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

Chicago Illinois Accident Lawyers

 CALL (312) 263-1080

Failure to treat infection leads to resident death at Elevate Care South Holland

By

IDPH has cited and fined Elevate Care of South Holland nursing home after a resident there died as a consequence of an infection of his dialysis fistula going untreated.

One of the basic truisms of care in a nursing home is that doctors are not present in a nursing home 24/7 the way that they are in a hospital.  Therefore, in the absence of physicians being in the building, nurses must act as “the eyes and ears” of physicians with regard to the residents who are under their care.  In that role it is part of their job to notify physicians of changes in the condition of the residents who are under their care as well as events such as the development of bed sores, medication errors, choking incidents, and falls.  After a doctor is notified of one of these things, the doctor has the option to issue orders for care over the phone, come into the nursing home to see the resident, or order the resident sent out to the hospital.

One of the types of conditions that nurses must notify doctors about is the onset of signs and symptoms of infection.  Nurses do not need to know whether what they are seeing is actually an infection, what kind of infection it is, or how to go about treating it – although experienced nurses often have a solid idea about all of these issues.  The most common course of action is to start an antibiotic and to obtain a relevant culture (for example, a urine culture if a urinary tract infection is suspected) to confirm the presence of the infection and whether the antibiotic ordered is appropriate for the type of infecting organism.

The resident at issue was a dialysis patient and had an AV fistula (the port through which dialysis is done) on his right upper arm.  The facility wound care nurse performed a routine readmission skin assessment on the resident and saw that there was purulent drainage coming from an abscess on the right upper arm.  The wound care nurse notified the resident’s nurse practitioner via text message and advised her that there was a wound with some drainage and that a wound culture had been obtained.  The wound care nurse also claims to have notified the wound care physician, but according to the citation, he denied knowing about the abscess until he was in the facility three days later.

The resident was scheduled for dialysis the following day but did not receive it for reasons that are not clear from the citation.  However, the nephrologist stated that had he been made aware of the presence of an abscess near the dialysis fistula, he would have obtained a wound culture and started an IV antibiotic through the dialysis fistula immediately.

The wound care physician arrived in the nursing home three days after the abscess was first noted.  He ordered Keflex, an oral antibiotic, and a consult with an infectious disease physician.  However, the nursing home did not have the antibiotic in stock and when they attempted to reach the infectious disease doctor, they only reached his answering service.  The antibiotic did not get delivered before the resident was sent to the hospital.  Therefore, neither of the orders were actually implemented before the resident was sent to the hospital the following morning.

The next morning the nurse on duty recognized that the resident’s condition was declining and his vital signs were troubling, so she called 911 to have the resident sent to the hospital.  The preliminary diagnosis there was that he suffered a stroke, so an MRI of his brain was ordered and this should evidence of septic emboli and a cerebral abscess – signs that the infection had migrated to his brain.  It was determined that he had a poor chance of neurological recovery and that he was a poor surgical candidate, so the family opted for comfort measures only, and he died five days later.

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

  • The skin assessment where the abscess was discovered was a readmission assessment.  Where was he being readmitted from and why was the infection not addressed there?  The citation does not give any indications on this issue.
  • It is unclear whether the wound care physician was in fact notified of the presence of the infection – the wound care nurse from the nursing home yes, the doctor says no.  There are a number of ways of resolving that issue.  One way would be to see who issued the orders for the wound culture and dressing.  Otherwise it becomes an issue of getting into phone records and the electronic medical record if it had a electronic messaging platform integrated with it.
  • Assuming that both the nurse practitioner and the wound care doctor were timely notified, the discussion ended without an order for an antibiotic.  An experienced nurse would have recognized that the usual course is to initiate antibiotics before the results of the culture are received.  In her role as a patient advocate, the nurse should have asked whether they wanted one started.
  • There were no clear lines of responsibility for who was managing this portion of the patient’s care.  It is a common adage that when everyone is responsible, no one is responsible.  Sadly, no one appears to have taken charge to ensure that the resident had an antibiotic started.
  • It appears that the resident did not go to dialysis as scheduled the day after the abscess was discovered.  The dialysis fistula is something that directly impacts the care that a nephrologist gives, but no one alerted the nephrologist about the apparent infection in the area.  It is clear from the citation that the nephrologist would have addressed the abscess with a good deal more urgency than either the wound care physician or the nurse practitioner.
  • When the antibiotic was ordered but not available, no one advised the wound care physician of this.  Many nursing homes carry a “house stock” of commonly used medications, and the one ordered would have likely fallen into that category.  When it was not available, the failure of the staff to notify the wound care doctor that they could not give the antibiotic as ordered denied the wound care doctor the opportunity to choose a different course of action – such as a different medication or ordering the resident to the hospital.  When an infection is left untreated, it can only be expected to worsen the in medically compromised population found in nursing homes.

This series of failures in the care that the resident received ultimately ended up causing his 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.

Other blog posts of interest:

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

Heartland of Galesburg resident dies due to untreated urinary tract infection

Resident suffers flesh-eating infection due to untreated skin tear at Regency of Sterling

 

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

Mattoon Rehab resident dies from infected bed sore

By

IDPH has cited and fined Mattoon Rehabilitation & Healthcare Center nursing home after a resident there died due to a bed sore that developed in the nursing home and became infected due to poor care.

“Bed sores” are the commonly used term for pressure ulcers, which are breakdowns in the skin which can lead to infections and other serious negative health consequences.  There are specific federal regulations which address the development and care of bed sores, so they are a source of intense focus in the long-term care industry.

There are actually two separate federal regulations which address the topic of bed sores.  The first relates to what is required when a resident is admitted to a nursing home without bed sores.  This provides in essence that a resident should receive care necessary to prevent the development of pressure ulcers unless the clinical condition of the resident demonstrates that they were unavoidable – which is a very high standard to meet.  The second addresses what happens after a resident has a bed sore.  In essence it provides that a resident must be provided care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new bed sores.

There are a number of factors which place a resident at risk for developing bed sores.  The most common are immobility, incontinence, and poor nutritional status.  There are other factors as well, and these are wrapped into an assessment tool known as the Braden Scale, which measures the resident’s risk of developing bed sores.

When this resident was admitted to the nursing home, she did not have a skin breakdown on her sacral area and was assessed as being at moderate risk for skin breakdown.  The citation does not describe a care plan having been created to address the resident’s risk of developing bed sores.  Since the resident was at risk, there should have been one created.  Some of the common steps would have included a turning and repositioning schedule to relieve pressure on the resident’s skin.  It should have also included a plan for prompt incontinence care as the chemicals in urine and feces as well as the associated moisture contribute to the breakdown of the skin.  These steps were necessary because the resident was dependent on the staff for bed mobility and toileting.

The resident’s record reflected that during 31 days she was in the nursing home, she was toileted two or more times on only 12 days. During the first three weeks the resident was in the facility, she was only bathed twice.  This lack of incontinence care means that the resident’s skin was being subject to breakdown from urine and feces. This was consistent with the observations of the family who told later treating health care professionals that the resident was often soaked in urine.

Nine days after admission, the resident was first identified as having a skin breakdown.  When a skin breakdown occurs in a nursing home resident, this is a change in condition requiring physician notification.  The purpose of notifying the doctor is to allow the doctor to either issue treatment orders over the phone, come in to see the resident, or have the resident sent to the hospital.  Beyond this, the wound must be described in the medical record, including the size and depth of the wound as well as its other characteristics.  This allows the care team to determine whether the wound is getting better or worse and whether the treatment being provided is effective or not.  It also should have triggered either the development of a care plan for pressure ulcers or a revision in the existing one, if there was one.

Even though these are basic, well-established first steps, neither were taken when the resident first showed signs of skin breakdown.  In fact neither of these steps were taken for another two weeks.  When the physician was notified, he gave orders for care and for consultation with the wound care physician.  However, that consultation was never obtained.  When there was finally a description of the wound in the chart, it was described as being 8.2 cm x 5.5 cm with 80% covered in slough (soft, dead tissue).  It was further noted that the pressure ulcer was acquired in-house.

Five days later, the resident’s chart showed that there a foul-smelling discharge coming from the wound.  This is a sign of infection.  A call was placed to the physician who ordered an antibiotic.  Later that same day, the resident fell from her wheelchair.  She had complaints of pain, so she was sent to the emergency room.

The emergency room staff recognized that the wound was in poor condition and had a surgical consult done in the emergency room.  These resident was brought into surgery two days later where the surgeon described the wound as being 21 cm x 10 cm (8×4 inches) with exposure of the periosteum (the layer of nerves and blood on the outer layer of the bone).  

Given the severity of the wound combined with urinary and stool incontinence, the surgeon recommended that the resident be placed on hospice.  She died five days later.  Cause of death was a Stage IV decubitus ulcer (pressure ulcer).

There are a number of failure in the care of this resident which led to her death:

  1.  There was a failure to provide routine preventative care, including turning and repositioning and prompt incontinence care.  If there was a care plan (and the citation in silent on that issue), these are steps which should have been included and carried out.  If there was no care plan, that is a separate failure.
  2. Once the bed sore developed, there was a delay in excess of two weeks in notifying the physician.  This resulted in the resident not receiving treatments over that period.  
  3. The development of the bed sore should have triggered either the development of a care plan or revision of one.  Clearly whatever steps were being taken was not sufficient to prevent the breakdown of this resident’s skin, so a new course of action was required.
  4. The consultation with the wound care physician was not obtained.
  5. The condition of the wound was not being tracked by the facility staff.  This wound deteriorated rapidly, but there were only two time that the condition of the wound was documented – when the first set of measurements were taken and when there was foul discharge from the wound.

There are likely a long list of other failures.  The sad fact about bed sores is that these are injuries which do not occur in a flash moment of time such as with a nursing home fall or a choking accident.  Rather these were failures that spread across multiple days, multiple shifts, multiple staff members.

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

Other blog posts of interest:

Newman Rehab resident suffers burns to leg from hot radiator

Dehydration leads to hospitalization for resident at Mattoon Rehab

Resident at Bridge Care Suites dies from infected bed sore

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

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

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

By

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

By

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.

Heartland of Galesburg resident dies due to untreated urinary tract infection

By

IDPH has cited and fined Heartland of Galesburg after a resident there died due to sepsis brought on by an untreated urinary tract infection.

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.  It is up to the doctor to make a diagnosis and decide how to treat the resident.  The nurse simply needs to be able to identify the change in condition, notify the resident’s physician, and give the doctor sufficient information for the doctor to make good decisions.

The presence of a urinary catheter places a resident at increased risk for developing a urinary tract infection.  There are a number of reasons for this, including the fact that the presence of the catheter opens up the body for entry of infecting organisms; bacteria can colonize the catheter itself; and the placement of the catheter can cause trauma to the urinary tract  and/or obstructions to the outflow of urine.  Because the risk of urinary tract infections is increased, their use is discouraged by federal regulations.  There must be medical justification for the use of a catheter in a nursing home, including a physician order for it.  Nursing homes are required to evaluate the use of a catheter on an ongoing basis and obtain orders for its removal when possible.  Catheter care, including monitoring for signs and symptoms of urinary tract infections, must be addressed in the resident care plan.  A well-done care plan will include monitoring for signs and symptoms of infection.

Nurses must know and be able to identify signs and symptoms of a urinary tract infection.  These may include: burning while urinating; foul-smelling, cloudy, or bloody urine; back or flank pain; mental status changes such as confusion or delirium; fever; and weakness or lethargy.  When a resident demonstrates signs and symptoms of a urinary tract infection, the nurse must notify the doctor who then must decide whether to order treatment over the phone (usually in the form or ordering a urinalysis and prescribing an antibiotic), come to the nursing home to evaluate the resident, or send the resident to the emergency room.  Left untreated, a urinary tract infection can cause sepsis leading to multi-organ failure and death.

The resident at issue was admitted to the nursing as a short-term admission to undergo rehabilitation after suffering a nondisplaced hip fracture at home (i.e., one that did not require surgery).  While she was in the emergency room, the staff there placed a catheter so that she would not have to get up to urinate.  Before that, there was no need for a catheter.  When she was transferred to the nursing home the following day, the catheter was left in place.  However, there were no orders entered for the use of the catheter and no assessment made of the suitability of removing the catheter.

Just over a week after the resident was admitted to the nursing home, the nurses noted on consecutive days that the resident had cloudy urine.  This is one of the signs of a urinary tract infection.  However, there was no notification of the doctor.  There were two additional days in which there was no note at all. However, aides told the state surveyor that in the interim, the urine had gained a foul odor and that there was

On the afternoon of the fourth day after the urine turned cloudy, the resident became lethargic.  It was recognized by the physical therapist, who reported it to the nurse on duty.  The nurse also noted that the resident was less talkative.  That evening, the nurse on duty also noted that the resident was lethargic, so she sent a fax to the resident’s doctor at 9:40 p.m.  Because the information was faxed to the doctor rather than the subject of a phone call, the doctor was not aware of the change in condition until the resident was already in the hospital the following afternoon.

Over the next day, the resident continued to decline until by early afternoon, the nurse on duty called 911 to have the resident transferred to the hospital.  The paramedics report stated that the resident had been sick since the day before and became unresponsive in the morning.  Upon arrival at the hospital, the resident was obviously ill – her appearance was described as “toxic”.  The collection bag for the catheter was described as being filled with dark brown urine with clumps of pus in it.  The urine was foul-smelling to the point that it made the nurse in the emergency room nauseous.  The catheter was changed out, but very little urine came out once the new catheter was placed.  This was an indication that the resident was in kidney failure due to sepsis.

The resident passed away approximately 12 hours after arriving in the emergency room.  Cause of death was multi-organ failure due to sepsis from the urinary tract infection.

There were multiple failures in the care of this resident that led to her death:

  • The nursing home allowed the resident to remain catheterized without a physician’s order for it use;
  • The nursing home allowed the resident to remain catheterized when there was no medical justification for the use of the catheter;
  • There was no assessment as to whether the resident’s condition actually required the use of a catheter;
  • The care plan for the use of the catheter included monitoring the resident for signs and symptoms of infection and notifying the physician of the onset of such.  This was not done;
  • Failed to notify the physician of the initial development of cloudy urine, which would have likely led to a urinalysis being done – and just as likely, an order for the removal of the catheter, since the doctor was familiar with the patient outside the nursing home and knew that she did not need a catheter;
  • Failed to recognize the development of a foul odor to the urine and the presence of pus in the urine – clear markers of infection;
  • Failed to report the onset of lethargy to the doctor to the doctor when it was reported by physical therapy;
  • When the staff finally notified the doctor of the onset of the change in condition, they did so by fax rather than calling the doctor, resulting in the doctor not receiving the communication from the nursing home;
  • Failed to notify the doctor the morning that the resident was transferred to the hospital of the declines that occurred overnight; and
  • The nursing home did not have policies and procedure in place regarding catheter use and care.

Ordinarily urinary tract infections are easily treated with antibiotics.  However, when there are substantial delays in the treatment of a urinary tract infection and can lead to sepsis, multi-organ failure, death – as happened here.  There were many opportunities for this tragic outcome to be avoided and to allows this resident to return home.  Sadly, they were all missed, over a period of several days and multiple shifts.

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:

Champaign-Urbana Rehab resident admitted to ICU due to untreated urinary tract infection

Rushville Nursing & Rehab resident suffers untreated surgical wound infection

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

 

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

By

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.

 

Champaign Urbana Nursing & Rehab resident admitted to ICU due to untreated urinary tract infection

By

IDPH has cited and fined Champaign Urbana Nursing & Rehab nursing home in Savoy after a resident there had a urinary tract infection go untreated for over a week due to the failure of the nursing staff to timely notify the resident’s doctor of changes in the resident’s condition and carry out orders for a urine culture.

When it comes to the relationship between nurses and doctors in a nursing home setting, nurses are responsible carrying out two major functions.  First, because doctors are not present in the nursing home on a 24/7 basis, they must serve as the “eyes and ears” of the doctor and report changes in the resident’s condition, including the presence of signs and symptoms of infection.  Second, nurses must timely carry out orders by the doctor for treating the resident.

The presence of a urinary catheter places a resident at increased risk for developing a urinary tract infection.  There are a number of reasons for this, including the fact that the presence of the catheter opens up the body for entry of infecting organisms; bacteria can colonize the catheter itself; and the placement of the catheter can cause trauma to the urinary tract  and/or obstructions to the outflow of urine.  Because the risk of urinary tract infections is increased, their use is discouraged by federal regulations.  Catheter care, including monitoring for signs and symptoms of urinary tract infections, must be addressed in the resident care plan.

Nurses are not required to be able to diagnose urinary tract infections or determine how to treat them, but they do need to know and be able to identify signs and symptoms of a urinary tract infection.  These may include: burning while urinating; foul-smelling, cloudy, or bloody urine; back or flank pain; mental status changes such as confusion or delirium; fever; and weakness or lethargy.  When a resident demonstrates signs and symptoms of a urinary tract infection, the nurse must notify the doctor who then must decide whether to order treatment over the phone, come to the nursing home to evaluate the resident, or send the resident to the emergency room.

The resident at issue had an enlarged prostate.  This caused him to experience urinary retention which is a risk factor for developing urinary tract infections.  To alleviate the urinary retention, use of a catheter was ordered.  The risk of developing a urinary tract infection was something that was specifically addressed in the resident care plan and physician orders.

The resident initially developed signs and symptoms of a urinary tract infection in the form of a fever and pain and burning with urination during the early morning hours on a Saturday.  The doctor was properly notified and ordered a urinalysis and culture and sensitivity test.  The nurse collected the urine sample.  However, the lab with whom the facility had a contract did not do pick ups on the weekend, so it was not brought to the lab until Monday.

When the results of the urinalysis were returned that same Monday, the nurse called the results over to the doctor.  However, the culture and sensitivity results were not available, so the doctor did not order any antibiotics.  Those results were not received until Wednesday.  However, no one called the doctor to inform him of the results of the the culture and sensitivity.  Usually, this testing is used to help determine what antibiotics the infection is susceptible to.  Without those results, there were no antibiotics ordered.

On Friday (one week after the signs and symptoms of the infection first appeared), the resident complained of painful urination which was producing bloody, cloudy, foul-smelling urine.  These are all signs of a urinary tract infection.  The nurse on duty called the nurse practitioner who ordered a urinalysis and culture and sensitivity.  However, given that this was a Friday and the lab had already come for the day, the nurse put in the order for the testing to be done the next day that the lab was in the building which would be the following Monday.

The urine culture was done the following Monday and the results arrived on Tuesday.  Based on the results, the nurse practitioner ordered an antibiotic for the resident.  However, the resident’s condition continued to decline, and he was brought to the emergency room two days after starting the antibiotic suffering from severe sepsis.  The infectious disease specialist noted that the resident had been having pain with urination for two weeks and that the catheter appeared to be infected.  The resident was sent to the Intensive Care Unit due to the severity of the infection.

There were a number of shortcomings in the care that this resident received leading to him developing severe sepsis requiring the admission to the Intensive Care Unit:

  1.  Neither the doctor nor the nurse practitioner were informed that the urine sample they ordered taken could not be delivered to the lab until the following Monday.
  2. The doctor was not informed of the result of the culture and sensitivity, delaying the start of antibiotic therapy.
  3. The catheter was described as having an infected appearance, indicating that there was poor catheter care throughout.
  4. The resident doubtless continued to have signs and symptoms of the a urinary tract infection after the signs first appeared, but there were only two notifications made to medical providers outside the nursing home.

All of these delayed the start of effective care for the urinary tract infection, resulting in the resident to experience such severe sepsis.  It is well-established that early intervention in an infection helps yield better outcomes and prevents the worsening of the infection into the kind of severe sepsis that this resident experienced.  Multiple chances a better outcome were let go by the wayside.

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

Dehydration leads to hospital admission for resident at Mattoon Rehab

Aperion Care of Wilmington resident suffers ruptured colon from fecal inpaction

Failure to notify doctor of abnormal labs at Momence Meadows

 

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

Rushville Nursing & Rehab resident suffers untreated surgical wound infection

By

IDPH has cited and fined Rushville Nursing & Rehabilitation Center nursing home after a resident there suffered significant complications from an untreated surgical wound infection.

One of the common reasons that people are admitted to nursing homes is for rehabilitation after a hospitalization.  This may include post-surgical care.  One of the basic functions of the nursing staff in caring for residents who are admitted for post-surgical care is to monitor for signs and symptoms of infection.  Signs and symptoms of infection may include abnormal white blood cell counts; foul-smelling purulent drainage (pus); fever; redness and warmth around the surgical site; the presence of slough and necrotic tissue; confusion; increased respiratory rate and pulse; and low blood pressure.

Nurses do not need to know how to treat an infection – that is for the doctors to determine.  However, because doctors are not present in an nursing home 24/7, the nursing staff is the “eyes and ears” of the doctors and must notify the doctor when signs and symptoms of infection are present.  The doctor then can decide to come to the nursing home himself to treat the patient, issue orders over the phone, or order the resident sent to the hospital to receive care there.

The resident involved was admitted to the nursing home after undergoing a complicated abdominal surgery which resulted in multiple surgical wounds, the placement of abdominal mesh, a surgical drain, and the need for the use of a wound vac.  However, there was no evidence of a wound infection at the time the resident was admitted to the nursing home, and the day before the resident was transferred, her lab work showed that there was a normal white blood cell count.  The orders were for dressing changes every Monday, Wednesday, and Friday and to return to the wound care clinic two weeks later.

The first 10 days after the resident was admitted to the facility were relatively unremarkable.  However, two days before she was to go to the wound clinic, the floor nurse noted a very foul odor to the would.  She notified the wound care nurse, who was scheduled to see the resident and do a dressing change that day.  The wound care nurse noted tunneling in the surgical wound, purulent drainage, a foul odor, reddened skin on the edges of the wound, moderate slough and necrotic tissue.  These were obvious signs of infection.  She faxed a note to the doctor’s office asking for an order to give an antibiotic.  In response, the physician’s nurse practitioner called and asked the floor nurse to check for warmth around the edges of the wound.  The floor nurse reported back that there was no warmth present, so the nurse practitioner decided to assess the wound herself the following day.

When the nurse practitioner arrived the following day, the wound vac and dressing were in place.  She chose to not take down the wound vac and the dressing to assess the wound itself. Seeing no signs of infection on the exterior and with the resident not running a fever, she decided to let the wound clinic address things when the resident went in for her appointment the following day.

The next day, the resident had her scheduled appointment with the wound care clinic.  However, when the transportation aide arrived in the resident’s room to take her to her appointment, she discovered that the resident was not dressed and could not be make the scheduled time at the wound clinic.  The staff told the aide that they did not get the resident dressed because they were unaware of the appointment at the wound clinic.  The clinic advised that they could not get her in later that day, so the appointment was rescheduled for five days later.  Later that same day, lab work for the resident showed an elevated white blood cell count.

Three days later the notes in the resident’s chart show that there was a foul odor and slough in the wound bed with edges of the wound being reddened.  However, there was no notification of the doctor of this.  The following morning, there as foul smelling drainage coming from the drain, but the doctor was not notified.  That evening, there was additional foul-smelling drainage from the drain, so the nurse on duty faxed a note to the doctor’s office after hours.

The next day was the rescheduled appointment at the wound clinic.  That morning the staff at the nursing home noted that the drain was producing thick, brown drainage.  The nurse practitioner was in and noted that the fax the day before had been received after hours and that the resident was scheduled to go to the wound clinic later that day.

On arrival, the staff at the wound clinic noted that the resident did not look well.  They took her blood pressure and found that it was low.  Inspection of the wound revealed that the abdominal wall had separated and that there was fecal matter in the wound and draining into the drain.  They concluded that the wound was badly infected and had the resident transferred to the hospital.  The nurse practitioner at the wound clinic later told that the state surveyor that the wound had not been cared for appropriately at the nursing home and that the wound did not deteriorate to that extent overnight.  She also said that the nurse practitioner at the nursing home told her that the staff at the nursing home did not tell her of the extent of the deterioration of the wound and that she had only looked that he exterior of the wound with the wound vac and dressings still in place.

At the hospital, lab work showed that the resident’s white blood cell had increased further.  She was diagnosed as suffering from low blood pressure, a necrotic wound of the abdominal wall with surgical site dehiscence, fecal matter draining into the surgical wound, and an intrabdominal infection.

As a general proposition, early intervention with an infection yields better outcomes.  There were a number of times when earlier intervention would have been appropriate, but the infection went unchecked for a week after the first signs of infection were present.  This allowed the infection to spread and worsen.  This resident will likely have to undergo multiple surgeries to try to resolve this infection and undergo a lengthy course of antibiotics.  Once the infection is clear, there will likely be extensive surgical wounds which will be difficult to close, leaving this resident at risk for further infections and complications.

There are a number of places where earlier action should have been taken which would have led to an improved outcome for this resident:

  • When the floor nurse first recognized that there was a foul odor to the wound, this was a sign of infection.  This in itself required physician notification, not just referral to the wound care nurse.  The wound care appropriately asked for an order for antibiotics.  The nurse practitioner should have likely given the order.  However, the content of what was communicated to the nurse practitioner is important because it was apparently not enough to justify a phone order for the necessary antibiotics.  Nurses need to communicate enough information to provide a basis for medical decision-making.
  • When the nurse practitioner came in the following day, she assessed the wound without taking down the wound vac and the dressing, making it impossible to see what was actually underneath.  This deprived her of vital information for her decision-making.  The supervising physician for the nurse practitioner reportedly told the administrator that he did not condone the practice of trying to assess the wound without removing the wound vac and dressing.
  • On the day of the scheduled appointment, the resident was not dressed and ready to go resulting in the cancellation and rescheduling of the appointment.  The resident was not ready to go because the staff was reportedly not aware that she had an appointment.  Getting residents to scheduled doctor appointments is a basic function in providing care in this setting.  There was a clear breakdown in that process.
  • Once it became apparent that the resident was not going to make the appointment as scheduled, the urgency of the resident being seen was not communicated to the wound care clinic.  The staff already had concerns about the resident having an infection and part of the thought process for the nurse practitioner the day before had been that there was a pending wound care clinic appointment.  When that was not going to happen, the clinic needed to know that there was some urgency for them to see the resident, and why.
  • During the days leading up to the rescheduled wound clinic appointment, the resident doubtless continued to show signs and symptoms of infection, most of which were not noted by the staff.  The few times that there notes suggestive of the presence of infection, there was no notification to the doctor until the after-hours fax was sent the evening before the rescheduled appointment.  When a resident is demonstrating the kind of advanced signs of infection that this resident was showing, simply faxing a note over was not sufficient – a call or page was required.  Why?  Because we know that no one responded to the fax sent the evening before – resulting in additional delay and spread of the infection.

There were multiple missed opportunities to drive a better outcome for this resident, spread across several days and several health care providers, including the nurse practitioner.  The net result is that this resident will experience significant, needless suffering and complications.

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

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

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

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

 

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

 

Aperion Care Wilmington resident suffers ruptured colon from fecal impaction

By

IDPH has cited and fined Aperion Care Wilmington nursing home after a resident there developed fecal impaction which led to a ruptured colon which required multiple surgeries.

The resident at issue suffered from mental illness and was receiving several psychotropic medications.  One of the risks associated with the use of these kinds of medications is that the resident will suffer from constipation.   When a resident is receiving psychotropic medications, one of the steps typically included in the resident care plan is to monitor the resident for signs and symptoms of constipation as well as tracking their bowel movements.

Prolonged periods of constipation increases the risk that the resident will experience fecal impaction.  When someone suffers from fecal impaction, there a hard balls of feces in their digest tract which are hard to push through to the end of the digestive tract.  The presence of a fecal impaction can cause abdominal pain and other digestive issues, and in advanced cases can cause perforation of the structures of the digestive tract.

Perforation or rupture of structures in the digestive tract results in the contents of the digestive tract leaking out into the abdominal cavity.  The causes a type of infection known as peritonitis.  Peritonitis is very painful and can be a life-threatening condition.  It is also a very difficult condition to treat and often requires a prolonged course of IV antibiotics and may require multiple surgeries to remove portions of the digestive tract.

The resident was discovered in bed with blood coming from his rectum the day that he was taken to the hospital.  Additional blood was found in the toilet.  At the hospital, the resident underwent a CT scan which showed the presence of free air in the abdominal cavity.  This is a sign of rupture of one of the structures in the digestive tract.

The resident was brought to surgery where it was discovered that the resident’s colon had ruptured, that there were digestive contents throughout the abdominal cavity, and that there was extensive evidence of infection throughout.  Several large balls of feces were found within the digestive tract.  There was also evidence of necrosis (tissue death) of the colon.  All of this indicated that this was a condition which was present for several days.

Ultimately, the resident underwent several surgeries, including removal of his colon and placement of an ileostomy, which is similar to a colostomy except that it removes waste matter from the end of the small intestine rather than the colon.  Besides being an issue of dignity, this has significant negative impacts on the nutrition of the resident.

When IDPH went to investigate this incident, they questioned the staff about the tracking of the resident’s bowel movements in the chart.  The answers made it apparent to the surveyor that there was no meaningful tracking of the resident’s bowel movements.  As a result this led to the resident suffering prolonged periods of constipation.

Had the resident’s bowel movements truly been tracked in a regular, systematic way, the resident’s constipation could have been addressed in a number of fairly simple ways, ranging from diet changes, use of a laxative  or stool softener, or digital removal.  This was not done, leading to a catastrophic outcome for this resident.

Additionally, the resident was suffering from necrosis of the colon and from a significant infection at the time he was brought to the hospital and this had likely been present for a long time before this.  This is a strong indicator that the staff was not monitoring the condition of the resident and did not notify the resident’s physician of changes in the resident’s condition.

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

Other blog posts of interest:

Failure to monitor anticoagulant levels at Greentree of Bradley

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

Failure to follow orders at Generations at Applewood

Failure to follow feeding tube orders leads to hospice admission for Parker Rehab resident

 

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

Accolade Paxton Resident Suffers Lingering Infection After Medication Error

By

The IDPH has cited Accolade Healthcare Paxton Senior Living in Paxton, IL, for a medication error affecting a resident with a knee infection. The infection began after the resident had a knee replacement surgery, and it persisted after the nursing home failed to provide her antibiotics.

Missed Antibiotics Crucial to Treat Infection

The female resident was originally admitted to the senior care facility because her knee prosthesis surgery led to a knee infection. At the time of her admittance, her prosthesis had been removed and replaced with a spacer, a device designed to fill the joint gap. She was meant to get antibiotics to clear up her infection, and only then would she get a new prosthesis.

Soon after her nursing home admission, there was concern that her infection was migrating to the soft tissue next to her knee joint. If the infection was allowed to move, she could lose her leg. Hence, she was sent back to the hospital.

Doctors allowed her to return to the nursing home with an order for two antibiotics called Fortaz and Vancomycin. However, neither was on hand at the nursing home when she arrived. A nurse practitioner found out four days later that the resident missed three doses of Fortaz and one dose of Vancomycin.

The resident developed a fever, which prompted another hospitalization. She had to undergo surgical removal of the spacer. On the operative note, the indication for surgery was the missed antibiotics.

Multiple Lapses in Resident’s Care

We see at least three shortcomings at the nursing home that led to this resident’s prolonged suffering.

One is the lack of continuity of care. Individuals who are admitted into a nursing home after a hospital stay should have the continued treatment they need to get well. Before the resident’s transfer, the hospital must send to the nursing home the treatment orders and medication list, and the nursing home must implement them as soon as the resident arrives.

This standard protocol for continued care was not followed through for the resident at issue. As a result, she missed her crucial medication and ended up having to get another surgery.

Another problem was the facility’s admittance of the resident without complete preparation. Nursing homes are supposed to be ready to implement a resident’s care plan to the letter, the moment the resident is admitted. In terms of medical treatment, a well-run facility will have a backup supply of medications or even an on-call pharmacy to supply what is needed.

Unfortunately, in this case, the nursing home did not take proper steps to prepare for the resident’s admittance. The lack of onhand medicine should have been addressed with a resupply.

The third issue was that the nursing home staff failed to check on the patient’s care and notify the physician. Senior care facilities are not required to have a doctor present 24/7, but they are required to let a doctor know when there’s a medical issue with any resident. Nurses and staff at the facility are supposed to be the doctor’s “eyes and ears” to spot these issues.

Sadly for this particular resident, no one at the nursing home checked if she was getting the ordered medicine. Thus, the doctor could not immediately advise on how to address it. Four days passed before a nursing practitioner noticed, and by that time, there was no choice but to send the resident back to the hospital.

No nursing home resident should have to suffer due to any of these lapses, much less a combination of several.  

Contact an Illinois Nursing Home Lawyer for Legal Help

We believe that most 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 results. 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.

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

Thank you for reading.

 

Other blog posts that might be of interest:

Dehydration leads to hospital admission for resident at Mattoon Rehab

Flora Gardens staff fails to give an antibiotic, leading to the death of resident

Alden Valley Ridge fails to give resident anti-seizure medications

Taylorville Skilled fails to obtain anti-convulsant medication for resident

Arcadia Care Resident Dies of Improperly Treated Urinary Tract Infection

By

The IDPH has issued a citation to Arcadia Care Danville following the death of one of its residents due to an improperly treated urinary tract infection (UTI). This is a case where two very basic yet critical responsibilities of a nursing home failed: the duty to be in touch with the doctor, and the duty to administer medication correctly.

Tragic Battle with Infection at Nursing Home

The resident’s complicated medical history included frequent urinary tract infections, to the point where some of the bacteria causing the infections became resistant. Because the usual antibiotics were no longer working, the patient needed additional testing to confirm the best course of treatment.

During one bout of UTI, the resident got the doctor’s order to take an antibiotic called Levaquin, and also to get a urinalysis with a “culture and sensitivity” test. This test was to determine exactly what kind of bacteria was causing the infection, and what drugs the organism would be susceptible to. The doctor wanted the culture and sensitivity test to see whether the Levaquin was working and whether he needed to adjust the treatment for the resident.

The resident’s test result revealed that the bacteria was resistant to Levaquin, and therefore the course of treatment needed adjusting. His doctor was never notified of the irregular lab result.

Patient’s Doctor was Not Notified About Abnormal Lab Results

Nursing homes are not required to have a physician on site 24/7, but they are responsible for communicating with the doctor when there is a medical irregularity in any of the residents. The doctor would then either come to the nursing home to personally examine the situation, issue orders by phone, or have the resident sent to the hospital.

In this case, the doctor was not notified of the abnormal lab result. Without the physician adjusting the treatment plan, the resident continued to take the medication that wasn’t effective against the UTI.

In the days that followed, the nursing home staff noted the resident’s changes in mental status, abnormal urine appearance, and possible seizure activity. These were all signs of a worsening infection. In addition, another set of labs showed that the resident had elevated creatinine and Blood Urea Nitrogen (BUN) levels, both of which indicated dehydration associated with UTI. His ammonia levels were also elevated — another abnormal finding that needed to be addressed.

Again, this was a situation that should have been communicated to the doctor, but no notification was made.

On top of these, lab tests could not detect the resident’s potassium levels. Potassium is a nutrient that drops to low levels during UTI, so the resident had to be on a potassium supplement to keep this nutrient in his body. Sadly, this supplement was missed when he was transferred from the nursing home into hospice. During the transfer, the hospice staff never received from the nursing home the full list of medications that he was supposed to take.

The resident suffered more symptoms of worsening infection, including increased lethargy, fever, and changes in mental status. Two and a half weeks after his initial abnormal urinalysis, the resident tragically passed away. 

The cause of death was sepsis from the improperly treated urinary tract infection, combined with dehydration and loss of potassium.

Preventable Resident Death, Lapses in Care

The doctor told the state surveyor that these two things — the failure to notify a physician and the medication error — contributed to the resident’s death.

Though these are basic responsibilities of a nursing home, these lapses are all too common among these facilities. We have seen numerous cases of resident injuries and deaths resulting from the staff’s lack of communication with the doctor, lack of vigilance to spot irregularities, and irresponsible handling of treatments. Such injuries and deaths would have been prevented had those nursing homes fulfilled their duties correctly.

Contact an Illinois Nursing Home Lawyer for Legal Help

We believe that most 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 results. 

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.

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

Thank you for reading.

 

Other blog posts that might be of interest:

Resident Undergoes Electroconvulsive Therapy After Palm Terrace Fails To Give Antipsychotic Medication

Flora Gardens Staff Fails To Give Antibiotic, Leading To Death Of Resident

Aperion Care Capitol Fails To Give Medication To Resident Suffering Bacterial Meningitis.

Lack Of Wound Monitoring Leads To Resident’s Infection At Regency Care of Morris

By

IDPH has cited the nursing home Regency Care of Morris after a resident there developed a wound infection that required surgical removal.

Wounds and wound infections are major concerns at long-term care facilities. One of the basic responsibilities of nursing home staff is to monitor any of the residents’ wounds and look out for signs of infection. When a symptom of infection is present, the staff must then bring it to the attention of the doctor. The physician then decides whether to instruct the nursing staff on appropriate treatment, to come to the facility and administer the treatment himself/herself, or to have the resident brought to a hospital.

It is crucial to have wound infection treated early. Allowing it to fester could lead to more serious conditions involving various body tissues.

The resident in this case had a wound from a hip replacement surgery. Upon her admittance to the nursing home, it would have been part of the staff’s job to monitor this wound. The resident had staples on the wound when she was admitted to the nursing home, but these staples were subsequently removed during her initial postoperative visit at the hospital. Unfortunately, there was no documentation that the wound was assessed after that postoperative appointment.

Eight days after that visit, the resident asked a nurse at the Regency facility for shower assistance. It was only then that the nurse saw bloody drainage coming from the resident’s surgical wound, and called the doctor.

The resident was brought to the hospital, where wound infection was recognized. She told the doctor and the Department of Public Health surveyor that she had reported the drainage to the nursing home staff a few days earlier, yet nothing was done about it.

By the time the resident was sent to the hospital, she had to undergo surgical debridement of the wound. Doctors had to cut away portions of her gluteus muscle and trochanter, a part of the femur or hip bone. This indicated some level of osteomyelitis, a type of bone infection.

Deep-tissue infections like this happen when a wound infection is left untreated for a time. This resident’s wound was left unchecked and untreated for at least several days. Had the nursing home staff been more diligent in carrying out their wound monitoring duty, and had they called for treatment sooner, the resident’s infection would not have reached a costly and dangerous extent. In short, this resident’s horrible experience could have been avoided.

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

Other blog posts of interest:

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

Failure to obtain treatment orders leads to surgical wound infection at Loft of Canton

Infection results from failure to care for surgical wound at Arcadia Care of Morris

Sharon Health Care Willows resident undergoes surgery for bed sore

Flora Gardens staff fails to give antibiotic, leading to death of resident

 

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

 

Thank you for reading.

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

By

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.

 

Sandwich Rehab fails to obtain test ordered by doctor

By

IDPH has cited and fined Sandwich Rehab after it took 8 days to get test results s for a resident showing signs and symptoms of a urinary tract infection.

The resident at issue suffered from urinary retention, a condition where the bladder does not empty completely.  To help the bladder empty, she was provided with an indwelling catheter.  One of the risks associated with the use of a catheter is the development of a urinary tract infection.

Nurses are required to be able to identify signs and symptoms of a urinary tract infection.  Some of the signs of a urinary tract infection in a resident with a catheter include cloudy or blood-tinged urine, strong smelling urine, burning at the catheter site, fevers, lower back pain, and generalized malaise.  When a resident demonstrates signs and symptoms of urinary tract infection, they are required to notify the doctor.

In this case, on September 12, the resident complained of burning at the catheter site and lower body pain.  The nurse caring for her did the right thing: she notified the doctor and obtained an order for a urinalysis with culture and sensitivity.  This is a test which would confirm the the presence of the urinary tract infection and let the doctor know which antibiotics would be most effective in combatting the infection.

The nurse drew the urine sample that day, but the lab failed to pick the sample up.  On September 15, another order was obtained from the doctor for a urinalysis with culture and sensitivity.  It wasn’t until September 20 — 8 days after the test was ordered — that the results came back, and the doctor then ordered keflex (an antibiotic).  During the interim, the infection progressed with the resident demonstrating additional symptoms of the urinary tract infection with sediment and blood in the urine, fevers, and chills.  On September 22, she was admitted to the hospital with sepsis.

When IDPH came to investigate this incident, the facility’s Director of Nursing turned on the lab, telling the inspector, “Our lab is horrible, horrible!” (exclamatino point in the original), relating to the surveyor that the urine sample was taken on the 12th, but no one came that day to pick it up.  A follow-up call was made on the 13th, but no one came.  On the 15th, the Director of Nursing said she “threw a fit” and was promised that someone would be out that day but no one came until the 17th when a new urine sample was taken to the lab.

Obviously, a significant part of the blame here rests on the lab – it is their job to get the sample in a timely way.  However, when the sample was not being picked up, more action than was taken was required; after all there was a resident with a serious illness.

Past that, this is a good example of how the decisions made by people at the business end of the nursing home industry impact the care that residents receive.  Most often this is seen in nursing homes being understaffed.  In this case, the people delivering the care are stuck working with a vendor (the lab) that isn’t getting the job done.  The DON’s description of the lab (“horrible, horrible!”) tells me that this is probably not the first time that they have had problems with the work being done by the lab.

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 residents are the inevitable results.  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 abuse at Sandwich Rehab

Crossroad Care Center fined for neglect

Pine Acres resident breaks neck in fall

Fall during transfer results in broken ankle at Sandwich Rehab

Failures in care lead to bed sores at Park Place of Belvidere

 

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

 

Infection from skin tear at Eldorado Rehab

By

Eldorado Rehab and Healthcare in Eldorado was cited and fined by IDPH after a resident developed an infection due to improper treatment of a skin tear.

The initial injury occurred when the when the legs to the resident’s wheelchair were being moved.  It was a significant skin tear measuring 12 cm, or just under 5 inches in length.  The nurses on duty closed the skin tear with steri-strips.  The nursing progress note entered that day described how the skin tear occurred and reflected that the doctor entered orders for treatment.  However, that order was never entered into the Physician’s Order Sheet, and the resident’s attending physician and the facility’s wound care doctor both denied having been advised that the resident suffered a skin tear.

One of the reasons that skin tears are concerning is that any breach in the skin opens up the body to infecting organisms – that is one of the reasons that bed sores are such an issue of concern in the long term care industry.  And indeed, this is just what happened to this resident.  She developed a cellulitis infection which led to am 8-day hospital admission.

There are three real problems with the care that was provided to this resident:

First, when a resident suffers a skin tear, it is an event which requires the nurse to notify the physician.  The doctor should be the one to make the determination about what should happen after a skin tear occurs.  A skin tear of this size really required a trip to the emergency room to have the wound closed more effectively than trying to pull it back together withe steri-strips.  The doctor denies that this occurred, which raises the next issue.

Second, the  progress note indicates that the doctor issued an order.  The doctor denies that this occurred, which would be an example of false charting.  One of the items that supports the doctor’s account of this is that there was no entry on the physician order sheet.  Many times nurses will call the doctor and get an order over the phone, in which case there still needs to be an entry on the resident’s chart for the order which the doctor will sign off on the next time he/she is in the nursing home.

Third, one of the things that nurses should be doing when a resident has a wound, whether it is a skin tear or a pressure ulcer, is checking it for sign and symptoms of infection.  By the time that this resident was brought to the hospital, there were obvious signs of infection which should have been recognized much earlier.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary injuries and illnesses and wrongful deaths of 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:

Surgical wound infection at Presence Villa Franciscan

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

Failure to obtain treatment orders leads to surgical wound infection at Loft of Canton

Resident dies from sepsis at St. James Manor in Crete

Fatal infection at Alden Northmoor

 

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

 

Surgical wound infection at Presence Villa Franciscan

By

The Presence Villa Franciscan nursing home in Joliet was cited and fined by the Illinois Department of Public Health after a resident admitted for rehab following a revascularization surgery developed a significant infection at the surgical site.

The resident at issue had been admitted to the nursing home after undergoing a femoral-popliteal bypass surgery.  There was a 7 cm incision at the surgical site which had been closed with 27 staples.  The discharge orders included instructions to notify the surgeon if there was redness, swelling, drainage, or foul smell from the incision site and to paint the incision twice per day with Betadine and to cover with a dressing.  Betadine is used to treat minor skin infections.

One of the basic jobs of a nurse is to notify the resident’s doctor when signs or symptoms of a cellulitis infection are present, and the things listed: redness, swelling, drainage, and foul odor are classic signs of an infection.

The resident returned to see the doctor 10 days after being admitted to the nursing home.  During that time in between, there was only one nurse’s note which indicated that the nurses inspected the surgical incision and that one reflected that the Betadine had not been used because its telltale staining was not present.  When the doctor saw the wound he quickly determined that there was an extensive infection that had been present for some time because the staples from the wound were coming out.  He brought the resident back in for an extensive surgery to remove the infection.  A wound vac was required to help close the wound.

One of the basic functions of the nursing staff is to monitor for signs and symptoms of infection.  It is not up to  them to diagnose and actual infection, determine what kind of infection is present, or how to treat the infection.  That is the role of the doctor, but the doctor cannot do that when the nursing staff fails to notify him that there may be an infection present.

When I take depositions of nurses I ask if they agree that the doctors are not there on a 24/7 basis and it is the job of the nursing staff to act as eyes and ears for the doctor.  I get universal agreement on that concept.  The nurses here failed that role and subjected this lady to a more extensive surgery and a worse surgical wound.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary injuries and illnesses and wrongful deaths of 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

Resident Chokes to Death at Presence Villa Franciscan

Fatal infection at Alden Northmoor

Infection from skin tear at Eldorado Rehab

Unsafe transfer at Alden Courts of Shorewood

 

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

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

Call Us Today

(312) 263-1080

Location

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

Practice Areas

TAP TO CALL