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Bria Of River Oaks Fails To Quickly Address Critical Changes In Resident Health, Contributing To Death Of Two Residents

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The Illinois Department Of Health has cited and fined Bria of River Oaks when two separate residents both experienced critical changes in their conditions that were not appropriately addressed by staff and ultimately contributed to their deaths.

The first resident in question was a male with a history of cerebral infarction, type II diabetes, and dementia.

He was found vomiting in his room one afternoon. The nurse on duty assessed the resident and found abnormal vital signs, including high blood pressure (177/94) and low oxygen saturation (87%). The Nurse documented that the resident “had four episodes of vomiting within the hour, looked pale and was confused.” Despite these concerning symptoms, emergency services were not called until two hours after the initial assessment.

When paramedics arrived, they found the resident alert but “complaining of shortness of breath with no relief from O2 (oxygen) via nursing home.” They increased his oxygen support, which improved his saturation. At the emergency room, the resident was diagnosed with a “large subdural hematoma (blood in brain) with midline shift,” a critical condition requiring “emergent neurosurgical consultation.” The resident was airlifted to another hospital for advanced care but unfortunately passed away.

The resident’s physician emphasized the seriousness of the situation, stating, “If a patient is experiencing an increase of blood pressure such as the 170’s or higher, it is important to assess mental status. If the mental status has decreased from baseline, it is an emergency and the patient should be rushed to the emergency room via 911 to rule out a stroke, brain bleed or hypertensive encephalopathy.” The delay in seeking emergency care for the resident potentially contributed to the severity of his condition and subsequent death.

The second case involved a resident with type II diabetes, chronic kidney disease, and hypertension.

On the day of this second incident, at around 9:15 PM, the resident was assessed by a Nurse with symptoms of low blood sugar, including “sweating and slow with speech.” His blood sugar was measured at 73. Despite attempts to raise his blood sugar with sugar packets and orange soda, a subsequent check at 9:40 PM showed it had dropped to 62. The Nurse administered an emergency glucagon injection, and at 10:00 PM, the resident’s blood sugar had risen to 107.

However, the situation took a dramatic turn less than an hour later. At 10:56 PM, the Nurse observed the resident “slow to respond” in bed. By 11:00 PM, the resident was found “unresponsive, not breathing and without a pulse.” CPR was initiated, and 911 was called at 11:02 PM. When paramedics arrived at 11:11 PM, they found the resident in cardiac arrest with a critically low blood sugar of 45.

The resident was revived and taken to the hospital, where he was treated for “hypoglycemia (low blood sugar), respiratory distress, and cardiac arrest.” He was later discharged to home hospice and passed away shortly thereafter, with the cause of death listed as “Hypoxic Brain Injury.”

The second resident’s physician highlighted the critical nature of managing low blood sugar, stating, “the resident should have quickly gone out to the emergency room after the nurse determined the blood sugar was critically low and a glucagon injection was needed in order to prevent further lowering of the blood sugar. If the blood sugar gets too low, as in the case of this resident and the patient can stop breathing, the brain loses oxygen and can lead to fatality.”

These cases illustrate significant failures in recognizing and responding to medical emergencies in a timely manner. The delays in seeking emergency care for both of these residents likely contributed to the severity of their outcomes, underscoring the critical importance of prompt assessment, intervention, and escalation of care in nursing facilities.

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.

Staff At Aperion Care Marseilles Fail To Follow Physician Orders, Refuse To Send Resident To ER, With Tragic Consequences

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IDPH has cited and fined Aperion Care Marseilles when staff members were embroiled in confusion, refusing to follow a physician’s order for a resident in seriously declining health. This failure resulted in a delay of treatment, leading to continued decline and eventual admission to the local hospital’s intensive care unit with multiple comorbidities, including Sepsis and Pneumonia.

On the day of the incident the Dialysis RN documented that the resident in question had been ill for a few days and was getting worse. The RN further noted that the resident had “rales in upper lobes per auscultation,” was unresponsive, had a temperature of 100.4°F, cloudy and brown urine with a strong odor, and oxygen saturation of 81% on room air.

Despite these concerning symptoms, the floor nurse believed it was due to “fluid overload” and that the resident “just needs dialysis.”

When the Dialysis Nurse received push back from the facility RN, she contacted the resident’s Nephrologist, who agreed that the resident should be evaluated in the emergency room.
The Dialysis Nurse wrote an order at 4:15 pm stating, “Please have nursing home send patient to emergency room for evaluation of elevated temperature, decreased O2 (oxygen) saturation, MS (mental status) changes, rales upper lobes.”

However, this order was scanned into the miscellaneous tab of the resident’s electronic health record and was not processed into the Physician Order tab.

Despite the fact that the order was scanned into the incorrect tab on the electronic health record, the Dialysis Nurse did give the order to the floor nurse at the facility. The facility RN then began to argue with the Dialysis Nurse and “basically refused to send the resident out.”

The Dialysis Nurse then spoke with the Director of Nursing (DON). The DON responded that “my staff got different vitals than you did and that the resident seems ok.”

The situation is a complex one, as the resident was also suffering from a UTI, and there was some belief on the facility’s part that if the resident received an antibiotic, she would be better in 24 hours.

The facility then went ahead and proceeded with dialysis treatment despite the resident’s condition.

After the dialysis treatment, the resident’s condition remained poor. The Dialysis Communication Report noted that the resident was “Moaning, confused, labored respirations” with a temperature of 99.5°F.

Despite the continued poor condition of the resident, she was not sent to the hospital until the next day.

The resident was admitted to the hospital ICU “with sepsis and very high troponin level.” The hospital discharge paperwork revealed multiple serious conditions, including “Sepsis related to MRSA infection, Pneumonia, ESBL UTI, MRSA bacteremia leading to acute endocarditis suspected related to catheter associated infection, Acute on chronic systolic heart failure with pulmonary edema,” and several other complications.

Multiple staff members, including a LPN, a RN, and a second RN, confirmed that there was confusion and disagreement about sending the resident to the hospital. When questioned, the DON even said that “If there was an order for her to be sent to the hospital (I) would not have, not sent her.”
It was later explained by the Dialysis Nurse that the facility staff members did not fully comprehend the risk involved with sending the resident out to dialysis. If there had been infection in the resident’s blood stream the infection could have been spread throughout the body during dialysis, making it worse for the resident. This is why the dialysis team was concerned about moving forward with the treatment and why the Physician felt the resident should be sent to the ER to be examined.

This incident highlights significant issues in the facility’s communication processes, order management, and decision-making regarding resident care, particularly in emergent situations. The delay in following the physician’s order resulted in a potentially preventable decline in the resident’s condition and subsequent intensive care hospitalization.

Nursing homes are businesses, and well-run businesses have systems in place to carry out their basic functions. Assuring that patients are not neglected and that they receive timely medical care and attention is one of those basic functions. Here there was clearly a problem with the system that the nursing home was operating under, as the facility’s failure to implement timely emergency care during the resident’s obvious medical crisis subjected her to a negligent delay in treatment.

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 When Facility Fails To Send To ER, Delaying Needed Care At Aliya On 87th

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IDPH has cited and fined Aliya On 87th when the facility failed on multiple levels, including failing to keep the resident elevated at mealtime, failing to follow code blue policy, failing to notify the physician in a timely manner, and failing to relay STAT lab results to the physician. These failures resulted in the resident remaining at the facility in place of being rushed to the ER, ultimately leading to the resident’s death.

The resident in question was admitted with multiple medical conditions, including dysphagia, cerebral infarction, and a history of aspiration pneumonia, amongst others.

According to the resident’s care plan and physician orders, staff were to keep the resident’s head elevated 45 degrees during and 30 minutes after tube feeding, provide one-to-one feeding assistance, and monitor for signs of aspiration, reporting any issues to the physician.

However, a certified nurse assistant (CNA) stated ”I made rounds and the resident was resting in bed. Dinner trays came up and I passed out the food trays, and I gave the resident a dinner tray as well. I did not reposition the resident or raise the head of bed up. Approximately around 5:30 PM, I was walking down the hallway picking up the dinner trays. I went into the resident’s room and saw half of his food missing from the food tray and he was making gurgling gasping sounds with vomiting coming from his nose and mouth. The vomit looked like it was his dinner, with food particles. The resident was lying down in bed and leaning on his side, shaking like he was having a seizure, and his eyes was rolled back into his head.”

The CNA further stated “I ran out and got the nurse. The Nurse went into the resident’s room and yelled out for help. The LPN said the resident is aspirating and get the crash cart. A Registered Nurse came running into the room to help with the crash cart. The Registered Nurse called over the speaker system code blue, and other nurses came to help. I passed the resident his dinner tray, I did not know the resident needed one to one feeding assistance. I thought he could feed his self. After the code, the Registered Nurse asked me if I gave the resident a food tray and did the resident feed himself alone. I told the RN I did give the resident his food tray, but I did not know the resident was a one-to-one feed assist. The RN told me that the resident was lying down too far and aspirated on his dinner while eating alone. The RN told me that the resident should have sitting up 90 degrees due to his aspiration precautions, and I needed to feed the resident.”

Even worse, when a Licensed Practical Nurse (LPN) and Registered Nurse responded to the incident, they failed to call 911, despite the resident’s unresponsiveness and difficulty breathing. The Registered Nurse stated, “I did not call 911 when the resident was unresponsive because the resident was left lying down in bed and aspirated, that situation could be managed by nursing interventions.”

Approximately three hours later that evening a Nurse Supervisor called the physician on call service, Third Eye Physician, and failed to provide a complete and accurate report of the resident’s condition. The Third Eye Physician stated, “I was not made aware that code blue was called in the facility for the resident at 5PM, three hours prior to calling me. I was not made aware that the resident was found lying flat in bed, unresponsive, oxygen level in the 70’s percentile, threw up food particles out of his nose and mouth, having difficulty breathing, needed to be suction, started oxygen, and needed continuous oxygen to sustain a blood oxygen of 92%. If the LPN gave me a completely accurate report of the resident’s condition, I would have given an order to send the resident to the hospital.”

Furthermore, the resident’s critical laboratory and diagnostic test results were never relayed to a physician. The Third Eye Physician stated, “I did not know the resident’s labs came back, and his white blood count was 15, and chest Xray showed early infiltrates in the right lung base. No one from the facility notified me or my staff at the Third Eye of the test results. Those results indicated the resident aspirated, and now developing pneumonia. If I would have received the test results, I would have sent the resident to the emergency room.”

The following morning after the incident the resident was found unresponsive in his bed.

While all of these failures are startling, a close read of the investigation report paints a hectic, borderline chaotic situation at the nursing home. The LPN assigned to the resident claims that she was busy with multiple code blues on the same day at the same time. The LPN states “I did not chart on the resident, the RN and Nurse Supervisor help me chart that day because there were a couple of code blues on the same day and same time. I did not call the resident’s physician; we must use Third Eye Physician on call service on the weekends. I did not call the Third Eye Physician, the Nurse Supervisor called third eye and spoke with the physician. I do not know what time the Nurse Supervisor called the physician.

The Nurse Supervisor that did speak with the on-call physician admitted that she had only peaked into the resident’s room and did not assist with the code blue. The Nurse Supervisor stated “I see the documented progress noted dated with my name, but I cannot remember. To access a call with a Third Eye physician, each nurses have their own individual log in and passwords to access the video call. No one could document or call the Third Eye Physician under my name; I must have called the Third Eye Physician. I am so confused, and I do not recall the code for this resident.”

This would explain why the Nurse Supervisor did not communicate all of the resident’s details in a complete and accurate manner to the physician. The three hour delay in calling the physician can also be explained by what appears to be an overworked staff, as there were multiple code blues occurring at the same time.

Another staff member, this time an Agency RN, paints a hectic picture the day of the incident. She states “I was so busy with the other residents and suctioning the resident (with the code blue) that I did not have time to ask another nurse (for help). I did not chart on the resident because I was too busy taking care of the other residents. I took one set of vital signs, but I did not place the vital signs in the resident’s electronic chart, I just ran out of time and forgot to put them into the system.”

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 such as the one detailed here 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.

Nurse Believes “Do Not Resuscitate” Means “Do Not Administer Care” At Center Home Hispanic Elderly

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IDPH has cited and fined Center Home Hispanic Elderly when the facility failed to provide emergency treatment and care to a resident, resulting in a nearly six hour delay in the administration of oxygen. A staff member mistakenly believed that “if a person has a DNR there are no interventions that should be provided.”

The resident in question was found at approximately 3:20am with hands that were cool to the touch and their oxygen saturation at 84%. Instead of immediately administering oxygen, the Licensed Practical Nurse (LPN) simply noted “resident DNR will continue to monitor” in the progress notes. At 6:00am, the resident’s SPo2 had dropped even further to 82%, yet the LPN still did not administer oxygen.

This failure to act was based on the LPN’s misinterpretation of the resident’s Do Not Resuscitate (DNR) status. In an interview the LPN stated, “if a person has a DNR there are no interventions that should be provided and with a DNR you should keep the the resident cleaned and comfortable.” This statement suggests a lack of understanding regarding the appropriate care for a resident with a DNR order.

The resident’s Physician Orders for Life-Sustaining Treatment (POLST) specified that while no CPR should be attempted, comfort-focused treatment should include the use of oxygen. The Director of Nursing (DON) reinforced this in an interview, stating, “DNR does not mean that a nurse does not provide care and care still needs to be provided.”

The LPN’s decision not to administer oxygen, despite the clear indication to do so based on the resident’s low SPo2 levels and the POLST, resulted in a significant delay in the resident receiving necessary care. It was not until 6:57am, when another nurse assessed the resident, that oxygen was finally administered. By this time, the resident’s condition had deteriorated to the point of requiring emergency hospitalization. Unfortunately the resident died the next day at the hospital.

This incident highlights the importance of ensuring that all nursing staff, including LPNs, fully understand the implications of a DNR order and the appropriate interventions that should still be provided to ensure patient comfort and well-being. The failure to administer oxygen in a timely manner, as a result of misinterpreting the DNR order, led to severe consequences for the resident

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. 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 Call 911 In Place Of Local Ambulance Service Results In Patient Death at Alden of Waterford

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IDPH has cited and fined Alden of Waterford when the facility failed to recognize the severity of a critically low potassium level. In place of calling 911, a RN called the local ambulance service, which took nearly two hours to arrive, only to find the resident in cardiac arrest, requiring CPR, and subsequently passing away at the hospital.

The resident’s progress notes written by an RN state that the lab called the nursing home facility and spoke with the RN about the low potassium level (of 2.4mmol (millimoles)/L (liter)). The RN paged the resident’s Primary Physician and spoke with a Nurse Practitioner. The NP advised that the RN send the resident to the ER. The notes further mention that the local private ambulance was called around 5:15 PM, and they stated an estimated pickup time of 1-2 hours later. Upon the ambulance’s arrival at approximately 7:13 PM (nearly 2 hours later), the resident was found unresponsive, and compressions were started. 911 was called at 7:15 PM, and paramedics arrived at the scene at 7:22 PM, transporting the resident to the ER at 7:34 PM. Later that evening the ER nurse informed the facility that the resident had expired in the ER.

The critical error in this case was the failure to immediately call 911 when the RN was informed that it would take 1-2 hours for the local ambulance service to arrive on site. The RN claimed that the resident’s vital signs were stable, and that when the lab called regarding the low potassium level “it did not seem urgent.” The RN mentioned that “the resident had a poor appetite but that even his oxygen level was ok.” Further, “If the potassium was low then it would cause heart issues. I would think there would be a change in his vital signs. There was no change since the AM. I had him all day.”

The Nurse Practitioner at the Primary Physician’s office stated “they were to send him to the ER. They should have called 911. With a potassium that low that would have been urgent. They never called me back to say that it was going to be 1-2 hours.”

The Director of Nursing, also expressed that waiting 1-2 hours for an ambulance was unacceptable and that with a critically low potassium level, they should have called 911.

The facility’s failure to follow their change of condition policy, assess the resident properly, and call 911 (in place of the local ambulance service) resulted in a delay in receiving a higher level of care and ultimately contributed to the resident’s death.

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 When Facility Failed To Properly Assess Condition, Takes Over 4 Hours To Get To ER At Continental Nursing & Rehab

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IDPH has cited and fined Continental Nursing & Rehab Center when a resident died after it took over four hours for the resident to be transported to an emergency room.

The resident in question had multiple medical diagnoses including asthma, cerebral infarction, type 2 diabetes, dysphagia, and dementia. The resident experienced an acute change in condition at the care facility. A registered nurse observed that the resident was lethargic, had continuous hiccups, and had oxygen saturation levels ranging from 82% to 90% on room air. The nurse administered oxygen at 4 liters per nasal cannula, which increased the resident’s oxygen saturation to 96%. However, the resident’s skin color was not good and slightly moist.

The nurse contacted the resident’s physician, who gave a telephone order to send the resident to the hospital for an emergency room evaluation. The nurse completed the necessary paperwork and called the facility’s contracted ambulance company around 9:20 PM, requesting transport to the emergency room. The ambulance company informed the nurse that there would be a two-to-three-hour estimated time of arrival. The nurse did not notify the physician or the Director of Nursing about the delay in transport.

According to the ambulance company’s “Patient Care Report,” the facility staff nurse called dispatch at 10:26 PM, not 9:20 PM. The ambulance arrived at the facility at 12:25 AM and made direct contact with the resident at 12:30 AM. The ambulance left the facility at 1:02 AM, and the resident arrived at the hospital emergency room at 1:38 AM, approximately 4 hours after the initial physician’s order to send the resident to the hospital.

Upon arrival at the facility, the ambulance crew, consisting of two Basic Emergency Medical Technicians, assessed the resident and found him to be lethargic, incoherent, unable to speak clearly, with an increased heart rate and wheezing in bilateral lungs. The nurse informed the crew that this was the resident’s baseline orientation and vital signs, with the exception of the newly administered oxygen. The nurse did not disclose to the crew that the resident’s oxygen saturation had earlier dropped to 82%. The EMT stated, “If I would have received that information in report, I would have called our advanced life support, if they were too far out the I would have called 911 and stayed with the resident until 911 arrived.”

At the hospital, the resident was diagnosed with acute respiratory failure with hypoxemia, altered mental status, hiccups, systemic inflammatory response syndrome, and elevated lactic acid. Despite receiving treatment, the resident passed away.

The resident’s family member expressed concerns about the delay in transport and the facility’s decision to send the resident to a hospital 19 miles away, bypassing several closer hospitals. The family member stated, “If the resident was stable, then why did the physician give the order to send a stable resident to the hospital emergency department. From the nursing home facility which is located on the north side of Chicago and transported the resident to a south side of Chicago hospital which was 19 miles away from each other, bypassing several closer hospitals that was terrible. The resident arrived at the hospital over 4 hours later in respiratory failure. The Administrator and the Director of Nursing seem not to understand, a delay in transport means a delay in receiving medical treatment, just maybe the resident would still be alive, all the nurse had to do was call 911.”

The facility’s Change in Resident’s Condition or Status policy states that during medical emergencies such as unstable vital signs or respiratory distress, 911 will be notified for transport to the hospital. However, the facility failed to follow this policy and did not immediately call 911 when the resident’s condition worsened.

The Director of Nursing, however, stated, “I understand the policy, however, once the resident was receiving 4 liters of oxygen he became stable, and the nurse should not have phoned 911. The change of condition policy was not followed in terms of calling 911, that was because the resident became stable, there was no reason to call 911.”

The resident’s physician, when informed of the details in the nurses’s progress note, stated, “Oh my goodness, the nurse absolutely did not tell me that the resident was lethargic, continues hiccups, elevated heart rate, oxygen saturation in the 80’s, skin color was not good, and skin was moist. I would have called 911 myself. I would have told the nurse to call 911 for immediate care, treatment, and transport. The nurse did not notify me that the ambulance service was going to be two-to-three hours getting to the facility. The nurse should have called 911 for this resident, he was not stable. I am so sorry that the resident expired. The nurse did not tell me all the information stated in her progress note, the nurse should have called 911.”

The facility’s failure to follow their change of condition policy, assess the resident properly, and call 911 when his condition worsened resulted in a delay in receiving a higher level of care and ultimately contributed to the resident’s death. The facility has since implemented corrective actions, including staff education and audits, to ensure compliance with the change of condition policy and prevent similar incidents from occurring in the future.

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 such as this one 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.

Resident Dies Of Sepsis As Leg Infection Goes Untreated For A Week At Belleville Healthcare Center

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IDPH has cited and fined Belleville Healthcare Center after the staff failed to order an antibiotic to treat a leg infection for over a week . . . and neglected to inform the resident’s doctor of the delay.  The resident subsequently died of sepsis shock and bacteremia.  

The resident in question suffered from multiple medical conditions including anemia, vitamin deficiency, and skin changes putting him at risk for complications. 

When the resident developed swelling in his left leg, doctors ordered tests and an antibiotic, cefixime, to treat early signs of infection.

Critically, the nurse at the nursing home could not enter the prescription due to a possible drug allergy alert. 

The nurse notified the wound care nurse of the issue but did not notify the doctor that the antibiotics were not started. Over the next week, the resident missed 10 doses of antibiotics. His leg continued deteriorating yet the doctor was not updated about the missed medication doses or worsening wound.

Approximately one week later the doctor had to reorder the same antibiotic prescription. 

Approximately another six days passed until a wound doctor first evaluated the resident and found a severe infection requiring debridement surgery, stating “By the time I was notified of the resident’s wound it was already really bad. I am not sure why they even waited so long for me to see him. The size of this wound was not something that would just appear overnight.  His whole left leg was a big bag of pus. I had never seen anything like it . . . The facility should have been monitoring the resident more closely.” 

Approximately two weeks after the appointment with the wound doctor the resident was admitted to the hospital for sepsis and shock. He tragically passed away from widespread infection four days later.  

Timely intervention with antibiotics and proper communication with doctors may have prevented such a tragic death.

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.

Resident’s Pleas To Be Sent To ER Neglected, Suffers Stroke And Permanent Disability At Aperion Care Bradley

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IDPH has cited and fined Aperion Care Bradley nursing home after the staff failed to adequately track and report a resident’s symptoms that lead to a delay in treating his stroke.  

The resident at issue, a 53-year old man with a mild cognitive issue, kept asking staff to take him to the hospital because of numbness and a “pin and needles” feeling in his right arm, which are common stroke warning signs.  He recounted clearly saying “Listen, I know my own body.  I knew something was very wrong. I was really scared from the numbness and tingling.  I pleaded with my nurse to please send me to the hospital right away but she said No.”

That morning, when the resident first told his nurse of his arm issue around 9 or 10 AM, she only focused on his high blood pressure of 177/102.  The nurse admitted “Maybe I didn’t mention his arm tingling to the Nurse Practitioner because I was overly worried about the blood pressure.”  So she failed to pass on this stroke indicator.  The Nurse Practitioner agreed “They should have informed me if the resident was still having numbness after getting blood pressure medicine.”

The nurse was also supposed to check the resident’s vitals that night because of new medications but the agency nurse never did the required checks. The agency nurse admitted ”I’m not supposed to take vitals unless the nurse tells me to.”

The next morning, a nurse found the resident inexplicably lying on the floor, slurring words, with a droopy face and weakness on one side.

Tragically, a scan at the hospital showed that the resident had already suffered an untreatable stroke with permanent damage. The director of the nursing home acknowledged they neglected handling the resident’s ongoing numbness complaint.

Their lack of monitoring and reporting of his symptoms led to his disability after a preventable stroke.

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 Misjudges Resident In Crisis, Fails To Call 911 In Time To Save Resident From Death At Fireside House Of Centralia

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IDPH has cited and fined Fireside House Of Centralia due to a failure of the staff to correctly obtain timely emergency care for worsening signs of a large gastrointestinal bleed, leading to the death of the nursing home resident en route to the Emergency Room.

One of the basic roles that a nurse in a nursing home setting plays is to serve as the eyes and ears of the resident’s doctor.  When a resident shows signs of a change in condition, has a nursing home fall, or is demonstrating some other condition of ill-being, it is the nurse’s job to notify the doctor.  The doctor then can issue orders over the phone for treatment to be delivered at the nursing home, go into the nursing home to see the resident himself, or order the resident sent to the hospital for examination and treatment there.  Occasionally a situation arises where the nurse does not have time to contact the doctor, and must make a decision as to whether or not to call an ambulance service or 911 when the resident’s condition warrants.  That was the case in this troubling nursing home death. 

The resident at issue was exhibiting altered mental status, with symptoms including sluggish dilated pupils, difficulty speaking, and abnormally slow responses. Although the LPN (Licensed Practical Nurse) initially stated “she was going to send the resident out to the hospital”, she inexplicably changed course and directed staff to get the resident prepared for her scheduled medical appointment that morning. However, when the resident was found to have a temperature of just 95.7 degrees, the LPN then ordered her back to bed and called the ambulance company at 6:55AM. Crucially though, upon being told no ambulances were currently available, the LPN explicitly stated she would continue to wait rather than contact 911 for emergency assistance.

Over the critical next hour, the facility staff stood by while the resident yelled out in pain, unable to verbally communicate, and even screamed “everywhere!” when asked where she was hurting – clear signs of emergent distress. A CNA reported she kept checking on the resident, who was trying to talk but couldn’t, while the patient continued to deteriorate now that the LPN had decided to delay ambulance transport. Later, another nurse would state “Honestly, if it came down to it, I would push them to the hospital. It is right next door,” indicating the staff were aware they had a duty to act.

Finally at 7:35AM the ambulance arrived, but by then the resident was documented as unresponsive. She went into cardiac arrest en route to the hospital ER, and was pronounced dead shortly thereafter due to complications of a massive gastrointestinal bleed.

Nursing homes are businesses, and well-run businesses have systems in place to carry out their basic functions.  Assuring that patients are not neglected and that they receive timely medical care and attention is one of those basic functions.  Here there was clearly a problem with the system that the nursing home was operating under, as the facility’s failure to implement timely emergency care during the resident’s obvious medical crisis subjected her to a negligent, hour-long delay in treatment and ultimately resulted in her death.

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.

Resident’s Pleas For Help Neglected By Nursing Staff, Dies At Chicago Ridge SNF

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IDPH has cited and fined Chicago Ridge SNF after a resident there suffered potential fluid overload in the lungs and subsequent death only three days after admission.  

Nursing home residents who are suffering from kidney failure may require dialysis, and when this is true, families often make the decision to pick one nursing home over another based upon the availability of an in-house dialysis unit in order to spare their loved one from having to be transported to an outside dialysis center.  These in-house units are usually operated by a separate company which means that coordination of care between the dialysis unit and the nursing staff is crucial to ensuring that the resident receives the care that is required. 

When this doesn’t happen, the results can be catastrophic.   When the kidneys are not functioning properly, the body cannot remove excess fluid and toxins.   Dialysis takes up that function in the absence of properly working kidneys.  When necessary dialysis sessions are missed, excess fluids and toxins can build up and cause serious problems throughout the body, most notably with the heart and lungs.

The resident at issue suffered from end stage renal disease, or kidney failure.  On the day that the resident was admitted, the internet was down from approximately 2:30 pm until approximately 1:00 am the following day.  While the in-house dialysis center was aware that the resident was arriving, they were never notified via email by the admitting nurse that the patient had actually arrived. 

Notes from the investigation highlight that this was most likely due to the initial lack of internet connectivity.  To make matters worse, the nursing staff neglected to send the email to the dialysis center once the internet was back up and running later the following morning.

The first signs of trouble appeared two days after the resident was admitted, when a nursing note documented that the resident was having trouble breathing and the blood oxygen level was 93%.  A nurse noted that to help the resident the nurse elevated the bed and the blood oxygen level rose back to 97%. 

The following afternoon the resident’s condition further deteriorated, with nurses noting that the resident was “coughing a lot and spitting up secretions.”   Nurses stated in the investigation that they were “too busy” to listen to the resident with a stethoscope and did not notify any doctors that the resident’s condition had changed for the worse, stating “I didn’t think to call the doctor at that time.  I just passed it onto the next nurse.”

Later that night notes indicate that a nurse visited the resident’s room at around 1:21 am.  The resident was reported to be talking but sounded upset.  While the residen’s breathing sounded congested and was slightly out of breath, the resident refused to be suctioned and was assisted by the nurse to lie back with head elevated.  The door was left open so that the nurse could hear if the resident needed assistance. 

The resident’s roommate, on the other hand, had a different story to tell.  The roommate claims that the resident was “screaming and yelling almost all night” and “coughing to the point of almost choking” screaming aloud “I can’t breathe.  Help me!”  The roommate claimed that a nurse visited the residence one time that night, telling the resident to “sit up and drink some water.” 

Unfortunately, at 6:45 am the morning nurse entered the resident’s room, only to find him without a pulse.   

There were a number of shortcomings in the care that this resident received:

  • When the resident initially developed shortness of breath and a low blood oxygen level, a doctor should have immediately been informed.  Further, there was no attempt to provide him with oxygen or send him to the hospital for further care.  It represented a change in condition and a real threat to the health and well-being of the resident.
  • There was no effort to regularly monitor the resident on the night before his death. Following the initial change in condition, the resident should have been checked on every two hours. The nurse on duty the night before the resident’s death admitted to not revisiting the resident after 1:21 am due to her busy schedule.  
  • There was inadequate response to possible fluid overload signs. The resident’s symptoms, such as respiratory distress, were indicative of potential fluid overload, yet no action was taken to address this.
  • Finally, when a resident is admitted needing dialysis, certain protocols must be followed.  In this case, the admitting nurse was able to order the resident’s medications, but failed to notify the in-house dialysis center, putting the patient in grave danger and contributing to the resident’s death just a few days after admittance.  

One of our basic 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.

 

Lemont Nursing & Rehab cited for failing to notify doctor of abnormal lab results

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IDPH has cited and fined Lemont Nursing & Rehabilitation Center nursing home in Lemont due to the failure of the staff to notify the resident’s doctor of abnormal lab results.

One of the basic facts of care in a nursing home is that there are not doctors on hand on a 24-7 basis.  However, members of the nursing staff are, and one of their functions is to serve as “the eyes and ears of the doctor” when the doctor is not actually in the nursing home.  Nurses are required to notify the doctor of significant events in the care of the resident, such as the occurrence of a fall, the development or a bed sore or its decline, abnormal lab or test results, and of any changes in the condition of a resident.

One thing that requires physician notification is the onset of signs and symptoms of infection.  Nurses are not required to be able to determine exactly what the infection is or how to treat the infection, but they do need to know when a resident is showing signs and symptoms of infection.  When a resident is showing signs and symptoms of an infection, the nurse is required to notify the doctor and the doctor can use that information to decide whether to issue orders for treatment over the phone, come into the nursing home to examine and treat the resident, or to have the resident sent to the emergency room.

The use of an indwelling catheter is something that predisposes nursing home residents to develop urinary tract infections.  There are a number of reasons for this, and as a general proposition, nurses working in a nursing home setting are well-schooled on what the signs and symptoms of a urinary tract infection are.  These might include: lethargy, confusion or other changes in mental status; fever; back or flank pain; burning while urinating; and changes in the color or appearance of the urine itself such as it becoming cloudy or darker, having pus or blood in it, or having a foul odor.  When those signs and symptoms occur, then physician notification is required.

The resident at issue here had an indwelling catheter.  He began to show increased confusion and the urine draining from catheter was cloudy.  These are signs of a urinary tract infection.  The physician was notified and he ordered a urinalysis and urine culture to determine whether the resident was suffering from a urinary tract infection and if so, what antibiotics would be most effective against it.

The resident also had a regularly scheduled Complete Blood Count (CBC) done the next day.  When the results of that came back that afternoon it showed that the white blood cell count was significantly elevated.  An elevated white blood cell count is an indicator that there is an infection present.  This abnormal lab result should have been reported to the doctor.  However, it was not.  In the context of this resident’s reported confusion and cloudy urine, the failure of the nursing staff to notify the doctor of the abnormal lab results deprived the doctor of a critical piece of information in medical decision-making.

Three days after the CBC test results came back, the results of the urinalysis came back.  These showed that the resident did in fact have a urinary tract infection.  The doctor was properly notified and started the resident on an antibiotic.  However, the following day the resident had to be sent to the hospital due to decreased urine output.  The resident was admitted to the intensive care unit with a diagnosis of elevated white blood cell count and sepsis.  After the family had the resident placed on comfort care only, the resident died a week later.

Here, there was a simple failure to follow standard nursing practices.  The doctor was notified when there was a change in the resident’s condition initially, resulting in the urinalysis being ordered.  The doctor was also notified when the results of that test came back with abnormal findings.  However, the staff failed to notify the doctor of the blood test showing the elevated white blood cell count.  This piece of information would likely have led to early administration of antibiotics and may have yielded a different outcome, as delay in the initiation on effective antibiotics increases ill-effects of infections.

One of our basic 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:

Untreated infection leads to resident death at Elevate Care South Holland

Grove of Elmhurst resident dies due to delay in physician notification

Aperion Care of Wilmington resident suffers ruptured colon due to fecal impaction

Resident at Arcadia Care in Danville dies due to improperly treated urinary tract infection

 

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

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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.

Grove of Elmhurst resident dies due to delay in physician notification

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IDPH has cited and fined the Grove of Elmhurst nursing home after a resident there died due to a 30-hours delay in notifying the resident’s physician about a fever exceeding 104 degrees.

One of the basic truisms of care in a nursing home setting is that doctors are not there on a 24/7 basis.  Because of this, nurses must be the “eyes and ears” of the doctors and let them know when there has been a change in the condition of a resident.  The nurse does not need to know what the change represents (though they often have a good idea) or how to treat it.  Those things are the role of the doctor.  The nurse simply needs to be able to identify the change in condition, notify the resident’s physician, and give the doctor enough good information about what is happening to allow good decision-making.  Once the doctor is informed of the problem, then the doctor must decide to come to the nursing home, issue orders over the phone, or order the resident transferred to the hospital.

The resident at issue had been admitted to the nursing home with a number of medical problem, including: multiple rib fractures, chronic respiratory failure, encephalopathy, a tracheostomy, and anoxic brain damage.  He was in a comatose state and dependent on staff for care.  At the time of admission, he had been running low-grade fevers (98-101), so the attending doctor requested consultations with an infectious disease physician who assigned a nurse practitioner to the patient.

On the morning of the fourth day after admission, the resident’s temperature rose to 104.5 degree.  This represented a change in condition for the resident, and should have triggered notification of the resident’s physician or the infectious disease nurse practitioner.  The resident’s temperature was taken 7 times during the course of that day, yielding temperatures of 102 degree or higher 5 times.   Neither the resident’s physician or the infectious disease nurse practitioner were notified of the rising temperatures.

The following day, the resident’s temperature was taken at 6:30 a.m. and was 102 degrees, but dropped down to 99.9 at 8:53 a.m. However, it climbed back to 104.5 degree by 10:57.  After the temperature climbed back up over 104 degrees, the staff called the doctor but he was not available so they had him paged.  No effort was made to reach the infectious disease nurse practitioner.

At 12:55 p.m., the respiratory therapist was treating the resident and noted a heart rate of 120-130 after suctioning.  The nurse assessed the resident and found that the resident had a temperature of 101.4 and a heart rate of 118.  Fevers and an elevated heart rate are signs of sepsis.  The primary care physician was paged again, although no effort was made to reach the infectious disease nurse practitioner.

The attending physician was paged again at 3 pm and this time the doctor was reached.  He was informed of the resident’s condition and ordered the resident be sent to the emergency room.  The staff first called a private ambulance service and was told that it would be 90 minutes for an ambulance to arrive.  The nurse went to assess the resident again and noted shallow breathing.  The nurse and the respiratory therapist began to do CPR using an ambu-bag.  911 was called, and the paramedics arrived 8 minutes later.  On arrival the resident had no pulse and was in respiratory arrest.  They were able to regain a pulse twice  in their resuscitative efforts, but the resident died less than an hour after the paramedics arrived.  The apparent cause of death was pneumonia – a condition which could have been better addressed in a hospital setting.

There were a number of shortcomings in the care that this resident received:

  • When the resident initially developed temperatures in excess of 104 degrees, no one was notified of the development of that high a fever.  It represented a change in condition and a real threat to the health and well-being of the resident.
  • There was no effort to notify the infectious disease nurse practitioner.  The fever and rapid heart rate were signs of sepsis and seeing as this specialist was brought in to help manage this aspect of the resident’s care, notifying the nurse practitioner was a reasonable option when the 104 degree fever developed and/or the attending could not be reached.
  • There was inadequate follow up when the attending physician could not be reached.  Once a doctor is paged and is not responding, additional follow-up efforts are required to actually reach the doctor to get his guidance.
  • Finally, when a doctor cannot be reached, the facility medical director should be contacted to obtain orders if necessary.  It is simply not acceptable to not get some medical direction when the resident’s situation calls for it.

The net result of all of this is that there was a 30 hour delay in getting the instructions that were required when the resident first developed the 104 degree fever.  This was a medically complex, medically fragile individual for whom timely care was required.  When a resident suffers from an infection like pneumonia, delays in receiving care can contribute to the development of complications like sepsis which can in turn feed other complications.

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

Other blog posts of interest:

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

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

Feeding tube error at Aperion of Westchester

Lack of wound monitoring leads to infection at Regency Care of Morris

Untreated infection leads to resident death at Elevate Care South Holland

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

 

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

 

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

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IDPH has cited and fined Regency of Sterling nursing home after a resident underwent surgery for a infected skin tear which had not been treated while at the nursing home.

One basic fact of life is that as we age, our skin gets thinner and more susceptible to injury.  This is why bed sore prevention is a focus of care in nursing homes.  With senior citizens, one form of injury to the skin that they are susceptible to skin tears.  A skin tear is a traumatic injury to the skin which results in the separation of the skin, frequently with peeling back of the skin.

Most often skin tears can be treated relatively easily by bringing the edges of the skin together and using steri-strips and dressings to promote healing of the wound.  However, as with any wound, the occurrence of a skin tear is something that requires physician notification and ongoing monitoring for healing and signs and symptoms of infection is absolutely required.  Intact skin is the most effective barrier to having infecting organisms enter the body, and having a skin tear is a breach of the integrity of the skin.

The resident at issue sustained a skin tear to her left lower outer leg while being assisted into bed by staff.   The resident had been recognized as being at risk for skin tears, and care should have been taken by the staff to avoid injury to the skin in transferring the resident to bed.

Once a skin tear occurs, the staff is then required to care for it properly and monitor for signs and symptoms of infection.  This nursing home had specific policies and procedures in place which were intended to set forth what should be done in the event of a skin tear.  These required notification of the physician after a skin tear occurs to obtain treatment orders, following the wound orders, and ongoing monitoring by the wound care nurse.  In practice the wound care nurse would do rounds on patients with wounds weekly and she would be notified by the nursing staff that there was a new patient with a wound that required care.

The first problem that occurred here is that the first step – notifying the physician and obtaining treatment orders never happened.  There was no record in the chart of the physician being notified.  There were no orders from the doctor recorded in the resident chart.  The resident was not added to the roster of patients who required care from the wound care nurse.  The Treatment Administration Record did not show that there was monitoring of the wound or care being provided.  The basic steps to initiate care were simply not taken.

The facility policies called for an incident report to be completed – and it appears from the text of the citation that an incident report was in fact completed.  However, in a well-run facility, incident reports are more than paperwork which is finished.  They should be a catalyst for the administration to investigate and make sure that proper follow-up was being done.  The records of this resident seem to indicate that was not the case here.

The failures of the nursing home in this case do not end there, however.  Even with a wound care nurse on staff, this does not absolve the nurses and staff on the floor of their responsibility to serve as the “eyes and ears” of the doctors and to notify the doctor when a resident is demonstrating signs and symptoms of an infection.  Nurses do not need to know how to treat an infection, but they do have to be able to recognize the signs and symptoms, which can include: fever, redness and warmth of the affected area, blistering of the skin, drainage, and changes in mental status, among other signs.

Five days after the resident sustained the skin tear, the resident demonstrated increased confusion.  After the nurse on the floor did an assessment, she paged the on-call nurse practitioner who ordered the nurse to call 911 and have the resident sent to the emergency room.

Once the resident was brought to the emergency room, her temperature measured 102.6 degrees.  Her leg showed large fluid filled blisters from her ankle up to mid calf with tenderness and red and blue discoloration.  The infectious disease physician diagnosed her as suffering from necrotizing fasciitiis, or flesh-eating disease.  He recommended antibiotics and immediate surgical debridement.

There were a number of issues with the care that this resident received:

  • Depending on the facts and circumstances, the skin tear itself could be evidence of improper technique or potential understaffing of the nursing home;
  • There was no notification to the doctor or even the wound care nurse, which resulted in inadequate treatment and monitoring of the wound;
  • There was no follow-up to the incident report which was generated concerning the incidence of the skin tear;
  • There was inadequate care by the staff on the floor after the skin tear occurred, as there were likely signs and symptoms of the infection days before the nurse practitioner was notified;
  • There were multiple violations of facility policies and procedures.

All of these failures together led to the resident experiencing a devastating infection which will require significant medical care, all of which could and likely would have been avoided with routine follow-up care to the kind of injury that happens fairly frequently in a nursing home setting.  Simple steps not taken led to disaster.

One of our basic 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:

Lack of wound monitoring leads to infection at Regency Care of Morris

Fall leads to brain bleed and death at Regency Care of Sterling

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

 

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

 

 

Alden Valley Ridge fails to give resident anti-seizure medications

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

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

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

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

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

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

Other blog posts of interest:

Catastrophic brain injury from medication error at Alden Town Manor

Grove of Elmhurst resident dies due to delay in physician notification

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

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

Failure to obtain anti-seizure medication at Gilman Healthcare Center

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

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

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

 

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.

 

 

 

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.

 

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.

 

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