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Improper transfer results in shoulder injury at Addolarata Villa

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IDPH has cited and fined Addolorata Villa nursing home in Wheeling after a resident there suffered a dislocation of a prosthetic shoulder due to an improper transfer performed by an aide.

Bed mobility is a term which is used to describe the movement of a nursing home resident in bed.  Some nursing home residents, due to generalized weakness or other issues, need assistance with being repositioned in bed.  When a resident needs assistance with bed mobility, it is incumbent upon the nursing home staff to provide that assistance safely.

The resident at issue had been determined to need the assist of two with bed mobility in part due to a history of having rheumatoid arthritis and rib fractures from falls.  On the night she was injured, at bed time she was seated near the foot of her bed when the aide assigned to her said that she would position her in bed.  The resident advised the aide that two people normally assisted her with that, but the aide insisted that she could do it herself.  She lowered the head of the bed, instructed the resident to lay down and grabbed around the top of the shoulders and began pulling her toward the head of the bed.  No lift sheet was used.  When she did so, there was a loud pop and the resident experienced significant pain.  The resident told the aide that her shoulder was hurting and the aide responded that she wasn’t going to touch her any more, and alerted the nurse on duty.

The nurse on duty notified the resident’s doctor who in turn ordered x-rays which showed that the resident’s artificial shoulder had become dislocated and that there was a fracture of the scapula.  As of the time the citation was written the resident remained in a sling and had significant pain in the shoulder which was poorly controlled by medication.

The underlying story here is one which has been told many, many times on this blog: the resident was injured as a result of one person attempting to do a two-person job.  See here, here, here, and here for just a few examples.  In the process, the resident’s safety was sacrificed and the injury to the resident was the predictable result.

The key question of course is why did the aide feel it necessary to do a two-person job by herself?  The answer will likely come back to understaffing of the nursing home.  Sadly, understaffing is a key component of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Fall from mechanical lift at Hillcrest Retirement Village

Alden Valley Ridge resident rolled from bed, breaks both legs

Multiple fractures from fall at Lutheran Home for the Aged

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

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

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

 

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

 

 

Fatal choking accident at Hillcrest Retirement Village

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

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

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

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

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

Sadly, it wasn’t.

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

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

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

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:

Riverview Rehab resident chokes to death

Fall from mechanical lift at Hillcrest Retirement Village

Fatal choking accident at Warren Barr North Shore

Resident chokes to death at Rosewood of St. Charles

Fatal choking accident at River Bluff nursing home

Resident chokes to death at The Moorings in Arlington Heights

Fatal choking accident at Spring Creek in Joliet

 

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

 

 

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

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

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

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

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

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

Other blog posts of interest:

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

Rushville Nurisng & Rehab resident suffers untreated surgical wound infection

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

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

Moorings staff fails to notify doctor

Infection goes unnoticed at Helia of Belleveille

Burbank Rehab resident hospitalized due to missed dialysis sessions

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

 

Resident develops pressure ulcers at Eastside Health & Rehab

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IDPH has cited and fined Eastside Health & Rehab in Pittsfield after a resident there developed pressure ulcers on his buttocks.

The citation that IDPH issued is interesting because it has two parts and taken together, it tells a story about what is happening at this facility.

Bed sores are also called pressure ulcers because one of the main causative factors is pressure from the weight of the body against a resting surface such as a bed or a chair.  Typically, they occur over bony prominences such as the hips, ankles, or heels.  Major risk factors for developing pressure sores include immobility, incontinence, and poor nutritional status.

Federal regulations relating to the issue of bed sores in nursing homes requires (a) that when a resident enters a nursing home without bed sores, they must receive care, consistent with clinical standards of practice, to prevent bed sores and not develop them unless they are unavoidable and (b) once they develop bed sores, they receive care, treatment, and services to promote healing, prevent infection, and prevent the onset of new bed sores.

The issue of bed sores is something which is addressed in the care planning process.  When a resident is admitted to a nursing home, they are assessed for risk of developing bed sores, usually through the use of a tool like the Braden scale.  If they are determined to be at risk for developing bed sores, then a care plan must be put into place.  The care plan will usually include elements like providing prompt incontinence care, use of barrier creams, turning and repositioning every two hours, and regular skin checks. The development of a bed sore or the decline of one is something which requires physician notification so that orders for treatment can be obtained.

The usual regimen of providing incontinence care, turning and repositioning, and doing frequent skin checks is a labor-intensive exercise.  As a general proposition bed sores do not develop as a result of a single violation of the care plan during a single shift.  However, as the shortcomings in the delivery of care pile up over time, then the onset of new bed sores becomes more predictable.

The first resident at issue was at risk for developing bed sores.  He developed Stage 2 pressure ulcers to both sides of the buttocks.  These healed, but then about a month and half later later, was noted to have unstageable pressure ulcers to both buttocks.  By definition, an unstageable pressure ulcer is at least a Stage 3 pressure ulcer because there is dead tissue in the wound bed which keeps the bottom of the wound bed from being seen.  When the state surveyor asked  the Director of Nursing why these were not discovered until they were unstageable, she was unable to explain it.

Which brings us to the other issue raised in the citation.  While the state surveyor was in the facility doing her inspection, she saw that one resident was left sitting in his wheelchair, asleep and unmoved for a four hour period.  The standard for preventing pressure sores is to turn and reposition every two hours.  When residents go longer than that, the prolonged amount of time that the skin is exposed to pressure increases the chance of a bed sores developing.

What these two instances together tell us is that the routine care that is necessary to prevent and treat bed sores is not being provided.  With regard to the first resident, regular skin checks should have detected the bed sore before it became unstageable.   Bed sores are more easily treated when they are less severe, and the decline from a Stage 2 to unstageable is significant.  Failure to detect that and notify the doctor before it became unstageable is a significant lapse in care.  In the same way, the failure to resposition the resident in his wheelchair is also a lapse in care which increased the risk of injury to that resident.  And all this is just a snapshot of what is happening at that nursing home.

The real question is why, of course.  And the answer to the likely lies in understaffing of the nursing home.  Understaffing of the nursing home is a key 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:

Unstageable pressure ulcer to heel at Willow Rose in Jerseyville

Resident develops bed sore on both heels at McLean County Nursing Home

Moweaqua Rehab resident suffers multiple declining bed sores

Mar Ka Nursing Home resident left on bed pan, suffers pressure sore

Resident develops bed sore on both heels at Eden Village

 

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

 

Resident sexually abused at Countryside Nursing & Rehab

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IDPH has cited and fined Countryside Nursing & Rehab in Dolton after a female resident was sexually abused by a male resident from that facility.

One of the basic items that families look to nursing homes to do is to protect their families members from being injured, abused, or otherwise taken advantage of while they are at the nursing home.  The staff is always a source of concern for families, but the potential for abuse does not begin and end with the staff – residents can be perpetrators of abuse as well …. and that is what the situation was here.

The incident which served as the basis for the citation began with a nurse observing a female resident who suffered from advanced dementia walking down the hallway with a sheet wrapped around her lower half, holding two dollars in her hand.  When the nurse asked her what happened and where the money came from, the resident was not able to explain exactly what had occurred, but from the discussion, the staff was able to identify a male resident. The male resident was summoned, at which point the female resident said that this was the man who raped her.

For his part, the male resident stated that the sex between them was consensual and that he would give her money or provide her with sweets such as a cupcake or pop after having sex.  The two men that he shared a room with told staff that he would bring an older lady into the room and could hear them having sex and never heard her say no.

The female resident was sent to the hospital for a rape exam.  The police investigator sent to the emergency room was unable to interview her due to her mental state.

Nursing home residents are adults, and as such, are actually free to engage in romantic relationships of their own choosing.  But for this to occur, both of the residents have to be able to consent to enter into that kind of relationship. If one of the residents is not capable of consent due to declines in their mental, intellectual, or psychological condition, then sexual activity involving another resident as here is actually a form of nursing home abuse – even where the staff is not the perpetrator of the abuse.

Where there is a potential for a resident to be the victim abuse, this is something that must be addressed in the resident care plan.  A care plan would include such items as keeping the resident under direction observation to keep the resident from being victimized.  Failing to do that is something that would serve as a basis for a nursing home abuse and neglect lawsuit.

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 assaulted by roommate at Countryside Nursing & Rehab

Multiple residents victimized by fellow resident at Winning Wheels

Resident sexually assualted by fellow resident at Dixon Rehab

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

Nurse violently attacked by resident at Parker Nursing & Rehab in Streator

 

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

 

 

 

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

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IDPH has cited and fined Accolade Paxton Senior Living after a resident there suffered injury from being left on a bed pan for over 2 hours.

Besides providing the basic care that nursing home resident require, it is part of the job of the nursing home staff to treat residents there with respect and to assure their dignity. The physical injuries that this resident suffered do not appear to have been severe, but the aide’s approach to caring for this resident can most fairly be characterized as being a prime example of nursing home abuse.

When a resident sounds a call light, it is part of the job of the staff to respond to the call light and attend to the resident’s needs in a timely way.  When the staff routinely fails to respond to call lights and meet the care needs of the residents, they are effectively training the residents that no one is coming for them when they sound the call light.  This sets the stage for disaster – residents who need help walking may simply give up on waiting for staff and get up on their own, setting the stage for a nursing home fall.

Many nursing homes have electronic call light systems where response times can be tracked for a particular resident, for a wing, or the facility as a whole, and this is information which we routinely request in nursing home abuse and neglect lawsuits.

This particular resident needed the assistance of a single staff member for transfers and for toileting.  She sounded the call light shortly after 4 a.m., and when the aide arrived, she told the resident that she was “too busy” to help her to the toilet and placed her on a bed pan.  After she was done using the bed pan, she sounded the call light over and over … with no response.

When the change of shift occurred at 6 a.m., the aide who was leaving told her replacement that the resident was on the bed pan, but did not say for how long.  After the resident sounded the call light again, the aide came to help her off the bed pan – at approximately 6:30 a.m.  When she did so, the resident said that it hurt and her skin tore away.  When the state inspector came, she saw visible yellow and purple buises on the resident’s buttocks.

The most powerful part of the citation is this:

[The resident] looked away and was visibly upset and shaky.  “Nobody came to help me untigl after the day shift came in.  It was stuck to me.  I think my skin came off!  Nobody came.  I was scared!  I can’t explain how bad it was.”  [The resident] sighed deeply and looked away.  [The resident’s] lower lip quivered.

The physical injuries to this resident may have been minor but the assault on her dignity was significant.  Events like this are why nursing home residents at times describe being afraid of staff members and reluctant to be assertive in demanding the care that they need – because the staff can simply leave them sitting on a bed pan for hours on end instead of taking them to the toilet like they requested because they are “too busy.”

Being “too busy,” having events like this occur, and having extended call light are the hallmarks of a nursing home that is understaffed.  Understaffing of a nursing home sets the stage for poor outcomes such as falls, bed sores, and medication errors.  Sadly, understaffing of a nursing home is part of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

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

Flanagan Rehab resident develops infection from bed sore

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

Resident develops bed sore from being left on bed pan at Mar Ka Nursing Home

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

Oak Brook Care resident develops Stage IV pressure ulcer from immobilizer

 

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

 

 

 

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

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IDPH has cited and fined McLean County Nursing Home in Normal after a resident there developed bed sores on both heels which worsened due to improper care after the wounds were discovered.

The resident at issue was admitted to the nursing home without any pressure ulcers, but had mobility deficits which left her chairfast and which required that the staff provide asisstance with respositioning.  Approximately two weeks after admission, there were blisters discovered on both heels.  The staff alerted the doctor who ordered that the resident not be placed in closed heel shoes, that the resident use pressure relieving boots, and that her heels be floated while she is in bed.

After a nursing home resident develops a bed sore, the next steps that must be taken are to notify the resident’s doctor to obtain orders and to update the resident care plan.  Part of the care planning process is to communicate the changes to the care plan to the staff responsible for delivering the care to the resident.  After all, a great care plan is of no use if the people charged with carrying it out do not know what it is.

This facility used a computerized system which assigned tasks to aides through the POC or Point of Care system.  By reviewing the tasks for each reisdent through the POC system, the aides would know what care to provide.  This is a very reasonable system …. as long as it is actually implemented.  And that is where the care for this resident broke down.

Over the course of the two and half months that followed the discovery of the blisters on the resident’s heels, these wounds declined to a Stage 4 pressure ulcer on one heel and a Stage 3 on the other.  When the surveyor arrived in the facility, she saw that the resident was wearing closed heel shoes, that she was not using presaure reliving boots, and that her heels were not being floated (lifted off the surface of the bed) when she was lying down in bed.

Federal regulations require that once a nursing home resident develops pressure sores, they are entitled to receive care treatment, and services to promote healing, prevent infection, and prevent the devlopment of new sores.  That didn’t happen here.  The resident had orders which in essence called for pressure relief on the heels and because the substance those orders was not incorporated into the care plan because the nurse whose responsibility it was to do this simply failed to do so.  A simple breakdown in the process with a serious result.

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

Other blog posts of interest:

Sharon Health Care Elms resident develops bone deep bed sore

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

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

Resident suffers from pressure ulcers at Parker Rehab

Resident develops pressur eulcers on both heels at Eden Village

Bed sore requires surgery for resident at Timbercreek Rehab

 

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

 

 

 

Resident missing for 6 days from Villa at Windsor Park

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IDPH cited and fined the Villa at Windsor Park nursing home in Chicago after a resident there left the facility and was missing for 6 days.

There are a number of things which prompt families to decide to admit a loved one to a nursing home.  One of these is when a parent or other family members wanders from home without supervision and is unable to return due to dementia or some other disease which affects their memory and/or thought process.

When a resident is admitted to a nursing home, they undergo a comprehensive assessment which is a part of the care planning process.  Assessing the risk of elopement (or wandering from the nursing home) is a standard part of the assessment.  Some of the risk factors for elopement include: being able to ambulate freely with or without an assistive device; a history of attempted elopement in the nursing home setting or wandering prior to admission; dementia; restlessness, anxiety, or agitation; and an expressed desire to go home or otherwise leave the facility.

When a resident is assessed an elopement risk, that must be addressed in the resident care plan.  Three of the more common steps which are part of the care plan would include placing the resident in a loccked or restricted unit, use of an alarm called a wanderguard, and frequent rounding.  The reason that this must be addressed in the resident care plan is because a nursing home resident who wanders from the facility is at risk of serious injury or death from due to being involved in an accident (such as a fall or being hit by a car) or the victim of a crime.  Put simply, their physical and mental limitations leave them vulnerable.

The resident at issue had a history of wandering before being admitted to the nursing home, and the family told the staff this.  They were assured that the resident would be placed in a locked unit. The resident was admitted to the third floor of the facility and an alarm was applied to him.  Upon entry to the elevator, an alarm was supposed to sound.  The staff told the surveyor that this was a silent alarm, but the director of nursing said that it wasn’t.  When they tested the alarm, they found that it did not sound.  The building’s maintenance director admitted to the state surveyor that he was checking off on maintenance logs that regular inspections of the alarm system were being done, but he had in fact not done any in a long time.  In short, it appears that this facility did not have a fully working alarm system.

After leaving the facility, the resident was missing for a 6-day period which included two visits to hospital emergency rooms from which he was discharged, once to a homeless shelter.  He was discovered by family six days after leaving the facility standing in the middle of a high traffic street.

There is a very basic set of steps that must be taken to address residents who are at risk of elopement, and having a working alarm system which alerts the staff that a resident is leaving a secure unit is on the front line.  Obviously, this facility did not have a fully working system because no one was actually checking to make sure that it was functioning.  This resident went missing during the month of June.  Had an absence of this length happened in the dead of winter, it is doubtful that this resident would have survived expsoure to cold for that length of time or not gotten seriously sick.  Past that, he was discovered in the middle of the street.  Getting hit by a car while wandering is one of the foremost risks with residents who wander from a nursing home which is why this is a part of the standard admitting assessment when a resident enters a 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 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 wanders from Alden Long Grove

Symphony of Midway resident suffers fatal fall from window

Niles Nursing & Rehab resident wanders, suffers fractures

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

Resident wanders from Aperion of Forest Park, falls into river and drowns

 

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

 

 

Mechanical lift accident at South Holland Manor

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IDPH has cited and fined South Holland Manor nursing home after a resident suffered a femur fracture as a result of a mechanical lift accident.

Mechanical lifts are by themselves a useful tool for doing things safely in a nursing home setting – safer for residents, safer for staff – as long as they are used properly.  To be used safely, two staff members need to be involved in executing the transfer.  When done properly, one staff member can operate the controls, the other can assure the safety of the resident during the transfer.  When a mechanical lift transfer is attempted with only one staff member, the element that goes by the wayside is the staff member whose role is to assure the safety of the resident – and the loss of this element sets the stage for disaster.

The resident at issue had been coded on her Minimum Data Set for extensive assist of two for transfers and here care plan called for use of a mechanical lift with an assist of two for all transfers.  On the day of this nursing home fall, the transfer was being attempted with a single aide.  It wasn’t clear from the text of the citation exactly what occurred.  The aide described the resident’s foot slipping off the foot rest while there were other staff describing the resident’s legs giving out.  In either event, the resident suffered a fractured femur which required surgery.

The story itself is one that we have told many times (see here, here, here, here, and here for examples) – one person doing a two person job.  It is a violation of the resident’s care plan, a violation of the facility’s own policies and procedures,  and contrary to the instructions in the owner’s manual for the lift.  The question of course is, why?  The aide told the state surveyor that she was in a rush.  This of course speaks to understaffing of the nursing home, which is something that is inherent to 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 rolled from bed at South Holland Manor

No fall prevention care planning at South Suburban Rehab in Homewood

Resident’s third fall at Bria of Chicago Heights nets brain bleed

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

 

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

 

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

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IDPH has cited and fined Royal Oaks Care Center in Kewanee after a resident there developed infected bed sores on the insides of both knees.

One of the reasons that pressure sores are commonly known as “bed sores” is because on of the main causative factors is pressure on the skin between a bony prominence and a resting surface such as a bed or a chair.  This is why some of the more common places that you see bed sores is on the buttocks, tailbone, hips, and the backs of the heels.

That is not the only place that you will see bed sores, and the citation that IDPH issued to this nursing home was for bed sores seen in an unusual location – in between the knees.  It isn’t clear from the citation why this resident developed the bed sores in that location, but the key failure of the nursing home is what happened after the resident developed the bed sores.

After a resident develops a bed sore, federal regulations require that a resident receive care, treatment, and services to promote healing, prevent infection, and prevent the development of new pressure sores.  In practice this means that the nurse must contact the doctor to let the doctor know that the resident has developed a bed sore and to obtain orders for treatment.  It also means that besides carrying out those specific orders, the pressure ulcer prevention care plan must be updated to reflect the resident’s change in condition and include the steps that must be taken by the nursing staff to promote healing and prevent the onset of infection of the existing sores and to prevent the development of new sores.

One of the steps that is generally taken is that there are regular inspections of the condition of the skin, particularly during dressing changes, for signs of infection.  Nurses are not required to know how to treat infections in the sense of knowing which antibiotic should be used to treat the infection, but as the eyes and ears of the doctor, they must be able  to identify signs of infection so that they can notify the doctor.  Cellulitis is an infection of the skin and signs of infection commonly include redness, drainage, malodor, pain, and fever.  When an infection works its way down to the bone, this is known as osteomyelitis.

The resident here was noted to have flaking of the skin on the insides of both knees on May 18.  On June 15, the resident’s doctor entered an order for cleansing of the wounds on the insides of the knees, application of an antibiotic ointment, and for a wound care consult.  On June 22, the wounds were described as being large open wounds on the insides of both knees.

When the resident arrived at the wound care clinic on June 25, there was obvious evidence of infection.  The wound care nurse treating the residnet recommended admission to the hospital because the wound required surgical debridement and IV antibiotics.  The wound care nurse told the state surveyor that the wounds had been present for a month or longer and that the resident should have been treated sooner.

Without knowing more about the resident’s underlying medical issues, it is hard to fault the nursing home for the onset of these bed sores – although that is an issue I would investigate if I were the family’s lawyer.  The key issue here is how the nursing staff handled the decline of the wounds and the onset of infection.  The presence of the signs of significant infection and the rapid decline in the condition of the wounds should have triggered notification of the resident’s doctor so that more aggressive treatment could be initiated.  This was obviously not done.

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:

Head injury from fall from lift at Presence St. Joseph Center in Freeport

Pressure ulcer from surgical boot at Amberwood Care Centre in Rockford

Resident suffers flesh-eating disease due to untreated skin tear at Regency of Sterling

Bed sore requires surgery for Timbercreek Rehab resident

Failure to notify doctor of pressure sore at Aperion of Moline

 

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

 

 

Pressure ulcer from surgical boot at Amberwood Care Centre

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IDPH has cited and fined Amberwood Care Centre nursing home in Rockford after a resident there suffered a significant pressure ulcer from a surgical boot.

Bed sores are also referred to sometimes as pressure ulcers or pressure sores because one of the main ingredients in producing them is pressure.  The main places that you tend to see pressure ulcers develop is on the bony prominences such as the hips, buttocks, tailbone, and heels.  However, pressure from lying on bed or sitting in a chair or wheelchair is not the only way that a nursing home home resident might develop a bed sore or pressure ulcer.  Sometimes pressure ulcers can develop due to the use a medical devices such as braces which are intended to immobilize the body part – which is what happened here.

This resident was admitted to the nursing home for rehabilitation after suffering a fractured ankle and having surgery.  At the time of her admission, there was a soft cast which was being used to immobilize to allow the fracture site to heal.

When the resident went in for her first follow up appointment, the doctor removed the soft cast and ordered use of a walking boot.  The purpose of the walking boot is to allow for some weight bearing while still protecting the fracture site.  After the healing process has begun, subjecting the fracture to mild pressure actually helps stimulate bone growth and accelerates the timeline for recovery.  However, use of the walking boot is not without risk as pressure from the boot or rubbing against the skin can cause a skin breakdown.

To combat against the risk of skin breakdown, the boot should be removed at least daily to check the skin for signs of skin breakdown.  If there are early skins of injury to skin such as redness, pain, or poor capillary refill (a sign of injury to the small blood vessels that supply the skin), then the nurse must notify the doctor so that he can issue orders to prevent further injury or make modifications to the boot so that the skin breakdown doesn’t worsen.

When the resident returned from the doctor’s office with the walking boot, the only wound which was present was the surgical incision which was on the outer aspect of the ankle.  The problem arose when the staff did not remove the walking boot or inspect the skin or dressing to the surgical wound for an entire week.  The facility wound care nurse came in a week later, removed the boot and saw that the resident had developed a wound on the outside of her foot where there was exposed tendon.  Ultimately, the resident had undergo surgical debridement of the pressure sore on her foot and have a wound vac placed in order to attempt to heal the wound caused by either pressure or rubbing from the surgical boot.

This is the kind of outcome which was utterly avoidable.  Residents who are at risk for skin breakdown should undergo daily skin inspections as a matter of course – and this was clearly a resident who was at risk for skin breakdowns as the presence of a medical device such as a walking boot is something which is a well-recognized as a risk factor for the development of skin breakdowns.

The more interesting question is why this resident went a whole week without any of the nurses or aides charged with caring for her doing a skin check when it was clearly needed.  One answer may be poor training of the staff, but an equally likely explanation is a breakdown in the care planning process.  The care plan drives the routine daily care which is provided to residents in a nursing home and must be periodically revised in light of changes in the resident’s condition.  The presence of a new medical device probably should have triggered a change in the pressure sore prevention care plan to include daily skin checks, but apparently this never happened and a serious and preventable injury was the result.

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

Other blog posts of interest:

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

Resident develops bed sores to both knees at Royal Oaks Care Center in Kewanee

Fatal choking accident at River Bluff nursing home in Rockford

Bed sore requires surgery for Timbercreek Rehab resident

Failures in care lead to bed sores at Park Place in Belvidere

 

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

 

 

Failure to properly administer medication at Landmark of Des Plaines

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IDPH has cited and fined Landmark of Des Plaines nursing home after the staff got an antifungal medication into a resident’s eyes, causing chemical conjunctivitis.

The resident at issue was suffering from a brain injury following a gunshot wound and was in need of significant ongoing care.  One of the problems which developed after his admission to the nursing home is that he developed a facial fungal infection and was also suffering from redness of the eyes.  The nurse practitioner tried treating the redness of the eyes with eye medications but the redness of the eyes persisted, so she ordered an antiufungal medication.  The theory was that by clearing the fungal infection on the face, the redness in the eyes would diminish.

The way that the order was written was to apply the antifungal cream to the bilateral eyes twice per day in addition to an anitbiotic ointment.  The problem with writing the order in this manner is that manufacturer instructions for the medication is that it is not indicated for opthalmic use and should not be put into the eye.  The pharmacy dispensed the medication and the staff applied the antifungal medication to the resident’s eyelids which led to the medication getting into the resident’s eyes.

Once the antifungal medication got into the resident’s eyes, he began to experience pain in the eyes, heavy redness, and yellowish discharge.  He was sent to the hospital, where an opthalmologist had the eyes irrigated to wash as much of the medication out as possible, ordered the antifungal medication discontinued, and ordered the resident begin receiving lacrilube and artificial tears.  Essentially, these are intended to treat drying of the eyes.

There are a number of issues associated with this nursing home medication error.  To begin with, the order that the nurse practitioner wrote was unclear at best as to the instructions that the nursing staff was to be following in giving this medication.  The goal of the therapy was to reduce the fungal infection on the resident’s face with the hope that this would also serve to reduce the redness in his eyes.  However, the way that the order was written, the medication was to be applied to the eye.  The pharmacy dispensed the medication with the order written in that manner without bringing to the attention of either the nursing staff or the nurse practitioner that the way that the order was written was contrary to manufacturer instructions.  Finally, the staff followed the order as written without consulting the warnings and labels on the packaging that this was not intended to be put into the eye itself.  As a result, this resident suffered chemcial conjuctivitis of the eyes – an utterly predictable and preventable outcome.

This is a situation where there is some degree of fault which rests on people other than the nursing staff.  Nurse practitioners are generally considered independent contractors meaning that they are not direct employees of the nursing home.  The same would hold true of the pharmacist.  Anyone considering pursuing a case against persons who are independent contractors working inside a nursing home (and the other major category in this would include people working in the various therapy departments – physical therapy, occupational therapy, and speech therapy) would do well to get quality legal help well in advance of the statute of limitations date because there are additional issues which need to be investigated in order to make sure that all of the proper parties are added to the lawsuit before the expiration of the statute of limitations.

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:

Bella Terra Wheeling resident receives roommate’s diabetes medications

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

Wrongful death from medication error at Valley Hi in Woodstock

Failure to give medications at Forest View Rehab

 

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

 

 

 

 

Resident suffers brain bleed in fall from bed at Meadowbrook Manor

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IDPH has cited and fined Meadowbrook Manor nursing home in Bolingbrook after a resident there suffered a brain bleed and other injuries when he fell from bed.

The resident at issue had left-sided weakness as a consequence of having suffered a stroke. As a result of this , he had difficulty moving in bed and caring for himself generally, and had been assessed during the MDS process as needing assist of two with bed mobility.  Bed mobility encompasses things like turning from side to side in bed, sitting up in bed, and getting ready to get out of bed.

Part of this resident’s morning routine was that he liked to get his back washed, and the aide assigned to care for him that morning was preparing to do so.  She had him move on to one side so that he could reach and hold onto the side rail of his bed while she did the washing of his back.  In the process of rolling the resident to his side, his leg went over the edge of the bed and pulled the rest of  him over the side.  He struck his face on the base of a piece of equipment in his room and had obvious bleeding from cuts on his forehead and nose.  The resident was sent to a local hospital where a CT scan showed that he had a brain bleed. He was then transferred to a medical center which was better prepared to address this critical medical issue.

The tale told about this nursing home fall is one which has been told many times in this blog – one person doing a two-person job, with the result being a fall from a lift, someone being rolled from bed, or otherwise mishandled with significant injuries such as a hip fracture or as here a brain bleed as a result.  Past the fact that not enough staff was involved in the task of respitioning the resident in bed, the aide rolled the resident away from her rather than bringing the resident toward her so that she would have been position to keep the resident from going over the edge of the bed in just the manner that happened.

This resident was in particular at risk of suffering a brain bleed because he had been on a blood thinner medication following his stroke. Having a resident at risk for brain bleeds due the use of a blood thinner is one reason that fall prevention safety measures must be followed rigorously, as brain bleeds can occur after a fall even without direct trauma to the head.

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:

Lakeshore Rehab resident rolled from bed, breaks leg

Side rail accident at Lexington of Lombard

Brain injury after being rolled from bed at Bria of Palos Hills

Resident rolled from bed at South Holland Manor

Resident falls from bed at Spring Creek in Joliet

 

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

Generations at Rock Island cuts respiratory staff, care suffers

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IDPH has cited and fined Generations at Rock Island nursing home for a series of potentially catastrophic events which followed a reduction in the number of respiratory therapists on staff.

One of the unique features of the nursing home industry is that it is the only sector of the health-care industry that is explicitly for-profit.  To be sure, many doctors would like to make a nice profit after paying themselves a good salary and taking care of the expenses of running a business and many hospitals are making bushels of money.  However, these are people and institutions who view themselves as being health care providers first and foremost.  This is often not the case with people who own and operate nursing homes – they view themselves as businessmen.  And this often has a dramatic negative impact on the quality of care that nursing home residents receive.

Computing a profit is at its base a pretty simple exercise – you take your revenue, subtract your expenses, and that is your profit.  Obviously, it is more complicated in practice, but that is the basic equation.  Nursing homes get paid on a per-resident, per-day basis, with the rates varying depending on the payor and the level of care required.  At a very simple level, the nursing home maximizes its revenues by filling as many beds as possible with as many truly sick people as possible.   On the expense side, the largest single item of expense is staff which is why you so often see understaffing of nursing homes and the  use of less qualified staff such as LPN’s rather than RN’s.  This helps minimize the staffing costs and boosts the bottom line.

What the IDPH cited this nursing home for is an especially ugly example of what happens when the nursing home business model collides with patient care.

At this nursing home, there are residents who are on ventilators and who have tracheostomies.  These are residents who have complex medical conditions and require specialized care and are the the kinds of residents for whom the nursing home receives a higher level of reimbursement.  These residents were being treated by a staff of nine respiratory therapists who were in the facility on a 24/7 basis.  One June 14, the nursing home cut the respiratory staff from nine to two – one Registered Respiratory Therapist and one Certified Respiratory Therapist.  Respiratory care was reduced to 8 hours per day, Monday through Friday.  For issues that arose over the weekend or outside of hours when the respiratory staff was in the building, the nursing staff would have to provide care for the residents.

The obvious problem with this is that the nursing staff was not up to the task.  When interviewed by the state surveyor, the nurses, many of them LPN’s, freely admitted that they were not comfortable caring for residents with ventilators or tracheostomies and did not know what to do with the equipment.  Many of them told the state surveyor that if there was a complication with a patient on a ventilator or tracheostomy, they would need to call 911. To remedy this lack of training, the nursing home had an in-service training called “Understanding Vent Troubleshooting” which was conducted by the one of the remaining respiratory therapists, and she told the surveyor that it was not an adequate substitute for the years of training and experience that trained respiratory therapists have.  Of note only six nurses actually attended the in-service – and 5 were from the first shift which is when the respiratory staff is generally in the building and only one from the second and third shifts when there might not be a respiratory therapist in the building at all.

So – what impact did this have on patient care?

One ventilator dependent patient experienced a mucous plug during the night.  For a patient on a ventilator, a mucous plug can be a fatal complication.  She sounded the call light, but the nurse didn’t come for 40 minutes, so she lowered her bed, reached for the suctioning machine, and cleared the mucous plug herself.  Another resident with a tracheostomy experienced heavy bleeding at the tracheostomy site.  The likely cause of the bleeding was that the oxygen he received dried out the tissue because the mositurizing bottle was empty.  This is another complication that has the potential to cause serious complications.  And these are events that took place during the first two weeks after the reduction in the respiratory staff.

This may be one of times where it is clearest that the nursing home business model negatively impacts resident care.  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:

Transport van accident at Generations at Rock Island

Sauk Valley Senior Living fails to provide proper tracheostomy care

California Gardens fails to obtain respiratory equipment

Generations at Rock Island fails to provide care for pressure ulcers

 

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

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

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IDPH has cited and fined Avantara of Elgin nursing home after a resident there developed an unstageable buttocks wound due to the failure of the nursing home to develop a pressure ulcer prevention care plan.

Bed sores or pressure ulcers are a major issue in the nursing home industry.  They have a significant impact on the long-term health and well-being of nursing home residents.  The federal government thinks that these are important enough that they are part of the nursing home’s Medicare star ratings.

One of the first thing that happens when a resident enters a nursing home is that they get a full body inspection to determine whether there are any skin breakdowns.  Bed sores are rated on a scale of 1 through 4, with 4 being the worst (involving exposed muscle or bone).  Some wounds are considered unstageable which means that they are at least a Stage 3 bed sore (into the subcutaneous tissue), but could be a Stage 4 bed sore, but the wound bed is obscured by dead tissue.  Federal regulations provide that when a resident develops a bed sore, they must receive care treatment and services to promote healing, prevent infection, and prevent the development of new wounds.  The presence of a bed sores, whether obtained before or after the resident enters the nursing home, is something that requires physician notification so that orders for treatment can be obtained.

When a resident comes into the nursing home with no bed sores, federal regulations provide that the nursing home must provide care consistent with professional standards to ensure that the resident doesn’t develop pressure sores unless they are unavoidable.  To comply with the regulation, the nursing home must do an assessment of the resident’s risk of developing bed sores, usually using a tool such as the Braden Scale.  If the resident is at risk for developing pressure sores, well -run nursing homes will put a pressure ulcer prevention care plan in place to prevent the resident from developing these kinds of wounds.  Typically, this includes frequent skin checks, use of pressure relieving devices, prompt incontinent care, and frequent repositioning.

The resident at issue was admitted with intact skin, meaning that he should not have developed bed sores unless they were unavoidable despite being providing with care consistent with professional standards.  That would involve developing a pressure sore prevention care plan which would include interventions or steps to be taken to keep him from developing bed sores.  However, one of the nurses told the state surveyor that they did not put interventions in place unless the resident came in with bed sores already present.

Sadly, the course of care for this resident seems to bear that out.  There was no pressure relieving devices such as a specialized mattress or wheechair cushion put in place until after the resident developed an unstageable pressure ulcer.  The resident further described being left unattended for a period of 6-8 hours and being placed in an incntinent brief when the staff did not think that they would be able to get him to the bathroom.  There was no regular program of repositioning the resident which led to him being left in his wheelchair for hours on end.

There are basic measures that are put into place for almost every resident that is at risk for developing pressure ulcers, including the ones outlined above.  It seems that none of these were put into place for this resident, and that seems to be the norm at this nursing home is you believe the statement made to the state surveyor.  It is a little like designing a car with no brakes and then adding them only after the car crashes.  It represents a horrible systemic failure that poses a risk of harm to each and every resident at this nursing home.

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

Other blog posts of interest:

Failure to treat pressure ulcer at Franciscan Village in Lemont

Bed sore requires surgery for Timbercreek resident

Failures in care lead to bed sores at Park Place in Belvidere

Residents develop bed sores at Elmwood Terrace in Aurora

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 leads to brain bleed and death at Regency Care of Sterling

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IDPH has cited and fined Regency Care of Sterling nursing home after a resident there fell from bed and suffered a brain bleed which resulted in his death.

The resident at issue was considered a fall risk and had an extensive fall prevention care plan.  This included the use of a bed alarm and half side rails on both sides.  A bed alarm is a pressure-sensitive strip which is placed under the resident’s sheets.  When the pressure from the resident’s body weight is reduced, the alarm is supposed to sound.  This should bring an immediate staff response while at the same time serving as a reminder to the resident that he should not be up unattended.  The side rails are not directly intended to keep a resident from getting out of bed (as that would serve as a restraint), but do help the resident move safely in bed and get in position to transfer out of bed safely.

This nursing home fall was discovered by an aide who found the resident on the floor next to his bed.  One side rail to his bed was up and the alarm was not sounding.  It was not clear who disarmed the alarm or lifted up the side rail, but the resident was unable to move the side rails independently.  Exactly how the alarm was disarmed and the bed rail lifted was not clear from the citation, but given his physical limitations, it was likely a staff member who did this.

When the aide discovered the resident on the floor, it was apparent to  her that the resident likely struck his head on the floor even though there was no obvious injury.  She notified the nurse who helped get the resident off the floor and did an assessment of the resident.  The occurrence of a fall is an event that requires physician notification.  This was especially true in this situation as the resident was on Plavix, a medication which inhibits the body’s ability to form blood clots and stop bleeding.  This resident also had a history of brain bleeds, which meant that he was susceptible to experiencing an uncontrolled brain bleed after a fall.  Notifying the doctor would have allowed the doctor to decide whether or not the resident should have been sent to the hospital.

Normally, when a resident experiences a fall, they are put on a 72-hour fall watch to see if they show signs of injury which are not immediately apparent from the fall.  This process usually starts with checks being made at fifteen minute intervals at first and then having larger intervals over the period of the watch.  This resident’s fall was discovered at approximately 7:00 a.m., but the doctor was not notified of the fall until after 11:00 a.m. when the resident’s wife brought a change in the resident’s condition in the form of seizure-like activity to the attention of the staff.  After attempting to reach the doctor, the nurse on duty called 911 and the resident was sent to the hospital.

On arrival, a CT scan of the brain was performed which showed an acute subdural hematoma.  The resident did not survive this brain bleed, resulting in the wrongful death of the resident five days later.

There are a couple of separate issues with the care that this resident received.  The first relates to the occurrence of the fall itself.  The bed alarm which was supposed to serve as a warning to the staff that the resident was getting out of bed had been disarmed.  Including a bed alarm in the care plan is only an effective intervention where the alarm sounds when the resident starts to get out of bed.  Disarming defeats the entire intervention.  Further, even though the side rails are not intended to serve directly as a means to keep residents in bed, they do have that effect, and since the resident was unable to move the side rails himself, that points at a staff member as being the likely person who moved them, especially given the time of day that the fall occurred.  Second, his post-fall care was deficient in that the doctor was not notified of the fall.  After a fall occurs, the resident’s doctor must be notified.  When interviewed by the state surveyor, the nurse practitioner who was on call that morning for the resident’s doctor indicated that she would have ordered him sent to the hospital – a prudent measure in light of the medications he was taking.  Further, it is not clear that the checks which are a standard part of the 72-hour fall watch were either done or done properly, as the onset of seizure activity is something that would be associated with significant pressure from the brain bleed.  There would have likely been indications of neurologic impairment before that which were not detected if the checks that are part of the 72-hour fall watch were done properly.

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:

Hope Creek resident breaks hip in fall from toilet

Waverly Place of Stockton resident fractures hip in unsafe transfer

Resident suffers unexplained broken arm at Oregon Living & Rehab

Transport van accident at Generations at Rock Island

Resident breaks both legs in fall from bed at The Grove of Fox Valley

Fall from wheelchair at LaSalle County Nursing Home

Resident falls from lift at Oregon Living & Rehab

 

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

Resident trips over towel and breaks hip at Oak Brook Care

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IDPH has cited and fined Oak Brook Care nursing home after a resident there fractured a hip when she tripped over a towel after being showered.

Falls are a major issue in the long-term care industry.  Many residents in nursing homes suffer from osteoporosis or brittle bone disease which predisposes them to suffering fractures during falls.  Also, many nursing home residents take blood thinners, or anti-coagulant medications, which place them at increased risk of suffering a brain bleed.  Moreover, falls tend to beget more falls, so preventing falls is a major focus in the nursing home industry.

One of the ways that fall prevention is addressed in the nursing home setting is through the care planning process where residents are specifically assessed for their risk of falling and a specific set of measures are put into place to minimize the risk of nursing home falls occurring.  Steps in a care plan are intended to be tailored and specific to the individual resident, but there are other steps which should be taken universally to help prevent falls.

One of these universal steps is to keep areas free of tripping hazards and clutter.  This stands to reason – with an aging population in the nursing home who are dealing with significant and progressive physical challenges, you want to present them with as few challenges as possible in moving from place to place.

The resident at issue suffered from a variety of health challenges which made her a fall risk including a history of falls, a history of hip fracture, chronic pain, weakness, lack of coordination, abnormal weakness, and right sided weakness due to stroke.  On the morning of the accident she was brought to the shower in a shower chair.  On return, the aide assisting the resident placed a towel on the floor so that the resident could move from the shower chair to the bed without slipping on the wet floor.  As the resident moved from the shower chair to the bed, she lost her balance and fell to the ground, suffering a fractured hip which required surgery.  Normally, the aide would have used a gait belt to transfer the resident from the shower chair to the bed, but the resident was naked so the aide didn’t want to apply the gait belt to her bare skin.

In this case, the towel on the floor was an obvious tripping hazard which should have not been left on the floor for the resident to trip over.  Obviously, a wet floor can cause someone to slip and fall, too, so the solution would have been to dry the resident (and preferably dress her too, so the gait belt could be used) before transferring the resident to bed.  Simple safety steps not taken – and major injury to the resident was the result.

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

Other blog posts of interest:

Side rail accident at Lexington of Lombard

AHVA Care of Stickney resident suffers fractured hip in fall

Both legs broken in fall from bed at Grove of Fox Valley

Resident breaks hip in fall from wheelchair at Meadowbrook Manor in Naperville

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

 

 

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

 

 

Resident suffers bed sore from being left on bed pan at Mar Ka Nursing Home

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IDPH has cited and fined MarKa Nursing Home in Mascoutah after a resident there developed a bed sore from being left sitting on top of a bed pan too long.

Bed sores are also called pressure sores or pressure ulcers because the key component in causing these wounds is pressure.  Usually that pressure is caused by the weight of the body over a bony prominence against a resting surface.  This is why you tend to see bed sores on the hips, buttocks, tailbone, and the heels.  It also helps explain why the sores are round or oval in shape typically.

However, the pressure caused by the weight of the body against a resting surface is not the only thing that can cause bed sores.  Medical devices such as casts or braces can also cause pressure sores when the device is not applied properly or the device is not removed frequently enough.  The cue that there was an injury caused by a medical device is that the shape and location of the wound corresponds to a contact point between the skin and the device.

That was the case in this instance, as a resident was placed on top of a bed pan and then left on the bed pan for an extended period of time.  Her daughter changed her and got her into bed the night before and her skin was free of any skin breakdowns.  The next day her daughter discovered a wound on her buttocks and tailbone which corresponded to the shape of the bed pain that was in her room.  The only explanation for this wound was that she was left sitting on top of the bed pan long enough to cause these injuries.  The director of nursing reported to the state surveyor that they were unable to determine who the aide was that placed her on the bed pan or who got her off.

The citation describes the total length of the wound as being 54 cm or more than two feet in length with portions of it being described as a deep tissue injury and portions of it being described as an unstageable wound.  In short, this is a large, significant, painful (the resident told the state surveyor that it hurt to sit) bed sore which was completely and utterly preventable.

This is the kind of wound that is a powerful indicator of understaffing of the nursing home.  A resident should spend more more than a couple of minutes on a bed pan, yet this resident was left on top of one long enough to cause serious injury.  The likely scenario for this is that a staff member put her on top of a bed pan and then simply got so busy attending to the needs of other residents that they either forgot about this resident or was simply never got around to getting her off the bed pan.  Since this occurred during the middle of the night when there are generally fewer residents in need of care, this speaks strongly to the nursing home being understaffed.  Understaffing of the nursing home places residents at risk for all sorts of needless injuries, in particular nursing home falls and bed sores.  A nursing home abuse and neglect lawsuit involving any of these issues should include a cxareful examination of the staffing levels at this nursing home.

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

Other blog posts of interest:

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

Resident develops bed sores on both heels at Eden Village

Nokomis Rehab resident suffers bed sore

Unstageable pressure ulcer to heel at Willow Rose in Jerseyville

Aperion Care Capitol fails to obtain equipment to treat bed sore

 

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

 

 

 

Chaplain sexually assaults residents at Good Samaritan Home in Quincy

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IDPH has cited and fined the Good Samaritan Home in Quincy after the chaplain of that nursing home sexually assaulted two residents at that facility.  He has since pleaded guilty to criminal charges associated with the assaults and has been sentenced to 26 years in jail.

Nursing home residents are an inherently vulnerable population.  They have physical and/or mental limitations which keep them from being able to live independently or with family.  They depend on staff to help them with the basic necessities, to give them the medication and care they need, to provide them with food and drink to sustain themselves, and to allow them to live their lives with some degree of dignity.  At a very basic level, families look to nursing homes to keep their loved ones safe and comfortable.

One of the basic elements of keeping residents safe is keeping them from people who engage in abuse, physcial, mental, or sexual.  And in this case, the nursing home failed seriously at this.

The resident whose complaint sparked the investigation which resulted in the arrest, prosecution, and conviction of the chaplain reported to staff that the chaplain entered her room and grabbed her breast for a period of about two minutes before she pushed his arm away.  After reporting it, she was tearful and upset and referred for mental health counseling to address her troubles in coping with what had happened to her.

The truly shocking part of this nursing home abuse is that this was not the first time that there had been complaints about sexual misconduct regarding the chaplain.  Prior to this incident, there were three separate allegations of sexual abuse against him, yet the police and Department of Public Health was never notified.  The chaplain was never suspended from working at the nursing home while the allegations against him were never investigated – because they were never truly investigated, and in one case were never even noted in the resident’s chart.  Incredibly with three allegations of sexual abuse against him, the administrator told the state surveyor that he could not identify a pattern of allegations against this individual.

A nursing home is a “home” for many residents where they can reasonably expect to live for an extended period of time, and they deserve to feel safe in their own homes.  When the nursing home employs individuals who abuse residents – mentally, physicall, or sexually – residents can no longer feel safe in their own homes.  This is a gross breach of the basic promise that nursing homes make to residents and their families when they agree to have a resident admitted to the nursing home.

At this point, what is known is that there were four separate episodes of sexual abuse by the chaplain against residents at this nursing home.  However, it is also clear from the investigation conducted by the state that he was a predator with free reign to go about the nursing home with access to all residents within the facility, so even with four known episodes, there may well be more.

What of the question of liability?

There is a doctrine in the law called respondeat superior which makes employers liable for the negligent acts of their employees.  This is why when there is a truck accident, the trucking company is responsible for the injuries for the accident.  An exception to this rule generally exists where the employee is guilty of criminal misconduct – after all the company doesn’t hire employees to engage in criminal misconduct.

However, the nursing home is subject to a statute called the Nursing Home Care Act which makes the nursing home liable for the intentional and negligent acts of their employees.  This means that the nurisng home will not be able to evade liability for the abuse which was inflicted on the nursing home residents by the chaplain.

However, this does not mean that there will be insurance coverage.  Most insurance policies esclude coverage for intentional or criminal acts, and this kind of abuse would likely fall squarely within that exclusion.  However, there are other theories which can be pursued, most specifically the negligence on the part of the administration to investigate the early episodes and remove him from the facility.  This is something that would trigger insurance coverage and would provide some avenue of securing commpensation for the victims of this abuse.

Generally, there is a 2 year statute of limitations which will apply to this kind of case.  However, statutes of limitations will be extended where the resident was under legal disability where they were unable to manage their own affairs, such as when they suffer from advanced dementia or Alzheimer’s.

Prosecuting this kind of case reuires the help of an experienced nursing home lawyer.  Contact our firm today for a free, no-obligation consultation if you are concerned that your family member may have been a victim of sexual abuse at this nursing home.

Resident breaks both legs in fall from bed at Grove of Fox Valley

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IDPH has cited and fined the Grove of Fox Valley nursing home in Aurora after a resident there  broke both legs in a fall from bed while his sheets were being changed.

The resident at issue had below the knee amputations of both legs.  Additionally, she had a contracture of the right hand which limited her use of the right arm. Prior to the accident, the Minimum Data Set (MDS) submitted to the federal government indicated that she required assist of two for bed mobility.  “Bed mobility” means moving within the bed, including turning from side to side, which means that in this case two people were required to assist her in moving from side to side.  Generally, one aide will be positioned on each side of the bed.  Part of the job of the aide who is on the side where the resident is rolling to is to assure the safety of the eresident by keeping the resident from rolling out of bed and hitting the floor.

At the time of this nursing home fall, an aide was changing the resident’s sheets while the resident was still in bed.  The aide told the state surveyor that she had been trained that the resident required the assistance of two, and that this was the first time she had repositioned the resident in bed by herself.  The resident on the other hand told the state surveyor that repositioning with the assistance of one was common during night shifts and weekends because of a lack of staff.

The accident happened after the aide asked the resident to roll onto her left side.  When she did so, her stronger left hand and arm were pinned beneath her body, leaving the weakened right arm to assist in positioning.  The head of the bed had been elevated while the changing of sheets was underway and as a result the resident had slid down toward the foot of the bed.  Partial side rails were in place on the top half of the bed to assist the resident in moving in bed, but there were no side rails on the bottom half of the bed. When the resident rolled over, she was unable to reach the side rail to steady her position and rolled out of bed onto the floor.

She was taken to the hospital where x-rays showed significant fractures of both femurs.  The treating orthopaedic surgeon stated that if the fractures do not heal properly, amputation of the leg(s) above the fracture site may be required.  The resident told the state surveyor that she experiences severe muscle spasms in the injured legs which cause her significant pain.

This is yet another instance where a resident suffers injury because one person was doing a two-person job (see here, here, here, here, and here for examples).  Generally the root cause of this kind of incident is due to understaffing of the nursing home, which is something that is inherent in the nusing 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.

What makes this particular citation so interesting is the facility’s response to this fall.  Care planning is the basis for much of the care that gets delivered on a day-to-day basis in a nursing home.  The first step is a resident assessment to determine what the care needs of the resident and then developing a written care plan to address those care needs.  It must be communicated to the staff which then must carry it out on a day-to-day, shift-to-shift basis.  Finally, it must be evaluated on an ongoing basis to determine whether the resident’s care needs have changed or if it has proven ineffective in practice.  If so, then it must be revised.

The occurrence of a nursing home fall is one thing that usually triggers a revision of the care plan.  Falls are a serious issue in the nursing home industry, as falls tend to beget more falls, and residents are at significant risk for injuries such as fractured hips or brain bleeds which can either cause the death of the resident or cause a significant decline in the quality of life.

After this fall, the care plan was indeed revised – but not in the way that you would expect.  The care plan was re-written after the fall occurred to authorize assist of one for bed mobility, notwithstanding the fact that the MDS which had already been submitted to federal government under oath stated that this resident required the assist of two with bed mobility.  Past that, an assist of one had already proven ineffective in practice – that was how this resident ended up on the floor with two broken legs!  Perhaps there is a legitimate reason for re-writing the care plan this way, but it seems like the most likely motivation for this was to paper up the chart in anticipation of the State coming in after this resident’s injuries.  Some people might use the term “cover-up” to describe that.

If you have had a loved one injured in an accident at a nursing home, 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:

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

Resident rolled out of bed by staff at Generations at Applewood

Brain injury after being rolled from bed at Bria of Palos Hills

Fall during transfer results in broken ankle at Sandwich Rehab

Resident falls from bed at Spring Creek

 

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

 

 

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

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IDPH has cited and fined Jerseyville Manor nursing home after a resident there suffered a fractured femur after being left unattended sitting on the edge of the bed.

One of the things that place nursing home residents at risk for falling is a lack of trunk control.  As people age and become debilitated or suffer from neuromuscular conditions, they tend to lose strength in the abdominal muscles and lower back muscles which help people maintain a good, upright position while seated.  Without having good trunk control, the weight of the upper body can easily pull the resident in one direction or the other, placing them at risk for falls from a seated position.

The resident here was at high risk for falls and per his care plan was a two person assist using a mechanical lift for transfers.  The aide had placed the resident in the sling for the lift with the resident seated at the edge of the bed and went out in the hall to get the resident’s high back reclining wheelchair.  While she was doing that the resident fell out of bed.

The initial post-fall assessment did not show any injuries, but later the staff noticed dark bruising behind the resident’s right knee.  They obtained orders for an x-ray which showed that the resident that the resident had a fractured leg.

This was a highly preventable nursing home fall. The edge of the bed is an especially difficult place for a resident with poor trunk control to be placed because residents will either be close to upright if they have their feet on the floor or if they are seated further back, there will be no point of contact with the ground.  It is a much more difficult place for a resident to stay upright where he has little to no trunk control.

This also is a one of the situations which we have blogged about repeatedly here: one person doing a two-person job (see here, here, here, here, and here for examples).  This resident should not have been left unattended while seated on the edge of the bed.  Having two people involved in a transfer allows one person to handle the equipment and one person to handle the resident.  With no one there to handle the resident, this fall resulted.

The real question is why was there no one there to actually handle the resident – and that goes to the issue of understaffing of the nursing home.  Understaffing is a planned part of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

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

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

Cedar Ridge resident breaks both legs in fall from bed

Randolph County Care Center resident suffers broken hip in fall from toilet

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

 

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

 

 

Resident given wrong medication at Villa Health Care East

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IDPH has cited and fined Villa Health Care East nursing home in Sherman after a resident was given the medications ordered for a different resident.

One of the basic functions of a nurse at a nursing home is to do medication pass.  Before actually dispensing the medication, one of the basic checks that a nurse must make is that they are giving the medication to the right resident.  To help assure that this is being done, many nursing homes have photos of the resident on the Medication Administration Record that is on the medication cart.  Additionally, the nurse is required to actually verify that the resident is the one that the medication for whom the medication has been ordered.  Giving a medication to the wrong resident carries with it the potential for disaster because of what can occur when the resident receives someone else’s medications and from the delay in receiving or failure to receive their own.

There was no issue that a medication error happened in this case.  Rather than push the medication cart down the hall and stop outside each room, the nurse responsible for the medication error out the medications into the dispensing cup at the nurse’s station and walked down the hall to give the medication to the resident for whom the medications were ordered.  Along the way, she stopped to talk to another resident.  That discussion distracted the nurse, and she then entered the wrong resident’s room and gave her someone else’s medications.  The nurse later explained that the discussion with the one resident in the hallway probably caused her to forget what she was doing and that because she was new and did not work that particular hallway, she did not know the residents well enough to know who was supposed to be getting what medications.  As a result of this medication error, the resident received blood pressure medications and insulin that was intended for another resident.

The nurse recognized the medication error later that shift and notified the resident’s doctor.  The doctor advised the staff to monitor vital signs every 15 minutes and when the resident’s blood pressure dropped and her heart rate dropped, orders were given to send the resident to the emergency room.  On arrival, she was transferred to the intensive care unit and was hospitalized for 5 days before she was stable enough to return to the nursing home.

One of the interesting tidbits found in the citation is that there was no actual documentation of the medication error in the resident’s medical chart.  The practice at that facility was to document incidents as this outside the nursing home chart.  There are a number of cases which we have handled where crucial information regarding choking accidents, nursing home falls, or bed sores were not properly documented in the resident chart and had to be obtained after the lawsuit was filed.  Having someone on board who knows what to ask for is one of the advantages of hiring an experienced nursing home lawyer.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of 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 give medication as ordered at River Crossing of Alton leads to hospitalization

Anticoagulant medication not given at H & J Vonderlieth Living Center

Medication error leads to hospitalization at Palm Terrace

Diabetes care mismanaged at Aperion Care Capitol

Medication error at Sunset Rehab in Canton

Failure to give HIV medications at Bria of Belleville

Failure to give diabetes medications at Bridge Care Suites

 

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

 

 

 

Medication usage leads to fall at Gilman Healthcare Center

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IDPH has cited and fined Gilman Healthcare Center nursing home after a resident fell and suffered a fractured arm and suffered additional complications after being given a dose of Ativan.

In our law firm, we usually look at two main factors as being the major drivers for nursing home falls: (1) musculoskeletal issues, balance problems, or general gait dysfunction and (2) intermittent or constant confusion.  This combination says that the resident has something physically wrong with them that predisposes them to fall, but because of their mental/psychiatric state, they can’t be counted on to follow instructions or make good decisions regarding their own safety.  In our office, this accounts for the great majority of the nursing home fall cases that we handle.

Of course, these are not the only risk factors and most nursing home take an array of other factors into the fall prevention care planning process.  One of those factors usually is medication usage.  Many nursing home residents take medications which contribute to fall risk.  Usually this is due to some of the known side effects of the medication or even its intended effect, as in the case of diuretics (or water pills).

Ativan is one of those medications which contributes to fall risk.  It is an anti-anxiety medication which is sometimes given as a scheduled medication, other times on an as-needed basis.  Its known side effects include: sedation, dizziness, weakness, and unsteadiness, all of which can influence fall risk.  When this medication is given as a scheduled medication, its effect is something which tends to become well-known to the staff.  When it is given on an as-needed basis, its effect on the resident is a bit less predictable and requires close monitoring of the resident.

The resident at issue was given a dose of ativan on an as-needed basis for “behaviors” and a few minutes later was walking down the hall with a nurse behind her when she fell forward.  The next morning she was noted to have discoloration and swelling about the shoulder and a painful range of motion.  The nurse notified the resident’s doctor who ordered her sent to the emergency room.

At the hospital the resident was diagnosed with a dislocated shoulder.  After the dislcocation was reduced, a repeat x-ray showed a fracture of the humeral head.  The resident was sent back to the nursing home in an immobilizer with orders to remain in the immobilizer until a follow-up with the orthopaedic surgeon.  However, when the resident was returned to the nursing home, she was tugging at the immobilizer so it was removed.  The following day, the staff saw that there was edema and warmth of the right arm and that the resident was very guarded with it.  The resident was sent back to the hospital where she was diagosed with a blood clot or deep venous thrombosis (DVT)  in the right arm. The nurse practitioner interviewed by the state surveyor stated that the failure to keep the shoulder immobilized would have caused increased pain and increased the rish of developing the DVT.

This will likely need to be treated with long-term use of an anticoagulant, or blood thinner, medication which places this resident at increased risk of suffering a brain bleed in a later nursing home fall.

There are a couple of major issues with the care that this resident received:

  1.  The staff failed to monitor the resident for the effect that the Ativan and provide her with assistance backto her room.  Federal regulations relating to nursing home falls require that residents receive supervision and assistance necessary to prevent falls.  Ativan has a known series of side effects which contribute strongly to fall risk, and this resident should have been assisted back to bed.
  2. There was a failure to follow the orders from the ermergency room where the should was not kept in the immobilizer which caused this resident to experience increased pain from the underlying injury.  This may have also led to the DVT’s occurring which will lead to her needing to stay on blood thinners for an extended period of time.

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:

Fall with head injury at University Rehab

Resident falls from bed at Spring Creek

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

Resident’s third fall at Bria of Chicago Heights nets brain bleed

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

 

 

Failures in care lead to bed sores at Park Place of Belvidere

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IDPH has cited and fined Park Place of Belvidere nursing home after a resident there developed multiple bed sores.

Bed sores are a major issue in nursing homes.  It is part of the data which nursing homes must report on each nursing home resident.  There are specific federal regulations in place relating to the the prevention and treatment of bed sores, and the failure to meet the requirements of those regulations can result in hefty fines for nursing homes.

Bed sores are one of the areas for which specific assessments are done during the admission and quarterly care plans, usually using a standardized tool like the Braden Scale.  When residents are at risk for developing bed sores, there is a pressure ulcer prevention care plan put into place.  Typically, this will include an array of pressure relieving devices, such as a special mattress, special wheelchair cushion, regular skin checks during incontinence care and showers, prompt incontinence care, and a turning and repositioning schedule.  Generally, bed sores will not develop immediately if there is a breakdown in the delivery of care for a few hours, but as the cumulative failures to deliver on the necessary care mount, the odds of a resident having a new bed sore increase.  When a resident develops a bed sore, this is a change in condition which requires physician notification.

The resident at issue in this citation had been assessed as being at risk for bed sores for a number of reasons, including dementia, incontinence of bowel and bladder, and needing the assist of two for bed mobility, meaning being moved from side to side in bed.  Despite the fact that she was at risk for developing bed sores, she was not provided with a pressure relieving mattress for her bed or a pressure relieving cushion for her wheelchair.  When the time for the quarterly care plan review came up, a repeat Braden assessment was not done, and as a result no changes were made to the resident care plan.

The fact that this resident developed bed sores was first noted in the resident chart on May 1 when a discolored area was noted on the left heel and then again on May 4 where another wound was noted on the right buttocks.  The facility brought in a wound care doctor on May 6 who actually noted three separate wounds including an unstageable bed sore on the right buttocks, a Stage 3 pressure ulcer on the sacrum, and an unstageable wound on the left heel.  However, the daily task sheets which were completed by the CNA’s noted incontinent care every shift with no notations of skin breakdown and of the five shower sheets which were completed during the month of May through when the state surveyor came on May 16, only the discoloration on the heel was noted on May 1 only.  On all of the other days, that wound and all of the others were not noted at all.  The wound care doctor was recommending surgical excisional debridement of the buttocks wound.

Caring for residents at risk for developing bed sores requires ongoing diligence, including providing the right kinds of equipment and careful consideration of the resident’s care needs during the care planning process.  Those basic steps were not being carried out as the resident did not have the specialized equipment necessary, nor was the Braden assessment done as part of the quarterly care planning.  Breakdowns in the delivery of care routinely lead to bad outcomes for nursing home residents.  Once residents have bed sores, they are entitled to the care, treatment, and services necessary to promote healing, prevent infection, and prevent new bed sores from developing.  When the regular skin checks are not being done by the aides, the nursing staff and the doctors are deprived of the information they need about the resident’s progress.

In short, there were a series of systematic failures in the delivery of care to this resident which resulted in the development of these bed sores and the further decline of these wounds.  This leave the resident at risk for further complications such as cellulitis and osteomyelitis. 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:

Bed sore requires surgery for Timbercreek resident

Grove at Berwyn fails to treat bed sore

Generations at Rock Island fails to provide treatment for pressure ulcers

 

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

 

Failure to follow recommendations leads to fall and facial fractures at Tower Hill

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IDPH has cited and fined Tower Hill Healthcare in Elgin after a resident fell and suffered facial fractures.

Care planning is intended to be a multidisciplinary, ongoing process where the staff develops a series of measures intended to assure the safety of residents.  Because nursing home falls have such serious consequences for residents, this is one area which is specifically care planned.

Care planning is a six step process.  It starts with the assessment, which identifies risks to the health and well-being of residents.  From there, the actual care plan is developed which is a series of measures or interventions which must be taken by particular disciplines within the nursing home on a day-to-day, shift-to-shift basis.  Once the care plan is developed, it must be communicated to the staff charged with carrying it out.  It must then be implemented on an ongoing basis. Finally, it must be evaluated for effectiveness on an ongoing basis and revised if it proves ineffective in practice or there are changes in the resident’s condition.  This is actually a part of the framework we use when investigating and prosecuting nursing home abuse and neglect cases.

The resident at issue was properly assessed as being a fall risk.  This was due to a number of factors including confusion, poor safety awareness, and gait abnormalities.  Her fall prevention care plan included having physical therapy evaluate and treat the resident.  When she was discharged from physical therapy, there were recommendations made by physical therapy which included having hand hold and contact guard assist while walking.  Contact guard assist means that there is a staff member literally holding onto the resident by a gait belt while the resident is walking.

The recommendations made by physical therapy were not a part of the resident fall prevention care plan at the time of her discharge from physical therapy.  Unfortunately, it did not become part of her care plan until after she had the fall which sparked this investigation by IDPH.

On the day of the fall, the resident an aide were walking down the middle of the hall together.  The aide was not employing a contact guard assist for this resident – in fact, she just happened to be going to down the hall at the same time as her, not ever thinking that the resident required any additional assistance.  And in the aide’s defense, there was no reason for her to think so because the need to use that had never been incorporated into the resident care plan or communicated to her that this was needed.

The aide went into another room and a few minutes later heard the resident calling for help.  She came out to find the resident on the floor with a large gash in her forehead.  The resident was sent to the hospital when the doctors diagnosed several facial fractures.

This is a case where the data was available to keep this resident safe, but it was never included in the resident care plan because of a breakdown in the system.  This resident was sent to physical therapy for the express purpose of getting treatment and evaluations, and the information that was developed during the course therapy was never put to use.

As you read the citation, it appears that the electronic charting system that they use at this nursing home played a role in the failure of the recommendations of physical therapy to make their way to the floor.  Broken systems have much larger implications than any one particular incident.  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:

Bella Terra Streamwood resident suffers multiple fractures in fall

Failure to follow care plan at Tower Hill Healthcare

Rosewood of Elgin resident dies due to fall from wheelchair

Failure to use gait belt results in fall at Friendship Village

Alden Valley Ridge resident rolled from bed, breaks both legs

 

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

 

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