wrongful death Archives - Page 2 of 2 - The Law Offices of Barry G. Doyle, P.C.

Fatal choking accident at Spring Creek in Joliet

May 22, 2020 By Barry G. Doyle

IDPH has cited and fined Spring Creek nursing home in Joliet after a resident there choked to death due to a lack of care planning.

The care planning process is the basis for for much of the routine care that is provided on a day-to-day basis in nursing homes. The process starts with an assessment which identifies the risk to the health and well-being of the resident and then puts into place interventions which need to be carried out by the staff on a day-to-day, shift-to-shift basis. The care plan must be communicated to the staff, and its effectiveness must be evaluated on an ongoing basis and changed if it proves ineffective in practice, fails to meet the care needs of the resident, or if there are changes in the resident’s condition.

Choking is something that may pose a risk to the health and well-being of nursing home residents. Residents may have difficulties with chewing or swallowing due to neurological or muscular disorders. Cognitive or behavioral issues might compound the problem by leaving the resident without real means to manage their behavior or with a lack of insight as to the risk that certain foods may pose to them. When this is the case, a well-done care plan usually includes a consultation with a speech therapist to help determine what sort of diet consistency is safe for the resident, assistance with eating which is provided at a feeder table in the dining room, and close supervision around food.

The resident at issue had a number of long term medical and cognitive issues and had been admitted to the nursing home from a group home. Among these issues were profound intellectual disabilities, a history of intracerebral hemorrhage, dysphagia (difficulty with swallowing), and Parksinson’s Disease. Around the time of his admission, the social services director spoke with the group home that the resident came from and was told that the resident engaged in pica (putting nonfood items in his mouth) and grabbing food off other resident’s plates. In short, this was a resident who was at very high risk for choking.

Given his risk profile with physical and mental/cognitive limitations that placed him at risk for choking, putting a choking prevention care plan into place was absolutely necessary. The social services director told the surveyor that she put one in place for the resident at the time admission, but that was never done. There was no referral to a speech therapist, no modified diet, no assistance or supervision with eating.

Even without the choking risk being addressed in the formal care planning process, there were other windows in which this resident’s choking risk could and should have been addressed. After the resident was admitted to the facility, nurses on the floor noted on five different occasions within the two weeks before the resident choked that the resident was taking food from other and residents and/or jamming food into his mouth.

On the day of this nursing home choking accident, the staff noticed that the resident was pushing his wheelchair through the dining room and was turning blue. The nurses swept his mouth clear of scrambled eggs and initiated CPR. 911 was called and when the paramedics arrived, they cleared additional eggs from the resident’s airway. When they attempted to intubate the resident, more eggs interfered with the placement of the tube. He was brought to the hospital where still more eggs were retrieved from the resident’s airway. The resident did not survive and was declared deceased in the emergency room.

There were a number of basic breakdowns in the care planning process that resulted in the wrongful death of this nursing home resident. First, even though the resident was clearly at risk for choking, there was no care plan put into place during the formal care planning process. After that, there were multiple episodes of behaviors which should have suggested to the nurses who were noting his behaviors of grabbing food and stuffing his mouth full that this was a resident who was at risk for choking and to see what the care plan was to address this. Discovery that this resident’s choking risk had not yet been addressed in the care plan should have led to a revision of the care plan. This is an outcome that could have been avoided by simply placing the resident at a feeder table where he could have been closely supervised during meals.

A simple breakdown in care leading to a horrific outcome – and the fact that no one took time to realize that this resident’s rather obvious risk of choking was not being properly addressed is a result of the fact that nurses in a nursing home setting often are stretched so thin by the grind of providing day-to-day care that they do not have time to give critical thought to the needs of resident’s. Sadly, that is directly related to the nursing home business model and understaffing of 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:

Resident at AHVA Care of Winfield chokes to death on peanut butter sandwich

Chicago Ridge Nursing & Rehab resident chokes to death on sandwich

Resident chokes to death at Rosewood of St. Charles

Fatal choking accident at Glenwood nursing home

Resident chokes to death at The Moorings in Arlington Heights

Resident falls from bed at Spring Creek

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

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

April 1, 2020 By Barry G. Doyle

IDPH has cited and fined Elmwood Nursing & Rehab Center in Maryville after a resident there died of a brain bleed following a fall.

Anticoagulant medications, or blood thinners, are often important medications in the treatment of nursing home residents. They are used to combat the risk of stroke associated with atrial fibrillation (irregular beating of the heart) of pulmonary embolisms due to deep vein thrombosis. They need to be carefully monitored to be sure that the resident’s blood is neither “too thick” or “too thin” as either can lead to serious medical problems. They can also set up residents for serious medical complications such as a brain bleed after a nursing home fall even without direct trauma to the head. And that was the case here.

This resident was taking an anticoagulant to prevent a pulmonary embolism. She had what on the surface seemed to be a minor fall. She went to sit on her bed, bounced awkwardly, hit her head on the headboard, and then rolled out of bed. There was a small cut over the eye which the nurse on duty closed with steri-strips.

What is often crucial where there are bad outcomes from a nursing home fall is what happened after the fall. Standard procedure would be for the nurse to notify the doctor and to start a 72-hour fall watch. The purpose of notifying the doctor is to allow the doctor to make a determination as to whether the resident should be sent to the emergency room. The purpose of the 72 hour fall watch is to watch for signs of injury that were not immediately apparent at the time that the fall occurred. Sometimes this is a hip fracture, but one of the most important injuries which has a late onset of signs and symptoms is a brain bleed.

There were a couple of areas where this broke down in the care of this resident.

After the fall occurred, the nurse on duty called the nurse practitioner and notified her of the fall. However, when the nurse called the nurse practitioner, she did not tell the nurse practitioner that the resident was on a blood thinner. When a doctor (or as here, a nurse practitioner) gets a call from a nursing home after hours, they don’t have the resident chart in front of them and likely do not have the resident’s medical history committed to memory, so the nurse needs to bring the pertinent information to the attention of the doctor. In a fall, that would include the fact that the resident was on blood thinners.

When a 72 hour fall watch is being done properly, it starts with frequent checks in the immediate aftermath of the fall and then the frequency diminishes as time passes after the fall. The whole point of doing the checks is to catch any changes in condition as they first occur so that they can be reported to the doctor for immediate action.

Here, the fall was documented as occurring at 11:15 p.m. There are then follow-up notes times in at 1:15 a.m., 3:30 a.m., and 4:45 a.m., all of which were pretty unremarkable – and also very incomplete as they did not note and changes in the skin or bruising. They also did not note any projectile vomiting of brown vomit with “red chunks” which is something that the CNA assigned to the resident said occurred and was reported to the nurse. For her part, the nurse denies that the CNA made that report to her. Either way – the CNA failing to tell the nurse of the nurse failing to act on it – are both breakdowns in the delivery of care.

At 5:35 a.m., the nurse noted that the resident complained of being “hot” even though she was cold and clammy. Her oxygen saturation dropped to 52% (mid to high 90’s is normal) on room air and the nurse was unable to obtain a blood pressure. The nurse called 911 and the resident was brought to the hospital where a CT scan was done which showed that the resident suffered a brain bleed. She died on the way back to the emergency room from getting the scan done.

There are at least three breakdowns in the delivery of care after this resident’s fall. First, the nurse on duty failed to let the nurse practitioner know that the resident was taking a blood thinner after the resident had a fall. This is something that both the doctor and nurse practitioner were critical of, and the nurse practitioner said that knowing that would have led her to send the resident to the emergency room. This would have given the doctors there a window of four to six hours to stabilize and treat the brain bleed. Second, the post-fall checks were not frequent enough and obviously did nto capture the declines in the resident condition. Any decline should have resulted in a call to the doctor which in turn would have led to the resident being sent to the hospital that much earlier. Third, either the CNA was at fault for not telling the nurse or the nurse was at fault for not acting on it, but the episode of vomiting was a flashing red light that something was wrong, but it was never acted on and a crucial opportunity was lost. Each of these failure were contributing causes to this resident’s death.

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

Swansea Rehab resident fractures hip in fall

Fall from edge of bed at Integrity of Alton

Mar-Ka Nursing Home resident falls, breaks both legs

Fall from bed yields broken leg at Eunice C. Smith Nursing Home in Alton

Resident breaks leg in fall from edge of bed at Jerseyville Manor

Hitz Memorial Home resident dropped from lift

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

Pittsfield Manor resident suffers fatal fall

March 8, 2020 By Barry G. Doyle

IDPH has cited and fined Pittsfield Manor nursing home after a resident from that facility suffered a fatal brain bleed while being transported to a dental appointment.

There are times when nursing home residents need to obtain services which cannot be offered in the facility. At times, family will take them, but when the nursing home takes on the role of transporting them to the outside appointment, the steps necessary to assure the safety of the residents must continue to be taken and the staff charged with handling the resident while outside the facility must be advised of the steps needed to assure the safety of the resident. Falls are a particular risk outside the doors of the facility as residents deal with busier and less familiar circumstances in an environment which is not designed to assure their safety.

This particular resident had long been assessed as being a fall risk on the standardized fall risk assessment tool used at this nursing home. She also had a history of multiple falls and one thing that we know is that falls tend to beget additional falls. She also had a diagnosis of Alzheimer’s which is of course a progressive disease. The last Minimum Data Set completed prior to the incident at issue indicated that she needed supervision of one with ambulation. However, she also had two additional falls after that , but there is no indication that the fall prevention care plan was updated following those two falls. Staff interviewed by the state surveyor indicated that the resident complained of increased dizziness and needing to have hand held while she was walking.

On the day of the accident, the resident had a dental appointment. She was going to be driven to the appointment by a staff member in the facility van. When the aide who was driving the van picked the resident up, she was told by another aide that the resident help climbing the steps to the van and needed help with the seat belt. The aide was not told that the resident had a history of falls or that she needed supervision or assistance with walking.

When they arrived at the dental office, the aide stopped the van in front of the entrance and helped the resident unbuckle her seat belt and get out of the van. She then left the resident unattended while she went to park the van. However, before she could pull away, the resident fell to the ground. The aide got out of the van and saw that the resident was bleeding from the head. She called 911 to have the resident brought to the emergency room. In the emergency room, she was diagnosed with a skull fracture and brain bleed. It was decided that she was not a good candidate for surgery and died three days later as a consequence of the fall.

Continuity of care is a critical issue when addressing the care needs of nursing home residents. This is why there are written care plans – to help ensure that the resident receives the care that they need on a day-to-day, shirt-to-shift basis. Here, the aide taking the resident to her dental appointment was not provided with the information she needed to help prevent this kind of fall.

Other blog posts of interest:

Hitz Memorial Home resident dropped from lift

Resident breaks leg in fall from edge of bed at Jerseyville Manor

Repeated falls at Heritage Health in Springfield end in broken arm and brain bleed

Fractured femur from failure to use lift at Granite Rehab

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

Fall from bed yields broken leg at Eunice C. Smith Nursing Home in Alton

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

Resident wanders from Aperion Care Forest Park, drowns in river

February 13, 2020 By Barry G. Doyle

IDPH has cited and fined Aperion Care of Forest Park nursing home after a resident there wandered from the facility, fell in a nearby river, and drowned. The body was found six days later and was not identified for another five days after that.

“Elopement” is the technical term for wandering from a nursing home. It is a highly hazardous situation because once the resident leaves the nursing home, they are at risk for serious harm due to the physical and mental deficits they have related to their underlying infirmities. They are at risk of injuries due to falls, being struck by a car, becoming a victim of a criminal assault, or as here, falling in a river and drowning.

One of the basic assessments as part of the care planning process when a resident is admitted to a nursing home is an elopement assessment. If a resident is identified as being at risk for wandering from the nursing home, this is something that must be addressed in the resident care plan which must then be carried out day-to-day, shift-to-shift. When there is an inadequate care plan or one which is not carried out on a regular basis, then a resident is placed at risk of all of the calamities that can follow.

There are a number of standardized risk assessment tools, but in the end, the resident who is at high risk of wandering from the nursing home has the following characteristics: 1) some form advanced dementia, where they cannot be counted on to follow instructions or make good decisions for their own safety, usually with some degree of disorientation, 2) an ability to ambulate reasonably well, as residents who have limited mobility or who are bedbound are not able to leave the nursing home effectively, and 3) some demonstrated intent to leave, whether by actually trying to exit the facility or an expression of an intention to leave (“I want to go home, to my daughter’s etc.”).

The usual approach to caring for a resident such as typically a mix of interventions, but the most crucial ones would include placing an alarm on the resident which sounds when they try to leave the building or the unit they resident on, close supervision, and other interventions intended to reduce the resident’s overall level of anxiety or agitation.

The resident at issue suffered significant issues with dementia for a host of reasons. He had demonstrated a host of behaviors which showed that he was an elopement risk, including actually trying to leave the facility and expressing an intention to leave. He was care planned for elopement which included the use of an electronic wandering device, identifying a pattern of wandering, and intervening as appropriate. There was no specific requirement for supervision or monitoring of his activities and no care plan to address wandering and exit-seeking behaviors.

On the morning that the resident left the facility, he was caught by a staff member at 9:30 a.m. getting onto an elevator to go downstairs. Approximately an hour and a half later, he could not be found during the medication pass, so the staff called a Code Pink (for missing resident),but he could not be found in the building or on the surrounding streets. A police report was made, but sadly, he was not found until his body was pulled out of the river.

The staff member who last saw him before he left the building told the state surveyor that his wandering alert bracelet was on when he was last seen, and indeed, it was still on the body when it was recovered from the river. The state investigation was not able to establish exactly how the resident got out of the building, but there are a limited number of options, none of which reflect well on the nursing home. Since the bracelet was on, either it or the alarm by the elevators was not working, or the staff failed to respond to the alarm when it sounded. No matter how this happened, there was an egregious breakdown in the systems that are intended to keep the residents safe.

Other blog posts of interest:

Resident from Chalet Living & Rehab leaves facility, fall and suffers broken leg

Resident missing for 6 days at Villa at Windsor Park

Niles Nursing & Rehab resident wanders, suffers fractures

Police fracture skull of resident who wandered from Integrity of Smithton

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

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

Fatal choking accident at Hillcrest Retirement Village

January 21, 2020 By Barry G. Doyle

IDPH has cited and fined Hillcrest Retirement Village in Round Lake Beach after a resident suffered two choking incidents over a three day period with the final one resulting in the death of the resident.

The resident was readmitted to the facility after being hospitalized due to aspiration pneumonia. Aspiration pneumonia occurs when something (commonly food) enters the lungs and causes an infection. People who have difficulties with swallowing often experience aspiration pneumonia because the swallow process for them is disorganized and as a result they end up having food particles enter the lungs, resulting in the infection. When the resident was readmitted to the facility, he was noted to have diagnoses of dementia and dysphagia (swallowing difficulty) and his care plan included monitoring for signs and symptoms of choking, coughing, and pocketing of food while eating. His diet order was for pureed foods and honey thickened liquids. This diet order was intended to reduce the risk of choking.

Additionally, he underwent three weeks of speech therapy. One of the important tasks that a speech therapist handles in a nursing home setting is treating residents with swallowing difficulties and making recommendations regarding diet orders. While many nursing home residents would prefer to eat as normal a diet as possible, getting a proper diet recommendation from a speech therapist is a key measure in reducing the risk of a nursing home choking accident. After the three weeks of speech therapy, the speech therapist recommended that the resident’s diet be upgraded to a general diet with no restrictions, and the resident’s doctor entered the order.

Two days after the resident’s diet was upgraded, he experienced his first choking incident. He was eating dinner when his face began to turn blue. One of the aides working in the dining room gave him back blows, and this was sufficient to expel some of the fish and bread he was choking on, and the staff was able to reach into his mouth and clear the remaining food away.

The nurse on duty at the time of the first choking accident noted the occurrence on the resident’s chart. However, she never notified the resident’s doctor or the speech therapist that there had been a choking incident. Both the doctor and the speech therapist told the state surveyor that had they been notified of this choking incident, they would have downgraded the resident’s diet to include foods with a consistency that poised a lower choking risk. The facility’s policies and procedures also permitted members of the nursing staff to downgrade a resident’s diet if there were safety concerns. However, the nurse was apparently unaware of that and believed that simply documenting the fact that a choking accident had occurred was enough.

Sadly, it wasn’t.

Three days later, the resident was eating dinner again, with the unchanged general diet order – despite the choking incident just a few days earlier. The resident again choked on food, but this time, lost consciousness and became pulseless and unresponsive. Paramedics were called and CPR was performed. The paramedics attempted intubation, but they were unable to place the tube due to the airway being obstructed by food. The resident was brought to the hospital where he died two days later.

Care in a nursing home setting is often looked at as being provided by an interdisciplinary team which obviously includes the nursing staff, but also includes professionals such as the speech therapist and the resident’s doctor. This is the kind of tragic outcome that results when the members of the team do not communicate with one another. It was the job of the nurse to let speech therapy and the doctor know about the incident, and both stated that they would have downgraded the resident’s diet, but they never were given the chance to do so. This is also the kind of outcome that results from a member of the nursing staff failing to appreciate the hazard that a choking incident represents and failing to know what tools were available to her to address that hazard. The nurse had the ability to downgrade the diet independent of the doctor and speech therapy. Given the opportunity to prevent this outcome by 1) notifying the doctor, 2) notifying speech therapy, and 3) acting independently to downgrade the diet, she did nothing, and the wrongful death of this resident was the result.

While a heavy dose of fault lies on the nursing staff, the role of the speech therapist also deserves careful consideration. It was the decision of the speech therapist to upgrade the resident from a puree diet to a general diet which set the stage for this outcome, and that decision deserves special scrutiny. It is important that this is done at the outset of any case because speech therapists are generally not direct employees of a nursing home, but are independent contractors.

Other blog posts of interest:

Riverview Rehab resident chokes to death

Fall from mechanical lift at Hillcrest Retirement Village

Fatal choking accident at Warren Barr North Shore

Resident chokes to death at Rosewood of St. Charles

Fatal choking accident at River Bluff nursing home

Resident chokes to death at The Moorings in Arlington Heights

Fatal choking accident at Spring Creek in Joliet

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

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

January 19, 2020 By Barry G. Doyle

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

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

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

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

Other blog posts of interest:

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

Rushville Nurisng & Rehab resident suffers untreated surgical wound infection

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

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

Moorings staff fails to notify doctor

Infection goes unnoticed at Helia of Belleveille

Burbank Rehab resident hospitalized due to missed dialysis sessions

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

Diabetes care mismanaged at Aperion Care Capitol

May 3, 2019 By Barry G. Doyle

IDPH cited and fined Aperion Care Capitol after its staff mismanaged the diabetes care of a resident which resulted in the wrongful death of the resident.

The resident was a 73 year old man who was a long-time diabetic who was cognitively intact and had a good understanding of how his diabetes should be managed. He was transferred into the facility on October 17 from another nursing home. On admission, there was an order in place for sliding scale insulin. This admitting order was adjusted by his attending physician two days after admission. The records indicate that this regimen was followed by the staff without any evidence of adverse effects.

On November 5, the resident was seen by a nurse practitioner who was employed by an outside company – not by the doctor, not by the nursing home. The nurse practitioner ordered the insulin regimen that the doctor had ordered discontinued and a new regimen put into place. The doctor was not notified of the changes made in the insulin regimen. On November 6, the resident complained of having blood in his urine social services. There was no record of that in the nurse’s notes and no indication that the doctor had been notified. On November 7, the nurse practitioner again changed the insulin regimen – and again the doctor was not notified of the changes in the insulin regimen. That same day, the doctor also issued an order for a change in the sliding scale regimen. The difference between the two regimens was essentially that the resident would receive higher doses of insulin when the resident has lower blood sugar level readings.

From November 5 through November 10, the nursing staff followed the sliding scale regimen put in place by the nurse practitioner, not the doctor, and never resolved the differences between the two sliding scale orders. As a result, the resident received higher doses of insulin at lower blood sugar levels which would have the effect of further depressing his blood sugar levels. There was nothing in the chart to suggest that the nurses were monitoring his response to the new sliding scale orders or determine why the resident was experienced below normal blood sugar levels.

On the morning of November 10, the resident was found unsresponsive with a blood sugar level of 12, a very low level. 911 was called and the resident was given an injection of glucagon which is intended to treat severe hypoglycemia, or low blood sugar. The resident coded while the paramedics were working on him and was taken to the hospital with the paramedics continuing to administer CPR. At the hospital, he was diagnosed with respiratory failure secondary to severe hypoglycemia and cardiac arrest. He was also diagnosed with severe sepsis due to a urinary tract infection. He was placed on a ventilator and died after the family consented to the removal of the ventilator.

The investigation by IDPH into this incident revealed several disturbing findings:

The nurse practitioner kept a separate set of notes on his treatment of the resident which were kept on his own computer which was not networked into the computer system of the nursing home or even able to be printed at the nursing home. The chart is an important communication tool among the various health care professionals involved in the care of the resident. There were no systems in place to ensure that the nurse practitioner’s notes were included in the resident’s chart.
He was unable to justify to the surveyor the orders he entered for ordering insulin to be given to the resident at lower blood sugar levels and told the surveyor that he was thinking an error occurred, but that the nurses should have known better than to follow his order.
The nurses here failed to resolve the inconsistencies between the orders given by the nurse practitioner and the doctor on November 7.
The nurse practitioner agreed that infections can cause a fluctuation in blood sugar levels. The fact that the resident had blood in his urine was never addressed by anyone caring for the resident. The doctor was not notified, and the nurses appear to have been unaware of the blood in the resident’s urine that he reported to social services. The resident was suffering for severe sepsis when he arrived at the hospital. The resident also had some cellulitis on his finger for which the nurse practitioner ordered an antibiotic. The role of this infection in affecting the resident’s blood sugar levels appears to have never been considered.
The most concerning findings come from the interview of the resident’s doctor, in part because he is also the medical director of the nursing home. He stated that he nurse practitioner is in the facility every day, but he is not privy to the orders that the nurse practitioner entered regarding his resident unless the facility tells him, which they do not always do. He sent his nurse to the nursing home for a meeting to discuss this, and the facility refused to give her access to the medical records regarding his patients.
The doctor further described when he rounds at the nursing home, he is accompanied by a nurse from the facility who is not always the nurse who cares for a resident and is often unfamiliar with the resident.
The doctor related to the inspector that he had standing orders regarding diabetes management, but the nurses don’t follow them. When the inspector asked the facility’s director of nursing for a copy of the doctor’s standing orders, she could not find a copy. She had to have the doctor’s office fax a copy over after the inspector asked.
When he was asked about nurses giving insulin to residents with low blood sugar, the doctor stated that the facility has nurses on staff who don’t follow standards of practice and that the facility uses agency nurses who are not familiar with the residents and as a result there are a lot of problems with continuity of care.

This is one of the more damning citation reports I have read, which is revealing a whole series of systemic problems with how this facility is operated. The fact that some of the harshest criticisms are coming from the medical director of the facility is eye-opening and reveals some deep dysfunction about how the facility is operated.

In the end, this resident died because his insulin regimen was mismanaged. On the surface, this is a simple story to understand. Looking at this incident on a deeper level, there were a whole series of failures which shows how the way in this nursing home is managed ended with this result. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary injuries and illnesses and wrongful deaths of residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

Anticoagulant medication not given at H & J Vonderlieth Living Center

Failure to give diabetes medications at Bridge Care Suites

Aperion Care Capitol fails to obtain equipment to treat bed sore

St. Anthony’s fails to treat resident pain during wound care

Alden Estates of Orland Park fails to give insulin

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

Failure to give HIV medications at Bria of Belleville

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