substandard nursing care Archives - Page 2 of 2 - The Law Offices of Barry G. Doyle, P.C.

River Bluff nursing home in Rockford resident suffers multiple fractures in fall

July 28, 2021 By Barry G. Doyle

IDPH has cited and fined River Bluff nursing home in Rockford after a resident there suffered multiple fractures in a fall.

Here, the resident at issue was involved in a nursing home fall in which she suffered a fractured pelvis and a fractured humerus. There was a care plan in place which called for the use of a bed alarm and a chair alarm, both of which were in place when the fall occurred. However, the resident had shut the chair alarm off when she got up to go to the bathroom and was returning from the bathroom when the fall occurred.

You may be asking yourself how this is the nursing home’s fault? The answer goes to the fundamentals of the care planning process.

Care planning is an ongoing process. It is not something that is done once and then forgotten about. There are in fact six steps to the care planning process: (1) the assessment of the risks to the health and well-being of the resident, (2) the development of a written care plan, (3) communication of the care plan to the members of the staff charged with carrying it out, (4) implementation of the care plan on a day-to-day, shift-to-shift basis, (5) evaluation of the effectiveness of the care plan, and (6) revision of the care plan if it proves to be ineffective in practice or if the care needs of the resident change.

The breakdown here occurred in the sixth and final step of the care planning process. The point of the fall prevention care plan was to prevent falls by avoiding having the resident up and about unattended which was when she was at highest risk for falls. However, this resident had a known behavior of disarming the alarm when she wanted to get up on her own. The nursing home staff was aware of this, but did not make any changes even though what they were doing was being shown to be ineffective in practice.

What should have been done instead?

A chair alarm or bed alarm essentially consist of two main components: the alarm box and the alarm device. The alarm device is either a pressure-sensitive pad (which was what was in use here) or a clip which is affixed to the resident’s clothing, usually between the shoulder blades where it is difficult to remove with a short cord which goes to the alarm box. If the pressure alarm is in use, the alarm sounds when the resident gets up off the pad; if the clip is used, the alarm sounds when the cord is pulled away from the alarm box.

Here the staff placed the alarm box in easy reach of the resident who simply shut it off before getting up. This was a known behavior on the part of the resident which had been shown on a number of occasions before this nursing home fall. All that would have been required to prevent this fall would have been to modify the resident care plan to include placing the alarm box out of the reach of the resident and making sure that this was communicated to the staff charged with caring for this resident. However, due to a lack of effort and critical thought, this change was never made. A care plan which is ineffective in practice is not one that meets the care needs of the resident. Making that simple change would likely have prevented this 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:

Hope Creek resident breaks hip in fall from toilet

River Bluff resident fractures elbow in fall from wheelchair

Fall from toilet at Alden Park Strathmoor

Resident left unattended in dining room at Ascension Saint Anne Place falls and fractures hip

Waverly Place of Stockton resident breaks hip in unsafe transfer

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

Burbank Rehab resident hospitalized due to missed dialysis sessions

July 23, 2021 By Barry G. Doyle

IDPH has cited and fined Burbank Rehabilitation Center nursing home after a resident there had to be hospitalized for fluid overload after not being brought to dialysis as ordered.

Nursing home residents who are suffering from kidney failure may require dialysis, and when this is true, families often make the decision to pick one nursing home over another based upon the availability of an in-house dialysis unit in order to spare their loved one from having to be transported to an outside dialysis center. These in-house units are usually operated by a separate company which means that coordination of care between the dialysis unit and the nursing staff is crucial to ensuring that the resident receives the care that is required. When this doesn’t happen, the results can be catastrophic. When the kidneys are not functioning properly, the body cannot remove excess fluid and toxins. Dialysis takes up that function in the absence of properly working kidneys. When necessary dialysis sessions are missed, excess fluids and toxins can build up and cause serious problems throughout the body, most notably with the heart and lungs.

The resident at issue suffered from end stage renal disease, or kidney failure. She was admitted to the nursing home from the hospital with orders to receive dialysis three days a week (Tuesday, Thursday, and Saturday). The orders are also called for the nursing staff to checks vitals after dialysis and to check the dialysis access site for signs of redness, bleeding, or swelling. The nursing home staff documented that the resident received dialysis as ordered for the first three scheduled sessions and that the post-sessions checks of vitals and of the access site were all done.

However, on the same day as the scheduled third session, the nursing staff noted that the resident was suffering from pitting edema, required supplemental oxygen, and was lethargic. The staff could not obtain her vital signs. Due to this change in condition, the nursing staff notified the resident’s doctor who ordered the resident sent to the hospital.

At the hospital, based on the resident’s presentation and abnormal labs, the resident was diagnosed as suffering from volume overload due to missed dialysis sessions. She was hospitalized for twelve days in order to resolve the condition.

The investigation into this incident revealed that the facility had policies and procedures in place for coordinating the care between the nursing home and the dialysis center for new admissions to the nursing home who required dialysis. However, even with the policy in place, the resident was not added to the list of residents who would be receiving dialysis on the days on which it was ordered. This breakdown in the process led to the missed dialysis sessions and the resident not receiving the care as ordered.

Beyond that, the nursing staff on the floor signed off on the resident as receiving dialysis on the days when it was ordered when it was in fact not done. Had the nursing staff realized that the care ordered had not been provided instead on simply checking off that it had been done, this situation would not have escalated to the point that it did.

One of the things that out firm does very carefully in prosecuting nursing home abuse and neglect cases is go through the chart very carefully for evidence of false charting – that is, documenting care that was never provided. We have seen examples of where the staff was documenting care being provided when the resident was in the hospital or in one case, after the resident was dead. When we find this evidence, it undermines the credibility of the other entries made on the chart and makes it very difficult for the nursing home to defend the care that was provided.

This is a situation where there were clear breakdowns in the basic operations of the nursing home. The process that was in place wasn’t followed and the staff was documenting care that was never provided. 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:

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

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

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

Dialysis patient bleeds to death at Warren Barr North Shore

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

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

July 22, 2021 By Barry G. Doyle

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

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

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

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

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

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

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

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

Other blog posts of interest:

Bethany Rehab resident suffers brain bleed due to medication error

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

Alden Valley Ridge fails to give resident anti-seizure medications

Aperion Care Wilmington resident suffers ruptured colon due to fecal impaction

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

Failure to monitor anticoagulant levels at Greentree of Bradley

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

Symphony at South Shore resident suffers open fracture of the leg

August 21, 2020 By Barry G. Doyle

IDPH has cited and fine Symphony of South Shore nursing home in Chicago after a resident there suffered an open fracture of the leg during a transfer.

In this blog, we spend a great deal of time discussing the care planning process because it is one of the main building blocks for how care is structured in a nursing home. There is a another set of assessments called the Minimum Data Set (MDS). The Minimum Data Set is prepared at regular intervals on admission and then quarterly and with a change in the resident’s condition. The MDS is supposed to be based on the completing nurse’s assessments, information provided by other staff members, and data that is generally tracked by aides and entered into either a piece of software or a tracking sheet and then incorporated into the MDS. When completed, the MDS is supposed to accurately reflect the condition of the resident and the level of assistance needed.

The MDS plays a role in the delivery of care in that it triggers something called a Care Area Assessment (or CAA) which is supposed to prompt care planning for the areas indicated. The MDS also determined the resident’s acuity level which is tied to the amount that the nursing home receives in revenue from the entity that pays for the care. Therefore, it needs to be signed under penalties of perjury by each person participating in completing it.

When the resident at issue went through the MDS process, the nursing home certified to the government that the resident required a two-person assist with transfers. However, when the care plan was completed, it called for the assist of one with transfers.

On the day of the accident, the resident was being transferred from her wheelchair to her bed by a single aide who was using a pivot transfer technique. The resident’s foot slipped during the transfer, and her leg went underneath the bed. The resident sustained an open fracture of the tibia (shin bone), meaning that the bone broke through the surface of the skin. She was taken to the hospital where she underwent a surgical repair of the fracture. On her return to the nursing home, she required a mechanical lift for transfers.

During the investigation by the State, the resident’s nurse practitioner referred the surveyor to the physical therapy department as to whether the resident should have been a one- or two-person transfer. They confirmed that she should have been a two-person transfer. When the surveyor spoke with the Director of Nursing, she was unable to reconcile the discrepancy between the care plan and the MDS and agreed that the care plan should reflect the care levels shown on the MDS.

Many of the nursing home falls we have covered here happened either because the care plan was not followed or because the care was not revised when it needed to be. Here, the care plan was inadequate to begin with in that it did not provide for the levels of care that this resident actually required. Poor care plans beget poor outcomes.

The other thing that is notable about this incident is that there was a variation between the MDS and the care plan. Since the MDS helps determine acuity level which determines payment level, this also means that the nursing home was getting paid for care it wasn’t actually providing. Sadly, this part of how many nursing homes operate. 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 use gait belt results in fall and fractured knee at Friendship Village

Broken ankle from unsafe transfer at Aperion Care International

Mechanical lift accident at South Holland Manor

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

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

August 16, 2020 By Barry G. Doyle

IDPH has cited and fined Alden Estates of Barrington nursing home after a resident there died from respiratory distress and an elevated potassium level after staff failed to inform the resident’s physician of pertinent information regarding the resident’s condition.

The resident at issue suffered from kidney disease and hypothyroidism (low thyroid), among other problems. This placed him at risk for developing edema and/or an electrolyte imbalance. There was a care plan which was specifically put into place to address this potential which included notifying the doctor of any acute changes and monitoring for fluid excess through monitoring for weight gain or the development of edema. Of course, notifying the doctor or changes in the resident’s condition is one of the basic tasks in a nursing home setting, including significant weight gains which is generally defined in the nursing home industry (and was defined in this facility’s policies and procedures) as more than 5% in one month, 7.5% in three months, or 10% in six months.

In the care of this resident, there were multiple failures on the part of the staff to notify the resident’s doctor of important changes and information regarding the resident’s condition:

Over a period of 10 days, the resident’s chart showed that his weight weight increased from 208 lbs to 242 lbs. There was an order in place for daily weights because of concern regarding fluid retention. Several days went without any weights being taken at all because the facility’s scale was broken. The resident’s doctor and nurse practitioner were not aware of the extent of the weight gain, and told the state surveyor that they would have sent the resident to the hospital to have fluid taken off.
The resident had labs taken which showed an elevated potassium level. Elevated potassium levels can cause irregularities in the heart. To address this, there was an order in place for a medication which was intended to drive down the potassium levels. However, the resident refused the medication. The staff failed to notify the doctor of the resident’s refusal. Had the doctor been informed of the resident’s refusal, he would have ordered the resident sent to the hospital to have the elevated potassium levels treated.
The resident had a chest x-ray performed which showed changes consistent with pulmonary venous congestion. The nurse practitioner explained to the surveyor that this meant fluid overload impending hypoxia due to fluids in the lungs. The nurse on duty at the time paged the doctor with the results. However, he did not return the page and endorsed the results over the nurse coming on to the next shift to pass the results on to the doctor. The nurse coming on at the next shift denies receiving a report about this at the change of shift report. The net result was that the results were never communicated to the doctor.

What was the net result all this? On the morning of the 10th day, the resident sounded the call light and asked to be repositioned promptly. Staff reported that he was anxious and was urging them to reposition him more quickly. After getting him into an upright position, he slumped forward. A code blue was called. The rescue squad could not resuscitate the resident, and he died. Cause of death per the death certificate included severe hyperkalemia or elevated potassium levels.

There were multiple opportunities to prevent this tragic outcome. This resident essentially suffocated on excess fluids. The potential for this was something that was supposed to be addressed in his care plan, by physician orders, facility policies and procedures, and basic standards of nursing practice. One way that care in a nursing home is different from a hospital is that there is not a doctor on site on a 24/7 basis, so nurses need to serve as the eyes and ears of the doctor to notify them about the kinds of changes that were occurring in this resident. This outcome is a sad lesson in what happens when this isn’t done properly.

Other blog posts of interest:

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

Staff at Grove of Evanston fails to notify doctor of resident’s decline

Alden Estates Huntley fails to give ordered antibiotic

Feeding tube error puts Burgess Square resident into heart failure

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

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

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

Bed bound resident at Elevate Care of Waukegan fractures arm

August 14, 2020 By Barry G. Doyle

IDPH has cited and fined Elevate Care of Waukegan nursing home after a bedbound resident there suffered a fractured arm while being repositioned in bed.

Turning and repositioning residents is a staple of care in a nursing home setting. One reason that it is so crucial is that it helps prevent the development of bed sores. However, like everything else in a nursing home, it must be done right, and as we have seen (see here, here, here, here, and here for examples) having one person do a two-person job is a formula for disaster. And this proved true here once again.

The resident at issue was bedbound and severely cognitively impaired to the point that he was unable to move his extremities. His care plan called for assist of two with bed mobility and transfers. However, when the resident’s family was interviewed by the state surveyor, they reported that the resident was often repositioned with a single aide because the nursing home was understaffed.

On the day of the incident, the resident was sent to the emergency room for evaluation of swelling and discoloration of the left shoulder. X-rays showed that he had suffered an acute fracture of the humeral neck (the portion of the upper arm that inserts into the shoulder) and an acute fracture of the proximal humeral diaphysis (the shaft of the upper arm). The aide assigned to the resident on the night shift before the injury was discovered admitted to the state surveyor that she routinely repositioned the resident on her own.

Of interest, the Director of Nursing told the family that the injury was due to brittle bones, but the nurse practitioner and orthopedist’s physician assistant both told the state surveyor that the injury was one which required the application of force to occur, even if the resident had a bone density disorder.

Obviously, there was a clear violation of the resident care plan which resulted in this fracture. The reason that two aides are sometimes required is to assure safety (so that the resident isn’t accidentally rolled out of bed) and to minimize the forceful tugging and pulling which is sometimes required to move someone who is incapable of voluntary movement. Residents who are bedbound do tend to have reduced bone density as a result of inactivity, and this can predisposes them to fractures. However, this pattern of fractures (especially with two separate fractures) is likely the result of improper handling of the resident in repositioning the resident with a single aide rather than the two called for in the resident care plan.

One person doing a two-person job is a hallmark of an understaffed nursing home and this was something that was confirmed with the family’s own observations. Sadly, understaffing is a feature, not a bug in the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

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

Improper use of sit-to-stand lift results in multiple fractures at Radford Green in Lincolnshire

Improper transfer results in shoulder fracture at Addolorata Villa in Wheeling

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

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

July 11, 2020 By Barry G. Doyle

IDPH has cited and fined Pearl Pavilion nursing home in Freeport after a resident there died of a pulmonary embolism brought about by the failure of the nursing home to authorize the purchase of an expensive blood thinner medication that had been ordered for him.

A pulmonary embolism is a blood clot that becomes lodged in the arteries in the lungs. Usually these blood clots are formed in other parts of the body, typically in the legs, and then break off and travel to the lungs. Symptoms of a pulmonary embolism include shortness of breath and chest pain. The development of a pulmonary embolism is a medical emergency as they are often fatal without prompt medical intervention. Use of blood thinner or anticoagulant medications is the main means of prevention of the development of blood clots that can lead to a pulmonary embolism.

The resident at issue was admitted to the nursing home from the hospital. He had been admitted to the nursing home after being treated for a pulmonary embolism. He suffered from a condition known as activated protein C resistenace (a condition which can increase the risk of developing blood clots which lead to a pulmonary embolism), and a history of transient ischemic attacks (“mini strokes”), and ischemic stroke (the kind of stroke caused by a blood clot to the brain). In short, this was a resident who needed to be on blood thinner medications.

When the resident was transferred from the hospital to the nursing home, the doctor ordered that the resident receive an anticoagulant medication called apixaban twice a day. However, when the resident arrived at the facility, the medication was not on hand. The facility ordered the medication from the pharmacy but it was not delivered because it was expensive and required specific authorization from the nursing home. This was never given.

Because the nursing home never authorized the purchase of the medication the doctor ordered, the resident did not receive that medication or any other anticoagulant during the three days that he was at the nursing home.

The Director of Nursing told the state surveyor that they were not aware of the issue until a week after the resident died.

When a resident arrives at a nursing home with orders to get a medication that is not on hand, there are a number of options available to the nursing home. Completely failing to address the medical need that the medication is intended to address is not one of them. The most obvious option is to order the medication. The nursing home did so, but did not agree to pay for it, so they never actually obtained the medication. Another option would be to contact the doctor an obtain an order for an alternative medication. The nursing home never did that. Finally, there is the option of sending the resident back to the hospital because they cannot provide the resident with the treatment he needs.

Over the course of three days, there were two separate times each day where the resident was supposed to receive his blood thinner during medication pass, but the nurse handling the medications did not give it to him. There was nothing in the resident chart to suggest that these nurses raised the issue of the medication not being in stock with the administration of the nursing home. There was nothing to suggest that they contacted the resident’s doctor to let him know that a patient who was at risk for developing blood clots was not getting the blood thinner that was ordered or any blood thinner at all.

On the morning that the resident died, an aide went into see the resident around 6:15 a.m. At that time the resident was sweaty and clammy and complaining that he was having a hard time breathing. He asked to have his blood sugar checked and it was 103. The aide did what she was supposed to do, and reported this to the nurse. In response, the nurse did not go to see the resident, but told the aide to get a set of vital signs. The aide returned to the resident and took a set of vital signs. When she went back in, he was complaining that his legs were killing him (a sign of blood clots in the legs) and was obviously having a hard time breathing.

At about 7 a.m., the resident called his sister and asked her to call the nursing home because one of his legs was hurting badly. He was short of breath over the phone. She called the nursing home but could not get anyone on the phone.

At approximately 7:50 a.m., the resident activated a call light to summon the nurse. The nurse’s response was, “If he is well enough to turn his call light on, he can wait till I am done up here to see him.” When the aide and the nurse returned to the room at 8:00 a.m., the resident continued to complain of leg pain, was having a hard time breathing and asked to be sent out to the hospital. His blood sugar was rechecked and was over 320 even though the resident had refused breakfast.

After leaving the room, the aide asked the nurse whether the resident was going to be sent to the hospital. In response, the nurse resulted in said, “I’m figuring that part out.” The Director of Nursing told the state surveyor that around 7:30 a.m., she was told that the resident said that he didn’t feel good, was nauseated, and refused breakfast. She claims to have told the nurse to make calls to the doctor and the resident’s family but these calls were never made.

At approximately 9:28 a.m., the aide was sent to the resident’s room to check his oxygen saturation level. She found the resident lying in bed, pale and with no pulse. She called for help and began to perform CPR. 911 was called at the paramedics arrived. They attempted to revive the resident and brought him to the hospital where further efforts at resuscitation proved fruitless, and the resident was declared deceased.

The resident’s physician told the state surveyor that he never received a phone call from the nursing home about the resident. Had he been called and told of the resident’s symptoms, he would have suspected a blood clot and told them to call 911 right away. He further stated that the nursing home had the ability to send the resident directly to the emergency room.

There are at least three levels of failures that resulted in this nursing home medication error causing the wrongful death of this resident:

The nursing home never obtained the blood thinner medication that was ordered for the resident. Obviously nursing homes are businesses and need to control their costs, so having a price threshold on medications is not an unreasonable thing to have in place. However, failing to either authorize the purchase or otherwise address the issue is completely unacceptable.
Over the course of three days, there were multiple medication passes that occurred without the resident receiving the blood thinner medication that ordered for him. None of the nurses passing the medications those days brought this to anyone’s attention so that the issue could be addressed. Failing to give medications which are ordered and doing nothing further is substandard nursing care.
On the morning that the resident died, he was demonstrating a clear change in condition with the complaints of pain and shortness of breath. Doctors are not in-house at nursing homes on a 24/7 basis, so nurses must serve as their eyes and ears and report to the doctors when a resident has a change in condition. We know what the result would have been had the nursing staff reported the changes in this resident’s condition to his doctor – he would have recognized it as the medical emergency it was and instructed them to call 911. This resident should have been in the emergency room 2-3 hours earlier which would have likely made all the difference.

Many of the nursing home cases we handle show this kind of pattern – multiple missed opportunities all along the way which would have avoided a catastrophic outcome. Here, there were opportunities from the moment this resident came in the door up until the last hour or so of his life to avoid this outcome. Missed opportunities yielding a tragic and avoidable outcome.

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

Other blog posts of interest:

Resident receives wrong medications at Manor Court of Freeport

Failure to notify doctor of abnormal labs at Momence Meadows

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

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

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

June 21, 2020 By Barry G. Doyle

IDPH has cited and fined Heritage Health nursing home in Carlinville after a resident died from acute metabolic encephalopathy due to sepsis from a urinary tract infection.

One of the ways that nursing home care differs from a hospital is that there are not doctors on hand on a 24/7 basis. When there is not a doctor on hand, it is part of the function of the nursing staff to serve as the “eyes and ears” of the doctor and report changes in the resident’s condition. When things happen such as a resident having a nursing home fall, developing a bed sore, having abnormal labs, or a medication error, it is part of the job of the nursing staff to let the doctor know what happened.

Outside of clearly defined events such as that, it is also part of the nursing staff to notify the doctor of changes in condition, which can be a bit more subtle, but just as important. Examples of this would be increased lethargy, increased confusion, or other changes in mental status.

When the doctor receives a report from the nursing home staff, the doctor has four basic options: to decide to come in to see the resident himself, order the resident sent to the hospital, issue orders for the nursing staff to carry out, or to make no orders at all. Whatever choice is made, the fact of the communication with the doctor and the response of the doctor should be recorded in the resident chart.

Of course crucial to all of this is the substance of what was communicated to the doctor. If the pertinent information is not communicated to the doctor, then that can result in poor decision-making by the doctor with the net being loss of opportunity to help the resident when help is needed most. And this brings us to this citation issued by IDPH …

The resident was admitted to the nursing home after apparently breaking her right leg in a fall. At the time of her admission on through the first several days of her admission, she was assessed as being cognitively intact, alert and oriented x3. However, she began to complain of significant pain apparently from muscle spasms on the side with the broken leg. The nurse practitioner prescribed Ropinrole to address the pain complaints.

The second day after the Ropinrole was started she began to demonstrate changes in mental status. One nurse noted that she demonstrated forgetfulness. Her daughter arrived in the facility and her mother told her that she was seeing bugs and ants which were not there, was seeing Cheerios on the floor, and that the ceiling black. The nurse to whom the daughter reported this also noted that she was less responsive, more lethargic, and difficult to arouse. She claims that she passed this information on to the nurse at the change of shift.

The nurse who had the next shift does not remember being told about hallucinations or anything out of the ordinary. She told the surveyor that she would have called the physician had she been told. She was told by other family members the next day that they were concerned that the new medication was making the resident confused. The Director of Nursing saw the resident later that day and there was discussion about the effects of the new medication. She looked the medication up and saw that many of the symptoms that were being reported were listed as side effects for the medication.

The Director of Nursing called the doctor, and what was said is a crucial issue. The Director of Nursing claims to have told the doctor about the reports of hallucinations, but he denied that, and his office record only noted a request to change her dose of pain medication and concerns over the side effects of the Roprinole. The doctor told the state surveyor that had he been told of hallucinations earlier, he would have ordered her sent to the hospital sooner.

The day after this phone call, she had a set of routine labs drawn. The results of this showed critically high abnormal scores. This prompted another call to the doctor who ordered the resident transferred to the hospital. At the local hospital, she diagnosed as suffering from Acute Metabolic Toxic Encepholapathy, a disease of the brain caused by a viral infection or toxins from the blood. She was sent to a hospital in Springfield where she died five days later. Cause of death was bacteremia from a urinary tract infection.

The key issues here relate to the substance and timing of the communication with the doctor. The doctor made it clear that had he been told earlier that the resident was having hallucinations, he would have sent her to the hospital. This goes all the way back to the first report by the family members to the nurse that the resident was seeing bugs and so forth, approximately 48 hours before she was finally sent to the hospital, and also to the call that was placed by the Director of Nursing approximately 24 hours later.

The fact that this was due to a urinary tract infection also deserves some attention that was not addressed in the citation by IDPH. There are a number of other issues worth examination: was the resident using a catheter? What were the vital signs? Were there changes in the amount, color, or smell of the urine? Were the complaints of burning while urinating? These are questions that should be addressed in any competent investigation of the care that this resident received.

Other blog posts of interest:

Staff at Grove of Evanston fails to notify doctor of resident’s decline

Infection goes unnoticed at Helia of Belleville

Failure to give diabetes medication at Bridge Care Suites

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

Transportation van accident at Generations at Rock Island

May 4, 2020 By Barry G. Doyle

IDPH has cited and fined Generations at Rock Island nursing home after a resident there had to be hospitalized due to blood loss following an accident which occurred while being transported by facility staff to an eye doctor appointment.

At times nursing home residents will need to leave the facility to attend doctor appointments. Sometimes family brings them to the appointment, but other times, the nursing home staff will take them in a vehicle owned by the nursing home. When the staff transports residents places outside the facility, they need to know how to do so properly and what to do if there is a mishap along the way.

There were shortcomings on both counts here.

The resident at issue needed to be taken to an eye doctor appointment. He used a wheelchair and was an assist of two for transfers. There was a single staff member who was charged with taking him to the appointment. She was a CNA at the nursing home and had been doing transports for about 2 months before the accident. Before taking on that role, she received a single day of training from her predecessor.

The resident was loaded onto the van and his wheelchair was placed facing to the rear. A strap was threaded through the wheels but not the frame of the wheelchair. As they were going down a hill and coming to a stop, the wheelchair tipped backward, with the resident hitting his head on the floor in between the two front seats of van.

The aide asked the resident if he wanted to go to the hospital, but he declined saying that he didn’t want to miss his eye appointment. The aide helped the resident up and brought him into the eye doctor appointment. She then left to go back to the nursing home to report what had happened.

She told the floor nurse who told her to report it to the Director of Nursing. While she was doing that, the floor nurse called into the Director of Nursing and informed her that the resident was on anticoagulants, which increases the risk of a brain bleed after a nursing home fall. The Director of Nursing said that the resident needed to get to the hospital and brought him to the hospital on her own.

Meanwhile at the doctor’s office, the resident was complaining of pain in the leg following the fall. The doctor took a look at the leg and said that the resident needed to go to the hospital. When the aide returned, she loaded him into the van on her own. En route, the resident continued to complain of pain in the leg until he felt a sudden change in pressure and saw there was significant bleeding from the leg.

At the hospital, the resident was treated in the emergency room and then admitted to the intensive care unit where he needed to receive multiple units of blood to make up for the blood loss he sustained as a result of the nursing home fall.

There a few major issues with what happened here.

First, the aide was not trained how to secure the resident into the van properly. After the accident, the aide was retrained. Sadly, this was done by the facility maintenance man who had to do his own research about how to properly secure a resident in the van. There were no pre-existing training materials or instructions. It is small wonder that the aide did not get it right.

Second, the aide did not know how to address an emergency. As a CNA, she should have known to not move a resident after a fall until there was a proper assessment done of the resident’s condition. Nonetheless, that was what happened. She also did not have a phone or other means of calling the nursing home for guidance. She was simply left to make decisions on her own. Poor training all the way around.

This kind of poor training 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. 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:

Macomb Post Acute Care resident suffers multiple fractures in van accident

Generations at Rock Island fails to care for pressure ulcers

Generations at Rock Island cuts respiratory staff

Resident falls from van at Casey Healthcare

Wheelchair transport accident at Heartland of Galesburg

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

Failure to follow orders at Generations at Applewood

May 3, 2020 By Barry G. Doyle

IDPH has cited and fined Generations at Applewood nursing home in Matteson after a resident there had to be hospitalized due to the failure of the staff to follow orders to hold the resident’s blood thinner medication.

Anticoagulant, or blood thinner, medications are an important tool in caring for nursing home residents. They are used to prevent the development of blood clots which can cause heart attacks, strokes, deep vein thrombosis, pulmonary embolisms, and a host of other serious problems. However, this is a medication where the results of the medication have to be monitored very closely. If the blood is “too thick” there is a higher risk of the blood clots developing; “too thin” and there is a increased risk of internal bleeding.

To measure the effectiveness of the treatment, blood tests called PT and INR are done regularly. If the results of the testing shows levels that are too low or too high, it is part of the job to the nurse to notify the doctor of an abnormal lab so that the doctor can issue orders to adjust the dosing of the blood thinner medication.

However, for those orders to be effective, the orders must actually be carried out, and that is where the problem arose here.

The resident at issue was receiving Warfarin, and underwent at PT/INR test. The PT level was 34 (normal level is between 12.5 and 15.1) and and INR level of 3.4 (normal 0.8-3.0). These are both elevated levels, indicating that the blood was “too thin” and that there was an increased risk of internal bleeding.

The nurse on duty called the nurse practitioner who ordered that the blood thinner not be given for 2 days with a repeat test to be performed after that. However, the resident chart does not document any orders to hold the medication or to give the repeat test. As a result, the resident continued to receive her blood thinner uninterrupted for an additional 2 weeks.e

Two weeks later, the staff noticed that the resident had blood in her stool. The doctor was notified and the resident was sent to the emergency room where labs showed elevated PT/INR levels and she was diagnosed with a gastric bleed related to the continued use of the blood thinners. She was admitted to the hospital for treatment.

One of the fascinating things about this citation is that there was no interview of the nurse who communicated with the nurse practitioner. There is no note in the resident chart about what was ordered, which raises a question of exactly what was ordered. Nurse practitioners are generally not direct employees of the nursing home, so this issue would need to be explored carefully before the statute of limitations expires. If the nurse practitioner’s account is correct, then this is a serious issue of substandard nursing care being provided to this resident.

A deeper question would be of course why did the nurse on duty fail to enter the note and order in the resident chart? The answer will likely come back to the she was too busy and simply dropped the ball. Being “too busy” is a hallmark of an understaffed nursing home, and this is a feature, not a bug in the nursing home business model.

Other blog posts of interest:

Moorings staff fails to notify doctor

Grove of Elmhurst resident dies due to delay in physician notification

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

Resident bleeds to death at Aperion of Forest Park

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

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

Breakdown in care leads to broken leg at Chalet Living & Rehab

February 28, 2020 By Barry G. Doyle

IDPH has cited and fined Chalet Nursing & Rehab nursing home in Chicago after a resident there fell while out on pass in the community and suffered a broken leg.

People in nursing homes are generally in nursing homes because they have care needs that cannot be met at home. Many have needs that require care and observation on a 24/7 basis, but others have needs that do not require that level of care. Some of these residents are reasonably self-sufficient and are able to handle the environment outside the nursing home, either independently or with the help of family or friends. These residents have what are generally known as “pass” privileges which allow them to leave the nursing home without the help of staff.

To evaluate whether a resident is able to handle pass privileges, a type of assessment typically called a community safety skill assessment is done. If the resident has the ability to leave the facility, then the “pass” will be issued to allow the resident to leave the nursing home, with or without family help.

The resident at issue was in a motorized wheelchair but had pass privileges to go out into the community independently. She was out in the community when she had a fall. She reported this when she returned to the nursing home and was placed on a 72-hour fall wtach. After that was done, the resident told social services that she wanted to regain her pass privileges, so she was referred to the restorative nursing department for a community safety evaluation.

However, the next day she left the nursing home to go out into the community. The community safety assessment had not been done by the restorative nursing team and the resident’s community pass privileges had not been reinstated. While she was out in the community, she got out of her wheelchair to ambulate and tripped and fell. She suffered a broken leg which required surgical repair.

The nursing home did the right thing by pulling the resident’s pass privileges and then placing her on the 72-hour fall watch after the initial fall in the community. They needed to verify that there was no more serious injury than was immediately apparent and they needed to evaluate the risk of a recurrence before allowing the resident back out into the community independently.

The breakdown occurred when the resident was still allowed out into the community without having active pass privileges. The front desk staff should be aware of who has and does not have privileges and should not allow residents without pass privileges to leave the facility. When a resident leaves the facility without being on pass, this is elopement, and this is just the kind of accident that happens when you have residents leaving the facility when it is not safe for them to do so.

Other blog posts of interest:

Police fracture skull of resident who wandered from Integrity of Smithton

Resident missing for 6 days at Villa at Windsor Park

Side rail accident at Lexington of Lombard

Niles Nursing & Rehab resident wanders, suffers fractures

Wandering Alden Town Manor resident falls down stairs, suffers fatal injuries

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

Failure to notify doctor of abnormal labs at Momence Meadows

February 19, 2020 By Barry G. Doyle

IDPH has cited and fined Momence Meadows nursing home after the staff failed to notify the resident’s doctor of a critically high lab value, resulting in the resident being sent to the hospital and placed on dialysis.

Doctors are not present in a nursing home on a 24/7 basis and when they are not there, one of the roles that the nurses play is to serve as “the eyes and ears” of the doctor. In that role, it is their job to notify the doctor when things occur like nursing home falls, the development of bed sores, and significant changes in the resident’s condition. One of the things that they are also responsible for is reporting when lab results show abnormal values. This allows the doctor to make a decision to issue orders over the phone, come into the nursing home to see the resident, or order the resident sent to the hospital.

This resident was admitted to the nursing home with an order to receive a powerful IV antibiotic called vancomycin in order to treat a cellulitis infection. Vancomycin is metabolized (or cleared) through the kidneys and when the kidneys are not clearing the vancomycin efficiently, then the vancomycin can cause significant injuries to the kidneys. Therefore, ongoing bloodwork is taken to melsasure the levels if vancomycin in the body. If the levels climb too high, the orders for the vancomycin can be changed to prevent injury to the kidneys.

In this case, the orders for this resident included giving three doses of vancomycin per day and then taking the resident’s vancomycin levels every third dose. On September 11, the lab results showed a vancomycin level of 65.6 (normal is 20-25). This a critically high level,

The pharmacy called the September 11 lab results into the nursing home, but the nurse did not call the doctor. The pharmacy did call the medical director who ordered that the vancomycin be held (not given) for a single dose on September 12 and then restarted on September 13. On September 11, the lab results showed a vancomycin level of 65.6 (normal is 20-25), a Blood Urea Nitrogen (BUN) level of 184 (normal 5-28) and creatinine level of 9.7 (normal 0.6-1.2). These are all critically high levels which called for physician notification. No one notified any of the doctors about the September 13 abnormal labs results until September 16, when the assistant director of nursing contacted the doctor regarding the abnormal September 13 lab results.

The wound doctor told the state surveyor that had he been notified of the abnormal lab results on September 13, he would have sent the resident to the hospital for treatment of vancomycin toxicity. The treating nephrologist told the state surveyor that the resident suffered acute kidney injury on top of chronic kidney disease and that she required dialysis and that it was not possible that time to tell whether the kidney injury was permanent.

There are a number of factors in play here, most notably the failure of the staff to notify the doctors involved of the abnormal lab results. The statement of the wound care doctor indicates that the resident should have been sent to the hospital much sooner which would have allowed for treatment of the vancomycin much sooner and likely would have resulted in less injury to the kidneys.

Past that, the role of the medical director deserves scrutiny. Medical directors are independent contractors and would face their own liability for the care they provide, and the decisions to not send the resident to the hospital after being advised of the September 11 critically high lab values and then restarting the vancomycin after holding a single dose should be closely reviewed. Further, the citation reflects that the vancomycin was ordered held on September 13 through September 18. It is unclear who issued this order, but the decision to simply hold the vancomycin when the lab values were so critically high also deserves serious scrutiny.

The citation reflects that there was no attempt to notify the doctors about these critically high lab values on and after September 13 up until the assistant director of nursing notified the doctor on September 16. Not surprisingly September 14 and 15 fall on a weekend when it is harder to keep the nursing home staffed as fully as it is during the week. 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 feeding tube orders leads to hospice admission for Parker Rehab resident

Burbank Rehab resident hospitalized due to missed dialysis sessions

Failure to monitor anticoagulant levels at Greentree of Bradley

Failure to follow medication orders at Generations at Applewood

Aperion Care Wilmington resident suffers ruptured colon due to fecal impaction

Failure to notify doctor of abnormal labs at Champaign-Urbana Nursing & Rehab

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

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

Staff at Grove of Evanston fails to to notify doctor of resident’s decline

January 19, 2020 By Barry G. Doyle

IDPH has cited and fined the Grove of Evanston nursing home following the death of a resident there after the staff failed to notify the resident’s doctor of declines in the resident’s condition over a period of several days.

One of the many ways that a nursing home is not the same as a hospital is that there is not a doctor on hand 24/7 the same way there usually is in hospitals in larger communities. Because the doctor is usually not present in the nursing home, one of the key roles that nurses in a nursing home setting play is to serve as the “eyes and ears” of the doctor. This means that the nursing staff has an obligation to notify the doctor of changes in the resident’s condition. The nurse doesn’t have to diagnose the condition or problem – she must simply notify the doctor of what has happened or is happening with the resident so that the doctor can make a determination whether to come into the nursing home, issue orders over the phone for treatment, or order the resident sent to the hospital. When the staff fails to notify the doctor when the situation calls for it, the failure to obtain needed care and treatment can have significant consequences in a medically fragile patient population, including resulting in the wrongful death of the nursing home resident.

The citation in the is instance reflected that the staff was aware that the resident’s condition was declining over a period of days. Rather than notify the doctor, the assistant director of nursing asked therapy to evaluate the resident. Over a period of four days, the resident’s condition continued to decline, until it declined so much that the staff called 911. When they did so, the resident’s oxygen saturations were at 87 with 10 liters of supplemental oxygen and a heart rate of 51. When the resident was brought to the emergency room, lab work showed that the resident had highly elevated white blood cell counts, lactate levels, and potassium levels. In short, this resident was critically ill. He was intubated and given three separate antibiotics, but died shortly after midnight, less than 18 hours after being sent to the hospital.

This is a case where the nursing staff failed to make the required notifications to resident’s doctor. Clearly, they recognized that something was amiss, as there were plans to have therapy evaluate the resident, but it is also clear from the citation that the resident’s chart drew a picture of ongoing declines in the resident’s condition. Without timely notification of the resident’s doctor, this resident was denied the opportunity to receive treatment which could have altered the course of the resident’s illness. This represented a basic failure to deliver the care that the resident needed and deserved.

Other blog posts of interest:

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

Rushville Nurisng & Rehab resident suffers untreated surgical wound infection

Failure to notify doctor of changes in condition leads to death of resident at Alden Estates of Barrington

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

Moorings staff fails to notify doctor

Infection goes unnoticed at Helia of Belleveille

Burbank Rehab resident hospitalized due to missed dialysis sessions

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

Generations at Rock Island cuts respiratory staff, care suffers

December 20, 2019 By Barry G. Doyle

IDPH has cited and fined Generations at Rock Island nursing home for a series of potentially catastrophic events which followed a reduction in the number of respiratory therapists on staff.

One of the unique features of the nursing home industry is that it is the only sector of the health-care industry that is explicitly for-profit. To be sure, many doctors would like to make a nice profit after paying themselves a good salary and taking care of the expenses of running a business and many hospitals are making bushels of money. However, these are people and institutions who view themselves as being health care providers first and foremost. This is often not the case with people who own and operate nursing homes – they view themselves as businessmen. And this often has a dramatic negative impact on the quality of care that nursing home residents receive.

Computing a profit is at its base a pretty simple exercise – you take your revenue, subtract your expenses, and that is your profit. Obviously, it is more complicated in practice, but that is the basic equation. Nursing homes get paid on a per-resident, per-day basis, with the rates varying depending on the payor and the level of care required. At a very simple level, the nursing home maximizes its revenues by filling as many beds as possible with as many truly sick people as possible. On the expense side, the largest single item of expense is staff which is why you so often see understaffing of nursing homes and the use of less qualified staff such as LPN’s rather than RN’s. This helps minimize the staffing costs and boosts the bottom line.

What the IDPH cited this nursing home for is an especially ugly example of what happens when the nursing home business model collides with patient care.

At this nursing home, there are residents who are on ventilators and who have tracheostomies. These are residents who have complex medical conditions and require specialized care and are the the kinds of residents for whom the nursing home receives a higher level of reimbursement. These residents were being treated by a staff of nine respiratory therapists who were in the facility on a 24/7 basis. One June 14, the nursing home cut the respiratory staff from nine to two – one Registered Respiratory Therapist and one Certified Respiratory Therapist. Respiratory care was reduced to 8 hours per day, Monday through Friday. For issues that arose over the weekend or outside of hours when the respiratory staff was in the building, the nursing staff would have to provide care for the residents.

The obvious problem with this is that the nursing staff was not up to the task. When interviewed by the state surveyor, the nurses, many of them LPN’s, freely admitted that they were not comfortable caring for residents with ventilators or tracheostomies and did not know what to do with the equipment. Many of them told the state surveyor that if there was a complication with a patient on a ventilator or tracheostomy, they would need to call 911. To remedy this lack of training, the nursing home had an in-service training called “Understanding Vent Troubleshooting” which was conducted by the one of the remaining respiratory therapists, and she told the surveyor that it was not an adequate substitute for the years of training and experience that trained respiratory therapists have. Of note only six nurses actually attended the in-service – and 5 were from the first shift which is when the respiratory staff is generally in the building and only one from the second and third shifts when there might not be a respiratory therapist in the building at all.

So – what impact did this have on patient care?

One ventilator dependent patient experienced a mucous plug during the night. For a patient on a ventilator, a mucous plug can be a fatal complication. She sounded the call light, but the nurse didn’t come for 40 minutes, so she lowered her bed, reached for the suctioning machine, and cleared the mucous plug herself. Another resident with a tracheostomy experienced heavy bleeding at the tracheostomy site. The likely cause of the bleeding was that the oxygen he received dried out the tissue because the mositurizing bottle was empty. This is another complication that has the potential to cause serious complications. And these are events that took place during the first two weeks after the reduction in the respiratory staff.

This may be one of times where it is clearest that the nursing home business model negatively impacts resident care. 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:

Transport van accident at Generations at Rock Island

Sauk Valley Senior Living fails to provide proper tracheostomy care

California Gardens fails to obtain respiratory equipment

Generations at Rock Island fails to provide care for pressure ulcers

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

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

November 15, 2019 By Barry G. Doyle

IDPH has cited and fined Avantara of Long Grove nursing home due to a failure of the staff to monitor and obtain treatment for worsening signs of congestive heart failure, leading to the the wrongful death of this nursing home resident.

One of the basic roles that a nurse in a nursing home setting plays is to serve as the eyes and ears of the resident’s doctor. When a resident shows signs of a change in condition, has a nursing home fall, or is demonstrating some other condition of ill-being, it is the nurse’s job to notify the doctor. The doctor then can issue orders over the phone for treatment to be delivered at the nursing home, go into the nursing home to see the resident himself, or order the resident sent to the hospital for examination and treatment there. What is never acceptable is to have the resident suffer a significant change in condition and have the nurse fail to notify the doctor.

Federal regulations require each resident to have an attending physician. This is the doctor who is managing the care of the resident. Doctors are required to see the resident at least every 30 days during the first 90 days of an admission to the nursing home and at least every 60 days thereafter.

Both of these things were serious issues which contributed to the death of this nursing home resident.

The resident at issue suffered from congestive heart failure. This is a condition which is usually managed with medications, including a diuretic, or “water pill” because one of the symptoms of congestive heart failure is increased edema or swelling in the lower legs and ankles. If a resident is suffering from an exacerbation of or worsening of congestive heart failure, that is one of the signs of that and is something that would require physician notification. Monitoring for signs of congetsive heart failure including edema in the legs and feet were a part of this resident’s care plan.

On May 12, a CNA told the nurse that the resident was having a hard time breathing. Shortness of breath is one the signs of congestive heart failure. The nurse on duty that day went to his room, pulled back the covers and saw that his legs were red and swollen. The resident was brought to the hospital where he died the following two days later due to septic shock from lower extremity cellulitis, acute hypoxic respiratory failure due to septic shock, and acute kidney failure. Edema from congetsive heart failure can cause cellulitis which in turn will lead to sepsis if not treated properly.

The investigation into this resident’s death showed that a nurse on duty two days earlier saw that the resident’s lower legs were stretched and hard to the touch due to there being so much edema present. However, she did not think try to notify the doctor because she considered it his “normal.” And to some extent, she was right, as the resident’s skin inspection sheets recorded that for six weeks prior to the resident being taken to the hospital, the skin of his lower legs was described as being red and swollen, all at least potential signs of cellulitis – yet no one tried to notify the doctor during that interval.

And what of the resident’s doctor? The doctor hadn’t seen the resident since November 29 the previous year, nearly five and half months earlier. When contacted by the surveyor regarding this incident, he advised that the resident was no longer under his care because he was no longer seeing patients at that nursing home. In other words – the resident had a doctor on paper, but not in reality.

The fact that the resident had no actual attending doctor is fascinating for a couple of reasons:

Doctors often see several patients at each nursing home they go to, which means that there were likely multiple residents who had this physician taking care of them. Assuming that the nursing home knew that he was no longer seeing patients there, what did the nursing home do to facilitate transition in care and how did this resident end up with no one?
It was not clear from the citation when the doctor stopped seeing patients at this nursing home, but the fact that no one recognized that this resident was without a doctor means that no one from the nursing thought to contact the doctor about this resident at any time about this or potentially any other resident he cared for after that or paid attention to the fact the doctor listed as the attending physician for this resident (a) was no longer seeing patients there and (b) hadn’t been in to see the patient in months.

This is a case where it seems that no one was minding the store, so to speak. This resident was demonstrating changes in condition which required notification of the doctor, but no one thought to do so and no one was paying attention to the fact that this resident didn’t actually have a doctor. This was a series of catastrophic failures which resulted in the death of this resident.

Other blog posts of interest:

Feeding tube error puts Burgess Square resident into heart failure

Resident-on-resident assault at Alden Long Grove

Staff at Grove of Evanston fails to notify doctor of resident’s decline

Resident wanders from Alden Long Gove

Failure to notify doctor of pressure sore at Aperion of Moline

Failure to notify doctor of abnormal labs at Champaign-Urbana Nursing & Rehab

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

Resident bleeds to death at Aperion of Forest Park

October 24, 2019 By Barry G. Doyle

IDPH has cited and fined Aperion Care of Forest Park after a resident there bled to death following the removal of a wound vac device.

Many nursing home residents take anticoagulant (or blood thinner) medications to prevent serious medical issues such as a stroke, heart attack, or pulmonary embolism, all of which can be fatal or cause serious, long-lasting, debilitating problems. They work by inhibiting the blood’s ability to form clots. The risk and the downside of taking these medications is that by inhibiting the blood-clotting ability of the body, when the resident experiences a bleed, it may go unchecked which can cause its own serious set of problems. This is one of the reasons that residents on anticoagulants require close monitoring after experiencing a nursing home fall – they may be experiencing a brain bleed which can prove fatal or seriously debilitating if allowed to continue.

The resident at issue was admitted to the nursing home after undergoing a vascular bypass surgery on January 8 to improve circulation to the left lower extremity. During the hospital admission, he also underwent amputation of the fourth and fifth toes of his left foot. There were orders in place for continuous use of wound vac to help close a non-healing wound where the toes had been amputated. The resident was also taking aspirin and Plavix to help prevent blood clots. The resident was to return to see the doctor on the morning of January 23.

The practice at the nursing home was that when a resident had an early morning doctor appointment, the wound vac would be removed the prior afternoon. This was because if the medical transport team arrived to take the resident to the doctor’s office before the wound care nurse arrived at the nursing home, there was a risk that the resident would be admitted to the hospital from the doctor’s office and the wound vac machine might not be returned to the nursing home. Therefore, to avoid the risk of loss of the wound vac machine, the wound vac would be disconnected the afternoon before the appointment at the doctor’s office.

On the afternoon of January 22, in keeping with the practice at the nursing home, the wound care nurse removed the wound vac and applied a dry dressing before leaving for the day. She told the state inspector that there was no active bleeding when she left the resident. However, less than an hour later, a staff member observed a pool of blood on the floor coming from the wound where the toes had been amputated and the resident was unresponsive and in cardiac arrest. 911 was called and the resident was brought to the emergency room, but the staff there was unable to revive the resident and he was declared deceased.

The state investigation revealed that the facility had no policy in place for monitoring residents after removal of the wound vac. Further they relied on representatives from the various manufacturers of the different types of wound vacs in use at the nursing home to train the staff, but they were unable to show what training had in fact been provided to the staff, although the operations manual to the wound vac called for special precautions for residents who are on anticoagulants.

Making matters worse, the resident’s doctor said that the wound vac should not have been removed to begin with, as his order was for continuous use and removing the wound vac denied the resident of the additional hours of treatment with it. He told the surveyor that the removal of the sponge that covered the wound when the wound vac was disconnected could have caused the bleeding which resulted in the death of this resident.

What this shows is that the nursing home did not train or have policies in place on monitoring residents after a wound vac was removed, but removed the wound vac in violation of doctor’s orders in order to guard against the possible loss of the wound vac in the event that the resident was admitted to the hospital from the doctor’s office. Good for the nursing home, not good for the resident, even without the tragic and avoidable outcome that we had here.

The practice of removing the wound vac to guard against the risk of it being lost is an example of how dollars and cents decisions adversely effect care for nursing home 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:

Staff at Grove of Evanston fails to notify doctor of resident’s decline

Dialysis patient bleeds to death at Warren Barr North Shore

Aperion Care Capitol fails to obtain equipment necessary to treat bed sore

California Gardens fails to obtain respiratory equipment

Aperion Care Wilmington resident suffers ruptured colon due to fecal impaction

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

Lack of wheelchair footrests leads to broken leg at Lexington of Orland Park

October 3, 2019 By Barry G. Doyle

IDPH has cited and fined Lexington of Orland Park nursing home after a resident there suffered a broken leg while being pushed in her wheelchair.

When it comes to wheelchair-bound residents, the term “self-propelling” means that the resident is able to move themselves in the wheelchair without staff assistance. Usually this is done primarily through the resident using their feet to walk the wheelchair forward with some use of the arms for steering. It is something which promotes the independence and dignity of the resident as it allows them move throughout the facility without having to wait on or depend upon the staff to push them. To improve the resident’s ability to self-propel, the footrests are usually removed from the wheelchair so that they don’t interfere with the resident’s ability to self-propel or cause skin tears or other injury to the resident by striking the resident’s legs.

The downside to self-propelling is that it is a slow process, and staff often doesn’t have time to wait for a resident to self-propel. When the staff needs to get the resident moved more rapidly, they can simply push the resident where they need to go.

This was the situation here – the resident was able to self-propel, but it was meal time so an aide began to push the resident toward the dining room. Because the resident usually self-propelled, her wheelchair had the footrests removed. Instead of placing the footrests back on the wheelchair, the aide simply had the resident hold her legs up. On the way to the dining room, the aide heard a loud popping sound and saw that one of the resident’s legs had gone under the wheelchair.

The resident was brought to the hospital where x-rays showed that she had a broken leg. The resident was placed in an immobilizer. The failure to use footrests on the wheelchair led directly to this injury.

This was a highy preventable injury. All that was required to transport this resident to the dining room safely was to place the footrests on the wheelchair, but the aide failed to do so, either due to the pressure of having to get too much work accomplished in too little time to get it done due to inadequate staff levels, or due to lack of training. Neither reflects well on the nursing home.

As a result, this resident sustained a broken leg which required the application of an immobilizer. This will eliminate her ability to self-propel while it is on, and due to disuse, she may end up losing that ability to self-propel all together. Loss of strength may lead an increased risk of suffering a nursing home fall. Past that, her immobility will also place her at increased risk of developing bed sores as immobility is a prime risk factor for that.

Other blog posts of interest:

Fall at Lexington of Orland Park results in facial fractures

Wheelchair accident at LaSalle County Nursing Home

Resident breaks leg in wheelchair accident at Heritage Health in Dwight

Resident at Chateau nursing home in Willowbrook suffers spinal fractures in wheelchair accident

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

Wheelchair accident at Avanti Wellness

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

Failure to obtain anti-seizure medication at Gilman Healthcare Center

September 10, 2019 By Barry G. Doyle

IDPH has cited and fined Gilman Healthcare Center nursing home after a resident there did not receive his required anti-seizure medications, resulting in the resident experiencing multiple seizures.

The resident at issue was admitted to the nursing home on a Friday with orders which included the administration of two anti-seizure medications (Onfi and Vimpat) two times daily. The two medications were not kept on hand at the facility and had to be obtained through the nursing home’s pharmacy. In order to get those medications, the nursing home needed a hard copy of the prescriptions from the doctor who ordered the medications at the hospital. The hard copy prescription did not arrive at the nursing home with the resident, however.

Faced with this situation, the nurse who admitted the resident did not call the hospital to have the hospital send over the hard copies of the prescriptions. Instead, she faxed a request over to the attending doctor at the nursing home, who did not respond to the fax all weekend long. As a result, the resident did not receive his anti-seizure medications Friday or over the weekend. Reason listed in the Medication Administration Record of the resident’s chart was Drug Unavailable.

On Monday morning, the Director of Nursing contacted the attending physician’s office again at 8:30 a.m. The doctor’s office staff informed her that it may be a while before they get a response because they needed to sort through some 50 (!) faxes that came in over the weekend and the doctor would not be in until 10:45 a.m.

What happened as a consequence of this resident not receiving his anti-seizure medication? Over the course of the weekend, the staff documented the resident experiencing multiple seizures. Throughout the course of the day Monday, the resident had several additional seziures while the nursing home staff waited for a return call. Shortly after 1 pm, the nursing home had the resident sent to the hospital, after which time the doctor called back saying he was not comfortable issuing the prescription for the anti-seizure medications. At the hospital, the resident was sedated and intubated and given an EEG which confirmed that the resident had multiple seizures. Transfer to a larger hospital was recommended to treat the seziures caused by this nursing home medication error.

There are multiple issues with what transpired with this resident:

When the hard copy of the prescription needed to order the medication did not arrive with the resident, the simplest course of action would have been to follow up with the hospital, but this was not done. Instead, they looked to the attending doctor from the nursing home (who, if you read the citation from the nursing home, was probably not expected to be very responsive) and who ultimately declined to get involved;
When they could not get a response from the doctor, they failed to contact the medical director or the hospital to get assistance;
Once the resident began to experience seizures, they failed to notify the doctor to get orders or instructions to get the resident to the hospital. As a result, the resident remained in the nursing home experiencing additional seizures.

Obtaining medications for nursing home residents who need them is a basic part of the services that nursing homes provide. Well-run businesses run on systems that provide the basic level of service without fail. The nursing home here quite clearly failed that task, much to the detriment of the resident.

Other blog posts of interest:

Anticoagulant medication not given at H & J Vonderlieth Living Center

Medication usage leads to fall at Gilman Healthcare Center

Failure to obtain anti-seizure medication at Alden of Orland Park

Medication error at Palm Terrace leads to hospitalization

Two medication errors at Alden Town Manor

Resident given wrong medications at Manor Court of Freeport

Failure to obtain anti-seizure medications at Gilman Healthcare Center

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

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

Infection goes unnoticed at Helia of Belleville

September 8, 2019 By Barry G. Doyle

IDPH has cited and fined Helia Healthcare of Belleville after a resident there suffered complications from an untreated infection at the surgical site for a pacemaker.

The resident at issue was admitted to nursing home after having surgery to have a pacemaker installed. When surgery is done to install a pacemaker, there is a surgical wound where the pocket for the pacemaker is located. Like any surgical wound, it requires regular skin checks for signs of infection. One of the basic skills of a nurse working in a long term care setting is being able to identify signs and symptoms of infection – and in the case of surgical wounds, cellulitis is one of the principal forms of infection to be concerned about. When signs of infection are present, it is the responsibility of the nurse to notify the doctor so that the doctor can either issues order for treatment over the phone, come into the nursing home himself, or have the patient transferred to the hospital.

In this case, the patient was brought into the doctor’s office for a post-op check about 5 months after the surgery was done. When the nurse practitioner saw the condition of the wound, she had the resident sent to the emergency room immediately. In the emergency room, the doctor saw an open wound with erythema, swelling, and very tender to touch. Wound cultures were taken which showed multiple multiple drug-resistant organisms in the wound. The resident was admitted to the hospital to have the pacemaker removed and a new one placed.

When the state surveyor asked the nurse practitioner how long the pacemaker wound was in that condition, she estimated 2-4 weeks before the patient came into the office. The surveyor then checked with multiple staff members all of whom had some responsibility for checking the condition of the resident’s skin. All of them denied noticing anything abnormal about the resident’s skin. The normal course of a cellulitis infection is that it starts off as a fairly mild redness around the edges of the wound which can treated fairly easily. Serious problems result though when the infection is left untreated which was apparently the case here given the severity of the infection and the appearance of the surgical wound. This means one of two thins is true: either the staff did not know what they were looking for (which is really a basic nursing skill), the checks were not being done (most likely), or that the abnormal findings were just not being reported to the doctor. None of these scenarios represent acceptable nursing care.

Other blog posts of interest:

Rushville Nurisng & Rehab resident suffers untreated surgical wound infection

Surgical wound infection of Presence Villa Franciscan

Failure to notify doctor of abnormal labs at Champaign Urbana Nursing & Rehab

Moorings staff fails to notify doctor

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

Failure to obtain treatment supplies at Pekin Manor

September 2, 2019 By Barry G. Doyle

IDPH has cited and fined Pekin Manor nursing home after a resident there had to be hospitalized with respiratory failure due to the failure of the staff to order necessary medical equipment.

The resident at issue was admitted to the nursing home with orders from his doctor to have his chest tube drained daily until draining the chest tube returned less than 100 cc’s of fluid, at which point the frequency with which the chest tube had to be drained less frequently. On Wednesday, February 27, the nurses treating this resident recognized that they were running low on the bottlesg necessary to drain the chest tube. A request was made internally at the nursing for an order to be placed, but the order was never placed. By Friday, March 1, they were down to the last bottle, so a request was made to have the supplies delivered on a 24-hour basis. However, the medical equipment supplier did not made 24-hour deliveries on weekends, so the resident did not get the chest tube drained over the weekend.

The resident was taken to the emergency room Sunday night suffering from respiratory failure. When he was in the emergency room, the doctors there drained 800 cc of fluid from the resident’s chest. The resident was admitted to the hospital.

One of the basic tasks that nursing homes are charged with are carrying out physician orders. In this case, that included doing daily drainage of the chest tube. In order to do that, the necessary supplies had to be on hand.

Nursing homes are businesses, and well-run businesses have systems in place to deliver the basic services that are supposed to be provided. In the nursing home setting that means having systems in place to ensure that supplies are on hand to deliver the care that the residents need. Here there was a system that simply failed: the supplies that were needed were not ordered. As a resulty, the nursing home failed to provide necessary care.

However, once the staff was aware that there were not going to be supplies on hand to provide the resident with the care that the doctor ordered, simply skipping it and hoping for the best was not a real option. This was a situation where physician notification was required, as it was not the nurse’s role to decide whether it would be okay for the resident to go without the care that was needed.

Other blog posts of interest:

Aperion Care Capitol fails to obtain equipment needed to treat bed sore

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

California Gardens fails to obtain respiratory equipment

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

Moorings staff fails to notify doctor

August 24, 2019 By Barry G. Doyle

IDPH has cited and fined The Moorings nursing home in Arlington Heights after the nursing staff failed to notify the doctor that a resident was having coffee ground emesis (a sign of internal bleeding) resulting in a delay in the resident obtaining care and the wrongful death of the nursing home resident.

One of the basic truisms about nursing home care is that there is not a doctor in the facility 24/7 like there is in a hospital. Therefore, one of the basic functions of a nurse in a nursing home is to serve as the “eyes and ears” of the doctor. When something happens with one of the doctor’s patients, it is the job of the nurse to notify the doctor that a resident has experienced a change in condition. It isn’t their job to diagnose what the problem is or determine what the right course of treatment for it is; it is just their job to present the problem to the doctor so that the doctor can decide whether to issue orders over the phone, come in to see the patient, or order the patient sent to the hospital. When there is a true emergency situation, the staff should bypass the doctor and

The problem arises when there is a failure on the part of the nursing staff to carry out this function. Without the nurse telling the doctor that something is happening with the patient, the doctor has not reason to know that anything needs to be done to help. When no one steps up to get a nursing home resident help when things go wrong, the situation can escalate rapidly – and that is a formula for disaster in a medically fragile patient population.

The resident at issue had a history of atrial fibrillation which is an irregular heartbeat. This can cause blood clots which can cause a host of complications, most notably a stroke. To combat the development of blood clots and thereby reduce the risk of stroke, people suffering from atrial fibrillation are commonly treated with a blood thinner or anticoagulant, in this case coumadin. He was also on antibiotics for an infection. When patients are getting both antibiotics and coumadin, they are at increased risk of gastrointestinal bleeding or bleeding in the stomach. One of the signs of this is so-called “coffee-grounds emesis” which is essentially blood-tinged vomit. This is an emergency situation and 911 should be called.

On the morning of June 2, paramedics were called to the nursing home for vomiting. The crew was informed that the resident had 4-5 episodes of coffee ground emesis the night before. The resident then vomited in front of the ambulance crew, this time vomiting bright red blood. He lost a pulse, and CPR was initiated, but the resident died that day. One cause of death on the death certificate was gastrointestinal bleeding.

This case presents a fairly simple instance of the nursing staff failing to recognize that a resident was experiencing a medical expergency and failing to take appropriate steps in response. Coffee grounds emesis is a sign of something serious, and even if the nursing staff did not recognize the full implications of a resident having that, a doctor would have. Either way — calling a doctor or calling 911 — this resident would have been sent to the hospital where there would be a real chance of avoiding this tragic outcome.

Other blog posts of interest:

Failure to notify doctor of changes in condition leads to death of resident at Alden Estates of Barrington

Failure to notify doctor of abnormal lab results at Momence Meadows

Fatal choking accident at The Moorings in Arlington Heights

Dialysis patient bleeds to death of Warren Barr North Shore

Injury from catheter placement at Marigold Rehab

Surgical wound infection at Presence Villa Franciscan

Failure to monitor anticoagulant medication at Greentree of Bradley

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

Injury from catheter placement at Marigold Rehab

June 20, 2019 By Barry G. Doyle

IDPH has cited and fined Marigold Rehabilitation & Healthcare Center in Galesburg after a resident suffered a urinary tract injury due to improper insertion of an indwelling urinary catheter.

The resident at issue had an indwelling catheter. An indwelling catheter is a tube which goes up the urethra to the bladder. Once the tip reaches the bladder, urine should begin to pass down the catheter tube. The passage of urine through the catheter is the signature that the catheter has reached the bladder. At that point a balloon at the tip of the catheter should be inflated which holds the opening to the bladder open and allow urine to continue to drain through catheter.

The male resident at issue had a catheter which needed to be replaced. He apparently suffered from significant dementia and struggled with the staff during catheter changes. This time, he was held down by the staff while a nurse inserted the catheter. She encountered some resistance in passing the catheter, but did not have urine draining from the catheter. Thinking she had reached the bladder, she inflated the balloon and attempted to remove the port for blowing up the balloon. When they did so, the catheter came out of the penis as did large amounts of blood.

The resident was sent to the emergency room to get the bleeding under control which was made more difficult due to the fact that he was taking blood thinners (which is part of why nursing home falls are such a serious issue for residents who are on blood thinners – internal bleeding can progress much further than would otherwise be the case).

The fundamental issue in this case is an issue of poor nursing technique. The nurse who was responsible for replacing the catheter did not use proper technique in placing the new catheter. Instead of inflating the balloon after the catheter had entered the bladder, she inflated the balloon while the catheter tip was still within the urethra – in other words, she inflated the balloon too early. The signature of a proper placed catheter is a flow of urine from the bladder into the bag. The nurse saw that there was no urine entering the bag but nonetheless inflated the balloon on the catheter. When nurses fail to follow proper technique, this is a form of nursing home abuse and neglect and can be the basis for a civil lawsuit.

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

Diabetes care mismanaged at Aperion Care Capitol

Urinary catheter injury at Friendship Manor

Wheelchair accident at Galesburg Rehab

Unsafe transfer at Heartland of Galesburg results in dislocated hip

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

Dialysis patient bleeds to death at Warren Barr North Shore

May 27, 2019 By Barry G. Doyle

IDPH has cited and fined Warren Barr North Shore nursing home in Lincolnshire after a resident bled to death after she manipulated her dialysis port.

The resident at issue was a long-term resident of the nursing home and received dialysis three times a week. In addition to the medical issues which required dialysis, she was on blood thinners and suffered from advanced dementia. She had a fistula for dialysis in her left upper arm. The fistula would allow the blood to drawn out of the body, have the waste filtered out, and the blood returned to the body.

Before the incident that resulted in the wrongful death of this nursing home resident, there were two other incidents where the resident experienced bleeding related to her dialysis site. The first of these took place approximately three months earlier, when an aide found the resident in bed with the resident’s sheets soaked with brown, hardened, coagulated blood. The fistula site was identified as the source of the bleeding. Approximately a month and a half later, a wound was found on the resident’s arm next to the fistula and the staff documenetd that the resident was known to scratch at the area.

During the survey process conducted by IDPH, other staff members and health care professionals acknowledged that the resident frequently scratched at the dialysis site. There was speculation that tape that held the port into place was an irritant.

At 11 pm the day before the resident died, the nurse took her hand away from the fistula site. She was checked on twice that night before being found the next morning around 4 am. The citation describes a horrific scene – the resident covered head to toe in blood, blood saturating the sheets and blankets, blood on the floor and wall. The resident was already deceased. Cause of death per the death certificate was exsanguination, meaning that she had bled to death.

This case demonstrates a breakdown in the care planning process and delivery of care is impacted by the nursing home business model. The underlying premise of the care planning process is that the risks to the health and well-being of the resident are identified and steps are taken to address the risks.

The staff here knew of a behavior which represented a threat to the health and well-being of the resident – her behavior of scratching at the fistula site. In fact, they got a preview of how serious an incident that could be in April when she had a significant bleeding incident caused by scratching at the fistula site. Further the staff had at least a notion of the underlying cause of the resident scratching at the fistula site: irritation of the skin from the tape.

There were at least a couple of simple solutions available to address this risk. One would be to use a different type of adhesive which did not cause the irritation. Without the irritation, there would be no scratching at the fistula site and this incident would not have occurred. The other option would have been to protect the fistula site with a dressing which would have kept the resident from dislodging it. Neither of these options appear to have been pursued and there is no indication in the citation that the risk of this kind of bleed-out was ever addressed in the care planning process.

The likely reason that this was never addressed in the care planning process is that it is not one of the specific areas that is part of the standard care planning process like the risks of nursing home falls, developing bed sores, or elopement (or wandering). One of our beliefs is that the nursing home business model stretches staff so far that little critical thought is given to the health and well-being of residents. This was a situation that called for a little extra critical, outside-the-box thought and consideration which never happened.

Order our FREE report, Built to Fail, to learn more about how the nursing home business model ends up causing unncessary injuries and deaths to nursing home residents. 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:

Forest City Rehab fails to send resident to dialysis

Staff at Grove of Evanston fails to notify doctor of resident’s decline

Resident rolled from bed at Warren Barr in Lincolnshire

Wheelchair fall at Hillcrest Retirement Village

Medication errors results in severe bleeding at Fairmont Care Centre

Short-staffing leads to fall at Warren Barr North Shore

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

Fall and Brain Bleed at Alpine Fireside

March 1, 2019 By Barry G. Doyle

The Illinois Department of Public Health issued a citation and fined Alpine Fireside Health Center in Rockford after a resident had a fall from a wheelchair and experienced a brain bleed.

This case is a classic example of a situation where things had been going wrong for weeks and everyone missed it.

The resident had a medical history which included atrial fibrilation. This is a condition where the heart at time beats in an irregular fashion and can produce blood clots. Blood clots can in turn cause a host of problems, most notably strokes. The usual treatment for this issue is drug therapy, most commonly a blood thinner like coumadin, and this is what the doctor ordered.

The use of coumadin is not risk free. When the blood is too “thin” this can lead to bleeding and when it is too “thick” this can cause clots. Find the “sweet spot” or the therapeutic range is done through a blood test called a PT/INR level test. Regular PT/INR testing is required to make sure that the resident stays in the therapeutic range. If the level goes too high (is supratherapeutic) or too low (subtherapeutic), then the dosage can be adjusted to bring it back into the therapeutic range.

Here the nursing home failed to get the required lab work done to measure whether PT/INR levels were in the therapeutic range. This apparently happened because the nursing staff failed to complete the lab requisition form. Without that lab work being done, the doctor did not know whether to adjust the coumadin and she continued to get the same dosage on a daily basis.

Things went on without incident until the resident had a fall while transferring herself from her wheelchair to her bed. There is no immediate indication that she struck her head and when she was assessed by the nursing staff she had elevated blood pressure and pain in her knees.

The ordinary course of action in most nursing home would be to do a 72-hour fall watch after an incident like this to make sure that there were no additional injuries which were not immediately apparent. This would include neurological checks to make sure that there was no head injury.

When the resident’s daughter arrived at the nursing home later that day, she recognized immediately that her mother was not herself and took her to the hospital herself. When she got there, lab work indicated that her PT/INR level was 7.4 (normal range 2.0-3.0) which was a critically high level. A CT scan of the head showed that there was a subdural hematoma, a form of brain bleed. The hospital discharge summary attributed this to the high coumadin levels.

This is a case where there were a number of issues:

The required lab work was not done as ordered which hid the fact that the PT/INR levels were climbing out of the normal range. This denied the doctor the ability to make adjustments to the coumadin dosage to bring it back into the normal range.
The circumstances surrounding the nursing home fall are not entirely clear, but a wheelchair-bound resident likely required assistance with transfer and this probably should have been included in her care plan. This is especially true because falls can have serious consequences for patients who use anticoagulant or blood thinning medications such as coumadin.
Once the fall happened, the follow-up was not done correctly. In most well-run nursing homes, there is a process for a 72-hour fall watch which would have detected the onset of neurolgic problems. Instead it was left to the resident’s daughter to discover them and act on them. That is not how things should be done.

We believe that many falls at nursing homes have their roots farther back in time than the day the resident hit the floor, and had the staff acted in the right way any time before that, the fall could have been avoided. Contact our law firm to have our experienced nursing home lawyers to review your situation. There is no charge for the call and your are not obligated to hire our firm if you do call.

River Bluff nursing home in Rockford resident suffers multiple fractures in fall

Burbank Rehab resident hospitalized due to missed dialysis sessions

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

Symphony at South Shore resident suffers open fracture of the leg

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

Bed bound resident at Elevate Care of Waukegan fractures arm

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

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

Transportation van accident at Generations at Rock Island

Failure to follow orders at Generations at Applewood

Breakdown in care leads to broken leg at Chalet Living & Rehab

Failure to notify doctor of abnormal labs at Momence Meadows

Staff at Grove of Evanston fails to to notify doctor of resident’s decline

Generations at Rock Island cuts respiratory staff, care suffers

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

Resident bleeds to death at Aperion of Forest Park

Lack of wheelchair footrests leads to broken leg at Lexington of Orland Park

Failure to obtain anti-seizure medication at Gilman Healthcare Center

Infection goes unnoticed at Helia of Belleville

Failure to obtain treatment supplies at Pekin Manor

Moorings staff fails to notify doctor

Injury from catheter placement at Marigold Rehab

Dialysis patient bleeds to death at Warren Barr North Shore

Fall and Brain Bleed at Alpine Fireside

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