IDPH has cited and fined Havana Health Care Center after a resident there suffered a painful infection of both testicles.
The resident at issue was experiencing ongoing scrotal pain, so he was seen by his primary care physician at the nursing home. After assessing the scrotal pain, the primary care physician ordered an ultrasound of the resident’s testicles and scrotum area to try to determine the underlying cause.
Unfortunately, the facility staff failed to properly schedule and complete the ultrasound as ordered by the physician.
Over a month went by without the diagnostic ultrasound being performed.
The resident’s scrotal pain then significantly worsened to the point that he was crying in pain and had to be sent to the emergency room for evaluation.
The ER doctor found that the ultrasound ordered nearly a month before had never been completed by the nursing facility staff. The ER doctor knew the resident well as a patient and noted this was abnormal behavior for him.
A bedside ultrasound was then urgently completed in the ER, which showed the resident had epididymitis, or inflammation of the testicles.
This would have been detected sooner if the ultrasound had been done when originally ordered by the primary care physician. The ER doctor confirmed that having the earlier ultrasound would likely have allowed them to diagnose and start treating the infection sooner with antibiotics, which could have prevented the resident’s pain from escalating to the point that he was in tears.
Assuring continuity of care is a critical part of helping nursing home residents maintain their health and well-being. Nursing home residents are almost always suffering from some condition of ill-being whether it is acute, as may the case with patients admitted for short-term rehabilitation, or may suffer from long-term chronic medical conditions. The common thread between them is that these conditions are being managed by a physician who is relying upon the nursing home staff to implement the care that they have ordered. When they do not, significant suffering, or worse, can result.
Nursing homes are businesses, and well-run businesses have systems in place to carry out their basic functions. Assuring continuity of care is one of those basic functions. Here there was clearly a problem with the system that the nursing home was operating under, as the sonogram ordered for this resident was not administered when the primary care physician ordered it.
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.
Nurse Fails To Complete Report, Notify Doctor & Family In Timely Manner After Resident Falls At Fairhaven Christian Retirement Center
IDPH has cited and fined Fairhaven Christian Retirement Center after staff members failed to assess and provide adequate pain medications in a timely manner to a resident after a fall that resulted in multiple pelvic fractures and that required hospitalization and surgery.
Maintaining continuity of care from the staff members of the night shift to the staff members of the day shift is critical for the safety and well-being of a resident. When a nurse or an aide fail to communicate the status of a resident, or fail to complete the work they are responsible for prior to leaving for the day, residents can suffer.
On the day of this nursing home fall, the resident was in the common area sitting in a recliner with her feet up from about 5:00 AM so staff members could keep a closer eye on her. A nurse reported to the investigator that around 6:15 AM or 6:30 AM she was at the other end of the hallway finishing her rounds when she saw the resident standing at the recliner holding the alarm box in her hands. The nurse said that the resident was taking stumbling steps forward and backward and was very unsteady. The nurse further said she yelled to the resident and ran toward her but could not get there in time. When she did get to the resident she was moaning and groaning in pain on the floor.
After assessing the resident, a night shift nurse made the decision that there were no major injuries and that the resident could be assisted from the floor back into the recliner.
This same nurse then proceeded to complete one half of an incident report, before handing off the report to a nurse that had arrived for the morning shift. Importantly, the night shift nurse did not complete the incident report, did not complete any charting, and did not notify the resident’s family or doctor of the fall.
Nearly three hours passed before a LPN (Licensed Practical Nurse) notified the DON (Director of Nursing) and the family of the fall. The DON instructed the nurse to order an x-ray, which subsequently showed multiple pelvic fractures. The resident was then sent to the ER with subsequent hospitalization and surgery.
The reason that this delay in treatment occurred was the failure to follow the system for completing incident reports that was in place. In this facility the nurse that begins an incident report is usually responsible for completing it in full and making the appropriate notifications to other doctors, family and staff members. The deeper question is why the system wasn’t followed. Investigation by IDPH revealed that the nurse who failed to complete the incident report and make the appropriate notifications was an agency nurse, or a temp. We tend to see a lot of agency nurses in facilities where they have hiring and retention problems, generally due to low pay and heavy work loads. Temporary staff can help address this, but there is little chance to ensure that they are trained in the systems and processes that must be followed for the consistent delivery of routine care.
In the end, this was an injury that was a product of the nursing home business model, where understaffing of the nursing home and lack of investment in the staff are cardinal features – and this is because those kinds of expenses cut into the bottom line.
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.
Bethany Rehab resident suffers brain bleed and seizures due to medication error
IDPH has cited and fined Bethany Rehabilitation and Health Care Center nursing home in DeKalb after a resident there suffered a brain bleed and seizures due to a medication error regarding the administration of his coumadin.
Many nursing home residents take anticoagulant or “blood thinner” medications. Used for a variety of purposes such as a history of blood clots, atrial fibrillation, stroke prevention, and management of other circulatory and cardiac conditions, this class of medication can be crucial for maintaining the health and well-being of the resident for whom the medication was ordered.
However, the use of this medication has to be carefully managed. If the blood is considered “too thick,” or subtherapeutic, it can lead to blood clots which can have catastrophic consequences; if the blood is “too thin,” or supratherapeutic, this can lead to uncontrolled bleeding.
To ensure that the resident remains in the desired or therapeutic range, the resident must receive regular blood testing called a PT/INR test which measures whether the blood is in the therapeutic range. If the blood is outside the therapeutic range, then the nurse must contact the doctor to notify him that the resident had an abnormal lab result. From there, it would be up to the doctor to make adjustments in the dosing of the blood thinner medication or to take other steps to treat the condition.
The resident at issue had a medical history which included atrial fibrillation, a stroke, and a pulmonary embolism – all conditions for which use of a blood thinner was warranted. The blood thinner which was used for him was coumadin and was being managed by a coumadin clinic.
The resident was seen at the coumadin clinic which gave orders that the resident should receive 5 mg of coumadin on Mondays and 2.5 mg of coumadin every other day with a PT/INR test to be done in weeks. When he was seen in the coumadin clinic, his INR level was 3.0, which was the high end of the normal range.
However, when the orders were entered into the record at the nursing home, it provided for the resident to receive 5 mg of coumadin on Monday and 7.5 mg of coumadin all other days. This means that the resident received three times the prescribed dose 6 days a week for a two-week period.
When the PT/INR test was scheduled to be performed at the end of the two weeks, the machine would not give a reading. A call was placed to the doctor and an order was received to redraw the blood the following morning. When the test was run again the following day, the lab called back stating again that the results were inconclusive. Plans were made to redraw the lab again the following morning.
The next morning, the resident started to show slurring of his speech which was getting progressively worse. The nursing staff paged the physician and nurse practitioner, but when they were not able to get a response, they called 911 and had the resident sent to the hospital. There labs were drawn which showed a prothrombin time (PT) of 181.5 (normal is 19.7 – 28.8) and an INR score of 21.54 (normal is 2.00 – 3.00). A CT scan of the head showed that the resident had a left-sided subdural hematoma. Following this, the resident demonstrated loss of cognitive function and suffered seizures.
Continuity of care is a critical issue in the long-term care setting. Residents are often seen by outside providers who issue orders for the ongoing care of the resident with the expectation that those orders will be carried out as specified. When that does not happen, disaster awaits. Here, the order were for the resident to receive 2.5 mg of coumadin every day other than Monday when he was supposed to receive 5 mg. The issue arose when the orders were not entered into the record correctly and the resident received 7.5 mg dose the other 6 days of the week. This led directly to the brain bleed sustained by the resident with catastrophic results for him.
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 give blood thinner leads to death of resident at Warren Barr Oak Lawn
Pearl Pavilion resident dies of pulmonary embolism after not receiving blood thinner
Hillside Rehab resident dies of brain bleed due to failure to obtain lab work
Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
Fondulac Rehab resident chokes to death
IDPH has cited and fined Fondulac Rehabilitation & Healthcare Center nursing home in East Peoria after a resident there was fed the wrong kind of diet and left unsupervised during dinner.
One of the lesser known risks to the health and well-being of nursing home residents is the risk of choking while eating. There are a variety of reasons that a resident may be at risk for choking including advanced dementia, behavioral issues that lead the resident to cram food in their mouths, or neuromuscular issues which impair the swallowing process. Most often, these are diagnosed following an assessment by a speech therapist. They are then addressed through the care planning process and physician orders which call for supervision while eating and therapeutic diets which which are intended to reduce the risk of choking.
The resident involved was initially admitted to the nursing home with orders for a general diet. However, after a hospital visit, she was readmitted to the nursing home with transfer orders for a therapeutic diet consisting of a mechanical soft diet with nectar thick liquids. Her care plan called for assistance of one while eating due to poor safety awareness, cognitive deficits, forgetfulness, and poor mobility. The care plan did not include the therapeutic diet. Further, the her diet orders did not include the therapeutic diet, so she continued to be fed a general diet.
On the night of this fatal nursing home choking accident, the general diet being fed to residents consisted of Salisbury Steak and other items. Due to covid precautions, all of the residents were being fed in their rooms, rather than in the dining room. The aide assigned to the resident brought the tray to the room, cut up her food, fed her a bite, and then went to deliver meal trays to other residents. As the aide came back up the hallway, she saw that the resident was blue. She got a nurse, and they pulled the resident from bed and began CPR. 911 was called and paramedics took over the resuscitation efforts, but those efforts were unsuccessful and the resident was pronounced deceased.
An autopsy was performed, and the cause of death listed on the death certificate was aspiration of food.
There are at least four issues with the care that this resident received:
- Continuity of care – We have written several times about how critical it is for the well-being of residents that the transfer orders that were in place for the resident upon discharge from the hospital be carried forward into the nursing home (see here, here, here, and here for examples). Nursing homes are businesses, and well-run businesses have systems in place to make sure that the routine and necessary operations of their business are carried out. Ensuring continuity of care is one of those operations, and this was not done here as the order for the therapeutic, mechanical soft diet was not implemented. As a result, the resident was fed the Salisbury Steak that she choked on.
- Failure to implement care plan – This resident’s care plan called for assistance of one with eating. After the tray was served to her she was left unattended and unsupervised. While she was alone, she choked. The whole point of incorporating the supervision while eating was to prevent just this kind of accident.
- Understaffing of the nursing home – All of the residents in the facility were eating in their rooms as a covid precaution, and aides were forthright with the state surveyor that they simply did not have enough people on hand to supervise all of the residents who needed help eating while they were all being served with in their rooms. Federal regulations require that nursing homes have enough staff on hand to meet the care needs of the residents 24/7. As a one aide put it, “We do not have enough staff to accommodate all those people that are being quarantined in tehri rooms that need assistance while eating. We normally only have about one or two people available to watch over the residents that need supervision with eating. None of the nurses or management staff help us, and it would be nice if they did.”
- Quarantine – The policy in place at the time was that is there was a positive case in the building (which there was), then all of the residents were quarantined, regardless of covid positive status. Not only is that sort of isolation harmful to residents, but in the case of residents who require supervision, it makes it difficult to impossible to provide the necessary supervision. Had the resident involved been allowed to eat in the dining room, she likely would have been seated at a feeder table where she would be fed under the direct supervision of staff, and this fatal accident would have been avoided.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
Other blog posts of interest:
Aperion of Spring Valley resident chokes to death
Fatal choking accident at River Bluff nursing home
Heartland of Moline resident develops pneumonia due to failure to follow diet orders
Sunset Rehab resident chokes to death
Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
Failure to give blood thinner leads to death of resident at Warren Barr Oak Lawn
IDPH has cited and fined Warren Barr Oak Lawn nursing home after a resident there died from a massive pulmonary embolism caused by the failure to give a blood thinner medication as ordered.
Maintaining continuity of care from a hospital to a nursing home is critical for the safety and well-being of a resident. When someone is admitted to a nursing home from the hospital, they are generally recovering from a significant injury, illness, or surgery and have significant near-term and long-term needs. Special care has to be taken to make sure that the care needs that the doctors and staff at the hospital have determined that the resident requires are being met during the initial stages of the resident’s admission.
When a resident is admitted to a nursing home from a hospital, the nursing home receives a list of medications that the resident is supposed to be receiving. That list is supposed to be verified with the providers at the hospital and then double-checked by a second nurse at the nursing home to ensure that all orders, including medications, are correctly entered into the resident’s chart. When this process does not happen, there is an increased risk that the resident will either not receive a necessary medication or be given a wrong medication or the incorrect dose of a medication that was ordered.
This kind of nursing home medication error can have catastrophic consequences, and that was the case here.
The resident at issue was admitted to the nursing home after having spinal surgery following a fall at home. When the resident was discharged from the hospital to the nursing home, there was an order in place for him to receive heparin, a blood thinner. Many patients will receive a blood thinner after a major surgery to prevent the developments of blood clots – a complication which is known to occur following major operations. This is especially true when the patient has significant mobility deficits, as was the case here.
However, when the resident was admitted to the nursing home, the order for heparin was not copied from the discharge papers onto the patient’s medical record. As a result, during the twelve days that the resident was in the nursing home, he did not receive a single dose of the blood thinner that was ordered.
On the twelfth day of his admission, the resident had episodes of vomiting and had a fixed stare. The nursing home staff had the resident sent to the hospital, where it was discovered that he had a massive pulmonary embolism, or a blood clot that became lodged in the lung. A pulmonary embolism can lead to cardiac arrest and death. Sadly, that was exactly what happened in this case, as the resident died later that day. Cause of death according to the death certificate was massive pulmonary embolism and cardiopulmonary arrest.
Well-run businesses run on systems, and a nursing home is a business. This nursing home actually had a system in place similar to the one described above. Unfortunately, it was not followed, leading to this very preventable medication error.
The obvious reason that this medication error occurred was the failure to follow the system that was in place. The deeper question is why the system wasn’t followed. Investigation by IDPH revealed that the nurse who made the mediation error was an agency nurse, or a temp. We tend to see a lot of agency nurses in facilities where they have hiring and retention problems, generally due to low pay and heavy work loads. Temporary staff can help address this, but there is little chance to ensure that they are trained in the systems and processes that must be followed for the consistent delivery of routine care.
In the end, this was a death that was a product of the nursing home business model, where understaffing of the nursing home and lack of investment in the staff are cardinal features – and this is because those kinds of expenses cut into the bottom line. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
Other blog posts of interest:
Catastrophic brain injury results from medication error at Alden Town Manor
Diabetes medications not given at Alden Estates of Orland Park
Failure to give anticoagulant medication at H&J Vonderlieth Living Center
Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
Moweaqua Rehab resident develops pressure ulcer from fracture brace
IDPH has cited and fined Moweaqua Rehabilitation & Healthcare Center nursing home after a resident there developed a pressure ulcer from a fracture brace.
The resident at issue was admitted to the nursing home after suffering a fracture to her femur. The resident was sent to the nursing home with a brace which was intended to immobilize the fracture.
One of the times that is fraught with risk for a nursing home resident is when a resident is admitted to a nursing home from the hospital. Typically, there are specific orders sent with or in advance of the resident’s arrival at the facility for the resident’s general medical needs as well as the specific medical issues that had the resident in the hospital to begin with. The reason that this is a time of high risk for the resident is that orders may be omitted or mis-transcribed. This can lead to things like nursing home medication errors or needed care not being delivered.
When the resident arrived in the nursing home, there were no orders in place with regard to the fracture brace – where it should be positioned, how long it should be on, how it should be padded, how skin checks should be performed. Bed sores are also known as “pressure ulcers” or “pressure sores” because one of the main causative factors is pressure from the skin. With bed sores, that is usually pressure put on the skin by the weight of the body against the resting surface (usually a bed or chair). When a resident is wearing a brace, cast, or other medical appliance, the pressure is between the skin and the medical device. With things like a splint, brace, or cast which is being used to treat a fracture, this is especially true because the device is intended to be on tight enough to immobilize the fracture site.
Two days after the resident was admitted to the nursing home, an aide saw that the brace was on the resident’s lower leg and that there was blood. She brought in the nurse who removed the brace and saw that there was an indentation from pressure from the brace. There was a wound just above the ankle and measured 10.5 cm x 4 cm with drainage and a foul odor. This wound was caused by misapplication of the brace. Eventually the wound declined to the point that there was exposed muscle and ligaments.
Due to the her immobility, the resident was also supposed to have been placed on a turning and repositioning schedule, but was not. As a result, she also developed bed sores to her heel and sacral area.
The proper course of action when this resident was admitted to the facility would have been to call the doctor to obtain orders for care. The resident was admitted with a readily obvious medical device in place. This should have prompted the nurses to ask, “What do we need to do to take care of this?” This simple question was not asked, and as a result, necessary care – proper placement of the brace, proper padding and pressure relief, inspection of the skin – was not done with disastrous results.
When nursing home staff does not have time to think to ask basic questions needed for proper care of the residents, that is a sign of an understaffed nursing home. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
Other blog posts of interest:
Newman Rehab resident suffers burns to leg from hot radiator
Mattoon Rehab resident dies from infected bed sore
Failure to obtain treatment orders leads to infection of surgical wound at Loft of Canton
Oak Brook Care resident develops pressure ulcer from immobilizer
Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
Infection results from failure to provide care for surgical wound at Arcadia Care of Morris
IDPH has cited and fined Arcadia Care of Morris nursing home after a resident there developed an infection of a surgical wound for a hip fracture, requiring IV antibiotics and a surgical debridement.
The resident at issue was admitted to the nursing home for post-operative care after suffering a broken hip in a fall. There was a surgical wound incision that had been closed with staples, and the resident was supposed to be seen in the surgeon’s office for removal of the staples in 1-2 weeks.
That didn’t happen – because the nursing home staff seems to have failed to recognize that there was a surgical wound, despite the fact the resident was being admitted for post-operative care.
When a resident is admitted to a nursing home from a hospital, there are a number of steps that must be taken. One of these is to take the discharge instructions and orders and have them added to the resident’s chart with the resident’s attending physician giving orders for care. This helps assure continuity of care – that the resident continues to get the care in the nursing home that the doctors in the hospital wanted them to get. The order is a head-to-toe inspection of the resident’s skin. Part of this is to ensure that the resident is not arriving at the nursing home with bed sores that the nursing home might otherwise be blamed for, but also to ensure that if there is some defect in the skin, that proper orders are obtained for caring for that.
When this resident was admitted to the nursing home, that comprehensive skin assessment was apparently not done, as there was no documentation of that. There were also no orders for wound care obtained from the resident’s physician. The resident’s 1-2 week follow up appointment was not set. The resident care plan, which is supposed to address all of the risks to the health and well-being of the resident, did not address wound care. A single note, done a month after admission by the wound care nurse, documents that there was no injury to the skin.
Two days after the note was generated by the wound care nurse, and more than five weeks after the surgery, the resident was brought to the orthopaedic surgeon’s office. He removed the staples and sent the resident to the hospital because there was evidence that the surgical wound was infected, likely due to the length of time that the staples were left in place and the lack of dressing changes. The resident was admitted to the hospital to get IV antibiotics for the infection and to have a surgical debridement done of the infected tissue. The orthopaedic surgeon told the state surveyor, “I have had problems with that facility lately and am thinking of mot letting my patients go there anymore.”
There were a number of failures in the care that this resident received. First, there was a basic breakdown of the systems which assure continuity of care. Second, the admitting nurse and almost every nurse after that failed to assess the wound or recognize that treatment was not being provided for it. Third, residents’ skin is normally checked by aides during baths or showers and defects are reported on “bath sheets”. Either this was not done or no action was taken with regard to that. Fourth, the care planning process is intended to be a comprehensive review of the resident’s care needs, and yet, in the process of doing the care plan, the need for wound care and skin assessments was completely missed. The net result of this is that the resident suffered a surgical wound infection, which can be a very grim condition indeed if it requires removal of the orthopaedic hardware. Yet, this is the risk that this resident is being subjected to due to a lack of basic care provided here.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
Other blog posts of interest:
Flanagan Rehab resident develops infection from bed sore
Surgical wound infection at Regency of Morris
Untreated pressure ulcer at Aperion Care of Bradley
Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
Failure to obtain treatment orders leads to infection of surgical wound at Loft of Canton
IDPH has cited and fined the Loft Rehab & Nursing of Canton nursing home after a resident there developed a surgical wound infection due to the failure of the staff to obtain orders for the care of the wound.
Many persons who undergo surgery are sent to nursing homes for post-operative rehabilitation. Often part of the care is actual rehabilitation – therapy that is needed to get them “back on their feet” so that they can go home. However, a crucial part of the care that residents receive is directed toward making sure that residents receive necessary medications and lab work, that the surgical incisions are healing and free of signs of infection, and other aspects of care that are directed to making sure that nothing goes awry.
When residents are admitted to the nursing home from a hospital, there are transfer orders that go with the resident. Typically these will include things like the medications the resident is supposed to receive, treatments that the resident requires, labs that must be completed, and so forth. This assures continuity of care. When the resident is being admitted the nurse at the nursing home is supposed to review the orders with a nurse from the transferring hospital.
Additionally, when the resident is admitted to the nursing home, they undergo a number of assessments, one of which is a head-to-toe skin inspection. One of the reasons for the skin inspection is to check for the existence and condition of any bed sores or pressure ulcers. However, in the context of a post-surgical admission, this inspection is to check to see if there are signs and symptoms of infection to any of the wounds and to make sure that there are appropriate orders for care of the surgical wounds.
The resident at issue here was initially admitted to the nursing home after undergoing the removal of her parotid glands and a resection of her neck due to malignancy. However, she developed a post-surgical infection and had to be readmitted to the hospital.
When she returned to the nursing home, there were four surgical wounds present, including one which under her left breast but which was recorded in the chart as being a “chest” wound. That “chest” wound included a drain, staples, and a surgical dressing. However, there were no orders for the care of that surgical wound, and no one called the doctor or the hospital get orders for care.
As a result, the resident was in the nursing home for a week with no care being provided for the wound under her left breast. This continued until the surgical wound developed an odor, was red and inflamed, and was draining yellow and green fluid. The resident was also lethargic, said that she was not feeling good and having nausea. These are all signs of infection. The resident was brought to the hospital where the dressings were changed and the resident was placed on antibiotics. The surgeon also ordered a culture of the wound. When the cultures were completed, they showed that the wound to the breast as well as wound on her clavicle were infected with MRSA. The resident was sent back to the hospital for management of the new wound infections.
There were a number of shortcomings in the care that this resident received:
- It is unclear from the citation whether the “chest” wound recorded on the admitting assessment referred to the clavicle wound or breast wound. If the breast wound was missed all together, that is a complete failure on the skin inspection;
- There were very clearly no orders for the breast wound. When the skin inspection revealed that there was a breast wound for which there were no treatment orders, it was incumbent upon the nursing home staff to contact the doctor for treatment orders, just as physician notification is required when a resident develops a bed sore;
- After the resident was admitted, there were multiple shifts where no one seemed to recognize that there were no orders for the treatment of the breast wound. Multiple opportunities missed.
- Typically, the condition of a post-operative wound is recorded on a per shift basis. This is because a surgical wound infection is a serious matter which needs to be addressed promptly. The condition of the dressing when the nurses first noted the odor was described as being filthy, which means that there had likely been multiple shifts where either no one paid any attention to the breast wound or to the fact the dressing had not been changed.
In short, there were several levels of failure at the nursing home in the care of this resident, all of which led to a serious infection of the surgical wound. The resident had been admitted to the hospital for care for this, but this will likely require extensive use of antibiotics and likely surgical excision of the infected tissues. This is a situation which was made worse, not better by 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:
Heartland of Galesburg resident dies due to untreated urinary tract infection
Rushville Nursing & Rehab resident suffers untreated surgical wound infection
Failure to notify physician leads to resident death at Alden Estates of Barrington
Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
