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Bria of River Oaks resident suffers ruptured eye globe due to being hit with broom

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IDPH has cited and fined Bria of River Oaks nursing home in Burnham after a resident there suffered a ruptured globe to his left eye after being struck with a broom by a staff member.

The resident at issue suffered from mental illness characterized by episodes of delusions which leads to agitation and anxiety. On the day of the incident, the resident was acting out in his room.  The aide assigned to the resident got another staff member to help remove chairs from the resident’s room.  In response the resident picked up a chair and threw it at the staff.  An aide then swung a broom at the resident, hitting him in the eye.  He was brought to the emergency room where he was diagnosed as having a ruptured globe in the left eye.  The resident was then transferred to a higher level hospital for definitive care.

It goes without saying that there is no good reason for a staff member to swing a broom at a resident.  When confronted with aggression by a resident, the right response is to de-escalate the situation or to get help from other staff, especially the nursing and social work staff who have more advanced skills for addressing this kind of problem.

Having a loved one be the victim of physical aggression by a staff member is one of the common fears that every family member of a nursing home resident has.   Because this kind of nursing home abuse was at one time so prevalent, the General Assembly  included a provision in the Nursing Home Care Act that makes nursing homes liable for both the intentional and negligent acts of their employees.

Oddly, in most kinds of personal injury lawsuits, one of the defenses that an employer can and does make when an employee commits an intentional act against some one else is that the employee was acting outside the scope of his employment – after all, no one hires an employee to deliberately hurt someone else.  And surprisingly, this can be a real defense for employers.  Not so with nursing homes.

However, one thing that a lawyer prosecuting a personal injury suit arising from this incident would have to keep in mind is that insurance coverage is not normally available for intentional acts.  However, a smart lawyer would also include a claim that the nursing home was negligent in failing to properly train the aide on de-escalating the situation and generally how to address these kinds of situations which certainly can occur with the kind of mental illness that this resident suffered from.

However, failing to properly train employees is one of the hallmarks of how for-profit nursing homes are managed as 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 sexually assaulted by staff member at Alden Estates Northmoor

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

South Suburban Rehab resident murdered by fellow resident

Chaplain sexually assaults residents at Good Samaritan in Quincy

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

 

Moweaqua Rehab resident suffers worsening bed sores

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IDPH has cited and fined Moweaqua Rehab nursing home after a resident there suffered declines in bed sores on his heel and on his coccyx.

Bed sores, or pressure ulcers, are a major issue in the long-term care industry.  There are two basic federal regulations pertaining specifically to the topic of bed sores.  The first essentially provides that when a resident enters a nursing home without a bed sores, the nursing home should provide care to the resident such that the resident does not develop them unless they are unavoidable.  The second addresses what happens once a resident has a bed sore, and this provides in essence that a resident who has a bed sore should receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new bed sores.

Bed sores are a specific issue issue that is addressed during the care planning process.  A resident’s risk of developing bed sores is assessed, typically using a standardized tool such as the Braden scale.  A care plan is then put into place which addresses the various risk factors that are present for the resident.

The primary risk factors are immobility, incontinence, and poor nutritional status.  Immobility is customarily addressed by a turning and repositioning schedule which provides for offloading of the body and through the use of pressure-reliving devices.  Incontinence is addressed by ensuring timely care after episodes of incontinence and through the use of barrier creams.  Poor nutritional status is addressed by adding additional servings of protein with meals or providing nutritional supplements.

When the resident at issue was admitted to the facility, he was assessed as being at high risk for bed sores.  He in fact entered into the nursing home with a bed sore – a Stage 3 wound to his sacrum.  The resident chart documented that care was being provided as ordered, but the only assessments of the wound were being done on the Weekly Wound sheets.  Approximately two and half months after admission, the resident was brought to the local wound clinic where he the wound was shown to be nearly double in size and considerably deeper, with exposed muscle and eschar in the wound bed.  The wound clinic order the use of a wound vac, and also issued orders for the use of pressure relieving devices, including a specialized mattress and special wheelchair cushion,  and for turning and repositioning.  However, those orders were never incorporated into the resident’s care plan or if they were ever carried out.  The resident’s record documented that wound vac was used after it was ordered, but there was no record as to how much fluid was being removed from wound by the wound vac.  Eventually, the resident was brought to the hospital to undergo surgical debridement of the bed sore.

At the same time that the resident was receiving the orders for the wound vac for his sacral bed sore, he also developed a Stage 2 bed sore on his heel.  There was an order for the use of heel boots, but wound continued to decline and by the time that the resident was undergoing surgery for the sacral bed sores, the one one the heel had declined to the point that it was unstageable.  Unstageable bed sores are by definition at least Stage 3, but could be Stage 4 bed sore, but the presence of dead tissue in the wound bed obscures the bottom of the wound bed keeps the wound from being staged definitively as Stage 3 or Stage 4.

When the state investigator interviewed staff from the wound clinic, they were clear in their opinions: that the nursing had failed to follow the instructions that they gave, and that this led to  the deterioration of the sacral wound and the development and decline of the wound on the heel.

Bed sores present a difficult issue for nursing homes in that the residents who develop them often have pre-existing conditions which leave them susceptible to developing them.  This basic fact is actually built into the Braden Scale.  Because the medical issues that leave residents are persistent, the care that the residents require truly  has to be provided on a 24/7 basis on a day-to-day, shift-to-shift basis.  The fact that this resident saw significant declines in wounds on two areas of his body says that this care simply was not being provided as needed.

When the kind of routine care that is needed to give residents a fighting chance against bed sores is not being offered, that is a sign of an understaffed nursing home, and having an understaffed nursing home is one of the 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:

Mattoon Rehab resident dies from infected bed sore

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

Unstageable ulcer to heel at Willow Rose in Jerseyville

Moweaqua Rehab resident develops pressure ulcer from fracture brace

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

Resident develops bed sore at Nokomis Rehab

 

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

Cornerstone Rehab resident falls from lift, breaks leg

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IDPH has cited and fined Cornerstone Rehab nursing home in Peoria after a resident fell from a mechanical lift during transfer, suffering a fractured leg.

Used properly, a mechanical lift is a great tool for assuring the safety of both residents and staff during transfers.  Of course, the key phrase there is “used safely” which requires two staff members participating in the transfer and all of the parts of the lift be in good shape and properly attached while in use.  When those things are not true, the potential for disaster lurks.

Such was the case here.

The resident at issue required a mechanical lift for transfers.  The aide involved acknowledged that two staff was required for transfers with the mechanical lift.  On the night of this nursing home fall, the resident was being transferred from her wheelchair to her bed.  The aide was in the room, as was a nurse who was preparing the formula for the resident”s tube feeding. The aide believed that she was had attached the loops of the sling to the lift.  She began to transfer the resident as the nurse continued to work on preparing the formula for the tube feeding.  After the resident was lifted up and the aide began to move the resident, the sling became detached from the lift, and the resident fell, hitting her head on the dresser and landing on her knees on the ground.  X-rays showed that the resident suffered a fractured femur.

There are two basic problems with the care that was provided here.  First, even though there were two people in the room, what really happened was that you had one person doing a two-person job, a situation that often ends in disaster as we have seen repeatedly here on this blog (see here, here, here, here, and here for examples.  It is not enough to have two people in the room.  You need to have two people actually participating in the transfer, and that was not the case here.  Second, the lift wasn’t even being used correctly in that the sling was not attached to the lift properly.  The chances of the transfer being completely successfully would have been higher had the sling been properly attached, but that still would have been a matter of good luck rather than good care and relying on good luck  is not a sound strategy for providing care in a nursing home setting.

The real question is why the aide went ahead with the the transfer when she had to have known that she was essentially doing it by herself – it may have been a matter of minutes for the nurse to finish preparing the formula.  The answer likely relates to an understaffed nursing home, and having an understaffed nursing home is one of the 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:

Mason City Area Nursing Home resident suffers fatal brain bleed in fall

Resident at Westminster Village suffers broken leg in fall from toilet

Wheelchair accident at Generations at Lincoln

Multiple fractures from fall at Accolade of Pontiac

Resident at University Rehab Northmoor in Peoria suffers broken hip in fall from bed

Fall results in broken vertebra at Heritage Health in Mendota

 

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

IDPH stops investigating abuse and neglect cases in nursing homes

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Recent news reports has shown that IDPH stopped investigating allegations in abuse and neglect during the period between approximately March 15 and June 30.

By way of background, the Illinois Department of Public Health is the agency which inspects nursing homes and issues citations for violations of state and federal regulations.  When a nursing home has a citation issued to it, they must submit a plan of correction to show what they will do to bring the nursing home back into compliance.  This often includes retraining of the staff or repair and inspection of broken equipment.  The citations are usually accompanied by a fine which usually tops out at $25,000 for the most serious violations that result in significant injury or death to the resident.  Citations may also result in issues with the nursing home’s license or with their Medicare star ratings.

The date that IDPH stopped doing the abuse investigations of course correlates with the onset of the coronavirus pandemic.  There can be no doubt that the pandemic has hit the nursing home industry particularly hard, especially in terms of resident and staff illnesses and deaths, and has made a hard task even harder.  However, the extra demands brought on by the pandemic does not mean that other care needs of the residents could not/should not be met.

(Related resource: IDPH  Long Term Care Facility Outbreaks COVID-19 – searchable database you can use to find out which facilities have COVID-19 case, how many, and how many deaths)

One of the recommendations that we make to families with a loved one in a nursing home is to be a frequent, but unpredictable visitor.  In other words, visit often, but not on a set schedule so that the staff always has to be on top of their game with your family member.  For example, if the staff know that you always come Tuesday evening, you can be sure that things will look good Tuesday evening … which may be a different story from Friday morning.  We also recommend that you be pleasant but assertive regarding your family member’s care.  None of this has been possible as of late with restrictions on visitors in nursing homes.

Over the last several months, we have heard from a number of families who have been very upset about their limited access to their family members, and justifiably so.

Investigations of abuse and neglect in nursing homes are often triggered by mandatory reporting by the nursing home to IDPH after an incident occurring in the nursing home or by a report submitted by a hospital or doctor who was concerned about the condition of a nursing home resident who was sent out for care.  While IDPH has been inspecting nursing homes for compliance with infection control measures, the inability of family members to get into the nursing home left IDPH as one of the last lines of defense when it comes to stopping nursing home abuse and neglect.

The pandemic has doubtless made many of the basic functions that need to be carried out on a day-to-day basis much more difficult and this has opened the door to many of the types of preventable injuries much more likely to occur.  Without even trying to address this in an exhaustive way, these are some of the ways:

Bed sores

The need to observe proper infection control measures makes going in an out of rooms something that takes longer, which means that the simple act of turning and repositioning bed-bound and chair bound residents is going to be harder to get done.  Further, that also feeds in to it taking longer to change a resident after an episode of incontinence.  This also makes it more difficult to make sure that residents get adequate amounts of food and liquid.

Why is this important?  Because immobility, incontinence, and poor nutritional status are three of the main factors which place residents at risk for developing bed sores and addressing these issues are key steps for promoting healing after someone has already developed a bed sore.

Nursing Home Falls

One of the main stays for fall prevention is to keep residents in a common area where they can be easily monitored by staff.  One of the ways of preventing the spread of the coronavirus is to keep residents in their rooms which neutralizes the effectiveness of this tactic.

Promptly responding to call lights and assisting residents to the bathroom when they need it are also key fall prevention measures.  Just as with turning and repositioning, this is a more difficult task in the current environment.

One of our core beliefs is that constant or intermittent confusion is a strong risk factor for nursing home falls because the resident cannot be counted on to make good decisions for their own safety or ask for help.  The combination of lots of social isolation and the staff being masked and gowned constantly is something that is likely to lead to further cognitive decline.

Past that, residents have a diminished ability to walk and exercise which leads to further decline in range of motion, strength, and balance.

Choking

Residents are no longer being served meals in dining halls.  This means that they are generally eating alone in their rooms which means that residents who are experiencing declines in their ability to swallow are not being noticed and referred for swallow evaluations by speech therapy.  Other residents who are already under care plans for choking risk are likely receiving lower levels of assistance and supervision with meals.

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One of IDPH’s roles is to prevent nursing home residents from suffering unnecessary injuries, illnesses, and wrongful deaths, and with families unable to watch out for and advocate for their loved ones, carrying out that responsibility was more important than ever.  Supposedly, IDPH has made a dent in the backlog of investigations that piled up while they stopped doing investigations, but the passage of time and the press of business makes it every more likely that those investigations will not be as thorough as they should be.

Unfortunately, failure was already baked into the system by which care was being provided in nursing homes in Illinois.  For more information on why that is the case, order our FREE report, Built to Fail.  If you have a loved one who you believe has suffered unnecessary injuries or been the victim of nursing home neglect or abuse during this time, please contact our experienced Chicago nursing home lawyers.  The initial call and meeting are free, and there is no obligation to hire us if you do call.  We serve nursing home residents and their families throughout the State of Illinois.

Symphony at South Shore resident suffers open fracture of the leg

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IDPH has cited and fine Symphony of South Shore nursing home in Chicago after a resident there suffered an open fracture of the leg during a transfer.

In this blog, we spend a great deal of time discussing the care planning process because it is one of the main building blocks for how care is structured in a nursing home.  There is a another set of assessments called the Minimum Data Set (MDS).  The Minimum Data Set is prepared at regular intervals on admission and then quarterly and with a change in the resident’s condition.  The MDS is supposed to be based on the completing nurse’s assessments, information provided by other staff members, and data that is generally tracked by aides and entered into either a piece of software or a tracking sheet and then incorporated into the MDS.  When completed, the MDS is supposed to accurately reflect the condition of the resident and the level of assistance needed.

The MDS  plays a role in the delivery of care in that it triggers something called a Care Area Assessment (or CAA) which is supposed to prompt care planning for the areas indicated.  The MDS also determined the resident’s acuity level which is tied to the amount that the nursing home receives in revenue from the entity that pays for the care.  Therefore, it needs to be signed under penalties of perjury by each person participating in completing it.

When the resident at issue went through the MDS process, the nursing home certified to the government that the resident required a two-person assist with transfers.  However, when the care plan was completed, it called for the assist of one with transfers.

On the day of the accident, the resident was being transferred from her wheelchair to her bed by a single aide who was using a pivot transfer technique.  The resident’s foot slipped during the transfer, and her leg went underneath the bed.  The resident sustained an open fracture of the tibia (shin bone), meaning that the bone broke through the surface of the skin.  She was taken to the hospital where she underwent a surgical repair of the fracture.  On her return to the nursing home, she required a mechanical lift for transfers.

During the investigation by the State, the resident’s nurse practitioner referred the surveyor to the physical therapy department as to whether the resident should have been a one- or two-person transfer.  They confirmed that she should have been a two-person transfer.  When the surveyor spoke with the Director of Nursing, she was unable to reconcile the discrepancy between the care plan and the MDS and agreed that the care plan should reflect the care levels shown on the MDS.

Many of the nursing home falls we have covered here happened either because the care plan was not followed or because the care was not revised when it needed to be.  Here, the care plan was inadequate to begin with in that it did not provide for the levels of care that this resident actually required.  Poor care plans beget poor outcomes.

The other thing that is notable about this incident is that there was a variation between the MDS and the care plan.  Since the MDS helps determine acuity level which determines payment level, this also means that the nursing home was getting paid for care it wasn’t actually providing.  Sadly, this part of how many nursing homes operate.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

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

Broken ankle from unsafe transfer at Aperion Care International

Mechanical lift accident at South Holland Manor

 

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

 

 

 

 

Taylorville Skilled resident sustains fractured hip after multiple falls

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IDPH has cited and fined Taylorville Skilled nursing home after a resident there suffered a fracture hip in a fall afteer experiencing three earlier falls.

One of the truisms in the long-term care industry is that falls tend to beget additional falls.  Falls are a serious issue in the nursing home industry in part because they happen with such frequency in a geriatric patient population and have such serious potential for serious injury, resulting in major declines in function and quality of life.

Because nursing home falls are such a serious issue, they are a specific area of focus in the care planning process.  The care planning process is a multi-step, multi-disciplinary process by which a series of steps (or interventions) are assigned to various categories of staff in the nursing home.

The last two steps are really the most critical: evaluation and revision of the care plan.  This requires the staff, on an ongoing to basis to evaluate the care plan to determine whether the care plan is meeting the needs of the resident.  If the care plan proves to be inadequate in practice or there are changes in the resident’s condition or needs, then the care plan must be revised to meet the needs of the resident.  When it comes to the topic of nursing home falls, the fact that a fall has occurred is almost always a sign that the fall prevention care plan needs to be revised because it was either inadequate to begin with or because the resident’s fall history is a predictor of additional falls.

This resident suffered three falls before a fourth resulted in a fractured hip.

Before the first fall, she was very clearly a fall risk.  She required stand-by assist for ambulation, had poor safety awareness, refused help, and was non-compliant with the call light.  Following the fall, 30-minute checks were added as a fall prevention measure.  When the second fall happened, she was found on the floor in her room with hematoma on the back of her head.  She was sent to the emergency room where she was diagnosed as also having suffered a fractured rib.  The care plan was updated to include the 30 minute checks due to noncompliance with the call light.  At the time of the third fall, the resident was found on the floor of her room, incontinent of stool.  The care plan was updated to include frequent checks and offering toileting every 2 hours.

When the fourth fall occurred, the resident was once again found on the floor of her room, bleeding from a head laceration and with an obvious leg deformity.  She was sent to the hospital where a fractured hip was diagnosed.  The hip fracture required surgical repair.  However, even with successful surgical repair, fractured hips often have serious consequences to the resident’s quality of life.

The nursing home did attempt to revise the care plan, but did so in ways that did not meet the care needs of this resident.  Residents who demonstrate consistent non-compliance with the use of a call light need to be kept in common areas where they can be kept under continuous direct observation by the staff.  Many nursing homes have gone away from the use of a bed or chair alarm as a matter of policy, but residents such as this are reasonable candidates for use of one even as their use is discouraged in federal regulations.

Offering assistance with toileting is also a reasonable step, but use of a toileting schedule is actually a more effective tactic to address the risk of a resident falling while on their way to the bathroom.  However, developing a toileting schedule requires an investment of resources to develop – an investment of staff time that understaffed nursing homes cannot make.  Sadly, understaffing is an inherent 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:

Failure to monitor resident leads to fall and refracture of broken hip at Barry Community Care

Taylorville Skilled resident falls and breaks hip

Auburn Rehab resident breaks hip in fall

Moweaqua Rehab resident suffers fractured hip in fall

Pittsfield Manor resident suffers fatal fall

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

 

 

 

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

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IDPH has cited and fined Alden Estates of Barrington nursing home after a resident there died from respiratory distress and an elevated potassium level after staff failed to inform the resident’s physician of pertinent information regarding the resident’s condition.

The resident at issue suffered from kidney disease and hypothyroidism (low thyroid), among other problems.  This placed him at risk for developing edema and/or an electrolyte imbalance.  There was a care plan which was specifically put into place to address this potential which included notifying the doctor of any acute changes and monitoring for fluid excess through monitoring for weight gain or the development of edema.  Of course, notifying the doctor or changes in the resident’s condition is one of the basic tasks in a nursing home setting, including significant weight gains which is generally defined in the nursing home industry (and was defined in this facility’s policies and procedures) as more than 5% in one month, 7.5% in three months, or 10% in six months.

In the care of this resident, there were multiple failures on the part of the staff to notify the resident’s doctor of important changes and information regarding the resident’s condition:

  • Over a period of 10 days, the resident’s chart showed that his weight weight increased from 208 lbs to 242 lbs.  There was an order in place for daily weights because of concern regarding fluid retention.  Several days went without any weights being taken at all because the facility’s scale was broken.  The resident’s doctor and nurse practitioner were not aware of the extent of the weight gain, and told the state surveyor that they would have sent the resident to the hospital to have fluid taken off.
  • The resident had labs taken which showed an elevated potassium level.  Elevated potassium levels can cause irregularities in the heart.  To address this, there was an order in place for a medication which was intended to drive down the potassium levels.  However, the resident refused the medication.  The staff failed to notify the doctor of the resident’s refusal.  Had the doctor been informed of the resident’s refusal, he would have ordered the resident sent to the hospital to have the elevated potassium levels treated.
  • The resident had a chest x-ray performed which showed changes consistent with pulmonary venous congestion.  The nurse practitioner explained to the surveyor that this meant fluid overload impending hypoxia due to fluids in the lungs.  The nurse on duty at the time paged the doctor with the results. However, he did not return the page and endorsed the results over the nurse coming on to the next shift to pass the results on to the doctor.  The nurse coming on at the next shift denies receiving a report about this at the change of shift report.  The net result  was that the results were never communicated to the doctor.

What was the net result all this?  On the morning of the 10th day, the resident sounded the call light and asked to be repositioned promptly.  Staff reported that he was anxious and was urging them to reposition him more quickly.  After getting him into an upright position, he slumped forward.  A code blue was called.  The rescue squad could not resuscitate the resident, and he died.  Cause of death per the death certificate included severe hyperkalemia or elevated potassium levels.

There were multiple opportunities to prevent this tragic outcome.  This resident essentially suffocated on excess fluids.  The potential for this was something that was supposed to be addressed in his care plan, by physician orders, facility policies and procedures, and basic standards of nursing practice.  One way that care in a nursing home is different from a hospital is that there is not a doctor on site on a 24/7 basis, so nurses need to serve as the eyes and ears of the doctor to notify them about the kinds of changes that were occurring in this resident.  This outcome is a sad lesson in what happens when this isn’t done properly.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Failure to adequately report changes in condition at Heritage Health in Carlinville

Staff at Grove of Evanston fails to notify doctor of resident’s decline

Alden Estates Huntley fails to give ordered antibiotic

Feeding tube error puts Burgess Square resident into heart failure

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

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

 

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

 

 

 

Bed bound resident at Elevate Care of Waukegan fractures arm

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IDPH has cited and fined Elevate Care of Waukegan nursing home after a bedbound resident there suffered a fractured arm while being repositioned in bed.

Turning and repositioning residents is a staple of care in a nursing home setting.  One reason that it is so crucial is that it helps prevent the development of bed sores.  However, like everything else in a nursing home, it must be done right, and as we have seen (see here, here, here, here, and here for examples) having one person do a two-person job is a formula for disaster.  And this proved true here once again.

The resident at issue was bedbound and severely cognitively impaired to the point that he was unable to move his extremities.  His care plan called for assist of two with bed mobility and transfers.    However, when the resident’s family was interviewed by the state surveyor, they reported that the resident was often repositioned with a single aide because the nursing home was understaffed.

On the day of the incident, the resident was sent to the emergency room for evaluation of swelling and discoloration of the left shoulder.  X-rays showed that he had suffered an acute fracture of the humeral neck (the portion of the upper arm that inserts into the shoulder) and an acute fracture of the proximal humeral diaphysis (the shaft of the upper arm).  The aide assigned to the resident on the night shift before the injury was discovered admitted to the state surveyor that she routinely repositioned the resident on her own.

Of interest, the Director of Nursing told the family that the injury was due to brittle bones, but the nurse practitioner and orthopedist’s physician assistant both told the state surveyor that the injury was one which required the application of force to occur, even if the resident had a bone density disorder.

Obviously, there was a clear violation of the resident care plan which resulted in this fracture.  The reason that two aides are sometimes required is to assure safety (so that the resident isn’t accidentally rolled out of bed) and to minimize the forceful tugging and pulling which is sometimes required to move someone who is incapable of voluntary movement.  Residents who are bedbound do tend to have reduced bone density as a result of inactivity, and this can predisposes them to fractures.  However, this pattern of fractures (especially with two separate fractures) is likely the result of improper handling of the resident in repositioning the resident with a single aide rather than the two called for in the resident care plan.

One person doing a two-person job is a hallmark of an understaffed nursing home and this was something that was confirmed with the family’s own observations.  Sadly, understaffing is a feature, not a bug in the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Resident suffers third degree burns in smoking accident at Elevate Care of Waukegan

Improper use of sit-to-stand lift results in multiple fractures at Radford Green in Lincolnshire

Improper transfer results in shoulder fracture at Addolorata Villa in Wheeling

 

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

 

 

Accolade of Pontiac resident breaks femur in fall

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IDPH has cited and fined Accolade of Pontiac nursing home after a resident there suffered a broken leg in a fall while transferring from the toilet to his wheelchair.

The resident at issue was cognitively intact, but required extensive assist with transfer, including the use of a sit-to-stand mechanical lift for transfers.  For toileting his care plan (which had not been changed in 6 months before the day of this nursing home fall) called for use of a gait belt and grab bars when transferring from the toilet to the wheelchair.  However, when the staff was interviewed by the state surveyor, multiple aides told the surveyor that they regularly used a sit-to-stand lift for the resident when transferring him from the toilet to his wheelchair.

On the day of this fall, there was a single aide attempting to help the resident transfer from the toilet to his wheelchair.  No gait belt was in use.  The resident was not able to maintain a standing position and attempted to sit down in the wheelchair.  However, he was not in the right position to to do and missed the seat, falling to the ground.  X-rays were done which showed that he had broken his femur just above the level of his prosthetic knee.

There are two issues here with the quality of care that this resident received.

The first relates to the updating of this resident’s care plan.  As written on the day that the resident fell, the care plan called for pivot transfers using a gait belt and grab bars.  However, in practice, the staff was often using a sit-to-stand lift to perform this transfer given the weakness of this resident.  Part of the care planning process calls for evaluating the effectiveness of the care plan on an ongoing basis and revising the care plan when the care needs of the resident changes or when the existing care plan was proving ineffective in practice.  In this case, practical experience was showing that this resident needed the help of the sit-to-stand lift to transfer safely.  However, the care plan was not updated to reflect this, and as a result, the resident did not get the help he really needed at the time of this fall.

The second way in which the care was not up to standard is that the existing care plan was not followed.  It called for the use of a gait belt.  A gait belt is a canvas strap which is applied to the midsection of the resident and allows the staff member to better control the resident during transfers and ambulation and to potentially prevent a fall when the resident begins to lose his balance or fall.  Had one been used during this transfer, this resident would have likely not suffered the severe injury he did.

The fact that the resident’s care plan was not revised as needed and the fact that the existing care plan was not being followed speaks to a staff that is struggling to meet the needs of the nursing home’s 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:

Multiple fractures from fall at Accolade of Pontiac

Mechanical lift accident at Meadows Mennonite Home in Chenoa

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

Resident fall from bed at Spring Creek

 

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

 

 

Auburn Rehab resident suffers hip fracture in fall

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IDPH has cited and fined Auburn Rehab & Healthcare Center nursing home after a resident there fell and suffered a fractured hip.

There are a handful of factors which make a resident a fall risk.  One factor is some form of musculoskeletal weakness or dysfunction.  Another is that the resident has some form of dementia or confusion.  There are a number of other factors such as poor safety awareness, medication usage, incontinence, and so forth.  However, the key issues are (1) musculoskeletal dysfunction because this is what leads to a fall from a physiological standpoint and (2) dementia/confusion because this leads to the resident failing to follow safety instructions or get assistance.

Once a resident is assessed as being a fall risk, a fall prevention care plan must be developed.  One of the standard parts of most well-developed care plans is to anticipate resident needs.  Why? Because when a resident needs something and doesn’t have it on hand, they are likely to get up on their own, especially if the facility is one where the staff has a dodgy reputation for responding in a timely fashion.  For example, if a resident is seated in a chair and wants a blanket, a book, the remote for the TV or whatever, and if it is not on hand, they may just go to get it with the potential for disaster all the way.

In order to effectively, anticipate the resident’s needs, the staff must be able to effectively communicate with the resident or determine what those needs are.

The resident at issue was one with whom there was a language barrier between the staff and the resident.  The resident was recognized as a fall risk due to long term and short term residents and needing the assist of two staff with transfers.  On the night of this nursing home fall, the resident was found out of bed on three different occasions.  There was no attempt at toileting the resident while At 5:15 a.m., the resident was found on the floor on the bathroom.  She reported to her son that she got up and made it to the bathroom on her own and was getting up from toilet when she lost her balance and fell.  The resident was brought to the emergency room where she was diagnosed with a fractured hip.

This was a highly preventable fall.  This was a resident who was recognized as a fall risk given her memory deficits and her mobility issues.  She was demonstrating some degree of restlessness as shown by the fact that she was seen out of bed on three different occasions that night.  With that in mind, increased rounding was called for and making sure that her needs were addressed was called for but was not done.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Moweaqua Rehab resident suffers fractured hip in fall

Loft Rehab of Rock Springs resident suffers hip fracture in fall

Taylorville Skilled resident falls and breaks hip

Failure to activate chair alarm leads to fall and brain bleed at Pleasant Meadows in Chrisman

Resident at Hickory Point Christian Village suffers multiple fractures in fall

Resident breaks leg in fall from edge of bed at Jerseyville Manor

 

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

 

 

Symphony of Midway resident suffers fatal fall from window

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IDPH has cited and fined Symphony of Midway nursing home in Chicago after a resident there suffered multiple fractures and died after falling from a fourth floor window.

The resident at issue had multiple issues including a history of alcohol abuse and alcohol induced dementia.  As part of the care planning process, he was assessed as being at risk for anxiety related to change in life style, physical and cognitive decline, among other reasons.  he was also assessed as being at risk for impaired thought processes related to dementia.  He was also assessed as being at risk for elopement (or wandering from the nursing home) to disorientation, aimless wandering, and impaired safety awareness.

When a resident is assessed as being at risk for elopement, there are a series of steps which are regularly taken by the nursing home.  These included placing a device called a wanderguard on the resident which will cause an alarm to sound if the resident leaves a designated area; regular visual checks on the resident by the staff; and eliminating means by which the resident can exit the facility.   It goes without saying that having the resident leave the nursing home can expose the resident to harm in a wide variety of ways.

In the days leading up to the incident, the resident had been expressing increased levels of anxiety related to a wound on his heel.  During the days leading up to the incident, he was seen by the staff with the window open and the screen missing.  He told the staff that he just wanted to get some fresh air.  Normally, the extent to which a window could be opened was limited by a window lock.  The nurse alerted the maintenance staff who replaced the screen and saw that the window lock was in place.

During the days that followed, the resident was seen by a psychiatrist and a nurse practitioner.  He denied suicidal ideation to both of them and expressed a desire to be moved to a lower floor where he believed that he would receive better care.  His care plan was upgraded to include 15 minute visual checks by the staff as an elopement prevention measure.  The psychiatrist and nurse practitioner recommended that resident be moved to a lower floor as a safety measure but this was never done.

On the day of this nursing home fall, the resident was seen by the staff as late at 4:15 p.m.  During the investigation that followed, the resident was seen walking on the hall; and then going into his room where no one checked on him after 4:35 p.m.  At around 5:30 p.m., a neighbor called the nursing home to tell the staff that they had seen someone falling from a fourth floor window and that they had called 911.  The staff went outside and found the resident on the ground.

The resident was brought to the hospital where he was diagnosed as having suffered fractures of the right femur, both ankles, the left heel, an open fracture of the right upper arm, the left radius, and bilateral pelvic bones.  He died at the hospital the following day.

There are a host of issues with the care that this resident received.  One of the basic steps in preventing resident elopement is securing the physical environment.  If the window lock was not in place, this is a serious problem with regard to the resident’s physical environment.  Second, there were several checks missed on this resident during the last half hour to an hour before he went out the window – opportunities lost to discover him opening the window.  These are violations of the resident’s care plan.  Finally, there was a recommendation to put him on a lower floor which was ignored.  Part of the purpose this would have served would be to lower his level of anxiety because the resident was upset about his heel wound and believed her would get better care on a different floor.  The other purpose that would have been served is to reduce the height of the fall should the resident try to go out the window as he did here.  That is something that was likely the difference between an injurious fall and a fatal one.

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:

Multiple injuries in fall at Symphony at Midway

Breakdown in care results in broken leg at Chalet Living & Rehab

Resident wanders from Aperion Care Forest Park, drowns in river

 

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

 

 

 

Police fractures the skull of resident who wandered from Integrity of Smithton

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IDPH had cited and fined Integrity of Smithton nursing home after a resident wandered from the nursing home and was injured by the police.

“Elopement” is the technical term for wandering from the nursing home.  Generally, the residents who at risk for elopement or wandering suffer from relatively few physical impairments but have significant cognitive or mental impairments.  When they leave the nursing home, they are at risk for injury from falls, being hit by a car, being exposed to extreme heat or cold, or suffering injury from other people in the community.

The resident at issue suffered from dementia and schizophrenia with long-term and short-term memory loss.  He was assessed as being at risk for elopement and an elopement care plan was put into place which called for checks on the resident every 15-30 minutes.  Before the day of the incident, he has successfully wandered from the facility about five and half months earlier.  The staff also documented him attempting to exit the facility five days before this incident.

On the day of the incident, he was last seen by the staff at approximately 2:00 a.m. walking around the dining room with another resident.   At 4:47 a.m., am alarm went off at a home approximately 2.2 miles from the nursing home because the resident was attempting to enter the home.  The homeowner called the police who responded to the scene.  When the police arrived, the resident was walking through a nearby field next to a pond.  When the resident failed to comply with the officers’ instructions to show his hands, the officers tackled him and took him to the ground.  Another responding officer recognized the resident as living at the nursing home, so he was brought to the hospital for treatment.  X-rays showed that he suffered a fractured skull.

The police officers in this case did nothing wrong.  They responded to a call from a homeowner who described a dangerous situation – someone trying to get into her house.  When the resident did not comply with their instructions, they used non-lethal force to bring the resident under control.  Had they made a different decision or had the homeowner gone for a gun, this situation could have ended in tragedy.  Even though this did not have the tragic end it could have, this situation demonstrates the potential for danger associated with the residents wandering from a nursing home: either the police officers or the homeowner could have used greater force in responding to the resident’s actions, the resident could have continued walking and fallen into the pond, and so much more.

The investigation of this incident showed that the staff last documented checks on the resident at 7 p.m.  He was seen by the staff up and walking about the facility including by the front door through out the night.  When the resident was found by the police, he had a jacket on.  For a resident who was a known risk for elopement, him wearing a jacket should have led to closer supervision of the resident.  Further, although the door was equipped with a door alarm, the alarm never sounded.

There is a long list of shortcoming in the care that this resident received.  His elopement risk was addressed in his care plan, but the steps that were required were not being implemented at the nursing home as there was no documentation of the required checks and he was gone for as long as two hours before the homeowner called the police.  Further, exit-seeking behaviors tend to be repetitive, and the fact that he had been attempting to leave just a few days earlier is something that the full staff should have been alerted to.  Finally, devices such as door alarms are the fail-safe to prevent injuries and deaths from residents wandering from the facility.  The citation did not establish why the alarm failed to sound, but a fail-safe must truly be a fail-safe to be effective.

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 wanders from Aperion of Forest Park, drowns in river

Resident wanders from Alden Long Grove

Resident wanders from Good Samaritan Society in Mt. Carroll

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

 

 

Hitz Memorial Home resident dropped from lift

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IDPH has cited and fined Hitz Memorial Home nursing home in Alhambra after a resident there fell from a lift during transfer, suffering a large hematoma which became an abscess.

Used properly, a mechanical lift is a great tool for use in a nursing home.  Used properly, it allows a resident to be transferred from bed to a chair, chair to wheelchair, to the toilet, etc., safely – for both the resident and the staff member.

The key phrase in the last sentence is “used properly,” because when a lift is not used properly, hazards abound which can result in serious injury to the resident.  “Used properly” includes using two staff members to assist with the transfer (see here, here, here, here, and here for examples of what happens when one person tries to do a two-person job) and making sure that the lift itself and the sling are in good condition, the right size for the resident, and properly attached to the lift.

The resident at issue apparently suffered from severe dementia because she was described as being functionally quadriplegic.  Her care plan called for total assist with mechanical lift transfers.

On the day of this nursing home fall, the resident was being transferred from her high-back wheelchair to bed using the lift.  There were actually three aides assisting with the transfer.  One operated the lift while the other two loaded the resident in the sling.  After the resident was positioned in the sling, one aide stepped away while the other pulled the wheelchair away, leaving the resident suspended in the air.  As they began to move the resident toward her bed, she slipped from the sling, landing on her left side.

The resident suffered significant bruising to her left side, on her arm and on her femur.  She developed a hematoma on the leg which became infected and formed and abscess, requiring treatment from a wound care nurse.  Eventually, this hematoma led the permanent disfigurement of the resident’s leg.

The investigation of this accident determined that the root cause of this fall was that the sling was too small for the resident.  I would add a second one: that there was no staff member controlling the resident in the sling once she was lifted from her wheelchair.  One aide stepped away while the other moved the wheelchair.  This meant that there was no one to stabilize the resident in the sling while the lift was being moved.  Sadly, this kind of fall more often results in more significant injuries such as a brain bleed or a fractured hip.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

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

Swansea Rehab resident fractures hip in fall

Integrity of Alton resident suffers fractured eye orbit in fall

Cedar Ridge resident breaks both legs in fall from bed

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

Failure to use gait belt at Jacksonville Skilled Nursing & Rehab

Fractured femur due to failure to use gait belt at Granite Rehab

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

 

Riverview Rehab resident chokes to death

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IDPH has cited and fined Riverview Rehab nursing home in Elgin after a resident there choked to death while being fed by an aide.

One of the functions that a speech therapist plays in the care of nursing home residents is assessing the resident’s ability to eat safely.  This is done by assessing the resident’s swallow function.  If there are issues with the resident’s swallow function, then the speech therapist will make recommendations for a modified diet and other safety precautions.   Left unaddressed, difficulties with swallowing can lead to a nursing home choking accident or aspiration pneumonia.

The recommendations made by the speech therapist are usually incorporated into the resident’s care plan or physician orders.  Either way, these precautions are critical to safety and well-being of the resident and must be carried out on a day-to-day, shift-to-shift basis.  Failing to do so can lead to disastrous outcomes.

The resident at issue was assessed by the speech therapist who determined that the resident was at risk for aspiration because of dysphagia (difficulty swallowing), brain injury, and communication deficits.   The resident was placed on a modified diet with mechanical soft foods and thickened liquids.  The resident had a history of eating very quickly, but was allowed to feed herself with supervision.  The staff was specifically instructed to make sure that the resident finished each bite and swallowed before taking the next one.

On the morning of the accident, the resident was being fed by an aide who was aware that she was at risk for aspiration.  The resident started feeding herself but was eating too quickly so the aide took the meal away and began to feed her.  However, the resident did not want to be fed, so the aide returned the tray to her and continued to watch her eat.  Gradually, the aide came to realize that the resident was “not looking good,” so she she went and got another aide who told her to get a nurse.  When the nurse arrived, the resident almost immediately lost consciousness, so the nurse cleared food from her mouth and began to do CPR.

911 was called, but when they arrived the resident had no pulse.  They were able to regain a pulse and brought the resident to the emergency room.  The resident was admitted to the intensive care unit, but the extent of the brain damage was so significant that the family placed her on hospice.  She died six days after the choking incident.  Cause of death per the death certificate was “Complication from aspiration of food bolus.”

There were many things that the nursing home did right here, but a couple of breakdowns in the care led to the death of this resident.  On the plus side, they got a proper assessment done of the swallow function and came up with a modified diet and steps to address her risk of choking.  The fact that the she was at risk for choking and what should be done was also properly communicated to the staff on the floor.

Where the care that this resident received failed was in two respects.  First, the tray was returned to the resident after she demonstrated impulsive eating behaviors and would not be fed by the staff.  The speech therapist and the Director of Nursing both agreed that the proper course of action here would have been to take the tray away, check the resident for pocketing of food, and alert the nurse.  Second, the aide failed to recognize that the resident was choking, failed to alert the nurse immediately (rather than another aide), and failed to take steps to clear the resident’s airway.  The minutes of delay when the resident’s airway was compromised was critical time lost to indecision.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Fondulac Rehab resident chokes to death

Sunset Rehab resident chokes to death

Fatal choking accident at Warren Barr North Shore

Fatal choking accident at Iona Glos

Resident chokes to death at Grove at the Lake

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

 

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

 

Lakeshore Rehab resident rolled out of bed, breaks leg

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IDPH has cited and fined Lakeshore Rehab & Healthcare nursing home in Joliet after an aide rolled a resident out of bed while providing incontinent care causing the resident to suffer a broken femur.

The resident at issue was described as a “larger lady” whose medical history included a stroke with residual left-sided weakness and a below the knee amputation on the right side.  This medical history is significant because it would significantly impact her bed mobility, or her ability to move around in bed and told keep a position in bed.  Because of this, she regularly received incontinent care with two aides – one to provide the care, the other to assure safe positioning in bed.

The resident’s care plan called for her to be provided with a valet bar which would give her something to hold onto grab to help her maintain position in bed.  However, this was never provided to her.

When the therapy staff was interviewed by the state surveyor, they were clear that one or the other – two staff or a valet bar – had to be provided to the resident to assure her safety and prevent her falling out of bed during incontinent care.  Sadly, neither was – with predictable results.

The aide who was assigned to care for the resident was a male who believed that he was strong enough to handle the resident on his own and had in fact done so before.  Interestingly, there were several staff members who knew that the resident did not want to be cared for by this aide because she considered him unprofessional because he would frequently sing, dance, and talk on his phone while caring for residents.

On the day of this nursing home fall, the resident was positioned onto her side, and when the aide went to pull the incontinent brief out from underneath her, she rolled from the bed and hit the floor.  The resident complained of immediate pain to the leg and was sent to the emergency room.

At the hospital, the resident was diagnosed as suffering from a fractured femur.  The family elected to not have surgery done, and the resident was placed in a cast which would be on for 6-8 weeks.  According to the citation, she complained of significant pain every time she was moved.  Past that, the immobility associated with the fractures places her at increased risk of developing additional problems such as bed sores or developing pneumonia.

This was a highly preventable injury.  There was a clear violation of the resident’s fall prevention care plan in that she was never provided with the valet bar that was called for.  Past that, providing incontinent care to a resident like this is always a two-person job regardless of how “big and strong” the aide is because there is still need for someone to help the resident maintain position in bed.  The results of having one person do a two-person job have been seen in this blog over and over (see here, here, here, here, and here for examples).

These failures – a long-running violation of the resident care plan, untrained and unprofessional staff delivering care to the resident speaks to systemic issues in the management of this 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:

Resident rolled out of bed at South Suburban Rehab

Brain injury after being rolled out of bed at Bria of Palos Hills

Resident rolled out of bed at Generations at Applewood

 

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

 

 

Niles Nursing & Rehab resident sustains fatal brain bleed in fall

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IDPH has cited and fined Niles Nursing & Rehabilitation Center nursing home after a resident there suffered a brain bleed in a fall which resulted in her death.

The care planning process is the fundamental method by which the routine care that is provided to residents in nursing homes is provided.  The whole point of the process is to make sure that the needed care is delivered to residents on a day-to-day, shift-to-shift basis.  In order to have an effective care plan, the components of it need to be reduced to writing and communicated to the staff charged with carrying it out.  Without this, the delivery of care is to a greater or lesser extent left to random chance, and that is never acceptable.

Unfortunately, that is what happened with this resident – and with disastrous results.

The resident at issue had been assessed repeatedly as being at high risk for falls due to ataxia (a degenerative condition of the nervous system which impacts balance) , muscle weakness, poor cognition, and poor safety awareness, among other issues.  She also had a history of falls, and it is well-recognized that with nursing home residents, having a fall predisposes them to having additional falls.  There was a fall prevention care plan and the staff was expected to check on her frequently even though this was something that was not incorporated into the care plan.

On the day of the accident, the resident was left in the dining room unattended with a group of other residents.  This was confirmed during the IDPH investigation when the Director of Nursing admitted to the state surveyor that she checked the video surveillance tape and saw that there was no staff in the dining room at the time of this nursing home fall.  The resident stood up from her wheelchair, but then lost her balance and fell backwards, striking her head on the floor.

The resident was sent to the emergency room where she was diagnosed with a subdural hematoma, a form of brain bleed.  They decided to not proceed with surgery and she was discharged back to the nursing home where she died twelve days later.  Cause of death per the death certificate was subdural hematoma caused by the fall.

This situation is one which demonstrates what happens when essential steps needed to keep a resident safe are not incorporated into the care plan – they are not done on a consistent basis.  This was a resident who needed close supervision because of her impulsiveness, poor judgment for her own safety, and poor balance.  She simply could not be counted on to do the things she needed to do on her own to keep her safe.  However, keeping her closely supervised was not incorporated into her care plan, and as a result she was left unattended in the dining room and fell while trying to get up out of her wheelchair.

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:

Generations Oakton Pavilion resident falls, fractures hip

Short staffing leads to fall at Warren Barr North Shore

Wheelchair accident at Avanti Wellness

Warren Park Health & Living Center resident suffers brain bleed in fall in stairwell

Alden Valley Ridge resident breaks leg in fall

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

 

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

 

 

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

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IDPH has cited and fined Pearl Pavilion nursing home in Freeport after a resident there died of a pulmonary embolism brought about by the failure of the nursing home to authorize the purchase of an expensive blood thinner medication that had been ordered for him.

A pulmonary embolism is a blood clot that becomes lodged in the arteries in the lungs.  Usually these blood clots are formed in other parts of the body, typically in the legs, and then break off and travel to the lungs.  Symptoms of a pulmonary embolism include shortness of breath and chest pain.  The development of a pulmonary embolism is a medical emergency as they are often fatal without prompt medical intervention.   Use of blood thinner or anticoagulant medications is the main means of prevention of the development of blood clots that can lead to a pulmonary embolism.

The resident at issue was admitted to the nursing home from the hospital.  He had been admitted to the nursing home after being treated for a pulmonary embolism.  He suffered from a condition known as activated protein C resistenace (a condition which can increase the risk of developing blood clots which lead to a pulmonary embolism), and a history of transient ischemic attacks (“mini strokes”), and ischemic stroke (the kind of stroke caused by a blood clot to the brain).  In short, this was a resident who needed to be on blood thinner medications.

When the resident was transferred from the hospital to the nursing home, the doctor ordered that the resident receive an anticoagulant medication called apixaban twice a day.  However, when the resident arrived at the facility, the medication was not on hand.  The facility ordered the medication from the pharmacy but it was not delivered because it was expensive and required specific authorization from the nursing home.  This was never given.

Because the nursing home never authorized the purchase of the medication the doctor ordered, the resident did not receive that medication or any other anticoagulant during the three days that he was at the nursing home.

The Director of Nursing told the state surveyor that they were not aware of the issue until a week after the resident died.

When a resident arrives at a nursing home with orders to get a medication that is not on hand, there are a number of options available to the nursing home.  Completely failing to address the medical need that the medication is intended to address is not one of them.  The most obvious option is to order the medication.  The nursing home did so, but did not agree to pay for it, so they never actually obtained the medication.  Another option would be to contact the doctor an obtain an order for an alternative medication.  The nursing home never did that.  Finally, there is the option of sending the resident back to the hospital because they cannot provide the resident with the treatment he needs.

Over the course of three days, there were two separate times each day where the resident was supposed to receive his blood thinner during medication pass, but the nurse handling the medications did not give it to him.  There was nothing in the resident chart to suggest that these nurses raised the issue of the medication not being in stock with the administration of the nursing home.  There was nothing to suggest that they contacted the resident’s doctor to let him know that a patient who was at risk for developing blood clots was not getting the blood thinner that was ordered or any blood thinner at all.

On the morning that the resident died, an aide went into see the resident around 6:15 a.m.  At that time the resident was sweaty and clammy and complaining that he was having a hard time breathing.  He asked to have his blood sugar checked and it was 103.  The aide did what she was supposed to do, and reported this to the nurse.  In response, the nurse did not go to see the resident, but told the aide to get a set of vital signs.  The aide returned to the resident and took a set of vital signs.  When she went back in, he was complaining that his legs were killing him (a sign of blood clots in the legs) and was obviously having a hard time breathing.

At about 7 a.m., the resident called his sister and asked her to call the nursing home because one of his legs was hurting badly.  He was short of breath over the phone.  She called the nursing home but could not get anyone on the phone.

At approximately 7:50 a.m., the resident activated a call light to summon the nurse.  The nurse’s response was, “If he is well enough to turn his call light on, he can wait till I am done up here to see him.”  When the aide and the nurse returned to the room at 8:00 a.m., the resident continued to complain of leg pain, was having a hard time breathing and asked to be sent out to the hospital.   His blood sugar was rechecked and was over 320 even though the resident had refused breakfast.

After leaving the room, the aide asked the nurse whether the resident was going to be sent to the hospital.  In response, the nurse resulted in said, “I’m figuring that part out.”  The Director of Nursing told the state surveyor that around 7:30 a.m., she was told that the resident said that he didn’t feel good, was nauseated, and refused breakfast.  She claims to have told the nurse to make calls to the doctor and the resident’s family but these calls were never made.

At approximately 9:28 a.m., the aide was sent to the resident’s room to check his oxygen saturation level.  She found the resident lying in bed, pale and with no pulse.  She called for help and began to perform CPR.  911 was called at the paramedics arrived.  They attempted to revive the resident and brought him to the hospital where further efforts at resuscitation proved fruitless, and the resident was declared deceased.

The resident’s physician told the state surveyor that he never received a phone call from the nursing home about the resident.  Had he been called and told of the resident’s symptoms, he would have suspected a blood clot and told them to call 911 right away.  He further stated that the nursing home had the ability to send the resident directly to the emergency room.

There are at least three levels of failures that resulted in this nursing home medication error causing the wrongful death of this resident:

  1.  The nursing home never obtained the blood thinner medication that was ordered for the resident.  Obviously nursing homes are businesses and need to control their costs, so having a price threshold on medications is not an unreasonable thing to have in place.  However, failing to either authorize the purchase or otherwise address the issue is completely unacceptable.
  2. Over the course of three days, there were multiple medication passes that occurred without the resident receiving the blood thinner medication that ordered for him.  None of the nurses passing the medications those days brought this to anyone’s attention so that the issue could be addressed.  Failing to give medications which are ordered and doing nothing further is substandard nursing care.
  3. On the morning that the resident died, he was demonstrating a clear change in condition with the complaints of pain and shortness of breath.  Doctors are not in-house at nursing homes on a 24/7 basis, so nurses must serve as their eyes and ears and report to the doctors when a resident has a change in condition.  We know what the result would have been had the nursing staff reported the changes in this resident’s condition to his doctor – he would have recognized it as the medical emergency it was and instructed them to call 911.  This resident should have been in the emergency room 2-3 hours earlier which would have likely made all the difference.

Many of the nursing home cases we handle show this kind of pattern – multiple missed opportunities all along the way which would have avoided a catastrophic outcome.  Here, there were opportunities from the moment this resident came in the door up until the last hour or so of his life to avoid this outcome.  Missed opportunities yielding a tragic and avoidable outcome.

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.  This is one situation where this is sadly true.  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 receives wrong medications at Manor Court of Freeport

Failure to notify doctor of abnormal labs at Momence Meadows

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

 

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

 

Fall at Lexington of Orland results in facial fractures

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IDPH has cited and fined Lexington of Orland Park nursing home after a resident there sustained multiple facial fractures in a fall.

One of the basic requirements for the right kinds of care to be delivered to residents in a nursing home is that the staff who is charged with delivering it must know what is required, whether it is in the form of physician orders, the resident care plan, or facility policies and procedures.  Well-run nursing homes have systems in place which ensures that the staff is properly trained and know what each resident’s requirements are.  When the staff doesn’t know what is needed, the potential for disaster lurks.

The resident at issue had been assessed as a fall risk due to a multitude of issues including a history of falls, dementia, and impairments of the lower extremities.  There was physician order in place for the use of a bed alarm with the staff to check for placement and function.  Use of a bed alarm with checks for function was also incorporated into the resident’s fall prevention care plan.

On the night of this nursing home fall, an aide saw that the resident was getting out of bed.  She assisted the resident to the bathroom and then back into bed.  Notably, the bed alarm was not sounding when she was seen getting out of bed, but the aide also did not know that the resident required a bed alarm and the resident was not placed on a bed alarm when she was returned back to bed.  A few hours later, the resident was discovered on the floor near the foot of her bed.  No alarm had sounded.

The resident was bleeding from the face and was sent to the hospital where a CT scan showed that she had sustained multiple facial fractures as a result of the fall.  The injuries were significant enough that surgery would have been performed but for the resident’s age.

This was a fall which could have been and should have been prevented.  Bed alarms serve two purposes: one is to alert the staff that the resident was out of bed, the other to remind the resident that they are supposed to wait for help.  Failing to use an alarm deprived the resident of those opportunities to prevent the fall from occurring.  Further, since the resident was found at the foot of her bed, this is an indicator that the alarm would have been sounding for a fairly long period of time before she started to fall.  The failure to follow orders and the care plan led directly to this fall.

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

Violation of care plan leads to fall and broken arm at Bria of Palos Hills

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

Unsafe transfer at Alden Estates of Orland Park

Prairie Manor resident suffers brain bleed after being rolled from bed

Alden Courts of Shorewood resident breaks both legs during unsafe transfer

Resident suffers fractures in fall at Chateau Nursing & Rehab

 

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

Bella Terra Wheeling resident receives roommmate’s diabetes medications

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IDPH has cited and fined Bella Terra nursing home in Wheeling after a resident there received the diabetes medication for his roommate, resulting in an intensive care admission for severe hypoglycemia.

One of the basic tasks that nurses have is passing medications.  When they pass medications, nurses are trained to follow the 5 rights: (1) right patient, (2) right medication, (3) right dose, (4) right route, and (5) right time.  To complete these checks, they need to concentrate when they work and work without distraction.

The resident at issue was not a diabetic, but his roommate was.  One of the medications he was receiving regularly was Glipizide.  Glipizide has the effect of stimulating the pancreas to produce insulin which in turn drives down the blood sugar levels.  Low blood sugar levels results in a condition called hypoglycemia.  Severe hypoglycemia is a medical emergency and can cause significant injury to the brain if not corrected.

On the day that the resident was admitted to the hospital, the staff noticed that the resident was sluggish and non-responsive.  They checked his blood sugar levels and found that they were at 30.  They notified the doctor of the change in condition who ordered glucagon which was intended to restore his blood sugars to normal levels.  When the resident’s blood sugar levels dropped again, he was sent to the emergency room.

In the emergency room, they ran a drug screen on him which showed that he had been administered Glipizide.  Further investigation revealed that this was a medication which was supposed to be administered to his roommate.  The nurse who was responsible for administering the medications was suspended and then terminated.  The nursing home reported to the state that she had been observed pre-pouring medications and then writing room numbers on the cup and then talking on her phone while doing medication pass.  This is something that would be a source of distraction during the medication pass.

This was obviously a highly preventable nursing home medication error brought about by failing to verify that the medication was being given to the proper resident.  Staff training and enforcement of safe medication pass practices is really what was required to prevent this from occurring.  However, that requires investment in the staff.  Failing to invest in staff training 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:

Failure to properly administer medications at Landmark in Des Plaines

Failure to follow orders at Generations at Applewood

Resident receives wrong medication at Manor Court of Freeport

Alden Estates Huntley fails to give ordered antibiotic

 

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

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

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IDPH has cited and fined Casey Healthcare nursing home after a resident there fractured a hip in a fall after the nursing home failed to follow the resident care plan.

The resident care plan is the framework for how most routine care get delivered in a nursing home.  There are six parts to it: (1) assessment – threats to the health and well-being of the resident are assessed, (2) care plan – a series of steps or interventions are developed which are intended to address those risks and are assigned to various categories of staff members, (3) communication – the care plan in communicated to the staff charged with carrying it out, (4) implementation – it is carried out on a day-to-day, shift-to-shift basis, (5) evaluation – the care plan is evaluated on an ongoing basis to see if it is effective and meets the care needs of the resident, and (6) revision – if the care plan proves ineffective in practice or the care needs of the resident change, it  must be revised.

The resident at issue had been assessed as being a fall risk.  Part of the fall prevention care plan which was put in place called for the use of a personal alarm (a form of bed alarm) when the resident was in bed or in a chair and to check the function and position of it each shift.  On the day of the accident, staff heard yelling coming from the resident’s room.  When they responded, they found both of the resident at issue and her roommate on the floor.  The roommate had fallen and the resident went to help her, with the net result being that both ended up on the floor.  The resident had rotation and shortening of the leg on assessment – signs of an apparent hip fracture.  She was brought to the hospital where this was confirmed.

As part of the investigation into this nursing home fall, it was discovered that the personal alarm was not in use at all.  This was a violation of the care plan, and more importantly, it represented a lost opportunity to prevent this fall.  Had the alarm been in place and operating, when the resident got up to help her roommate, the alarm would have sounded.  This would have served to remind the resident that she should not be up, while at the same time alerting the staff that she was up unattended.  Given the length of time that it would have taken for her to get up from her own chair to get to where she was found on top of her roommate, the sounding of the alarm would have given the staff enough time to respond to prevent the fall.

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:

Odd Fellow-Rebekah Home resident suffers fatal brain bleed in fall

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

Resident falls from van at Casey Healthcare

Fractured hip in fall at Heartland of Casey

Fall from shower chair at Charleston Rehab

 

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

 

Taylorville Skilled nursing home resident falls and breaks hip

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IDPH has cited and fined Taylorville Skilled Nursing & Rehabilitation Center after a reside there fell and suffered a fractured hip.

The resident at issue was coded on her Minimum Data Set (MDS) as requiring the extensive assist of one with ambulation.  Extensive assistance means that the staff member provides actual weight bearing assistance with walking.  When this is done properly, it requires the use of a gait belt.  A gait belt is a large canvas strap that is applied around the midsection of the resident.  The staff member then uses the belt to control the resident and to control the rate of descent should the resident begin to fall.  The resident had also been assessed in the care planning process as being at risk for falls based on a number of factors including dementia, medication usage, dizziness, poor safety awareness, and a history of falls.

On the day of this nursing home fall, the resident was in the dining room and got up, apparently to go to the bathroom.  An aide was standing nearby at the time of the fall believing that the resident required only supervision.  No gait belt was applied to the resident, and when she started to fall, the aide tried to stop the fall by grabbing at the resident’s pants.  The resident fell to the floor and was later diagnosed as having suffered a fractured hip.

There are at least two issues with this fall.  First, the aide was not using a gait belt when the use of one was clearly necessary. Secondly, she did not know what the care plan for this resident required, as she believed that the resident was supervision only.  One of the parts of the care planning process is having a means whereby the plan is communicated to the staff who is required to care it out.  After all – having the world’s greatest care plan counts for zero if the people charged with carrying it out do not know what is supposed to be done.  If the care plan is not being properly communicated to the staff, it speaks to breakdowns in the basic delivery of care systems at this 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:

Loft Rehab of Rock Springs resident suffers hip fracture in fall

Auburn Rehab resident suffers fractured hip in fall

Resident fall at Walker Nursing Home

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

Taylorville Skilled resident suffers fractured hip after multiple falls

 

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

 

Staff at Hilltop Skilled Nursing fails to follow orders, Stage 4 bed sore results

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IDPH has cited and fined Hilltop Skilled Nursing and Rehabilitation in Charleston after the staff there failed to follow physician’s orders, resulting in a resident developing a Stage 4 bed sore on her heel.

While we often discuss in this blog how important care plans are in delivering the routine care that nursing home residents need, following physician orders is also something that is mandatory.  Failing to follow physician orders can be just as devastating.

The resident at issue developed a bed sore to her left heel.  A wound care physician was brought into manage her care.  He issued orders for the care of the wound, including use of heel protectors due to her immobility.  A heel protector is something that is used to reduce the incidence of bed sores on the heels and to promote healing of any bed sores already present by reducing pressure on the skin between the bed and bony portion of the heel and by eliminating the exposure to shear.

The care provided by the doctor was effective in healing the bed sores, and when the wound care doctor discharged the patient, he included an order to continue present skin care and breakdown prevention.  This would have included the use of heel protectors because they are used as tools for both healing and prevention of bed sores.  There was never any documentation of the use of heel protectors, and the Director of Nursing admitted to the state surveyor that the heel protectors which had been ordered were not used after the wound on the heel closed.

Approximately 2 weeks later, the resident was diagnosed as having an unstageable wound to the left heel.  The wound care physician did a bedside surgical debridement and determined that after all the dead tissue was removed, that it was a Stage 3 bed sore.  Unfortunately, the wound continued to decline, requiring an additional bedside surgical debridement.  After that was completed, the resident was left with a Stage 4 bed sore on the heel – exposed muscle and/or bone.  Having a bed sore of this severity is significant for nursing home residents because it leaves the resident at greatly increased risk for an infection like osteomyelitis.

The resident’s attending doctor attributed the development of the bed sore to the failure of the staff to use the heel protectors as ordered.  Nursing homes often defend bed sore cases by claiming that the bed sores were unavoidable due to the chronic medical conditions of the resident but the statement from the physician.  The fact that this resident had sores which healed is also significant because it tends to show that there were no real biological impediments to healing which undermines the idea that the chronic medical conditions doomed this resident to suffering 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:

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

Resident develops bed sore at Nokomis Rehab

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.

 

Failure to adequately report changes in condition at Heritage Health in Carlinville

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IDPH has cited and fined Heritage Health nursing home in Carlinville after a resident died from acute metabolic encephalopathy due to sepsis from a urinary tract infection.

One of the ways that nursing home care differs from a hospital is that there are not doctors on hand on a 24/7 basis.  When there is not a doctor on hand, it is part of the function of the nursing staff to serve as the “eyes and ears” of the doctor and report changes in the resident’s condition.  When things happen such as a resident having a nursing home fall, developing a bed sore, having abnormal labs, or  a medication error, it is part of the job of the nursing staff to let the doctor know what happened.

Outside of clearly defined events such as that, it is also part of the nursing staff to notify the doctor of changes in condition, which can be a bit more subtle, but just as important.  Examples of this would be increased lethargy, increased confusion, or other changes in mental status.

When the doctor receives a report from the nursing home staff, the doctor has four basic options: to decide to come in to see the resident himself, order the resident sent to the hospital, issue orders for the nursing staff to carry out, or to make no orders at all.  Whatever choice is made,  the fact of the communication with the doctor and the response of the doctor should be recorded in the resident chart.

Of course crucial to all of this is the substance of what was communicated to the doctor.  If the pertinent information is not communicated to the doctor, then that can result in poor decision-making by the doctor with the net being loss of opportunity to help the resident when help is needed most.  And this brings us to this citation issued by IDPH …

The resident was admitted to the nursing home after apparently breaking her right leg in a fall.  At the time of her admission on through the first several days of her admission, she was assessed as being cognitively intact, alert and oriented x3.  However, she began to complain of significant pain apparently from muscle spasms on the side with the broken leg.  The nurse practitioner prescribed Ropinrole to address the pain complaints.

The second day after the Ropinrole was started she began to demonstrate changes in mental status.  One nurse noted that she demonstrated forgetfulness.  Her daughter arrived in the facility and her mother told her that she was seeing bugs and ants which were not there, was seeing Cheerios on the floor, and that the ceiling black.  The nurse to whom the daughter reported this also noted that she was less responsive, more lethargic, and difficult to arouse.  She claims that she passed this information on to the nurse at the change of shift.

The nurse who had the next shift does not remember being told about hallucinations or anything out of the ordinary. She told the surveyor that she would have called the physician had she been told.  She was told by other family members the next day that they were concerned that the new medication was making the resident confused.  The Director of Nursing saw the resident later that day and there was discussion about the effects of the new medication.  She looked the medication up and saw that many of the symptoms that were being reported were listed as side effects for the medication.

The Director of Nursing called the doctor, and what was said is a crucial issue.  The Director of Nursing claims to have told the doctor about the reports of hallucinations, but he denied that, and his office record only noted a request to change her dose of pain medication and concerns over the side effects of the Roprinole.  The doctor told the state surveyor that had he been told of hallucinations earlier, he would have ordered her sent to the hospital sooner.

The day after this phone call, she had a set of routine labs drawn.  The results of this showed critically high abnormal scores.  This prompted another call to the doctor who ordered the resident transferred to the hospital.  At the local hospital, she diagnosed as suffering from Acute Metabolic Toxic Encepholapathy, a disease of the brain caused by a viral infection or toxins from the blood.  She was sent to a hospital in Springfield where she died five days later.  Cause of death was bacteremia from a urinary tract infection.

The key issues here relate to the substance and timing of the communication with the doctor.  The doctor made it clear that had he been told earlier that the resident was having hallucinations, he would have sent her to the hospital.  This goes all the way back to the first report by the family members to the nurse that the resident was seeing bugs and so forth, approximately 48 hours before she was finally sent to the hospital, and also to the call that was placed by the Director of Nursing approximately 24 hours later.

The fact that this was due to a urinary tract infection also deserves some attention that was not addressed in the citation by IDPH.  There are a number of other issues worth examination: was the resident using a catheter?  What were the vital signs?  Were there changes in the amount, color, or smell of the urine?  Were the complaints of burning while urinating?  These are questions that should be addressed in any competent investigation of the care that this resident received.

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:

Staff at Grove of Evanston fails to notify doctor of resident’s decline

Infection goes unnoticed at Helia of Belleville

Failure to give diabetes medication at Bridge Care Suites

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

 

Gardenview Manor resident suffers broken hip during unsafe transfer

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IDPH has cited and fined Gardenview Manor nursing home in Danville after a resident there suffered a fractured hip due to unsafe technique being used during a transfer with a mechanical lift.

Mechanical lifts are frequently used in nursing homes, and used properly, they can be a tremendous benefit to both residents and staff.  For residents, it offers a safe, relatively comfortable way of being moved from bed to chair and so forth.  For staff, it greatly reduces the risk of suffering injuries to their backs, shoulder, and knees from the physical strain of trying to physically lift a resident from place to place.  However, the key to this is “used properly” – as we have seen many instances where residents were badly injured as a result of one staff member attempting to transfer the resident alone instead of with two people as is required (see here, here, here, and here for examples).

For the staff to use the mechanical lift properly, they must be trained in the use of the lift.  Most nursing homes have training programs for staff to develop competency in using the lift.  At a minimum, this should include information which tracks the instructions for use in the owner’s manual or operations manual from the manufacturer.  Having staff not properly trained in the use of the lift is a formula for disaster.

The resident at issue was dependent on use a mechanical lift for transfers.  On the day of the accident, there were in fact two staff on hand to complete the transfer.  When two staff are being used (as should always be the case), one staff member has the responsibility of operating the controls while the other steadies the resident in the sling during the transfer.  The staff loaded the resident into the sling, and began the transfer.  As the resident was suspended in the air, the aide assigned to steady her had to move some bags out of the way of the path of the lift.  As she did so, the resident began to rock in the sling, leading the sling to topple over, causing the resident to hit the floor and suffer a fractured hip.

The investigation into this fall revealed a number of causes of this nursing home fall.  First, the resident’s both of the resident’s legs were positioned on one side of the lift mast.  This resulted in the resident’s weight being distributed on one side of the lift which reduced the stability of the lift.  Second, the resident was not lowered after being lifted from the bed.  A lower center of gravity also promotes stability during transfers.  Third, the legs to lift were not in the widest position which reduced the width of the base of the lift.  These three factors – weight distributed to one side, a high center of gravity, and a narrow base – placed the lift at risk of toppling over.

The last factor that led to the fall is that the aide on the sling had to let go of the resident during the transfer to clear bags out of the way.  One basic part of every fall prevention care plan is to keep floors and walkways clear of clutter and debris.  The overwhelming likelihood is that even with the bad technique being employed during the lift, this could have been accomplished without incident (which is different form being done safely) had the aide not had to clear things out of the way.

The poor technique used is the fruit of poor training of the staff.  Indeed when the state surveyor asked for records showing that the staff had training on the proper use of the lift, the administrator was unable to produce any.  Failing to invest in proper training of the staff is one way that nursing home ownership fattens its bottom line.  Sadly, poor training of the staff leads to poor care and poor outcomes.

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 suffers fatal brain bleed in fall at Pleasant Meadows Senior Living in Chrisman

Danville Care Center cited for unsafe transfer

Critical medication error at Gardenview Manor

Fall results in fractured kneecap at Country Heath in Gifford

 

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

Forest City resident pushed to ground, fractures hip

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IDPH has cited and fined Forest City Nursing & Rehab Center in Rockford after a resident there was hit and pushed to the ground by another resident, suffering a fractured hip and broken ribs.

One of the surprising things about nursing homes in Illinois is the number of younger people who reside in them.  Some of have long term medical conditions which leave them truly debilitated and in need of ongoing care.  Others suffer from forms of mental illness which is significant enough that they need a structured living environment and ongoing supervision and services, but have relatively few true physical disabilities.  Where this can present a powder keg is when the younger resident decides to lash out physically toward a geriatric resident who, due to physical and/or mental disabilities or limitations is unable to protect themselves and especially susceptible to sustaining injury.

This is what occurred here.  The aggressor was at the time of the incident 31 years old and suffered from a list of mental health conditions, including bipolar disorder, autism, cognitive communication deficits, and insomnia.  On the day of the assault, the victim was saving a chair for a friend in the dining room when the aggressor attacked him.  As a result, he suffered a fractured hip which required surgical repair and broken ribs.

The fractured hip places him at increased risk for developing bed sores due to loss of mobility and at increased risk of experiencing further nursing home falls.  Further, the broken ribs can cause diminished respiratory effort which can set the stage for developing pneumonia.  These are significant injuries for a nursing home resident to suffer.

What was at once fascinating and disturbing about the situation is what followed this resident-on-resident assault.  Nursing homes are required to run criminal background checks on resident at or before the time of admission.  The nursing home ran a check on the aggressor at the time he was admitted to the nursing home (about 6 weeks before the assault), but they entered the wrong date of birth while doing the check, and as a result, the background check came up “clean” – no criminal background.  Had the proper date of birth been entered, it would have shown two separate charges of aggravated battery with the victim 60+ in the last year as well as a number of other felony assault charges dating back to 2005.   And while the facility could claim to not have known about the criminal history because of the failed background check, one physician progress note before this assault noted that the resident reported that he was going to court later that day for having assaulted someone in the past.

While the failed background check is troubling and an obvious failure on the part of the nursing home, what is even more disturbing is the response to this incident by the nursing home:

  • 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.”

One of the basic commitments that nursing homes make is to do the things that are necessary to keep its residents safe.  If a nursing home is going to admit a resident to the facility who has a history of assaulting senior citizens, this needs to be addressed in the resident care plan which would include frequent, detailed monitoring of the resident’s behavior for signs of aggressive behavior.  Because of the failed background check, when this resident was assessed for aggressive or harmful behaviors, he was scored as a moderate risk, in part because the portion of the assessment which considered his history of criminal behavior was scored as a zero, which was obviously not true.  Poor assessments lead to poor care plans which lead to bad outcomes.

The more telling (and disturbing) statement was the one from the Director of Nursing where she said that the nursing home would have admitted him anyway, even knowing of the history of having assaulted two other people over the age of 60.  Nursing homes are one of the few explicitly for-profit sectors of the health care industry, and part of their revenue depends on keeping beds filled so that they can be paid their per-day fee from whatever entity is footing the bill.  The proper course for a nursing home is to decline the admission of the resident when they are not able to meet the care needs of the resident or when that admission jeopardizes the health and safety of the other residents of the facility.

The fact that this resident would have been admitted even with the pending battery charges against victims who were 60+ tells you that the business considerations, not the safety of residents drives decision-making in this 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:

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.

 

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