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

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IDPH has cited and fined Farmington County Manor nursing home after a resident there suffered a broken leg due to the failure of an aide to follow the care plan for safe resident transfers.

The resident at issue was a hospice patient, admitted to the nursing home suffering from a degenerative neurologic condition which left her without full use of her arms or her legs.  Because of the loss of use of her legs, she was wheelchair bound and a care plan was put into place which called for the use of a hoyer lift for transferring the resident – for example, moving her from bed to her wheelchair.   When a transfer is done with a hoyer lift, this requires the help of two staff members – one to actually operate the controls of the lift, the other to keep the resident steady in the sling.

On the day of the injury, the CNA assigned to care for the resident transferred the resident from bed to wheelchair using a technique known as a pivot transfer.  This involves placing a gait belt around the midsection of the resident, lifting the resident to a standing position, and pivoting, moving the resident from bed to wheelchair.  In so doing the resident’s leg twisted and she suffered a broken femur.  The resident was sent to the emergency room where an orthopaedic surgeon was brought in for a consultation.  Ultimately considering her overall condition, he recommended that she be placed in an immobilizer and returned to the nursing home.

This injury was very clearly the result of a violation of the resident care plan.  When a resident is admitted to a nursing home a care plan is developed which is intended to address the risks to the health and well-being of the resident.  In this case, due to the weakness associated with her neurologic condition, the resident was not able to bear weight sufficiently to be safely transferred in any way other than the use of a lift.  It was part of the aide’s job to follow that care plan to help assure the safety of the resident.

This injury was the very predictable result of failing to follow the care plan.  When people are non weight bearing for an extended period of time, they tend to develop osteoporosis, or brittle bone disease, which leaves them susceptible to suffering fractures due to movements which may not ordinarily cause injury.  In this case the twisting that occurred during the pivoting movement cause the fracture.  This caused the resident to suffer significant unnecessary pain.

While the failure to follow the care plan was a very clear cause of this injury, the facts here raise a question as to whether this was an understaffed nursing home.  Whenever you see staff taking shortcuts in the care of residents, such as having one person doing a two-person job, it raises questions about whether this is an understaffed nursing home.  Unfortunately, understaffing a nursing home is really a part of the nursing home business model, and one of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

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

Failure to monitor resident leads to fall and refracture of broken hip at Barry Community Care

Resident at University Rehab Northmoor in Peoria suffers broken hip in fall from bed

Mechanical lift accident at Meadows Mennonite Home in Chenoa

Heddington Oaks resident suffers broken leg due to unsafe transfer

Cornerstone Rehab resident falls from lift, breaks leg

 

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

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

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

Background

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

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

Poor Record-Keeping Leads to Medication Errors 

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

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

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

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

Unnecessary Pain is a Form of Abuse

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

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

Contact a Nursing Home Abuse Lawyer Today

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

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

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

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

 

Other blog posts that might be of interest:

Catastrophic brain injury from medication error at Alden Town Manor

Lexington Of Orland Park Resident Suffers Stage 4 Bed Sore

Sharon Health Care Willows Resident Undergoes Surgery For Bed Sore

Stephenson Nursing Center Resident Undergoes Surgery For Bed Sore

Southgate Nursing Home in Metropolis Cited After Resident Dropped from Lift

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Southgate Nursing Home in Metropolis received a citation from the Illinois Department of Public Health (IDPH) after a resident was dropped from a lift and sustained two fractures to her lower back and a brain bleed.

Background 

The resident was assisted by only one staff member who helped her shower, moved her from the shower chair and back into her bed. In the process, the sling tore and the resident fell, landing on top of the legs of the lift. 

An ambulance was called and she was transferred to the local hospital where it was determined that she sustained two fractures in her lower vertebrae and had a brain bleed. 

About Mechanical Lifts

Mechanical lifts are used to move people who can’t stand on their own, or whose weight makes manually moving or lifting them unsafe. They are designed to drastically reduce the strain from lifting the patient and lower the risk of injury and accidents during the moving process.

They’re usually used in hospitals, clinics, and other healthcare settings to transfer patients from their bed to their wheelchair, and other locations. 

When used properly, mechanical lifts are invaluable tools for nursing homes, especially because many residents have mobility issues. 

A mechanical lift should be operated properly to ensure the safety of the person being moved. Although there are various types of lifts, the principles to operate them are essentially the same. It requires the assistance of two staff members — one to hold the resident steady in the sling and another to control the lift and devices on it. 

Understaffing Results in Serious Injuries

In this particular case, the nursing home failed on two levels. 

First, the sling wasn’t an actual sling. Instead, it was a lift sheet with loops in the corner. This makeshift sling tore and resulted in the resident’s fall. 

Second, the staff member was single-handedly doing what was supposed to be a two-person job. 

Since mechanical lifts require two people to safely operate, the main issue in this is that the nursing home was woefully understaffed.

Understaffing results in a lack of adequate care for the residents because staff members feel pressured to cut corners to accomplish all assigned tasks. Fatigue and overwork may also lead to the abuse and neglect of residents, whether intentionally or unintentionally. 

And as evidenced by this case, understaffing can lead to avoidable injuries. 

Call an Illinois Nursing Home Lawyer Today

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

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

Contact us to schedule a consultation.

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

 

Other blog posts that might be of interest:

Lexington Of Orland Park Resident Suffers Stage 4 Bed Sore

Sharon Health Care Willows Resident Undergoes Surgery For Bed Sore

Stephenson Nursing Center Resident Undergoes Surgery For Bed Sore

Resident at Bridge Care Suites Dies from Infected Bed Sore

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In a tragic case, the IDPH has issued a citation to Bridge Care Suites in Springfield, IL, after one of its residents died from an infected bedsore. 

What was supposed to be a short stay turned into an agonizing and ultimately fatal battle for the resident. 

From Post-Injury Rehab to Fatal Infection

The resident had broken her hip in a fall and was admitted into Bridge Care for short-term rehabilitation. At the time of her admission, she already had a small bedsore on her tailbone, about 3×4 centimeters.

When a resident comes to a nursing home with a bedsore, the standard practice is for the facility’s staff to contact the doctor for treatment orders. This was not done, because staff were instructed to only call the doctor if the bedsore was Stage 3 or higher. The fact that they didn’t reach out to a doctor upon the resident’s admission indicates that her bedsore was only Stage 1 or 2.

Within 19 days of her stay, the resident’s bedsore grew to the stage 3 category. At this point, her care plan only included the use of a pressure-relieving cushion on her wheelchair and no other intervention for bedsore. Her wound had worsened, but nobody obtained additional treatment orders from the doctor.

The resident then visited a wound care clinic. There, a nurse practitioner saw that the resident’s wound was not properly dressed and that she was not on a pressure-relieving wheelchair cushion.

In the NP’s account to the state surveyor, she was mortified by the resident’s condition, particularly to the “nasty” wound that already had a foul smell. It had also grown in size, had dead tissue on the wound bed, and was tunneling underneath such that bone was palpable. The NP debrided the wound, which was now classified as a Stage 4 bedsore.

Unfortunately, the nursing home still did not update the resident’s care plan despite the progression of the wound. Within four days of her return to the home, she began to suffer significant pain at her coccyx (tailbone), a common sign of osteomyelitis or bone infection.

Again, despite the new complaints, there was no call made to the doctor. The resident’s pain increased, and she now also had nausea and changes in mental status.

Meanwhile, her son had grown concerned and called the nursing home. He had to wait for a callback from the nurse’s station, at which point they asked him what he wanted to do.

Paramedics arrived at the nursing home and transported the resident to the ER. On arrival, she was already struggling to breathe and had no pulse or blood pressure. She was pronounced deceased within an hour. The pathologist certified her cause of death as sepsis and decubitus ulcer, and also found neglect in the case.

Multiple Failures in Resident’s Care

There were multiple failures in caring for this resident, which started at the moment of her admission when the staff did not notify the doctor about the bedsores. Her care plan was thus inadequate.

Second, her care plan was not revised as her wound worsened. Updating the care plan is a fundamental step in the care planning process. Nursing homes have the responsibility to look out for progressing medical issues in any of their residents and to reach out to a physician so that the resident’s care plan can be revised accordingly.

Bedsores are a particularly crucial issue because they are so common and can easily lead to serious medical conditions. The US has specific federal regulations mandating nursing homes to provide care to prevent sore infection, promote its healing, and prevent additional bedsores. 

The deceased resident’s bedsore should have been taken seriously.

Further, her additional complaints of increasing pain should have prompted immediate medical action. Yet the physician was not called even at this point.

In an interview with the state surveyor, the wound care nurse at the facility said that when he began there, they did not have a wound care nurse in place. As he took on the role, he only got minimal training and almost no supervision. He did not even know of any policy or procedure to guide him in the provision of care. 

These comments indicate serious shortcomings in facility management, involving poorly trained, unqualified, or inadequate staff.

This substandard condition sadly led to the demise of an individual — a very preventable death. A nursing home can take steps to prevent or heal bedsores and thus protect their residents from life-threatening infections — if only the facility is serious and competent in fulfilling their duties.

Contact an Illinois Nursing Home Lawyer for Legal Help

We believe that most 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 results. 

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.

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

Thank you for reading.

 

Other blog posts that might be of interest:

Rushville Nurisng & Rehab resident suffers untreated surgical wound infection

Lexington Of Orland Park Resident Suffers Stage 4 Bed Sore

Sharon Health Care Willows Resident Undergoes Surgery For Bed Sore

Stephenson Nursing Center Resident Undergoes Surgery For Bed Sore

Mayfield Care Resident Suffers Dislocated Shoulder After Rolling Off Bed

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The IDPH has cited the Mayfield Care Center in Chicago, IL, after a resident there fell off her bed and suffered a dislocated shoulder.

Fall was Due to Failure to Provide a Two-Person Assist   

A two-person assist is often necessary to prevent residents from falling off their beds. While some residents just need one aide to help with their mobility, many others tend to roll on their bed away from the aide who’s trying to assist them. Thus, they need a second staff member to prevent them from falling off that other side.

In this case, one person from the nursing home staff did a two-person job. The resident had been assessed as in need of a two-person staff assist for her bed mobility. This meant that she had to have one staff member at each side of her bed to help her turn, reposition, and get up.

The resident was supposed to have two assisting staff members for bed mobility, but one of them reportedly had left the room to get towels. This momentary lapse in care caused the resident to roll and fall off the bed, dislocating her shoulder.

Care Plans Must Be Strictly Followed 

It cannot be stressed enough that every resident’s care plan has to be implemented to the letter. The care planning process includes assessing the resident’s needs and planning specific steps to address those needs. These carefully planned steps have to be communicated to the nursing home staff, who must then follow them day by day, shift by shift.

This particular resident’s designation as needing two-person assist should not have been ignored or taken for granted. Her injury might have been avoided if the nursing home staff followed the care plan steps properly.

What’s worse is that improper implementation of the care plan happens too often in nursing homes, sometimes resulting in much more serious injuries. Over the last two years, we’ve written about residents who fell from their bed and sustained broken hips, severe fractures, and even brain bleeds. All that painful and costly suffering could have been avoided had the nursing homes fulfilled their duty.

Contact an Illinois Nursing Home Lawyer for Legal Help

We believe that most 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 results. 

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.

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

Thank you for reading.

 

Other blog posts that might be of interest:

Warren Barr North Shore Resident Rolled From Bed, Suffers Fractured Ankle

Warren Park Health & Living Center resident suffers brain bleed in fall in stairwell

Understaffing At Generations At Rock Island Leads To Fall And Hip Fracture

Sheridan Village resident suffers hip fracture in fall

Fall Leads To Brain Bleed And Death At Regency Care Of Sterling

Accolade Paxton Resident Suffers Lingering Infection After Medication Error

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The IDPH has cited Accolade Healthcare Paxton Senior Living in Paxton, IL, for a medication error affecting a resident with a knee infection. The infection began after the resident had a knee replacement surgery, and it persisted after the nursing home failed to provide her antibiotics.

Missed Antibiotics Crucial to Treat Infection

The female resident was originally admitted to the senior care facility because her knee prosthesis surgery led to a knee infection. At the time of her admittance, her prosthesis had been removed and replaced with a spacer, a device designed to fill the joint gap. She was meant to get antibiotics to clear up her infection, and only then would she get a new prosthesis.

Soon after her nursing home admission, there was concern that her infection was migrating to the soft tissue next to her knee joint. If the infection was allowed to move, she could lose her leg. Hence, she was sent back to the hospital.

Doctors allowed her to return to the nursing home with an order for two antibiotics called Fortaz and Vancomycin. However, neither was on hand at the nursing home when she arrived. A nurse practitioner found out four days later that the resident missed three doses of Fortaz and one dose of Vancomycin.

The resident developed a fever, which prompted another hospitalization. She had to undergo surgical removal of the spacer. On the operative note, the indication for surgery was the missed antibiotics.

Multiple Lapses in Resident’s Care

We see at least three shortcomings at the nursing home that led to this resident’s prolonged suffering.

One is the lack of continuity of care. Individuals who are admitted into a nursing home after a hospital stay should have the continued treatment they need to get well. Before the resident’s transfer, the hospital must send to the nursing home the treatment orders and medication list, and the nursing home must implement them as soon as the resident arrives.

This standard protocol for continued care was not followed through for the resident at issue. As a result, she missed her crucial medication and ended up having to get another surgery.

Another problem was the facility’s admittance of the resident without complete preparation. Nursing homes are supposed to be ready to implement a resident’s care plan to the letter, the moment the resident is admitted. In terms of medical treatment, a well-run facility will have a backup supply of medications or even an on-call pharmacy to supply what is needed.

Unfortunately, in this case, the nursing home did not take proper steps to prepare for the resident’s admittance. The lack of onhand medicine should have been addressed with a resupply.

The third issue was that the nursing home staff failed to check on the patient’s care and notify the physician. Senior care facilities are not required to have a doctor present 24/7, but they are required to let a doctor know when there’s a medical issue with any resident. Nurses and staff at the facility are supposed to be the doctor’s “eyes and ears” to spot these issues.

Sadly for this particular resident, no one at the nursing home checked if she was getting the ordered medicine. Thus, the doctor could not immediately advise on how to address it. Four days passed before a nursing practitioner noticed, and by that time, there was no choice but to send the resident back to the hospital.

No nursing home resident should have to suffer due to any of these lapses, much less a combination of several.  

Contact an Illinois Nursing Home Lawyer for Legal Help

We believe that most 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 results. 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.

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

Thank you for reading.

 

Other blog posts that might be of interest:

Dehydration leads to hospital admission for resident at Mattoon Rehab

Flora Gardens staff fails to give an antibiotic, leading to the death of resident

Alden Valley Ridge fails to give resident anti-seizure medications

Taylorville Skilled fails to obtain anti-convulsant medication for resident

Arcadia Care Resident Dies of Improperly Treated Urinary Tract Infection

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The IDPH has issued a citation to Arcadia Care Danville following the death of one of its residents due to an improperly treated urinary tract infection (UTI). This is a case where two very basic yet critical responsibilities of a nursing home failed: the duty to be in touch with the doctor, and the duty to administer medication correctly.

Tragic Battle with Infection at Nursing Home

The resident’s complicated medical history included frequent urinary tract infections, to the point where some of the bacteria causing the infections became resistant. Because the usual antibiotics were no longer working, the patient needed additional testing to confirm the best course of treatment.

During one bout of UTI, the resident got the doctor’s order to take an antibiotic called Levaquin, and also to get a urinalysis with a “culture and sensitivity” test. This test was to determine exactly what kind of bacteria was causing the infection, and what drugs the organism would be susceptible to. The doctor wanted the culture and sensitivity test to see whether the Levaquin was working and whether he needed to adjust the treatment for the resident.

The resident’s test result revealed that the bacteria was resistant to Levaquin, and therefore the course of treatment needed adjusting. His doctor was never notified of the irregular lab result.

Patient’s Doctor was Not Notified About Abnormal Lab Results

Nursing homes are not required to have a physician on site 24/7, but they are responsible for communicating with the doctor when there is a medical irregularity in any of the residents. The doctor would then either come to the nursing home to personally examine the situation, issue orders by phone, or have the resident sent to the hospital.

In this case, the doctor was not notified of the abnormal lab result. Without the physician adjusting the treatment plan, the resident continued to take the medication that wasn’t effective against the UTI.

In the days that followed, the nursing home staff noted the resident’s changes in mental status, abnormal urine appearance, and possible seizure activity. These were all signs of a worsening infection. In addition, another set of labs showed that the resident had elevated creatinine and Blood Urea Nitrogen (BUN) levels, both of which indicated dehydration associated with UTI. His ammonia levels were also elevated — another abnormal finding that needed to be addressed.

Again, this was a situation that should have been communicated to the doctor, but no notification was made.

On top of these, lab tests could not detect the resident’s potassium levels. Potassium is a nutrient that drops to low levels during UTI, so the resident had to be on a potassium supplement to keep this nutrient in his body. Sadly, this supplement was missed when he was transferred from the nursing home into hospice. During the transfer, the hospice staff never received from the nursing home the full list of medications that he was supposed to take.

The resident suffered more symptoms of worsening infection, including increased lethargy, fever, and changes in mental status. Two and a half weeks after his initial abnormal urinalysis, the resident tragically passed away. 

The cause of death was sepsis from the improperly treated urinary tract infection, combined with dehydration and loss of potassium.

Preventable Resident Death, Lapses in Care

The doctor told the state surveyor that these two things — the failure to notify a physician and the medication error — contributed to the resident’s death.

Though these are basic responsibilities of a nursing home, these lapses are all too common among these facilities. We have seen numerous cases of resident injuries and deaths resulting from the staff’s lack of communication with the doctor, lack of vigilance to spot irregularities, and irresponsible handling of treatments. Such injuries and deaths would have been prevented had those nursing homes fulfilled their duties correctly.

Contact an Illinois Nursing Home Lawyer for Legal Help

We believe that most 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 results. 

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.

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

Thank you for reading.

 

Other blog posts that might be of interest:

Resident Undergoes Electroconvulsive Therapy After Palm Terrace Fails To Give Antipsychotic Medication

Flora Gardens Staff Fails To Give Antibiotic, Leading To Death Of Resident

Aperion Care Capitol Fails To Give Medication To Resident Suffering Bacterial Meningitis.

2 Residents At Carriage Rehab Suffer Untreated Bedsores; Doctor’s Orders Ignored

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IDPH has cited the nursing home Carriage Rehab & Healthcare in Rockford, IL after they failed to follow doctor’s orders for the bedsores of not one but two residents.

Bedsore care and treatment are supposed to be a top priority at long-term care facilities. Also known as pressure sores, these lesions or wounds are anticipated among residents who have reduced mobility, as they tend to stay in one position for long periods of time. We have federal regulations that entitle nursing home residents to proper care that promotes the healing of existing bed sores, prevents their infection, and prevents the development of new ones.

When a resident develops a bedsore, the nursing home staff is required to notify the doctor, and the doctor then enters orders for treatment. These treatment instructions typically have to be carried out by the staff on a daily basis. Haphazard treatment for bed sores could lead to worsening wounds and serious infection of surrounding tissues.

In this case at Carriage Rehab, one resident had a bedsore on her heel, and another resident on the side of her foot. The wound care doctor ordered daily dressing changes for each of them. It is standard procedure to write the date of the dressing so that people know when it was last changed.

As the doctor was making his weekly rounds, he discovered that the dressing on one resident had been left unchanged for an entire week, as indicated by the date on it. The next week, he found that the same had happened to the other resident.

The doctor went to the nursing home administrator to explain that this was unacceptable and needed to be reported to the State of Illinois.

The two residents had to undergo debridements or the removal of dead tissue from their wounds. This process would likely have been unnecessary if their bedsores were encouraged to heal with daily dressing changes. Likewise, the prolonged pain of these residents might have been mitigated had the nursing staff followed the doctor’s instructions.

It speaks volumes that the doctor’s orders were skipped not just for a couple of days but for a whole week, and in two separate cases within the same facility. Citations like this are strong indicators of the quality of care that each individual resident receives in a 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 Orland Park resident suffers Stage 4 bed sore

Sharon Health Care Willows resident undergoes surgery for bed sore

Integrity of Smithon resident develops infected pressure ulcer

 

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

 

Thank you for reading.

Lack Of Wound Monitoring Leads To Resident’s Infection At Regency Care of Morris

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IDPH has cited the nursing home Regency Care of Morris after a resident there developed a wound infection that required surgical removal.

Wounds and wound infections are major concerns at long-term care facilities. One of the basic responsibilities of nursing home staff is to monitor any of the residents’ wounds and look out for signs of infection. When a symptom of infection is present, the staff must then bring it to the attention of the doctor. The physician then decides whether to instruct the nursing staff on appropriate treatment, to come to the facility and administer the treatment himself/herself, or to have the resident brought to a hospital.

It is crucial to have wound infection treated early. Allowing it to fester could lead to more serious conditions involving various body tissues.

The resident in this case had a wound from a hip replacement surgery. Upon her admittance to the nursing home, it would have been part of the staff’s job to monitor this wound. The resident had staples on the wound when she was admitted to the nursing home, but these staples were subsequently removed during her initial postoperative visit at the hospital. Unfortunately, there was no documentation that the wound was assessed after that postoperative appointment.

Eight days after that visit, the resident asked a nurse at the Regency facility for shower assistance. It was only then that the nurse saw bloody drainage coming from the resident’s surgical wound, and called the doctor.

The resident was brought to the hospital, where wound infection was recognized. She told the doctor and the Department of Public Health surveyor that she had reported the drainage to the nursing home staff a few days earlier, yet nothing was done about it.

By the time the resident was sent to the hospital, she had to undergo surgical debridement of the wound. Doctors had to cut away portions of her gluteus muscle and trochanter, a part of the femur or hip bone. This indicated some level of osteomyelitis, a type of bone infection.

Deep-tissue infections like this happen when a wound infection is left untreated for a time. This resident’s wound was left unchecked and untreated for at least several days. Had the nursing home staff been more diligent in carrying out their wound monitoring duty, and had they called for treatment sooner, the resident’s infection would not have reached a costly and dangerous extent. In short, this resident’s horrible experience could 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:

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

Failure to obtain treatment orders leads to surgical wound infection at Loft of Canton

Infection results from failure to care for surgical wound at Arcadia Care of Morris

Sharon Health Care Willows resident undergoes surgery for bed sore

Flora Gardens staff fails to give antibiotic, leading to death of resident

 

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

 

Thank you for reading.

Resident Left Without Gait Belt Fractures Arm at Clayberg Nursing Center

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The Illinois Department of Public Health cited the Clayberg Nursing and Rehabilitation Center in Cuba, Illinois due to an injurious fall that ended up in a broken arm. 

Patient Had a Recognized Fall Risk 

The injured resident had a recognized fall risk marked by her history of falling alongside unsteadiness and some weakness in her legs. Specifically, she had been designated to require extensive assistance when doing transfers and using the toilet. 

When a nursing home resident has this requirement, a staff member has to physically ‘lay a hand’ on them to assist them with their movements, as opposed to just watching them and letting them move on their own.

In this particular case, the Clayberg resident had an aide that assisted her in showering, bathing, and getting dressed. However, as the aide was picking up towels, the resident was left in a standing position without a gait belt on and without someone physically assisting her as she stood. The resident lost her balance and suffered a fall that resulted in her arm fracture.

Most Nursing Home Falls can Be Prevented  

In many cases, nursing home residents require the use of a gait belt, a wide canvas strap that wraps around the midsection of their body and is held by the nursing home aide. This allows the aide to keep the residents upright and help them control their movements. Additionally, if the resident loses their balance, the aide can maneuver the fall to minimize the chances of injury on the resident.

This incident highlights the responsibility of nursing homes and their staff to follow care protocols to the letter. Even just a momentary deviation from gait belt use can lead to painful injuries, especially for older or impaired residents. An incident like this could just as easily result in life-threatening conditions like head trauma or spine injuries.

It also illustrates that many nursing home injuries could be prevented, if only the facility upholds its obligations towards residents. Often, injuries on residents are chalked up as accidents when they are a direct result of the facility’s or their staff member’s failure to do their duty.

Call an Illinois Nursing Home Abuse Lawyer 

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 results. 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.

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

Thank you for reading.

 

Other blog posts that might be of interest:

Mishandling of resident results in broken shoulder at Havana Health Center

Christian Nursing Home resident suffers severe leg injury in fall

Fondulac Rehab resident suffers fatal injuries in fall

River Bluff resident fractures elbow in fall from a wheelchair

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

Understaffing at Generations at Rock Island leads to fall and hip fracture

Southpoint Nursing & Rehab resident breaks leg in an improper transfer

Resident Breaks Hip After Fall in McLean County Nursing Home

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IDPH has cited the McLean County Nursing Home in Normal, Illinois after one of its residents with a high “fall risk” suffered a hip fracture from falling in the home.

Staff Was Aware of High Fall Risk 

On the evening of the fall, a nursing home aide had brought the resident to her bathroom at 5 p.m. The resident was then seen at 6:45 p.m., seated on her wheelchair by the foot of her bed. Then about an hour later, staff heard her calling for help. They found her on the floor with obvious signs of injury. They brought her to the hospital, where she had to undergo surgery for her broken hip.

Prior to this incident, there were obvious signs that the resident needed protection from falls.

Her quarterly assessments showed that her risk of falling went from “moderate” to “high.” She was also specifically assessed to be unsteady when standing from a seated position. These should have prompted revisions to her care plan, with proactive steps for the staff to reduce her fall risk. For instance, her unsteady motion when trying to stand up meant that she needed extensive assistance when using the toilet.

This is especially important because the resident had a known behavior of frequently getting up to go to the bathroom on her own. Staff members themselves were well aware of this. They described to the state surveyor that she would get up from her wheelchair and try to go to the bathroom unassisted.

Worse, they would find her walking down the hallway with her Depends around her ankles after she had used the bathroom on her own, unable to lift the sanitary garments back into place. An impediment around the ankles is dangerous for someone who has a high fall risk.

On top of all these, the resident was known to have dementia. 

Nursing homes must take into account that residents with dementia might not be able to follow instructions well, recognize their physical limitations, or make good decisions for their safety. This should be factored into a resident’s care plan.

However, for this particular resident, the main intervention that was planned was to have the resident use the call light. This is an instruction that a person with dementia might not be able to follow. It was not likely to be an effective intervention for this resident who had dementia and a high fall risk.

Proactive Care Was Required but Not Undertaken

Considering her profile, the resident needed more proactive care around her. This could have included a toileting schedule that is developed from her observed bowel and bladder patterns. 

This nursing home could have noted the usual times when she needed to use the toilet, then provided her with an aide to assist her during those times. Other measures could have included regular rounding and placing the resident in common areas instead of by herself.

Her painful fracture might not have occurred if she was given more appropriate attention and care at the nursing home.

Call an Illinois Nursing Home Abuse Lawyer 

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 results. 

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.

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

Thank you for reading.

 

Other blog posts of interest:

Resident at University Rehab Northmoor in Peoria suffers broken hip in fall from bed

Red Bud Regional Care staff fails to respond to call light, leading to fall

Resident suffers fatal brain bleed in fall at Pleasant Meadows Senior Living in Chrisman

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

Heritage Health Pana staff violates care plan, resident falls and breaks hip

Understaffing at Generations at Rock Island leads to fall and hip fracture

After a Series of Falls, Resident Suffers Broken Hip at Tower Hill Nursing Home

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The IDPH has issued a citation to Tower Hill Nursing Home in Elgin, following a broken hip injury sustained by one resident. The injurious fall is the most recent in a series of falls that the resident had suffered, which could have been prevented had the care plan been updated and adhered to.

Nursing Home Care Planning and Fall Risk   

It is standard procedure at nursing homes to revisit a resident’s care plan once the resident suffers a falling incident. This is because “a fall begets more falls,” meaning that if a resident falls once, it is a sign that they are at higher risk of falling again. One fall should trigger a revision of their care plan to determine what measures should be implemented to reduce the risk of subsequent falls.

However, this particular resident at Tower Hill was not protected by appropriate preventive measures, even after she experienced three falling incidents leading up to her injury.

Patient Suffered Several Falls  

The first fall was an unwitnessed incident in her room. Her care plan was actually updated after this, referring her to physical therapy. However, for some reason, this was not carried out.

She fell again five weeks later, also unwitnessed in her room. This time, she was referred to physical therapy, but was discharged quickly because her dementia prevented her from participating in a meaningful way.

The physical therapy clinic instead recommended that she be supervised. She was found to require contact guard assist, which meant that an aide should physically put hands on her to help steady her movements. The clinic also recommended restorative care for her ambulation or walking about. 

These recommendations were not incorporated into her care plan.

Two months later, the resident fell again in an unwitnessed incident, and this time, she broke her hip. She had to be sent to the hospital to undergo surgery.

Care Plan Diligence is Crucial for Injury Prevention 

This injury might have been avoided if significant updates to the patient’s care plan were implemented and followed through. 

Any long-term care facility should have recognized that a resident with her profile needed aggressive fall preventive measures. She had balance issues, mobility issues, dementia, and a previous diagnosis of traumatic brain injury. She also now had a history of falls that the nursing home was well aware of.

The contact guard assist that was recommended after her second fall would have helped to keep her steady and might have prevented her third and injurious fall. There are also other strategies to prevent such incidents. One is to place the resident in common areas where the staff can supervise her. The nursing home could also implement frequent rounding, or having somebody check on the resident at regular intervals, perhaps every 15 minutes.

The fact that she was not protected by relevant anti-fall measures points to substandard care. 

Contact an Illinois Nursing Home Lawyer for Legal Support 

Falls are a major consideration in the long-term care industry. At the very minimum, nursing homes are supposed to have explicit care plans for this particular issue, plus vigilant reassessments and meticulous implementation of these plans.

Without these, it’s a matter of good luck rather than good care that a resident doesn’t suffer serious injuries. And residents’ safety should not be left to luck.

We believe that most 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 results. 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.

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

Thank you for reading.

 

Other blog posts that might be of interest:

Addolorata Villa resident fractures hip in fall

Alden Courts of Shorewood resident breaks both legs during unsafe transfer

Understaffing at Generations at Rock Island leads to fall and hip fracture

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

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

Heritage Health Pana staff violates care plan, resident falls and breaks hip

Center Home Resident Suffers Broken Arm, Requires Surgery After Fall

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IDPH has cited the Center Home for Hispanic Elderly in Chicago after one of its residents broke her arm in a fall, requiring surgery.

Nursing homes must have measures to avoid injurious falls among their residents. One of these measures is the fall risk assessment, which is the first step in every resident’s care planning process. Upon admittance to a nursing home, the resident goes through this evaluation to see whether they should be tagged as someone with a “fall risk” and should have a fall prevention care plan. The whole process is then redone every 90 days to ensure that the resident’s care plan is up-to-date.

Several factors are examined to determine a person’s risk for suffering falls. Two major factors are gait or balance dysfunction and intermittent or constant confusion.

In this particular case at Center Home, the resident underwent an incomplete fall risk assessment. Specifically, her gait assessment was never completed by the restorative nurse assigned to the task. Thus, the resident was not flagged for fall risk, and she did not have a fall prevention care plan.

Had the gait analysis been completed, the resident would likely have shown a risk of falling due to her polyneuropathy, a nervous condition that affects one’s gait and balance. In fact, she was already largely dependent on a wheelchair due to her physical weakness. Though her balance and gait were clearly compromised, the lack of a complete fall risk assessment meant that there was no fall prevention plan for her at the nursing home.

Five months after she was admitted, the resident suffered a fall that broke her arm. She was initially hospitalized for immediate treatment, and then a second time for surgical repair of the fracture.

It’s additionally notable that she had been in the home for five months and within that time, her care plan had not been revised to include fall prevention. Each resident’s care planning is supposed to be reviewed every 90 days, which means that this particular resident should have had at least one review during her stay. A proper review of her care plan would have shown her fall risk and hence put in place a fall prevention plan that might have prevented her injurious accident.

In short, this injury was avoidable at two different points: first, during the resident’s admittance and initial care planning, and second, during the quarterly review of the care plan. Yet in both instances, the nursing home failed to provide the fall prevention plan she needed.

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:

River Bluff resident fractures elbow in fall from wheelchair

Warren Park Health & Living Center resident suffers brain bleed in fall in stairwell

Understaffing at Generations at Rock Island leads to fall and hip fracture

Red Bud Regional Care staff fails to respond to call light, leading to fall

 

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

 

Thank you for reading.

Lexington of Orland Park resident suffers Stage 4 bed sore

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IDPH has cited and fined Lexington of Orland Park nursing home after a resident there was found with a Stage 4 bed sore on her sacrum.

Bed sores are an area of intense focus in the long-term care industry for a number of reasons, not the least of which is that the development of bed sores has serious adverse consequences for the quality of life of a resident who suffers one.  Federal regulations provide that a resident who enters a nursing home without a bed sore (or pressure ulcer) should receive care, treatment, and services necessary to prevent one from occurring unless the resident’s condition shows that they are unavoidable.  The regulations also provide that after a resident develops a bed sore, they are entitled to care, treatment, and services which are necessary to promote healing, prevent infection, and prevent the development of new pressure ulcers.

It is an area which is specifically addressed during the care planning process.  It begins with an assessment of the resident, usually using the Braden scale to determine the resident’s risk level of developing pressure ulcers.  There are a number of risk factors, but they key risk factors are immobility, incontinence of bowel or bladder, and poor nutritional status.  If a resident is at risk for developing bed sores, this must be addressed in the resident care plan with steps that should be taken on a day-to-day, shift-to-shift basis.  If a resident does develop a bed sore or has a decline in an existing one, this is something that requires physician notification and revision of the care plan.

The resident at issue was admitted for short terms rehab after a fall in which she suffered a broken back with no bed sores present.  However, she was at risk for developing bed sores due to immobility associated with the fractures and incontinence of bowel and bladder.  The care plan which was put into place including daily monitoring of the skin.  Usually this is a task which is done by the aides which assisting a resident with getting dressed, bathing, or providing incontinence care.  If an aide sees an area of concern, it is the aide’s responsibility to notify the nurse who can then make a determination what it is and notify the doctor if need be.

Bed sores or pressure ulcers are rated as Stage 1 through Stage 4.  A Stage 4 is the most severe, involving exposed muscle and bone.  However, advancing from a Stage 1 to a Stage 4 takes time, and treatment can and should slow the progression, if not actually heal the wound once it is discovered.  This is why physician notification is required after a resident is discovered to have a bed sore.  Without treatment, further decline is almost a certainty.

When the staff first reported that this resident had a bed sore, it was a Stage 4 bed sore on her sacrum with sloughing and exposed bone.  In other words, this was an advanced wound, and the presence of sloughing is often associated with dead, bacteria-laden tissues which can set the resident up for complications such as cellulitis or osteomyelitis infections.  The resident was referred to a wound care doctor for treatment.

The fact that this wound was so advanced when it was first documented says that one of a number of things, but either the aides did not realize that this was a resident for whom daily skin inspections was required; they did not realize what they were looking at when they were dressing, showering, or providing incontinence care to the resident; or they did not know that skin defects needed to be reported to the nursing staff.  None of these reflect well on the quality of care that was being provided 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:

Infection results from failure to care for surgical wound at Arcadia Care of Morris

Oak Brook Care resident develops Stage IV pressure ulcer from immobilizer

Grove of Berwyn fails to treat bed sore

Failure to treat pressure ulcer at Franciscan Village in Lemont

Untreated pressure ulcer at Aperion Care of Bradley

 

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

 

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

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IDPH has cited and fined Warren Barr North Shore nursing home in Highland Park after a resident there was rolled out of bed while receiving incontinence care, suffering multiple fractures of the tibia and fibula.

Bed mobility is a term that generally refers to a resident’s ability to move and change position in bed.  Some residents, due to musculoskeletal issues, need the assistance of one or more staff members with bed mobility.  This is important for changing positions to prevent bed sores, for example.  It also is important when a resident needs incontinence care so that they can get into a side-lying position to allow staff members to clean them and apply barrier cream.

When a resident requires assistance with bed mobility, this is something that should be addressed in the care plan and recorded in the Minimum Data Set.  Depending on the degree to which assistance is needed in safely positioning the resident, this may require the help of two staff members.

Having two staff members on hand for assistance with bed mobility is critical for the safety of the resident in order to prevent injuries from rough handling, or as here, being rolled out of bed.

The resident at issue had significant musculoskeletal deficits and had been care planned as requiring the extensive assistance of two staff members with bed mobility.  On the day of this nursing home fall, there was a single aide providing incontinence care to the resident.  While this was happening the resident rollled over the edge of the bed.  The aide attempted to slow the descent of the resident, but she still landed on her ankle.  She was brought to the hospital where a CT scan showed that there were four separate fractures of the tibia and fibula (bones of the lower leg).

For regular readers of this blog, it is part of the familiar story of what happens when you have one person doing a two-person job (see  here, here, here, and here for examples) with predictably disastrous results.

One person doing a two-person job is also consistent with a understaffed nursing home, something that was a specific issue raised in a citation involving a fall at this nursing home last year.  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:

Park Place Christian Community resident rolled out of bed by staff

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

Resident rolled out of bed at Warren Barr – Lincolnshire

Short-staffing leads to fall at Manorcare – Libertyville

Inverness Health & Rehab resident suffers multiple fractures in fall

 

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

 

 

 

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

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IDPH has cited and fined Palm Terrace nursing home in Mattoon after staff there failed to give a prescribed antipsychotic medication to one of the residents, leading to a breakdown of the resident which required the resident to be hospitalized and undergo electroconvulsive therapy.

The resident at issue had a history of mental illness and was discharged from the hospital to the nursing with an order to receive an injection of an antipsychotic medication called Invega approximately two weeks after admission to the nursing home.  The nursing home apparently failed to order the medication, and by the time that the due date for giving the medication came, the pharmacy which supplied the medication informed the nursing home that the medication was not covered by the resident’s insurance.  As a result, the resident did not receive the medication.

About two weeks after the missed dose of the medication, the resident experienced a psychiatric breakdown which involved him being threatening to the staff and refusing to keep his clothes on.  The resident was brought to the hospital and admitted to the psychiatric unit where he underwent three rounds of electroconvulsive therapy in an effort to resolve the breakdown.

There were at least two major breakdowns in the care that this resident received.

First was the medication error which resulted in the resident not receiving the Invega which was prescribed for him.  When a resident is going to be admitted to a nursing home, the admissions staff receives and reviews information about the resident to ensure that they can meet the care needs of the resident.  If they can’t, the proper course is to deny the admission.  One of the pieces of information that they receive is a list of the medications which have been prescribed so that they can order the medications to have them ready or on order when the resident is admitted.  There was clearly a breakdown in this process – otherwise, the medication that the resident needed would have been on order when the resident arrived.  If it could not be obtained, then other measures had to be taken.

Second was the failure of the nursing staff to notify the doctor that the medication which he prescribed was not being given to the resident.  Doctors generally work on the assumption that their orders will be followed and that prescribed medications will be given.  If this medication could not be obtained and was not given to the resident as ordered, the doctor was required to be notified so that he could determine what other course of action to take.  Simply not giving the resident critical medications and hoping for the best was never an acceptable course of action.

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:

Marshall Rehab resident fractures back in van accident

Taylorville Skilled fails to obtain anticonvulsant medication for resident

Flora Gardens staff fails to give antibiotic, leading to death of resident

Medication error at Palm Terrace leads to hospitalization

 

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

 

 

 

 

River Bluff resident fractures elbow in fall from wheelchair

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IDPH has cited and fined River Bluff Nursing Home in Rockford after a resident there suffered a fractured elbow in a fall from her wheelchair.

For residents who are a fall risk, staying in a seated position is often the safest place to be.  However, when a resident has poor trunk control as a result of weak core muscles, that is not always true.  When a resident has poor trunk control, their torso can move well outside the center of the body, bringing their center of gravity forward or over to the side, resulting in them falling forward out of the chair or over the sides of the chair.  To address this, a resident with poor trunk control may be seated in a chair or wheelchair that tilts backwards or with high arms to prevent falls.

This resident apparently had poor trunk control which was combined with a behavior of frequently bending forward to adjust the footrests on her wheelchair.  Because of this behavior, part of her fall prevention care plan called for her to be seated in a tilted position in her wheelchair.  However, due to poor maintenance of the wheelchair, she was not tilted back on the day of her fall.  Further, the nurse on duty believed that since she was not demonstrating the behavior of bending forward to adjust the footrests it was not necessary to place her in a tilted position.

The net result?  The nurse on duty left her in a regular seated position and then went to attend to other residents.  After she did so, the resident leaned forward and fell out of her wheelchair.  As a result of this nursing home fall, the resident suffered a broken elbow and a significant laceration to the head.

There are at least two issues with the care that this resident received.  First, federal regulations provide that a resident receive care, treatment, and services necessary to prevent accidents, which includes falls.  This includes making sure that the equipment that they use is well maintained and in good working order.  Second, care plans are intended to be carried out on a day-to-day, shift-to-shift basis, and leaving the resident in a regular seated position when the care plan called for the resident to be tilted backwards was a violation of the care plan.

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:

Understaffing leads to fall and hip fracture at Generations of Rock Island

PA Peterson resident breaks both legs in fall

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

 

Flora Gardens staff fails to give antibiotic, leading to death of resident

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IDPH has cited and fined Flora Gardens Care Center nursing home in Flora after a resident there died after the staff failed to give her the antibiotics which had been prescribed for a urinary tract infection.

One of the places where failures in the delivery of care can occur in nursing homes is in transitions in care – generally from the hospital to the nursing home.  This is because residents are often re-admitted to the nursing home after a hospital visit with new prescriptions for medications and new orders for treatment.  When the nursing home fails to give the new prescriptions or follow the new orders, disaster is the likely result.

This resident was brought to the emergency room with a urinary tract infection.  Urinary tract infections are unpleasant for anyone, but for nursing home residents they can prove fatal if they go unchecked.  Fortunately, they are often treated successfully with front-line antibiotics.

And that was the plan for this resident.  She was brought to the emergency room and returned later that day with a prescription for the antibiotic levaquin which was to be given once a day for 7 days.  The hospital faxed the order for the antibiotic over to the nursing home and returned the resident back to the facility the same day.  However, the resident did not receive the antibiotic as ordered and the medication error went undiscovered for three days until a family member called the nursing home to get an update as to how the resident was doing.  At that point the medication error was discovered.  The medication was then ordered from the pharmacy and the resident’s doctor was notified.

Five days after the medication started to be given the resident was returned to the hospital.  There she was diagnosed as suffering from severe sepsis and was discharged back to the nursing home to receive end of life care.  The resident’s physician told the state surveyor that he believed that the delay in starting the antibiotic contributed to cause the death of the resident in that it permitted the infection to enter the bloodstream and become systemic whereas it had been a localized infection at the time the resident left the hospital.

A nursing home is a business and a well-run business has systems in place to ensure that the routine operations of the business get done without fail.  Making sure that orders for treatment and medication get carried out when a resident is admitted or re-admitted to a nursing home or after a doctor or hospital visit.  Obviously, the systems that were supposed to ensure that this resident received the medication she was prescribed broke down – ultimately with fatal consequences.

Topping all this off was what happened after she was returned to the nursing home to receive end-of-life care.  She was prescribed a scolpamine patch to help her stay comfortable up through the time that she passed, but this medication was not given either.  She died about 6 hours after returning to the nursing home.  Her family placed multiple calls to find out what her condition was like but no one took or returned their calls until after she had died, denying them a chance to see her in her last moments even through the nursing home window.

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:

Fatal medication error at Warren Barr Oak Lawn

Taylorville Skilled fails to obtain anticonvulsant medication for resident

Failure to give HIV medications at Bria of Belleville

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

Medication error at Palm Terrace leads to hospitalization

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

 

Understaffing at Generations at Rock Island leads to fall and hip fracture

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IDPH has cited and fined Generations at Rock Island nursing home after a resident there sustained a fractured hip caused in part by the understaffing of the nursing home.

In this blog, we often discuss the importance of the care planning process in delivering the routine care that is absolutely necessary to assure the health, safety, and well-being of residents (see here, here, here, and here for recent examples).  However, even the best care plan is of no use if there is not enough staff around to actually carry it out.

There are two basic regulatory standards that have to be met in terms of staffing levels at nursing homes.  One is the state standard which uses a mathematical formula to determine appropriate staffing levels.  The second standard is the federal regulation which is more flexible, yet more demanding.  It provides that the nursing home must have enough appropriately trained staff on hand to meet the care needs of the residents on a 24/7 basis.

Understaffing has always been a part of the nursing home business model.  It is part of why we believe that nursing homes are inherently built to fail and why we wrote a free report with the same name.  In essence, nursing homes are one of the few explicitly for-profit sectors in the health care industry.  They generate revenue per resident, per day and maximize revenue by filling as many beds as possible with as many ill people as they can.  On the expense side, staff is the biggest expense item and  to maximize profits, you need to keep staffing expense to a minimum.

The net result of this is that resident suffer poor care because there is not enough staff on hand to meet the care needs of the resident.  Residents are not turned and repositioned and do not receive prompt incontinence care, leading to bed sores.  Residents don’t get help and/or supervision while eating, leading to malnutrition and dehydration as well as nursing home choking accidents.  Nurses get distracted while doing medication pass, leading to medication errors.  And finally as here, staff is unable to answer call lights, leading  to nursing home falls.

The citation that IDPH issued to this nursing home is long (130 pages) and covered a multitude of issues involving several different residents, but we are focusing here on the staffing issue and how it related to this resident’s fall.  As a starting point, one of the things that the nursing home was explicitly cited for was understaffing. Understaffing is a common feature of care in nursing homes and is often the root cause of many unnecessary deaths and injuries to nursing home residents, but it is rarely the explicit subject of a citation issued by IDPH.

How bad was the understaffing that IDPH found?  In one portion of the citation, a nurse described having 43 residents to care for with her and one aide.  There is simply no way that residents can get the care they need with that kind of resident to staff ratio.  The pandemic has clearly made things more difficult for nursing homes, but ending up with staffing levels like that is a failure of management.

What was the impact of the short-staffing on this resident?

She was assessed as being a fall risk due to difficulty walking and dementia. Dementia is a key factor is a resident’s fall risk because residents suffering from dementia cannot be relied upon to follow instructions or make good decisions for their own safety.  Before the fall in which she broke her hip, she had a fall in which she suffered a bump on the head.  One of the truisms in the nursing home industry is that the occurrence falls tend to beget additional falls, and her care plan was revised to include 15 minute checks on the resident.

Frequent checks on residents who are fall risks is an excellent step for preventing falls – if it is actually done.  However, we know that this nursing home was understaffed and this was something that was not feasible for the staff given the staffing levels.  However, the care planning process requires more than writing down good ideas on paper; it requires actually carrying them out.

On the day of this nursing home fall, the resident sounded the call light to get help to go to the bathroom.  Her roommate told the state surveyor that the call light hand been on for about a half hour.  The resident leaned against her table while going toward the bathroom.  The table broke and she fell to the ground, suffering a fractured hip.

This is a situation where the is an explicit link between understaffing of the nursing home and a resident injury.  The resident was supposed to be checked on every 15 minutes.  That didn’t happen, as the roommate told the state surveyor that she had been waiting a half hour after sounding the call light, so the care plan was clearly not being implemented.  This was also likely not the first time that this had happened, and when there are repeated instances of not getting a timely response to a call light, the residents are essentially trained that no one is coming when they sound a call light, so they are ever more likely to take risky actions.

The net result for this one resident is that she suffered a serious injury that has real long-term consequences, assuming that this not a case where the hip fracture ends up being an ultimately fatal injury.

Other blog posts of interest:

Brain bleed the final result of multiple falls for Monmouth Nursing Home resident

Hope Creek resident breaks hip in fall from toilet

Generations at Rock Island fails to care for pressure ulcers

Pleasant View Rehab resident breaks hip in fall

Vandalia Rehab cited for understaffing

Aperion of Spring Valley resident suffers fatal brain bleed in fall

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

 

Red Bud Regional Care staff fails to respond to call light, leading to fall

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IDPH has cited and fined Red Bud Regional Care Center nursing home after a resident there fell after getting out of bed to shut the lights off because the staff did not respond to her call light.

There are a number of factors which can contribute to a resident being a fall risk.  Among these are musculoskeletal, balance, or gait deficits; a history of falls; and poor safety awareness.  When the resident is at risk for falling, then a fall prevention care plan must be developed and implemented.  Well-constructed fall prevention care plans will generally include as elements of it anticipating the resident’s needs and promptly responding to call lights.  The reason that these are commonly included in the fall prevention care plan is so that residents don’t get up unassisted when they actually need help with walking or transferring.

The resident at issue had been admitted to the nursing home for rehabilitation after a fall at home in which she broke her clavicle and her left hip. She was considered a fall risk due to poor balance, a weak gait, her history of falls, and poor safety awareness.

On the night of this nursing home fall, the resident had been put to bed.  Normally, she liked the lights off when went to bed, but for whatever reason the staff left them on when they left the the room.  She activated her call light to have the staff turn the lights off, but no one responded for a half hour.  Tired of waiting, she got her walker went over to turn the lights off herself, and as she turned to head back to bed, she lost her balance and fell to the floor.  She called for the staff to come help her, but when no one responded for over 20 minutes, she called her son with her cell phone, who in turn called the nurse’s station.  The staff then went to the room and found the resident on the floor.

She was brought to the hospital where she was diagnosed with a femoral neck fracture.  This is the bridge of bone that connects the femur (or thigh bone) to the ball of the hip.  Even though it is described as a fracture of the femur, it is really a fractured hip.  Since this was the same hip that she had broken earlier, this will undoubtedly be a complicated recovery from this injury which may leave her with additional mobility deficits.

This is case where simple failures of care led to a significant injury.  Had the lights been shit off when the staff left the room (that would be an example of anticipating the resident’s needs), the resident would not have been up.  Had the staff responded to the call light, the resident would not have been up.  Often in a nursing home setting, these simple breakdowns in the delivery of care lead to horrific results.

When we investigate this kind of case where the use of the call light is at issue, one step we take is to find out what make and model the call light system was.  Many call light systems record data regarding the time the call light was sounded until when it was shut off.  This can provide really accurate data as to how long the call light had gone unanswered for any particular event.  Past that, data can usually be obtained for that resident over the course of the admission, for the resident’s room, for the hall she lived on, or for the facility itself.  If the data shows that the staff frequently left residents waiting for extended periods of time, this is essentially trains the residents that no one is coming for them when they sound the call light, reducing the chances that they will wait for assistance.  This increases the risk of falls and catastrophic injury, such as broken hips or brain bleeds.

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

Elmwood Nursing & Rehab resident fractures and dislocates hip in two separate falls

University Rehab resident breaks leg due to lift failure

Red Bud Regional Care resident breaks hip and leg in fall

Hitz Memorial Home resident dropped from lift

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

 

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

 

Bella Terra Wheeling resident chokes to death

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IDPH has cited and fined Bella Terra Wheeling nursing home after a resident there choked to death while eating dinner without supervision.

We have written in this blog many times about the significance of the care planning process, and the tragic results that can come from a lack of care planning, poor care planning, or the failure to actually implement the resident care plan.  This incident arises from failing to understand what the interventions in the care plan are.

The care planning process begins with an assessment which is intended to identify the risks to the well-being and safety of the resident.  At the same time, the Minimum Data Set (MDS) is completed which records the results of a comprehensive assessment of the resident.  The MDS helps form the basis by which the nursing home is paid for services provided to the resident, so this must be completed under penalties of perjury.  From the assessment, a care plan is completed which must then be communicated to the staff who in turn must carry out the care plan on a day-to-day, shift-to-shift basis.  Finally the effectiveness of the care plan must be evaluated on an ongoing basis and then revised if it proves to be ineffective in practice.

For this resident, the MDS recorded that he required supervision with eating, and his care plan also showed he required supervision with eating due to dementia with behaviors.  The speech therapist told the state surveyor that “supervision” meant having the resident in view while eating.

On the day of this nursing home choking accident, the aide brought the resident’s dinner tray into the room.  The resident did not want to get out of bed, so the aide left tray with the resident after elevating the head of the bed to 90 degrees and then left the room.  About five minutes later, the nurse was making her rounds and saw that the resident was slumped over, blue in the face, and gasping for air.  She attempted the Heimlich, but was unable to clear the airway.  The resident was pronounced dead by the paramedics who were called to the nursing home.

Staff interviewed by the state surveyor told the surveyor that “supervision” while eating meant reminding the resident to take small bites or that the food is on front of them and then periodically checking on them.  The speech therapist explained that what the staff though was “supervision” was actually “cueing,” and that supervision meant keeping the resident within sight.

Here, this resident choked to death because there was a disconnect between what the care plan called for and what the staff thought it meant.  This speaks to a lack of training of the staff.  This shows a lack of interest in investing in the staff on the part of the ownership and management of the nursing home.  Sadly, this is a common theme in the choices management makes in how to operate a 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:

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

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

Resident chokes at Grove at the Lake

Winston Manor resident chokes on peanut butter sandwich

Hillcrest Retirement Village resident chokes to death

Resident chokes to death at the Moorings in Arlington Heights

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

 

 

 

Sharon Health Care Willows resident undergoes surgery for bed sore

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IDPH has cited and fined Sharon health Care Willows nursing home in Peoria after a resident there developed a bed sore on his buttocks which declined to the point that it required surgery and treatment with IV antibiotics.

Federal regulations provide that when a resident enters a nursing home without having a bed sore, he should receive care, treatment and services such that the resident will not develop them unless they are clinically unavoidable.  Further, once a resident does develop a bed sore, he must receive care, treatment and services necessary promote healing, prevent infection, and prevent the development of new sores.

Because they are so specifically addressed in the federal regulations, prevention of bed sores is a specific area of focus in the care planning process at every nursing home.  The care planning process begins with an assessment of the resident’s skin condition and then their risk of developing beds sores, most often using a standardized risk assessment tool called the Braden Scale.  If a resident has bed sores or is at risk for developing bed sores, a care plan is developed which includes a series of steps that are to be taken to reduce the risk of having a resident actually develop bed sores.  That pressure ulcer prevention care plan must then be communicated to the staff who then must carry it out on a day-to-day, shift-to-shift basis.  Finally, the care plan must be evaluated on an ongoing basis to see whether it is effective in practice or whether it is meeting the care needs of the resident, taking into consideration any changes or declines in the resident’s condition.

Aides are responsible for regularly checking the skin of the residents they care for while dressing them, providing incontinence care, or giving showers. If they identify an area of skin breakdown, it is their job to alert the nurse.  Nurses are also responsible for periodic skin checks as well.  if a skin breakdown is identified, it is the nurse’s job notify the doctor of the bed sore so that the doctor can enter orders for treatment.  Further, the development of a bed sore or the decline of an existing one is an event that requires revision of the care plan.

This citation tells the story of what happens when there are multiple breakdowns in this process because staff members do not know what their responsibilities are.

When the resident at issue was admitted to the nursing home, he had no skin breakdowns.  This means that he should not have developed any unless they were clinically unavoidable.  A Braden assessment was performed which showed that he was at moderate risk for developing bed sores.  Even though the resident was at risk, no pressure ulcer prevention care plan was put into place.  A well-thought out care plan would have included a turning and repositioning schedule, use of pressure relieving device, use of barrier creams, and regular skin inspections.

Just over two weeks before the resident was sent to the hospital, an aide discovered a skin breakdown on the buttocks.  However, none of the aides reported the skin breakdown to the nurse.  The treatment nurse was responsible for doing weekly skin inspections.  However, she never identified the area of skin breakdown because the resident was in a low bed (as a fall prevention measure) making it difficult to see the area of the buttocks where the skin breakdown occurred, which was in between the folds of the buttocks.  The treatment nurse further reported to the state surveyor that the skin checks which were supposed to be done each shift by the aides was documented as being done, but were not in fact done, and on other shifts the skin checks were not completed at all.

A week before the resident went to the hospital, the treatment nurse did a quarterly reassessment of the resident’s Braden score to measure pressure ulcer risk.  This showed that the resident’s condition had declined and was now at high risk – notwithstanding the fact that resident already had a bed sore that she was unaware of.  Of course, the resident’s condition had probably declined to the point where the resident was at high risk well before that, but that did not trigger any of the nurses on the floor to suggest revision of the care plan.

Even though the treatment nurse now recognized that the resident was at high risk for skin breakdowns, she did not revise the care plan.  She expected that the care plan coordinator would revise the care plan.  The care plan coordinator acknowledged getting the Braden scores showing that the resident was now at high risk, but told the state surveyor that she didn’t know what to do with them.

On the day that the resident was sent to the hospital, the treatment nurse was helping an aide clean up the resident after an episode of incontinence.  While she was doing so, she saw two necrotic areas on the resident’s buttocks.  She alerted another nurse and they contacted the doctor who ordered the resident sent to the hospital.

T o summarize the areas where the care of this resident broke down, we have:

  • The resident was assessed as being at moderate risk of skin breakdown, but no care plan was put into place.
  • Multiple shifts in which skin inspections were supposed to be completed by aides which were not done or which were documented as having been done but were in fact not done.
  • When the skin breakdown was discovered it was not reported to the nurse by the aide who discovered it, nor by multiple other aides during later shifts over the next two weeks plus.  Due to the failure of the aides to notify the nurses, the doctor was not notified of the skin breakdown for over two weeks, resulting in a delay in the resident receiving the care he needed.
  • The skin breakdown was not noticed by the treatment nurse during her weekly skin inspections for at least two weeks, in part due to the resident being in a low bed which made seeing the wound difficult.
  • The resident’s condition declined to the point that he was at high risk for skin breakdowns, yet none of the nurses recognized that this was the case so as to suggest revision of the care plan based on the change in his condition.
  • The treatment nurse conducted a Braden assessment without recognizing that the resident already had a skin breakdown.
  • Once the Braden was done showing that the resident’s risk of skin breakdown had increased from moderate to high risk, there was still no revision of the care plan.

So – what was the consequence of all this?

The resident was brought to the hospital, where the wounds were assessed as being Stage 4 bed sores.  Surgery was performed, and the resident was started on IV antibiotics because there was evidence that the infection of the soft tissue had worked its way into the bone (osteomyelitis).  These wounds would not have necessarily progressed to that point with proper steps being taken to prevent the bed sores or with the timely initiation of treatment for these wounds.

The failure of the aides, the treatment nurse, and the care plan coordinator to recognize what their roles are in the prevention and treatment of bed sores speaks to a nursing home which fails to invest in the training of its staff.  Unfortunately, failing to make this kind of investment in the people who work for them is common in the nursing home industry.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Resident suffers from multiple pressure ulcers at Parker Rehab

Bed sore requires surgery for Timbercreek resident

Flanagan Rehab resident develops infection from bed sore

Resident develops bed sores to both heels at McLean County Nursing Home

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

 

Alden Valley Ridge fails to give resident anti-seizure medications

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IDPH has cited and fined Alden Valley Ridge Nursing Home in Bloomingdale after a resident there had to be hospitalized after experiencing grand mal seizures brought on by a failure to give prescribed anti-seizure medications.

The resident at issue had a history of epilepsy with seizures.  When he was discharged from the hospital to the nursing home, there were orders in place and prescriptions written for at least three anti-seizure medications which were to be given twice per day: dilantin, onfi, and keepra.  When the resident arrived at the facility, these medications were not on hand and had to be obtained from the pharmacy.  These medications were not obtained during the first 36 hours of the resident’s admission to the facility, and as a result, he did not receive his anti-seizure medications.

As a result, the resident experienced two grand mail seizures.  The doctor was not notified about the first, and as a result, was not sent to the hospital.  After the second occurred, the doctor was notified and the resident was sent to the hospital where labs showed that he had critically low levels of dilantin.  He was admitted to to the hospital for several days to stabilize his condition.

Before a resident is accepted for admission to a nursing home, the facility receives a package of materials about the resident which includes a medication list.  This is so that the nursing home can determine whether it can meet the care needs of the resident and if they decide to accept the resident, they can order necessary medications.  Well-run nursing homes have processes in place to ensure that routine items such as this get handled properly so that critical medications such as this are on hand when the resident arrives.  Past that, when there is a critical medication like an anti-seizure medication that is unavailable for a resident, there are processes in place to ensure that  the medication is delivered in a timely fashion.

Past that, there were events during this admission which required physician notification.  The first of these was the fact that there was a medication error because these was no medication available and that there were multiple missed doses of medication.  Had the doctor been notified, the doctor would have had the option of ordering other medications or taking other steps to help the resident maintain his dilantin levels to prevent the seizures.  The second of these was the occurrence of the first seziure.  When a resident experiences a significant event like that, it requires care regardless.  It is also an indication that the missed doses of the anti-seziure medication are having adverse effects on the health and well-being of the 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:

Catastrophic brain injury from medication error at Alden Town Manor

Grove of Elmhurst resident dies due to delay in physician notification

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

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

Failure to obtain anti-seizure medication at Gilman Healthcare Center

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

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

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

 

Heritage Health Pana staff violates care plan, resident falls and breaks hip

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IDPH has has cited and fined Heritage Health – Pana nursing home after a resident there was left unattended in her wheelchair in violation of her care plan.  The resident tried to get up from her wheelchair on her own and fell, breaking her hip.

The care planning process is the foundation for much of the routine care that gets delivered in a nursing home setting.  Fall prevention is a special area of emphasis in the nursing home setting because falls tend to beget additional falls and any fall tends to have serious long-term consequences for nursing home residents.

The care planning process starts with an assessment of the resident’s fall risk.  The tools that nursing homes use to measure fall risk vary widely, but there are a number of factors that tend to be given weight: balance, gait, or musculoskeletal dysfunction; dementia or intermittent or constant confusion; incontinence; and a history of prior falls.  If the resident is assessed as being a fall risk, then a fall prevention care plan must be developed which includes a series of steps or interventions that should be performed .  That care plan must be communicated to the staff charged with carrying it out, and then it must in fact be implemented on a day-to-day, shift-to-shift basis.  The care plan must be evaluated for effectiveness on an ongoing basis and then revised if it is either ineffective or there are changes in the resident’s condition.

Of course, it all comes down to the care plan being carried out on a day-to-day, shift-to-shift basis.  The best assessments and the best care plans have no value if they are not actually implemented, and that was the source of this nursing home fall.

This resident had a history of a prior fall with a broken left hip.  The Minimum Data Set (MDS) showed that the resident required extensive assistance from two staff members for transfers and had severe cognitive impairments.  The assessment also noted a behavior of getting up unassisted.  In short, she was a clear fall risk and was assessed as such.  Part of her care plan was that when the resident was up in her wheelchair, she should be placed in a high traffic/highly visible area (in the common room or by the nurses’ station would be examples).  This is a very common intervention to address this form of fall risk.  The care plan was recorded on the kardex which was stored on the back of the door to the resident’s room.

On the day of this nursing home fall, the staff reported finding the resident trying to crawl from her bed to her wheelchair.  They assisted her into her wheelchair.  Then, rather than bring her out to an area where she could be kept under observation, she was left unattended in her room.  Shortly after being left in the room, the resident attempted to get up unassisted, and fell.  She was brought to the emergency room, where x-rays showed that she had fractured her left hip – the same one which had been broken before.

The obvious cause of this nursing home fall and the injury sustained by this resident was the failure of the aide to care out the care plan.  The resident was left unattended in her room in her wheelchair.  This was a violation of the care plan, and the Director of Nursing conceded as much to the state surveyor.  For her part, the aide told the state surveyor that she did not know that the resident needed to be supervised.

In situations such as this, where the staff cannot take the time to access readily available information to know how to properly care for a resident, this is a strong indicator that this is an understaffed 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:

Moweaqua Rehab resident suffers fractured hip in fall

Taylorville Skilled nursing home resident falls and breaks hip

Piatt County Nursing Home resident fractures hip in fall

Pleasant Meadows Senior Living resident breaks hip and wrist in fall

Repeated resident falls at Heritage Health in Springfield ends with broken arm and brain bleed

Failure to train staff leads to broken hip and death at Heritage in Jacksonville

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

 

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