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Bethany Rehab resident suffers brain bleed and seizures due to medication error

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IDPH has cited and fined Bethany Rehabilitation and Health Care Center nursing home in DeKalb after a resident there suffered a brain bleed and seizures due to a medication error regarding the administration of his coumadin.

Many nursing home residents take anticoagulant or “blood thinner” medications.  Used for a variety of purposes such as a history of blood clots, atrial fibrillation, stroke prevention, and management of other circulatory and cardiac conditions, this class of medication can be crucial for maintaining the health and well-being of the resident for whom the medication was ordered.

However, the use of this medication has to be carefully managed.  If the blood is considered “too thick,” or subtherapeutic, it can lead to blood clots which can have catastrophic consequences; if the blood is “too thin,” or supratherapeutic, this can lead to uncontrolled bleeding.

To ensure that the resident remains in the desired or therapeutic range, the resident must receive regular blood testing called a PT/INR test which measures whether the blood is in the therapeutic range.  If the blood is outside the therapeutic range, then the nurse must contact the doctor to notify him that the resident had an abnormal lab result.  From there, it would be up to the doctor to make adjustments in the dosing of the blood thinner medication or to take other steps to treat the condition.

The resident at issue had a medical history which included atrial fibrillation, a stroke, and a pulmonary embolism – all conditions for which use of a blood thinner was warranted.  The blood thinner which was used for him was coumadin and was being managed by a coumadin clinic.

The resident was seen at the coumadin clinic which gave orders that the resident should receive 5 mg of coumadin on Mondays and 2.5 mg of coumadin every other day with a PT/INR test to be done in weeks.  When he was seen in the coumadin clinic, his INR level was 3.0, which was the high end of the normal range.

However, when the orders were entered into the record at the nursing home, it provided for the resident to receive 5 mg of coumadin on Monday and 7.5 mg of coumadin all other days.  This means that the resident received three times the prescribed dose 6 days a week for a two-week period.

When the PT/INR test was scheduled to be performed at the end of the two weeks, the machine would not give a reading.  A call was placed to the doctor and an order was received to redraw the blood the following morning.  When the test was run again the following day, the lab called back stating again that the results were inconclusive.  Plans were made to redraw the lab again the following morning.

The next morning, the resident started to show slurring of his speech which was getting progressively worse.  The nursing staff paged the physician and nurse practitioner, but when they were not able to get a response, they called 911 and had the resident sent to the hospital.  There labs were drawn which showed a prothrombin time (PT) of 181.5 (normal is 19.7 – 28.8) and an INR score of 21.54 (normal is 2.00 – 3.00).  A CT scan of the head showed that the resident had a left-sided subdural hematoma.  Following this, the resident demonstrated loss of cognitive function and suffered seizures.

Continuity of care is a critical issue in the long-term care setting.  Residents are often seen by outside providers who issue orders for the ongoing care of the resident with the expectation that those orders will be carried out as specified.  When that does not happen, disaster awaits.  Here, the order were for the resident to receive 2.5 mg of coumadin every day other than Monday when he was supposed to receive 5 mg.  The issue arose when the orders were not entered into the record correctly and the resident received 7.5 mg dose the other 6 days of the week.  This led directly to the brain bleed sustained by the resident with catastrophic results for him.

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

Other blog posts of interest:

Failure to give blood thinner leads to death of resident at Warren Barr Oak Lawn

Pearl Pavilion resident dies of pulmonary embolism after not receiving blood thinner

Hillside Rehab resident dies of brain bleed due to failure to obtain lab work

 

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

 

 

 

 

 

Failure to give blood thinner leads to death of resident at Warren Barr Oak Lawn

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IDPH has cited and fined Warren Barr Oak Lawn nursing home after a resident there died from a massive pulmonary embolism caused by the failure to give a blood thinner medication as ordered.

Maintaining continuity of care from a hospital to a nursing home is critical for the safety and well-being of a resident.  When someone is admitted to a nursing home from the hospital, they are generally recovering from a significant injury, illness, or surgery and have significant near-term and long-term needs.  Special care has to be taken to make sure that the care needs that the doctors and staff at the hospital have determined that the resident requires are being met during the initial stages of the resident’s admission.

When a resident is admitted to a nursing home from a hospital, the nursing home receives a list of medications that the resident is supposed to be receiving.  That list is supposed to be verified with the providers at the hospital and then double-checked by a second nurse at the nursing home to ensure that all orders, including medications, are correctly entered into the resident’s chart.  When this process does not happen, there is an increased risk that the resident will either not receive a necessary medication or be given a wrong medication or the incorrect dose of a medication that was ordered.

This kind of nursing home medication error can have catastrophic consequences, and that was the case here.

The resident at issue was admitted to the nursing home after having spinal surgery following a fall at home.  When the resident was discharged from the hospital to the nursing home, there was an order in place for him to receive heparin, a blood thinner.  Many patients will receive a blood thinner after a major surgery to prevent the developments of blood clots – a complication which is known to occur following major operations.  This is especially true when the patient has significant mobility deficits, as was the case here.

However, when the resident was admitted to the nursing home, the order for heparin was not copied from the discharge papers onto the patient’s medical record.  As a result, during the twelve days that the resident was in the nursing home, he did not receive a single dose of the blood thinner that was ordered.

On the twelfth day of his admission, the resident had episodes of vomiting and had a fixed stare.  The nursing home staff had the resident sent to the hospital, where it was discovered that he had a massive pulmonary embolism, or a blood clot that became lodged in the lung.  A pulmonary embolism can lead to cardiac arrest and death.  Sadly, that was exactly what happened in this case, as the resident died later that day.  Cause of death according to the death certificate was massive pulmonary embolism and cardiopulmonary arrest.

Well-run businesses run on systems, and a nursing home is a business.  This nursing home actually had a system in place similar to the one described above.  Unfortunately, it was not followed, leading to this very preventable medication error.

The obvious reason that this medication error occurred was the failure to follow the system that was in place.  The deeper question is why the system wasn’t followed.  Investigation by IDPH revealed that the nurse who made the mediation error was an agency nurse, or a temp.  We tend to see a lot of agency nurses in facilities where they have hiring and retention problems, generally due to low pay and heavy work loads.  Temporary staff can help address this, but there is little chance to ensure that they are trained in the systems and processes that must be followed for the consistent delivery of routine care.

In the end, this was a death that was a product of the nursing home business model, where understaffing of the nursing home and lack of investment in the staff are cardinal features – and this is because those kinds of expenses cut into the bottom line. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Catastrophic brain injury results from medication error at Alden Town Manor

Diabetes medications not given at Alden Estates of Orland Park

Failure to give anticoagulant medication at H&J Vonderlieth Living Center

 

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

Catastrophic brain injury results from medication error at Alden Town Manor

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IDPH has cited Alden Town Manor nursing home in Cicero after a resident there was given glipizide when it was not part of his medication regimen.

Almost all nursing home residents receive medications on a regular basis.  To ensure that residents receive medications as ordered, nurses are supposed to follow the five “rights” in administering medications: right patient, right medication, right dose, right time, and right route.  Not getting all five “rights” just right can result in a critical nursing home medication error.  Sadly, that is what happened here.

The resident was admitted for treatment of a urinary tract infection.  While he was a diabetic, glipizide was not a part of his medication regimen.  Glipizide is a type of medication known as a sulfonylureas. These medications stimulate the release of insulin from your pancreas, directing your body to store blood sugar.  This helps lower your blood sugar levels.  However, when taken by someone who does not need this medication, it can drive their blood sugar down to critically low levels.  Abnormally low blood sugar levels is known as hypoglycemia.  Hypoglycemia can have widespread negative effects on your health and well-being.

When the resident was initially admitted to the nursing home, he was anxious and restless.  However, 5 days later when the nurse went to do the afternoon medication pass, she was unable to rouse him.  She checked his blood pressure and found that it was normal.  She then checked his blood sugar and got a result of 24 (normal range 140-199), which is a critically low result.

When the resident was sent to the hospital where a screening test showed that he had glipizide in his system.  The diagnosis was neuroglycopenic injury secondary to hypoglycemia.  He had to be intubated in order to protect his airway.  When he was extubated, he was still unresponsive.  A PEG tube had to be place for long-term nutritional needs due to the brain injury he sustained.  He was discharged from the nursing home, where the staff described him as being unresponsive to stimuli.

Investigation at the nursing home showed that there was only one other resident who had an order for glipizide and he was in the room across the hall from the resident.  These facts strongly suggest that the resident received the medication which had been ordered for the person across the hall.    The system for avoiding just this kind of error was apparently not followed – the check for the right patient was not done – because there is no other way that the resident  could have ended up with glipizide in his system.

The simple failure to follow this time-tested system resulted in a very avoidable medication error with catastrophic results.  This resident suffered a catastrophic brain injury and is no longer capable of meaningful communication or voluntary movement.  Chances are strong that complications from this medication error will result in the wrongful death of this resident, whether from bed sores caused by immobility, pneumonia, feeding tube complications, or any number of other complications that beset a severely medically compromised patient like this resident.

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

Other blog posts of interest:

Bella Terra Wheeling resident receives roommate’s diabetes medications

Alden Estates of Huntley fails to give antibiotics as ordered

Diabetes medications not given at Alden Estates of Orland Park

 

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

Medication error at River Crossing of Alton leads to hospitalization

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IDPH has cited and fined River Crossing of Alton nursing home after a resident there had to be hospitalized with hepatic encephalopathy after not receiving a medication as had been ordered for her.

Ammonia is a waste product that builds up in the blood as part of the digestive process.  Ordinarily, ammonia is filtered through the liver where it is converted to urea which is then removed from the body through urination.  When the liver is not functioning properly, ammonia builds up in the body and can be toxic to the brain and other organs.  One way in which ammonia levels in the body can be brought down is through the use of a drug called lactulose.

The resident at issue had a diagnosis of cirrhosis of the liver and her admitting orders called for receiving lactulose every 8 hours, or 3 times per day.  However, during the first two days of her admission to the nursing home, she received only one dose each day and then did not receive any the third day that she was in the nursing home because she was out of the facility at the time that medication was passed.

The resident’s chart reflects that a friend called the nursing home on the evening of the third day of her admission and told the nurse that he had spoken to the resident and she reported to him that she was only getting her lactulose once a day and should have been getting it two or three times a day.  There does not appear to have been any action taken in response to that phone call, as the next morning when staff checked on the resident first thing in the morning, she was unresponsive.

The resident was brought to the hospital where her lab work showed that she had ammonia levels of 238 (normal range is 15-45).  She was admitted to the hospital with a diagnosis of hepatic encephalopathy, which is a loss of brain function brought on by the failure of the liver to remove toxins from the blood.  Here, the brain injury was caused by the failure to give the medication as ordered.

There are two major breakdowns in the care that this resident received.  First, the admitting orders were not transcribed properly, resulting in her receiving one dose of lactulose per day rather than the three which were ordered.  This nursing home medication error led directly to the brain injury that this resident suffered.  The IDPH citation further stated that the Director of Nursing admitted that there had been some problems with accurately transcribing orders.  Second, there was no apparent action from the call from the friend.  It is more than likely that if the resident was raising the medication issue with the friend, she was also raising it with the staff.  At a minimum this should have sparked some effort by the staff to verify that the orders were correct and to discuss the matter with the resident.  Instead the call brought  no apparent response, with the resident being taken to the hospital unresponsive the following morning.

This breakdown in the care that this resident received is what happens when the staff does not take the time to actually meet the care needs of the resident by doing things like checking to make sure that orders are entered properly and that concerns about the care are at least considered.  When these things don’t happen, it raises questions about whether this is an understaffed nursing home.  Unfortunately, understaffing a nursing home is a basic feature 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:

Failure to give HIV Medications at Bria of Belleville

Aperion Care Capitol fails to give medication to resident suffering from bacterial meningitis

Rushville Nursing & Rehab resident suffers from untreated surgical wound infection

 

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

 

 

Failure to give anti-seizure medications at Generations at Rock Island

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IDPH has cited and fined Generations at Rock Island nursing home after a resident had to be hospitalized due to seizure activity after not receiving his anti-seizure medications for 36 hours after admission.

The resident at issue had been admitted to the facility from home.  He had a history of a brain injury and seizures and was to receive two anti-seizure medications (levetiracetam and oxcarbazepine) twice per day, at 8 am and 8 pm.  Before being admitted to the nursing home, his seizures were being managed by a neurology clinic which had prescribed these medications.

Before a resident is admitted to the nursing home, there is a process by which the resident is screened to determine whether the nursing home can meet the care needs of the resident.  If the nursing home cannot meet the care needs of the resident, then the proper course of action is to decline the admission.  Part of the screening process is obtaining information about the resident’s medical history, their active diagnoses, and the medication and other treatment orders.

Once the resident is admitted to the nursing home, the resident must have an attending physician for manages the overall medical care of the resident, including signing orders for medications and other treatment orders as needed.  Obtaining the signed orders for medications is important in assuring proper care for the resident because there are some medications which the nursing home will not keep on hand and the pharmacy will not dispense to the nursing home without a signed order.  Anti-seizure medications fall into that category.

When the resident arrived at the nursing home during the middle of the afternoon, the admitting nurse asked a nurse practitioner who was in the facility to sign off on the orders for the anti-seizure medications, but she declined to do so.  The admitting nurse then contacted the medical director, but could not speak with him and left a message.  He did not return the call until 1:55 p.m. the following afternoon, and the medication orders were not entered into the resident’s electronic medical record until after 4 p.m.  As a result, the medications did not arrive in the facility during the resident’s second day in the nursing home.  Because of this, the resident missed three doses of each of the two anti-seizure medications he was due to receive – the 8 pm dose the first day he was in the facility, and both doses the second day.

At about 8:30 p.m. on the second day, the resident was able to speak normally with an aide.  About 10 minutes later, that same aide walked by the resident’s room, looked in and saw that the resident was having a seizure.  The resident had wet himself, the right side of his body was limp, but he was shaking violently, nonresponsive, and had his eyes rolled back into his head.

911 was called and the resident was brought to the hospital to receive care for the seizures.  His treating doctor attributed the seizures to the missed doses of medication.

Making sure that medications are given as ordered is crucial to ensuring the well-being of nursing home residents.  When the nurse practitioner refused to assume care of the resident, the admitting nurse did the right thing by reaching out to the medical director to get orders for the medication.  However, when she could not reach him, simply waiting for a return call was not acceptable practice given the importance of the medication in the overall care of the resident.  Follow-up phone calls to the medical director or contacting the regular prescribing doctor was what was required.  This nursing home medication error to a critical lapse in the care of this resident.

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

Other blog posts of interest:

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

Pearl Pavilion resident dies of pulmonary embolism after not receiving blood thinners

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

 

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

 

 

Psych med usage leads to bed sores at Eastview Terrace

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IDPH has cited and fined Eastview Terrace nursing home in Sullivan after a resident there suffered significant weight loss and developed bed sores due to lethargy associated with the use of psychotropic medications.

The use of restraints is strongly discouraged in the long-term care industry for a number of reasons, but most particularly, they pose a serious risk of harm to nursing home residents and are also an affront to their right to dignity.  Tying a resident into a bed or chair is something which is generally not acceptable nursing practice.  Use of a chemical restraint – that is medicating a resident in such a way that the resident is so sedated to the point that their movement or freedom is restricted – also carries serious risks to the health and well-being of nursing home residents and is an affront to their right to dignity.

Certain medications especially psychotropic medications carry a high risk of becoming chemical restraints by sedating nursing home residents to the point that they are unable to move.  Federal regulations limit the use of psychotropic medications to the extent necessary to treat the symptoms and prohibit the use of unnecessary drugs.  Regulations also require monitoring for the presence of side effects.

The resident at issue was initially admitted to the nursing home with a diagnosis of dementia with behavioral disturbances.  He weighed 184 pounds and was ambulatory.  Ten days after admission, he was transferred to a geripsych facility after attacking a staff member.

When he returned there were dramatic changes in the resident’s condition.  He was no longer ambulatory, required extensive assist of two staff members for activities of daily living, and was largely nonverbal.  He was on a regimen of six psychotropic medications, including receiving some more than once daily.  A week after admission, the staff called the doctor with concern about the resident’s lethargy.  The nurse practitioner came to the facility and ordered a lab check for levels of one medication and ordered that the medication be held if the resident appeared sleepy.  It did not appear as though the medication was ever held.

The resident continued to demonstrate lethargy, requiring extensive assistance from the staff with activities of daily living including eating.  He did not demonstrate much appetite, and when he did try to eat independently, he often missed his mouth.  He was discharged from both physical and occupational therapy due to inability to participate.  he was wheelchair bound and was using a high-backed wheelchair to aid in positioning.

There was nothing in the citation that suggested that his behaviors were being tracked or monitored for the side effects of the psychotropics, even though the care plan called for monitoring of somnolence and to notify the doctor if the side effects outweigh the benefits.  There was no further notification to the resident’s doctor even though he was seen twice via telehealth during which the staff advised that there were no concerns.  There was no apparent referral to a psychiatrist to modify the drug regimen.

What was done with this resident is a near classic example of a chemical restraint.  While the resident’s behavior was absolutely a source of concern, there was no meaningful attempt to monitor for side effects to eliminate potentially unnecessary medications.  The net result of this was that the resident was so sedated that he was unable to move independently to the point that he was unable to feed himself, unable to participate in therapy, unable to care for himself, and unable to stand and move independently.

There are a number of dangers associated with chemically restraining a resident, including having nursing home falls and developing bed sores.  There are three main risk factors for developing bed sores: (1) incontinence, (2) immobility, and (3) poor nutritional status.

The citation demonstrated two of the three factors clearly.  The resident had immobility based on the inability to participate in the therapy, the well-documented lethargy, and the change from being ambulatory to needing a high-backed  wheelchair for positioning.  He also had poor nutritional status in that poor appetite and an inability to eat were explicitly documented.  He also had documented significant weight loss in that his weight decreased from 185 pounds when he was initially admitted to 172 pounds after being readmitted from the geripsych unit to 159 pounds a month later.  He also likely had some element incontinence given that he was dependent on staff for activities of daily living and would have been dependent upon them for toileting.

It should be small surprise then that this resident ended up developing bed sores.  He developed a deep tissue injury on his coccyx and pressure ulcers on his sacrum and on his left and right buttocks.

These injuries are the predictable results of employing a chemical restraint on a resident.  Lethargy with an inability to move and loss of appetite with associated weight loss predictably led to the development of multiple bed sores.  Recovering from them will be very difficult without any modification of his psychotropic medication regimen.

While the staff was rightly concerned about the resident’s aggressive behavior, the solution to that is not to sedate the resident into total inactivity without making any effort to minimize the side effects of the psychotropics that the resident was receiving,  Yet, that is what occurred here.

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

Other blog posts of interest:

Resident undergoes electroconvulsive therapy after staff at Palm Terrace fails to give antipsychotic medication

Resident develops bed sore at Nokomis Rehab

Moweaqua Rehab resident suffers worsening bed sores

 

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

 

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

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IDPH has cited and fined Hillside Rehabilitation and Care Center in Yorkville after the nursing home failed to obtain lab tests for a resident who was taking blood thinner medication.

Many nursing home residents take anticoagulant or “blood thinner” medications.  Used for a variety of purposes such as a history of blood clots, atrial fibrillation, stroke prevention, and management of other circulatory and cardiac conditions, this class of medication can be crucial for maintaining the health and well-being of the resident for whom the medication was ordered.

However, the use of this medication has to be carefully managed.  If the blood is considered “too thick,” or subtherapeutic, it can lead to blood clots which can have catastrophic consequences; if the blood is “too thin,” or supratherapeutic, this can lead to uncontrolled bleeding.

To ensure that the resident remains in the desired or therapeutic range, the resident must receive regular blood testing called a PT/INR test which is measures whether the blood is in the therapeutic range.  If the blood is outside the therapeutic range, then the nurse must contact the doctor to notify him that the resident had an abnormal lab result.  From there, it would be up to the doctor to make adjustments in the dosing of the blood thinner medication or to take other steps to treat the condition.

The resident at issue had a history of blood clots and had peripheral vascular disease (poor circulation to the extremities) and was receiving blood thinner medications to treat this.  As part of his treatment regimen, there was also an order in place for regular blood draws for PT/INR testing.

When lab work is ordered for nursing home residents, this is performed by an outside laboratory who will send a technician to the nursing home to do the blood draw and then take the sample back to the lab to have the test done.  Results will then be forwarded to the nursing home who in turn will notify the doctor of any abnormal results.

Here, the nursing home had a contract with a single lab to perform the testing.  However, the technician did not show up to perform the testing, so no test was performed.  The following day the resident was sent to the hospital suffering from a brain bleed.  In the emergency room a PT/INR test was performed.  The result was a score of 7.5 when the normal range is 0.8-3.5.  The conclusion at the hospital was that the brain bleed was due to supratherapeutic INR.  In other words, the resident’s blood was too thin, leading to the brain bleed.  Had the ordered lab work been performed, the doctor could have acted on the elevated INR and prevented the brain bleed from occurring.

There are a number of issues with the care that this resident received.  First, the lab that had contracted with the nursing home did not provide the services that were required, raising questions of its liability for failing to provide the ordered testing. Second, the nursing home staff was aware that over the past few months leading up to this incident, the quality of the lab’s performance had dropped and that there had been problems getting ordered tests performed.  However, nursing home management had a contract with a single lab and did not have options available for the staff to look elsewhere for testing.  Third, the nursing home staff failed to notify the doctor that the tests he ordered had not been done.  All of these issues led to a very preventable injury to this nursing home resident.

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

Other blog posts of interest:

Bethany Rehab resident suffers brain bleed due to medication error

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

Alden Valley Ridge fails to give resident anti-seizure medications

Aperion Care Wilmington resident suffers ruptured colon due to fecal impaction

Pearl Pavilion resident dies of pulmonary embolism after not receiving blood thinners

Failure to monitor anticoagulant levels at Greentree of Bradley

 

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

 

Southpoint Nursing & Rehab Cited for Failing to Give Prescribed Pain Medications

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The Illinois Department of Public Health (IDPH) issued a citation to Southpoint Nursing and Rehabilitation Center in Chicago after a resident failed to receive the pain medications that had been ordered for him. 

Background

The resident in this case, like many other nursing home residents, entered Southpoint Nursing & Rehab from a hospital. He suffered from a series of gunshot wounds that left him with a broken jaw. Because of the injury, he needed to receive tube feedings. 

When the state surveyor came to the facility, it was found out the resident had been suffering from high levels of pain throughout his stay. He wasn’t receiving tube feedings regularly. He was also very rarely receiving the high dosage of Tylenol indicated in the order, and he never received any oxycodone because of the issue with the signature from the hospital. 

Poor Record-Keeping Leads to Medication Errors 

Typically, when residents are transferred to nursing homes from the hospital, there are medication orders that follow them. Part of the transfer orders for this resident was to get the tube feedings, receive a high dosage of Tylenol and oxycodone, when necessary. Ideally, these orders should have been transcribed into the medication administration records so the resident can receive them as intended. 

Oxycodone, an opiate pain reliever, required the signature of the ordering physician before it can be administered by the nursing home staff members to the resident. 

However, the paperwork from the hospital didn’t have this.

This omission should have been easily resolved — the nursing home could have reached out to the hospital to obtain the necessary signature or the attending physician at the nursing home could have signed off on the order issued by the hospital. Either one of these two possible solutions should have been implemented to make sure that the resident received the medication he needed, especially given the nature of his injuries. 

Unnecessary Pain is a Form of Abuse

For residents that are moving from a hospital to a long-term care facility like a nursing home, continuity of care is very important. When the standard of care provided drops along the way, errors like the one, in this case, turn out to be fatal. The resident suffered from significantly high levels of pain throughout his three-week stay in the nursing home. 

Any unnecessary pain can be considered a form of abuse, and this is exactly what this resident experienced. This is a medication error that could have been easily avoided had the proper protocols been observed properly.

Contact a Nursing Home Abuse Lawyer Today

We see that nursing homes are built to fail due to the business model they follow. Unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable results. 

Check out our FREE report, Built to Fail to learn more. 

Our experienced Chicago nursing home lawyers are ready to help you. We will help you understand the legal options available to you, determine if you have a case, and ensure that your rights and interests are protected throughout the process. Contact us to schedule a consultation.

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

 

Other blog posts that might be of interest:

Catastrophic brain injury from medication error at Alden Town Manor

Lexington Of Orland Park Resident Suffers Stage 4 Bed Sore

Sharon Health Care Willows Resident Undergoes Surgery For Bed Sore

Stephenson Nursing Center Resident Undergoes Surgery For Bed Sore

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