a use of a bed alarm or a chair alarm which sounds when a resident gets up out of bed or out of his/her chair.  It serves two purposes: one to alert the staff that the resident is up and moving; the other to remind the resident that they should not be up unattended.

The resident at issue was 91 years of age and suffered from confusion and musculoskeletal weakness.  She used a walker with the assistance of one staff member.  Before the fall that led to this citation, she experienced 7 falls in a year and a half.  Her care plan called for the use of a bed alarm (but no chair alarm) and for her to be closely monitored in the dining room.

On the day of this nursing home fall, the resident was in the dining room and an aide was assigned to monitor the residents in the dining room.  However, the aide assigned to the dining room left to care for the other residents she was assigned to care for.  While she did that, the resident got up to leave.  As she walked away from the dining room unattended, her legs gave out from under her and she fell, suffering a fractured hip which required surgery.

There are a few levels of failures in the care that this resident received.  First, the aide violated the care plan by leaving the resident unattended and unsupervised in the dining room.  That supervision was absolutely necessary in light of the resident’s known behavior and history of prior falls.  Second, this is a facility which used alarms, and chose to use a bed alarm but not a chair alarm.  If the use of a bed alarm was appropriate for this resident, the use a chair alarm likely was also, especially with the number of prior falls this resident had experienced.  Finally, the aide reported to the state surveyor that the nursing home was short staffed and that was why she left the residents in the dining room unattended while she went to care for others.

Federal regulations require nursing homes to have enough staff on hand to meet the care needs of the residents on a 24/7 basis.  Clearly that was not the case here.  Sadly, understaffing is a common feature 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:

Alden Valley Ridge resident breaks leg in fall

Addolorata Villa resident fractures hip in fall

Niles Nursing & Rehab resident sustains fatal brain bleed due to fall

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

Grosse Pointe Manor resident breaks leg in unsafe transfer

 

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

 

 

 

Integrity of Smithon resident develops infected pressure ulcer

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IDPH has cited and fined Integrity of Smithton nursing home after a resident there developed a pressure ulcer on his heel which became infected and required hospitalization.

Federal regulations regarding pressure ulcers or bed sores provide that when a resident is admitted to a nursing home without pressure ulcers a resident should receive care, treatment, and services consistent with professional standard so that they should not develop them unless they are clinically unavoidable.  When a resident enters a nursing home with pressure ulcers or develops them after admission, then the regulations require that the resident receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new pressure ulcers.

When a resident is admitted to a nursing home, one of the steps in the care planning process is to assess the resident’s risk for developing bed sores, usually using a tool like the Braden scale.  If a resident is at risk for developing bed sores, then that should be addressed in the care plan.  If a resident develops new bed sores or has a decline in an existing wound, then this is something that requires physician notification to obtain new treatment orders and a revision of the resident care plan.

When this resident was first admitted to the nursing home, he was ambulatory, but then developed a pressure ulcer to his heel.  When the wound was first documented, it was listed as being an unstageable deep tissue pressure injury/pressure on his left heel measuring 6×11 cm with a 2.5×2.5 cm necrotic area in the center of the heel.  An unstageable pressure injury is one in which the base of the wound bed cannot be seen due to the presence of dead tissue in the wound.  By definition, it is considered a Stage 3 or Stage 4 wound.

The nursing home staff notified the doctor who issued orders for treatment including floating the heels from the surface of the bed and using a pressure relieving boots to help reduce pressure on the wound.  The onset of the wound coincided with the loss of the ability of the resident to bear weight on the leg, resulting in his discharge from physical therapy and occupational therapy.

A little less than 2 months after the wound developed, the wound care nurse noted an odor coming from the wound along with an increase in drainage.  These are signs of infection, and the nurse obtained an order from the doctor to send the resident to the emergency room.

There, the resident was diagnosed as suffering from osteomyelitis (a bone infection).  He was placed on IV antibiotics and underwent a surgical debridement of the wound.  If the debridement and antibiotics are not successful in resolving the infection, amputation is the likely outcome.  Either way, this resident had been significantly debilitated by the development of the bed sore.  This has led to a loss of his ability to walk and to transfer, all of which will have long-term negative effects on the quality of his life, assuming that he survives.

When interviewed by the state surveyor, the Director of Nursing claimed that the wound was a vascular ulcer and that therefore the nursing home was not responsible.  However, it was assessed as being a pressure ulcer at the outset by the nursing staff and the treating vascular surgeon also characterized the wound as a pressure ulcer, noting that vascular ulcers do not normally develop in the area where this wound occurred.

In nursing home abuse and neglect lawsuits involving pressure ulcers, the medical issues are often front and center.  Many nursing home residents have risk factors for the development of these wounds, and nursing homes often defend these cases aggressively by claiming that the wound was not a pressure ulcer or that the development of the wound was the natural progression of the underlying risk factors, i.e., that the resident was old and sick, rather than the poor care which the resident received.

Understanding the difference between the various kinds of wounds and how they develop is a critical part of being an effective nursing home abuse lawyer, and in particular how they result from the systemic poor care that nursing home resident receive.  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:

Psych med usage leads to bed sores at Eastview Terrace in Sullivan

Unstageable pressure ulcer to heel at Willow Rose in Jerseyville

Police fracture skull of resident who wandered from Integrity of Smithon

Resident develops bed sores on both heels at Eden Village

 

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

Michaelsen Health Center resident suffers fatal hip fracture in fall

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IDPH has cited and fined Michaelsen Health Center nursing home in Batavia after a resident there experienced a fall which led to a hip fracture and the death of the resident.

In providing care for nursing home residents, there are certain fundamentals which must be followed to prevent nursing home falls.  One example of this is using two staff members for mechanical lift transfers (see here, here, and here for examples of what happens when this doesn’t happen).

One of those other fundamentals is the use of a gait belt when performing a resident transfer where the resident needs assistance with transfers.  A transfer is moving a resident from one place to another, such as from bed to a wheelchair or a wheelchair to a chair.  A gait belt is a canvas strap that is applied around the midsection of a resident during transfers to help control the resident and if a fall occurs, to arrest or slow the fall in order to reduce the chances of serious injury.

The injury suffered by this resident was exactly the kind of injury which is likely to result when there is a failure to use a gait belt during a transfer.

This resident was being transferred from a wheelchair to the shower chair in preparation for being showered.  To get the resident from the wheelchair to the shower chair, a pivot transfer technique was used.  Usually, this entails placing the wheelchair at a 90 degree angle to the bed or chair that the resident is being transferred to or from.  The resident is then assisted from the original surface and pivoted over to the new one (hence the name “pivot transfer”).  A gait belt is necessary for this kind of transfer to assure the safety of the resident while rising, while pivoting, and then assuring the proper positioning and safety of the resident on the new surface.

During this transfer, the wheelchair was placed facing the shower chair, requiring more movement on the part of the resident.  No gait belt was used.  The shower chair was also very high for the resident, making it difficult for her to get seated on it properly.  As a result of the all of the above, when she was seated on the shower chair, she was not on it squarely, and and in scooting herself to get seated on it properly, she went off the edge of the seat and fell to the floor, landing on her hip.

She was brought to the emergency room where she was diagnosed with a hip fracture.  She underwent surgery the next day.  The citation includes information from the coroner relating to the fall and the hip fracture but doesn’t spell out exactly what happened after undergoing surgery.  One of the reasons that hip fractures are such an important issue in the long term care industry is that many nursing home residents suffer complications either during or immediately following surgery to repair hip fractures which results in the death of the resident.

There were a number of breakdowns in the fundamentals here, in particular the failure to use the gait belt.  Using a gait belt here would have helped the resident get on the shower chair properly, helped her safely adjust her position, and potentially have slowed her fall and avoided the fractured hip.  Prevention of this kind of fall is exactly what use of a gait belt is a must.

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:

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

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

Fall during transfer results in broken ankle at Sandwich Rehab

Fall at Lexington of Orland results in facial fractures

 

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

 

 

Forest City Rehab resident murders roommate

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IDPH has cited and fined Forest City Rehab nursing home in Rockford after a resident there murdered his roommate.

Sadly, this is not the first time that we have written about resident on resident assaults at this facility.  In one recent post, we described an incident where a resident was pushed to the the ground by a fellow resident, suffering ae fractured hip.

This kind of injury is disturbing in and of itself, but the attitudes which were on full display for the state surveyor made the situation even more disturbing and really set the stage for this incident.  Part of the problem in the earlier incident was that when the nursing home ran the required background check on the aggressor resident, it entered the wrong date of birth and therefore missed the fact that the aggressor had multiple arrests, including two arrests in the last year for assaults on persons over 60 years of age.  When this information came out, this was the reaction that the state surveyor recorded:

  • The social services director told the state surveyor, “We do our best, but we can’t have eyes on people 24/7 365 days. All residents are treated the same, behaviors can happen whether it is a person with a history or a little old lady.”
  • The Director of Nursing told the state surveyor, “Even if the background check was done correctly, it wouldn’t have changed anything. We would not have done anything different for him [the aggressor] anyway. We don’t base our admissions on background checks.”

That is a proverbial shrug of the shoulders – “wouldn’t have made any difference any way.”

With that incident in the rear view mirror and a citation and hefty fine from the State, you would think and hope that the nursing home would clean up its act and be more proactive about assuring the safety of its residents from one another.

You would be disappointed.

The aggressor and victim were roommates.  When you see the backgrounds of these gentlemen (below), you will wonder why they were ever put in a room together to start with.  Past that, they asked for a change, were told that they would get one when a room was available.  There were rooms open – but the social services director did not think that it was necessary, leaving a volatile situation brewing until things went completely wrong.

The victim had been in another nursing home before this one.  There, he had complaints about his roommate, specifically that the roommate smelled bad.  This led to a physical altercation between the roommate where our victim was the aggressor.  These issues were described in records from the earlier nursing home which were supplied to this nursing home.   However, that information was never considered in care planning or in making placement decisions.

The aggressor had diagnoses related to mental illness.  He had an extensive criminal history and problems at a number of different living situations including with families, hotels, and other health care facilities.  He had a reported history of impulse control.  The Identified Offenders Report indicated that he needed closer observation and more frequent monitoring than most residents.

The staff on the floor told the state surveyor that they were not aware of the histories of the two residents or that they required additional monitoring, so it was not being done.  Their room was located near the end of the hall, second furthest from the nurse’s station.

On the night of the incident, the aggressor came to the nurse’s station at approximately 11:30 pm, asking to use the phone.  The nurse commented that it was late to be calling family, and in response the aggressor stated that he thought that he killed his roommate.  The bed was pushed to one side.  There was a broken window and a hole in the wall which was not present earlier.

The nurse ran down to the room and found the victim on the floor motionless and pulseless.  911 was called and he was brought to the hospital where it was shown that the victim was not going to recover and he died several days later.

The aggressor told police that they were arguing over whether the light should be off or or.  The aggressor wanted the light on, so he got up to turn it on.  The victim punched him, so he put the victim in a headlock, keeping him there until he was no longer moving.

There are so many problems with the care that these residents were provided that the list is hard to make.  It begins with the fact that the nursing home apparently did not learn anything from the earlier incident regarding the admission and/or monitoring of residents with a criminal history.  These are men who were likely never suitable admissions to any nursing home, let alone being placed in the same room.  They clearly recognized it and asked for a change which the nursing home could have made but failed to do so.

Past that, the need for close monitoring was never recognized in the care planning process or communicated to the staff who would have been charged with carrying it out.

Further, this resident-on-resident assault was one which was allowed to take place over a span of several minutes at a minimum.  They had been arguing over the light for some period of time before the final assault.  One the physical altercation started, it was violent enough that the bed in the room was moved, a hole was punched through the wall, and a window was broken.  Despite all of the noise that was undoubtedly generated from this, the first time the staff went into the room was after the aggressor reported to them that he thought that he killed his roommate.

This is a story of failures that started well before these residents actually entered the nursing home and continued up through the moments that one was choking the life out of the other.

The real question is why would a nursing home accept this kind of situation and the easy answer is that they are paid by the state each day a bed is kept full.  If their motivation was delivering quality care to those who need it, this situation would not be allowed to persist at this facility.  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:

Forest City Rehab fails to send resident to dialysis

Resident sexually assaulted by fellow resident at Dixon Rehab

Assault by fellow resident leads to broken hip at Stephenson Nursing Center

Multiple residents victimized by fellow resident at Winning Wheels

 

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

 

Lexington of Chicago Ridge resident breaks ankle in unsafe transfer

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IDPH has cited and fined Lexington of Chicago Ridge nursing home after a resident there suffered a broken ankle in an unsafe attempt at transferring the resident from her bed to a wheelchair.

The resident care plan is fundamental to providing good care to nursing home residents.  It measures the threats to the health and well-being of the resident and outlines a series of steps which must be followed to keep the resident safe and healthy.  However, for the care plan to work, the staff must be trained to follow it and then it must in fact be implemented on a day-to-day, shift-to-shift basis.  When the care plan is not followed, a resident’s safety and well-being is the result of good luck, not good care – and that is no way to run a nursing home.

The resident at issue suffered from a series of musculoskeletal issues including multiple sclerosis, paraplegia, and generalized weakness.  A few months before her injury, she had been enrolled in physical therapy where use of a slide board for transfers was one of the goals.  However, that goal was discontinued without having been met.   Her care plan called for full body lift which means using a mechanical lift for transfers.

On the day of this accident, a CNA brought in from an agency was assigned to care for the resident.  The resident needed to be transferred from her bed to her wheelchair, and the decision was made to use the slide board to attempt the transfer.  A second aide came in to assist with the transfer, and in the process of attempting this transfer, the resident’s foot rolled underneath her.  She experienced pain and swelling in the ankle.  X-rays showed that the ankle was fractured.  This required surgical repair.

This was a highly preventable accident but due to an unsafe transfer, avoidable injury occurred.  There was a care plan which was in place that called for an appropriate method of transfer in light of the resident’s condition and limitations.  There was even a way of communicating that to the staff – there was a card in the resident’s room that had the necessary information.  None of the staff apparently looked at it the day of this injury, and as a result, this resident suffered an unnecessary fracture.  With the amount of recovery time necessary for this injury, this resident is likely to suffer significant loss of ability to bear weight and/or ambulate over the long term which sets the stage for developing bed sores.

The fact that the staff did not know to or did not care to look at the resident information card speaks to a poorly trained staff.  Having a poorly trained staff or an understaffed nursing home speaks to an unwillingness on the part of management to invest in the staff at the nursing home.  Unfortunately, this is one of the calling cards 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:

Prairie Manor resident suffers broken leg in fall

Unsafe transfer at Alden Courts of Shorewood

Manorcare of Palos Heights East fractures hip in fall

Southpoint Nursing & Rehab resident breaks leg in improper tranfer

Mechanical lift accident at South Holland Manor

Prairie Manor resident suffers brain bleed after being rolled from bed

 

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

 

Aperion Care Fairfield resident falls from wheelchair and breaks leg which goes untreated

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IDPH has cited and fined Aperion Care Fairfield nursing home after a resident there fell from her wheelchair, suffered a broken leg, and then had the fracture go untreated for two weeks.

The resident at issue was wheelchair-bound and suffered from advanced dementia.  There was an order in place for the use of a seat belt to prevent her from sliding out of the chair.  This is in itself unusual because a seat belt is a form of restraint, and the use of restraints are  discouraged in the nursing home industry for a wide variety of reasons.  However, a restraints can be used in some very limited circumstances, and then only after a doctor’s order is obtained and informed consent is given by the resident or their surrogate decision-maker.  Once the use of a restraint is authorized, the way in which it used must be carefully followed.

The intended purpose of the seat belt was to keep the resident from falling out of the chair.  To get the order for the use of this restraint, this had to be a recurrent risk to the health and well-being of the resident and its use had to be necessary.  When the use of a restraint is authorized by physician order, that order should be followed by the nursing home staff.

This nursing home fall occurred when the resident was in the dining room seated in her wheelchair.  The seat belt for the seat belt for the wheelchair was not on.  The resident fell forward out of the wheelchair, and as she did so, she reached forward and grabbed onto a tablecloth.  As she did so, she pulled the table cloth down as well as a television set which was placed on top of the tablecloth.  The television set landed on the resident’s leg.

The aides in the dining room responded right away and lifted the television set off the resident and helped her to her wheelchair right away rather than summoning a nurse to assess the resident.  One of the aides reported the fall to the nurse assigned to the resident, but apparently failed to mention that the television set landed on the resident.  When the nurse checked on the resident, she was already in her wheelchair with no obvious signs of injury and given that the nurse was under the impression that this was a “simple fall,” no detailed assessment was done of the resident’s condition nor was the fact of the fall documented in the resident chart or was a 72-hour fall watch started.  There was also no physician notification of the fall.

Over the next several days, the condition of the resident obviously declined.  She remained in bed curled up in a fetal position and was resistive to staff moving her, comforting her, or otherwise trying to care for her.  She began to experience vomiting which is something that the doctor was notified about as well as the change in behaviors, but was not told about the occurrence of the fall.

Two weeks after the fall, the during the administration morning meeting the topic of the resident’s decline was mentioned.  The medical records custodian mentioned that she had heard one of the staff members mention that the resident had a fall.  The administrator told the state surveyor that this was the first time that he had heard that there was a fall.  He instructed the nursing staff to obtain an order from the doctor for x-rays which showed that the resident had a fractured femur.  She was brought to the local emergency room before being transferred to a medical center where she underwent surgery for the fracture.

There are a number of shortcomings in the care that this resident was provided:

  • While restraints are disfavored in the long term care industry, they can be used when they are necessary and orders for their use are obtained.  This resident had an order in place for a seat belt, and this order was obtained in order to prevent falls out of the wheelchair.  The seat belt was not on at the time of the accident, and as a result the kind of nursing home fall that the seat belt was intended to prevent occurred.
  • The aides moved the resident after the fall without getting cleared by the nursing staff.  It is the role of the nurse to check a resident for injury and moving a resident without being cleared poses a grave risk to the safety of the resident.  Here, the resident was in the wheelchair when the nurse assessed the resident.  It appears from the citation that the nurse did not realize the nature of the fall, contributing the inadequate post-fall assessment.
  • The nurse failed to follow up properly on the fall that occurred.  It was never documented in the resident chart, the family was not notified that it had occurred, and the doctor was not informed of the fall.  These are all steps that must be taken following a fall.  Further, at most facilities, after a fall, the resident is placed on a 72-hour fall watch during which the nursing staff should be monitoring for the delayed onset of signs of injury, such as a brain bleed or pain associated with fractures.  The failure to start a 72-hour fall watch doubtless contributed to the long delay in obtaining care for the fractures.
  • The resident’s pain and injuries went without proper treatment.  Subjecting a resident to unnecessary pain for that length of time is simply a form of nursing home abuse.

This series of failure in the care point to an understaffed nursing home and a poorly trained staff.  Sadly failing to have enough staff and invest in staff training are hallmarks 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:

University Rehab resident breaks leg due to lift failure

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

Casey Healthcare resident breaks hip in fall due to failure to follow care plan

Resident fall at Walker Nursing Home

Fall from shower chair at Charleston Rehab

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

 

Manorcare of Palos Heights East resident suffers hip fracture in fall

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IDPH has cited and fined Manorcare of Palos Heights East nursing home after a resident there suffered a fractured hip in a fall.

Care planning is intended to be more than an exercise in paperwork.  It is supposed to be a framework for the actual delivery of care, and in order for the care planning process to be effective, it must have meaning and must be communicated to the team which is delivering care to the resident.

The care planning process begins with an assessment which is intended to root out what the threats to the health and well-being of the resident are.  Falls are a major threat to the life and quality of life of nursing home residents, so this is an area which is specifically addressed during the care planning process.  If a resident is identified as a fall risk, a series of steps must be laid out which should be carried out on a day-to-day, shift-to-shift basis, and then must be revised if the care plan proves to be inadequate in practice or if there are further declines in the condition of the resident.

There are a number of factors which can place a resident as being at risk for falls.  The two major factors are having some degree of musculoskeletal dysfunction and intermittent or constant confusion.  The musculoskeletal issues obviously increase the risk of falls, but the intermittent or constant confusion means that the resident cannot be relied upon to make good decisions for their own safety or call for help as needed.  Falls tend to beget additional falls, so a history of falls can also contribute to a resident’s fall risk.

The resident at issue was a fall risk.  She actually had a fall while using the bathroom two days before the fall at issue, but should have been considered a fall risk regardless as her Minimum Data Set (MDS) showed moderate cognitive impairments and need for two-person extensive physical assistance.  The nursing staff further told the state surveyor that the resident felt like she could do more on her own than she really could – a sign of poor safety judgment.

In this facility, the residents who are considered fall risks are given a band to wear, but this resident did not have hers on at the time of her fall.  As a matter of routine residents who are fall risks are kept congregated in the common room or at the nurse’s station for easier supervision.  After the fall she had two days earlier, her care plan was updated to include the resident not being left alone in the bathroom.

On the night of this nursing home fall, an aide left a room across the fall and found the resident laying on her side, complaining of left hip pain.  The resident had been trying to change into bed clothes on her own, lost her balance and fell.  The resident was wheelchair-bound and was not able to propel herself, but no one was able to determine how the resident returned to her room.

The resident was brought to the hospital where x-rays showed that she had a fractured hip.  Fractured hips have a significant mortality rate for senior citizens and often result in significant declines in the quality of life for residents who suffer one even when they do survive.

There were a number of breakdowns in the delivery of care to this resident.  The resident was very clearly a fall risk given what was shown on her MDS and the recent fall.  However, the band which was designed to alert staff to that fact was not on the resident – a missing communication tool.  Past that the resident was brought to her room and left unattended to change into bed clothes, resulting in a lack of supervision for a resident who needed it badly.  These simple steps, not taken, led to a significant injury for 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:

Lexington of Chicago Ridge resident breaks ankle in unsafe transfer

Two serious falls at Holy Family Villa

Sheridan Village resident suffers hip fracture in fall

Fall at Lexington of Orland results in facial fractures

Mechanical lift accident at South Holland Manor

 

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

 

 

 

South Suburban Rehab resident murdered by fellow resident

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IDPH has cited and fined South Suburban Rehab nursing home in Homewood after a resident there was shot to death by a fellow resident.

One of the basic tasks that families look to nursing homes to do is to keep their family members safe.  Sadly, there are incidents each year where residents are victimized by other residents whether by physical or sexual assaults.  This is one which turned fatal.

The perpetrator of this assault was a 32 year old man who was a paraplegic due to injuries he sustained in a shooting a number of years earlier.  He was admitted to the nursing home approximately two weeks before the murder.  The nursing home ran a background check on him which showed that he had felony convictions for possession of controlled substances, battery, and unlawful possession of a firearm.

The victim was a 77 year old man who suffered from mental illness.  He had been involuntarily discharged from the facility earlier in the year due to his aggressive physical and verbal behaviors toward other residents and staff.

During the days leading up to the shooting, there had been a number of altercations between the two residents, leading the younger man to make threatening remarks and comments to fellow residents about the victim.  He managed to leave the facility, obtain a gun and return.  On his return to the facility, he showed the gun to at least one other resident.  The resident who saw the gun told the state surveyor that he told a CNA and a nurse about the gun.  However, the staff members deny having been told about the gun.

On the night of the shooting, the younger man was agitated and moving about the facility in his wheelchair and on at least one occasion tried to leave the facility before being brought back by the staff.  At about 3 am, he went into the victim’s room and shot him multiple times.  The staff, hearing the gunshots, left the floor and called 911 to advise that shots had been fired and that there was an active shooter on the premises.  Police and paramedics arrived shortly thereafter, but the victim was mortally wounded.  The murder weapon was recovered from the backpack located on the rear of the wheelchair of the younger resident.

Obviously, this is a tragic situation, but one which could have been prevented.  As a starting point, the issue of whether the staff was aware of the presence of the firearm on the premises is in dispute.  However, there is at least one account which establishes that at least two staff members were aware of the presence of the gun.  It is un known whether other residents would say that additional staff members were aware of the presence of the gun.  Assuming that were the case, the gun certainly should have been confiscated and the younger resident removed from the facility.

Past that, there were other opportunities to prevent this tragedy.  Care planning is a mainstay for addressing the potential for resident-on-resident assaults.  This is usually done by keeping the residents separated.  The victim here had a long and well-known history of aggressive verbal and physical behaviors toward other residents, to the point that he had to be sent out for a psychiatric hospitalization. Closely monitoring the behavior of residents with these types of behavioral patterns and promptly intervening is a mainstay of preventing altercations between residents.  However, it does not appear that proper care planning was done to address this potential.  Past that, staff told the state surveyor that they were understaffed which would have badly inhibited the ability of the staff to monitor the behaviors and interactions of the residents under their care.

Additionally, it appears from the citation that the shooter got the gun out in the community.  It also appears from the citation that the resident did not have community pass privileges which would allow him to come and go as he pleased from the facility.  Assuming this to be the case, the resident would have had to wander (wandering from a nursing home is also known as elopement) from the facility and return without it being noted in the chart.

The defense of this claim in any later nursing home abuse and neglect lawsuit resulting from this incident will doubtless cast blame for the incident on the shooter and claim that the shooting was an unforeseeable criminal act.  Shockingly, this can be a viable defense, one which is further complicated by limitations in the ability of the family to obtain police records and witness interviews.  This is all the more reason to hire a well-qualified nursing home abuse and neglect attorney for this kind of case.

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:

Bria of Smithton resident suffers fractured hip in assault by fellow resident

Resident assaulted by roommate at Countryside Nursing & Rehab in Dolton

Resident on resident assault at Alden Long Grove

Forest City Rehab resident murders roommate

Assault by fellow resident results in broken hip at Stephenson Nursing Center

 

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

 

 

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

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IDPH has cited and fined Aperion Care Capitol nursing home in Springfield after the nursing staff there failed to complete the admissions process for a newly-admitted resident suffering from bacterial meningitis, resulting in her not receiving any form of care for the first 42 hours she was in the facility.

Nursing homes are businesses, and well-run businesses have processes which are intended to help assure that the basic services that the business is there to provide are in fact delivered in a routine fashion.  When those routine processes are not followed, then there is almost inevitably a breakdown in the provision of those services. In the case of a nursing home those are nursing services necessary to assure the health and well-being of the resident, and failing to provide those services is a form of nursing home abuse and can have catastrophic consequences.

The starting point of the process by which nursing care is provided starts when the resident is first admitted to the facility.  The resident is added to the roster of residents that it is caring for.  Usually these days it is an electronic record keeping system.  The admission orders for the resident sent over from the hospital are reviewed with the attending doctor and the orders are entered into the system.  The care planning process begins with a resident assessment and the development of a preliminary care plan.

What happened to this resident is a study of what happens when a resident is brought to the nursing home, but the admissions process is never initiated.

The resident at issue was admitted from the hospital suffering from bacterial meningitis and was to be receiving IV vancomycin.  She was also a paraplegic and was unable to get out of bed on her own.  The resident arrived at 5:50 p.m., but the nurse on duty did not have time to admit the resident, so she passed the resident onto the nurse on the next shift.  That nurse never admitted the resident.

Due to the failure to even start the process of caring for this resident, the nursing home effectively did not know that the resident was even in the facility.  Over the next 42 hours:

  • The resident was not fed because there was not an order for her to receive a meal tray;
  • The resident did not receive her IV vancomycin, resulting in the resident having critically low levels of vancomycin, meaning that she was not receiving the therapeutic benefit of being on the medication;
  • There were not proper supplies for the resident to self-catheterize as was the usual method for her to pass urine;
  • She was not turned and repositioned, setting the stage for developing bed sores;
  • She did not receive pain medication, even though she complained to the staff of pain levels of 10/10;
  • Isolation precautions were not put into place for staff coming in and out of the resident’s room, placing other residents at risk of infection.

Each of these items had the potential for truly catastrophic results.  The real question though is how in the world could this happen?

The likely answer relates to understaffing of the nursing home.  Nursing homes are one of the true for-profit sectors in the health care industry, and staffing costs are one of the largest line-item expenses for a nursing home, so management will always endeavor to keep these under control.  Would admitted this resident have resulted in the receiving nurse having to work overtime when doing so was discouraged?  It is a question which is worth asking.

Staff in an understaffed nursing home are often stretched to the breaking point, and the nurse on the next shift should have taken the task of admitting the resident over, but that is a time-intensive task which apparently slipped by.

Whatever the specific reasons why things happened the way that they did, the care of this resident was an apparent casualty 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 Illinois 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:

Diabetes care mismanaged at Aperion Care Capitol

Resident given wrong medication at Villa Health Care East

Flora Gardens staff fails to give antibiotic, leading to death of resident

Taylorville Skilled fails to obtain anticonvulsant medication for resident

Aperion Care Capitol fails to obtain equipment necessary to treat bed sore

 

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

Red Bud Regional Care resident breaks hip and leg in bathroom fall

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IDPH has cited and fined Red Bud Regional Care nursing home after a resident there suffered a broken hip and leg in a fall occurring when she was left alone in the bathroom.

Nursing home falls have serious implications for the long-term well-being of residents.  Many nursing home residents suffer from osteoporosis or brittle bone disease, which leaves them at risk for suffering hip fractures in falls.  Others are taking blood thinner medications which leave them at risk for suffering brain bleeds after a fall.

For this reason, fall prevention is a specific area of focus in the care planning process.  The process begins with an assessment to determine whether a resident is a fall risk.  Nursing homes use various standardized tools to help make this determination, but there are two common areas in all of these tools which are specific factors.  One is whether there is any balance or musculoskeletal dysfunction which can lead to a fall.  The other is whether there is some form of cognitive issue such as dementia, confusion, or poor safety awareness.  If any of those cognitive factors are present, the resident cannot be counted on to follow instructions or make good decisions for their own safety which increases the risk of a fall.  Wtionhen a resident is a fall risk, then a fall prevention care plan must be put into place.

The resident at issue had been admitted for rehabilitation and had a history of falls and a diagnosis of dementia.  The Minimum Data Set (MDS) specific that she was an assist of two staff with transfers and walking and that she suffered from severe cognitive impairments.  She required stand-by assistance while washing her face and hands or brushing her teeth or hair.

On the day of this nursing home fall, the resident was at the sink brushing her teeth and washing her face in the morning.  The aide assigned to help her told her to wait at the sink while the aide brought her roommate down to the dining room.  Shortly after the aide left the room, she heard a sound coming from the resident’s room and found that the resident was on the floor, having stepped away from the sink to get clothes to start getting dressed.

The resident was brought to the hospital where x-rays showed that the resident had suffered a fractured hip and femur (thigh bone), all of which required surgical repair.  The resident returned to the nursing home but was unwilling to participate in physical therapy even with family encouragement, whereas before this fall, she had been participating in therapy and making good progress.   Now, she is wheelchair-bound.  Loss of the ability to walk, even minimally sets the stage for a number of other health issues to develop such as bed sores, worsening osteoporosis, pneumonia, blood clots, and other ills.

This was a predictable and very preventable fall.  Nursing home staff should know better than to rely on residents with severe cognitive impairments to make good decisions about their own safety, and where supervision is needed, it should be provided, as required by federal regulations.  All that had to be done in this case was to finish attending to the resident and making sure that she was in a safe position before bringing the roommate down to the dining room.

The fact that the aide elected to cut this corner is part of the dynamics of what happens in an understaffed nursing home.  Sadly, not having enough help is a feature 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:

Red Bud Regional Care staff fails to respond to call light, leading to fall and broken hip

Hitz Memorial Home resident dropped from lift

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

Broken ankle from fall at Aperion of Mascoutah

 

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

Heddington Oaks resident suffers broken leg due to unsafe transfer

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IDPH has cited and fined Heddington Oaks nursing home in Peoria after a resident there suffered a broken leg while being transferred from her bed to her wheelchair.

In this blog, we often focus on the care plan when nursing home residents suffer needless injuries.  This is because the care plan is the road map for how routine care in the nursing home should be delivered.  When there is a breakdown in the care planning process, this leads to poor care.

One area that we often do not focus on is the care plan itself.  The care plan should reflect the needs of the resident as shown during the assessment and should be tailored to the needs of each resident and should be specific enough that the staff knows what needs to be done.  However, when the care plan does not accurately reflect the needs of the resident, you can have the staff faithfully implementing the care plan, and the resident is still not getting the care he/she really needs.  Such was the case here.

There is a document which nursing homes are required to prepare called the Minimum Data Set, or MDS.  The MDS is submitted under oath to the federal government and is supposed to accurately reflect the care that the resident needs, based upon the assessment of the resident, the data that the staff compiles and upon interviews done by the MDS nurse with the staff.  The reason that it is submitted under oath is that it forms part of the basis of how the nursing home is paid.

When the MDS is completed, the result of the MDS triggers a process known as the CAA, or Care Area Assessment which is a prompt for the care planning staff to develop a care plan in that area which should reflect the needs of the resident as shown during the assessment.

In this particular case, the resident’s MDS showed that the resident needed extensive assist of two staff members with transfers.  However, as written, her care plan as written called for transfers to be done with moderate assist of one using a gait belt due to generalized weakness.  Therefore, there was a mismatch between what the assessment said the resident needed (and what they certified to the federal government that they were doing) and what the care plan actually said.

One the day of this nursing home fall, the resident was being transferred from her bed to her wheelchair by a single aide who was using a gait belt.  While the transfer was being performed, the resident reported that her legs were giving out.  The aide used the gait belt to lower the resident to the floor, but in the process of doing so, one her legs went out to the side, and the resident suffered a fractured femur.

It is hard to fault the aide for this particular accident – she was doing what the care plan said she should be doing.  The problem was that the care plan did not reflect what the true needs of this resident were.  Bad care plans beget poor outcomes, and this is an example of that.

Sadly, this injury will probably have serious long term consequences for this resident, much as a hip fracture would.  This resident will have an extended period of immobility due to the injury, and with her underlying conditions and issues, it will be hard for her to regain any real ability to ambulate again which will in turn set the stage for other issues such as pneumonia or 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:

Lutheran Home resident dropped from lift during transfer, breaks hip

Aperion of Spring  Valley resident suffers fatal brain bleed in fall

Cornerstone Rehab resident falls from lift, breaks leg

Pekin Manor resident suffers brain bleed in fall

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

Fondulac Rehab resident catches fire in smoking accident

 

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

 

Grosse Pointe Manor resident breaks leg in improper transfer

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IDPH has cited and fined Grosse Pointe Manor nursing home in Niles after a resident there sustained multiple fractures during an unsafe transfer from his bed to a shower chair.

Poor care planning is often at the root of unnecessary injuries and illnesses for nursing home.  Poor assessments, inadequate care plans, plans not communicated to the staff charged with carrying them out, and plans not revised when the situation called for it have all been culprits in accidents which have resulted in injuries to residents in a multitude of settings from nursing home falls to choking accidents to the onset of bed sores and their decline.

Of course, even an well-done plan is useless if the staff charged with carrying it out does not do what it is supposed to do.  And such was the case here.

This resident was 101 years old and suffered from Parkinson’s and osteoporosis (also known as brittle bone disease).  His Minimum Data Set and the care plan both indicated that the resident required the assist of two using a mechanical lift for transfers.  Given that this was the level of care that this resident required, it fell to the staff on the floor to actually deliver that care.

So, what happened to this resident?

On the morning of this accident, the resident needed to be transferred from his bed to a shower chair so that he could be brought to the shower and bathed.  However, the staff caring for him that morning could not find the right sling for the mechanical lift, so they attempted to transfer the resident by placing a sheet underneath the resident and using a pivot transfer technique.  While they were transferring the resident in this manner, he suffered  a comminuted fracture of the tibia and a spiral fracture of the fibula.

Obviously, this was a highly preventable accident.  There was a care plan which determined what care was required, but the floor staff simply didn’t deliver on it.  The circumstances surrounding this accident though speaks to an understaffed nursing home.  The staff knew what needed to be done but took a shortcut in delivering on it, likely due to the press of work.

Unfortunately, understaffing of a nursing home is consistent with the nursing home business model, and 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:

Grosse Pointe Manor resident falls and breaks hip after being left unattended

Niles Nursing & Rehab resident sustains fatal brain bleed due to fall

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

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

Fall from shower chair leads to brain bleed and death at Manorcare of Arlington Heights

 

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

 

 

Fall with broken hip at Heritage Health in Mt. Zion

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IDPH has cited and fined Heritage Health nursing home in Mt. Zion after a resident there suffered a fractured hip in a fall.

The care planning process is a staple of nursing home care, and even though this is something that needs to be done for every resident, the actual care plan is supposed to be individualized to the risks and needs of the particular resident.  The federal regulations in fact refer to this as “comprehensive, person-centered care plans.”  This means that while there are a range of standardized assessments that are used in the care planning process, the care plan should reflect the needs of THAT particular resident and provide the safety and well-being of THAT particular resident in a way that is appropriate.

The resident at issue here suffered from advanced dementia and was recognized as a fall risk.  There was a fall prevention care plan which included many of the usual fall prevention steps.  However, the staff recognized from experience that she would become very agitated when her husband would leave the nursing home after visiting her and would get up from her wheelchair to leave, saying that she needed to go home and be with her family.  When her husband would leave, the staff would place her in her wheelchair in the hallway so that she could be supervised by staff.  In the past, they would also give her a word search puzzle to do, but had found lately that this did not work as well because her advancing dementia made finding the words more difficult.  While these are reasonable steps to take, they were not incorporated into her care plan nor were their diminishing effectiveness taken into account.

On the day of this nursing home fall, the resident’s husband had come to visit.  After he left, the resident was brought out into the hallway by her room in her wheelchair so she could be supervised by staff.  At some point, the resident got up from her wheelchair, saying that she needed to go with her family, setting of her chair alarm.  At that moment, all of the aides were in resident rooms attending to the needs of other residents.  One of the two nurses on the hall was on the phone.  The other nurse raced to get to the resident, but was not able to get there in time, and the resident fell backwards.

She suffered a broken hip in the fall which required surgery.  Hip fractures are significant injuries for anyone, but especially so for senior citizens.  For people in this age group, hip fractures often lead to a significant deterioration in the quality of life and frequently lead to the death within a peiod of months following the fracture.

So – what did the nursing home do wrong here?  There are are really two major issues.

First, there were shortcomings in the fall prevention care planning in a couple of respects.  The resident was properly assessed as a fall risk and reasonable steps were put into place to address her fall risk generally.  However, the particular, individualized risk of falls associated with her agitation when her husband left were not addressed at all.  The staff knew that steps had to be taken to address that, but without incorporating those steps into the care plan, these steps amounted to random acts of care which did not address the specific, predictable risks of falling for this particular resident.

The other way in which the care planning process fell short is that nothing addressed the diminishing effectiveness of the steps that were being taken to address the fact that it was getting harder to manage the resident’s agitation after her husband left.  The staff had managed her agitation by giving her word search puzzles to do but that wasn’t working as well because her advancing dementia left her unable to do the puzzles.  Since that tool wasn’t working, as a “care plan” these steps needed to be changed.

Second, the resident wasn’t placed in an area where she could be effectively monitored and assisted by the nurses on duty.  Residents in need of close monitoring are customarily placed by the nurse’s station not down the hallway.  It is entirely predictable that aides might all be off the hall attending to residents in their rooms, and leaving residents far from the nurse’s station means that the nurses may not be able to reach a resident in time, as happened 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:

Aperion Care St. Elmo resident breaks hip in fall

Taylorville Skilled resident falls and breaks hip

Resident at Hickory Point Christian Village suffers multiple fractures in fall

Repeated falls by resident at Heritage Health in Springfield ends with broken arm and brain bleed

Tuscola Health Care Center resident dropped from lift, suffers fractured ankle

Auburn Rehab resident suffers fractured hip in fall

 

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

Alden Poplar Creek resident chokes to death

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IDPH has cited and fined Alden Poplar Creek nursing home in Hoffman Estates after a fatal choking accident involving one of the residents.

There a number of conditions which can place a nursing home at risk for choking.  Among these are difficulty with swallowing (known as dysphagia), dementia, poor dentition, Parkinson’s disease, and a number of other neuromuscular disorders.  A resident’s risk of choking can be evaluated by a speech therapist in a clinical setting or the resident can be sent to a hospital for a video swallow study.

However a resident is determined to be at risk of choking, once that determination is made, that risk must be addressed in the resident care plan.  One thing that a speech therapist does is assess deficits in the resident’s swallowing function and then recommends various strategies to minimize the risk of choking.  Often these will take the form of a modified diet and supervision at meals.  These recommendations should be tailored to the particular needs of the resident and should be incorporated directly into the resident care plan so that all of the staff charged with caring for the resident know what steps should be taken to keep the resident safe.

Here, the resident was at risk for choking.  He had been diagnosed with dysphagia, Parkinson’s, and dementia.  The resident had a video swallow study done at the hospital after a prior choking episode.  This confirmed that the resident had swallowing difficulties.  When he returned to the nursing home, the speech therapist made a number of specific recommendations regarding the resident’s eating which were intended to address the risk of choking.  These included: one-to-one supervision during meals and cuing the resident to take sips of water in between bites because due to the Parkinson’s, he often did not swallow all of the food in his mouth on the first effort.  The resident’s care plan addressed the risk of choking, but did not include all of the recommendations made by the speech therapist.

On the day of this nursing home choking accident, the resident was seated in a small dining room in the memory care unit.  He had finished eating but the tray was left in front of him with food still on the tray, as well as some food his family had brought to the facility for him to eat.  The staff in the dining room were all attending to other residents.  The aides heard a gurgling sound coming from the resident and brought the nurse in.  The nurse attempted the Heimlich, but could not clear the airway and lowered the resident to the floor.  A nurse practitioner and a doctor who happened to be in the building came to assist with resuscitation efforts.  After paramedics arrived, they intubated the resident but were unable to revive him.  He was pronounced dead at the nursing home.  Cause of death was asphyxia due to choking on a food bolus.

There were a number of issues with the care that this resident received which contributed to his death.  First, the care plan failed to include the recommendations made by the speech therapist.  The whole point of having a speech therapist make recommendations is to find out what has to be done to assure the safety of the resident.  If those recommendations are not incorporated into the care plan to be carried out on a day-to-day, shit-to-shift basis, then the recommendations have no real value.  One of the crucial recommendations that was made is that the resident needed one-to-one supervision while eating, and if a resident is left with a food tray and other food in front of him, then there is a risk due to the resident’s dementia that they will go ahead and continue eating with no supervision.  That is what occurred here.

Second, the staff left the resident’s tray in front of him thinking that he was done eating.  This is contrary to what the speech therapist said needed to be done, as well as the facility’s own policies and procedures.  Had these procedures and recommendations been followed, this resident would not have died in this manner.

Having staff that is unaware of the facility’s own policies and procedures is a mark of poor training.  Nursing homes are businesses and well-run businesses have policies and procedures (“this is how we do things here”) that tell them how to deliver the basic services that the business provides, and the staff must be trained on them.  Without training of the staff, good policies do nothing more than fill binders on a shelf, and nursing home residents deserve better than that.

Sadly, having a poorly trained staff is entirely consistent with now most nursing homes operate, because training staff costs money and that cuts into profits. 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 AHVA Care of Winfield chokes to death on peanut butter sandwich

Fatal choking accident at Spring Creek in Joliet

Hillcrest Retirement Village resident chokes to death

Bella Terra Wheeling resident chokes to death

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

Resident chokes to death at the Moorings in Arlington Heights

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

 

Bethany Rehab resident suffers broken arm in fall

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IDPH has cited and fined Bethany Rehab nursing home in DeKalb after a resident there suffered a broken arm in a fall while walking from her chair to bed with the help of an aide.

Skipping over steps that are required to do things safely is a well-worn path to disaster in a nursing home.  By way of example, we have seen it multiple times here in this blog where you have one person doing a two-person job (see here, here, here, here, and here for examples).  This particular accident resulted from not following the fundamentals that must be followed to assist a resident who needs help with walking.

When a resident requires assistance with walking, the are a couple of “musts” that went by the wayside here.  One is that the resident must be wearing proper footwear.  The other is that the aide must use a gait belt.  A gait belt is a large canvas strap which must be applied to the mid-section of the resident and allows the staff member to gain control of the resident in the event that there is a loss of balance.

The resident at issue here had left-sided weakness due to residuals from an earlier stroke and needed assistance with walking.  However, on the day of the accident, there aide elected to assist the resident in walking from a chair to her bed without using a gait belt (holding onto her clothing instead) while the resident was wearing regular socks, not shoes or non-skid socks.

While walking in this manner, the resident fell, landing on her outstretched left arm.  Another aide was summoned and the lifted the resident to bed and alerted the nurse that a fall had occurred.   The resident did not receive x-rays for about a week, having to live with pain from the broken arm which was treated with Tylenol only until it was actually treated.

However, the nurse did not notify the doctor that a fall had occurred.  One situation where a nurse must notify a doctor is when a fall occurs.  This was not done which resulted in the resident being denied necessary care for almost a week.

There were a number of problems with the care that this resident received.  First, the transfer was attempted without a gait belt and without the resident having proper footwear on.  This led directly to this resident’s nursing home fall.  Second, the aides transferred the resident to bed without first having the resident assessed by a nurse.  Moving a resident after a fall can cause additional injury, and assessment of a resident by a nurse is needed to determine whether movement of the resident is safe.  Finally, the nurse failed to notify the doctor that the fall occurred, resulting in a week-long delay in care.

The basic facts of this case also speak to poor training and an understaffed nursing home.  One of the hallmarks of an understaffed nursing home is when you have accidents resulting from staff skipping simple measures necessary to assure the safety of residents – like putting on shoes and using a gait belt or notifying a nurse before moving a resident after a fall happens.

It also speaks to poor training of the staff.  All of the things that were missed during and after this fall are things that are basics for providing care in nursing homes.  Sadly, poor training of staff and having understaffing of a nursing home are hallmarks of the nursing home business model because they all require investing in the care of 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:

Pleasant View Rehab resident breaks hip in fall

Fall leads to brain bleed and death at Regency of Sterling

Fall results in broken vertebra at Heritage of Mendota

Aperion of Spring Valley resident suffers fatal brain bleed in fall

Understaffing at Generations at Rock Island leads to fall and hip fracture

 

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

Aperion of Spring Valley resident suffers fatal brain bleed in fall

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IDPH has cited and fined Aperion of Spring Valley nursing home after a resident there died due to brain bleed which resulted from a fall while left unattended in the bathroom.

The resident at issue was receiving care at the nursing home after having a hip replacement done.    She was considered a fall risk and her care plan called for following facility fall protocols.  Her Minimum Data Set, which reports to the federal government the level of assistance that each resident requires, indicated that the resident was not steady and required assistance of staff when moving from seated to standing position, walking, turning around, moving off and on the toilet, and with surface-to-surface transfers.  The facility policies stated that residents who require assistance will not be left alone to bathe, shower, or toilet.  As part of her medication regimen, she was receiving two anticoagulant (“blood thinner”) medications which can increase the risk of a brain bleed or other uncontrolled bleeding after a fall.

On the day of this nursing home fall, the resident was brought to the bathroom by an aide.  On the way to the bathroom, the resident reported feeling unsteady, but said that she was okay after arriving there.  The aide positioned her standing in front of the toilet with her walker in front of her and then left the bathroom to clear away her roommate’s dinner tray and to give the resident some privacy.  After being left alone in the bathroom, the resident reached for the door handle and tripped on the walker, falling to the ground and hitting her head.  The aide got the nurse who did a brief assessment of the resident and applied steri-strips to control the bleeding.  However, the bleeding would not stop (likely due to the blood thinners) and the resident was sent to the hospital.

At the hospital, a CT scan was done which showed that there were multiple areas of hemorrhage in the brain with a midline shift.  There were also multiple facial fractures.  Based on the results of the CT scan, she was intubated and transferred to a regional trauma center.  A neurosurgical consult was obtained, but the surgeon indicated that if she survived surgery, she would not make a meaningful recovery.  The family elected for comfort measures only because the resident had always indicated that would not want heroic measures.  She was extubated and died several hours later.  Her death certificate indicated cause of death was subdural hematoma and subarachnoid hemorrhage from a fall.

There are a couple of obvious issues with the care that this resident received.  First, her care plan was inadequate in that all it called for was following facility protocols.  A well-done care plan calls for specific steps that must be taken for each resident and must be communicated to the staff charged with her care.  This resident was at high risk for falls due to her unsteadiness on her feet and was assessed as needing help with getting off and on the toilet but was left alone in the bathroom.  Because she was on blood thinner medications, any fall that this resident experienced had a high risk of resulting in catastrophic injury, including the kind of brain bleed she in fact experienced.  The aide involved told the state surveyor that she did not know that the resident could not be left alone.  The facility failed both the aide and the resident by not putting the aide in a position to deliver the care that the resident truly needed.

There was also a violation of the facility policies which required that residents who required assistance with toileting not be left alone.  The aide did not know that this resident could not be left alone which indicates that she did not know what the facility policies required.  Not knowing what the facility policies are is an indicator of poor training which is especially problematic when care plans are reduced to “following facility protocols” rather than spelling out a detailed set of steps which must be taken.  Poor training failed both the resident and this aide.

Sadly, poor training is consistent with the way that most for-profit nursing homes are run because training is an investment in the staff which costs the nursing home money.  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:

Heddington Oaks resident suffers broken leg in unsafe transfer

Fall leads to brain bleed and death at Regency of Sterling

Fall results in broken vertebra at Heritage of Mendota

Aperion of Spring Valley resident chokes to death

Cornertsone Rehab resident falls from lift, breaks leg

 

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

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