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

Chicago Illinois Accident Lawyers

 CALL (312) 263-1080

Grove of Berwyn Resident Violently Assaults Another Resident

By

The Centers for Medicare and Medicaid Services have cited The Grove of Berwyn based on interview and record review and has determined that the facility failed to protect a cognitively impaired resident from assault from another resident with a history of violent behavior.

The injured resident was admitted to the facility in February of 2023 with a diagnosis of dementia. In April of 2023 another resident with a history of violent and criminal behavior that had often led to the requirement of restraints and security watch was allowed to walk unsupervised into another resident’s room and assaulted her. 

The assault resulted in the attacked resident falling to the ground with injuries after being violently pushed. The injured resident was emergently transferred to the hospital for care that included repair of a fractured femur requiring surgical intervention and pain management.

Upon interview of staff, the Grove of Berwyn LPN stated she did not actually see the fall, she saw the resident when she was already on the ground and that she called paramedics. When asked if she was aware of either resident having a record of a violent past, she stated “I did not, I don’t normally work here. No one told me anything about violent behavior and whether either resident should be monitored. I am from an agency and haven’t worked there since the incident.”

Progress notes contradict this interview and read “Patient was in another resident’s room when the resident pushed a patient in her back to get her out of her room. Patient landed on her knees and then laid on the floor and turned her left arm while lying on the floor and sustained abrasion to left elbow, cleaned and dry. 911 called.” Staff will continue to monitor for aggression.

The facility policy titled Abuse and Neglect reads in part: “It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment”. Based on the interviews, The Grove of Berwyn was cited for a failure to follow their policy and procedure for admissions by not ensuring the resident was protected from the resident that posed a known risk.

Failing to protect residents from injury and abuse and treat them with respect is all too commonplace in the nursing home setting. (See here, here, and here for examples). This is most often caused by an understaffed nursing home, the utilization of temporary employees that are not informed appropriately about resident needs, and lack of proper monitoring of residents. 

Unfortunately, ignoring regulations and failing to relay important information to new and existing staff regarding safety measures is the standard level of care for many nursing homes.  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 supervise Westmont Manor resident results in fall with hip fracture

Park Place Christian Community resident rolled from bed by staff

Sunny Hill resident suffers fractured leg after lift tips over

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

 

Southgate Health Care Center Resident Dies When Brought To Shower Without Supplemental Oxygen

By

The Centers for Medicare and Medicaid Services have cited Southgate Healthcare Center of Illinois with violations after interviews and records uncovered that the facility failed to provide prescribed oxygen therapy during a resident’s shower, leading to the residents death. 

Noncompliance in following prescribed orders is an all-too-common reason for nursing home error. (See here, here, and here for examples). 

Errors of noncompliance are most often caused by lack of training, disorganization, and failing to follow changes in the prescribed orders for the resident. This incident demonstrates that incidents occur when the staff are not properly trained and are noncompliant.

In this case, the resident was admitted to Southgate facility with diagnoses including Pulmonary fibrosis, chronic respiratory failure, COPD (chronic obstructive pulmonary disease), and continuous dependence on supplemental oxygen. The resident required 2-2.5L of oxygen continuously at the time of admission. Additionally, he was determined to require the physical assistance of one person for bathing activity due to his impaired balance, limited mobility, and the necessity of supplemental oxygen. 

During his stay, therapy notified nursing that the resident’s oxygen levels had been dropping in the 80’s when trying to work with him. The nurse checked resident tubing for kinks. The resident appeared to be anxious and holding his breath, causing his oxygen to drop into the high 80’s. 

Medication records showed that the resident had been prescribed Buspirone 10 mg. for anxiety, three times daily. Physical therapy asked if the resident could be prescribed anything additional for his anxiety. The resident’s Primary Care Physician’s office was notified of the request. The physician placed a new order for an increase to 3L of oxygen by nasal canula, active on every shift. 

During interview the CNA stated she went to the resident’s room and told him it was his shower day and stated, “I asked if he wanted a bed bath or shower. He looked at me and stated, you know I haven’t had a shower since I’ve been here, I’m sticky. I want a shower.” CNA said she then took the resident from his room without his oxygen to the shower room. She estimated that the time from his room to the time he became unresponsive in the shower room was about 10 minutes. “I did a quick one for him because I know the oxygen situation. He wanted his head washed really good. He was greasy. I know oxygen patients can’t be off of oxygen long. I’m terrified to take the oxygen machine into the shower because of electrical concerns. I monitored his 02 stats the whole time and they were “high” (mid to high 90’s). I don’t do that kind of paperwork, but I used the 02 sat monitor on his finger. He was talking with me the whole time and he said, Baby, are we about done? I told him yes and we were drying off and getting dressed. I had him out of the shower, he was in the shower chair. I turned to my left to grab his shirt and went to put his shirt on, and he had his arms up to put the sleeve holes, I got his arms in and then his arms fell into his lap. I called for help immediately. I stuck my head in the hall and a CNA was right there in the hall (we were using that shower room because they were working on skilled back shower room water). I told him to get the nurse STAT that the resident was unresponsive I never left him alone in the shower. Not even a minute later the nurse came in. I’m pretty sure someone took his vital signs, but I don’t remember. I think that someone could stay off oxygen for 10 minutes, but in my experience, I didn’t think 10 minutes would be that long. What scared me was that he had been talking to me.” 

When asked what electrical concerns one might have with portable oxygen, the staff member said she was not aware she could take a portable with her to the shower and stated, “I did not know that this resident was required to be on continuous oxygen. We have residents who take their oxygen off to go to the dining room, but I was assuming he was the same way. This was the second time I had ever worked with him, and it was never conveyed to me he was continuous oxygen.” When asked if the resident had ever sustained a fall, the CNA stated not that she was aware of.

Facility notes read, “This nurse was on hall passing medicines when a CNA came to get me telling me they need a nurse. I went into the hall shower room and found the resident non-responsive. I immediately called 911. The LPN stated when she entered the shower room the resident was sitting in the shower chair just outside the shower itself. His dentures were protruding from his mouth. The CNA relayed to the nurse that she was drying the resident off, and he started not breathing very well. It was noted that the resident’s oxygen was not in the shower room and the nurse immediately instructed “the male staff” to go and get his oxygen, then called 911. 

When asked if the resident had experienced a fall at any time, the LPN said she was told he had not, that he remained in the shower chair. LPN continued that she asked what the resident’s code status was, but that the CNA did not know how to read the board. At this time the nurse was able to confirm the code status was DNR. 2-3 minutes later, the male staff returned with resident’s portable oxygen. The resident’s oxygen per nasal cannula was administered at 2L and, according to records, his color returned. LPN stated she kept calling the resident’s name and he would gasp but did not speak. “He was still in distress, and I was praying the ambulance would get there quick.” She added that prior to this incident, the resident was cognitive with confusion, but could hold a conversation with her and could tell her exactly how he liked his pills. When asked if any vitals were taken during the incident, she stated no, she had been on the phone with 911. She said EMS took vitals on arrival. “Had I realized he was being taken down to the shower room, I would have suggested he have his 02 with him. I would have rather he stayed in bed and had a bed bath because he gets out of breath with movement, but he has that right to a shower. 

The nurse confirmed if a resident requires a continuous 02 you would take the portable to the shower and work around it. You would never not take the 02 with them to the shower, stating, “they could meet Jesus on the way.” When asked how a CNA would determine whether a resident required oxygen and whether it would be intermittent, as needed, or continuous, both the CNA and nurse stated the easiest thing would be to ask the nurse and that’s what they would do. When asked how they would handle a situation in which a resident who was ordered continuous oxygen for all activities asked for a shower, both nurses stated they would take the portable oxygen tank. The portable tanks do not need to be plugged in.

EMS facility notes staff state that they were told the patient went to go take a shower and the staff found him unresponsive on the shower floor. According to EMS the CNA sat him up and then noticed that he was still unresponsive, so they called 911. 

Upon arrival to Southgate, the staff brought EMS to the bathing room where they found the patient sitting in shower chair with CNA holding patient up with nasal cannula with oxygen delivered at 2L. 

Staff stated patient had been taking a shower and talking with no problem. CNA stated she turned around to grab a towel and turned back and patient head was slumping down and not responding to stimuli. Resident was transported and the family notified.

Based on interview and record review the facility failed to ensure this resident received continuous oxygen therapy as required during a shower. This failure resulted in the resident becoming unresponsive requiring emergent care with subsequent hospitalization.

Upon admission to the ER the patient was found unresponsive but had a pulse. Patient was in acute respiratory failure requiring intubation. Upon reassessment after treatment, the resident began to become more awake and started pulling at his tube. He was left on the ventilator to reduce carbon dioxide levels. The patient was extubated to a non-invasive high-flow respiratory support system and ultimately the decision to extubate and provide comfort measures was made. He remained in the company of family and passed away two days later. The cause of death was determined to be Acute Chronic Respiratory Failure with a duration of two days and Community Acquired Pneumonia.

The interview and review of records concluded that post incident, the resident suffered an elevated troponin level, indicating heart muscle damage not due to acute coronary syndrome, weakness, pulmonary fibrosis but from respiratory failure due to the lack of oxygen (hypoxia) and subsequently developed pneumonia.

When the Director of Nursing was asked about the resident’s hospital records documenting his history that was taken by EMS indicating that the resident was found on the floor unresponsive. The director reiterated that the resident never sustained a fall, especially on the date of the shower incident and that the information obtained was either misunderstood or recorded incorrectly in the report.

During the interview the director stated if a resident required continuous oxygen, you would make sure to take the portable 02 with the resident in the shower and only remove while washing the face to ensure the oxygen was off as short a time as possible because some residents have COPD and “things like that”.

The facility stated that access resident information is available at the kiosk or tablet Kardex where charting is performed but was not sure if their information would define whether a resident required continuous 02, but that most CNAs would ask the nurse. The facility confirmed if a resident required continuous oxygen for all activities, a portable tank would be taken to the shower room. The male staff member stated they would be afraid to take a resident out of their room for the fear they may become short of breath, but if they requested a shower, he would not take them without some form of 02.

This facility estimated the resident was without his oxygen for approximately 10 minutes from the time he left his room for the shower until the time he became unresponsive, and oxygen was started again 2-3 minutes later. When asked if he felt being off oxygen during this time would have contributed to an acute respiratory distress event, the staff member stated, “In my mind the main thing with the resident was he had end stage lung disease/pulmonary fibrosis and if he was without oxygen longer than 10 minutes, he would definitely think that could trigger an event and that anything less than 10 minutes would not contribute to acute respiratory distress. When asked if he thought this could have contributed to the resident’s death while in the hospital, the facility did not think the incident would directly relate to his death. He reiterated the time frame involved and stated the resident was oxygen dependent, and he had a terminal illness.

Unfortunately, noncompliance with physician orders and poor training is the standard level of care for many nursing homes. 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 supervise Westmont Manor resident results in fall with hip fracture

Park Place Christian Community resident rolled from bed by staff

Sunny Hill resident suffers fractured leg after lift tips over

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

 

Violation of care plan at Generations Oakton Pavillion leads to fall and fracture

By

IDPH has cited and fined Generations Oakton Pavillion after a resident there suffered a fractured leg in a fall which occurred due to staff attempting to manually transfer her from wheelchair to bed without using a lift, in violation of the resident’s care plan.

Much of the routine care that residents receive in a nursing home setting is shaped by the resident care plan.  In the care planning process, an assessment is done to identify the resident’s care needs and risks to the health and well-being of the resident.  A series of steps, or interventions, are then put into place which are intended to meet the resident’s needs.  The staff members assigned to carry out those interventions then must do so on a day-to-day, shift-to-shift basis.

The resident at issue was morbidly obese and had left-sided weakness from having had a stroke in the past.  She was unable to bear weight, so her care plan called for transfers with a mechanical lift with the assistance of two staff members.

On the day of this nursing home fall, the sling for the lift that normally would have been left underneath the resident as she sat in her wheelchair was not in place.  Because there was no sling readily available, the aides attempted to transfer the resident manually without using a gait belt.  As they attempted to pivot to turn from the wheelchair to the bed, the resident’s legs gave out and she fell to the ground, landing on her knees.  She was helped from the floor to bed by the aides.

After the fall, the resident had complaints of pain in the knee and swelling and bruising below the knee.  The resident was transferred to the hospital where x-rays showed that the resident had a fracture of the upper portion of the tibia, extending into the knee joint, and a patellar tendon avulsion.  The resident underwent surgery to repair the injuries from the fall.

The nursing home had a reasonable care plan in place for this resident – the problem was that the staff did not implement it.  The care plan called for transfer with a lift, which was appropriate given her inability to bear weight.  Rather than follow this care plan, the staff attempted to transfer the resident manually.  This was never likely to succeed given her inability to bear weight – and the chances of ensuring an injury-free transfer dropped when they elected to not use a gait belt, either.

The fact that the staff plowed ahead with trying to transfer the resident manually raises a question of whether this is an understaffed nursing home.  This is true anytime you see the staff taking shortcuts which sacrifice resident safety and there were two such shortcuts taken – attempting the transfer without the lift and then not using a gait belt.  Sadly, understaffing a nursing home is a core feature of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Unsupervised resident falls and fractures hip at Lutheran Home for the Aged

Resident fractures leg in unsafe transfer at Ascension Nazarethville in Des Plaines

Addolorata Villa resident fractures hip in fall

 

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

 

Fairhaven Christian Retirement Center resident dropped from lift, breaks hip

By

IDPH has cited and fined Fairhaven Christian Retirement Center nursing home in Rockford after a resident there suffered a fractured hip when she was dropped from a lift during a transfer.

Used properly, a mechanical lift is a great tool for providing care for nursing home residents with severe mobility deficits.  They allow residents to be moved safely from bed to wheelchair, wheelchair to chair or toilet, etc.  They allow residents to be moved safely while being bathed.  They also prevent injuries from being twisted while being moved manually.  They save wear and tear on the backs, knees, shoulders, and so forth of the staff and help prevent injury to staff as well.

Of course, the key phrase in that first sentence of the paragraph above is “used properly.”  When not used properly, they set the stage for serious injury to the resident.  Proper use includes having two staff members operate the lift (see here, here, here, here, and here for examples of what happens when one person does a two-person job); it includes safe operation of the lift itself (see here and here for examples of what happens when the lift isn’t used properly); and it includes making sure that the lift itself is in good condition and that all of the slings and accessories are in good condition and appropriate for use (see here, here, and here for examples for when that is not true).

This incident shows what happens when you have one person doing a two-person job.

The resident at issue had significant cognitive and mobility impairments such that she required assistance of two staff members with transfers.  Further, the resident care plan called for the use of a mechanical lift with two staff assist.  Having the care plan call for two staff members to participate in transferring the resident with a lift is consistent with prevailing safety practices in the long term care industry, as safe operation of a lift requires one staff member to operate the controls of the lift while the other staff member keeps the resident safe and properly positioned in the sling.

On the morning of this nursing home fall, an aide was walking down the hallway when she heard a loud noise come from the resident’s room.  She entered the room to find the resident on the floor lying on the top of the legs of the lift with blood coming from her head.  The only other person in the room was another aide.  The aide explained that she was transferring the resident from her wheelchair to bed by herself.  While the transfer was in progress, the resident rolled to the right and fell from the sling.  Because there was only a single staff member involved in the transfer, there was no one who was able to help keep the resident in the sling.

The resident was transferred to the hospital where she was diagnosed with a fractured hip.  Surgical repair was attempted, but the fracture was complicated and proved to be nonrepairable.  The resident was returned to the nursing home for comfort measures, including pain management.

This is another example of the disaster that results when one person attempts to do a two-person job.  Not only was this a violation of the resident care plan, there were also facility policies in place which required the use of two staff for transfers with a mechanical lift.  And the nursing home not only had a policy in place, but also provided the staff with radios to call for help with transfers.  The aide involved clearly knew that this was not something she should be doing, as she told the first person to enter the room, “I always ask for help.”  Sadly she didn’t do so this time, and the resident paid the price.

When you have staff taking shortcuts in the care of residents, this raises the question as to whether this is an understaffed nursing home.  Unfortunately, understaffing a nursing home is a feature of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Staff at Bella Terra Schaumburg knowingly uses broken lift, resulting in brain bleed for resident

Waverly Place of Stockton resident breaks hip in unsafe transfer

Resident left unattended in dining room at Ascension Saint Anne Place suffers fractured hip in fall

 

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

Use of improper lift at Sunset Home leads to intensive care unit admission

By

IDPH has cited and fined Sunset Home nursing home in Quincy after a resident there had to be admitted to the intensive care unit at the hospital due to internal bleeding caused by the use of an improper lift by staff.

There were three key variables in this incident: use of blood thinner medication, a mechanical lift, and violation of the resident care plan.

Blood thinner medications are one of the useful tools in maintaining the health and well-being of nursing home residents.  They can be used to help prevent blood clots, strokes, and a host of other circulatory problems.  However, one of the risks associated with their use is that of uncontrolled internal bleeding which is a reason why residents are customarily placed on a 72-hour fall watch after experiencing a nursing home fall.

Mechanical lifts are also great tools in a nursing home setting when used properly.  They allow residents who have mobility deficits to be transferred from bed to wheelchair, wheelchair to chair, etc. with greatly reduced risk of injury to both the resident and staff.  They phrase, though, is “used properly.”  This includes using an appropriate type of lift and properly sized, well-maintained, suitable accessories for the  lift.

The resident care plan is the tool by which much of the routine care in a nursing home setting is delivered. The care planning process has six steps: (1) a resident assessment where the risks to the health and well-being of the resident are identified, (2) the development of  a care plan which identifies steps or interventions to be taken to address the risks to the resident and assigns various staff to carry out those steps, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) evaluation of the effective of the care plan on an ongoing basis, and (6) revision of the care plan if the resident’s needs change or if the care plan proves to be in ineffective in practice.

When a resident uses a mechanical lift, this is covered by the resident care plan.  It will specify the reasons why the resident needs the use of a lift, what kind of lift should be used, and how many staff members should be involved in transfers with the lift.  (Hint: it should always be two, because having one staff member try to transfer a resident with a mechanical lift is a formula for disaster – see here, here, here, here, and here for examples).

The resident at issue had a medical history which included atrial fibrillation.  This is an irregular heart beat which causes the formation of blood clots in the heart which can lead to stroke or heart failure.  It is one of the conditions for which a blood thinner is commonly prescribed, and in this case the resident was receiving Elliquis (a blood thinner medication).  The resident was also morbidly obese and had significant strength and mobility deficits.  The resident also had a documented inability to stand for long.  The resident used a full mechanical lift, but a sit-to-stand lift would be used for toileting.

There are differences between a full mechanical lift and a sit-to-stand lift.  With a full mechanical lift, the resident has a sling placed underneath them and their whole body is lifted using the lift.  With a sit-to-stand lift, the resident’s feet are placed on a plate at the base of the lift, the resident’s shins are placed against a support pad, and a sling is placed under the resident’s armpits and around their chest and the device lifts them up into a standing position.  One of the key differences between the two kinds of lifts is that with a sit-to-stand lift, the resident must be able to bear some weight in a standing position, whereas the full mechanical lift requires no physical input from the resident.

On the morning of this incident, two aides went to get the resident out of bed and dressed for the day.  Normally this would have been done using the full mechanical lift, but there were no lift slings available for the full mechanical lift.  The aides instead elected to use a sit-to stand lift while trying to get the resident dressed.  The sling that they used was a regular sized sling, rather than a larger sling which this resident needed.  While the aides had the resident in a standing position while trying to get on his pants, the resident was unable to maintain himself in a standing position and his legs gave out.  The aides lowered the resident to the floor.

Over the next three days, large, hard, dark bruises appeared under the resident’s armpits and he began to complain of pain especially when the bruised areas were touched.  When the bruising began to extend into the back, the resident was transferred to the hospital.  At the hospital, the resident was determined to be anemic from acute blood loss to the point that a blood transfusion was required.  A CT scan of the chest multiple large hematomas of the left side of the chest.  The resident was transferred to the ICU and remained hospitalized as of the time that the state surveyors arrived at the nursing home, some 9 days after the resident was sent to the hospital.

The issue in the care that this resident received is that the aides attempted to use the sit-to-stand lift for a purpose which was not suitable for this resident.  The resident was not able to maintain a standing position for a long period of time, yet they elected to use the sit-to-stand lift to attempt to dress him.  The key difference between the two kinds of lift is that the sit-to-stand lift does require some physical input from the resident – which this resident was not able to provide.

Compounding the poor decision to use an unsuitable lift, the lift sling (the strap that goes under the armpits) was regular size rather than the large one this resident needed.  This likely resulted in there being additional trauma to the resident when the resident’s legs gave out.

These decisions, together with the resident’s use of a blood thinner, caused the serious injuries that this resident suffered.

When you see staff taking shortcuts in the care of residents, this is a mark of a nursing home which is probably short-staffed.  Rather than find a sling to use with the full mechanical lift for the resident, they used the sit-to-stand lift.  Rather than ask a nurse whether this would be okay, they went ahead anyway.  Rather than find a large sling for the sit-to-stand, they used a regular sized sling.  These decisions are examples of poor care -and they would have likely avoided serious consequences had this resident not been on a blood thinner.  Of course, there could have been other issues that resulted from this – and avoiding those would have been a matter of good luck, not good care.

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

Other blog posts of interest:

Mishandling of resident results in broken shoulder at Havana Health Care Center

Mason City Area Nursing Home resident suffers fatal brain bleed in fall

Sling breaks during transfer at University Nursing & Rehab

 

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

 

Violation of care plan and orders leads to broken leg at Meadowbrook Manor in Bolingbrook

By

IDPH has cited and fined Meadowbrook Manor nursing home in Bolingbrook after a resident there suffered a broken leg while being transferred to bed manually by a CNA rather than with a lift as called for by the resident care plan and by the orders from her doctor.

In a nursing home, the Minimum Data Set (MDS) is a tool which assesses the overall function of the resident and the care needs of the resident.  One of its uses is that it forms part of the basis by which the nursing home is paid for services so it must be completed under penalties of perjury when it is submitted to the federal government.  For this resident, her MDS stated that she was cognitively intact but that she needed extensive assist of two staff with all activities involving transfers, likely due to a history of past strokes.  The resident care plan was reflective of this in that it called for assist of two using a mechanical lift for transfers, as did the orders from her physician.

On the night of this nursing home fall, the resident was being transferred to bed by a single aide from an agency, rather than being transferred to bed with a lift being operated by two aides.  During the transfer, the resident tripped and the aide fell on top her.  The aide got the resident into bed and then reported to the nurse on duty that the resident had lower extremity pain after being transferred to bed using a mechanical lift with the assistance of another aide from that same agency.  However, when that second aide was questioned about the incident she denied having transferred any resident with a lift, denied having been asked to help with a transfer by the first aide, and stated that she worked on a different hallway that evening.

Following the incident, the resident remained in bed for three days before being sent to the hospital due to discoloration of her lower leg.  There, an x-ray showed an acute comminuted fracture of the proximal tibia (a new fracture of the shin bone closer to the knee with the fracture having many fragments).  Her physician told the state surveyor that it was a recent fracture and was the kind of fracture that was caused by an impact and did not just happen spontaneously.

During the hospitalization, the resident experienced a hypotensive event (a drop in blood pressure) which in turn led to increased confusion due to encephalopathy.  Her family elected against aggressive treatment and she returned to the nursing home to be placed on hospice.

The obvious cause of this fall was the failure of the aide to follow the care plan and the physician orders to transfer the resident with two staff members using a mechanical lift rather than transferring her manually by himself.  A likely deeper cause would be the use of agency staff and the failure to adequately train them and orient them to the care needs of the residents.  And while the staffing agency and the nursing home are directly responsible for this fall and injury, the management choices made at the nursing home are a likely culprit as well.

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:

Promedica Skilled Homewood resident falls and breaks hip

Park Place Christian Community resident rolled from bed by staff

Westmont Manor resident suffers brain bleed after being rolled from bed

 

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

 

 

Fondulac Rehab resident chokes to death

By

IDPH has cited and fined Fondulac Rehabilitation & Healthcare Center nursing home in East Peoria after a resident there was fed the wrong kind of diet and left unsupervised during dinner.

One of the lesser known risks to the health and well-being of nursing home residents is the risk of choking while eating.  There are a variety of reasons that a resident may be at risk for choking including advanced dementia, behavioral issues that lead the resident to cram food in their mouths, or neuromuscular issues which impair the swallowing process.  Most often, these are diagnosed following an assessment by a speech therapist.  They are then addressed through the care planning process and physician orders which call for supervision while eating and therapeutic diets which which are intended to reduce the risk of choking.

The resident involved was initially admitted to the nursing home with orders for a general diet.  However, after a hospital visit, she was readmitted to the nursing home with transfer orders for a therapeutic diet consisting of a mechanical soft diet with nectar thick liquids.  Her care plan called for assistance of one while eating due to poor safety awareness, cognitive deficits, forgetfulness, and poor mobility.  The care plan did not include the therapeutic diet.  Further, the her diet orders did not include the therapeutic diet, so she continued to be fed a general diet.

On the night of this fatal nursing home choking accident, the general diet being fed to residents consisted of Salisbury Steak and other items.  Due to covid precautions, all of the residents were being fed in their rooms, rather than in the dining room.  The aide assigned to the resident brought the tray to the room, cut up her food, fed her a bite, and then went to deliver meal trays to other residents.  As the aide came back up the hallway, she saw that the resident was blue.  She got a nurse, and they pulled the resident from bed and began CPR.  911 was called and paramedics took over the resuscitation efforts, but those efforts were unsuccessful and the resident was pronounced deceased.

An autopsy was performed, and the cause of death listed on the death certificate was aspiration of food.

There are at least four issues with the care that this resident received:

  1.  Continuity of care – We have written several times about how critical it is for the well-being of residents that the transfer orders that were in place for the resident upon discharge from the hospital be carried forward into the nursing home (see here, here, here, and here for examples).  Nursing homes are businesses, and well-run businesses have systems in place to make sure that the routine and necessary operations of their business are carried out.  Ensuring continuity of care is one of those operations, and this was not done here as the order for the therapeutic, mechanical soft diet was not implemented.  As a result, the resident was fed the Salisbury Steak that she choked on.
  2. Failure to implement care plan – This resident’s care plan called for assistance of one with eating.  After the tray was served to her she was left unattended and unsupervised.  While she was alone, she choked.  The whole point of incorporating the supervision while eating was to prevent just this kind of accident.
  3. Understaffing of the nursing home – All of the residents in the facility were eating in their rooms as a covid precaution, and aides were forthright with the state surveyor that they simply did not have enough people on hand to supervise all of the residents who needed help eating while they were all being served with in their rooms.  Federal regulations require that nursing homes have enough staff on hand to meet the care needs of the residents 24/7.  As a one aide put it, “We do not have enough staff to accommodate all those people that are being quarantined in tehri rooms that need assistance while eating.  We normally only have about one or two people available to watch over the residents that need supervision with eating.  None of the nurses or management staff help us, and it would be nice if they did.”
  4. Quarantine – The policy in place at the time was that is there was a positive case in the building (which there was), then all of the residents were quarantined, regardless of covid positive status.  Not only is that sort of isolation harmful to residents, but in the case of residents who require supervision, it makes it difficult to impossible to provide the necessary supervision.  Had the resident involved been allowed to eat in the dining room, she likely would have been seated at a feeder table where she would be fed under the direct supervision of staff, and this fatal accident would have been avoided.

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

Other blog posts of interest:

Aperion of Spring Valley resident chokes to death

Fatal choking accident at River Bluff nursing home

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

Sunset Rehab resident chokes to death

 

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

Sharon Heath Care Elms resident develops bone-deep bed sore

By

IDPH has cited Sharon Health Care Elms nursing home in Peoria after a resident there developed a Stage 4 bed sore on her ankle due to the failure of the staff to apply protective boots as called for in the resident care plan.

There are a number of factors which predispose nursing home residents to developing bed sores, also known as pressure ulcers.  Chief among these is immobility.  Lack of movement over a prolonged period of time creates pressure on the small blood vessels which supply the skin.  This pressure is produced by the squeezing of the skin in between the bony prominences and the resting surface, usually a bed, chair, or wheelchair.  One of the chief strategies for preventing the onset of bed sores is the relief of pressure through frequent turning and repositioning through the use of pressure-relieving or other protective devices.

Bed sores are a significant issue in the long-term care industry and are a specific focus in the care planning process.  During the care planning process, the risks to the health and well-being of the resident are identified, and a series of specific steps, or interventions, are developed to address those risks and then assigned to various members of the staff to carry those out on a day-to-day, shift-to-shift basis.

The resident at issue has severe cognitive impairments and quadriplegia with spasticity.  She was bedbound and her lower legs were contracted due to inactivity.  One of the complications that results from a nursing home resident developing contractures is that the legs lay on the bed differently than they might otherwise, exposing different portions of the legs to pressure than might be the case if the resident was laying flat in bed. In this case, the way that the resident’s legs lay on the bed resulted in her inner ankle resting on the bed.

To address the risk of the resident developing pressure ulcers to the ankle, there was a physician order in place for use of protective boots.  Use of these boots was incorporated into the resident pressure ulcer prevention care plan.  Between the order and the care plan, it was incumbent on the staff to make sure that the protective boots were used with regard to this resident.  However, the facility wound care nurse told the state surveyor that these were used for the resident until after the bed sore on her ankle developed.

Due to the failure of the staff to use the protective boots, the skin on the resident’s inner ankle was exposed to pressure (from her unusual lying position) and friction (associated with her spasticity), all of which led to the development of a Stage 4 bed sore on the resident’s ankle.  A wound care physician had to be brought into the nursing home to treat the resident, including doing a surgical debridement of the wound.  This was the exact scenario that the care plan and the physician order were intended to prevent.

When interviewed by the state surveyor, the Director of Nursing admitted that there was a problem with residents developing bed sores in the facility.  She further admitted that the skin assessments were being done only weekly by a wound care nurse and that rather than doing doing daily skin assessments, the floor nurses had been instructed to give the resident’s skin “a good look.”  When pressed as to why this resident did not have the protective boots on, she also admitted that there were issues getting the staff to implement physician orders or care plans intended to prevent the development of pressure ulcers. The fact that this is occurring at scale in this nursing home is a massive failure of the care that the residents at this facility are entitled to.

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

Other blog posts of interest:

Sharon Health Care Willows resident undergoes surgery for bed sore

Resident suffers pressure ulcers to both knees at Royal Oak Care Center

Resident develops pressure ulcers at Eastside Health & Rehab

 

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

 

 

 

 

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

By

IDPH has cited and fined Piatt County Nursing Home after a resident there fell and suffered a fractured hip due to the failure of the staff to comply with the resident care plan which called for the use of a bed alarm and a chair alarm.

The care planning process is how much of the basic care is provided to nursing home residents on a day-to-day basis.  There are six steps in the care planning process: (1) a resident assessment where the risks to the health and well-being of the resident are identified, (2) the development of  a care plan which identifies steps or interventions to be taken to address the risks to the resident and assigns various staff to carry out those steps, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) evaluation of the effective of the care plan on an ongoing basis, and (6) revision of the care plan if the resident’s needs change or if the care plan proves to be in ineffective in practice.

The resident involved was properly assessed as being at risk for falls.  She had a number of fall risk factors.  One of these was a history of falls, as it is well-recognized in the long-term care industry that falls tend to beget additional falls.  Another risk factor was an impaired gait.  Finally, the resident suffered from cognitive impairments which caused her to overestimate or forget limits.  This means that she could not be counted on to follow instructions or make good decisions for her own safety.

A fall prevention care plan was put into place to address the resident’s risk of injury due to falls.  Among the steps that were put into place was the use of a bed alarm and a chair alarm.  These are devices which are designed to sound an alarm when the resident attempts to get out of bed or their chair or wheelchair.  The sounding of the alarm serves two purposes: it alerts the staff that the resident is getting up and it reminds the resident that they should be waiting for help.  The requirement for use a bed alarm or chair alarm was backed by a physician order for the staff to check that the alarm was in place and functioning.

On the day of this nursing home fall, the resident involved was suffering from a urinary tract infection.  For senior citizens, urinary tract infections are well-known to cause increased confusion, and indeed earlier on the day of the fall, the resident had been noted to have increased episodes of confusion.  To address the resident’s increased confusion, the resident was placed in her wheelchair and brought out into the hallway where she could more easily be monitored by staff.  However, when she was moved to the hallway, the chair alarm was not taken from her room chair and placed on her wheelchair, so there was no alarm in place.

The aide who discovered the fall exited another resident’s room and saw the resident standing in front of her wheelchair.  She was unsteady and fell to  the floor.  She was diagnosed with a fractured hip.

During interviews with the staff by the state surveyor, the aide acknowledged that the chair alarm should have been placed on the wheelchair when the resident was moved to the hallway, but that she did not know this was supposed to be done.  This is a breakdown in the communications portion of the care planning process – there was a reasonable care plan in place (backed by a physician order to boot), but the staff charged with carrying it out did not know what was supposed to be done.  All staff acknowledged that the use of the alarm would have alerted them that the resident was getting up and would have given them an opportunity to try to prevent the fall.

Beyond that, the whole purpose of bringing the resident out in the hallway was to keep her under direct observation.  This was a reasonable thing to do given that increased confusion should have been anticipated and was in fact observed due to the urinary tract infection.  The problem with this is that this was not assigned to anyone in particular, and she was left unattended in the hallway.  This gives proof to the adage in business, “When it’s everyone’s job, it’s no one’s job.”  Since it was no one’s job, the plan to keep her under direct observation (a good plan) was not executed, with the fall and broken hip a result.

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:

Lutheran Home resident dropped from lift during transfer, breaks hip

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

Westminster Village resident suffers multiple fractures in fall

Piatt County Nursing Home resident breaks hip in fall

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

 

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

 

 

 

Swansea Rehab resident fractures hip in fall

By

IDPH has cited and fined Swansea Rehabilitation & Health Care Center nursing home after a resident there suffered a fractured hip in a fall after she was left unattended while going to the bathroom.

The resident at issue was recognized as being at risk for falls.  She suffered from cognitive impairments, was not steady on her feet and only able to stabilize with staff assistance while walking.  This combination of physical and cognitive impairments is a leading indicator of fall risk because they are not able to walk safely, but at the same time cannot be counted on to follow instructions or make good decisions for their own safety.

Due to her fall risk, a fall prevention care plan was put into place.  The fall prevention measures included one person assist with use of a gait belt for all ambulation.

On the day of this nursing home fall, the resident was brought to the bathroom by an aide to use the toilet before dinner.  While the resident was using the toilet, the aide left the resident to get a washcloth.  When she returned, she found the resident in a seated position on the floor of her room.  The aide admitted to the state surveyor that she knew that she should not have left the resident alone on the toilet.  She also admitted to the state surveyor that she told the nurse on duty that she was in the room when the resident fell when actually was not because she did not want to get into trouble.

The aide reported the fall to the nurse who in turn notified the resident’s physician.  The doctor ordered x-rays which showed that there was an acute fracture of the hip.  The resident was then sent to the hospital for further care.

The cause of this fall and injury to the resident is readily apparent – the aide admitted that the resident should not have been left unattended while on toilet, but she was.  The aide told the surveyor that she thought she would be gone for 30 seconds, but it was clearly longer than that, given that the resident finished going to the bathroom, got up from the toilet, and walked into her room where the fall occurred.  More troubling than this is the fact that the aide lied to the nurse about what happened, which raises questions as to exactly what was really being done to care for this resident.

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

Other blog posts of interest:

Resident rolled from bed, breaks leg at Stonebridge Nursing & Rehab in Benton

Resident dies from brain bleed after fall at Elmwood Nursing & Rehab in Maryville

Aperion Care St. Elmo breaks hip in fall

Mar-Ka Nursing Home resident breaks both legs in fall

 

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

 

Heritage – Mt. Sterling resident breaks leg in fall

By

IDPH has cited and fined Heritage of Mt. Sterling nursing home after a resident there suffered a broken leg in a fall which occurred due to the failure to use a gait belt while providing care and failing to provide care with two qualified staff members as required.

One useful tool in  the care of nursing home residents is the Minimum Data Set (MDS).  The MDS serves as repository of data regarding the abilities and care needs of nursing home residents.  One unusual feature of the MDS is that the data contained on it is certified to the federal government as being accurate, as it forms part of the basis by which nursing homes are reimbursed for the care that they provide to residents.

This resident’s MDS included findings that she required extensive physical assistance of two staff with dressing, bed mobility, and transfers.  During the care planning process, the resident was assessed as a fall risk due to a history of falls, poor cognition, and overestimating or forgetting her limitations.  Her medical history also included a diagnosis of muscle weakness.  The care plan called for two staff to assist with all transfers.

The nursing home also had standing policies which the staff was to follow in the care of residents.  One of those was a policy regarding the use of gait belts.  A gait belt is a woven strap that is applies around the midsection of residents while residents are receiving assistance with transfers or walking.  It allows the staff member to better control the balance of the resident and either stop or slow down the rate of falls when the resident loses their balance.

On the day of this nursing home fall, the resident was seated on the edge of the bed while being dressed by an aide.  There was no gait belt applied.  The resident moved toward the edge of the bed to stand to transfer her from the bed to her wheelchair, but the resident’s legs gave out from underneath her, and she fell to the ground.

At the time of the fall, there was a second staff member called a unit assistant.  However, that person was not trained to provide direct patient care to residents and was two feet away when the fall occurred.   The administrator and director of nursing both told the state surveyor that a unit assistant did not qualify as a second staff person when the resident required the assistance of two staff with dressing and transfers.

The resident had immediate pain by the knee and was sent to the hospital where she was diagnosed as having a displaced periprosthetic fracture of the distal femur – meaning that there was a fracture of the thigh bone near the resident’s artificial knee where the two sides of the fracture were no longer in alignment.  The team at the hospital elected against surgery, and the resident was placed in an immobilizer.

This injury will likely have significant impacts on the well-being of this resident, as her period of immobility will likely result in her no longer having even the limited ability to bear weight on the lower extremities.  This in turn can set the stage for issues like the onset of pneumonia or the development of bed sores.

There are two obvious causes of this resident’s injury.  One is the failure to use the gait belt as required by the facility’s own internal policies.  The second is the failure to have two qualified staff people participating in the transfer as called for in the resident care plan – seeing as the unit assistant was not qualified to participate in helping with the transfer.

There is a deeper level to this, and it likely is that the nursing home was understaffed.  When you see shortcuts being taken in the resident care such as not applying a gait belt or there not being two staff available when needed, these are signs of an understaffed nursing home.  Sadly, understaffing is a part of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Mason City Area Nursing Home suffers fatal brain bleed in fall

Fondulac Rehab resident suffers fatal injuries in fall

Monmouth Nursing Home resident sustains multiple falls leading to brain bleed

 

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

 

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

By

IDPH has cited and fined Charleston Rehabilitation & Health Care Center nursing home after a resident there suffered a brain bleed and a fractured hip in a fall from bed.

There are two basic means by what care the resident is to receive in a nursing home is determined.  First, the are physician orders.  If there is an order in place, it is the obligation of the nursing staff to execute those orders.  The second is through the care planning process.  In the care planning process, the nursing staff makes an assessment of the risks to the health and well-being of residents.  Based on that assessment, a series of steps, or interventions, or assigned to various members of the care team to be carried out on a day-to-day, shift-to-shift basis.

The resident at issue here suffered from significant cognitive impairments and his Minimum Data Set (MDS) showed that he needed extensive assist with bed mobility, which includes changing and maintaining position within bed.  He was apparently also a restless sleeper as there were physician orders in place for the use of side rails and the care plan called for placement of a body pillow on the edge of the bed as a reminder, with other pillows to be used when the body pillow was not available.

Before the day of this nursing home fall, the resident had side rails as ordered on his bed.  However, he contracted covid and had to be moved to another room.  When he returned, the side rails had been removed from his bed and were not re-installed.  On the day of the fall, the staff heard a loud crashing sound from the resident’s room.  The entered the room to find the resident laying face up next to the bed.  There was no body pillow is use.

The resident was brought to the hospital where he was diagnosed as having suffered a brain bleed and a fractured right hip.

There were good fall prevention measures in place for this resident: (1) the physician-ordered side rails and (2) the use of the body pillow as incorporated into the care plan.  Sadly, neither of these measures were being carried out, and as a result, the resident suffered a very preventable fall with serious injuries resulting.

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:

Unsupervised resident at Odd Fellow Rebekah Home has fall, suffers brain bleed

Aperion Care St. Elmo resident breaks hip in fall

Piatt County Nursing Home resident suffers fractured hip in fall

Moweaqua Rehab resident fractures hip in fall

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

 

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

Inverness Health & Rehab resident suffers multiple fractures in fall

By

IDPH has cited and fined Inverness Health & Rehabilitation nursing home after a resident there suffered multiple fractures in a fall due to violations of the resident care plan.

The resident care plan is one of the building blocks by which much of the routine care a resident in a nursing home requires is provided.  Once a care plan is put into place, it falls the to the staff charged with carrying out the various steps in the care plan to actually implement the care plan on a day-to-day, shift-to-shift basis.

For the resident at issue, her Minimum Data Set (MDS) showed that she required the extensive assistance of two staff members with all transfers.   This means that the resident required the hands-on help from two people to move from bed to wheelchair, wheelchair to chair or toilet, and so forth.  The data in the MDS is certified under penalties of perjury to the federal government and the care needs shown on the MDS should be reflected in the resident care plan.

On the day of this nursing home fall, the resident was being transferred to the toilet by a single aide, not two staff members as called for by the resident care plan.  Having one person do a two-person job is a formula for disaster, as we have written about many times on this blog  (see here, here, here, here, and here for examples).  In attempting to complete the transfer, the resident fell to the floor.  As a result of the fall, the resident suffered fractures to the kneecap and to the tibia and fibula (the long bones of the lower leg) – but these injuries would not be discovered or treated for over a day.

When an aide is involved in a resident fall, it must be reported to the nurse so that the nurse can do an assessment on the resident.  It then falls to the nurse to report the fall to the resident’s  family and the resident’s doctor so that he can make orders about further care for the resident.

However, after this fall the aide simply helped the resident from the floor before reporting the fall to the nurse, exposing the resident to risk of injury from being moved when it was not safe to do so.  Further the failure to report the nurse delayed the onset of care because nothing was done about the injuries until the following morning when the resident refused to get out of bed due to the pain she was experiencing.

The nursing staff then called the physician and the doctor’s physician’s assistant ordered STAT x-rays.  The portable x-ray company advised that it could not make it the facility in a timely way, so the staff called the PA back and were advised to send the resident to the hospital.  However, that did not actually happen for nearly 9.5 hours.  Most nursing home staff members would agree that subjecting a resident to unnecessary pain is a form of nursing home abuse.

The immediate cause of the injuries to this resident was a violation of the resident care plan.  The deeper question is why this occurred the way that it did.  It likely relates to understaffing of the nursing home and the training of the staff.  Having staff take dangerous shortcuts in the care of the resident (such as attempting a transfer with one when two are required) is a sign of an understaffed nursing home.  Failing to invest in training of the staff so that the staff knows to follow the care plan and report falls when they occur is also something that reflects the choices that management makes regarding the nursing home.  Sadly, understaffing the nursing home and failing to invest in the staff is consistent with the core features of the nursing home business model.

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

Other blog posts of interest:

Violation of care plan at Generations Oakton Pavillion leads to fall and fracture

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

Grove of St. Charles resident suffers fractured hip after being rolled out of bed by staff

Glenview Terrace resident suffers multiple fractures after lift topples over during transfer

Assisi at Clare Oaks resident suffers broken neck in fall from wheelchair

 

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

 

Sharon Health Care Elms resident suffers brain bleed in fall while on smoking patio

By

IDPH has cited and fined Sharon Health Care Elms nursing home in Peoria after a resident there suffered a brain bleed and a compression fracture of a vertebra in her neck after a fall that occurred while she was left unsupervised on the smoking patio.

People unfamiliar with nursing homes are sometimes surprised that nursing home residents are permitted to smoke.  Even though nursing homes are health care institutions, they are also truly the homes of the people who live there, so people are permitted to smoke.  Due to restrictions on indoor smoking, smoking must be done outdoors, usually on a deck or patio which has been designated as a smoking area.

However, beyond just the well-known negative health effects of smoking, there are additional risks associated with smoking for nursing home residents.  This principally includes the risks of fires or getting burned, mainly due to careless handling of smoking materials by residents suffering from confusion or dementia or due to movement disorders such as Parkinson’s or due to smoke near compressed oxygen equipment.

A lesser known, but still present risk is a risk of falls.  This is primarily associated with residents not paying attention to what they are doing due to anxiety or distraction associated with the desire to smoke.

Whatever risks are present associated with residents who smoke, this should be addressed through the resident care plan.  Once a care plan is put into place it must be carried out on a day-to-day, shift-to-shift basis.  One of the principal forms of addressing risk associated with smoking is by supervision of residents on the smoking patio.  To facilitate this, many nursing homes set certain hours during which the smoking deck is open for use.

The resident at issue here was assessed as being a fall risk, in part because of diminished safety awareness and apparent significant visual deficits (per the citation, she told a fellow resident that she was going blind) which affected her ability to see and perceive things around her.  Before the fall at issue, over the last year or so, she had four nursing home falls, all on the smoking patio.  Her care plan included being supervised on the smoking patio as a fall prevention measure.

The resident fell at approximately 6:30 a.m. while on the smoking patio.  She was on the patio unsupervised, having followed another resident who would sometimes give her cigarettes out onto the patio.  There was no staff present.  While she was out of the smoking deck, she tripped over a decorative landscaping and hit her head.  There was immediate bleeding, including from the nose, so the other residents went into the facility and altered the nursing staff.  When the nursing staff was unable to stop the nosebleed, they sent her to the hospital.  There scans showed that she had a brain bleed and a fracture in her cervical spine.  She was transferred to another hospital for advanced care.

This fall was a result of the resident not being supervised on the smoking patio.  The lesson that should have been drawn from the prior falls is that her visual deficits and distraction while on the smoking patio left her particularly susceptible to falls.  The resident care plan called for it, but there was a clear violation of the resident care plan.

Part of the reason that she was not supervised on the smoking patio is that even though there were supposed to be a set of scheduled hours when the patio was permitted to be used, there was no consensus as to when those hours were, not apparently, on who was supposed to be supervising residents on the patio.

The deeper question is of course why there was no supervision, and the root answer to that question is likely understaffing of the nursing home.  More than one of the residents interviewed by IDPH told the surveyor that there was not enough staff on hand to provide regular care to the residents, let alone supervise them when they are smoking.  Unfortunately, understaffing of nursing homes is a featured component of the nursing home business model.

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

Other blog posts of interest:

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

Pekin Manor resident suffers brain bleed in fall

Christian Nursing Home resident suffers severe leg injury in fall

Fondulac Rehab resident catches fire in smoking accident

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

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

 

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

 

 

Feeding tube error at Aperion of Westchester

By

IDPH has cited and fined Aperion Care of Westchester nursing home after a resident there developed pneumonia due to improper care while being fed through a feeding tube.

At a minimum pneumonia is a serous illness for senior citizens and other medically fragile individuals, and can prove fatal in some cases.  One of the common causes of pneumonia in a nursing home setting is aspiration of foreign substances into the lungs.  This can occur when things like food, saliva, or digestive tract contents are inhaled.

Aspiration pneumonia is one of the recognized risks of tube feeding.  Essentially, the risk is that the feeding solution will make its way up into the respiratory tract before being digested.  To help combat this risk, the person receiving the tube feeding should be kept with the the head of the bed elevated to at least 30 degrees while the tube feeding is underway and then for another 30-60 minutes after the tube feeding is completed.  Here, the resident’s care plan included those precautions.

On the day of the incident, the nurse completed giving the resident their feeding via the feeding tube and flushed the tube.  She left the room with the head of the resident’s bed elevated at 30 degrees.  Approximately an hour later, the nurse was summoned to the room by an aide who was not assigned to the resident but happened to be going down the hallway and could tell that the resident needed assistance.

When the nurse arrived in the room, she found the resident laying flat in her bed.  There were yellowish secretions consistent with the feeding tube solution coming from the resident’s mouth.  The resident was in apparent distress with elevated heart and respiratory rates, but her oxygen saturations having dropped to 78.

The paramedics were called.  They found the resident in severe visual, respiratory distress with foreign matter coming from the mouth.  The paramedics reported that they were told by the staff that the resident had been receiving her g-tube feeding while laying flat.  The resident was brought to the hospital to receive care for severe respiratory distress.

The investigation into the incident by IDPH did not reveal how the head of the bed ended up in a flat position, although the statements made by the staff to the paramedics suggest that it was in a low position throughout.  At a minimum the condition of the resident was such that it could not have been lowered by her, so someone else did this.  This amounts to a violation of the care plan and is evidence of poor training of the staff seeing as this is a fundamental when it comes to providing care to residents with feeding tubes.

Sadly, training the staff properly requires making investments in the staff.   The choice to not invest in the training of the staff is unfortunately a part of the nursing home business model.

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

Other blog posts of interest:

Feeding tube error puts Burgess Square resident into heart failure

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

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

 

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

 

Failure to supervise Westmont Manor resident leads to fall and broken hip

By

IDPH has cited and fined Westmont Manor & Rehabilitation nursing home after a resident who was a known fall risk there was left unsupervised at the nurse’s station, and a result fell and suffered a fractured hip which required surgery.

When a resident is considered a fall risk, developing and implementing a fall prevention care plan is required.  One of the mainstays of a good fall prevention care plan is keeping residents who are at risk for falls in an area where they can be easily supervised by staff.  In fact federal regulations require that residents receive supervision and assistance necessary to prevent accidents, and falls are definitely accidents.  In practice, this means that residents who are at risk for falls are placed in areas like the dining room, the activities area, or by the nurse’s station so that staff can keep them under direct observation.  This of course requires staff to actually be present in those areas.

The resident at issue was a known fall risk, and in fact before the fall at issue, had three prior falls.  One of the truisms about nursing home falls is that the occurrence of a fall is a predictor for additional falls and is a factor considered in almost all high-quality fall risk assessment tools.  Other crucial factors include some type of musculoskeletal or gait dysfunction and some form of cognitive impairment such as confusion, dementia, or poor safety awareness of judgment.  The reason that cognitive impairments feed into fall risk is that the residents cannot be counted on to make good judgments for their own safety or follow instructions from the staff intended to minimize fall risk.

This resident was wheelchair bound and required the extensive assistance of two staff with transfers and suffered from dementia.  She also had poor trunk control and had a history of stroke.  With the history of multiple falls and her physical and cognitive impairments, she was properly assessed as being a fall risk, and a fall prevention care plan was put into place.  One of the steps in that fall prevention care plan was to  keep her in an area where she could be supervised while up.

On the day of this nursing home fall, the resident was brought to the nurse’s station in her wheelchair.  The nurse was due for his break, so he went into the dining room – just a short distance from the nurse’s station.  While he was on break, an aide was assigned to monitor the residents at the nurse’s station.  However it was also the time for shift change for the CNA’s, so the aide was down at the other end of the hallway getting ready to end her shift.  As a result no one was monitoring the residents at the nurse’s station.

While he was sitting in the dining room on break, the nurse heard a thud.  He went to the nurse’s station and found the resident on the floor.  He went and got the aide who was getting ready to leave and returned to the resident.  He assessed the resident and then got her off the floor.  The resident had a bump on the forehead and was complaining of pain in the left hip, so the resident was sent out to the hospital.

At the hospital, scans showed that the resident had a femoral fracture extending into the intertrochanteric space – in lay terms, a fractured hip.  She underwent surgery with the placement of nails to repair the fracture.

This fall was the direct result of a violation of the resident care plan.  The whole point of having the resident in a location where she could be monitored is so that someone would be watching and in a position to intervene if she attempted to get up unassisted – a known behavior for this resident.  However, when the nurse assigned took his break and the aide left the nurse’s station to get ready to go home, the resident was left unsupervised.  Care plans need to be implemented on a 24/7 basis – and this is the result when they are not.

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:

Westmont Manor resident suffers brain bleed after being rolled from bed

AHVA Care of Stickney resident suffers hip fracture in fall

Alden Courts of Shorewood breaks both legs in unsafe transfer

Improper transfer leads to broken leg at Springs at Monarch Landing in Naperville

 

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

 

Failure to provide required assistance leads to fall and broken arm for Bria of Palos Hills resident

By

IDPH has cited and fined Bria of Palos Hills nursing home after a resident there fell and suffered a broken arm due to the failure of staff to provide care called for by the resident care plan.

Care planning is a process by which risks to the health and well-being are identified and measures are put into place and carried out on a day-to-day basis to prevent those risks from coming to fruition.  One of the ways that proof of nursing home abuse and neglect is proven is by showing violations of the resident care plan.  Delivery of the care called for in the care plan is fundamental to providing quality care to residents in a nursing home setting.

There are six steps to the care planning process: (1) an assessment of the risks to the health and well-being of the resident; (2) a written care plan is developed which identifies a series of steps or interventions intended to reduce the risks to the resident.; (3) communication of the care plan to the staff who are charged with carrying it out; (4) implementation of the care plan on a day-to-day, sift-to-shift basis; (5) ongoing evaluation of the effectiveness of the care plan; (6) revision of the care plan if it proves to be inadequate in practice or if the care needs of the resident change.

The resident at issue was identified as being a fall risk, and a fall prevention care plan was put into place.  Among the steps that were to be taken was extensive assist of one staff with toileting and ambulation.  “Extensive assist” generally means provided physical support with weight bearing during the activity, including the use of a gait belt.

One the day of this nursing home fall, the nurse on duty had been told that the resident was not feeling well and went to the room.  As she approached the room, she saw that the call light was on.  She looked into the room and saw that there was an aide in the room already and that the resident was standing, walking toward the bathroom.  Assuming that the aide was there to assist the resident, she left to care for other residents.

Moments later she heard the resident call out the she had fallen and returned to the room and found the resident on the floor of the bathroom.  She told the staff that she lost her footing and fell.  She was bleeding from a wound from the head and was complaining of pain to her arm.  She was brought to to the emergency room where she was diagnosed with a comminuted fracture of the surgical neck of the humerus (upper arm).

There was a care plan in place which was intended to prevent just this kind of injury.  The resident was a fall risk and the care plan called for the assistance of one staff member to prevent falls, which can be so devastating to nursing home residents.  Care plans must be communicated to the staff so that they can actually be implemented.  Here, there were two staff members – the aide who was already in the room and the nurse who looked into the room – who saw that the resident was up without assistance.  Neither helped this resident, and as a result, the fall occurred.  The failure to carry out the care plan led directly to 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:

Westmont Manor resident suffers brain bleed after being rolled from bed

Resident at Chateau Nursing Home in Willowbrook suffers spinal fractures in wheelchair accident

Manorcare of Palos Heights East suffers hip fracture in fall

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

By

IDPH has cited and fined Pleasant Meadows Senior Living nursing home in Chrisman after a resident who was a known fall risk suffered a brain bleed due to a fall caused by the failure of the staff to activate his chair alarm.

Chair alarms and bed alarms are useful tools in preventing falls.  These alarms come in two basic forms – one is a pressure sensitive strip which is placed in the chair or bed.  When the pressure on the strip is lifted, this causes an alarm to sound.  The other kind of alarm is referred to as a mobility alarm.  It has a length of cord that is affixed to the resident’s clothing (usually between the should blades to make it difficult to remove) at one end.  On the other end of the cord is a alarm box.  When the cord is pulled away from the alarm box, the alarm sounds.  The sounding of the alarm serves two functions: (1) it alerts the staff that the resident is up unattended – and they should respond immediately and (2) reminds the resident that they should not be up on their own.

Of course for the alarm to have an use as a fall prevention tool, the alarm has to be activated.  This citation tells the story of what happens when the alarm is not activated.

The resident at issue was a recognized fall risk.  His Minimum Data Set (MDS) recorded that she suffered from severe cognitive impairments, required the assistance of two staff with transfers, was not steady and was only able to stabilize with the assistance of staff, and had a history of falls with injury.  His care plan called for the use of bed and chair alarms.  The staff reported to the state surveyor after the fall at issue that the alarms were an effective fall prevention tool for this resident and that they were frequently going off.

On the day of this nursing home fall, the resident was brought to physical therapy.  When the resident was taken from the room to go to physical therapy, the resident was in his recliner, but when he was assisted from the chair, the alarm did not go off.  Upon his return to the room from physical therapy, the alarm was not activated.

Shortly after this, the resident got up from his chair and began to make his way to the hallway.  As he reached his door he lost his balance, striking his head on the door frame on the way down. 911 was called and the paramedics reported in their notes that the staff reported physical therapy had not turned on the alarm.  The resident was brought to the hospital where he was diagnosed as suffering a brain bleed and a fractured hand.

Here there was a clear violation of the resident fall prevention care plan.  The care plan called for the use of a chair alarm.  This sort of fall prevention measure is only effective if it is carried out on a day-to-day, shift-to-shift basis.  The failure of the physical therapist to ensure that it was on was a violation of the care plan, likely sparked in part by the fact that it was apparently not on when the resident was taken from his room to therapy.

There were also shortcomings in the actual care planning itself.  The staff told the state surveyor that the alarm was going off “all the time,” indicating that the resident was frequently up.  While catastrophic falls had apparently been avoided, that was a matter of luck, not good care.  Additional interventions such as keeping the resident in common areas, frequent rounding, and having a room near the nurse’s station were additional steps which could and should have been taken.

From a legal perspective, the involvement of physical therapy is an important issue because physical therapists are often not direct employees of the nursing home but are employees of an outside company which bears responsibility for the poor care of its employees.  This adds an extra layer of complexity to any nursing home abuse and neglect case.

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:

Odd Fellow-Rebekah Home resident suffers fatal brain bleed in fall

Loft of Rock Spring resident suffers hip fracture in fall

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

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

Unsupervised resident at Odd Fellow Rebekah Home has fall, suffers brain bleed

 

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

 

Grove of St. Charles resident suffers fractured hip after being rolled out of bed by staff

By

IDPH has cited and fined the Grove of St. Charles nursing home after a resident there suffered a fractured hip due to being rolled out of bed while receiving incontinence care.

The resident involved suffered from incontinence of bowel and bladder.  Her Minimum Data Set (MDS) showed that she required the assistance of two staff members with bed mobility (turning from side to side and changing and holding positions in bed) and her care plan called for the assistance of two staff members with incontinence care.

One the day of this nursing home fall, the resident was in bed on a low air loss mattress.  She was receiving peri care after an episode of incontinence.  There was a single aide who was providing the incontinence care.  As the resident’s leg was moved over across her body, the leg went over the edge of the bed and the resident followed, landing on her knees.

She was brought to the hospital where a hip fracture was diagnosed.  However, even though the nature of the fracture likely warranted it, the decision was made to not proceed with surgery because of her pre-injury lack of mobility, her risk factors, and other medical issues.  She now has to be transferred using a lift.  In the meantime, she has unstable hip which is subject to movement during transfers with the lift, while being turned and repositioned to prevent bed sores, and while receiving incontinence care.

This a tale that we have told many times about the results you get when you have one person doing a two-person job (see here, here, and here  for examples).  When two people are required to assist with bed mobility, the purpose of the second staff member (the one not providing the incontinence care) is to provide safety and help prevent the resident from falling out of bed.  This is especially necessary where the resident is on a low air loss mattress because they tend to provide less friction and resistance and make it easier for the resident to slide out of bed.

This is a simple case of a staff member violating the resident care plan and taking a short-cut in providing care to the resident.  The deeper question of course is why did she feel compelled to provide care to the resident on her own when two were required?  The answer likely lies in short-staffing of the nursing home.  Unfortunately, understaffing is a feature and 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:

Michaelsen Health Center resident rolled from bed, suffers brain bleed

Warren Barr North Shore resident rolled from bed, suffers fractured ankle

Bella Terra Streamwood resident suffers multiple fractures in fall from bed

Grove of Skokie resident breaks leg due to violation of care plan

 

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

Cedar Ridge resident breaks both legs in fall from bed

By

IDPH has cited and fine Cedar Ridge Health & Rehabilitation Center nursing home in Lebanon after a resident suffered fractures to both legs in a fall from bed.

The resident at issue had an extensive medical history which included a below the knee amputation, morbid obesity, and a host of other medical issues.  Her Minimum Data Set (MDS) reflected that she required the extensive assistance of two persons with transfers and bed mobility.  The entry of that information on the MDS is significant because the MDS is completed under oath since it forms part of the basis of payment for the nursing home.  The resident care plan also called for assist of two with bed mobility.  The resident was regularly transferred with the use of a Hoyer lift, which requires two staff for safe operation.

On the day of this nursing home fall, the resident was getting ready to be transferred from bed to her wheelchair using the Hoyer lift.  As part of the transfer process the sling of the lift had to be placed underneath the resident, requiring her to roll from side to side while the sling is positioned underneath her.

During the process of getting the sling positioned underneath her, the resident rolled to one side.  Once the sling was positioned beneath her she rolled to the other side, but rolled off the edge of the bed, landing on her knees.  She felt and heard a pop in both knees.  X-rays showed that there were fractures to both femurs which required her to be transferred to a teaching hospital for further care.

We frequently write on this blog about mishaps that occur when you have one person doing a two person job, as that is often a formula for disaster (see here, here, here, here, and here for examples).  Here it was unclear whether there was one or two staff people in the room at the time of the fall.  The resident quite clearly described there being only a single aide involved.  The aide claimed that there was agency staff in the room at the time but that the agency staff was not near the bed at the time of the fall.  Whether there was one or two staff people on the room, if only one was involved in repositioning this resident, then the resident was not receiving the level of assistance required to keep her safe – a violation of federal regulations and a violation of the resident care plan.

While the care plan violations was most clearly the cause of this resident’s fall, there is potentially a deeper level to this: the understaffing of the nursing home.  The resident related here that there would normally be only a single aide involved in getting her on to the sling for transfers even though two was required.  When there is one person doing a two person job, that raises a fair question about understaffing.  Sadly this is a feature and 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:

Use of improper lift at Sunset Home leads to admission to intensive care unit

Vandalia Rehab cited for understaffing

Sling breaks during transfer at University Nursing & Rehab

Hitz Memorial resident dropped from lift

Resident dies from brain bleed after fall at Elmwood Rehab in Maryville

 

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

 

University Rehab Northmoor resident suffers fractured hip in fall from bed

By

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

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

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

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

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

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

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

Other blog posts of interest:

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

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

Fondulac Rehab resident suffers fatal injuries in fall

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

Aperion Spring Valley resident suffers fatal brain bleed in fall

 

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

 

Resident at Aspen Rehab in Silvis chokes to death due to violation of care plan

By

IDPH has cited and fined Aspen Rehabilitation & Health Care nursing home in Silvis after a resident there choked to death on a sandwich due to a violation of the resident care plan.

The resident involved in this nursing home choking accident was a long-term resident of the nursing home.  He suffered from schizophrenia, anxiety, and dementia.  Some people afflicted with this set of conditions tend to eat very quickly, shoving food into their mouth and swallowing without chewing.

This is something that places the resident at risk for choking, and this had proven to be the case for this resident.  Prior to being admitted to the nursing home, the resident had a choking incident which led to an admission to the hospital intensive care unit.  He also had at least three other known choking incidents at the nursing home before the fatal one.  This was a resident who was clearly at risk for choking.

When there are threats to the health and well-being of nursing home residents, this must be addressed in the care planning process.  There are six basic steps to the care planning process: (1) an assessment of the risks to the well-being of the resident, (2) development of a written care plan consisting of a series of steps or interventions that must be taken to address those risks, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) ongoing evaluation of the effectiveness of the care plan, and (6) revision of the care plan if there are changes in the resident’s condition or if it proves to be ineffective in practice.

The nursing home recognized that that the resident was at risk for choking, and consulted with a speech therapist for recommendations to help ensure that the resident was able to eat safely.  These steps included obtaining an order for a modified diet to mechanical soft and mositening bread before serving.  It also included supervision of the resident while eating, cutting food into small pieces, cueing the resident to eat nore slowly and to take sips of water in between bites.  These steps were all incoporated into the resident care plan.

The resident’s family was permitted to bring food in for the resident periodically, but it had to be prepared and served by the staff.  On the day of the incident, the resident’s family brought in a tuna melt sandwich.  The sandwich was microwaved in the kitchen but not moistened.  Due to the pandemic, the residents were all eating in their individual rooms.  The resident’s meal was brought to him in his room by an aide who then left the room to pass additional meals.  She returned to the room about 5 minutes later to assist the resident’s roommate.

When she got to the room, she heard a gasping sound coming from the resident and realized that he was choking.  She called for help and began resuscitation efforts.  However, the resident’s airway was filled with food which they were not able to successfully clear.  The resident’s heart beat was lost and they were not able to regain it.  An emergency room physician instructed the paramedics and staff to cease resuscitation efforts and the resident was declared deceased.  Cause of death per the death certificate was anoxia due to choking on food.

There were a number of failures that led to the death of this resident.

First is that the resident was not being supervised while he was eating.  The nursing home properly recognized that he was at risk for choking and took reasonable steps to identify a number of steps which could be taken to mitigate that risk.  The key one here was supervision of the resident while eating – and this was not done here and was a violation of the resident care plan.

Why was there a violation of the care plan?

The simple answer is that the aide who served the meal did not know that he was supposed to be supercised while eating.  She did not know this because no one told her.  The resident care plan is more than paperwork – it is the game plan for the delivery of routine but necessary care for the resident.  If the staff charged with carrying out the care plan doesn’t know what they are supposed to be doing, the effort in coming up with the care plan is wasted.  More than that it represents a breakdown in the basic system that is intended to assure the safety of residents throughout the facility.  It is a major systems failure.

The second reason was that the kitchen staff failed to follows the orders for mositening of the bread.  The mechanical soft diet is supposed to help residents who have swallow difficulties and the moistening of the bread is intended to reduce the choking risk associated with bread.  This step which was intended to mitigate the risk of choking was also not followed.

In the end, these failures resulted in the very preventable death of this resident.

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

Other blog posts of interest:

Fondulac Rehab resident chokes to death

Aperion of Spring Valley resident chokes to death

Fatal choking accident at River Bluff nursing home

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

Sunset Rehab resident chokes to death

 

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

 

Grove of Skokie resident breaks leg due to violation of care plan

By

IDPH cited and fined the Grove of Skokie nursing home after a resident there suffered a broken leg due to an unsafe transfer which was also a violation of the resident’s care plan.

The basic purpose of a care plan is to outline a series of steps that the nursing home staff can take on a day-to-day, shift-to-shift basis to reduce the risks of harm to the resident.  The nursing home staff will almost always agree when asked that it is part of their job to implement the care plan.

The resident at issue here suffered from multiple sclerosis and as a result had significant mobility deficits.  Therefore, her care plan called for the assist of two staff and the use of a mechanical lift for all transfers – meaning that any time she was being moved from bed to wheelchair or wheelchair to chair and so forth that two staff members would use a mechanical lift to accomplish the transfer.

On the day of the injury, the resident was getting a shower and needed to be transferred from her wheelchair to the shower chair.  Rather than use the mechanical lift as called for in the care plan, two aides attempted to transfer the resident to the shower chair with a two person manual transfer.  During the transfer, the resident was not able to continue to bear any portion of her own weight and the staff lowered her to the floor.

When a nursing home chart describes a resident being “lowered to the floor,”  that is actually a nursing home fall.  A fall is generally considered to have occurred when there is an unplanned change in the vertical level of the resident.  And despite the benign description of being “lowered to  the floor,”  this is something that can and frequently does produce injury to the resident.

Following this incident the resident began to complain of leg pain.  X-rays showed that the resident suffered a comminuted fracture of the leg, meaning that it was broken in multiple places.

Here, the resident’s injury was clearly produced by the violation of the care plan.  The care plan was in place to prevent just this kind of injury, but the staff chose to not follow it, and a very predictable and preventable injury was the result.

The violation of the resident care plan was the obvious cause of the resident’s injury, but a deeper look at the circumstances surrounding this injury raises questions as to whether this was an understaffed nursing home.  Use of the mechanical lift was called for by the resident care plan, but the staff chose to not follow it, likely because it would have taken more time than attempting the manual transfer.  Any time you see information which indicates that the staff is taking shortcuts which sacrifice resident safety, understaffing should be a consideration.

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:

Violation of care plan at Generations Oakton Pavillion leads to fall and fracture

Resident falls and fractures hip and Lutheran Home for Aged in Arlington Heights

Brain bleed from fall at Landmark of Des Plaines

Failure to provide needed assistance leads to fall at Generations of Elmwood Park

Multiple fractures from fall at Lutheran Home for the Aged

Grosse Pointe Manor falls and breaks hip after being left unattended

 

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

Alden Courts of Shorewood resident breaks both legs during unsafe transfer

By

IDPH has cited and fined Alden Courts of Shorewood nursing home after a resident there broke both legs during an unsafe transfer.

Nursing homes must complete a document called the Minimum Data Set (or MDS) for each resident in the nursing home.  The MDS is supposed to reflect how much care the resident is receiving from nursing home staff.  It is part of the basis by which the resident’s acuity level is determined and therefore is part of the basis used to determine how much money the nursing home receives for caring for the resident.  Because of the financial implications of the MDS, the staff signing are required to sign it under oath.

Depending on how the various sections of the MDS are completed, this can trigger a Care Area Assessment or CAA.  When an area on the CAA is indicated, this is supposed to serve as a trigger for the nursing home staff to care plan for that area.  For example, an entry on the MDS indicating that the resident has a history of recent falls, may trigger the CAA and direct the nursing home staff to put a fall prevention care plan into place.

The care planning process has six steps: (1) an assessment of the risks to the health and well-being of the resident, (2) development of a care plan, (3) communication of the care plan to the staff charged with carrying it out, (4) implementing the care plan on a day-to-day, shift-to-shift basis, (5) evaluating it effectiveness on an ongoing basis, and (6) revising it if the resident’s care needs change or if it proves to be ineffective in practice.

Here, the resident’s Minimum Data Set reflected that she was receiving assist of two with transfers.  Accordingly, the resident’s care plan also indicated that she was to receive extensive assist of two with transfers.

On the day of the incident, the resident was being transferred from her bed to her wheelchair with the assist of a single aide.  The aide was attempting the transfer with a technique known as a pivot transfer.  In a pivot transfer, a gait belt is placed around the midsection of the resident, and the resident is helped to a standing position and pivoted from where they are sitting to where they want to go – in this case, from bed to wheelchair.  In order to do this safely, the gait belt must be applied properly and the resident must be able to bear weight sufficiently to assist in the pivoting portion of the transfer.

As the transfer got underway, the gait belt slipped upwards on the resident’s torso.  The aide grabbed at the resident’ pants which tore and the resident was not able to bear enough weight to stay upright so the aide lowered the resident to the floor and left to get a nurse.  X-rays showed that the resident suffered fractures of both tibias (the weight bearing bone of the lower leg) just below the knee.

During the investigation, the state surveyor learned that the usual practice at this nursing home was to have the number two posted above the resident’s bed when a two-person assist was required.  There was no such positing for this resident until after this nursing home fall occurred.  As a result, sometimes two staff were used for transferring the resident, sometimes not.

Here the nursing home accurately assessed the resident’s need for help in transferring and came up with a reasonable care plan to meet that need.  However, the contents of the care plan were not properly communicated to the staff charged with carrying it out.  As a result, the resident was not transferred in a safe manner and the injury the care plan was intended to prevent occurred.

Past that the fact that the care plan was not properly communicated to the staff means that there were a number of days prior to this when the care plan was not being followed, and if there are deficiencies in how the contents of care plans are communicated to the staff, then there may be a systemic problem at this nursing home.

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:

Lexington of Chicago Ridge resident breaks ankle in unsafe transfer

Manorcare of Palos East resident breaks hip in fall

Violation of care plan leads to fall and broken arm at Bria of Palos Hills

Multiple fractures from fall at Accolade of Pontiac

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

 

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

Call Us Today

(312) 263-1080

Location

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

Practice Areas

TAP TO CALL