Nursing Home Abuse Blog - Page 15 of 35 - The Law Offices of Barry G. Doyle, P.C.

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

March 25, 2020 By Barry G. Doyle

IDPH has cited and fined Symphony of Buffalo Grove nursing home when a resident suffered fractures to both legs during an unsafe transfer.

The resident at issue had been receiving hospice services for over a year based on a diagnosis of a failure to thrive. She was not able to communicate in a meaningful way, and required extensive assist with all transfers and activities of daily living. Her care plan called for the use of a mechanical lift for all transfers.

On the day of the accident, the resident was brought to the shower by a hospice aide (the fact that a hospice aide was involved in this is significant from a legal perspective because hospice staff are usually independent contractors) after having been transferred from bed to the shower chair using the mechanical lift. When they returned to the room, the lift was apparently not available so the hospice aide asked a CNA to help her lift the resident into bed using a towel under legs. They completed the transfer that way and got the resident into bed.

The following day, when an aide went to get her from bed, he saw that the resident’s legs did not look right, with there being an obvious bulge to one leg and the resident moaned in pain when it was touched. He got a nurse who in turn notified the doctor, who ordered an x-ray that showed both of the resident’s legs were broken.

The citation does not indicate whether the resident underwent surgery to repair the broken legs. Given her age and some of her pre-existing medical conditions, she likely would have been a poor surgical risk. However, similar to what happens to residents who suffer a hip fracture in a nursing home fall, these kind of fractures do not bode well for the long-term outlook for this resident.

The cause of these fractures was the violation of the resident care plan by the nursing home staff. When the CNA was asked about the transfer, and why they didn’t use the mechanical lift, he told the surveyor that he was busy that day. The staff being “too busy” to follow a care plan is a hallmark of an understaffed nursing home, which is of course a regular 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:

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

Bedbound resident at Elevate Care of Waukegan suffers broken arm

Inverness Health & Rehab resident suffers multiple fractures in fall

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

Fall from shower chair leads to brain bleed and death at Manorcare of Arlington Heights

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

Fall from mechanical lift at Hillcrest Retirement Village

Grove of Skokie resident suffers broken leg du to violation of care plan

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

Resident develops bed sore at Avantara of Elgin

March 23, 2020 By Barry G. Doyle

IDPH has cited and fined Avatara of Elgin nursing home after a resident there developed a bed sore after the staff failed to take basic preventive measures after admission.

There are a handful of factors that place a resident at risk for developing bed sores. The most prominent of these is immobility. To combat that risk factor, putting residents who are incapable of respositioning themselves on a turning and respositioning schedule is a mainstay for pressure ulcer prevention.

The resident at issue was admitted to the facility with no pressure ulcers. This means that under federal regulations, the resident was entitled to care, treatment, and services necessary to prevent bed sores and should not develop them unless they are unavoidable. There are certain medical conditions which may result in a truly unavoidable bed sore. Among these is suffering from cancer.

When the resident was admitted, he had a number of diagnoses which placed him at risk for developing bed sores, including hemiplegia (near paralysis on one side, usually the result of a stroke), malnutrition, suffered from incontinence of bowel, and was receiving radiation therapy for prostate and bladder cancer. These are factors which placed the risk at high risk for developing bed sores.

The resident was properly assessed as being at risk for developing bed sores, but the floor staff was advised that turning and respositioning was required for this resident. The assessment is only the first step in the pressure ulcer care planning process. From there, an actual care plan has to be developed and then communicated to the staff actually charged with caring for the resident. This is an obvious point of breakdown in the delivery of care for this resident – either a written care plan was never developed or was never communicated to the staff.

The net effect? The resident developed an unstageable pressure ulcer to the coccyx. The wound was cultured and shown to be growing out drug-resistant organisms. The resident was sent to the hospital for further treatment.

There was an obvious breakdown in care here which had serious consequences for a medically fragile resident. This resident was at very high risk for developing bed sores because of the underlying medical problems he had, but was never given even a fighting chance because of the breakdown in the delivery of care. Making matters worse, the fact that the wound culture grew out drug-resistant organisms is a grim finding because patients undergoing chemotherapy for cancer already have highly compromised immune systems.

Other blog posts of interest:

Failure to care plan leads to bed sore at Avantara of Elgin

Pressure ulcer from surgical boot at Amberwood Care Center

Failure in care lead to bed sore at Park Place in Belvidere

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

Resident assaulted by roommate at Countryside Nursing & Rehab

March 18, 2020 By Barry G. Doyle

IDPH has cited and fined Countryside Nursing & Rehab in Dolton after a resident there was assaulted by her roommate and sustained multiple injuries.

One of the little-known facts about the nursing home industry is that many nursing homes accept residents who suffer from significant forms of mental illness. Many times these are residents who are significantly younger than your “typical nursing home resident” and do not have the same kinds of physical limitations that many nursing home residents have. When their form of mental illness manifests itself in aggressive behavior, there is a real risk of significant abuse.

The victim in this case was a 99 year old woman who suffered from Alzheimer’s disease. Her Minimum Data Set indicated that she was rarely to never understood. She was assessed as being at risk of harm due to serious mental illness. Her care plan called for close monitoring by staff and redirecting her from situations where there is a potential for harm. According to the interviews with the staff, she was a good fit for her roommate because she rarely received visitors.

The aggressor in this case was her roommate. She was 65 years old and suffered from schizophrenia. Before this incident, she had been involved in three other instances of physical aggression against other residents, two of whom were her roommates. The staff believed that part of the reason that she had become aggressive with past roommates is that she did not like having other people in the room and her old roommates had received visitors frequently. Her care plan included assessing her behavior and intervening if her behavior became a threat to others.

In the days leading up to this resident-on-resident assault, she exhibited signs that she was experiencing delusions and had been verbally aggressive with staff. Further, she was refusing some of the medications that had been ordered by her treating psychiatrist. The staff failed to notify the psychiatrist that she was refusing medications and that she was exhibiting signs of delusional behavior.

The assault was discovered by a staff member who saw the victim on the floor with a number of bruises, cuts, and other signs of injury. The aggressor was laying in bed when the staff discovered the victim on the floor. When the aggressor got out of bed, they saw that she had a belt with her that had blood on it. The victim was brought to the hospital where in addition to receiving treatment for the beating that she had received, she also underwent x-rays which showed that she had a broken finger and a broken wrist.

The hall where these residents resided was staffed by an aide and a nurse. The aide brought the victim back to her room around 6:30 p.m. Both she and the nurse clocked out around 8:30 p.m. for their meal break, leaving the residents unsupervised. The attack was discovered shortly before 9:00 p.m. The Director of Nursing told the state surveyor that the residents should not have been left unsupervised during meals – if they were both going to go, they needed to arrange coverage.

There are a number of problems with the care that was being provided. First, the victim was assessed as being at risk for abuse, yet they chose to room her with a resident who had a demonstrated history of aggressive behavior toward her roommates. Second, the staff failed to notify the psychiatrist that the aggressor had been exhibiting signs of delusion and had been refusing her medication. This denied the doctor a chance to intervene in the resident’s behavior before it escalated. Third, the residents were left unsupervised even though this is the front-line mechanism for preventing abuse between residents.

Other blog posts of interest:

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

Residents terrorized by fellow resident at Carmi Manor

Multiple residents victimized by fellow resident at Winning Wheels

Resident sexually abused at Countryside Nursing & Rehab

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

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

Resident receives wrong medications at Manor Court of Freeport

March 17, 2020 By Barry G. Doyle

IDPH has cited and fined Manor Court of Freeport nursing home after a resident there received the medications which were to be given to another resident resulting in an admission to the intensive care unit.

Dispensing medications is one of the basics tasks that a nurse in a nursing home does on a regular basis. Given the number of residents that they are caring for and the number of medications that each receives, it is a task that carries a high risk of error and the potential for disaster given the medically fragile condition of most nursing home residents. to prevent medication errors, nurses are supposed to follow the five “rights” in administering medications: right patient, right medication, right dose, right time, and right route. Not getting all five “rights” just right can result in a critical nursing home medication error.

When nurses are preparing their medication trays, attention to detail is required. If they become distracted or fail to give the task their full attention, they can very easily lose track of what they are doing and one or more of the five “rights” can be missed. That was the case here.

While the nurse assigned to the resident at issue was preparing medications for the patient assigned to her, the resident began to get up from the table unassisted. The nurse saw this and went to help her, but when she returned to her task of preparing the medications, she lost track of what she was doing and ended up giving the resident at issue not only her own medications, but also the medications that were ordered for another resident. This resulted in the resident not only receiving her own dose of Lasix (a diuretic or “water pill”), but also another resident’s dosage of Lasix, plus two blood pressure medications and and two diabetes medications which she did not need at all.

Fortunately, the nurse recognized the error shortly after the error occurred and she was sent to the hospital where she was admitted to the intensive care unit.

The resident’s daughter reported to the state inspector and the doctors at the hospital that this was not the first time that her mother had been the victim of a medication error. The Director of Nursing told the state inspector that the nurse involved had been written up and then transferred out of the dementia unit due to the fact that this was not the first time that this nurse had made a medication error due to becoming distracted during medication pass. She was instead sent to a unit with non-dementia patients who should be able to recognize when they are being given wrong medications in the event that the nurse made an error in dispensing medications.

Other blog posts of interest:

Failure to give anti-seizure medications at Generations at Rock Island

Fatal medication error at Valley Hi in Woodstock

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

Medication error leads to hospital admission at Arista Healthcare

Diabetes medication not given at Lexington of Orland Park

Bella Terra Wheeling resident receives roommate’s diabetes medications

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

Resident wanders from Claridge Healthcare Center

March 13, 2020 By Barry G. Doyle

IDPH has cited and fined Claridge Healthcare Center in Lake Bluff after a resident wandered from the facility and suffered facial injuries in a fall while crossing a 4-lane road nearly a half mile from the facility.

Elopement is the technical term for wandering from the nursing home and is something that poses a serious risk to residents who do so. One of the basic factors driving a family’s decision to admit a family member to a nursing home is the fact that they are unable to keep a loved one safe at home. Sometimes that is due to the fact that they wander from home due to advancing dementia and confusion and are unable to make good decisions about how to keep themselves safe.

When a nursing home accepts a resident into their their facility, there are a number of standard assessments which are done as part of the care planning process. One of these is assessment of elopement risk. Every facility has a slightly different tool for assessing risk of elopement, but there are three main risk factors that show that a resident is at risk for elopement: (1) confusion or dementia, (2) the ability to ambulate (someone is not a high risk for leaving the facility if they cannot get around reasonably well), and (3) either an expressed desire to leave (“I want to go home”) or a history of having left the facility or attempted to do so.

If a resident is at risk for elopement, then a care plan must be put into place which is tailored to the needs and behaviors of the particular resident. Frequently, this involves placing them on a locked unit so that they cannot easily leave the facility. Past that, it also usually includes regular, close supervision of the resident and either monitoring and/or alarming of exit doors.

The resident at issue here was at risk for elopement. She suffered from dementia, was able to move quite well (the citation noted that she moved from very quickly), and she had a history of multiple attempts to leave the facility. One of the staff interviewed told the surveyor that they were “usually” able to get her before she left the parking lot to the nursing home.

The citation did not spell out exactly what the care plan was, but there were a number of failures in the care which was provided. First, the nurse on duty did not know that the resident was an elopement risk and assumed that her absence was due to being part of a group that went on an outing to Walmart that afternoon, apparently unaware that residents who are at risk for elopement are not allowed to go on those kind of outings. Second, the aides may have also been unaware that she was an elopement risk as they were only able to identify 3 of the 7 residents at risk for elopement when they were questioned by the state surveyor.

Finally, the alarms were not working as they should. The resident’s room was on the second floor. Customarily, stairwells in nursing homes are alarmed as a fall prevention measure. When the state surveyor arrived, the stairwell was barricaded by a laundry cart, but the alarm itself was not working. The maintenance man suggested that this was due to the battery being dead from residents constantly opening the door. The stairwell led down to the basement where there was another rear door. The alarm on that door was not on either. The staff explained that the alarm was shut off on the day the resident left the facility because a delivery was coming and was never turned back on.

There was no determination made as to how the resident left the facility – whether she took the stairwell down to the basement and went out the back door or simply walked out the front with no one noticing. Either way she walked almost a half mile from the nursing home and was crossing a 4 lane road when she fell. Passers-by called 911 and she was brought to the emergency room where she was treated for facial injuries.

The injuries in this cased were not severe, but that is a matter of good luck instead of good care, as residents who wander from nursing homes are at high risk for injuries from falls, from criminal assaults, and from exposure to the elements. If a resident is missing for an extended period of time, they will also not be receiving necessary medications and treatment. Nursing home residents need to have more than good luck – they need good care.

Other blog posts of interest:

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

Resident wanders from Alden Long Grove

Niles Nursing & Rehab resident wanders, suffers fractures

Resident wanders from Aperion of Forest Park, drowns in river

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

Multiple medication patches at Seminary Manor result in seizure

March 11, 2020 By Barry G. Doyle

IDPH has cited and fined Seminary Manor nursing home in Galesburg after a resident there was overdosed with a medication intended to treat dementia and suffered seizures as a result.

There are some medications that are administered by way of a transdermal patch, meaning that there is a patch applied to the person receiving the medication. The medication is then received by the patient through the skin. The main advantage to delivering the medication in this fashion is that it is delivered steadily over the course of the day. The danger of course is from accidental overdose through misuse of the medication. For this reason, instructions for use must be carefully followed.

Rivastigmine (also known as Exelon) is a medication intended to address the effects of dementia. This resident had orders when discharged from the hospital to the nursing home for use of this medication by way of a transdermal patch. The instructions for use of this medication and physician orders required that old patches be removed before a new one is placed on the patient.

When the resident was discharged from the hospital, there was a patch already in place. On admission to the nursing home, the resident under went a complete body (which is standard procedure to determine whether the resident suffered from bed sores). The skin inspection sheet failed to note the presence of any transdermal patches. The next day, when a new patch was supposed to be applied, the nurse on duty simply applied a new patch without removing the old one. She was unaware that there was a patch in place and assumed that the use of a patch was new.

The next day, the resident was found with blood coming from her mouth, unresponsive, with eyes dilated. She was sent to the hospital where she had a seizure. The hospital found that the resident had three rivastigmine patches in place. They contacted poison control which informed them that the seizures were the likely result of an medication overdose due to the failure of the nursing staff to remove the old patches before putting the new patch on.

This was a completely preventable nursing home medication error. Medications are crucial to maintaining the health and well-being of nursing home residents, but they have to be administered carefully, in accordance with manufacturer guidelines and physician orders. Here the guidelines and orders to remove old patches before placing a new one was not followed, and this resident suffered seizures as a result.

Other blog posts of interest:

Failure to give medication as ordered at River Crossing of Alton leads to hospitalization

Medication error at Sunset Rehab in Canton

Failure to give HIV medications at Bria of Belleville

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

Resident given wrong medication at Villa Health Care East

Failure to give anti-seizure medications at Generations at Rock Island

Seminary Manor resident suffers fatal brain bleed in fall

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

Pittsfield Manor resident suffers fatal fall

March 8, 2020 By Barry G. Doyle

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

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

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

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

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

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

Other blog posts of interest:

Hitz Memorial Home resident dropped from lift

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

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

Fractured femur from failure to use lift at Granite Rehab

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

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

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

Failure to treat pressure ulcer at Franciscan Village in Lemont

March 5, 2020 By Barry G. Doyle

IDPH has cited and fined Franciscan Village nursing home in Lemont after a pressure ulcer on a resident’s foot decline due to a lack of treatment, resulting the resident developing osteomyelitis.

Federal regulations regarding bed sores provide that after a resident develops a pressure ulcer or bed sore, they are to receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new pressure ulcers.

The development or worsening of a bed sores is an issue which requires physician notification so that the doctor can issue orders for treatment. It also requires revision of the care plan for treatment and prevention of bed sores. While the doctor is the one who issues the orders, in many nursing homes, the doctor defers almost entirely to the judgment of people who have been specially trained in the care and treatment of bed sores such as wound care nurses or wound care doctors.

The resident here had been under the care of a wound care doctor for a bed sore on his foot from the time of the start of this admission up until the point where his Medicare days had been exhausted, at which point, care of the bed sore was transitioned over to the primary care doctor who in turn apparently allowed the wound care nurse to manage the care of the wound. When questioned by the state surveyor, the wound care nurse confirmed that this was the case and in any event, multiple progress notes from the primary care doctor had no notation of the condition of the wound.

Approximately a month after the wound care doctor stopped seeing the resident, the wound declined and an order for daily dressing changes and the use of a chemical debriding agent was obtained. These orders were left in place for two months, at which time, the orders for the dressing changes and the use of the chemical debriding agent were no longer part of the monthly physician order sheets. These orders were missing from the Treatment Administration Records for two months until they reappeared about a week before the resident went to the hospital. The resident chart indicates that the care had stopped.

The bottom line: this resident went almost two whole months without there being any record of the daily dressing changes being done and without the chemical debriding agent being done.

This changed when another nurse noted there being a malodor to the foot and there being serosanguinous drainage from the wound on the foot. These are all signs the wound had become infected. The resident was sent to the hospital 10 days later where he was diagnosed with chronic osteomyelitis of the foot.

There are a number of failures which contributed to the poor outcome for this resident. The most obvious is the cessation of treatment for the wound when the wound had not yet healed, the physician had not ordered treatment stopped, and the resident was still in need of care. The reason for this was not made clear in the citation, but in context, it appears to be due to a clerical error in continuing orders in form month to month in the resident chart.

However, that is far from the end of the strong of failures. The attending doctor was carrying a resident with a diagnosis of having a pressure ulcer to the foot but did nothing to actually monitor the course of care. One of the protocols that is followed in the nursing home industry when a resident is suffering from a pressure ulcer is that there are regular (usually daily) checks done of the condition of the skin, and either none of these were being done or no one was reporting or documenting the decline of the wound until it was badly infected enough that drainage and malodor were present.

Other blog posts of interest:

Failure to follow orders leads to infected bed sore at Generations Oakton Pavillion

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

Victorian Village resident develops pressure ulcer from orthotic boot

Untreated pressure ulcer at Aperion Care Bradley

Grove of Berwyn fails to treat bed sore

Resident develops bed sore at Avantara of Elgin

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

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

March 4, 2020 By Barry G. Doyle

IDPH has cited and fined Eunice C. Smith Nursing Home in Alton after a resident fell from the edge of her bed and suffered a broken leg.

The resident at issue was admitted to the nursing home for rehab. Her Minimum Data Set indicated that she required an extensive assist of two for bed mobility and transfers, which means that two staff were required to help move in bed and out of bed. She was on a law air loss mattress to help in healing of a bed sore.

On the day of this nursing home fall, the resident had an appointment in the wound care center. She sounded her call light to bring staff to help her. One aide arrived and lowered the “bumpers” (likely the side rails) and brought the resident to the side of the bed. The aide was holding onto the resident’s hand, but let go of it to change her position, and when she did so the resident slid from the edge of the bed and fell to her knees on the floor. The reason that she slid from the edge of the bed was that the air mattress was so slick.

She was sent to the emergency room where she was diagnosed with a complete fracture of the distal end of her femur. For lay people, this means the end of her thigh bone closest to her knee. This kind of injury is one which will likely require surgical repair, and for a resident whose ability to walk was already compromised, this is a serious injury indeed. Fractures which require surgical treatment (such as fractured hips) carry a high mortality rate in the months following the surgery for geriatric patients, assuming that she is even a surgical candidate.

This is of course a very preventable accident. The basic story here is that there was one person doing a two-person job, which has been a story that has been told repeatedly on this blog (see here, here, here, here, and here for examples). We believe that the most important question to ask is why did the aide proceed to try to transfer this resident by herself when it was a two-person job? The answer either lies in poor training or understaffing of the nursing home, both of which are features of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

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

Fractured eye orbit from fall at Integrity of Alton

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

Fractured femur from failure to use lift at Granite Rehab

Broken ankle in fall at Aperion of Mascoutah

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

Nurse attacked by resident at Parker Nursing & Rehab

March 2, 2020 By Barry G. Doyle

IDPH has cited and fined Parker Nursing & Rehabilitation Center in Streator after a series of incidents involving a physically aggressive and violent resident which ended with a nurse having to be taken to the hospital.

Some readers of this blog may feel that we are unfair to nurses and that they get unfairly blamed for bad things that happen under their watch. And while we don’t want to discount the importance of being responsible for the things that you do or don’t do, we believe that nurses in nursing homes are often dealt a bad hand by the nursing home business model and that they mostly do the best they can given the circumstances and conditions that they work in.

In this case, a nurse was the one who was the one who suffered the most due to the business decisions that were made at this nursing home to admit one resident in particular. This gentleman had spent time in prison for aggravated domestic abuse and had diagnoses which included Alzheimer’s, restlessness, and agitation. He had been a resident at another nearby nursing home where he had a demonstrated history of being physically aggressive.

According to the staff interviewed by the state surveyor, multiple staff members including the Director of Nursing, asked that the resident not be admitted to the nursing home, but the administrator overruled their requests and allowed him to be admitted to the nursing home.

Over the two and a half months that the resident was at the nursing home, there were multiple events where the resident at issue had been physically aggressive and had behaved in an intimidating way with other residents in his locked dementia unit. There were also incidents in which he was aggressive and threatening to staff members.

Abuse is a nursing home setting is still abuse even when it is perpetrated by one resident against another. Among the other things that must happen is that it must be reported to the State and steps be taken to prevent the recurrence of abuse. When the issue involves the resident as a perpetrator, it requires adjustment of the care plan and taking steps to discharge the resident from the facility when they cannot keep other residents safe.

Part of the issue with resident-on-resident assaults is that the a nursing home is the “home” for the resident who is the victim, and everyone, including and especially nursing home residents, deserve to feel safe in their homes. When the nursing home fails to protect other residents against an aggressor, the other residents have real cause to not feel safe in their own homes.

This string of incidents came to an end with a serious assault on a nurse. The resident had been acting aggressively and two aides summoned the nurse from another unit because the nurse who was assigned to work the locked dementia unit was running late. When the nurse arrived, he grabbed her tightly by the wrists. As she tried to calm him, she asked if he needed to use the toilet. He said yes, so she took him to the bathroom. She saw there were feces on the seat so she went to clean it off. As she was cleaning off her hands, he hit her in the face with a plastic soap bottle. He grabbed her by the hair and slammed her face into the door frame repeatedly. He grabbed her stethoscope and began to choke her with it. She lost consciousness and began to exhibit seizure-like activity. 911 was called and the nurse was taken to the hospital and the resident was removed in handcuffs.

The nurse here deserves to be treated as the hero of the story because she ended up paying a serious price for trying to keep this resident away from his fellow residents. Any one of them could just have easily been a victim of this kind of attack.

What is most striking – and chilling – about this citation are the actions of the administrator. She was the facility’s abuse coordinator, in charge of the investigating episodes of abuse and coordinating the nursing home’s response. She did not treat any of the episodes prior to the attack on the nurse as abuse because she either deemed them “behaviors,” decided that no investigation was required because of the lack of injuries, or simply failed to investigate the incidents.

Her response to the attack on this nurse deserves special examination. Someone who is the victim of that kind of attack at work deserves unwavering support, but that was not what happened to this nurse. What the nurse had to say, from the citation:

Am I in trouble? [The administrator] keeps telling me that I am the reason you are here and the facility is going to get in a lot of trouble if I tell you the truth. We have been told so many times to not chart certain things that will get us in trouble by [the administrator]. One time [the administrator] even erased the charting I did in a resident’s chart because [the administrator] said it would be too damaging to the facility. …. [The administrator] even came to the hospital ER [after the incident] and came into my room, even though I told [the administrator] not to. [The administrator] kept telling me all I had was a panic attack. I was physically assaulted. Now [the administrator] is telling me I better not tell you everything or the facility is going to be in trouble. They said you are here because of me.

This tells you almost everything you need to know about how this place is run – residents are accepted who never should be, problems being swept under the rug, and doing the right thing coming in a distant second place to what the business needs. This nurse paid the price for the way this nursing home is being run, but it could just as easily have been another resident.

There are so many poor choices that were made here for the benefit of the bottom line of the nursing home as a business. 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-on-resident assault at Alden Long Grove

Multiple residents victimized by fellow resident at Winning Wheels

Resident sexually assualted by fellow resident at Dixon Rehab

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

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

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

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

February 28, 2020 By Barry G. Doyle

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

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

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

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

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

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

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

Other blog posts of interest:

Police fracture skull of resident who wandered from Integrity of Smithton

Resident missing for 6 days at Villa at Windsor Park

Side rail accident at Lexington of Lombard

Niles Nursing & Rehab resident wanders, suffers fractures

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

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

Unstageable ulcer to heel at Willow Rose in Jerseyville

February 26, 2020 By Barry G. Doyle

IDPH has cited and fined Willow Rose Rehabilitation & Health nursing home in Jerseyville after a resident there developed an unstageable pressure ulcer to the heel.

Bed sores are also called pressure ulcers or pressure sores because one of the main things that cause these wounds is pressure on the small blood vessels which supply the skin, usually from the weight of the body between a bony prominence such as the hips, heels, or tailbone against a resting surface. One of the main strategies for combating the development of bed sores is pressure relief through the use of pressure relieving devices and a turning and repositioning schedule. Pressure relief is also a mainstay for helping nursing home residents heal from bed sores once they develop.

Federal regulations require that once a resident develops a bed sore, they receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new sores. In order for that to happen, regular skin checks need to be performed so that once a resident develops a bed sores, the nurse can notify the doctor to obtain orders for treatment. This also allows treatment to begin before the wound has declined to Stage 3 or Stage 4 bed sores or becomes an unstageable pressure ulcer.

The staff noted the discovery of an unstageable pressure ulcer on the resident’s heel on June 25. The nurse on duty contacted the doctor who issued orders for treatment. However, those treatment orders were not transcribed onto the Medication Administration Record, so the treatment orders were not carried out until July 1, when they started a new Medication Administration Record page in the resident chart.

Another part of the resident chart was the Skin Inspection Report which did not note the presence of the bed sore on the residents heel at all- even after it was noted in the chart elsewhere.

While the state surveyor was in the facility, she observed that the resident was not moved in bed for a 3.5 hour period even though her care plan called for being turned and repositioned every 2 hours.

When interviewed by the state surveyor, the resident’s doctor stated that he expected that the bed sore would have been discovered before it became unstageable. The administrator was unable to offer an explanation as to why the bed sore was never noted on the skin inspection report and acknowledged they had trouble maintaining the every two hour turning and repositioning schedule.

As a whole, this is a facility which has a series of failures which will likely lead to more residents developing serious bed sores. They are not maintaining the 2 hour turning and repositioning schedule, not accurately completing skin inspections, not getting orders for treatment onto the resident’s chart, and not delivering the care needed to allow residents to recover from the bed sores. This series of failures is setting up residents for getting bed sores, letting them decline, and putting residents at risk for developing infections like cellulitis and osteomyelitis.

These kinda of failures are not a one-off event, but are happening repeatedly, which is a sign of an understaffed nursing home. Sadly understaffing is one of the features of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

Failure to notify doctor of bed sore at Aperion Care of Moline

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

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

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

Resident falls from van at Casey Healthcare

February 24, 2020 By Barry G. Doyle

IDPH has cited and fined Casey Healthcare nursing home after a resident there fell from a van while being unloaded after an outing.

The nursing home has arranged for a pontoon boat outing for the residents and transported them back and forth from the outing with a van equipped with a lift. When the group returned from the outing, the wheelchair-bound residents were being unloaded one by one. The staff had unloaded one resident and was bringing that resident into the facility. The resident at issue had been loaded onto his wheelchair. There was one aide left on the van and she claims to have applied his wheelchair brakes. She turned her back on the resident ans when she turned around she saw that he was propelling himself backwards toward the open lift door to the van. She tried to reach him, but he toppled over backwards out of the open doorway landing on his back and shoulders. He was taken for x-rays which showed that he has suffered two broken ribs.

Broken ribs are a surprisingly serious injury for nursing home residents. Having fractured ribs makes it difficult to breathe in deeply which in turn increases the risk of developing pneumonia which can start its own downward spiral for the overall health and well-being of the resident.

There are a couple of simple ways that this nursing home fall could have been prevented. The first of these would have been to simply raise the lift plate back into place before bringing the other resident back into the nursing home. Leaving an open doorway like that is dangerous in the same way that leaving a stairwell door unlocked or the opening to an elevator shaft open. These are things that pose a risk of significant harm to the resident with no corresponding benefit. The other way to prevent this accident would be to simply supervise the resident more closely. The aide who was left in the van claims to have applied the brakes to the wheelchair (and if this wasn’t in fact done, that would be its own issue), but the resident allegedly released them on his own. Assuming that to be the case, simply staying with easy reach of the resident with eyes on the resident while he was near the door opening would have prevented this accident.

The fact that the aide on the ground could not take the time to raise the lift gate before bringing the other resident into the facility and the fact that the aide in the van had other things to do other than attend to the resident near the door opening speaks to not having enough help on hand to properly attend to the residents who were part of the outing. Understaffing of the nursing home is one of the features of the basic 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:

Macomb Post Acute Care resident suffers multiple fractures in van accident

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

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

Fractured hip in fall at Heartland of Casey

Fall from van at Heartland of Galesburg

Randolph County Care Center resident falls and suffers broken hip

Fall from shower chair at Charleston Rehab

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

Failure to give HIV medications at Bria of Belleville

February 22, 2020 By Barry G. Doyle

IDPH has cited and fined Bria of Belleville nursing home after the staff there failed to give him the medications required treat his HIV.

Nursing home residents are in nursing homes for a reason – either they are unable care for themselves, or they have chronic diseases or conditions which require ongoing care. Regardless of the reason, it is the job of the nursing staff to provide the care, treatment, and services necessary to keep them as healthy and comfortable as possible and to live out their lives with dignity.

The resident at issue was admitted to the nursing home for a short-term admission before he was to be readmitted to the hospital for chemotherapy related to his HIV. One of the medications that he was given was Dolutegravir, an HIV medication which is intended to decrease the levels of HIV in the blood and increase the number of white blood cells necessary to fight infection. This medication was to be given once daily.

The resident arrived at the nursing home with the medication, but the medication was never entered into the Medication Administration record, and as a result, he did not receive his HIV medication over the 10-day period in which he was at the nursing home before returning to the hospital.

The oncology nurse interviewed by the state surveyor stated that missing the doses Dolutegravir caused the resident’s HIV to progress and that there was new evidence of swelling of the brain which was not present before.

Nursing homes are businesses, and well-run businesses have systems in place to make sure that the basic services get provided in a routine manner. In nursing homes, one of those routine services is giving medication as ordered by a doctor. When the order is given, then the order is supposed to be entered into the Medication Administration Record (MAR) which tells the nurses on duty what, when, and how to give the medication and keeps track of whether the medication was in fact given as ordered. These are crucial steps for preventing nursing home medication errors.

However, the first step in that process is to make sure that the medications ordered were in fact properly entered into the MAR. Here the Dolutegravir was never entered into the MAR and was therefore never given. In well-run nursing homes, there is usually a process by which the entry of medication and other orders are double checked when a resident is admitted to the nursing home. The citation issued to the nursing was unclear as to whether there was simply no such process at this nursing home or whether the process was in place but failed. Either way, the resident did not get the medications he needed.

Even though this resident had a condition for which his prognosis was not good, he was still entitled to get good care at this nursing home – the same as every other resident. This is a gentleman who was medically frail, and his condition was made that much worse due to the failures in care at this nursing home.

Other blog posts of interest:

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

Medication error leads to hospital admission at Arista Healthcare

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

Multiple medication patches lead to seizures at Seminary Manor in Galesburg

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

Failure to notify doctor of abnormal labs at Momence Meadows

February 19, 2020 By Barry G. Doyle

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

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

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

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

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

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

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

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

The citation reflects that there was no attempt to notify the doctors about these critically high lab values on and after September 13 up until the assistant director of nursing notified the doctor on September 16. Not surprisingly September 14 and 15 fall on a weekend when it is harder to keep the nursing home staffed as fully as it is during the week. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

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

Burbank Rehab resident hospitalized due to missed dialysis sessions

Failure to monitor anticoagulant levels at Greentree of Bradley

Failure to follow medication orders at Generations at Applewood

Aperion Care Wilmington resident suffers ruptured colon due to fecal impaction

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

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

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

Fall results in fractured kneecap at Country Health in Gifford

February 17, 2020 By Barry G. Doyle

IDPH has cited and fined Country Health nursing home in Gifford after a resident there suffered a fractured kneecap in a fall.

Falls are a serious issue in the long-term care industry. When nursing home residents fall, they tend to suffer catastrophic injuries such as fractured hips and brain bleeds at a rate far greater than may be experienced in the community at large. Even when they don’t sustain those kind of catastrophic injuries, falls tend to beget more falls and even less serious injuries often have significant negative long-term consequences for the health, well-being, and quality of life for a resident who has experienced a fall.

With this is mind, falls are a significant point of focus in the care planning process, which begins with a fall risk assessment. Every nursing home will have a multifactorial fall risk assessment tool, but the two most crucial factors are having some form of balance or musculoskeletal dysfunction (which leaves you at risk of losing your balance) combined with some degree of constant or intermittent confusion, dementia, or poor safety judgment (which leaves you at risk for making poor decisions regarding your own abilities and/or obtaining help with walking or transfers). When a resident is a fall risk, then a fall prevention care plan must be developed which addresses the resident’s particular fall risk factors. The care plan must then be carried out day-to-day, shift-to-shift. Federal regulations require that nursing home residents be provided with supervision and assistive devices necessary to prevent accidents.

This background brings us to the citation issued here. This was a resident who had been properly assessed as being a fall risk for a number of factors, but including dementia. She had a well-known history of being impulsive regarding waiting for help and required a quick response per her care plan. On the night of the fall, a nurse discovered her sitting on the edge of her low bed, expressing a desire to go upstairs (notwithstanding the fact that the facility had only one floor). Rather than help her up to walk, or placing her back to bed or in her wheelchair, the nurse told the resident to wait and she would get an aide.

The aide was at that moment warming up his dinner, but left to go help the resident. As he walked into the room, she stood up on her own, lost her balance and fell to her knees and hitting her head on the side table. She was brought to the emergency room where she received four stitches to close the wound to her head and was diagnosed with a fractured kneecap. The kneecap was treated by being placed in am immobilizer. This is something that will likely have serious adverse effects on her overall level of mobility in the future.

The basic problem with the course chosen by the nurse is that she relied upon a resident with dementia to follow instructions, especially in light of the fact that the resident expressed a desire to get up and expressed a desire to go upstairs when there was no upstairs – evidence of significant confusion. In light of this the proper options would have included sounding a call light to get help, helping the resident herself, or putting the resident back to bed or in a wheelchair while the aide was returning. Instead, she left a resident who was ready to get up and walk unsupervised in a position where she was ready to do so. This is exactly the kind of fall that demonstrates why residents who are unable to make solid judgments regarding their own safety should not be left in a position where their safety depends on them following instructions.

Other blog posts of interest:

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

Multiple fractures from fall at Accolade of Pontiac

Resident falls from van at Casey Healthcare

Mechanical lift accident at Meadows Mennonite Home in Chenoa

Fractured hip in fall at Heartland of Casey

Medication usage leads to fall at Gilman Healthcare Center

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

Medication error leads to hospital admission at Arista Healthcare

February 16, 2020 By Barry G. Doyle

IDPH has cited and fined Arista Healthcare nursing home in Naperville after a resident did not receive medications needed to treat his rheumatoid arthritis leading to a flare-up of the disease which required hospitalization.

When a resident is admitted to a nursing home from a hospital, one of the things that the nursing home receives at the time of the admission is a list of prescribed medications and orders to be followed by the nursing home. When the transfer orders are received, these are customarily entered into the resident’s chart by the admitting nurse. In well-run nursing homes, the entry of these orders is double-checked to insure that all of the orders are entered into the chart correctly. Assuring continuity of care is absolutely crucial to assuring the health and well-being of nursing home resident because the failure to give ordered medications or to carry out treatments or orders can have catastrophic consequences.

The resident at issue here was readmitted to the nursing home from the hospital after experiencing a rheumatoid arthritis flare-up. When Assuring continuity of care is absolutely crucial to assuring the health and well-being of nursing home resident because the failure to give ordered medications or to carry out treatments or orders can have catastrophic consequences. When the resident was brought into the facility by paramedics, they brought paper copies of the discharge orders from the hospital. These were taken by the receptionist and scanned. However, due to a scanning error, only 4 of the 5 pages were scanned, and as a result, there was a whole page of medications that were prescribed for the resident that was never entered into the resident chart. This the sort of error which double checking the chart against the transfer orders is supposed to catch, but no one actually did the double checking, so the error was never caught, and as a result, the resident did not receive the medications on the missing page.

Unfortunately, two of the medications which were listed on the missing page were medications which were critical to keeping the resident’s rheumatoid arthritis under control. Over a thirteen day period, the resident did not receive these medications, and the resident experienced a repeat flare-up of the rheumatoid arthritis. The error was finally discovered when the resident was admitted to the hospital from his rheumatologist’s office because he was experiencing severe pain and had obvious signs of a flare-up.

Obviously, this nursing home medication error led to this resident experiencing significant unnecessary pain. The source of this error is clear, but the nursing home also failed this resident by failing to notify the resident’s doctor about the severe pain that the resident was experiencing.

Other blog posts of interest:

Failure to properly administer medications at Landmark in Des Plaines

Two medication errors at Alden Town Manor

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

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

Resident wanders from Aperion Care Forest Park, drowns in river

February 13, 2020 By Barry G. Doyle

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

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

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

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

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

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

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

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

Other blog posts of interest:

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

Resident missing for 6 days at Villa at Windsor Park

Niles Nursing & Rehab resident wanders, suffers fractures

Police fracture skull of resident who wandered from Integrity of Smithton

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

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

Lack of footrests on wheelchair leads to broken ankle at South Holland Manor

February 10, 2020 By Barry G. Doyle

IDPH has cited and fined South Holland Manor nursing home after a resident there suffered a broken ankle while being transported in a wheelchair that had no footrests.

There are many items of equipment in a nursing home which are there to help residents maintain an optimal state of health and safety – items such as a Hoyer lift or an air mattress. The flip side of many of these items is that when they are not used correctly, they can pose an unnecessary risk of harm to the resident. And so it is with the wheelchair ….

For a wheelchair to be used safely, the footrests must be properly attached and the resident’s feet placed on them. Without the use of footrests, the legs can get caught underneath the wheelchair while it is moving, resulting in orthopaedic injuries; the resident can tip forward out of the chair and suffer lacerations, fractures, or a brain bleed; or the resident’s feet and legs can strike a piece of furniture or a doorway, resulting in fractures or skin tears.

This is what occurred here. The resident was removed from bed by an aide and placed in his wheelchair. No footrests were used. As the aide attempted to take the resident around a corner, his foot got caught against his roommate’s bed. The resident was eventually taken to the emergency room where it was determined that he suffered an ankle fracture. Because the resident was nonambulatory already, the family elected to have the fractured healed by placing it an orthopaedic boot rather than having the resident undergo surgery.

It is obvious that the aide should not have tried to move this resident without the use of the footrests to the wheelchair. The real question is, why not? Putting footrests on a wheelchair is a pretty simple thing to do – a practiced hand should be able to get both footrests on and in position with the resident’s feet and legs properly placed in a matter of a couple of minutes. I would venture to bet that if the aide were asked, he would say that he was in a hurry, was behind, or something similar. These are answers which are a strong indicator of an understaffed nursing home, and in understaffed nursing homes, there are many times when resident safety is sacrificed in the name of expediency.

Other blog posts of interest:

Resident breaks leg in wheelchair accident at Heritage Health in Dwight

Wheelchair accident at LaSalle County Nursing Home

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

Wheelchair accident at Avanti Wellness

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.

Alden Valley Ridge resident rolled from bed, breaks both legs

February 9, 2020 By Barry G. Doyle

IDPH has cited and fined Alden Valley Ridge nursing home in Bloomingdale after a resident there was rolled out of bed while receiving a bed bath and as a result, suffered fractures of both of her legs.

The resident at issue had suffered a stroke and has significant residual weakness on both sides. She required max assist of two with bed mobility because she was unable to contribute to movement or control her body while she was being moved in bed. “Bed mobility” includes things such as being turned from side to side while receiving a bed bath or while being turned and repositioned in an effort to prevent bed sores or to assist in healing after bed sores have already occurred.

Assist of two means that two staff members have to be involved in moving the resident in bed. Not only is this something that is safer for the staff and help prevent things like back injuries to staff members, but it also is intended to help keep the resident from falling out of bed, as we have seen many times in this blog (such as here, here, here, here, and here) where a resident has been rolled out of bed because a single aide was doing a job by themselves that was meant to be done with the help of two people.

In this case a single aide was giving the resident a bed bath. As he rolled her onto her side to wash her back, she went over the edge of the the bed and landed on the floor. She was taken to the hospital where she was diagnosed with fractures to both legs, including multiple fractures in one leg.

On the surface level, this would appear to be like many of the other nursing home falls we have covered in this blog where a resident is rolled out of bed due to a single staff member doing the job of two people – except for the explanation offered by the aide as to why the resident ended up on the floor. He said that she as he rolled her onto her side, the air mattress she was laying on compressed, causing her to slide off the mattress onto the floor.

Further examination by the state surveyor determined that the mattress was inflated to a middle setting as an aid to preventing bed sores. However, the owner”s manual also stated that when it was inflated to its maximum setting, the mattress would provide a harder surface for safer use during transfers. In other words, the compression of the mattress that caused this fall was something that was addressed in the owner’s manual for the mattress – yet that staff never received nay training along those lines and did not know to adjust the settings on the mattress to help prevent just this kind of accident.

A single aide doing the job of two is an indication of an understaffed nursing home – and failing to adequately invest in staff training is another telltale sign of the nursing home business model at work. 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:

Alden Valley Ridge resident breaks leg in fall

Multiple fractures from fall at Lutheran Home for the Aged

Unsafe transfer at Rosewood of Inverness results in fractures of both ankles

Resident at Lexington of Streamwood suffers femur fracture due to unsafe transfer

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

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

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

February 8, 2020 By Barry G. Doyle

IDPH has cited and fined the H & J Vonderlieth Living Center in Mount Pulaski after a resident there suffered a stroke due to the failure of the nursing staff to administer an anticoagulant (blood thinner) medication ordered by the resident’s doctor.

Atrial fibrillation is an irregular heart beat where the upper chambers of the heart contract in a way that is out of rhythm with the lower chambers of the heart. It is a condition which can have serious complications, including strokes and heart attacks. When you have an irregular heart beat, blood can pool in the upper chambers of the heart and form blood clots. Either whole clots or broken-off portions of clots can travel from the heart to the brain, where it can impede circulation to the brain, resulting in what is known as an embolic stroke.

To combat the risk of stroke, doctors often prescribe anticoagulant medications, or blood thinners, which are intended to prevent the formation of the clots which cause the strokes. However, for the medications to be effective, they must be given as ordered so the resident’s blood remains within the therapeutic range. Too “thin”, and the resident will be at risk of excessive bleeding; too “thick”, and there is an outsize risk of blood clots forming.

The resident at issue was admitted to the nursing home after apparently being treated for an infection. The transfer orders included orders to give antibiotics as well as 150 mg of Pradaxa (an anticoagulant medication) every 12 hours. When the transfer orders arrived, the Acting Director of Nursing transcribed the orders onto the resident Medication Administration Record. However, she failed to include the anticoagulant medication on the list of medications to be given and as a result, the resident never received the medication.

Five days after arriving at the nursing home, the resident was found to have left sided weakness and was nonverbal. The resident was sent to the emergency room where she was diagnosed as having suffered an embolic stroke (a stroke caused by a blood clot to the brain) due to missing the ten doses of her anticoagulant medication.

Additionally, the investigation by the state showed that orders for two antibiotics were not copied as ordered in the transfer orders from the hospital, and as a result, the resident did not receive those medications as ordered. Further, there were two additional medications that did not make it onto the Medication Administration Record at all, and as a result, were never given : an order for Tylenol for pain and an order for a cough medication.

The sum total: medication errors with 5 separate medications, one resulting in catastrophic injuries for this resident.

Nursing homes are businesses, and well-run businesses have systems in place to make sure that the routine operations of the business get accomplished seamlessly. The receiving and transcribing of orders for newly-admitted or readmitted residents to the nursing home is one of those routine operations. This nursing home did not have a system in place at all at the time to make sure that orders received were entered into the chart properly, and as a result, the care that this resident received was rife with errors, one of which resulted in unnecessary injury to this resident.

Other blog posts of interest:

Bethany Rehab resident suffers brain bleed due to medication error

Resident given wrong medication at Villa Health Care East

Failure to give diabetes medication at Bridge Care Suites

Medication error at Sunset Rehab in Canton

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

Multiple medication patches lead to seizures at Seminary Manor in Galesburg

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

Untreated pressure ulcer at Aperion Care Bradley

January 29, 2020 By Barry G. Doyle

IDPH has cited and fined the Aperion Care of Bradley nursing home after a resident there had a bed sore worsen from a Stage 2 to a Stage 4 bed sore which became infected.

There are two basic federal regulations which relate to the issue of bed sores or pressure ulcers. The first of these relates to what is required when a resident enters a nursing home without having any bed sores. It requires nursing homes to provide care, treatment, and services consistent with professional standards to ensure that a resident does not develop a pressure ulcer unless it is unavoidable. The second of these relates to what happens after a bed sore develops. It requires the nursing home to provide care, treatment, and services to promote healing, prevent infection, and prevent the development of new sores.

The second of the two regulations is what was at issue with this citation.

When a resident develops a new bed sore has one decline (go from a Stage 2 to a Stage 4 bed sore, for example), this is a significant change in condition. It requires revision of the resident’s pressure ulcer prevention care plan and is something that requires physician notification. The reason that the doctor must be notified when there is a new or worsening bed sore is that this allows the doctor to issue new orders for treatment, refer the patient to a specialist, or have the resident sent to the hospital for care.

This resident developed a bed sore to his left heel, Stage 2-3, measuring 3 x 3 cm with a dark center to it. The staff promptly notified the doctor, who issued orders for treatment. However, the wound care nurse discontinued the treatment orders two days later. The reason: she thought that the order was in error because she was unaware that there was a wound on the left. There was already a wound on the right side and no one told her about the new wound.

The net effect of this is that the wound went untreated for a month and worsened from a Stage 2 or Stage 3 bed sore to a Stage 4 bed sore (exposed muscle or bone). During that time, none of the staff questioned why the resident was not getting treatment for a wound that they knew about it; no one notified the doctor of the ongoing decline in the wound.

Even after treatment orders were restarted, the wound continued to decline and became infected. The resident was transferred to this hospital with an infection of the soft tissues (known as cellulitis) and a likely infection of the bone (known as osteomyelitis).

There are obvious significant issues with the care that this resident received. There is likely some liability on the part of the wound care nurse (who may be an independent contractor and not a direct employee of the nursing home) for discontinuing necessary orders for treatment. That does not relieve the nursing home completely of liability, as no one raised the issue that a resident with a bed sore on his heel was not getting the care that he needed. It also appears that the nursing staff failed to bring the further decline of the bed sores to anyone’s attention.

Other blog posts of interest:

Failure to follow orders leads to infected bed sore at Generations Oakton Pavillion

Failure to notify doctor of bed sore at Aperion Care of Moline

Resident suffers injury from being left on bed pan at Accolade of Paxton

Victorian Village resident develops pressure ulcer from orthotic boot

Failure to treat pressure ulcer at Franciscan Village in Lemont

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

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

Resident chokes to death at Warren Barr North Shore

January 28, 2020 By Barry G. Doyle

IDPH has cited and fined Warren Barr North Shore nursing home in Highland Park after a resident there choked.

Broadly speaking, we all are at some risk of choking, but when it comes to nursing home residents, there are two basic categories of residents who are increased risk of experiencing nursing home choking accidents. One category is residents with chewing or swallowing difficulties due to some physical issue. These residents are usually assessed by a speech therapist, receive a recommendation and an order for a mechanically altered diet to reduce choking risk, and are supervised while eating at a so-called “feeder table” in the dining room. The other category of resident who has a behavioral issue, typically relating to the consequences of stroke, brain injury, or some form of psychological disorder, which causes them to eat in an unsafe manner. These residents require close supervision while eating because of their lack of control over their own behavior.

The resident involved in this fatal choking accident fell into the second category. He was only 46 years old and suffered from frontotemporal dementia which led to a lack of control in eating. He would shove food in his mouth without chewing, would take food off other resident’s trays, and overeat to the point of vomiting. According to his Minimum Data Set, he required the supervision with one person assist while eating.

On the day of the incident, a nurse brought the resident’s tray into his room. The resident was seated upright on his bed, eating and watching television. She left the room to attend to other resident’s but did not take his tray with her. When she returned about 15 minutes later, he was unconscious, blue in color, and unresponsive. When they tried to revive him, they found his mouth stuffed with food. He was pronounced shortly thereafter.

This was a highly preventable death. All that was needed to stop this from happening was to provide this resident with the supervision that everyone knew that he needed. Instead, the nurse left him alone with his tray while she went to do other things. Had the tray been taken away or someone else found to supervise this resident, this death would not have occurred.

The real question of course is why did the nurse leave the resident unattended? The answer probably relates to understaffing of the nursing home which is a deliberate 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 chokes to death at Grove at the Lake

Fatal choking accident at Iona Glos nursing home

Winston Manor resident chokes on peanut butter sandwich

Resident chokes to death at The Moorings in Arlington Heights

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

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

Resident rolled from bed at South Suburban Rehab

January 25, 2020 By Barry G. Doyle

IDPH has cited and fined South Suburban Rehab in Homewood after a resident there was rolled out of bed by an aide during incontinence care.

The story that this citation tells is one that has been told many, many times on this blog: staff tries to provide care with a single person where the help of two is required, and as a result, the resident suffers serious injury. For examples, see here, here, here, here, here, and here …. and sadly that is not all of them even in the last year.

The resident required extensive assistance with incontinence care and had a care plan in place which called for care for her to be provided in pairs. The care plan was spelled out for the aide on duty on the resident care card, but as the aide later told the state surveyor, she did not read the care card before beginning to provide care to the resident. The resident had an episode of incontinence and required changing of her diaper. Rather than wait for help from a second staff member, the aide attempted to provide the incontinence care herself, and in the process, rolled the resident off the edge of the bed. As a result of this nursing home fall, she suffered a fractured hip.

A fractured hip is a serious injury for anyone, but can be deadly for a nursing home resident. Assuming that the resident survives the surgery itself, there are complications from hip fractures such as heart attack, DVT, pulmonary embolism, and stroke all in play during the immediate post-operative period. Past that, many nursing home residents never fully regain the ability to walk which places them at risk further further falls, developing bed sores, and suffering pneumonia. When one of these complications is a contributing cause to the death of a resident, that can serve as the basis for a wrongful death lawsuit.

We know that the aide certainly should have waited for the help of a second staff member before attempting to provide the incontinence care, but the real question of course is why didn’t she? She told the state surveyor that she was in a hurry and that it was approaching the end of her shift. The surveyor further asked when she last attended an in-service training regarding providing ADL care, the aide told the surveyor it was probably years earlier. What this really says is that the problem is the nursing home business model. “Being in a hurry” is a hallmark of an understaffed nursing home. Going years without in-service training on basic functions speaks to a lack of investment in the staff, which is also a feature, not a bug in the nursing home business model.

Other blog posts of interest:

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

No fall prevention care planning at South Suburban Rehab

Resident falls from bed at Spring Creek

Park Place Christian Community resident rolled out of bed by staff

Mechanical lift accident at South Holland Manor

Aperion Care International resident fractures ankle in unsafe transfer

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

Resident scalded in shower at Westchester Health & Rehab

January 24, 2020 By Barry G. Doyle

IDPH has cited and fined Westchester Nursing & Rehab after a resident there was scalded while taking a shower.

One of the inevitable facts of aging is that as we age, our skin gets thinner and less resilient. This is one of the factors that makes geriatric patients more at risk for things like bed sores and skin tears. Skin is also more vulnerable to injury when the resident suffers from malnutrition and/or dehydration. Because the skin is thinner and more fragile, special care must be taken to keep if from injury.

This bring us to the citation that was issued here. The resident was brought into the shower and left in the shower unattended for a period of 10 minutes. When the staff returned, the resident had redness and peeling of the skin and neck. The resident was taken to the emergency room and then transferred to the Intensive Care Unit at the local hospital with a burn unit. The physician there diagnosed the resident as suffering from partial thickness burns, an injury which does not happen when the water is below 131 degrees. When interviewed by the state surveyor, the maintenance director stated that the water was tested daily and was between 108-110 degrees. However, the state surveyor also interviewed a number of residents who uniformly described the water as being too hot, with one of them describing it as so hot “it could take feathers off a chicken.”

Maintaining the hot water heater properly so that it does not produce scalding hot water is a basic part of the nursing home’s responsibility to keep the property in safe condition for its residents, as defects in the property such as broken alarms, defective baseboard heaters, and the like can result in serious injury to the residents in the facility.

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

Other blog posts of interest:

Resident burned by hot pack at Miller Health Center

Resident suffers burns at Village at Victory Lakes

Burn from hot packs at Walnut Manor

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

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

Resident develops bed sore at Avantara of Elgin

Resident assaulted by roommate at Countryside Nursing & Rehab

Resident receives wrong medications at Manor Court of Freeport

Resident wanders from Claridge Healthcare Center

Multiple medication patches at Seminary Manor result in seizure

Pittsfield Manor resident suffers fatal fall

Failure to treat pressure ulcer at Franciscan Village in Lemont

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

Nurse attacked by resident at Parker Nursing & Rehab

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

Unstageable ulcer to heel at Willow Rose in Jerseyville

Resident falls from van at Casey Healthcare

Failure to give HIV medications at Bria of Belleville

Failure to notify doctor of abnormal labs at Momence Meadows

Fall results in fractured kneecap at Country Health in Gifford

Medication error leads to hospital admission at Arista Healthcare

Resident wanders from Aperion Care Forest Park, drowns in river

Lack of footrests on wheelchair leads to broken ankle at South Holland Manor

Alden Valley Ridge resident rolled from bed, breaks both legs

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

Untreated pressure ulcer at Aperion Care Bradley

Resident chokes to death at Warren Barr North Shore

Resident rolled from bed at South Suburban Rehab

Resident scalded in shower at Westchester Health & Rehab

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