The Law Offices of Barry G. Doyle, P.C.

Chicago Illinois Accident Lawyers

 CALL (312) 263-1080

Resident Nearly Suffocates Due To Lack Of Critical Breathing Tube Equipment At Aperion Care Elgin

By Leave a Comment

The Illinois Department of Health has cited and fined Aperion Care Elgin when they failed to maintain proper emergency tracheostomy supplies for a resident with a tracheostomy tube, resulting in delayed care during a respiratory emergency. The resident suffered from acute respiratory distress and had to be transferred to the hospital for treatment of acute respiratory failure after facility staff could not properly address a tracheostomy tube obstruction.

The resident in question was admitted to the facility with multiple medical conditions including a subarachnoid hemorrhage from an intracranial artery, ruptured aneurysm, acute respiratory failure with hypoxia, and had a tracheostomy (an artificial opening in the neck with a tube inserted to help with breathing). The resident was receiving supplemental oxygen at 6 liters via a trach collar.

This incident was not the first time the resident experienced problems with his tracheostomy. Less than a week before the emergency, the resident’s entire tracheostomy tube had become dislodged. A Licensed Practical Nurse (LPN) attempted to reinsert it but was unsuccessful, resulting in the resident being transferred to the hospital. The resident returned the same day with a new, smaller tracheostomy tube (changed from a size 6 to a size 4).

On the night of the emergency, the resident began experiencing low oxygen levels. The nurse administered a nebulizer treatment and then attempted to suction the tracheostomy but encountered resistance. When the nurse tried to change the inner cannula (the removable part inside the main tracheostomy tube), she also met resistance. According to the nurse, “I was not trained in changing entire tracheostomy tubes,” so she contacted the resident’s physician who ordered transfer to the hospital.

When emergency paramedics arrived, they found the resident’s oxygen levels were worsening. They attempted to ventilate and suction but also encountered resistance. The paramedic explained, “The protocol for when resistance is met with patients with tracheostomies is to change the entire trach tube.” When the paramedic asked the nurse if she had attempted to change the tube, she responded that she “was not trained to change entire trach tubes.”

The nurse provided the paramedic with a tracheostomy kit, but it contained the wrong equipment—an uncuffed tracheostomy tube without an obturator (a guide used to help insert the tube safely). Despite having inadequate equipment, the paramedics managed to change the tracheostomy tube and ventilate the resident before transferring him to the hospital.

At the hospital, the resident was admitted for “acute on chronic hypoxic respiratory failure.” Hospital notes indicated “EMS attempted to change the inner cannula, but they did not have the proper equipment; however after the clogged inner cannula was removed his SpO2 improved.” The hospital report continued: “Upon arrival to the ED he presented with stable and appropriate vitals but he quickly became hypotensive and hypoxic. His trach was connected to mechanical ventilation.”

An inspection of the resident’s bedside supplies revealed serious deficiencies. A box of size 6 inner disposable cannulas at the bedside had expired nearly a year earlier. The nurse acknowledged that “tracheostomy equipment should be checked and disposed of when expired.” More concerning, there were no emergency tracheostomy exchange kits for the resident. The nurse confirmed that residents with tracheostomies required emergency exchange tube kits with an obturator “for emergency situations at the bedside.”

The Respiratory Therapist Manager, who provided consulting services to the facility, confirmed that residents with tracheostomies required specific emergency equipment at bedside, including “trach tube kits with the same type of trach tube and an obturator.” She specified the kits should include “one of the same size and a downsized one” and that equipment “should be checked routinely to ensure safe trach care is being provided.” She also noted that licensed nurses could change tracheostomy tubes “if there was a doctor’s order and if they were trained appropriately.”

The Director of Nursing confirmed that when the resident returned from his previous hospital visit, his tracheostomy tube had been replaced with a smaller size 4 tube. She stated the facility expects nursing staff to ensure residents with tracheostomies have the required emergency supplies at bedside, including kits with a tube of the same size, a downsized tube, and an obturator. Importantly, she stated she “expects nurses to be able to change entire trach tubes monthly as ordered and during emergencies.”

The resident’s care plan specifically included “TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside.” Furthermore, the resident’s orders clearly stated “Trach: Licensed nurse may re-insert trach tube, as needed for dislodgment” and “Trach: Change Trach tube every day shift every 1 month(s).”

The facility’s Admission Data Form for tracheostomy patients specified that equipment needed included “one same size trach and one downsized trach at the bedside at all times.” However, the facility’s Tracheostomy Care policy contradicted this by stating: “Emergency Care: If outer tube comes out, stay with resident and summon assistance. A rubber tipped hemostat maybe used to maintain opening. If necessary, suction the resident through the opening. Physician generally responsible for reinserting new tube.”

This conflicting policy may have contributed to the nurse’s belief that she was not authorized to change the tracheostomy tube, despite having physician’s orders permitting her to do so. The policy also did not provide instructions on how to perform the procedure, suggesting inadequate training for staff on this critical emergency procedure.

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

Resident Dies From Respiratory Distress When Facility Fails To Realize Urgency Of Situation At Bria Of Elmwood Park

By

IDPH has cited and fined Bria of Elmwood Park when the facility failed to respond urgently and quickly to a resident’s respiratory distress and need for suctioning, resulting in a delay of care and ultimately the resident’s death.

Around 9:00 AM on the morning of the incident, a LPN (Licensed Practical Nurse) noticed the resident gesturing and pointing to his tracheostomy, indicating a need for suctioning. The LPN informed the Respiratory Therapist, who was working with another patient next door. Critically the LPN did not ensure that suctioning was provided immediately.

The Respiratory Therapist stated that she provided routine morning tracheostomy care, including suctioning, around 9:25 AM – 9:30 AM, noting that the resident was agitated before, during, and after the care.

At approximately 10:30 AM, a CNA found the resident unresponsive and notified the LPN, who initiated a code blue. During the resuscitation efforts, it was discovered that the resident’s tracheostomy tube was dislodged. Despite the staff’s efforts and the arrival of EMS, the resident was declared deceased at 11:07 AM.

One of the most significant shortcomings in the resident’s care was the nursing home staff’s inadequate response to his clear signs of respiratory distress. When the resident was observed gesturing and pointing to his tracheostomy, indicating an urgent need for suctioning, the LPN (Licensed Practical Nurse) failed to recognize the severity of the situation and did not take immediate action to ensure that the resident received the necessary care. This lack of urgency was a contributing factor to the delay in the resident’s treatment.

Furthermore, the Respiratory Therapist failed to prioritize the resident’s needs when informed of his distress. Instead of immediately attending to the resident, the RT continued with routine tracheostomy care for other residents, only reaching the resident nearly 30 minutes later. This delay in providing crucial suctioning support was problematic given the resident’s agitated state and the well-known risks associated with inadequate airway clearance in tracheostomy-dependent patients.

The nursing home’s substandard policies and insufficient staff training regarding respiratory care and suctioning also played a significant role in the suboptimal care the resident received. The inconsistencies in staff members’ understanding of their roles and responsibilities in responding to respiratory emergencies highlight the facility’s failure to ensure that its staff was adequately prepared to handle such critical situations. This lack of proper education and clearly defined protocols directly contributed to the confusion and delay in the resident’s care.

Moreover, the nursing home’s inadequate staffing levels and lack of proper monitoring equipment for residents with tracheostomies not connected to ventilators further compromised the resident’s safety. The facility’s decision to prioritize cost-cutting measures over resident well-being, by failing to provide sufficient respiratory therapists and neglecting to install necessary alarm systems to alert staff of potential tracheostomy dislodgement, created an environment in which the resident’s deteriorating condition went unnoticed until it was too late.

The culmination of these shortcomings in the resident’s care – the lack of urgency in care, the delay in providing necessary suctioning, the inadequate policies and staff training, and the insufficient staffing levels and monitoring equipment – resulted in the resident suffering from prolonged respiratory distress, ultimately leading to cardiac arrest and death. This tragic outcome could have been avoided had the nursing home fulfilled its fundamental duty to provide timely, competent, and attentive care to its 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. 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.

Resident Suffers Split in Penis As Catheter Care Goes Neglected At Caseyville Nursing & Rehab

By

IDPH has cited and fined Caseyville Nursing & Rehab Center after a resident there suffered a slit in his penis due to poor catheter care.

The use of catheters is discouraged under federal regulations for nursing homes, in large part due to the risk of the development of urinary tract infections.  However for males especially, there is a risk of damage to the urethra from prolonged catheter use.  A catheter is a thin tube which is threaded through the urethra into the bladder to allow urine to be drained from the bladder.  The risk of tearing of the penis comes from friction from the catheter and pressure from the tubing and collection device.

The resident in question suffered from numerous health issues and ultimately needed a catheter installed to help him urinate. On a daily basis nurses would have to care for his catheter and the surrounding area.

At first, the catheter made the resident’s penis skin red and sore. There was a care plan made that instructed nurses to watch the spot daily and protect it with ointment. But over many months, the nurses failed to consistently care for the area – oftentimes days would go by without checking the resident’s catheter.

Gradually, a cut formed on the tip of the resident’s penis.  The cut grew worse over time and spread all the way down his penis, eventually becoming an open slit. Nurses applied ointment to the cut but did not measure it or keep records of how bad it was getting.

One key mistake was that a nurse incorrectly thought the resident was in hospice. Hospice is limited to comfort care for people near the end of their lives.  In hospice the goal is not to heal injuries. So that nurse claimed since the resident was supposedly in hospice, he was not sent to the ER to get the worsening penis slit the medical care it required.

In reality, however, the resident had been removed from hospice care approximately 10 months beforehand. A hospice supervisor confirmed that there was no record of any penis injury for the resident while he was receiving care in hospice. So the resident could (and should) have been sent to the hospital to fix the issue at a much earlier date.

The bottom line – months of poor catheter site care allowed the penis wound to increase in size and worsen. Ignoring internal facility rules to check and care for the catheter wound allowed the injury to grow more severe. 

Finally, after 8 months, the resident had to have surgery to implant a new catheter and fix the fully split penis. 

The situation likely could have been prevented had the nurses been aware of the resident’s hospice status and if the nurses had followed catheter care policies on a consistent basis. 

Sadly, the resident endured much needless and preventable pain and suffering.

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.

Communication Failure Leads To Fall And Death At The Arc At Normal

By

IDPH has cited and fined The Arc At Normal after a resident fell and died after attempting to toilet on his own.

There is a framework for providing the vast majority of routine care in a nursing home setting.  This is referred to as the care planning process.  When it is done properly, the risk of residents suffering unnecessary injuries, falls  and wrongful deaths is greatly reduced.  However, oftentimes there are serious deficiencies in the care-planning process which sets the stage for disaster.

When the resident in question was admitted to the nursing home, the initial assessment listed the resident at a moderate risk for falls.  The only fall prevention intervention documented at that time was to make sure the call light was within reach.

The resident’s family, on the other hand, informed the admitting nurse that their loved one was a high fall risk with frequent intermittent confusion and requested that he not take the ordered Eliquis (blood thinner) due to his frequent falls and prolonged bleeding. Importantly, they communicated to the admitting nurse that their loved one be toileted at 1:00 am and 4:00 am, as that is what he was accustomed to when they were caring for him at home.

When the family was leaving the facility later that night they communicated to another nurse that they were concerned about their loved one.  The nurse assured them that residents are checked on every 2 hours and toileted at those times.  Further, since the resident was confused and often tried to get up, the nurse assured the family that a nurse would check on the resident every hour to see if he needed anything.   

Critically, the admitting nurse never communicated to other nurses, including the night staff, that this particular resident needed to be toileted at 1:00 am and 4:00 am.  

Without this critical information, tragedy struck.  

An aide did stop to toilet the resident sometime between 9:00 pm and 10:00 pm, but did not return again until midnight.  When the aide saw that the resident was sleeping, she decided to let the resident sleep without toileting him.

The next interaction anyone had with the resident was at 1:15 am when the aide found the resident lying face down on the floor, behind the door and bleeding from his head. 

The resident was rushed to the hospital but passed that same night.  Cause of death was Intracranial Hemorrhage with anticoagulant used for AFib (Atrial Fibrillation).

In this case the major breakdown in the care planning process was with communication.  Once the care plan has been developed, it must be communicated to the members of the nursing home staff charged with carrying it out.  This should be a simple enough process, but in practice, nurses and other staff members often have a hard time explaining how that occurs which leaves the issue in doubt as to whether the contents of the care plan are ever communicated to the people charged with doing the work.

These systemic failures are often a sign of an understaffed nursing home.  Sadly, that is a basic 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.

Failure to supervise Westmont Manor resident leads to fall and broken hip

By

IDPH has cited and fined Westmont Manor & Rehabilitation nursing home after a resident who was a known fall risk there was left unsupervised at the nurse’s station, and a result fell and suffered a fractured hip which required surgery.

When a resident is considered a fall risk, developing and implementing a fall prevention care plan is required.  One of the mainstays of a good fall prevention care plan is keeping residents who are at risk for falls in an area where they can be easily supervised by staff.  In fact federal regulations require that residents receive supervision and assistance necessary to prevent accidents, and falls are definitely accidents.  In practice, this means that residents who are at risk for falls are placed in areas like the dining room, the activities area, or by the nurse’s station so that staff can keep them under direct observation.  This of course requires staff to actually be present in those areas.

The resident at issue was a known fall risk, and in fact before the fall at issue, had three prior falls.  One of the truisms about nursing home falls is that the occurrence of a fall is a predictor for additional falls and is a factor considered in almost all high-quality fall risk assessment tools.  Other crucial factors include some type of musculoskeletal or gait dysfunction and some form of cognitive impairment such as confusion, dementia, or poor safety awareness of judgment.  The reason that cognitive impairments feed into fall risk is that the residents cannot be counted on to make good judgments for their own safety or follow instructions from the staff intended to minimize fall risk.

This resident was wheelchair bound and required the extensive assistance of two staff with transfers and suffered from dementia.  She also had poor trunk control and had a history of stroke.  With the history of multiple falls and her physical and cognitive impairments, she was properly assessed as being a fall risk, and a fall prevention care plan was put into place.  One of the steps in that fall prevention care plan was to  keep her in an area where she could be supervised while up.

On the day of this nursing home fall, the resident was brought to the nurse’s station in her wheelchair.  The nurse was due for his break, so he went into the dining room – just a short distance from the nurse’s station.  While he was on break, an aide was assigned to monitor the residents at the nurse’s station.  However it was also the time for shift change for the CNA’s, so the aide was down at the other end of the hallway getting ready to end her shift.  As a result no one was monitoring the residents at the nurse’s station.

While he was sitting in the dining room on break, the nurse heard a thud.  He went to the nurse’s station and found the resident on the floor.  He went and got the aide who was getting ready to leave and returned to the resident.  He assessed the resident and then got her off the floor.  The resident had a bump on the forehead and was complaining of pain in the left hip, so the resident was sent out to the hospital.

At the hospital, scans showed that the resident had a femoral fracture extending into the intertrochanteric space – in lay terms, a fractured hip.  She underwent surgery with the placement of nails to repair the fracture.

This fall was the direct result of a violation of the resident care plan.  The whole point of having the resident in a location where she could be monitored is so that someone would be watching and in a position to intervene if she attempted to get up unassisted – a known behavior for this resident.  However, when the nurse assigned took his break and the aide left the nurse’s station to get ready to go home, the resident was left unsupervised.  Care plans need to be implemented on a 24/7 basis – and this is the result when they are not.

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:

Westmont Manor resident suffers brain bleed after being rolled from bed

AHVA Care of Stickney resident suffers hip fracture in fall

Alden Courts of Shorewood breaks both legs in unsafe transfer

Improper transfer leads to broken leg at Springs at Monarch Landing in Naperville

 

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

 

Failure to provide required assistance leads to fall and broken arm for Bria of Palos Hills resident

By

IDPH has cited and fined Bria of Palos Hills nursing home after a resident there fell and suffered a broken arm due to the failure of staff to provide care called for by the resident care plan.

Care planning is a process by which risks to the health and well-being are identified and measures are put into place and carried out on a day-to-day basis to prevent those risks from coming to fruition.  One of the ways that proof of nursing home abuse and neglect is proven is by showing violations of the resident care plan.  Delivery of the care called for in the care plan is fundamental to providing quality care to residents in a nursing home setting.

There are six steps to the care planning process: (1) an assessment of the risks to the health and well-being of the resident; (2) a written care plan is developed which identifies a series of steps or interventions intended to reduce the risks to the resident.; (3) communication of the care plan to the staff who are charged with carrying it out; (4) implementation of the care plan on a day-to-day, sift-to-shift basis; (5) ongoing evaluation of the effectiveness of the care plan; (6) revision of the care plan if it proves to be inadequate in practice or if the care needs of the resident change.

The resident at issue was identified as being a fall risk, and a fall prevention care plan was put into place.  Among the steps that were to be taken was extensive assist of one staff with toileting and ambulation.  “Extensive assist” generally means provided physical support with weight bearing during the activity, including the use of a gait belt.

One the day of this nursing home fall, the nurse on duty had been told that the resident was not feeling well and went to the room.  As she approached the room, she saw that the call light was on.  She looked into the room and saw that there was an aide in the room already and that the resident was standing, walking toward the bathroom.  Assuming that the aide was there to assist the resident, she left to care for other residents.

Moments later she heard the resident call out the she had fallen and returned to the room and found the resident on the floor of the bathroom.  She told the staff that she lost her footing and fell.  She was bleeding from a wound from the head and was complaining of pain to her arm.  She was brought to to the emergency room where she was diagnosed with a comminuted fracture of the surgical neck of the humerus (upper arm).

There was a care plan in place which was intended to prevent just this kind of injury.  The resident was a fall risk and the care plan called for the assistance of one staff member to prevent falls, which can be so devastating to nursing home residents.  Care plans must be communicated to the staff so that they can actually be implemented.  Here, there were two staff members – the aide who was already in the room and the nurse who looked into the room – who saw that the resident was up without assistance.  Neither helped this resident, and as a result, the fall occurred.  The failure to carry out the care plan led directly to this injury.

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

Other blog posts of interest:

Westmont Manor resident suffers brain bleed after being rolled from bed

Resident at Chateau Nursing Home in Willowbrook suffers spinal fractures in wheelchair accident

Manorcare of Palos Heights East suffers hip fracture in fall

Mechanical lift accident at South Holland Manor

 

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

 

Failure to follow care plan results in fall with broken arm for resident at Heritage of Hoopeston

By

IDPH has cited and fined Heritage Health of Hoopeston after a resident there suffered a broken arm in a fall brought on by the failure to follow the resident’s care plan.

The care planning process is how much of the routine care provided in nursing homes gets delivered.  There are six steps to the care planning process.  First there is an assessment of the risks to the health and well-being of the resident.  Second a care plan is developed which identifies a series of steps or interventions which are to be done to reduce the risks to the resident.  Third, the care plan is communicated to the staff who are charged with carrying it out.  Fourth, the care plan must be implemented on a day-to-day, sift-to-shift basis.  Fifth, the effectiveness of the care plan must be evaluated on an ongoing basis.  Sixth, the care plan must be revised if it proves to be inadequate or if the care needs of the resident change.

The resident at issue was identified as being at risk for falls.  Two of the interventions that were listed in her care plan were: (1) transfer the resident with two staff when suffering from acute illness and (2) place non skid strips on the floor.

In the days leading up to the nursing home fall, the resident was diagnosed as suffering from cellulitis of the right leg and from covid.  As a consequence of her covid diagnosis, she was placed in another room.  According to her care plan, the nonskid strips should have been placed on the floor of her room, but were not.  On the day of her fall, she was being transferred from her recliner to the bathroom with the assistance of a single aide.  As the aide was transferring the resident, the resident’s feet began to slide out from under her due to the lack of nonskid strips on the floor.  The aide attempted to support the resident by holding her from under her armpits, but there was a loud cracking sound and the resident experienced immediate pain and was unable to move the arm.  She was brought to the hospital where x-rays showed that she suffered a broken arm and a separated shoulder.

The two elements of the care plan discussed above were violated, and the fall and the injury to this resident were the result.  Even though the resident was placed in a new room due to her covid diagnosis, the nonskid strips on the floor were still required.  The lack of the nonskid strips on the floor led to the resident’s feet sliding out from under her, leading to the loss of balance.  When the one aide attempted to stop the fall she was working alone and was not able to.  Having a second staff member present for the transfer likely would have prevented the injury to the resident.

The most direct and obvious cause of the injury to this resident was the violation of the care plan.  However, understaffing of the nursing home is a likely culprit as well.  The aide involved admitted to the state surveyor that she knew that there was supposed to be a second aide assisting with the transfer but she tried to get it done on her own.  When you have staff taking shortcuts in the care of residents, understaffing is a likely culprit.  Sadly, understaffing is a feature, and not a bug, in the nursing home business model.   One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Piatt County Nursing Home resident brakes neck in fall from power recliner

Gardenview Manor resident suffers broken hip during unsafe transfer

Fall results in fractured kneecap at Country Health in Gifford

 

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

Pleasant View Rehab resident fractures hip in fall

By

IDPH has cited and fined Pleasant View Rehabilitation & Health Care Center in Morrison after a resident there suffered a fractured hip in a fall.

The resident at issue was admitted to the nursig home three and a half months before the fall at issue.  Four days after admission, the resident was discovered lying flat on his back on the floor of his room.  When a nursing home resident is discovered on the floor like this, it should be presumed to have been the result of a fall.  It is well-recognized in the nursing home industry that falls tend to beget additional falls, so the resident’s fall prevention care plan was updated to include the use of a bed alarm.

Beyond the resident’s history of falls, the resident was considered a fall risk due to dementia and poor safety awareness.  When a nursing home resident demonstrates either intermittent or constant confusion, this is considered a contributor to fall risk because the resident cannot be counted on to make good decisions for their own safety.  This is why a measure like a bed alarm is considered an appropriate fall prevention tool – because the sounding of the alarm serves to alert the staff that the resident is up and to remind the resident that they should wait for help.

Two and half weeks before the fall, the resident’s care plan was updated to reflect that the resident had a known behavior of getting up out of bed unattended.  A floor mat was added to the fall prevention care plan.

On the day of the resident’s nursing home fall, the CNA and nurse was at the nurse’s station when they heard the noise of the fall coming from the resident’s room.  They went to the room immediately and found the resident lying on the floor with bleeding coming from the head,complaining of pain to the leg.  The alarm had not sounded and the floor mat was away from the bed on the other side of the room.

The resident was brought to the hospital where a fractured hip was diagnosed. Surgery was performed, and the resident was returned to the nursing home.  Unfortunately, the resident developed a post-operative wound infection and was receiving antibitoics for the infection at the time that the citation was issued.

The nursing home properly recognized that this resident was a fall risk.  The hospital records described the resident as being nonambulatory, and the resident had a history of falls, confusion with poor safety awareness, and a known behavior of getting out of bed unattended.  The steps care planned were a reasonable start to attempting to prevent further injury to this resident by calling for the use a bed alarm and floor mats.  However, the bed alarm did not sound when the resident got out of bed and the floor mats were found on the other side of the room when the staff responded to the noise from the fall.  A care plan not actually implemented is useless.

Past that, there were likely additional measures that could have been taken to help prevent this fall.  Given that the resident had a known behavior of getting out of bed unattended, increased rounding was called for.   The fall occurred at 6:20 a.m., an hour when the resident may have been waking up with an urge to use the bathroom.  A toileting schedule would have likely been an effective fall prevention measure because it would have helped the staff better anticipate known behaviors of the resident which presented increased fall risk.  Truly effectivecare plans actually tailored to the needs of the resident – and in fact, this is what federal regulations require.

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

Other blog posts of interest:

Rochelle Rehab resident breaks leg due to unsafe use of wheelchair

Waverly Place of Stockton resident breaks hip in unsafe transfer

Aperion of Spring Valley resident suffers fatal brain bleed in fall

 

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

 

Westminster Village resident suffers multiple fractures in fall

By

IDPH has cited and fined Westminster Village nursing home in Bloomington after a resident there sustained multiple fractures in a fall.

The resident involved was admitted for rehabilitation following a urinary tract infection and for age-related debility.  However, less than 2 weeks after being admitted to the nursing home, the resident was discharged from physical therapy.  The therapy discharge summary stated that the resident required stand by assist for all functional mobility due to decreased awareness of limitations.  It also stated that the resident had limited potential for further gains and that resident would likely not achieve independent levels of function.

The resident was assessed as being at risk for falls and a fall prevention care plan was put into place.  This called for assistance with activities of daily living and  supervision with toileting and transfers.  However, her Minimum Data Set showed a more extensive level of assistance being required: supervision with toileting, transfers, personal hygiene, and walking in her room.

On the night of this nursing home fall, the aide assigned to care for the resident set things up for the resident to get ready for bed including brushing her teeth.  He left to attend to other residents because he believed that she was independent with those activities.  He was unable to return for a while because other resident’s call lights were sounding.

After the resident got done brushing her teeth, she pushed the door to leave the bathroom and lost her balance, falling forward and hitting her face on the floor.  She was complaining of chest pain, so she was sent to the hospital where she was diagnosed as having rib fractures, a fractured sternum, and multiple fractures of the jaw.  The jaw fractures were significant enough that she required transfer to another hospital for a higher level of care.

There was a disconnect between what the resident needed and what the resident required in the way of care.  The discharge summary from physical therapy called for the resident to get stand-by assist with all functional mobility, while the CNA assigned to the resident believed that she was independent.  The care plan only called for supervision with activities of daily living.  Clearly there was a breakdown in what was needed and was being provided.  This resident needed someone in the room helping at the time of the accident, but did not get that help, and as a result sustained serious injuries in this fall.

The injuries that this resident sustained are significant above and beyond the pain which she experienced from the broken bones.  Rib fractures and a fractured sternum make it difficult to inhale and exhale normally which can set the stage for developing pneumonia.  The jaw fractures will result in decreased oral intake, which can set the stage for the resident to develop bed sores.

The fact that the aide was not able to return to the room in a timely fashion because of the needs of other residents raises a question of whether this is an understaffed nursing home.  Unfortunately, not having enough staff on hand to meet the care needs of the residents is a common feature in the long-term care industry.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Resident at Westminster Village suffers broken leg in fall from toilet

Resident breaks hip in fall at McLean County Nursing Home

Fall results in fractured kneecap at Country Health in Gifford

Failure to assist resident to bathroom leads to fall at Heritage Health in Peru

 

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

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

By

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

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

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

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

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

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

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

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

Other blog posts of interest:

Niles Nursing & Rehab resident suffers fatal brain bleed in fall

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

Alden Valley Ridge resident rolled from bed, breaks both legs

 

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

 

 

 

 

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

By

IDPH has cited and fined Farmington County Manor nursing home after a resident there suffered a broken leg due to the failure of an aide to follow the care plan for safe resident transfers.

The resident at issue was a hospice patient, admitted to the nursing home suffering from a degenerative neurologic condition which left her without full use of her arms or her legs.  Because of the loss of use of her legs, she was wheelchair bound and a care plan was put into place which called for the use of a hoyer lift for transferring the resident – for example, moving her from bed to her wheelchair.   When a transfer is done with a hoyer lift, this requires the help of two staff members – one to actually operate the controls of the lift, the other to keep the resident steady in the sling.

On the day of the injury, the CNA assigned to care for the resident transferred the resident from bed to wheelchair using a technique known as a pivot transfer.  This involves placing a gait belt around the midsection of the resident, lifting the resident to a standing position, and pivoting, moving the resident from bed to wheelchair.  In so doing the resident’s leg twisted and she suffered a broken femur.  The resident was sent to the emergency room where an orthopaedic surgeon was brought in for a consultation.  Ultimately considering her overall condition, he recommended that she be placed in an immobilizer and returned to the nursing home.

This injury was very clearly the result of a violation of the resident care plan.  When a resident is admitted to a nursing home a care plan is developed which is intended to address the risks to the health and well-being of the resident.  In this case, due to the weakness associated with her neurologic condition, the resident was not able to bear weight sufficiently to be safely transferred in any way other than the use of a lift.  It was part of the aide’s job to follow that care plan to help assure the safety of the resident.

This injury was the very predictable result of failing to follow the care plan.  When people are non weight bearing for an extended period of time, they tend to develop osteoporosis, or brittle bone disease, which leaves them susceptible to suffering fractures due to movements which may not ordinarily cause injury.  In this case the twisting that occurred during the pivoting movement cause the fracture.  This caused the resident to suffer significant unnecessary pain.

While the failure to follow the care plan was a very clear cause of this injury, the facts here raise a question as to whether this was an understaffed nursing home.  Whenever you see staff taking shortcuts in the care of residents, such as having one person doing a two-person job, it raises questions about whether this is an understaffed nursing home.  Unfortunately, understaffing a nursing home is really a part of the nursing home business model, and one of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Resident left unsupervised on smoking patio at Sharon Health Care Elms falls and suffers brain bleed

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

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

Mechanical lift accident at Meadows Mennonite Home in Chenoa

Heddington Oaks resident suffers broken leg due to unsafe transfer

Cornerstone Rehab resident falls from lift, breaks leg

 

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

The Law Officecs of Barry G. Doyle, P.C.

Call Us Today

(312) 263-1080

Location

Skokie, IL
  • Law Offices of Barry G. Doyle, P.C. 4709 West Golf Road, Suite 1140
    Skokie, IL 60076
  • Phone: (312) 263-1080
  • Get Directions

Practice Areas

TAP TO CALL