Nursing Home Abuse Blog - Page 14 of 35 - The Law Offices of Barry G. Doyle, P.C.

Randolph County Care Center resident falls from toilet and breaks hip

June 11, 2020 By Barry G. Doyle

IDPH has cited and fined Randolph County Care Center after a resident there was left unattended while going to the bathroom and fell, suffering a broken hip.

For resident who at risk for nursing home falls, using the toilet can be a surprisingly high-risk activity. The act of sitting and then rising from the toilet can result in a loss of balance. Residents with poor trunk control can slump forward or to one side and slide off the commode onto the floor. Other residents who have strength or balance deficits combined with either dementia, impulsiveness, intermittent or constant confusion, or general poor safety awareness may attempt to get up on their own, leading to a fall. Other times, hurrying to get to the bathroom to avoid having an episode of incontinence may lead to a fall.

Because this is a well-recognized risk, this particular scenario must be addressed in the resident fall prevention care plan. The most common measure is to have a resident supervised while going to the bathroom and reminding the resident to use a call light for assistance. Toileting schedules can also be used to help eliminate accidents associated with a resident hurrying to use the bathroom.

The resident at issue here had been admitted to the nursing home after having a fall at home which resulted in a compression fracture at home. He suffered from dementia and his family was considering long term placement at the nursing home because he was not safe to live at home by himself. The resident was assessed as being a fall risk, and his care plan called for supervision necessary to prevent accidents. Further, his Minimum Data Set (MDS) showed that he needed extensive assist of one staff for transfers to and from the toilet.

On the day of this nursing home fall, he was brought to the bathroom by an aide and helped to the toilet. The aide left the resident in the bathroom to get something from the linen closet. When she returned a few moments later, she found the resident on the floor. It was unclear (and the resident was unable to say due to his dementia) whether he fell from the commode or whether he tried to get up and fell.

The resident was left unattended only for a few moments, yet this fall occurred. Unfortunately, this is all that it takes sometimes, which is why the care plan needs to be carried out on a day-to-day, shift-to-shift basis. This fall could have been averted by simply getting the needed supplies before bringing the resident to the bathroom or by calling for help from a fellow staff member.

The resident was brought to the hospital where he wad diagnosed with a fractured hip. Most fractured hips are repaired surgically, but it appears from the citation that this resident’s was not. Surgical repair has its own set of risks associated with the use of anesthesia and other intra- and post-operative complications. Foregoing surgery has its own set of risks associated with immobility, in particular the development of bed sores.

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:

Mar-Ka Nursing Home resident falls, breaks both legs

Integrity of Alton resident suffers fractured eye orbit in fall

Improper transfer at Southgate Nursing Home

Seminary Manor resident suffers fatal brain bleed in fall

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.

Broken ankle from unsafe transfer at Aperion Care International

June 5, 2020 By Barry G. Doyle

IDPH has cited and fined Aperion Care International nursing home in Chicago there after a resident there suffered a fractured ankle as a result of an unsafe transfer with a mechanical lift.

The transfer of a resident with a mechanical lift is inherently a two-person job. One staff member actually operates the lift itself; the other steadies the resident in the sling and guides them into place at the destination, whether that it the bed, a chair, etc. We have told the tale far too often here (see here, here, here, here, and here for examples) of what happens when one person tries to do a two-person job by themselves. The result is almost inevitably a nursing home fall with serious injury such as a hip fracture or a brain bleed.

This resident suffered from dementia and unsteadiness on her feet. She was coded on her Minimum Data Set (MDS) as having total dependence and requiring the assist of two with transfers. Her care plan called for use of a mechanical lift with the assist of two for all transfers.

On the day of the accident, the aide was transferring the resident from her bed to the wheelchair without the help of another aide. As the resident was placed into the wheelchair, she began to slide forward out of the sling. The aide attempted to slowly lower her to the ground, but she came down on top of her ankle, breaking her tibia and fibula.

The citation does not say what was done for her in the way of medical care, but this is an injury which would normally require surgical repair. Given her age and overall condition, they hay have attempted to address the fracture by casting. Either way, this injury will cause significant additional debility and set the state for additional complications such as bed sores.

This was the kind of injury which should never have happened. This was a resident who required the help of two for this transfer, but the aide attempted to do so on her own. Having one person attempt a two person job is the hallmark of an understaffed nursing home. Sadly, understaffing a nursing home is a hallmark 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:

Symphony at South Shore resident suffers open fracture of leg in unsafe transfer

Resident suffers broken hip in unsafe transfer at Pearl of Rolling Meadows

Mechanical lift accident at South Holland Manor

Multiple injuries in fall at Symphony at Midway

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

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

June 3, 2020 By Barry G. Doyle

IDPH has cited and fined Elevate Care nursing home in Waukegan after a resident there suffered third degree burns in a smoking accident.

Nursing home residents are adults, and as adults they still have the right to engage in certain habits that are not good for their health, and smoking is one of them. In a nursing home setting, there are two specific risks associated with smoking that are not generally present in the community at large. Like any risk to the health and well-being, the risks associated with smoking must be addressed in the resident care plan.

The first of these risks is the risk of flash fires associated with the use of compressed oxygen equipment. The second of these are burns and fires occurring due to residents dropping or mishandling cigarettes and other smoking materials due to shaking of the hands or weakness often associated with neurological or muscular disorders. Similar to nursing home falls, the likelihood of having an adverse event is multiplied when the resident suffers from dementia, confusion, or otherwise shows poor judgment for their own safety.

In most nursing homes, there is an outdoor area designated for smoking and set times when the residents are allowed out to smoke under the supervision of staff. Residents who demonstrate noncompliance with smoking safety practices must have this behavior addressed in the resident care plan.

In this situation, the resident suffered from chronic obstructive pulmonary disease (COPD) and dependent on supplemental oxygen. On the day of this nursing home smoking accident, the resident went out onto the smoking deck unattended before the time that was designated for smoking. The staff was aware that he had done so multiple times before this, but this behavior was not addressed in the resident care plan.

The fire occurred as the resident was lighting cigarette butts without shutting off his supplemental oxygen. The flash fire from the ignition of the supplemental oxygen caused first, second, and third degree burns to his face, eyes, and nostrils. He was taken to the hospital for treatment of his burns.

After the fire occurred, the nursing home placed locks on the door to the smoking deck to prevent unsupervised resident access to that area.

This was an accident which should have been easily prevented: limiting access to the smoking deck during hours when staff is not present and taking away smoking materials such as a lighter from the resident when unsupervised. Unfortunately, it too often takes a serious accident such as this to spur a nursing home to take the steps necessary to prevent accident injury to residents.

Other blog posts of interest:

Bedbound resident at Elevate Care of Waukegan suffers broken arm

Unsupervised resident falls on smoking deck at Uptown Health Center

Resident burns to death at Lake Shore Health and Rehabilitation

Resident chokes to death at Grove at the Lake

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

Integrity of Alton resident suffers fractured eye orbit in fall

June 1, 2020 By Barry G. Doyle

IDPH has cited and fined Integrity of Alton nursing home after a resident there suffered a fractured eye orbit in a fall.

Falls are a serious issue in the nursing home industry. They are the subject of federal regulations and are one area that is specifically addressed in the resident care plan. One very basic step in preventing falls is keeping areas where residents will be walking free of clutter and slipping and tripping hazards.

The resident at issue was legally blind, had been assessed as being at risk for falls and had a history of falls. In short, this is the kind of resident for whom safe walkways is a must. Unfortunately, on the day of this nursing home fall, this resident’s roommate was getting ready to move out of the facility, and as a result, in the words of the Director of Nursing, “There was stuff everywhere.”

The resident tripped over his roommate’s belongings and hit his head against the headboard on the way down. He was taken to the emergency room where a CT scan showed that he suffered a fractured eye orbit.

This was an easy-to-prevent nursing home fall. The staff had to have been aware that the roommate was moving out, and providing some measure of assistance to that resident in the packing process would have helped keep the room clear of clutter. Keeping walkways free of clutter is Fall Prevention 101. These are steps that should be taken in workplaces and retail establishments where there aren’t people with physical and cognitive impairments that are more susceptible to having falls and to having serious, long-term consequences from having a fall. The failure to keep this resident’s room free of clutter led to this unnecessary injury.

Other blog posts of interest:

Fall from edge of bed at Integrity of Alton

Broken ankle in fall at Aperion of Mascoutah

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

Cedar Ridge resident breaks both legs in fall from bed

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.

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

May 31, 2020 By Barry G. Doyle

IDPH has cited and fined The Spring at Monarch Landing nursing home in Naperville after a resident there suffered a broken leg during an unsafe transfer.

A resident care plan is intended to be a “road map” for the safe, proper delivery of the care that nursing home residents require on a day-to-day, shift-to-shift basis. It is the product of a multidisplinary assessment of the resident’s care needs. It identifies steps to be taken to assure the safety and well-being of the residents, and must be communicated to the staff who must implement the care plan on a day-to-day, shift-to-shift basis. Violation of the resident care plan is a violation of federal regulations and is a form of nursing home abuse because it subjects residents to unnecessary risk of injury.

The resident at issue here suffered from among other things Parkinson’s Disease and Alzheimer’s. She had been assessed per the Minimum Data Set as requiring the assistance of two for transfers and her care plan called for the use of a mechanical lift to transfer the resident. At this nursing home, one way that the content of the care plan was communicated to staff was through care cards that were located in the resident’s closet.

On the day of this nursing home fall, a single aide attempted to transfer the resident from bed to a wheelchair to bring her to breakfast. No gait belt was used at all, and in the process of attempting the transfer, the resident’s legs gave out and she was lowered to the floor by the aide. The aide then called for the help of a second aide to get the resident from the floor (even though she should have been assessed first by a nurse) to her wheelchair and then taken to breakfast.

The aide did report the fall to a nurse who said that no incident report was required because no fall occurred. The nurse was wrong about this – in the long term care industry, a fall is generally defined as an unplanned change in elevation. The “lowering to the floor” of this resident by an aide qualifies as a fall. Because the nurse wrongly considered the incident to not be a fall, the doctor was not notified and the later shift was not told about the incident. As a result, there was a lengthy delay in obtaining care for this resident.

During a later shift that day, the resident was complaining of pain to the leg. A nurse readily saw that one leg was larger than the other, and notified the resident’s doctor who ordered a stat x-ray of the leg. This showed a fractured femur, and the order was given to send the resident to the hospital.

There are a number of problems with the care that this resident received. To start with, a mechanical lift wasn’t used, as was called for in the resident care plan. If a lift was used, this fall would never have happened. Past that, the aide attempted the transfer alone, rather than with the help of a second staff member as was necessary. The aide also failed to use a gait belt which may have helped her in arresting the fall before the resident ended up on the floor. A cascade of failures resulted in this resident’s broken leg.

The failures continued after the resident’s fall. The aides moved her on their own without getting a nurse in to assess her for injury. They did report the fall, but the nurse failed to recognize it as such and failed to advise the resident’s doctor or advise the later shifts that the fall had occurred. This means that the resident was left with an untreated broken leg for hours before the injury was finally recognized.

This series of failures is a snapshot of a facility which is not properly training its staff. Failing to invest in staff training is a feature of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

Resident suffers brain bleed in fall from bed at Meadowbrook Manor in Bolingbrook

Chateau Nursing & Rehab resident suffers fractures in fall

Lakeshore Rehab resident rolled from bed, breaks leg

Resident at Park Pointe in Morris sustains multiple fractures in fall down stairwell

Resident trips over towel and breaks hip at Oak Brook Care

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

Fall during transfer results in broken ankle at Sandwich Rehab

May 29, 2020 By Barry G. Doyle

IDPH has cited and fined Sandwich Rehab nursing home after a resident there suffered a broken ankle during an unsafe transfer from the toilet to her wheelchair.

The resident at issue had cognitive issues, muscular weakness, and a right foot drop. These are factors which would have made her at risk for falls. In the normal course of things in a well-run nursing home, this would have resulted in the development of a fall prevention care plan which would have stated what kind of assistance the resident required for transfers. However, there was no care plan done which meant that the staff did not know what was required for transferring the resident. Some thought that she required the help of a sit-to-stand lift, others thought she was a two person assist, and still yet others thought that she was a one person assist with a gait belt.

On the day of the accident, she was being assisted from the toilet to her wheelchair by a newer aide. This aide thought that the resident required a sit-to-stand lift, but the lift was broken and she could not find anyone to help her transfer the resident, so attempted to do it herself. She got the resident up from the toilet and while the resident was in the process of pivoting, her legs gave out and she fell top the floor landing on top of her foot and ankle and breaking her ankle. The aide was not able to control her fall properly because she did not apply a gait belt to the resident, instead trying to hold onto her by her pants. Needless to say that did not work well, and the resident was taken to the hospital with a broken ankle.

There are three separate areas where the nursing home failed this resident, leading to this very preventable nursing home fall.

The first way is that there was no care plan which addressed what needed to be done to safely transfer a resident and prevent falls. When a resident is at risk for falling, a care plan needs to be put into place which is communicated to the staff and then carried out on a day-to-day, shift-to-shift basis. Without a care plan, patient safety is left to random chance. That is never acceptable.

The second way is the aide failed to use a gait belt. The whole point of having a gait belt is to control the resident during transfers and to arrest a fall should one occur. The aide (who in fairness, was relatively new) admitted that she forgot to use one. The consequences of not using the gait came home when this resident hit the floor and broke her ankle.

The third way is that the nursing home failed to devote appropriate resources to the care of its residents. The aide was not trained to use a gait belt. The fall prevention care plan was never put into place. There was not enough staff to help this aide. The lift was broken. These failures speak to a nursing home that is not spending the money that it required to properly care for its residents.

Other blog posts of interest:

Accolade of Pontiac resident fractures femur in fall

Fall results in broken vertebra at Heritage Health in Mendota

Broken leg in fall at Generations at Neighbors

Third degree burns from fall at Sauk Valley Senior Living

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

Multiple fractures from fall at Accolade of Pontiac

May 27, 2020 By Barry G. Doyle

IDPH has cited and fined Accolade of Pontiac nursing home after a resident there was left unsupervised and fell, sustaining multiple fractures.

There are a number of factors which are considered risk factors for residents experiencing a nursing home fall. Two of the most important are some form of musculoskeletal weakness or dysfunction and either intermittent or constant confusion or dementia. The reason that dementia or confusion is a risk factor for nursing home falls is that the resident cannot be counted on to consistently follow instructions or make good judgments for their own safety.

When a resident is at risk for falls, it is incumbent on the nursing home to develop and implement a fall prevention care plan. A proper fall prevention care plan will contain steps or interventions that the members of the nursing home staff are to take on a day-to-day, shift-to-shift basis to help ensure the safety of the resident. Federal regulations regarding nursing home falls require that the nursing home to develop the care plan which would include steps to assure that the resident receives supervision and assistance necessary to prevent accidents.

The resident at issue had severe cognitive impairments and required extensive assist of two staff members with transfers. She was not able to stabilize herself while standing and had at least one other fall in the months leading up to the incident at issue. The chart notes also reflected that the staff had seen her attempting to transfer herself on multiple occasions before this incident occurred.

This resident was one who was very clearly a fall risk. She suffered from cognitive impairments and musculoskeletal issues which placed her at risk for falls. Her lack of ability to make good judgments for her own safety and follow instructions was demonstrated by the fact that she had been seen and it had been documented that she was attempting to transfer herself on multiple occasions before this incident. Finally, she had experienced at least one fall before this incident. Falls tend to beget additional falls, and are a sign that additional steps need to be taken to assure the safety of the resident.

This is a situation where not only should there have been a fall prevention care plan, but the care plan should have been revised to take additional steps to prevent falls in light of the fact that there had already been at least one fall and that the resident was being seen on an ongoing basis self-transferring when the help of two was needed.

Even though this was a situation which cried out for a fall prevention care plan, there was none. The net result of this was sadly predictable.

On the day of the accident, the resident was left unattended in the solarium. As the resident, tried to get up from her chair to move to her wheelchair, she lost her balance and fell to the ground. The resident was bleeding from the head and complained of pain in the lower extremities and hips. The resident was sent to the hospital.

At the hospital, the resident received sutures to close the head wounds. Radiographs showed that the resident suffered pelvic fractures, a fractured humerus, broken ribs, and fractures of two vertebrae in her spine. The pelvic fractures will likely leave the resident bed bound for a significant period of time, placing her at risk for developing bed sores. Rib fractures will also place her at risk for developing pneumonia. These injuries are significant in the own right but also have serious longer term implications for the health and well-being of this resident.

The failure to care plan for falls for this resident was inexcusable. She was clearly at risk for falls and was not only demonstrating behaviors which showed that risk, she also had a fall which was a warning sign of more to come. In the end, this resident will pay a real price in terms of the quality of life for this failure.

Other blog posts of interest:

Fall from wheelchair at LaSalle County Nursing Home

Resident falls from bed at Spring Creek

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

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

Accolade of Pontiac resident fractures femur in fall

Resident fall and fractures hip due to failure to follow care plan at Casey Healthcare

Accolade of Pontiac resident suffers fractured hip in fall after call light left out of reach

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

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

May 25, 2020 By Barry G. Doyle

IDPH has cited and fined Radford Green nursing home in Lincolnshire after a resident there sustained multiple fractures to her lower leg after an aide attempted transfer using a sit-to-stand lift.

A sit-to-stand lift is a type of lift commonly used in nursing homes. A sit-to-stand lift should be used only with residents who have some ability to bear weight with their light sand who are cognitively intact enough to follow instructions from the staff. As with Hoyer lifts, this requires the assistance of two staff members to use it safely – one to operate the controls of the lift, the other to assure the safety of the resident.

The resident at issue had been recently admitted to the nursing home for rehabilitation and strengthening. All of the assessments done on the resident to that point had indicated that she was an assist of two for all transfers, but additionally facility, policies called for two staff in using a sit-to-stand lift.

This nursing home fall is like many we have described in many other posts in that there was one person doing a two-person job (see here, here, here, here, and here for examples). Here, an aide has asked for help from a nurse in transferring the resident, but when the nurse did not arrive quickly enough, the aide attempted the transfer by herself. During the transfer, the resident’s legs gave out and she ended up suffering a fractured tibia and fibula (both bones of the lower leg).

The obvious immediate cause of this fall was one person doing a two person job. The deeper question is one of why was the aide not properly trained to know that attempting this transfer by herself an “absolutely not” kind of proposition and why was there not enough help to get this work done? The likely answer to this question relates to the understaffing of the nursing home which is a feature of the nursing home business model.

Other blog posts of interest:

Avantara Lake Zurich resident suffers lower leg wound during unsafe transfer

Symphony of Buffalo Grove resident suffers catastrophic injuries in fall from lift

Resident suffers facial burns in smoking accident at Elevate Care of Waukegan

Fall from mechanical lift at Hillcrest Retirement Village

Grove at the Lake resident suffers multiple injuries in mechanical lift accident

Resident suffers jaw, facial fractures at Dimensions Living in Prospect Heights

Multiple fractures from fall at Lutheran Home for the Aged

Resident suffers from broken hip in unsafe transfer at Pearl of Rolling Meadows

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

Fall from toilet at Alden Park Strathmoor

May 24, 2020 By Barry G. Doyle

IDPH has cited and fined Alden Park Strathmoor nursing home in Rockford after a resident there suffered a broken hip while being transferred to the toilet.

The resident at issue had a history of having had a stroke and had some left-sided weakness as a result of the stroke. Her care plan called for the assist of two staff members with transfers and toileting. The nursing home’s own policies and procedures called for the use of a gait belt (a canvas strap that is applied around the resident’s midsection to help control the resident and prevent falls and injuries) during transfers.

On the day of this nursing home fall, the resident was being transferred to the toilet with the assistance of a single aide rather than the two that the care plan called for. The aide doing the transfer was also not using a gait belt. When the resident was positioned on top of the toilet stool, she was not squarely on the toilet stool but slightly off to her left, stroke-weakened side. She slid off the toilet stool, landing on her left side.

She was brought to the hospital where she was diagnosed as having a fractured left hip. She underwent surgical repair of the broken hip.

There are a couple of obvious failures in the care that was being provided here. First, the aide was attempting the transfer by herself when the help of two people was called for in the care plan. One person doing a two-person job is a recurrent theme (see here, here, here, here, and here for examples) in many of the nursing home falls which we have covered in this blog. Second, the aide failed to use a gait belt during the transfer in violation of the nursing home’s own policies. Had a gait belt been used, the aide would likely have found it easier to properly place the resident on the commode and would have likely been able to stop or slow the fall once it occurred.

This resident survived the surgery and the immediate post-operative period. This is not always the case, which would result in a basis for a wrongful death lawsuit. Even when nursing home residents survive the surgery itself, having a fractured hip often bodes poorly for their long-term outlook due to complications associated with hip fractures.

Of course, there are obvious immediate reasons why this nursing home fall occurred which we discussed above. The deeper and more interesting issues relate to why this aide attempted the transfer by herself instead of getting help and why the aide failed to take the time to use a gait belt. The answers to those questions likely relate to the understaffing of the nursing home, which is an essential feature of the nursing home business model.

Other blog posts of interest:

Failure to use gait belt leads to fall and broken hip at Fair Oaks Rehab in South Beloit

River Bluff nursing home resident suffers multiple fractures in fall

Broken leg in fall at Generations at Neighbors

Presence St. Anne resident suffers broken neck in fall from lift

Third degree burns from fall at Sauk Valley Senior Living

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

Fatal choking accident at Spring Creek in Joliet

May 22, 2020 By Barry G. Doyle

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

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

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

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

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

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

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

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

A simple breakdown in care leading to a horrific outcome – and the fact that no one took time to realize that this resident’s rather obvious risk of choking was not being properly addressed is a result of the fact that nurses in a nursing home setting often are stretched so thin by the grind of providing day-to-day care that they do not have time to give critical thought to the needs of resident’s. Sadly, that is directly related to the nursing home business model and understaffing of nursing homes. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

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

Chicago Ridge Nursing & Rehab resident chokes to death on sandwich

Resident chokes to death at Rosewood of St. Charles

Fatal choking accident at Glenwood nursing home

Resident chokes to death at The Moorings in Arlington Heights

Resident falls from bed at Spring Creek

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

Broken leg in fall at Generations at Neighbors

May 9, 2020 By Barry G. Doyle

IDPH has cited and fined Generations at Neighbors nursing home in Byron after a resident there suffered a broken leg in a fall.

One of the basic truisms regarding nursing home falls is that falls beget falls – meaning that once a nursing home resident experiences a fall, they tend to experience additional falls. One of the important tasks of the nursing home staff has after a resident fall (beyond dealing with any injury that may have resulted from the fall) is figuring out why the resident fell and adjusting the resident fall prevention care plan to account for the factors that contributed to cause the fall. For example, if the resident fell while getting to go up to the bathroom on their own, placing the resident on a toileting schedule so that they are brought to the bathroom at regular intervals may help reduce the risk of falling.

The resident at issue here had three prior falls before the one at issue. The resident had severe cognitive impairments and suffered from anxiety. Sh required the assist of one with transfers and ambulation. One of the “knowns” about her behavior was that she had a strong preference for a tidy room and t hat she would often get up to close drawers and adjust things in her room.

On the day of her injury, the staff was alerted by a visitor that the resident was on the ground. When the staff arrived in her room, they found her on the floor with a plastic hangar on top of her. She told the staff that there was a plastic hangar out of place and that she fell while going to hang it back up in the closet.

She was taken to the hospital where she was diagnosed as having suffered a fractured femur in between her artificial knee and artificial hip. Obviously with orthopaedic hardware already in place, the surgery to correct the broken leg will be complex. Further any type of extensive surgery will place her at risk for losing her ability to walk, placing her at increased risk for developing bed sores and other complications.

One of the basic fall prevention measures that should be a part of either the facility’s fall prevention policies and procedures or a resident’s fall prevention care plan is to anticipate the needs of the resident. In a case like this, where there is a resident who suffers from anxiety and cognitive impairments the staff should understand that they have limited ability to control their own behavior both in terms of making good decisions about their own safety and resisting their own impulsive behaviors. In this context, one the things that would go under the heading of anticipating the resident’s needs would be to make sure that the room is tidy before leaving her unattended because she will not be able to control her own desire to tidy things up. Unfortunately, that proved to be the case here and led to serious injury for this resident.

Other blog posts of interest:

Fall and brain bleed at Alpine Fireside

Spinal fracture in fall from bed at Pine Acres in DeKalb

Fall lead to brain bleed and death at Regency of Sterling

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

Transportation van accident at Generations at Rock Island

May 4, 2020 By Barry G. Doyle

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

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

There were shortcomings on both counts here.

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

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

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

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

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

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

There a few major issues with what happened here.

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

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

This kind of poor training speaks to a lack of investment in the facility staff which is a hallmark of the for-profit business model that most nursing homes follow. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

Macomb Post Acute Care resident suffers multiple fractures in van accident

Generations at Rock Island fails to care for pressure ulcers

Generations at Rock Island cuts respiratory staff

Resident falls from van at Casey Healthcare

Wheelchair transport accident at Heartland of Galesburg

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

Failure to follow orders at Generations at Applewood

May 3, 2020 By Barry G. Doyle

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

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

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

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

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

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

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

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

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

Other blog posts of interest:

Moorings staff fails to notify doctor

Grove of Elmhurst resident dies due to delay in physician notification

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

Resident bleeds to death at Aperion of Forest Park

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

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

Elmiron and pigmentary maculopathy

May 1, 2020 By Barry G. Doyle

Our office has recently begun accepting cases where people have suffered eye or vision damage due to a condition called pigmentary maculopthy due to taking the prescription drug Elmiron to treat interstitial cystitis.

Our early investigation has shown that the manufacturer was aware that this drug was producing eye problems while it was being developed and that there were adverse event reports submitted to the FDA concerning this issue shortly after the drug was released in the marketplace.

Most alarmingly, there are no warnings on the label for this drug and no precautions or contraindications for its use in the United States even though Canadian authorities have been requiring a warning.

Our office stands ready to assist users of Elmiron recover the compensation they deserve. Contact us for a free, no-obligation consultation if you have any concerns about whether the use of Elmiron has caused injury or damage to your eyes or vision.

Resident-on-resident assault at Alden Long Grove

April 22, 2020 By Barry G. Doyle

IDPH has cited and fined Alden Long Grove nursing home after one resident was assaulted by another resident.

Psychiatric medications are an important tool in the arsenal of caring for residents with dementia or other psychiatric conditions. However, the use of the medications and the effects and effectiveness of the medications must be carefully monitored. If a resident is over-medicated, this often has severe negative side effects and can set the stage for other issues such as malnutrition or dehydration, nursing home falls, or bed sores. However, if the resident is not receiving a sufficient dose of the medication, then the behavior which the medication was intended to address may not be altered.

When a resident has a dosage of a psychiatric medication changed, one thing that needs to also suffer be monitored carefully and care-planned for are changes in behavior.

The resident who was the assailant here here had a history of restlessness and agitation, vascular dementia with behavioral disturbances, and a mood disorder. He had expressed homicidal ideation toward a family member in the past and had other episodes of verbal aggression. The staff was aware that he did not get along with other residents, and was very territorial. As a result, he had a private room where he often stayed with the door shut.

He was receiving psychiatric care and was on a mood stabilizing drug. However, the dose that he was receiving left him sedated and as a result, the dosage was reduced. After the dosage was reduced, he began to demonstrate increased aggressive behaviors. The resident’s son raised this as an issue of concern with the staff who consulted with the psychiatric nurse practitioner who refused to restore the original dosage to avoid the sedating effects of the medication.

The resident who was the victim also suffered from dementia and had a history of wandering in and out of other resident’s rooms.

The incident occurred when the victim wandered into the resident’s room. The assailant told him to get out. A verbal altercation ensued and the victim threw some soup at the assailant. The assailant punched the victim in the head multiple times and was in the process of dragging the victim out by his heels when the staff intervened.

The victim suffered bruising and skin tearing about the face, but more alarmingly, had lost the ability to walk in between the time that the assault took place and the time that the investigation was conducted by the state. Loss of mobility is something that bodes poorly for the long-term well-being of nursing home residents.

Where were the shortcomings in the care provided by the nursing home?

With regard to the assailant, the staff did the right thing by notifying the nurse practitioner about increased aggression, but the key issue in that would be what was expressed and what data was available. Many nursing homes do behavior tracking in the resident chart which gives a more detailed, data-filled basis for making medical decisions regarding medication usage and whether that data was developed and whether it was communicated to the nurse practitioner are issues worth investigation. Further, increased verbal aggression is sometimes a precursor toward physical aggression in dementia patients. Knowing that this was going on, it is also worth investigating whether the staff on hand was aware of that through the 24-hour sheet reporting or nurse to nurse shift reports and what was done about that.

With regard to the victim, intruding on another resident’s personal space, wandering into their rooms, and failing to respect their belongings are often a flashpoint for conflict among nursing home residents, leading to a resident-on-resident assault such as this. If the resident was truly in the habit of wandering into others’ rooms, then this behavior needed to be addressed in the resident care plan.

Other blog posts of interest:

Bria of Smithton resident suffers fractured hip in assault by fellow resident

Forest City resident pushed to the ground, fractures hip

Resident assaulted by roommate at Countryside Nursing & Rehab in Dolton

Assault by fellow resident results in broken hip at Stephenson Nursing Center

Resident suffers facial burns in smoking accident at Elevate Care of Waukegan

Resident wanders from Alden Long Grove

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

COVID-19 and Illinois Nursing Homes

April 20, 2020 By Barry G. Doyle

The nursing home industry in Illinois (and really nationwide) has been hard-hit by the coronavirus/Covid-19 pandemic. Here are the things that you need to know.

The Illinois Department of Public Health has a link – click here – which provides a searchable database of which nursing homes have had confirmed cases of coronavirus and whether there have been related deaths. This is a page which is being updated on a weekly basis, so you can check back here for additional information as it develops.

The fact that a nursing home has coronavirus cases and/or deaths is not necessarily an indicator that they are providing poor care – it has been a struggle to contain the virus everywhere, and once it is in the building, it is that much more difficult. However, under the circumstances now, I certainly would not choose to admit a loved one to a nursing home with confirmed cases, and this is the best resource for identifying which facilities have confirmed cases.

What about the legal situation?

As I am writing this, there are a lot of open questions which I have not had to consider too deeply, because our office has not as of yet accepted any cases involving coronavirus and am uncertain that we will.

Cases involving the coronavirus will likely be inherently difficult. To win a nursing home abuse and neglect case, you need to prove that the nursing home provided substandard care. Proof that this was the case is going to be hard to come by, as much of what could stand as proof will not be in the resident chart, which is a primary source of proof in all nursing home cases. Further, because of the no-visitors rules in place at nursing homes around the state, testimony from family members will be missing as well. Further you need to show that the substandard care caused the negative outcome which is something that will be difficult to show as well.

Complicating all of this is the Executive Order issued by Gov. Pritzker declaring Covid-19 a state health emergency. One of the provisions in the executive order provides that persons and entities providing care in response to the outbreak will be immune from liability unless the negligence is either gross negligence or willful misconduct. This is a greatly heightened standard of proof.

Obviously, this order is intended to allow health care providers to offer care without having the same concerns about legal liability they ordinarily would have. I have no idea right now whether that governor-created immunity from negligence in the provision of care would withstand constitutional challenge under the Illinois State Constitution, when and if it is challenged. For now, that certainly stands as extra hurdle that nursing home residents and their families might face should something happen which might otherwise warrant legal action.

As for other types of cases such as bed sores, nursing home falls, choking accidents, and other forms of nursing home abuse and neglect: our office is still accepting appropriate cases for representation. However, you can be sure that nursing homes will try to use the Executive Order as a defense against even these ordinary, non-coronavirus type of cases, and one of the issues which will have to be resolved at the outset is whether the Executive Order applies to the regular care that is supposed to be provided in nursing homes, in additional the issue of whether it is constitutional or not.

You can also be sure that many of these cases will be defended much more aggressively with nursing homes explaining poor care as being a product of the crisis and the additional strains that the crisis brought on.

For all of these reasons, it is ever more crucial that in the event that you or your family are considering legal action against a nursing home during this time that you get the help of an experienced Chicago nursing home lawyer to assist you. Contact our office for a free, no-obligation consultation.

Fall from lift at Presence St. Joseph Center

April 15, 2020 By Barry G. Doyle

IDPH has cited and fined the Presence St. Joseph Center nursing home in Freeport after as resident there was dropped from a sling during transfer, suffering a head injury.

Mechanical lifts are a useful tool in a nursing home. They assist the staff with transferring residents from surface to surface such as to or from a bed, chair, wheelchair, or toilet. Used properly, they reduce the risk of injury to residents and actually reduce the risk of back, neck, and injuries to staff from straining to move residents. However, the key part of that sentence is, “used properly….”

The resident at issue was dependent upon the staff to move her from the wheelchair to her bed. Her care plan called for the use of a mechanical lift with the assist of two staff members. On this particular day, there were actually two staff members available to participate in the transfer (something which is not always the case, as we have seen (see here, here, here,and here for examples)).

Part of transferring a resident safely using a lift involves making sure that the sling is properly hooked onto the lift itself. When it isn’t, there is a risk that the sling will come detached from the lift itself causing the resident to fall from the sling.

This appears to have been the case here. The resident was being transferred from her wheelchair to the bed. The aides got the resident placed properly in the sling and attached the sling to the lift itself. However, during the lift, the sling holding her right leg came detached from the lift causing the resident to fall from the sling and land on the floor, hitting her head. There was immediate, profuse bleeding, so 911 was called.

The investigation into the incident revealed that there were no defects with the lift itself or the sling, and that the resident didn’t move or do anything which would have caused her to fall or the sling to become detached. The only explanation for this nursing home fall is that the sling was not properly attached to the lift itself.

The paramedics brought the resident to the hospital where scans were negative for more significant findings such as a brain bleed or a fracture. The head wound was closed with two staples and she was returned to the nursing home. However, the fact that the injury was not more serious was a matter of good luck, not good care, and relying on good luck to keep nursing home residents safe is a poor way to go.

Other blog posts of interest:

Fall from toilet at Alden Park Strathmoor

Pleasant View Rehab resident breaks hip in fall

Resident falls from lift at Oregon Living & Rehab

Presence St. Anne resident breaks neck in fall from lift

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

Transport van accident at Generations at Rock Island

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

Resident suffers unexplained arm fracture at Oregon Living & Rehab

April 14, 2020 By Barry G. Doyle

IDPH has cited and fined Oregon Living & Rehab Center nursing home after a resident there sustained an unexplained fracture of the humerus.

Many nursing home residents, especially females, suffer from osteoporosis, or “brittle bone disease” which leaves them at greater risk for injuries such as hip fractures after nursing home falls. Other common injuries associated with osteoporosis include compression fractures of the lower and mid-back and broken wrists. But there are some fractures which occur which really cannot be explained at all, and that was the case here.

The resident at issue suffered from advanced dementia. She also had a history of having two failed hip replacements, so she did not have functioning hip joints. She required the assistance of two for all transfers and activities of daily living. In short, she was dependent on staff for doing any kind of movement at all.

The injury was discovered when an aide went to her room to begin to prepare her for bed. He saw that they entire arm was bruised up through the back of her neck and that the there was an indentation pushing out against the skin of her arm. X-rays were obtained which showed that she had a comminuted (broken in at least two places) fracture of the humerus, or upper bone in the arm. Her orthopaedic surgeon told the state surveyor that the fracture was likely traumatic in nature given that the bruising extended all the way to the back of her neck.

So how did it happen? The nursing home investigated, and everyone denied doing anything that could have caused the injury, which is of course completely inconsistent with the nature of the injury and the residents own physical limitations. In the words of the nurse assigned to the resident, “I’m furious because somebody knows what happened.”

There is actually a doctrine in the law called res ipsa loquitur which can be used in cases like this. In Latina, res ipsa loquitur means “the thing speaks for itself” which requires the injured party to show that there was an injury which would not have occurred in the absence of negligence, and this is the kind of injury that would likely qualify. Clearly bones like the humerus do not simply shatter in the way that happened here which would make that theory of liability applicable under these circumstances.

So what was the consequence of this injury? This resident was on hospice, but was actually going to be discharged from hospice because her condition was not declining, but after the fracture, the nurse assigned to her advised the state surveyor that she expected a decline in the resident’s condition, similar to that which you might see after a hip fracture.

Other blog posts of interest:

Broken leg in fall at Generations at Neighbors

Fall results in brain bleed and death at Regency Care of Sterling

Presence St. Anne resident breaks neck in fall from lift

Transport van accident at Generations at Rock Island

Resident falls from lift at Oregon Living & Rehab

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

Side rail injury at Lexington of Lombard

April 11, 2020 By Barry G. Doyle

IDPH has cited and fined Lexington of Lombard nursing home after a resident there suffered a 20 cm bone-deep laceration from a side rail on her bed.

Many families are unaware of the risks that side rails on beds can pose to nursing home residents, and are often surprised to learn that their use is discouraged in the long-term care industry. They would prefer that a side rail be used to keep their mother or father from rolling out of bed or getting up unassisted. Using a side rail to keep someone from getting out of bed is actually using one as a restraint, and the use of restraints is limited by federal regulations.

Side rails are associated with nursing home falls where residents try to climb over the top of the railing. They are also associated with suffocation accidents where residents get trapped between the edge of the mattress and the side rail. The are also associated with strangulation injuries where residents slide off the edge of the bed and get caught with their head or neck under or between sections of side rails. For these reasons, their use is discouraged in the long-term care industry, and most well-run nursing homes have standard assessments regarding the need for their use and policies and procedures about how and when they can be used.

The resident at issue was a new admission to the nursing home. She had suffered a fractured kneecap and was apparently suffering from dementia. When residents are newly admitted to a nursing home, they undergo an assessment which is part of the care planning process. The resident was in bed while the nurse was performing the assessment and tried to get out of bed. This led the nurse to put the side rails up.

However, having the side rails up did not stop this resident from getting out of bed. She apparently tried to slide between the upper and lower sections of the side rails (the very thing which at time leads to strangulation accidents) and cut her leg on a sharp section of the side rail. The cut was 20 cm long and bone-deep in sections. She was taken to the emergency room where the cut was stitched together. However, one of the functions that intact skin serves is that it keeps infecting organisms out, and the length and depth of this cut puts her at increased risk for potentially severe infections like cellulitis and osteomyelitis. Unsurprisingly, her family decided to not return her to the facility.

What was fascinating about this investigation is what the investigation revealed about this facility’s practices regarding side rail usage:

Assessments for side rail usage was not a part of the admission assessment process, not just for this resident, but generally;
The nurses were simply permitted to use side rails in their discretion. When side rails serve as a restraint (as they did here), there should be a very specific process that ends with the consent of the family and a physician order, none of which was done here;
There was no policy in place regarding the use of side rails.

In short, it is well-recognized in the industry that side rails pose some very real risks of harm and for this reason, their use is generally discouraged. However, here there were no policies regarding their use, no standard assessments to determine whether they were appropriate, and nurses were simply left to their own judgment whether to use them or not rather than follow industry norms about treating them as restraints when they were being used in the manner they were here. This resident suffered a bed laceration, but it is an injury that could have been much worse.

What happened here demonstrated a lack of training of the staff and a lack of investment in developing safety practices that are consistent with industry standards. This is something that is a feature, not a bug in the for-profit nursing home business model.

Other blog posts of interest:

Resident injured in side rail accident at Illini Heritage

Park Pointe resident suffocates as a result of fall

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

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

Residents terrorized by fellow resident at Carmi Manor

April 8, 2020 By Barry G. Doyle

IDPH has cited and fined Carmi Manor & Rehabilitation nursing home in Carmi after multiple residents there were assaulted and generally terrorized by a fellow resident over a period of months.

When a resident is being considered for admission to a nursing home, one of the judgments that the admissions staff must make is whether there resident has care needs which would make him unsuitable for the facility or has care needs which cannot be met at the facility. This is an especially critical judgment where a resident has a demonstrated history of psychiatric and behavioral issues which demonstrate a pattern of aggressive or threatening behaviors because a nursing home is often filled with residents who due to physical or mental infirmities may not be able to fend off an aggressor.

The nursing home administration here made a horrifically bad decision to admit this resident and then compounded the problem by failing to train or empower the staff as their proper role in protecting residents and then failing to report and/or investigate abuse that this resident perpetrated on his fellow residents.

The resident at issue was 62 years old (relatively young for a nursing home setting) and had no major physical limitations, but had a current diagnosis of paranoid schizophrenia and had a history of physically and sexually aggressive behaviors. This included a history of having been found unfit to stand trial on rape charges which had previously been lodged against him. Despite this history, the administrator and social services director decided to accept this resident into the facility.

The citation itself is lengthy, and documents at length a disturbing pattern of behavior against his fellow residents. There were seven residents who were victimized by this one resident, both male and female. The male residents were punched and threatened and had their cigarettes stolen from them. Most of the victims were female and they described mainly one of two behaviors. Either they were physically grabbed on the breast by this resident. The other behavior which was directed toward female residents was that he would enter their room proclaim that the female resident was his wife, and act as though he would want to have sex with them. Needless to say this terrified the female residents in the room. The staff would at times simple remove him from the room, but at other times, residents would use their cell phone call 911.

The responses to the calls to 911 were especially disappointing. In one instance, law enforcement simply responded by calling the nurse’s station. One nurse related to the surveyor that the local police department refused to make an arrest because they did not want a psychotic person in their jail. So, of course, they left that psychotic person in a nursing home.

The victims of this resident’s behavior was not limited to his fellow residents. There were staff members who were manhandled and groped. One CNA found herself alone in a room with him with the door closed and screamed because she was afraid of what he would do to her. This was clearly a situation where the staff was not in control of the nursing home.

When a resident is victimized in a resident-on-resident assault, it is incumbent upon the administration to determine whether that resident should remain in their facility. If they cannot keep residents safe, then they need to take steps to discharge the resident. If they believe that the behavior can be managed, then resident abuse prevention care plans need to be modified to take specific and aggressive measures to deter further episodes of abuse. This is another area of failing, as the staff told residents who complained of this resident’s behavior on multiple occasions that they could not do anything about it because they didn’t see this themselves. There really isn’t even a kernel of truth in that. If the staff truly believed that, it represents a massive failure to train. If the staff didn’t actually believe that to be true, it represents a massive failure of leadership because the staff knew that they would not be supported. My guess is that the latter is probably the case because many of the incidents which were described in the citation were never investigated by the administrator who does have an affirmative duty to investigate allegations of abuse.

The net effect of these widespread, repeat failures at this nursing home is that these residents were victimized repeatedly by a resident who likely never should have been admitted in the first place, but was then allowed to stay long after it should have been obvious that this was not a proper resident to have in the facility. A nursing home is a “home” for many residents where they live full time. They do not deserve to be terrorized in their own home. They do deserve to be defended from this kind of nursing home abuse, but there were choices made here to not provide the residents with the level of protection they deserved.

Other blog posts of interest:

Bria of Smithton resident suffers fractured hip in assault by fellow resident

Multiple residents victimized by fellow resident at Winning Wheels

Nurse attacked by resident at Parker Nursing & Rehab

Resident sexually assaulted by fellow resident at Dixon Rehab

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

Resident sexually assaulted by staff member at Alden Estates of Northmoor

April 6, 2020 By Barry G. Doyle

IDPH has cited and fined Alden Estates of Northmoor nursing home in Chicago after a resident there was sexually assaulted by a staff member.

The resident at issue was a female, 34 years old and alert and oriented x1. She suffered from incontinence and used an adult diaper.

On the night of the occurrence, a nurse was walking down the hallway and saw a male member of the housekeeping staff standing in the resident’s room at bedside with his hand inside her disposable brief. The nurse went into the room and confronted him. He explained that he was picking up a diaper in the trash and left before he could be questioned further. The nurse got another staff member to watch the resident while she alerted the Director of Nursing who called the police. The staff member was placed under arrest.

The members of the nursing staff did the right thing. The nurse who saw something being done wrong stopped it, protected the resident, and reported it. The DON called the police and obtained medical care for the resident.

This does not mean that the nursing home will escape liability. Illinois has a specific statute called the Nursing Home Care Act which imposes liability on the nursing home for negligent or intentional acts which injure a resident. This kind of nursing home abuse is squarely covered by that provision.

You would actually think that a special statutory provision like that would be unnecessary, but when it comes to criminal acts by their employees employers (not limited to nursing homes) usually try to defend the case by claiming that the act by the employee was outside the scope of their employment. Having this provision in places smooths the road for victims and their families to receive compensation.

Other blog posts of interest:

Chaplain sexually assaults residents at Good Samaritan Home in Quincy

Resident sexually abused at Countryisde Nursing & Rehab

Resident sexually assaulted by fellow resident at Dixon Rehab

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

Fall from mechanical lift at Hillcrest Retirement Village

April 4, 2020 By Barry G. Doyle

IDPH has cited and fined Hillcrest Retirement Village nursing home in Round Lake Beach after a resident there fell from a lift during a transfer and suffered multiple fractures.

A mechanical lift is an important piece of equipment in a nursing home. It aids the staff in transferring residents from bed to wheelchair, wheelchair to chair, and so forth. It reduces the risk to staff from injury while attempting to do transfers manually and helps reduce the risk of injury to residents when staff attempts a manual transfer when a mechanical lift is really required (as we have seen here, here, and here, for example). However, for the lift to be as useful as it should be, the staff must be properly trained in the use of the lift and the lift and all of its component parts must be in good working order.

The resident at issue was being transferred by staff from her bed to a wheelchair using a lift. While the transfer was in progress on of the metal hooks that attached the sling to the lift frame broke, causing the resident to fall from the sling and land on the legs of the lift.

The cause of the hook failure was metal on metal friction. The lifts were supposed to be checked monthly but the staff had not been doing it. The nursing home did not have any logs as to when the lift was inspected or when maintenance work was done. The last time the nursing home had any record of the facility’s lifts being inspected was approximately 15 months prior to the accident.

This nursing home fall proves the adage, “when it’s everyone’s job, it’s no one’s job” which is another way of expressing the idea when no one has specific accountability for getting a task done, it very often doesn’t get done. That certainly appears to be the case here as the “monthly” inspections of the lift did not get done for 15 months before disaster struck. As it turns out, the owner’s manual recommended periodic application of oil to parts where metal contacted metal. Because the inspections were not getting done and no one was responsible for maintenance of the equipment, this simple bit of maintenance never happened which in turn led to this mechanical lift accident.

So what was the consequence of this bit of routine work not being done? The resident suffered a broken clavicle, a broken scapula, and multiple broken ribs. She has severe pain and it hurts for her to be moved. It hurts to breathe and she coughs frequently. She has been placed on a puree diet to prevent a choking accident. Her doctor is very concerned that she could develop pneumonia which could turn fatal for her.

Other blog posts of interest:

Fatal choking accident at Hillcrest Retirement Village

Fall from wheelchair at Hillcrest Retirement Village

Resident breaks both legs in unsafe transfer at Symphony of Buffalo Grove

Improper transfer results in shoulder injury at Addolorata Villa

Unsafe transfer results in both ankles broken at Rosewood of Inverness

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

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

April 3, 2020 By Barry G. Doyle

IDPH has cited and fined Generations at McKinley Place nursing home in Decatur after a resident there developed a pressure ulcer to her calf.

As people age, they become more susceptible to suffering fractures in falls. At times they suffer fractures which would be repaired surgically in a younger person, but due to their surgical risk profile and lack of mobility, the course of treatment consists of immobilizing the fractures. In the past, this would normally be done with a cast, but is more often done now with a removable device which immobilizes the fracture site allowing the fracture to heal while at the same time allowing the device to be removed to allow for skin care and to start rehabilitation.

The problem with stabilizing devices like boots and immobilizers is that by their very nature, they are intended to hold the fracture in place and as a result, create pressure. “Bed sores” are also called pressure ulcers because one of the main factors that produce bed sores is pressure on the skin between a bony prominence (such as the hips, buttocks, heels, or tailbone) and a resting surface (such as a bed or chair). This is why prolonged exposure to pressure as a result of immobility is one of the main risk factors for developing bed sores. Devices such as boots or immobilizers create a risk of developing pressure ulcers in much the same way, except the pressure point is between the skin and the device. This requires regular removal of the device and inspection of the skin for early signs of skin breakdown.

This resident was an immobilizer after suffering a broken foot. Initially, the fracture was casted. Then, during a follow-up office visit a small scabbed area (1×2 cm) to the back of her calf was noted, so the doctor switched her into a brace, applied a dry dressing, and ordered that the nursing home staff do daily skin checks and dressing changes. The orders from the orthopaedic surgeon were never entered into the resident chart. Skin checks would ordinarily be performed at the time that the resident received a shower, but this resident was exclusively receiving bed baths. As a result, there were no dressing changes and no skin checks done.

Approximately five weeks after the resident was placed into the immobilizer, an aide reported that there was an odor coming from the resident’s leg. When the nurse came to find out what the source of the odor was, he removed the immobilizer. This revealed an unstageable pressure ulcer measuring 9.5 cm long, 5.5 cm wide and 1.5 cm deep with obvious signs of infection. The resident was sent to the hospital where she underwent surgical debridement of the pressure ulcer. The doctors there believed that the wound was caused by the immobilizer and that had the doctor’s orders been followed, the wound would not have progressed to such an extent.

Federal regulations provide that when a resident enters a nursing home without pressure ulcers, they should not develop them unless they are unavoidable. When a resident either develops a pressure ulcer or an existing one starts to decline, this is something that requires a nurse to notify the doctor to obtain treatment orders and a revision of the resident pressure ulcer prevention care plan. When a resident has already developed pressure ulcers, federal regulations require that they receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new wounds.

Here, the physician orders for daily skin checks and dressing changes were not followed. Compounding this, since the resident was only receiving bed baths, she did not receive the skin checks that would happen during showers. As a result, the progression of the wound went undetected until it became so badly infected that it was malodorous.

Other blog posts of interest:

Mattoon Rehab resident dies from infected bed sore

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

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

Resident develops pressure ulcers at Eastside Rehab in Pittsfield

Staff at Hilltop Skilled Nursing fails to follow physician orders, Stage 4 bed sore results

Psych med usage leads to bed sores at Eastview Terrace in Sullivan

Pressure ulcer from surgical boot at Amberwood Care Centre

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

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

April 1, 2020 By Barry G. Doyle

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

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

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

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

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

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

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

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

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

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

Other blog posts of interest:

Swansea Rehab resident fractures hip in fall

Fall from edge of bed at Integrity of Alton

Mar-Ka Nursing Home resident falls, breaks both legs

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

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

Hitz Memorial Home resident dropped from lift

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

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

March 27, 2020 By Barry G. Doyle

IDPH has cited and fined Heritage Heath nursing home in Springfield after a resident there sustained repeated falls, the last of which ended with her suffering a broken arm and a brain bleed.

One of the things that motivates a family to admit a loved one to a nursing home is the occurrence of falls at home, to the point that the family has accepted the reality that they cannot keep them safe at home. When this happens, they are looking to the nursing home to provide a level of safety and supervision that could not be managed at home.

That was the case here, as one of the things leading this family to admit their mother to a nursing home was the fact that their mother had an unsteady gait and was often confused and would forget to ask for help before getting up on her own. Further, she was obsessed with neatness and would often be up straightening and adjusting things. Before her admission to the nursing home, she had one fall which resulted in a broken humerus.

This is a resident who was clearly at risk for a nursing home fall when she came in the door. She had suffered from confusion, had an unsteady gait, and a history of prior falls. She was assessed early on as being at risk for falls, and a fall prevention care plan was put into place.

Nonetheless before her final final fall, she sustained a total of 24 (!!!) falls. When residents experience falls, especially repeated falls, review and revision of the care plan is in order. Falls tend to beget additional falls which means that progressively more aggressive measures are in order.

The second to last fall that this resident experienced was less than a week before the final one. After that fall, her care plan was reviewed, but no changes were made to her care plan. The final fall was an unwitnessed fall. As a result of the fall, she suffered a broken humerus and a brain bleed.

This resident was one who was clearly at high risk for falls. She had a history of falls and had demonstrated and inability to control her behavior to mitigate the risk of falling. To that end, keep her under constant direct observation was called for. A request for a psychiatric consult was also likely in order. Given that the resident experienced an unwitnessed fall, the step of keeping her under constant direct observation was either not incorporated into her care plan or was not being implemented.

Other blog posts of interest:

Resident at Hickory Point Christian Village suffers multiple fractures in fall

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

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

Loft Rehab of Rock Springs resident suffers hip fracture in fall

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

Fall from toilet at Leroy Manor

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

Randolph County Care Center resident falls from toilet and breaks hip

Broken ankle from unsafe transfer at Aperion Care International

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

Integrity of Alton resident suffers fractured eye orbit in fall

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

Fall during transfer results in broken ankle at Sandwich Rehab

Multiple fractures from fall at Accolade of Pontiac

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

Fall from toilet at Alden Park Strathmoor

Fatal choking accident at Spring Creek in Joliet

Broken leg in fall at Generations at Neighbors

Transportation van accident at Generations at Rock Island

Failure to follow orders at Generations at Applewood

Elmiron and pigmentary maculopathy

Resident-on-resident assault at Alden Long Grove

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Fall from lift at Presence St. Joseph Center

Resident suffers unexplained arm fracture at Oregon Living & Rehab

Side rail injury at Lexington of Lombard

Residents terrorized by fellow resident at Carmi Manor

Resident sexually assaulted by staff member at Alden Estates of Northmoor

Fall from mechanical lift at Hillcrest Retirement Village

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

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

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

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