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Resident Chokes On Food, Dies At Midway Neurological & Rehab Center

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IDPH has cited and fined Midway Neurological & Rehab Center when the facility failed to develop an individualized plan of care that incorporated the recommendations of a speech therapy evaluation. This failure resulted in the resident choking on a meal that included lamb, falling unconscious, going into cardiac arrest and ultimately passing away a few days later in the hospital.

The resident in question had significant cognitive impairments and a history of alcohol-induced dementia.

The CNA that usually cares for the resident stated that on this day she had cut up the resident’s food but was preoccupied doing a one-to-one observation with another resident that was experiencing a behavior episode.

She did not provide any further assistance to the resident during the meal.

The CNA further stated that she often worked with the resident and that he did not need any assistance with meals. She said that she has never assisted the resident with any meals and that the only reason she cut the food up for him was because that’s what they do for all the residents on the dementia floor.

The resident, after finishing his lunch, walked out of the dining room into the hallway, where he began to have choking symptoms and jerky movements. Another CNA noticed the resident’s distress and lowered him to the ground, where he became unconscious and unresponsive. A code blue was called, and CPR was initiated as the resident had no pulse and was not breathing. Emergency services were contacted, and upon arrival, the fire department crew noted “an excessive amount of food in the patient’s airway.” The resident was transported to the hospital, where he was diagnosed with cardiac arrest due to aspiration, and a significant amount of food was removed from his airway.

Unfortunately the resident passed away in the hospital a few days after the incident, with the cause of death listed as complications of choking.

This might be written off as an unfortunate series of events . . . but upon additional investigation it becomes clear that the facility failed the resident.

Specifically, a speech therapy evaluation had identified the resident as having a swallow disorder involving the oral phase and had provided specific recommendations to facilitate safe and efficient oral intake, including general swallow techniques, alterations of liquids/solids, rate modification, bolus size modifications, and upright posture during and after meals.

In addition, two separate Restorative Nurses stated that the resident required extensive assist of one-person physical assist with meals. One nurse even stated that the staff should be assisting with feeding by sitting with the resident, cutting up the resident’s food, cueing the resident as needed, and assisting the resident with eating.

However, and critically, the facility failed to incorporate these recommendations into the resident’s individualized plan of care. The only recommendations in the care plan that concerned eating stated that the resident needed “assistance with meals as needed” and that staff members should “monitor for chewing difficulty, monitor for mouth, or tooth pain.”

Many of the recommendations concerning meals that were cited in the speech therapy evaluation or suggested by the Restorative Nurses simply never made it into the plan, and therefore were never implemented by the CNA’s as they worked with the resident in the dining hall.

Unfortunately the consequences of the oversight in this case were tragic.

Pointing to an inadequate care plan provides an easy answer as to why this resident choked on his food, but the deeper question is why this happened. The real answer to that question probably relates to the management of the nursing home – the staff was so stretched and stressed that they did not have the time or ability to give this resident’s needs the critical thought and attention they required. Unfortunately, that is typical of how nursing homes are operated.

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.

Facility Fails To Update Care Plan After Resident Falls Twice, Suffering Distal Femur Fracture

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IDPH has cited and fined Goldwater Care Bloomington after a resident experienced multiple falls, resulting in facial bruising and a distal femur fracture.

Falls are a special area of focus in the care of nursing home residents, in part because the occurrence of a fall tends to beget more falls and because the injuries sustained in falls have such a negative impact on the health, well-being, and quality of life of nursing home residents.  Nursing homes use a number of different tools to assess a resident’s fall risk, but three major factors in determining a resident’s fall risk are: (1) whether the resident has a history of falls, (2) any type of gait or musculoskeletal weakness of dysfunction, and (3) any type of cognitive impairment or lack of safety  awareness which makes it less likely that a resident will understand or follow instructions for their own safety or make good decisions regarding their own safety.

When a resident is at risk for falls, a fall prevention care plan is required.  A fall prevention care plan sets forth a series of steps that the staff will take on a day-to-day, shift-to-shift basis to prevent falls.

The first nursing home fall occurred when the resident in question was in the restroom with a CNA.  The resident was reaching for the sink when she slipped out of her wheelchair and hit her face on the sink, resulting in a bloody nose and bruising to the face.  The second fall occurred nine days later, when the resident was found on the floor after reaching for her book, falling face forward from her wheelchair.  

This second fall resulted in a distal femur fracture, a trip to the emergency room and an operative procedure to treat the injury.

There were a number of shortcomings in the care of this resident which contributed to the serious injury that she suffered.  The first involved the fact that three days elapsed after the first fall before the IDT (Inter-Disciplinary Team) met to discuss the incident and begin to put in place improvements to the care plan in an effort to prevent future falls.

Once they did meet, a health status note mentions that the resident’s care plan had been updated and a seatbelt or chest harness had been ordered.  This was to offer the resident additional support to help prevent the resident sliding out of the wheelchair.  Unfortunately it did not arrive before the second, more serious fall occurred.  

The second significant shortcoming in care was the fact that while the health status note mentions that there was an update to the care plan, the investigator was unable to find any update in the care plan nor any documentation or interventions addressing either of the falls in the plan.  As far as the care plan was concerned it was as if the falls had never occurred.  

This lack of documentation meant that no interventions were put in place after the first fall.  One can only imagine that if fall interventions had been put in place, the second, and more serious fall, might have been prevented.  

When a resident fails to get the care which is required, it raises a fair question as to whether this was an understaffed nursing home.  Residents failing to get needed care is a hallmark of an understaffed and is also a hallmark 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.   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 at Fondulac Rehab in East Peoria catches fire in smoking accident

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IDPH has cited and fined Fondulac Rehabilitation & Health Care Center nursing home in East Peoria after a resident there caught fire in a smoking accident.

People unfamiliar with the nursing home industry may be surprised to hear that nursing home residents are permitted to smoke – they are in a health care institution after all.  However, nursing homes are the homes of residents, and they are adults who are permitted to smoke if they so choose.  However, the right to smoke is not unrestricted.  Smoking is permitted only within designated areas of the nursing home home and under terms that are set by the nursing home.

There are a couple of dangers associated with smoking for nursing home residents that are not large issues with the general population, but are certainly important with nursing home residents.  The first of these is smoking near concentrated oxygen equipment, as the oxygen equipment can cause a flash fire.  The second of these is fires resulting from the mishandling of smoking materials, such as when a resident is not able to handle a lighter safely or drops lit cigarettes onto the themselves or their clothing.  This can happen when the resident has some type of movement or musculoskeletal disorder.  The dangers of all these are worse when the resident suffers from cognitive or memory impairments or from poor safety awareness.

Like any risk to the health and well-being of a nursing home resident, the risks associated with smoking should be addressed in the resident care plan.  There are six basic steps in the care planning process: (1) an assessment of the risks to the resident, (2) the development of a care pan to address those risks, (3) communication of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) evaluation of the effectiveness of the care plan, and (6) and revision of the care plan if it proves to be ineffective in practice or if the care needs of the resident changes.  Care plans should be be reviewed at least quarterly and changes made as needed.

The resident at issue here suffered from emphysema for which he was prescribed supplemental oxygen.  When he was last assessed, he had the physical ability to smoke and did not have cognitive impairments which kept him from smoking.  However, that assessment was not current, and there had not been an assessment of his smoking risk in the current quarter.  The failure of assess was important here because there had been declines in both his cognitive abilities and in his ability to use a lighter safely.

On the morning of this nursing home smoking accident, the resident stopped by the nurse’s station to get a fresh tank of oxygen and then went to the smoking patio with a another resident.  The other resident told the state investigator that they knew the code to exit the building onto the smoking patio and that they routinely smoked without staff present, despite facility policies requiring staff supervision of smoking.

The resident was unable to light his lighter himself, so the other resident went to start the lighter for him.  Unfortunately, his supplemental oxygen was on and this started a flash fire, setting the residents beard and face on fire.  The other resident grabbed the tubing and threw it to the ground and stomped out the fire, but it was too late.

The resident suffered superficial and deep partial thickness burns to his face, lips, and eye.  Soot was found in his nasopharynx and oropharynx.  He had to be intubated and placed on a ventilator and was placed under the care of a wound care physician.

There were at least failures that resulted in the injuries to this resident.  The first is that the smoking risk assessments were not kept current, and the declines in the is resident’s cognitive state and ability to safely handle smoking materials was not addressed in his care plan as a result.  Second the facility policies regarding supervision of smoking activities was not followed.  There was no staff present.  Staff would have known to make sure that the supplemental oxygen was turned off before attempting to light the resident’s cigarette.  Other residents may not know that, and responsibility for that cannot be handed off from the staff to someone else.  Clearly, the facility policies were no being followed as a matter of routine, much to the detriment of this resident.

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

Other blog posts of interest:

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

Fondulac Rehab resident suffers fatal injuries in fall

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

 

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

 

Fondulac Rehab resident suffers fatal injuries in fall

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IDPH has cited and fined Fondulac Rehabilitation & Healthcare Center nursing home in East Peoria after a resident there fell and suffered a fractured hip, resulting in his wrongful death two days later.

The care planning process is the basic tool for delivering routine care in a nursing home setting.  There are six basic steps to the care planning process: (1) assessment of the risks to the health and well-being of the resident, (2) development of a care plan which spells out various steps or interventions that are to be taken on a day-to-day, shift-to-shift basis to address those risks and assigning those measures to staff members, (3) communicating the care plan to the staff charged with carrying it out, (4) actual implementation of the care plan, (5) evaluation of the effectiveness of the care plan, and (6) revision of the care plan if it proves in effective in practice or if there are changes in the condition of the resident.

Successful care planning requires all six of these steps, but one thing that is actually required by the federal regulations is that the interventions in the care plan be individualized and suited for the resident.  In other words, the steps in the care plan itself should be tailored to the needs of the resident.

The resident involved was recognized as a fall risk.  He had a history of falls, had document cognitive impairments with severely impaired decision-making.  He used a wheelchair at times and required staff assistance for bed mobility, transfers, and locomotion.  The staff was aware that the resident would frequently ambulate within his room and transfer himself.  The fall prevention care plan called for assistance as needed when the resident was not feeling well or was weak or dizzy and as needed with change of condition.  It further included educating the resident to lock his wheelchair and to ask staff for assistance.

Two days prior to the fall, the resident had been transported to the local hospital because he was drooling, lethargic and not acting appropriately.  He was sent back to the nursing home the same day.  The following day he was having shortness of breath and below-normal oxygen saturation levels.

On the day of this nursing home fall, the resident got out of bed unassisted at 8:00 a.m. to adjust his pants.  In doing so, he lost his balance and fell to the ground, suffering a fractured left hip.   Sadly, for persons in this age cohort, hip fractures carry a high mortality rate, and this gentleman was one of those for whom a hip fracture proved fatal.  According to the coroner, the fall and hip fracture was one of the causes of this resident’s death.

There are a number of shortcomings with the care that this resident received.  First, he was a known fall risk and his behavior of walking and transferring himself in his own room was well-known to the staff.  This was a resident for whom walking in his room was a risky endeavor, and to reduce the risk of this kind of fall, he should have been kept in areas where he could be easily observed such as in the dining room or by the nurse’s station.  Secondly, his care needs required reassessment after the hospital visit two days before in terms of his strength and cognitive status.  Due to this change he likely required closer observation than usual.  Third, the steps in the care plan were not suitable.  As the nurse appropriately told the state surveyor, “I do not think educating a confused resident to ask for assistance is a good intervention for a fall.”  This is completely accurate – one of the reasons that cognitive impairments is a contributing factor for fall risk is that the resident cannot be counted upon to make good decisions for his own safety.

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

Other blog posts of interest:

Fondulac Rehab resident catches fire in smoking accident

Mason City Area Nursing Home resident suffers broken hip in fall due to failure to use gait belt

Pekin Manor resident suffers brain bleed due to fall

Mishandling of resident results in broken shoulder at Havana Health Center

River Crossing of East Peoria resident suffers brain bleed due to fall from unsafe use of lift

 

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

 

Elmwood Nursing & Rehab resident fractures and dislocates hip in two falls

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IDPH has cited and fined Elmwood Nursing & Rehabilitation Center nursing home in Maryville after a resident fractured his left hip in a fall, underwent surgery to repair that fracture, and then dislocated that same hip in a fall occurring five days after his return to the nursing home.

The initial nursing home fall occurred for a simple reason: the resident was wearing two different shoes which were of different heights leading to a loss of balance and the fall which resulted in the hip fracture.

The citation issued by IDPH does not mention whether this resident was considered a fall risk prior to the fall where the hip was initially fractured.  It appears that he was walking independently when the fall occurred, but the citation also references a statement from a nurse who described the resident as being some degree of confusion before the fall occurred.  Regardless of whether the resident was considered a fall risk, having residents in proper footwear is considered a basic fall prevention measure that should be employed for all residents.  Having shoes of different height contributing to loss of balance falls short of that standard, and if the resident was demonstrating confusion even before the initial fall, simple checks on the resident were likely in order.

After the initial fall occurred, the resident was brought to the hospital where he underwent surgical repair of the fracture.  Three days after the fall occurred, he was returned to the nursing home for further care and rehabilitation.

Upon his return to the nursing home, he would definitely be considered a fall risk based upon his history of a recent fall, together with the weakness and general musculoskeletal dysfunction from the original injury.  The fall prevention care plan included monitoring per facility protocol and reminding the resident to use a call light.  The nurse referenced earlier also advised the state surveyor that after returning from the hospital following the hip fracture, the resident demonstrated increased confusion.  Constant or intermittent confusion, dementia, poor safety awareness, or other cognitive impairments can be a major fall risk factor because the resident can no longer be counted on to follow instructions or make good decisions for their own safety.

The second fall occurred when the resident was found on the floor of his room five days after returning from the hospital.  He could not be supervised at the nurse’s station because he was required to be quarantined due to COVID restrictions.  The inability to supervise the resident along with the increased confusion that followed his readmission to the facility rendered the care plan ineffective because the regular pattern of supervision was not practicable and the resident could not be relied upon to use the call light.  Poor care plans here led to poor results, and that is what happened here.

The resident was brought to the hospital where it was discovered that the recently repaired hip had been dislocated.  Care for this injury will complicate the recovery from the initial injury and diminish the chances that the resident will ever be able to walk again.  Immobility increases the risk of further complications such as the onset of pneumonia, the development of blood clots, and/or the development of bed sores.

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

Other blog posts of interest:

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

Pittsfield Manor resident suffers fatal fall

Mar-Ka Nursing Home resident breaks both legs in fall

 

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

Pekin Manor resident suffers brain bleed due to fall

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IDPH has cited and fined Pekin Manor nursing home after a resident there sustained a brain bleed in a fall.

Falls are a significant issue in the long term care industry because of the serious adverse effects they have on the mortality rate and overall quality of life for nursing home residents.  Because of this, falls are a specific area of focus in the care planning process.  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) development of a care plan which spells out specific steps (or interventions) to be taken to address the risks to the resident’s health and well-being, (3) communication of the care plan to the staff members charged with carrying it out, (4) implementation of the care plan on a day-to-day, shift-to-shift basis, (5) evaluation of the effectiveness of the care plan on an ongoing basis, and (6) revision of the care plan if proves to be ineffective in practice of if changes in the resident’s condition warrant it.  An effective care plan is one that meets the risks of resident and are tailored to that particular resident.

When it comes to falls there is no “gold standard” risk assessment tool similar to the Braden Scale used for assessing the risk of developing bed sores.  However, there are two major fall risk factors which appear in just about every well-designed fall risk assessment tool.  The first of these is some form of balance or musculoskeletal dysfunction which leaves the resident at risk of falling.  The second major fall risk factor is some form of cognitive deficit such as constant or intermittent confusion, dementia, forgetfulness, or general poor safety awareness or judgment.  The reason that cognitive deficits contribute to fall risk is that the resident cannot be counted on to follow instructions or make good decisions for their own safety.  When the cognitive deficits are significant contributors to fall risk, the care plan should reflect this.

The resident was admitted to the nursing home as a short-term admission for rehabilitation and strengthening.  Her preliminary care plan assessed her as being a fall risk.  The care plan called for “call light education” as an intervention to address her fall risk.  During the days that followed, the full extent of her cognitive impairments became apparent.  Her Minimum Data Set (MDS), which is submitted under oath to the federal government, documented her as having severe cognitive impairments.  The nursing home social worker told the state surveyor after the fall that she suffered from cognitive impairments to the point that she was unable to recognize family members.  Her roommate told the state surveyor that she would forget things that she had been told five minutes earlier.

In light of this, call light education was an inadequate care plan.  She simply could not be relied upon to use the call light, completely undermining that as a fall prevention strategy.  Federal regulations call for residents to receive supervision and assistance as necessary to prevent accidents, and falls are a form of accident.  As the extent of her cognitive impairments became apparent, her care plan should have been revised to include supervision as a primary means of fall prevention, rather than depending on her to use the call light.

On the day that this nursing home fall occurred, the resident was found on the floor of her room with bruising to the back of her head.  She was sent to the emergency room where a CT scan showed that she suffered a brain bleed as a result of the fall.

Sadly, the basic step of having an adequate care plan was not taken in this case.  Both her doctor and the director of nursing told the state surveyor that the care plan was not proper in light of her cognitive impairments.  Without an adequate care plan, fall prevention was left to random chance.

Pointing to an inadequate care plan providers an easy answer as to why this resident fell and was injured, but the deeper question is why this happened.  The real answer to that question probably relates to the management of the nursing home – the staff was so stretched and stressed that they did not have the time or ability to give this resident’s needs to the critical thought and attention they required.  Unfortunately, that is typical of how nursing homes are operated.   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

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

Christian Nursing Home resident suffers severe leg injury in fall

University Rehab Northmoor resident suffers broken hip in fall from bed

 

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

 

Chicago Ridge Nursing & Rehab resident chokes to death

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IDPH has cited and fined Chicago Ridge Nursing & Rehab nursing home after a resident there choked to death on a sandwich.

One thing that families almost never envision being a possible outcome when they admit a family member to a nursing home is the possibility that their loved one could choke to death on food.  However, there are residents in nursing homes who are at risk of choking and sadly for some, that possibility comes to pass with deadly results.

There are two main factors that place residents at risk for having a nursing home choking accident.  The first of these is physical; the other is psychiatric or behavioral.  The kinds of physical issues that place residents at risk for choking would include things like poor dentition or some form of chewing or swallow dysfunction – often associated with neuromuscular issues such as movement disorders or the residual effects of strokes.  The kinds of psychiatric issues that may place a resident at risk for may include dementia or some form of behavioral disorder which results in compulsive or uncontrolled behaviors with regard to food.

When a resident is at risk for choking, this should be addressed in the care planning process.  This may include having a swallow evaluation done by a speech therapist to come up with modified diet orders or other approaches to eating which can serve to reduce the risk of choking.  The recommendations of the speech therapist should be incorporated into physician orders and/or the resident care plan, which then must be carried out on a day-to-day, shift-to-shift basis.

One of the kinds of records that are unique to the nursing home industry is the Minimum Data Set, or MDS.  The MDS collects information regarding the resident’s condition, care needs, and the levels of assistance needed.  The MDS forms part of the basis by which the reimbursement (or payment) levels for the nursing home are set, so there is a requirement that the MDS be completed under oath.  Because the MDS is certifying that the resident needs and is receiving a given level of care, the care shown on the MDS is usually incorporated into the resident care plan.

The resident at issue had a number of medical issues, including suffering from dementia and having had a history of stroke.   There was a physician order in place for a puree diet.  The resident had a series of know n behaviors, including frequently goin into other resident’s rooms and stealing food from other residents.  Her care plan included one person assistance and supervision while eating and supervision related to her dementia. The staff interviewed after this choking incident however told the state surveyor that she was able to eat without supervision and was alert and oriented to person, time, and place.

Her Minimum Date Set (MDS), however, told a different story.  It described her as having severe cognitive impairments.  With regard to eating, it stated that she required supervision of one while eating,  that she experienced loss of food or liquid from the mouth while eating, and that she showed signs of a swallowing disorder in the form of pocketing while eating.  This is very clearly the picture of a resident who was at risk for choking and required supervision.  This is also consistent with the care plan.

On the day of this nursing home choking accident, the resident was found unresponsive in bed with a piece sandwich in her mouth.  She was not breathing.  Paramedics were called, but since she was a DNR, they did not attempt to resuscitate her and did not bring her to the hospital.  Case of death per the death certificate was asphyxia due to choking on a food bolus.

There were a number of shortcomings in the care that this resident received which led to her death:

  • The staff was not aware of what the care plan called for – they believed that the she was capable of eating independently when she required supervision due to her swallow difficulties and cognitive impairments.  Communicating the contents of the care plan to the staff charged with carrying it out is a basic part of the delivery of care via the care planning process;
  • The care plan did not address her known behavior of taking food from other residents.  The physician’s order called for a puree diet and consumption of anything that was not pureed would be a violation of that order.  As part of the care planning process, the care plan must be revised when it prove inadequate in practice.  If the resident was taking food from other residents which placed her at risk for choking, this is a risk to the health and well-being of the resident which must be addressed in the care plan.  Sadly, it was not.
  • The care plan called for supervision of the resident, but we know that leading up to the choking incident, she obtained a sandwich from somewhere, began to eat it, and choked on it – all without the knowledge of the staff.  As noted above, the staff should have been monitoring this resident specifically for the taking of food which she was not supposed to have, but that was not being done – and it also appears that the more general supervision was lacking as well.

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

Other blog posts of interest:

Winston Manor resident chokes on peanut butter sandwich

Bella Terra Wheeling resident chokes to death

Alden Poplar Creek resident chokes to death

 

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

 

Dehydration leads to hospital admission for resident at Mattoon Rehab

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IDPH has cited and fined Mattoon Rehabilitation & Health Care Center nursing home after a resident there had to be sent to the hospital suffering from encephalopathy and acute kidney injury due to dehydration.

One of the basic commitments that nursing homes make when they accept a resident for admission is that they will do what is required to help maintain the resident’s basic health.  Many people are therefore shocked to hear of  nursing home residents suffering from conditions like dehydration and malnutrition.

This resident was admitted for treatment with IV antibiotics, including vancomycin and cephapime, for treatment of osteomyelitis and discitis.  Her medical history included congestive heart failure for which she was receiving a diuretic (commonly known as a “water pill”).  One of the effects of taking a diuretic is that you urinate frequently (hence the term “water pill”), which can lead to dehydration.  Because this is a known risk of use of a diuretic, it is something that should be addressed in the resident care plan.

The care planning process is the road map for providing much of the routine care that resident’s receive in a nursing home.  It begins with the resident assessment which identifies the known risks to the health and well-being of the resident.  From there, a care plan is developed.  This includes a series of steps, or interventions which must be taken on a day-to-day, shift-to-shift basis to minimize the risks to the health and well-being of the resident.  Once a care plan is put into place it must be communicated to the staff charged with carrying it out and then actually implemented on a day-to-day, shift-to-shift basis.

When a resident is at risk for dehydration due to the use of a diuretic, this is something that should be addressed in the resident care plan.  This would include simple measures such as encouraging fluids, monitoring fluid intake, and monitoring signs and symptoms of dehydration.  These would include a dry mouth, diminished urine output, darker colored urine, and increased lethargy and confusion.

Having and executing a care plan to address the risk of dehydration is especially critical in residents who are receiving the antibiotic vancomycin.  Vancomycin is known to have adverse effects on the kidneys, made worse when the patient is suffering from dehydration.

When the resident was admitted to the nursing home, she was assessed as having no cognitive issues, was alert and oriented, and able to make her needs known.  Over the first few days of her admission to the nursing home, she was not eating much and was only taking a few sips of water.

One the sixth and seventh days after she was admitted to the nursing home, the staff noted that the resident was having disorganized thinking, difficulty with finding words, and slowed response times.  The resident chart further recorded that had poor appetite and was tired.  These were signs and symptoms of dehydration.  The onset of these signs and symptoms represented a change in resident condition which should have prompted physician notification.

On the eighth day after she was admitted, a nurse returned from vacation and cared for this resident for the first time.  She was advised by the staff that the resident was able to make her needs known and was alter when she was admitted.  The nurse contacted the resident’s physician who ordered labs drawn the next day.

Unfortunately, the evening, the resident experiencing muscle jerking and twitching and was sent to the hospital.  Labs drawn there showed elevated BUN and creatine levels – markers of dehydration and diminished kidney function.  The resident was diagnosed with acute kidney injury and encephalopathy (brain dysfunction) all related to her dehydration.  She had to be admitted to receive fluids – something which is dangerous for a patient suffering from congestive heart failure as this resident was.

Additionally, the resident was discovered to have developed multiple bed sores.  When the resident was admitted to the facility, she did not have any skin breakdowns.  Federal regulations require that resident receive care, treatment, and services necessary to prevent the development of bed sores.  Dehydration is a known risk factor for the development of bed sores.  Immobility is another one, something that was likely true for this resident as she became weak and lethargic due to her dehydration.

These issue – the dehydration and all of its complications, as well as the bed sores – are the simple result of routine care not being provided to this resident.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Mattoon Rehab resident dies from infected bed sore

Arcadia of Danville resident dies due to improperly treated urinary tract infection

Failure to report changes in condition at Heritage Health in Carlinville

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.

 

Moweaqua Rehab resident fractures hip in fall

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IDPH has cited and fined Moweaqua Rehabilitation  & Health Care Center nursing home after a resident there suffered a fractured hip in his second fall in as many days.

Falls are a major issue in the long-term care industry.  Virtually all of the patient population in nursing are either elderly or medically frail (or both).  The statistics are that a significant portion of the senior citizens who suffer hip fractures die within 6 months of the injury due to either intra-operative or post-operative complications or due to complications brought on by debility from the injury.

Because falls represent such a risk to the health and well-being of nursing home residents, they are a major focus of the care planning process.  The care planning process is fundamental to the delivery of routine care in nursing homes.  In short, it is a process by which the risks to the health and well-being of the resident are identified and steps, or interventions, are put into place to prevent that harm from coming to fruition.

There are six steps to the care planning process: (1) the assessment of the risks to the health and well-being of the resident, (2) the development of a written care plan, (3) communication of the care plan to the members of the staff charged with carrying it out, (4) implementation of the care plan on a day-to-day, shift-to-shift basis, (5) evaluation of the effectiveness of the care plan, and (6) revision of the care plan if it proves to be ineffective in practice or if the care needs of the resident change.

When a resident experiences a fall, even one with no injury, this is a major event which requires physician notification and evaluation of the care plan.  The reason the reevaluation of the care plan is required is because (a) it may not be effective, seeing as a fall just occurred and (b) it is well-recognized that falls tend to beget additional falls, so that after a fall has happened, the resident’s fall risk is actually higher than it was even the day before.

The resident at issue suffered from multiple conditions and had been assessed as a high fall risk.  The first fall occurred just after 2:00 p.m. when the resident was found on the floor of his bathroom with his pants around his ankles.  The cause of the fall was specified as resident actions with no further description or revision of the care plan.  The next fall occurred at 7 am the following morning where the resident was again found on the floor of his bathroom.  The investigation revealed that the resident was tryin to pull his pants up and lost his balance.  The Director of Nursing reported to the state inspector that the resident required assistance but would refuse to use the call light at times.

The citation revealed a couple of important points.  First, the staff knew that the resident had behavior of getting up without using his call light.  This kind of behavior is a powerful contributor to fall risk – and to the extent that it was a known behavior, it should have been accounted for in the care plan.  Second, there was apparently no consideration given to revising the care plan in light of the fall.

There were a number of steps which could have been taken to help prevent this fall.  Putting the resident on amore aggressive rounding schedule would likely have been of help.  The other measure would be to put the resident on a toileting schedule.  How this works is that the resident’s bathroom habits are observed over a period of days, and when this happens, certain patterns are likely to emerge.  Once the pattern is identified, the resident is assisted to the bathroom and through going to the bathroom.  The net result of this should be that the resident is not left unattended in the bathroom.

Of note, one of the fall prevention measures taken was that a sign was placed in the resident’s room reminding him to call, not fall.  Unfortunately, the resident was blind, leaving this of questionable value.

After this nursing home fall was discovered, the resident was brought to the hospital where he was diagnosed with a fractured hip and a collapsed lung.

The injuries to this resident could have been prevented with the application of critical thought about his care needs.  However, nurses in a nursing home setting are often given too little opportunity for this given the demands of the residents they care for.  Sadly, this is a direct result of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Loft of Rock Spring resident suffers hip fracture in fall

Resident at Hickory Point Christian Village in Forsyth suffers multiple fractures in fall

Fall with broken hip at Heritage Health in Mt. Zion

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

 

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

 

 

Christian Nursing Home resident suffers severe leg injury in fall

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IDPH has cited and fined Christian Nursing Home in Lincoln after a resident there suffered a serious injury to her leg after a fall after experiencing two falls during the first three days she was in the nursing home.

The resident at issue was admitted to the nursing home for rehabilitation after having a stroke which left her with some left-sided residual weakness.  Before that, she was living in the community and had 24-hour care because she had some issues with dementia.

When a resident is admitted to a nursing home, a care plan must be developed.  There are six basic 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 outlining the various steps, or interventions, which must be taken by the staff on a day-to-day, shift-to-shift basis to address the risks identified during the assessment.  These must be tailored to the specific needs of the resident.  Third, the care plan must be communicated to the staff.  Fourth, the care plan must in fact be implemented on a day-to-day, shift-to-shift basis.  Fifth, the effectiveness of the care plan must be evaluated on an ongoing basis.  Sixth, it must be revised when it proves to be inadequate in practice of due to changes in the condition of the resident.

One area that is always assessed in the care planning process is the resident’s fall risk.  This is because falls are a well-recognized threat the life and well-being of nursing home residents and because there are federal regulations on falls.  There are no gold standard tools for assessing fall risk in nursing homes like how the Braden scale is used for the risk of developing bed sores, but almost all of the assessment tools have some features in common.

Two of the commonly recognized risk factors includes (1) some degree of musculoskeletal, gait, or balance dysfunction and (2) dementia, intermittent of constant confusion, and/or poor safety awareness or judgment.  The physical aspect relates to the resident’s ability to safely walk, stand, transfer, or even maintain a seated position.  The cognitive aspects come into play because where a resident has cognitive deficits or poor safety awareness or judgment, they cannot be counted upon to make good decisions for their own safety or follow safety instructions.  These are factors which must be taken into account in developing the resident’s care plan.

On admission, the resident was assessed as being at high risk for falls.  Findings in the assessment included: unsteadiness while walking, use of a wheelchair, rushing to use the bathroom due to incontinence of bladder, significant cognitive impairments, and impaired functional problem solving and safety awareness.  The care plan included frequent checks and assistance with transfers.

The first nursing home fall occurred during the evening of the second day of her admission.  The resident had been changed into clothes for bed, but within an hour was found on the floor dressed in her normal clothes.  She told the staff that she wanted to get changed before her husband came home, obviously showing a significant degree of disorientation and cognitive impairment.

The occurrence of this fall was a significant event.  First, it showed that the resident had more significant cognitive impairments than was perhaps initially recognized.  Second, it is well-recognized in the long-term care industry that falls tend to beget more falls.  For this reason, revision of the care plan was required.  And it was – to add in a sign to remind the resident to call, not fall.

The second fall occurred the following day.  An aide was going down the hall, shutting off lights at bed time and checking on residents.  When she got to this resident’s room, she saw that the resident was not in bed.  She went into the bathroom and found the resident on the floor, not wearing shoes, just socks.  There were obvious signs of injury to her left leg, so she was sent immediately to the hospital.  There she was diagnosed with dislocation of the hip and a fractured femur.   She was then transferred to another hospital for surgery.

The investigation into this revealed a number of shortcomings in the care that this resident received.  As a starting point, they failed to take into consideration the fact that the resident had 24-hour care at home and had significant cognitive deficits even though those items of information were a part of the information that the nursing home received from the hospital at the time of transfer.  Had they been taken into account, the Director of Nursing admitted to the state surveyor that the resident would have been admitted to the dementia unit where the staffing patterns would have allowed for increased supervision which may have prevented the fall.

Past that there were a number of shortcomings in the care that this resident received.  First there was no effort at implementing a toileting schedule for an incontinent resident who suffered from significant dementia and was a high fall risk.  Second, the care plan did not include use of proper footwear – a key point since the resident was found on the floor at the time of her second fall wearing only socks.  Finally, the revision to the care plan after the first fall was wholly inadequate.  That first fall was her dementia and poor safety awareness/judgment in action and relying on her to read and heed a sign was foolish.

The net effect of all these is that this resident suffered a serious and unnecessary 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:

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

Resident breaks hip in fall at McLean County Nursing Home

Piatt County Nursing Home breaks neck in fall from power recliner

University Rehab Northmoor resident suffers fractured hip in fall from bed

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

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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.

 

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