substandard nursing care Archives - The Law Offices of Barry G. Doyle, P.C.

Aliya of Oak Lawn Resident Dies After Nursing Staff Fail to Monitor Heart Pump Battery

December 11, 2025 By Barry G. Doyle Leave a Comment

The Illinois Department of Health has cited and fined Aliya of Oak Lawn when a 71-year-old resident with a left ventricular assist device died after nursing staff failed to monitor and change the device’s batteries, causing the heart pump to stop. The resident was found unresponsive, transported to the emergency room in cardiac arrest, and pronounced dead after the batteries completely depleted and the backup battery also failed.

The Incident

The resident in question was admitted to the nursing home with severe heart failure and a left ventricular assist device—essentially a mechanical heart pump that keeps blood flowing because his own heart was too weak. The device runs on external batteries that need to be monitored and changed when they drop to half capacity, or it can be plugged into a wall outlet to charge. The resident also had cognitive deficits and a history of wandering and sometimes tampering with his own equipment.

On the evening shift, a nurse checked the resident’s batteries and found them at three bars (adequate charge). However, the nurse did not change the batteries even though they had dropped to half capacity, which violated the facility’s protocols. The nurse stated that he would wait for the resident to ask to be plugged in at bedtime rather than proactively connecting the device to the wall outlet. The nurse remained on duty for seven hours after observing the low battery level but never changed them or plugged the device in.

During the overnight shift, the situation became critical. The night nurse claimed she changed the resident’s batteries around 3:30 in the morning, but video surveillance proved this was false—she never entered the resident’s room between 1:00 a.m. and when she left her shift in the morning. Instead, cameras captured her sitting at the nurse’s station using her personal phone, “blowing kisses while on the phone, laughing,” rocking in her chair, and walking down hallways waving her hands in the air. When she documented vital signs for the resident, she simply copied results from the previous morning rather than actually assessing him.

The morning nurse arriving for the next shift claimed she checked on the resident and “observed his chest rise and fall,” but video surveillance again contradicted this account—she only briefly poked her head in the doorway without entering the room. She admitted she didn’t check the device because the night nurse had told her everything was fine and the batteries were “full.”

According to the device’s event log, the batteries began showing low voltage warnings early in the morning, progressing to hazardous levels. When the external batteries finally died, the device automatically switched to its emergency backup battery and reduced the pump to minimum speed. Eventually, the backup battery also depleted and the pump completely stopped. A nursing assistant found the resident unresponsive later that morning. Emergency responders noted that when they arrived, the device “had been on battery backup for over 300 minutes” before anyone discovered the problem. Despite attempts at resuscitation and restoring power to the device at the hospital, the resident died.

Systemic Failures

The tragedy exposed widespread problems at the facility. Multiple nurses admitted they had never received proper training on the devices at this nursing home, though some had worked with them at other facilities. The Assistant Director of Nursing, who was supposed to be the facility’s expert and trainer on these devices, confessed “she is not competent in LVAD training” and had “never entered the resident’s room to observe his LVAD system.” She acknowledged she never told the nursing staff she was supposed to be their resource person “because she did not feel competent in her role.”

When asked to demonstrate how to check the battery level, one nurse “picked up the gray battery” and “flipped the battery over and over” but “did not identify the button on the front of the battery to check the battery capacity.” The facility’s training materials clearly stated: “change batteries if down to two lights (50%)” and emphasized that batteries “must always” have adequate charge, yet staff either didn’t know this or didn’t follow through.

The resident had no care plan specifically addressing his device despite its life-sustaining importance. While there was an order to check the device twice daily at 9:00 a.m. and 5:00 p.m., there was no plan for overnight monitoring even though the resident was known to tamper with his equipment. One nurse who regularly cared for the resident said “all the nurses were aware” that he would sometimes remove his own batteries, yet the facility implemented no additional safeguards.

The facility’s medical director stated that “if the batteries to the resident’s LVAD were depleted it would exacerbate his death” and emphasized “there should be at least one nurse on duty that is trained on the LVAD.” He also noted that the facility never informed him of the incident. The Director of Nursing discovered during the investigation that she had no documentation proving staff had received training, despite earlier assumptions that training had occurred.

Regulatory Response

Health inspectors declared an Immediate Jeopardy situation—the most serious type of violation indicating substantial likelihood of death or serious harm. The facility responded by immediately suspending and later terminating the night nurse who falsified records and failed to provide care. They conducted emergency training for all nursing staff on proper device monitoring, battery management, emergency response protocols, and the requirement to conduct resident rounds at least every two hours. The facility also implemented daily audits to ensure compliance and reviewed their policies with the medical director.

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

Bria of Wood River Cited After Staff Unable to Properly Resuscitate Two Residents With Tracheostomies

November 15, 2025 By Barry G. Doyle

The Illinois Department of Health has cited and fined Bria of Wood River when staff failed to properly perform CPR on two residents with tracheostomies, placing breathing bags over their mouths instead of their tracheostomy tubes because they didn’t know how to attach the equipment and had never been trained. Both residents died after receiving inadequate respiratory ventilation during resuscitation attempts, with staff admitting they either didn’t provide any ventilation or placed the bag over the wrong airway.

The first resident was admitted with chronic obstructive pulmonary disease, asthma, and a tracheostomy. His assessment showed he was cognitively intact and independent with mobility. His care plan documented he was a full code, meaning all resuscitation efforts should be performed if needed.

When the resident was found unresponsive and appeared blue, staff initiated CPR. A registered nurse later stated “we tried to do CPR over his tracheostomy, but we did not have the correct tubing to attach it, so we just tried to cover the tracheostomy with a gloved hand and attempted ‘bagging’ (placing bag valve mask) over his mouth.” Even more troubling, a nursing assistant stated clearly that “staff did not provide any ventilation during CPR and only did chest compressions. There were multiple bags in the room, but none would fit over his tracheostomy. The one on the crash cart did not work either, so they continued with compressions, but did not provide any ventilation during the resuscitation.” Emergency medical services continued resuscitation efforts but the resident was pronounced dead.

The second resident was admitted with anoxic brain damage, paraplegia, respiratory failure, and a tracheostomy. His assessment showed he was severely cognitively impaired, completely dependent for mobility, and required high concentration oxygen therapy and tracheostomy care. His care plan documented he was a full code.
When nursing assistants were providing care to this resident, they found him unresponsive and alerted a nurse. However, the assigned nurse was on break at the time.

A registered nurse from another unit started chest compressions while a nursing assistant attempted to provide breathing support. The nursing assistant explained what happened: “I started bagging the resident by mouth. I was not aware the bag had to be on the tracheostomy. I don’t even know how to attach the thing. I have never bagged a trach before. I think that is something we need to be educated on. None of us in there knew. I even asked. The nurse gave me the oxygen and I just took the bag and went with the mouth because that’s all I knew how to do. The nurse said she did not know how to attach it either.”

The registered nurse confirmed this account, stating “there was tube feeding coming out of the resident’s trach, so they just placed the respiratory bag over his face and turned the oxygen up.”

The fire department’s incident report revealed the severity of the problem: “Fire department units arrived on scene and found staff bagging the patient’s mouth and performing CPR on the patient while he was still in bed. Staff states they were bagging the patient’s mouth and not his trach tube due to secretions coming from the tube while CPR was being performed.” The fire department crew took over, noting the resident “was cold to the touch” when they arrived. They “took the bag valve mask off the patient’s mouth, mask was removed, and the bag valve mask was connected to the patient’s trach tube.” Despite following advanced cardiac life support protocols, the resident remained in asystole and medical control advised crews to terminate resuscitation efforts. The resident was pronounced dead.

The local fire department chief stated clearly that when his staff arrived, “facility staff were bagging the resident with the bag valve mask over the naso-oral pharynx which is not the standard place for the bag valve mask when a resident has a tracheostomy. The bag valve mask should have been via tracheostomy.”

When facility leadership was interviewed, they acknowledged the failures. The assistant director of nursing stated “there is a bag that goes over the tracheostomy when you provide CPR.” The director of nursing stated “there is a bag that goes on the trach, and those bag valve masks should be at bedside” and admitted she “was not previously informed of any issues with staff getting the bag valve masks on the tracheostomy.” The administrator stated “standard CPR protocol should be followed for residents with tracheostomies, but the respiratory bag should go over the tracheostomy site or the residents would not be getting air.” The medical director stated “he would expect staff to know how to perform CPR on residents with tracheostomies and would expect the facility to have the necessary equipment and supplies for both maintenance and emergent situations.”

Investigators also discovered that several nursing assistants did not have proper CPR certification from the American Red Cross or American Heart Association with hands-on, in-person training, despite the facility’s policy requiring it. The facility’s own tracheostomy care policy stated “it is the policy of this facility that residents with tracheostomies receive care to maintain a patent airway,” and the Code Blue policy instructed staff to “provide 2 breaths via ambu or manually if ambu is not available” and “continue CPR per BLS guidelines until EMS arrives.”

The facility failed on multiple critical levels: staff were not trained on how to perform CPR on residents with tracheostomies, the facility either didn’t have the correct equipment available or staff didn’t know how to use it, some staff lacked proper CPR certification, and leadership was unaware of these gaps until two residents died.

Hallmark Healthcare of Pekin Resident Suffers Severe Medical Neglect Leading to ICU Hospitalization

August 16, 2025 By Barry G. Doyle

The Illinois Department of Health has cited and fined Hallmark Healthcare of Pekin when staff failed to notify the resident’s physician about a significant decline in condition, resulting in two weeks with minimal medical treatment. The resident was eventually hospitalized in the ICU with severe dehydration, sepsis, kidney failure, and multiple other life-threatening conditions.

The resident in question, who had dementia and an indwelling urinary catheter, began showing signs of deterioration including refusing to eat, sleeping constantly, darker urine output, increased pain, and developing contractures in his lower legs that prevented him from straightening them.

Multiple staff members noticed these changes but failed to follow the facility’s own policies requiring immediate physician notification for acute changes in condition. A Certified Nursing Assistant observed that “Usually I could talk to the resident and the resident would talk back. The resident started sleeping all the time and wasn’t eating as much. I did notice the resident’s urine was darker than usual with a little less output.” A Licensed Practical Nurse acknowledged “I reported about the resident’s decline in condition. I did not notify the doctor however and should have.”

Instead of contacting the physician, staff focused on discussing hospice care with the family. The Social Services Director contacted family members about the resident’s decline but admitted “I did not call the resident’s physician regarding the resident’s condition and I am not aware if nursing notified the physician of the resident’s condition.” When the family member asked if the resident should be sent to the hospital, the Director of Nursing reportedly told them that the hospital would likely just send him back because there was nothing they could do.

The situation became critical when a Registered Nurse found the resident “lethargic with involuntary jerking, very slow to respond, increased weakness and fatigue noted, slow to respond and slurred speech, hypotension noted, Blood Pressure 66 systolic/44 diastolic.” At this point, the nurse sent the resident to the emergency room, later stating that “she could not take it anymore with the resident’s condition and that her conscience got the best of her.”

Upon arrival at the hospital, medical staff discovered shocking evidence of neglect. The admitting nurse described finding the resident’s “mouth and teeth were caked with black sludge that took me ten minutes and 12 different swabs to even try to get it out of his mouth” and noted “a lack of oral care like no one ever cleaned his mouth.” The resident’s catheter area was severely compromised, with the nurse observing that “The head of the resident’s penis, from the catheter rubbing and not cared for, was actually split.”

Hospital staff had to immediately replace the resident’s urinary catheter and discovered a massive blockage, with “immediate return of two liters (2,000 milliliters) of purulent appearing urine.” The hospital physician stated that “His creatine lab was 4.94 which indicates someone has been dehydrated for at least more than two days” and concluded that “the resident did not get like that in just one day. I felt the resident should have been hospitalized well before he was sent to us.”

The resident’s physician confirmed he had not been contacted about any decline, stating “I was not made aware of the resident’s declining condition. I last saw the resident on 4/8/25 and I do not have any record of the facility notifying me of the resident’s change in condition. I would have sent the resident right to the hospital and not messed with doing anything in house if the facility would have notified me of his condition.”

Medical records revealed the resident had lost nearly 14% of his body weight over six months, had not received ordered weekly weights, consumed only 25% or less of his meals for most of an eleven-day period, and showed no documentation that his urinary catheter had been changed since January. The facility’s own policies required staff to contact physicians immediately for acute changes in condition and to monitor residents with catheters for signs of infection.

The resident was diagnosed with Medical Neglect, Severe Dehydration, Acute Encephalopathy, Hypernatremia, Bladder Obstruction, Lactic Acidosis, Complicated Urinary Tract Infection, Sepsis, Metabolic Acidosis, Contractures to the Lower Extremities, and
Bacterial Pneumonia. He required intensive care unit treatment and remained hospitalized at the time of the investigation. The facility was cited for an Immediate Jeopardy violation, the most serious level of deficiency in nursing home care.

Resident Dies When Staff Fail to Perform CPR on Choking Resident At Bethany Rehab & Healthcare Center

April 9, 2025 By Barry G. Doyle

The Illinois Department of Health has cited and fined Bethany Rehab & Healthcare Center when staff failed to initiate cardiopulmonary resuscitation (CPR) on a full-code resident who stopped breathing after choking on food. The delay in resuscitation efforts continued until emergency responders arrived approximately eight minutes later, despite facility policy requiring immediate CPR for residents designated as “full code.”

The incident involved a female resident who had been identified as having difficulty swallowing related to facial pain from burn wounds. According to nursing notes, the resident had been “sleeping on and off” throughout the day and had eaten only “25% of her lunch.” During an evening family visit, a family member alerted a Licensed Practical Nurse (LPN) that the resident was choking. The nurse entered the room to find family members attempting to position the resident upright while food was visible “in and around her mouth.”

The nurse reported that he cleaned food from the resident’s mouth and heard “gurgling” sounds, which led him to believe she had aspirated food. He decided to call 911, leaving the room to make the call. While the nurse was calling 911, a family member approached him at approximately 5:35 PM, making a hand gesture across his neck and stating the resident had “stopped breathing.” Although the nurse claimed he “rushed for the crash cart,” he admitted he did not initiate CPR before paramedics arrived at 5:41 PM – approximately six minutes after being informed the resident had stopped breathing.

Multiple staff accounts confirmed that no CPR was performed prior to paramedics’ arrival. A Registered Nurse stated she was called by the LPN “to verify a resident’s death” before paramedics arrived and found the resident with “no heart rate, no respirations.” She assumed the resident was DNR (Do Not Resuscitate) because “V4 did not call a code or initiate CPR.” Another Certified Nursing Assistant confirmed that “CPR was not started until the paramedics arrived.”

The paramedic who responded to the call reported that when he arrived at the facility, he was initially told by the male nurse that the resident “had passed away.” Upon entering the resident’s room, he found no staff members present, only family, and “CPR was not being performed.” When he inquired about the resident’s code status and learned she was “full code,” he informed the family that CPR would need to be initiated. Despite the son’s objection, the paramedic explained that “according to protocol, CPR must be initiated because the resident was a full code, and none of the family members were her POA (Power of Attorney).” Paramedics finally began CPR at 5:43 PM – approximately eight minutes after staff were notified the resident had stopped breathing.

Both the facility’s on-call nurse and Medical Director confirmed that CPR should have been started immediately upon determining the resident had no pulse or respirations. The Medical Director emphasized, “You must start CPR immediately to achieve the best outcome. Ten minutes is way too long to wait and could definitely affect the outcome of a resident.” The paramedic similarly stated, “Six to ten minutes is a long time to wait to start CPR. There would be no blood return to the brain and brain death/cell death occurs.”

The facility’s own policy explicitly states that “the chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse.” Multiple facility records, including the Transfer/Discharge Report and Order Summary Report, confirmed the resident was designated as “Full Code,” meaning life-saving measures were required.

Resident Urinates On Phone Charger In Bed, Smoke And Sparks Fly, Receives Serious Burn At Allure Of Knox County

March 22, 2024 By Barry G. Doyle

IDPH has cited and fined Allure of Knox County when a resident, after urinating in bed, received an electrical burn on his backside when the urine entered into the charger and the charger started to smoke and spark.

The resident in question suffered a serious burn injury due to the improper use of electrical devices in his bed. The incident occurred when the resident, who is dependent on staff for repositioning, was found lying on top of his cell phone charging block, which was plugged into an extension cord. When the resident became incontinent of urine, the liquid entered the charging port, causing the device to spark and smoke, resulting in a severe burn to the resident’s left buttock.

According to the facility’s incident report, “the resident had cell phone power cord underneath his left buttock, cord got wet from urine, and created a burn.” The facility’s policy on electrical safety for residents states that “The resident will be protected from injury associated with the use of electrical devices, including electrocution, burns, and fire.”

The resident did report that his charger was plugged into an extension cord he had from home as he wanted to be able to be on his phone while in bed as it was charging.

A certified nursing assistant who responded to the resident’s call for help, stated, “When I went into the room the resident was yelling, ‘it burns, it burns.’ I said, ‘where is it burning at?’ and the resident said under his bottom. That’s when I noticed his phone cord was sparking and smoking. I ripped it out of the wall and then pulled it out from under him.”

The burn injury to the resident’s left buttock has required multiple surgical debridements to remove necrotic tissue and promote healing. The resident has been receiving daily wound treatments and pain medication to manage his discomfort.

The resident and his spouse stated that the phone charger and extension cord had been in use for months without any staff members expressing concerns. The spouse said, “We didn’t know what we could or couldn’t have.”

The facility’s administrator acknowledged that the resident should not have been using an extension cord in his room and that the staff should have noticed and addressed the issue as a team.

This incident highlights the importance of proper electrical safety practices in care facilities and the need for staff to be vigilant in identifying and addressing potential hazards to prevent resident injuries.

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

Significant Delay In Providing Care Leads To Pain, Suffering and Death At Arcadia Care Auburn

March 14, 2024 By Barry G. Doyle

IDPH has cited and fined Arcadia Care Auburn when the facility failed to schedule a vascular consultation promptly, resulting in a deterioration of the resident’s condition and a delay in critical medical interventions.

The resident in question was admitted to the facility with a history of end-stage renal disease, peripheral vascular disease (PVD), and other comorbidities. Upon admission, the resident’s left great toenail was missing with an open wound, and her legs were edematous.

The Wound Physician noted that the resident’s feet were cool to touch, had moderate edema, and dark discoloration of the toes. The resident complained of 8/10 pain in both feet/toes. The Wound Physician recommended an ankle-brachial index (ABI) test and a vascular consult “if considered appropriate by med director/primary.”

Two days later an ABI was ordered by the physician due to pain and cool feet/toes. A week after the test was ordered, a Podiatrist assessed the resident and noted that her left foot was “ice cold from the distal digits to the ankle,” with absent hair growth and cyanosis bilaterally. The Podiatrist noted that “the entire hallux left foot is showing lines of demarcation for gangrenous changes” and requested a vascular consultation.

A little over a week later the resident’s Physician/Medical Director noted progressive worsening of PVD and significant pain in her lower extremities, increasing her pain medication. The Physician referred the resident to vascular surgery for further evaluation and three days later the ABI results confirmed claudication, a symptom of PVD.

A Nurse Practitioner noted the resident’s continued decline and recommended a referral to vascular surgery or hospice for better pain control. The same day an RN documented that the resident’s left great toe was “mottled, black-necrotic, hard, cold” and right 2-4th toes were “mottled, black-necrotic, hard, and cold.” Over the following days, the resident was constantly screaming out in pain, and her pain medications were not effectively controlling her symptoms.

A full three weeks after the first diagnosis, an RN ordered a vascular consultation for the resident’s bilateral toes. The Wound Physician also recommended a vascular consult or hospice care with aggressive pain control. However, the vascular appointment had not been scheduled by the time the resident was transferred to the hospital, a full 3 and ½ weeks after the initial consult.

At the hospital, the resident was diagnosed with septic shock and bilateral lower extremity gangrene. The Emergency Physician noted that “her legs are no longer salvageable and there are no revascularization options for her at this time. She would need bilateral lower extremity amputations. She is quite sick and unstable at this time.” Unfortunately the resident passed away the following day.

Facility staff acknowledged that the resident’s vascular consultation should have been scheduled more promptly. The Nurse Practitioner stated, “I expected the vascular consult to be done timelier,” while the resident’s Physician said, “facility should have gotten her into see vascular doctor sooner.”

The facility failed to document discussions with the resident’s family regarding her condition and prognosis, despite her deteriorating state and the need for critical decision-making.

Unfortunately, the facility had multiple shortcomings:

1. Significant delay in providing timely vascular consultation and treatment.

Despite recommendations from multiple healthcare professionals, the facility failed to schedule a vascular consultation promptly, resulting in a deterioration of the resident’s condition and a delay in critical medical interventions.

2. Inadequate pain management and symptom control.

The resident experienced severe, uncontrolled pain that was not effectively managed by her prescribed medications, leading to constant screaming and suffering.

3. Insufficient communication and decision-making with the family.

The facility did not adequately communicate with the resident’s family regarding her condition, prognosis, and treatment options, particularly concerning her declining health and the potential need for hospice care.

4. Inconsistent monitoring, reporting, and care coordination.

There were inconsistencies in staff reporting of the resident’s condition, as well as a lack of clarity on decision-making processes regarding her care, suggesting inadequate monitoring and care coordination among healthcare professionals.

5. Non-adherence to facility policies and best practices.

The facility did not follow its own change of condition policy, which required consulting with the doctor and family for any changes in a resident’s condition. Additionally, there was a potential delay in recognizing and addressing the severity of the resident’s condition, leading to a late transfer to the hospital.

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

Resident Dies After Facility Is Unable To Assure That Airway With Tracheostomy Is Clear During CPR Attempts

March 7, 2024 By Barry G. Doyle

IDPH has cited and fined Aliya of Palos Park when a resident died after the facility failed to assure that the airway with a tracheostomy was free of obstruction during CPR attempts.

The resident in question was suited with a tracheostomy and various diagnoses including Acute Bronchitis, Dysphagia, Chronic Respiratory Failure, and Vascular Dementia. When the resident developed respiratory distress, staff members were unable to locate a spare inner trach tube to provide oxygen and clear the resident’s airway.

A Licensed Practical Nurse (LPN), noticed the resident’s distress and started chest compressions, stating, “I started chest compressions and the resident had a faint pulse.” A registered Nurse (RN), attempted to suction the resident and reported, “I suctioned the resident and she was clear.” However, the RN later admitted, “no one had trained me at the facility with trach care.”

During the code, paramedics arrived and asked for a new inner cannula for the resident, but the staff was unable to find one. The resident’s family member, who had recently arrived, stepped in to assist. The family member said, “I removed my mother’s inner cannula and it was clogged with mucus. You could not see through the inner cannula that had been removed.”

Paramedic records from the incident document, “Crew tried to bag patient and met with great resistance. Crew asked nurses to change the port tube for the trach, and they had to find someone to do it. Crew unable to vent patient appropriately due to how clogged the tube was. Crew also notes, the facility staff was “trying to bag without the oxygen cylinder on.”

The resident was transported to the local emergency room. Hospital records noted, “patient has a trach that per EMS ‘was so clogged we were pulling out chunks.” Despite efforts, the resident was pronounced deceased.

The care facility had several shortcomings that contributed to the incident involving the resident:

1. Lack of staff training: A Registered Nurse admitted that no one had trained her on trach care at the facility. This lack of proper training likely contributed to the staff’s inability to handle the emergency situation effectively.

2. Inadequate emergency equipment: During the code, staff could not locate a spare inner cannula for the resident’s tracheostomy tube. This suggests that the facility did not have adequate emergency equipment readily available.

3. Insufficient documentation: The facility’s records did not document the removal of the resident’s trach tube to check for clogs during the emergency, despite the facility’s Tracheostomy Care Policy stating that the inner cannula should be removed and a new one inserted.

4. Incomplete facility assessment: The facility’s assessment tool did not identify Respiratory Therapy Services, and the number of residents with tracheostomy care was listed as zero. This suggests that the facility may not have been properly prepared to care for residents with tracheostomies.

5. Staff not current with CPR certification: Several staff members did not have current CPR cards on file. This indicates that some staff may not have been adequately prepared to handle emergency situations.

6. Lack of proactive planning: The facility appeared to be unprepared for the admission of a resident with a tracheostomy, as evidenced by the lack of staff training, insufficient emergency equipment, and incomplete facility assessment.

These shortcomings collectively contributed to the facility’s inability to provide proper care for the resident during the respiratory emergency, ultimately leading to the resident’s death.

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

Resident Bleeds To Death At Pearl Pavilion in Freeport

December 23, 2023 By Barry G. Doyle

IDPH has cited and fined Pearl Pavilion nursing home in Freeport after a resident died when his wound vac machine became disconnected, resulting in him bleeding to death.

The resident at issue was found unresponsive in a wheelchair in his room by a nursing assistant around 7:11AM. There was blood all over the floor. The assistant alerted the nurse on duty about the situation. When the nurse came to assess, she saw that the resident was nonverbal, saturated in blood, with more blood on the floor. But she did not identify where the bleeding was coming from or monitor the resident continuously.

Approximately 27 minutes went by before the Assistant Director of Nursing was told at 7:38AM. When she came to the resident’s room, his wound vac machine was laying on the floor disconnected and he was bleeding out. The resident could only say “ugh” before he slumped over unresponsive in his wheelchair. The Assistant Director of Nursing decided to leave him with the nurse while she left to get paperwork. Neither checked him fully or applied pressure to stop the bleeding.

Soon after, 911 was called. But when EMTs arrived, they found that the staff had not monitored the resident or given any care. EMTs discovered that the resident had a large, actively bleeding wound on his right groin area which led to severe blood loss and heart stoppage. They had to start CPR and aggressively resuscitate him while transporting to the hospital ER. Tragically, the blood loss was too severe and he passed away in the ER later that morning despite receiving many rounds of CPR.

Interviews with nurses on staff showed concerning gaps in emergency training and clinical judgment. One said she assumed care was being handled so she “just moved on.” Another admitted she may have had to cut his clothes off to find the wound and wasn’t sure where the blood was coming from when EMTs arrived. The Assistant Director stated “it all happened pretty fast” and care wasn’t prioritized over paperwork.

This startling lack of care and compassion speaks to a lack of investment in the facility staff which is a hallmark of the for-profit business model that most nursing homes follow. It also makes one think that these nurses may just be overworked, and have lost respect for the residents they care for on a daily basis.

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.

Split penis the result of poor catheter care at Piatt County Nursing Home

June 23, 2023 By Barry G. Doyle

IDPH has cited and fined Piatt County Nursing Home after a resident there suffered a split in his penis from the tip to the scrotum due to poor catheter care.

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

The resident as admitted to the nursing home with a catheter in place for urinary retention. Despite having a catheter in place on admission, there was no care plan developed with regard to the use of the catheter. One month after admission, the staff documented a split in the tip of the resident’s measuring 1 cm x 0.5 cm. A wound care physician was brought in to address the tear, and he issued orders which included application of petroleum jelly and consult with a urologist.

When a resident develops a wound like this, this represents a change in condition which requires physician notification (which was done). It also requires revision of the resident care plan. This was not done.

When the staff was interviewed by IDPH as part of its investigation, one nurse said that it appeared that the resident had issues at the nursing home where he resided previously. If there was in fact a tear present when the resident was admitted to the facility, the fact that it went unaddressed for a month is troubling as well. When residents are admitted to a nursing home, the undergo a head-to-toe skin assessment, and if that wound was missed not only during that assessment but also during regular catheter care during the first month of the resident’s admission to this nursing home, that is also substandard care. It means that the wound would not have been reported to the physician, it would not have been addressed in the care plan, and there would have been no treatment for it.

The staff applied the petroleum jelly for four days but then stopped because it was causing drainage. However, the staff did not notify the wound care physician and no order was ever issued to discontinue the use of petroleum jelly. The urology consult was scheduled. However, the earliest date for an appointment which could be obtained was nearly two months later. On the day of the appointment, the resident was not able to go to the appointment because his high-backed wheelchair could not fit into the van which was to take him to the appointment. The appointment was canceled and had not been rescheduled as of the time of the investigation by IDPH.

A month after the urology consult was canceled, the attending physician was notified that the catheter has been changed 3 times in one week due to nonpatency (there was a blockage which kept the urine from flowing through the catheter), that the resident had not yet been seen by a urologist, and that the resident’s penis was split down the the scrotum. IDPH arrived a few days later and found that the urine bag was on the floor next to resident’s bed rather than hanging from the rail. The surveyor observed that the penis was filleted open from the tip to the scrotum. When the surveyor asked whether it was sore, the resident replied, “Yes, more than you know.”

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

If there was in fact a tear present on admission, it was not discovered by the staff during their initial skin assessment or during subsequent care, nor was the wound addressed in the care plan or in treatment orders.
Care of the catheter was not addressed in the resident care plan.
The staff failed to follow the physician’s order for the application of petroleum jelly or advise the physician that application of it was causing additional drainage.
Once the wound was recognized in the facility, care of the wound was not addressed in the resident care plan.
The staff failed to obtain a timely appointment for the consult with the urologist, failed to make arrangements for proper transportation to the appointment, failed to advise the wound care physician or the attending doctor that the appointment was canceled, and failed to reschedule it.
Left the urine collection bag on the floor, resulting in additional pressure on the penile tissues.

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 follow care plan leads to fall and fractured hip at Piatt County Nursing Home

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

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

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

Newman Rehab resident suffers burns to leg from radiator

April 14, 2023 By Barry G. Doyle

IDPH has cited and fined Newman Rehab & Health Care Center after a resident there suffered burns to his right lower leg and both feet due to his bed being placed directly against a hot electric baseboard heater.

The resident at issue suffered from multiple conditions, including dementia, Parkinson’s, myofascial pain, lumbar radiculopathy, and history of stroke. He had frequent falls, so as a fall prevention measure, his bed was kept in the lowest position which brought it down almost to the floor. However, because he was known as a difficult resident, the staff would at times skip rounding on him if he was sleeping to avoid “waking the bear” and also moved his bed right up against the radiator so that they could monitor him by keeping the door open without waking him up.

In each of the rooms at this nursing home, there was an electric baseboard heater which was originally installed in 1973. It allowed the temperature to be controlled in each room individually. When the temperature would be set at its highest setting (over 80 degrees), it was well-known to the staff that the baseboard radiator units would get very hot. Staff told the state surveyor that when beds were pushed directly against the radiators, it would be very difficult to pull them apart. They further told the state surveyor that when they came into contact with the radiator, they would have to move away quickly to avoid being burned.

During the inspection by IDPH, the regional maintenance director told the state surveyor that when the temperature is turned all the way up, the internal heating element for the radiator will run full speed until the target temperature is reached. When this happens. the heating element can reach 450 degrees. The nursing home no longer had the manuals for the heaters but some were located online which stated that there should be at least 6 inches between the radiator and any furniture. The regional maintenance director further told the state surveyor that they determined that at the maximum temperature setting, the metal covers could reach 175 degrees.

On the night that this resident was injured, the temperature was set at above 80 degrees – the highest possible temperature setting. The CNA on duty rounded on the resident between midnight and 1:00 a.m. but had to leave at 2:00 a.m. when another aide came on duty to replace her. The resident was not rounded on again until approximately 4:30 a.m., at which time she found that the resident’s bed was directly against the radiator with his right lower leg and left foot laying directly on the radiator. The resident’s room was very hot and he was in bed with a blanket and sheet and he had moved his legs out from underneath the blankets. The resident’s right calf was blistered and the outer portion of his foot was very red. There was skin peeling off the great toe of the left foot. Another aide who entered the room said the room smelled of hot burning flesh.

The resident was sent out to the emergency room where he was admitted for wound care and pain control. The wound on the resident’s right leg measured 27 x 9 cm, while the foot wound measured 5 x 3 cm, and the left foot wound measured 6 x 3 cm. He ultimately underwent surgery for skin grafting. The podiatrist who did the procedures reported to the state surveyor that there was some bleeding of the right leg wound when the procedures were done which indicated that there was some perfusion to the tissue which was a favorable sign for healing. However, the wounds to both feet did not have any bleeding which indicated poor circulation which placed the resident at risk for more debridements, more skin grafting procedures, infections, and possible amputations.

This was a very preventable injury – indeed much of the staff at the nursing home attributed the resident’s injuries to a lack of “common sense” – that a dementia resident’s bed should not be placed directly against the radiator and have the heat turned all the way up. The staff was well aware from their own experiences that even brief contact with the radiator would burn and that the heat was enough that after the beds were pushed up against the radiators it would be hard to pull them apart. Nursing home residents often have thin skin as a consequence of aging – this is one of the reasons that they are prone to developing bed sores – which also places them at risk for horrific burns from exposure to a hot radiator. When this is coupled with a mobility deficit, it sets the stage for just the kind of injury that was suffered 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:

Unlocked furniture causes fall and broken leg at Mt. Vernon Countryside Manor

Odd Fellow Rebekah Home resident suffers fatal brain bleed in fall

Resident suffers broken ankle in unsafe transfer at Loft Rehab of Rock Springs

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

Landmark of Richton Park resident dies due to mishandling of tracheostomy

April 22, 2022 By Barry G. Doyle

IDPH has cited and fined Landmark of Richton Park nursing home after a resident there died after a respiratory therapist cut sutures to a fresh tracheostomy without a physician order, leading to the loss of the airway and cardiac arrest.

A tracheostomy is a surgically-created airway. A surgeon cuts a hole, or stoma, in the front of the neck and through the trachea. A tube is then placed in the hole and allows the person to breathe through the hole. A tracheostomy is commonly used for ventilator-dependent patients to reduce complications associated with the use of a ventilator.

The tracheotomy tube actually consists of three parts. One is known as the outer cannula. The outer cannula has a neck plate flange which is stitched into place in the hole (or stoma) in the neck at the time of surgery. There is an inner cannula which fits inside the outer cannula and can be removed and cleaned. Finally, there is an obturator which is used only while the inner cannula is being placed. After it is placed, it is removed and disposed of.

Because the hole (or stoma) is a surgical wound, it must be given time to heal. Premature removal of the stitches can cause subcutaneous emphysema, or leaking of air under the soft tissues. Removal of the tube is not recommended for several days after initial placement because this can lead to rapid loss of the airway.

The resident at issue was admitted to the nursing home the day before the incident with a newly-created tracheostomy. During rounds, the wound care nurse advised the respiratory therapist that dressing wound did not look like it had been cleaned. The respiratory therapist saw that there was some dried blood in the area and decided to clean it. She asked the wound care nurse to borrow a pair of scissors so that she could cut a resident’s sutures. The wound care asked if was okay to do and the respiratory therapist said yes. She then proceeded to cut all of the sutures and clean the area.

Later that day, the alarms to the ventilator went off. The respiratory therapist went in and found that the resident was having a hard time breathing. Believing that the resident had a mucus plug (an accumulation of mucus in the airway which restricts airflow), she attempted to suction out the airway but did not get anything out and was not able to see the plus. She called for help and the rest of the staff responded. According to the respiratory therapist, the staff attempted to remove and replace the tracheostomy tube and ventilate the resident using an ambu-bag. However, there was resistance when they squeezed the bag on the ambu-bag, indicating that there was a loss of the airway. The resident began to turn blue and her face began to swell as they attempted to ventilate the resident.

Paramedics arrived, and they recorded on their report that the staff told them that the respiratory therapist had been the one to remove the tracheostomy tube. The paramedics were unable to re-establish the airway, and the resident went into cardiac arrest. She was brought to the hospital, but did not survive. When the resident arrived at the hospital, the staff noted extensive evidence of subcutaneous emphysema.

There are a number of issues with the care that this resident received. First, the sutures for the tracheostomy were removed prematurely, and done so without a physician order. Second, the tracheostomy tube was removed during the resuscitation effort. This likely contributed to the loss of the airway. It would be critical in any nursing home abuse and neglect lawsuit to determine exactly who removed the tracheostomy tube, as respiratory therapists often work for an outside company. Finally, the nurse provided the scissors to the respiratory therapist when she was likely aware that removing the sutures was inappropriate and that there was no physician order for doing so.

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 dropped from lift, breaks both legs

Generations at Rock Island cuts respiratory staff, care suffers

Aperion Care Wilmington resident suffers ruptured colon from fecal impaction

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

Dehydration leads to hospital admission for resident at Mattoon Rehab

December 29, 2021 By Barry G. Doyle

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

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

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

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

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

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

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

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

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

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

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

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

Other blog posts of interest:

Mattoon Rehab resident dies from infected bed sore

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

Failure to report changes in condition at Heritage Health in Carlinville

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

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

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

November 27, 2021 By Barry G. Doyle

IDPH has cited and fined Parker Nursing & Rehabilitation Center in Streator after a resident there developed sepsis from aspiration pneumonia due after vomiting because his orders for administering nutrition through his feeding tube were not followed, leading to him be admitted to hospice for end of life care.

One of the basic truisms in the nursing home industry is that a nursing home should not accept the admission of a resident when they are not able to meet the care needs of the resident. This is what happens when that fundamental is not followed.

When a resident is admitted to a nursing home from a hospital, the discharge planner from the hospital forwards information to the nursing home regarding the medical history and care needs of the resident. Those records are reviewed by a senior member of the nursing staff to determine whether or not the resident is suitable for admission to the nursing home. If so (and the financial portion of the admission is worked out), then the resident can be admitted to the nursing home.

The resident at issue was admitted to the nursing home for rehabilitation after experiencing a stroke. He had a tracheostomy and a feeding tube. However, the admission screening information from the hospital stated that he was a “short stay” admission. The discharge orders included continuous infusion of the solution for the feeding tube at 75 mg per hour. Delivery of the solution would ordinarily require use of a pump to ensure that the resident received the solution at the desired rate.

The decision to accept a resident at this nursing home would ordinarily be made the quality assurance nurse, who at this facility was a LPN. However, she was gone on vacation at the time that the admission was being considered and her role was being covered by another nurse, the MDS Coordinator. This nurse okayed accepting the resident into the facility, apparently unaware that they did not have a pump for use for this resident.

There were other members of the staff who were aware that there was no pump available for this resident. However, no one called the resident’s doctor to notify him that they could not carry out the doctors’ orders due to the lack of a feeding pump. The resident’s doctor told the state surveyor that he should have been notified and that had the staff done so, he would have changed the orders.

Without a pump to regulate the flow of feeding tube solution to the resident, the rate of the feeding tube was left to gravity – in other words, the bag with solution was left to hang on an IV pole and simply empty out. The problem with this is that the rate at which the solution was delivered to the resident was not controlled, which in this case meant that the solution was delivered to the resident far too quickly. The net result of this is that the resident was badly overfed and began to vomit, with vomit coming from the resident’s mouth and out of the tracheostomy.

Vomiting from a resident represents a change in condition which requires physician notification. However, the doctor was not notified. Further, the nurse did not shut off the tube feeding, resulting in the resident continuing to be overfed. As the resident continued to receive more and more solution, he continued to vomit.

The nurse reported to the state surveyor that she did not suction the resident initially, but did so later. Even then, it was a superficial suctioning, not a deep suctioning which would have been necessary to clear the airway. Suctioning was necessary to clear the airway because when a person inhales foreign substances into the lungs, this causes aspiration pneumonia.

Aides assigned to care for the resident reported to the state surveyor that throughout the night they advised the nurse on duty that the resident was continuing to vomit and that the resident did not look good. Despite this, the nurse did not go to check on the resident and did not suction the resident’s airway.

Some 5 hours after the resident began to vomit, the nurse called for an ambulance to take the resident to the hospital. There, the resident was diagnosed with severe sepsis due to aspiration pneumonia caused by overfeeding. The resident was admitted to hospice to receive end-of-life care.

There were multiple failures in the care that this resident received:

The nursing home accepted the resident for admission when it did not have the equipment necessary to treat him consistent with physician orders;
They did not advise the doctor that they did not have the pump necessary to control the delivery of feeding tube solution to the resident, precluding the doctor from issuing other orders for the feeding of the resident;
They failed to advised the doctor that the resident was receiving far more feeding solution than was ordered;
They failed to advise the doctor of the onset of vomiting by the resident;
Once the resident began to vomit, they failed to stop the delivery of the feeding tube solution;
The nurse on duty failed to suction the resident’s airway once he began to vomit, setting the stage for him to develop aspiration pneumonia;
The nurse on duty failed to assess the condition of the resident despite being advised by aides that the resident was continuing to vomit and did not look good.

All of these failures set the stage for the resident to be admitted to hospice to receive end-of-life care. This is a resident who despite his recent medical issues, was admitted to the nursing home as a rehabilitation patient – in other words, there was an expectation that he would eventually return home. This was not be be due to the failures in 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:

Feeding tube error at Aperion of Westchester

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

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

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

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

Christian Nursing Home resident suffers severe leg injury in fall

November 19, 2021 By Barry G. Doyle

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

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

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

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

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

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

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

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

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

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

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

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

Other blog posts of interest:

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

Resident breaks hip in fall at McLean County Nursing Home

Piatt County Nursing Home breaks neck in fall from power recliner

University Rehab Northmoor resident suffers fractured hip in fall from bed

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

Grove of Elmhurst resident dies due to delay in physician notification

November 17, 2021 By Barry G. Doyle

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.

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.

Marshall Rehab resident fractures back in van accident

November 15, 2021 By Barry G. Doyle

IDPH has cited and fined Marshall Rehabilitation after a resident there suffered a fracture to her lumbar spine in an accident while a passenger on board a van from the nursing home.

Many nursing homes operate passenger vans which are used to transport residents to and from doctor appointments or community events. When the nursing home uses a van that way, it is responsible for three things: (1) that the van is operated in a safe manner, (2) that the residents who are passengers in the van are handled and secured properly within the van, and (3) that the staff is properly trained on both of the other points. This citation was about what happens when neither is true.

The resident was in a wheelchair in the facility van returning from a doctor appointment in Champaign. There was road construction on the way back. While passing through the road construction zone, the driver hit a large bump in the road. The impact with the bump caused the resident to be jolted up and down in her wheelchair. When she came down, she felt a pop in her lower back and began to have significant ongoing pain in the low back which persisted even with the use of strong pain killers. Her doctor eventually ordered an MRI which showed an acute compression fracture in the lumbar spine. the doctor ordered that she be placed in a LSO brace (turtle shell brace) for six weeks.

The investigation into this incident showed that even though the van was equipped with a restraint system, it was not in use because the aide who was driving the can had not been trained in how to use it.

This was a highly preventable injury has the nursing home and its staff adhered to the three basic principles outlined above. First, safer driving in the form of reduced speed and keeping a safer lookout in a construction zone would have likely reduced the violence of the impact with the bump. Second, the resident was not in the restraint system which would have kept her from being thrown up out of her seat. Finally, the aide admitted that she had not been trained in the use of the restraint system.

Of the three failures, the last is the one which is most predictable given the basic nursing home business model, which includes failing to invest in the training of staff. 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:

Transportation van accident at Generations of Rock Island

Resident falls from van at Casey Healthcare

Hilltop Skilled resident breaks leg in fall from bed

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

November 3, 2021 By Barry G. Doyle

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:

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.
The doctor was not informed of the result of the culture and sensitivity, delaying the start of antibiotic therapy.
The catheter was described as having an infected appearance, indicating that there was poor catheter care throughout.
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.

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.

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

October 20, 2021 By Barry G. Doyle

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

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

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

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

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

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

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

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

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

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

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

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

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

Other blog posts of interest:

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

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

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

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

Rushville Nursing & Rehab resident suffers untreated surgical wound infection

October 13, 2021 By Barry G. Doyle

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.

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

October 11, 2021 By Barry G. Doyle

IDPH cited and fined Piatt County Nursing Home in Monticello after a resident there fell from a power recliner chair and suffered fractures to her neck, leading to placement in hospice.

Any piece of equipment used in the care of nursing home residents must be safe for use with that particular resident, and it is upon the staff to make assessments as to whether that piece of equipment is safe for use. If the equipment is not safe or could not be made safe through adjustments to the equipment, education of the resident, or close supervision of the resident, then the equipment should not be put into use.

That of course assumes that the assessment of the safety and appropriateness of the equipment is made. This incident is about what happens when a proper assessment is not made.

The equipment at issue is a chair known as a power recliner. It is a chair which tilts backward like a regular recliner, but is useful for people who have a hard time getting up from a seat because it tilts forward and boosts the back upwards to make it easier for the user to get up from a standing position. The chair moves from a reclined (tilted back) to a tilted forward position with a power control which can be operated by the user.

The power recliner had been in use at the nursing home for a long time – to the point that they no longer had the owner’s/operations manual. During the investigation into this incident, the IDPH representative contacted the manufacturer who advised that they had stopped manufacture of this particular chair in 2007. However, the manufacturer had advised that in order to use the chair safely the resident had to have the ability to bear weight independently and be alert enough with the cognitive ability to safely use the chair.

The resident involved in this incident had a history of stroke with residual left-sided weakness. Those impairments were significant enough that she required the use of a mechanical lift for transfers. She had been assessed as having moderate cognitive impairments.

On the night of this nursing home fall, the resident had been dangling her foot over the edge of her bed and telling the staff that she needed to leave to go somewhere. The staff transferred her with a lift to the recliner. At some point during the night, the resident used the remote to lower the chair and then bring it forward so that she was in a position where she was tilted forward.

As she reached that position, she fell forward, hitting her face on the floor. There was immediate obvious bleeding, so she was sent to the hospital. There she was diagnosed as having fractures of the C1 and C2 vertebra. After a brief hospital admission, she was returned to the nursing home under the care of hospice. The

This was a case where the proper assessments were not made for the resident to use this equipment. She had demonstrated, known cognitive impairments, known musculoskeletal deficits, and was not able to bear weight well enough to participate in regular transfers. She did not meet any of the standards for use given the manufacturer’s recommendations for the use of this equipment. Past that, the resident had been verbalizing a desire to go elsewhere. As with residents who elope from the nursing home, her expressed desire to go elsewhere was a sign that she was likely to try to get up unassisted, and the use of this chair made that all the more hazardous. Very simply, this was a resident for whom use of this equipment was not suitable as a general proposition, but especially that night. The net result – catastrophic yet preventable injuries for 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:

Pleasant Meadows Senior Living resident breaks hip and wrist in fall

Failure to follow care plan leads to fall, fractured hip at Piatt County Nursing Home

Arcadia Care Bloomington resident breaks hip and back in from from wheelchair

Piatt County Nursing Home resident fractures hip in fall

Sling breaks during transfer at University Rehab in Edwardsville

Gardenview Manor resident suffers broken hip during unsafe transfer

Westminster Village resident suffers multiple fractures in fall

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

Hilltop Skilled resident breaks leg in fall from bed

October 6, 2021 By Barry G. Doyle

IDPH has cited and fined Hilltop Skilled Nursing & Rehabilitation Center nursing home in Charleston after a resident there suffered a broken leg in a fall from bed.

The resident at issue had a complex medical history which included paraplegia, a right arm contracture, and a Stage 4 pressure ulcer to the buttock and another bed sore to the sacrum. After a nursing home resident develops a bed sore, federal regulations require the nursing home to provide care, treatment, and services to promote healing, prevent infection, and prevent the development of new pressure ulcers. Here, as part of the wound care strategy, there was an order in place for the use of a low-air loss mattress.

One of the main risk factors for the development of bed sores is pressure (part of why they are called pressure ulcers). Pressure is also an impediment to wound healing. A low-air loss mattress helps to prevent bed sores and aid in the healing of existing ones by reducing pressure. One of the downsides of the use of a low-air loss mattress is that it is harder to maintain a safe position in bed because of the way that the mattress supports the body. This is especially true with resident who have impaired mobility, as was the case with this resident who suffered from paraplegia and had an upper extremity contracture. These mobility impairments were recognized in advance of this nursing home fall as the resident’s Minimum Data Set showed that the resident required the assist of two staff with bed mobility and transfers.

Further, even before the fall occurred, the staff was aware that the resident had difficulty maintaining her position in bed as the staff would find that she had slid down to the bottom of the bed or at other times found that she had her feet hanging over the edge of the bed.

This situation – the use of an air mattress with a resident who had known impairments to bed mobility and who had demonstrated recurrent problems with safe positioning in bed – presented a picture where the resident was at risk of falls, specifically sliding out of bed and being injured. When there is a risk of a resident experiencing a fall, then a fall prevention care plan must be put into place. Unfortunately, despite the need for a care plan to address this risk of injury to the resident, nothing was done. During IDPH’s investigation, the administrator admitted that the care plan should have been updated to include monitoring the resident’s position in bed and that the resident’s injury was their fault.

On the morning of this nursing home fall, the resident was discovered on the floor at about 6 am by the staff. She told the staff that she slid out of bed. The resident was complaining of pain, but the staff failed to notify the resident’s physician, but instead called to have a portable x-ray service come in. The x-rays were no performed until the early evening. The results from the radiologist who read the films did not come in until nearly 9 pm. The x-rays showed a fracture of the lower part of the femur. At this point, the resident’s physician was notified and he ordered the resident sent to the hospital.

Besides the resident experiencing an unnecessary fall, this resident was also subjected to experiencing prolonged unnecessary pain by the failure of the staff to timely notify the doctor. The doctor told the state surveyor that had he been made aware of the situation, he would have sent the resident to the emergency room earlier. Most nursing staff will agree when asked that subjecting a resident to unnecessary pain is a form of nursing home abuse.

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:

Pleasant Meadows Senior Living resident breaks hip and wrist in fall

Unlocked furniture results in fall and fracture at Mount Vernon Countryside Manor

Charleston Rehab resident suffers brain bleed and fractured hip in fall from bed

Grove of St. Charles resident suffers fractured hip after being rolled from bed

Tuscola Health Care Center resident dropped from lift, breaks ankle

Aperion Care Fairfield resident falls from wheelchair, fractured leg goes untreated

Casey Healthcare resident breaks hip in fall due to failure to follow care plan

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

Feeding tube error puts Burgess Square resident into heart failure

September 21, 2021 By Barry G. Doyle

IDPH has cited and fined Burgess Square Health Center nursing home in Westmont after a resident there was given tube feedings well in excess of that ordered by the physician, causing her to experience acute congestive heart failure and requiring hospitalization.

One of the basic functions of nurses in a nursing home setting is to provide care in accordance with physician orders. Each resident will have a diet order. Some residents have an order for a general diet, other residents have a modified diet such as a mechanical soft diet which is intended to reduce the risk of nursing home choking accidents. Still other residents receive their nutrition through tube feedings, and this is something which requires the help of the nursing staff.

When a resident receives nutrition through a feeding tube, the order will usually include what kind of formula should be given and how much. Failing to give the right kind of formula can cause medical problems for the resident, while failing to give as much as ordered can lead to malnutrition and other illnesses for the resident. Here, we have a situation where the resident was given far more than ordered.

The order that was in place called for the resident to receive a 275 ml of formula three times a day. Typically, that amount would be given over two to three hour period. Instead of providing the tube feeding as ordered, the nurse gave the resident 275 ml of formula per hour for five hours. This means that the resident received a far greater amount than was ordered, far faster than was ordered.

The net result of this was that the resident experienced fluid overload which led to acute congestive heart failure. The resident experienced severe abdominal pain from overfeeding. She also experienced significantly elevated blood sugars. All of this led to an unnecessary hospitalization for her.

The root cause of this feeding tube accident was that the order was not followed. The order was for a 275 ml bolus (single dose), rather than 275 ml per hour continuously. In much the same way that medication errors in nursing homes can be prevented by making the proper checks, this incident could have been easily avoided by checking the physician order before administering the tube feedings.

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:

Feeding tube error at Aperion of Westchester

Grove of Elmhurst resident dies due to delay in physician notification

Aperion Care Wilmington resident suffers ruptured colon due to fecal impaction

Burbank Rehab resident hospitalized due to missed dialysis sessions

Failure to obtain treatment for congestive heart failure at Avantara Long Grove

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

August 24, 2021 By Barry G. Doyle

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.

Oak Brook Care resident develops bed sore from immobilizer

August 12, 2021 By Barry G. Doyle

IDPH has cited and fined Oak Brook Care Center nursing home after resident there developed a Stage 4 bed sore from an immobilizer.

“Bed sores” are also known as “pressure ulcers” because one of the main factors that cause these wounds is pressure. Most often the pressure that causes them is pressure brought about by immobility which is why you normally see bed sores develop on the bony prominences such as the hips, buttocks, sacrum, or heels. However, immobility-related pressure is not the only type of pressure which can cause skin breakdown as pressure from medical devices and equipment such as braces, immobilizers, catheters, casts, bed pans, and other devices and equipment can cause bed sores or pressure ulcers to develop as well.

Because the risks of developing pressure ulcers from medical devices and equipment is well-recognized, interventions such as regular skin checks should be included as part of the care-planning process and should be incorporated into the nursing home’s policies and procedures. When early signs of a skin breakdown are identified, physician notification is required so that the physician can determine whether there are suitable alternatives to the device that is causing the pressure, whether the use of the device is necessary, or whether there are ways in which the use of the device can be modified so as to eliminate or reduce the pressure caused by the device. It also allows the physician to enter orders for treatment.

The resident at issue was admitted to the nursing home with an immobilizer in place for treatment of a fractured kneecap. At the time that the resident was admitted to the nursing home, there were no bed sores present, according to her Minimum Data Set (MDS). Federal regulations provide that when a resident is admitted to a nursing home with no pressure ulcers present, they must receive care consistent with standards or professional practice such that the resident does not develop pressure ulcers unless they were unavoidable.

Within two weeks of her admission to the nursing home, the resident developed some redness to the calf, likely caused by some rubbing by the brace. The nursing staff noticed the wound and referrals for treatment by a wound care nurse and a wound care physician were obtained. However, the family was not notified and the treating orthopaedic surgeon was not notified for over a week.

When the treating orthopaedic surgeon was notified of the presence of the wound, he gave instructions that the immobilizer could be removed when the resident was in bed but that it needed to be left on during transfers and while the resident was in her wheelchair. Limiting the time that the resident was in the immobilizer would have helped with healing the wound on the calf by reducing the exposure of skin to the pressure from the use of the immobilizer. However, compliance with this order was not tracked in any meaningful way.

By the time that the wound care physician saw the resident for the first time over a week after when the wound was first seen, the wound was characterized as a full thickness wound and was much larger in size. It also had slough and necrotic tissue, indicating that there was dead tissue from the wound. This represented a significant decline in the condition of the wound from when the wound was detected. There was no notification to the family of the decline in the wound.

The wound care physician issued orders for the treatment of the wound. However, there were multiple days when those treatment orders were not carried out. The wound continued to decline and worsened to a Stage IV pressure ulcer with exposed tendon. Additionally, the facility failed to keep multiple telehealth appointments with the treating orthopaedic surgeon who was also unaware of the continued decline in the condition of the wound.

Approximately 8 weeks after the wound on the calf was first detected, the resident was transferred to the hospital for a urinary tract infection. The hospital recognized that the wound had a cellulitis infection and began to treat it with a bedside debridement and use of a wound vac. The care of the wound was being managed by a plastic surgeon. The treating orthopaedic surgeon told the state surveyor that the nursing home did not advise him of the decline in the condition of the wounds and that the wound would not have declined to the point that it did had his instructions to remove the brace been followed.

For their part, the administrator and Director of Nursing blamed agency staff for failing to complete ordered wound treatments and stated that it had been an ongoing issue with agency staff. Of course, the nursing home remains responsible for the provision of care and the administration of the nursing home is responsible for the operation of the nursing home. The failure to hire or retain qualified staff or get agency staff in who will get the job done will inevitably have consequences for the health and well-being of the residents. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

Resident at Christian Nursing Home in Lincoln develops pressure ulcer from brace

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

Victorian Village resident develops pressure ulcer from orthotic boot

Pressure ulcer from surgical boot at Amberwood Care Center

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

University Rehab Northmoor resident suffers fractured hip in fall from bed

August 11, 2021 By Barry G. Doyle

IDPH has cited and fined University Rehab Northmoor nursing home in Peoria after a resident there suffered a fractured hip as a result of a fall from bed.

The resident at issue here suffered from cerebral palsy, cognitive deficits, and paraplegia. This is someone who would have had a great deal of difficulty assisting in her care due to her physical and cognitive challenges. There was a care plan put into place which called for assist of two with bed mobility, keeping the bed in the lowest position, and use of bilateral floor mats. When a care plan is put into place, it falls to the staff charged with caring for the resident to implement it on a day-to-day, shift-to-shift basis.

On the day when this nursing home fall, there was a single aide who was providing incontinence care to the resident. While doing so, the aide had raised the bed and moved one of the floor mats to get better access to the bed. In the process of providing incontinence care to the resident, the aide recognized that she needed a bed pan. She left the room with the bed still in a raised position, the resident unattended, and one of the floor mats moved out of position. When she returned to the room, she found that the resident had fallen from bed.

X-rays were done, which showed that the resident suffered a fractured hip requiring surgical repair.

There were at least three violations of the care plan that took place that resulted in the fall. First, the aide was providing incontinence care to the resident by herself instead of with two people. The care plan called for the assist of two with bed mobility. Bed mobility refers to the ability to change and maintain a position in bed, something that is necessary when a resident is receiving incontinence care. Two people should have been assisting with this rather the one who was actually providing this care. Having one person do a two-person job is a well-recognized formula for disaster (see here, here, here, here, and here for examples). Second, the care plan called for the bed to be in a low position. The bed was in a raised position when the resident fell. Third, it also called for floor mats on both sides of the bed, and the floor mats had been removed so that the aide could get at the resident to provide care, but then the aide left the resident unattended with a floor mats out of position. As a result, we have the resident falling, hitting the floor and suffering a broken hip.

At one level, those violations of the care plan are the cause of this resident’s injuries. However, there is a deeper level to that, and that relates to the understaffing of the nursing home. When the aide was questioned by the state surveyor as to what happened, the aide explained to the surveyor that she just didn’t have time to ask for help in providing this care. When you have a staff that is describing not having time to ask for help, when you have staff that are taking shortcuts in the care that’s being provided to the resident, then that’s a sign of a nursing home which is understaffed, and that’s a nursing home which places residents at increased risk for adverse events, such as falls, bedsores, nursing home choking accidents, medication errors, and so forth.

Unfortunately, understaffing is part of how nursing homes are run. 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:

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

Resident at The Clayberg breaks arm due to failure to use gait belt

Fondulac Rehab resident suffers fatal injuries in fall

River Crossing of East Peoria resident suffers brain bleed due to unsafe transfer

Aperion Spring Valley resident suffers fatal brain bleed in fall

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

Aliya of Oak Lawn Resident Dies After Nursing Staff Fail to Monitor Heart Pump Battery

Bria of Wood River Cited After Staff Unable to Properly Resuscitate Two Residents With Tracheostomies

Hallmark Healthcare of Pekin Resident Suffers Severe Medical Neglect Leading to ICU Hospitalization

Resident Dies When Staff Fail to Perform CPR on Choking Resident At Bethany Rehab & Healthcare Center

Resident Urinates On Phone Charger In Bed, Smoke And Sparks Fly, Receives Serious Burn At Allure Of Knox County

Significant Delay In Providing Care Leads To Pain, Suffering and Death At Arcadia Care Auburn

Resident Dies After Facility Is Unable To Assure That Airway With Tracheostomy Is Clear During CPR Attempts

Resident Bleeds To Death At Pearl Pavilion in Freeport

Split penis the result of poor catheter care at Piatt County Nursing Home

Newman Rehab resident suffers burns to leg from radiator

Landmark of Richton Park resident dies due to mishandling of tracheostomy

Dehydration leads to hospital admission for resident at Mattoon Rehab

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

Christian Nursing Home resident suffers severe leg injury in fall

Grove of Elmhurst resident dies due to delay in physician notification

Marshall Rehab resident fractures back in van accident

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

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

Rushville Nursing & Rehab resident suffers untreated surgical wound infection

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

Hilltop Skilled resident breaks leg in fall from bed

Feeding tube error puts Burgess Square resident into heart failure

Aperion Care Wilmington resident suffers ruptured colon from fecal impaction

Oak Brook Care resident develops bed sore from immobilizer

University Rehab Northmoor resident suffers fractured hip in fall from bed

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