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Fatal choking accident at River Bluff nursing home

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IDPH has cited and fined River Bluff nursing home in Rockford after a resident there choked to death on a peanut butter and jelly sandwich.

There are certain medical conditions which can increase the risk of a nursing home resident having a choking accident.  One of these is Alzheimer’s; another is having a history of having had a stroke.  With Alzheimer’s patients the advancing disease may cause the brain to no longer properly process the commands to chew and swallow, leading to an increased risk of choking.  With regard to a history of stroke, the damage from the stroke may cause deficits in chewing and swallowing which lead to an increased risk of choking.

As with any risk to the health and well-being of a nursing home resident, the risk of choking is one which should be addressed in the resident care plan which then must be communicated to the staff charged with carrying out the task of supervising the resident while eating and then whatever steps are provided for must be carried out on a day-to-day, shift-to-shift basis.  When the steps outlined in the care plan are not carried out, this exposes the resident to an increased and unnecessary risk of experiencing a choking accident.

The resident at issue here was at risk for choking.  She suffered from Alzheimer’s and apparently had a stroke in the past as also suffered from hemiplegia (paralysis on one side of the body) and dysphagia (difficulty swallowing), both of which are common residuals from having suffered a stroke.  She also had experienced a choking incident a year earlier in which she choked on a piece of a grilled cheese sandwich.

To address the choking risk, the nursing home had a care plan which included a mechanical soft diet following an assessment and recommendations from a speech therapist.  There was also a physician order in place for a mechanical soft diet.  A mechanical soft diet is often used to address a resident’s choking risk and consists of items which are easily swallowed with minimal chewing effort.

On the day of the accident, the resident was eating dinner in the dining room of the memory care unit with two aides at the table.  She did not want the chili that was being served that night, so the aide assigned to help feed her that evening made a peanut butter and jelly sandwich for her.  She prepared this, in her words, “the same way I would do for my kids” with jelly packets, creamy peanut butter, and bread.  As the resident ate the sandwich, she began to show signs of choking.  One of the aides brought in a nurse who performed the Heimlich maneuver which cleared small amounts of the sandwich from her airway.  She was brought by paaramedics to a local emergency room where she was pronounced deceased.

So what was the problem here that led to the wrongful death of this nursing home resident?  There are two major issues:

  1.  The aide caring for her at the time of this choking accident did not know that she was on a mechanical soft diet.  Assuming that things were done properly, she would have received a mechanical soft diet from the kitchen, but having the staff who was supervising this resident while she ate not know what her diet was represents a serious breakdown in the delivery of care, as it meant that neither the care plan not the doctor’s orders were being carried out.
  2. The sandwich that she made was not safe for this resident to eat.  The tackiness of the peanut butter is something that requires more swallow effort than a resident on a mechanical soft diet should be expected to offer, so making a sandwich like you do for your kids is not an option for residents on a mechanical soft diet.  There was an option for these residents to get a peanut butter and jelly sandwich, but that involved sandwiches that were premade by the kitchen in a way that blended the peanut butter and jelly to thin the peanut butter out to make it easier to swallow.  These staff members did not realize that what was required to provide a peanut butter and jelly sandwich and did not know that there was a safe alternative available in the kitchen.

A series of simple failures leading to a tragic 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:

Fatal choking accident at Spring Creek in Joliet

Resident chokes to death at Rosewood of St. Charles

Aspen of Silvis resident chokes to death due to care plan violation

Fatal choking accident at The Moorings in Arlington Heights

Broken neck in fall from lift at Presence St. Anne

 

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

 

 

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

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IDPH has cited and fined Avantara of Long Grove nursing home due to a failure of the staff to monitor and obtain treatment for worsening signs of congestive heart failure, leading to the the wrongful death of this nursing home resident.

One of the basic roles that a nurse in a nursing home setting plays is to serve as the eyes and ears of the resident’s doctor.  When a resident shows signs of a change in condition, has a nursing home fall, or is demonstrating some other condition of ill-being, it is the nurse’s job to notify the doctor.  The doctor then can issue orders over the phone for treatment to be delivered at the nursing home, go into the nursing home to see the resident himself, or order the resident sent to the hospital for examination and treatment there.  What is never acceptable is to have the resident suffer a significant change in condition and have the nurse fail to notify the doctor.

Federal regulations require each resident to have an attending physician.  This is the doctor who is managing the care of the resident.  Doctors are required to see the resident at least every 30 days during the first 90 days of an admission to the nursing home and at least every 60 days thereafter.

Both of these things were serious issues which contributed to the death of this nursing home resident.

The resident at issue suffered from congestive heart failure.  This is a condition which is usually managed with medications, including a diuretic, or “water pill” because one of the symptoms of congestive heart failure is increased edema or swelling in the lower legs and ankles.  If a resident is suffering from an exacerbation of or worsening of congestive heart failure, that is one of the signs of that and is something that would require physician notification.  Monitoring for signs of congetsive heart failure including edema in the legs and feet were a part of this resident’s care plan.

On May 12, a CNA told the nurse that the resident was having a hard time breathing.  Shortness of breath is one the signs of congestive heart failure.  The nurse on duty that day went to his room, pulled back the covers and saw that his legs were red and swollen.  The resident was brought to the hospital where he died the following two days later due to septic shock from lower extremity cellulitis, acute hypoxic respiratory failure due to septic shock, and acute kidney failure.  Edema from congetsive heart failure can cause cellulitis which in turn will lead to sepsis if not treated properly.

The investigation into this resident’s death showed that a nurse on duty two days earlier saw that the resident’s lower legs were stretched and hard to the touch due to there being so much edema present.  However, she did not think try to notify the doctor because she considered it his “normal.”  And to some extent, she was right, as the resident’s skin inspection sheets recorded that for six weeks prior to the resident being taken to the hospital, the skin of his lower legs was described as being red and swollen, all at least potential signs of cellulitis – yet no one tried to notify the doctor during that interval.

And what of the resident’s doctor?  The doctor hadn’t seen the resident since November 29 the previous year, nearly five and half months earlier.  When contacted by the surveyor regarding this incident, he advised that the resident was no longer under his care because he was no longer seeing patients at that nursing home.  In other words – the resident had a doctor on paper, but not in reality.

The fact that the resident had no actual attending doctor is fascinating for a couple of reasons:

  1. Doctors often see several patients at each nursing home they go to, which means that there were likely multiple residents who had this physician taking care of them.  Assuming that the nursing home knew that he was no longer seeing patients there, what did the nursing home do to facilitate transition in care and how did this resident end up with no one?
  2. It was not clear from the citation when the doctor stopped seeing patients at this nursing home, but the fact that no one recognized that this resident was without a doctor means that no one from the nursing thought to contact the doctor about this resident at any time about this or potentially any other resident he cared for after that or paid attention to the fact the doctor listed as the attending physician for this resident (a) was no longer seeing patients there and (b) hadn’t been in to see the patient in months.

This is a case where it seems that no one was minding the store, so to speak.  This resident was demonstrating changes in condition which required notification of the doctor, but no one thought to do so and no one was paying attention to the fact that this resident didn’t actually have a doctor.  This was a series of catastrophic failures which resulted in the death of this resident.

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

Other blog posts of interest:

Feeding tube error puts Burgess Square resident into heart failure

Resident-on-resident assault at Alden Long Grove

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

Resident wanders from Alden Long Gove

Failure to notify doctor of pressure sore at Aperion of Moline

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

 

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

 

 

 

Multiple fractures from fall at Lutheran Home for the Aged

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IDPH has cited and fined Lutheran Home for the Aged nursing home in Arlington Heights after a resident suffered multiple fractures in a fall which was followed by the staff failing to promptly obtain treatment for the resident’s injuries.

This fall has a common theme with many of the nursing home falls and mechanical lift accidents we have described here in this blog: one person doing a two person job and the resident suffering the consequences.  For a sampling of incidents which we have addressed see here, here, here, here, and here.

The resident at issue had been assessed as having functional limitations in range of motion on one side and needed the assistance of two with transfers for toileting.  On the morning of the accident, the resident was getting out of bed and asked to be taken to the bathroom.  The aide knew that the resident needed two people to be transferred to the toilet, so she went and asked a fellow aide to help transfer the resident to the bathroom, but that aide said that she could not help right away because she had other residents to attend to.  The resident was insistent about using the toilet so the aide attempted to transfer her to the toilet by herself using a sit to stand lift.  However, before they were able to reach the toilet, the resident was no longer able to support any of her own weight and the aide was not able to get her onto the toilet so she gently lowered the resident to the ground.

“Gently lowering the resident to the ground” is a euphemism for a nursing home fall, and given what was found, how “gently” this resident was lowered to the ground should be a subject of fierce debate.  A “fall” has a technical definition in the long-term care industry and generally it is considered to be a failure to maintain an appropriate standing, sitting, or lying position, resulting in an individual’s abrupt, undesired relocation to a lower level.  Saying that someone was “gently lowered” are words that are used to mask the fact that a fall has occurred.

When an aide is aware that a resident has fallen, it is their job to notify the nurse, who in turn is responsible for assessing the resident, notifying the resident’s doctor, and starting the 72-hour fall watch procedure.  The fact that a fall has occurred should be noted on the 24-hour sheets, which are not an official part of the resident’s chart, but which are an important communication tool among the nursing home staff.

Here the aide notified the aide notified the nurse, who claims to have assessed the resident and not found any signs of injury.  The nurse did not notify the resident’s doctor, did not report the fall to the nurse coming on duty for the following shift, and did not note the fall in the resident chart.  Asked why by the state surveyor, she said, “I don’t know why I didn’t report this as a fall at the time; I just had a lot going on.”  The failure to report the fall to the doctor denied the resident the opportunity to get prompt treatment for her injuries.  The failure to notify the oncoming nurse denied her the chance to be monitored for injuries which come on more slowly, like a brain bleed.

During the course of the day, the resident complained of increasing pain which was not relived with pain medication, so the nurse on duty called the resident’s doctor.  Because shew as unaware of the fall, when she was asked by the doctor if the resident had fallen, she said that there was no fall, so the doctor believed that the resident was suffering from an inflammatory process and not the effects of injuries.  It was not until the nurse who had been on duty at the time of the fall came on duty for her next shift and learned that the resident had been experienced increasing, significant pain through out the day was the doctor told that there was fall.  The doctor’s reaction: “I’m absolutely appalled by this situation; I feel the whole situation is neglectful and abusive to the resident.”

When the resident was brought to the hospital, x-rays showed that the right leg showed a markedly displaced and overriding impaction fracture of the right distal femoral shaft in respect to the distal femur and condyles.  The x-ray of the right arm showed that there was an acute impaction fracture through the right humeral neck.  In other words, there were ugly fractures of the right arm and right leg, which raises real questions about just how “gently lowered to the ground” this resident was.  Past that, the aide who had been asked to help before the accident came into the room after the accident occurred and told the state surveyor that she saw the resident laying on the floor saying “My shoulder, my shoulder.”

These facts tend to show that this was a much more traumatic fall than the description of someone being “gently lowered to the ground” would ever suggest.  Moreover, it wasn’t treated as a fall which resulted in the resident being denied treatment for her injuries for an extended period of time and not being monitored for the onset of more severe problems.

The real question of course is, why did all this happen?  The easy answer is that the aide did a two-person job with only one person, but the deeper answer probably lies with the understaffing of the nursing home.  Past the fact that the aide felt rushed to get the transfer done by herself, there is also the nurse on duty saying that she didn’t treat this fall as such because she had “a lot going on.”  These are the kinds of things that you hear when the nursing home staff simply does not have the help it needs to get the work 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:

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

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

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

Resident found with 57 maggots in ear at Lutheran Home for the Aged

Glenview Terrace resident suffers multiple fractures when lift topples over during transfer

Aperion Care International resident fractures ankle in unsafe transfer

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

 

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

 

 

 

Fall from wheelchair at LaSalle County Nursing Home

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IDPH has cited and fined the LaSalle County Nursing Home in Ottawa after a resident fell from his wheelchair due to the absence of a slip-resistant cover for the seat cushion, and as a result suffered fractures to the elbow and hip.

Wheelchairs are one of the basic pieces of equipment in a nursing home and where you have a resident who is wheelchair-bound, there is more to using a wheelchair than just plopping them into the seat and pushing them where they need to go.  The wheelchair must be properly maintained and have the right pieces accessories such as footrests, anti-tipping bars, and a proper cushion.  Residents must still be repositioned within the chair every two hours at a minimum to provide pressure relief to prevent the development of bed sores.  If the resident is going to be taken somewhere outside the nursing home in a van, the wheechair needs to be properly loaded and secured in the transport vehicle before the driver starts to pull away.  Not having all of these things in place anytime the wheelchair is in use places the resident using it at risk for unncessary injury.

This nursing home fall was brought about by the failure to equip the wheelchair with a proper cushion.  Wheelchair cushions besides providing pressure relief must be covered with a non-slip material to prevent the cusion with the resident on top of it from sliding forward out of their chairs and getting hurt as a result of the fall.  The resident’s family bought a new cushion which was put into use right away.  However, the cover with the non-slip surface on the bottom which was intended to keep the cushion from sliding out of the chair was not in use.

The usual practice when a new piece of equipment for a wheechair is put into use is that the therapy department evaluates it to ensure that the chair is still safe for use.  That evaluation was never done – a crucial breakdown in the system.

As a result, the resident was leaning forward while brushing his teeth and the cushion slipped forward out of his wheelchair, causing the resident to fall to the floor.  He suffered a broken hip and and elbow, and at 97 years of age, he is unlikely to recover fully from his injuries.

Well-run nursing homes operate on systems which make help ensure that routine items of care get delivered as required.  When those systems are not actually implemented, then there are crucial breakdowns in the delivery of care such as this one which result in needless injuries to the resident.  Here, there was a well-defined system of what was supposed to happen – therapy was supposed to check the cushion to make sure that it was safe to use.  They would have recognized that the absence of the cover with the nonslip surface was a safety hazard and brought that to the attention of family and staff so that issue could have been corrected.

Past that, a more basic question is why was the family providing a wheelchair cushion to begin with.  Federal regulations regarding nursing home falls require nursing homes to provides supervision and assistive devices necessary to prevent falls.  In this context, the wheelchair cushion is as much an assistive device as the wheelchair itself.  If the old cushion needed to be replaced because it was worn, soiled, or needed to be replaced for any other reason, it was the responsibility of the nursing home, not the family to provide that cushion.

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

Other blog posts of interest:

Resident suffers unexplained broken arm at Oregon Living & Rehab

Wheelchair accident at Generations of Lincoln

Accolade of Pontiac resident fractures femur in fall

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

Fatal fall from wheelchair at Rosewood of Elgin

Good Samaritan of Pontiac resident suffers fractured knee and leg in wheelchair accident

 

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

 

Failure to give diabetes medication at Bridge Care Suites

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IDPH has cited and fined Bridge Care Suites nursing home in Springfield after a resident there had to be admitted to the intensive care unit after staff there failed to administer her diabetes medications.

The resident at issue was admitted to the facility late in the afternoon with orders to get three medications to treat her diabetes: 1) Lantus (a long acting insulin) at bedtime, 2) Humulin, given on a sliding scale, before meals and at bedtime, and 3) Lispro, before breakfast, lunch, and dinner.  At the time that she was admitted to the facility, she was alert and oriented.  None of the diabetes medications were given on the day of admission.  The reason stated in the chart was that the medications had not yet arrived from the pharmacy.   Her bed time glucose reading was 124.

The next morning, her glucose level was not checked on time because the nurse could not find a working glucometer.  It did get checked, late, at 7:30 a.m. and was at 568.  The resident was described then as being awake but drowsy.  The resident did not receive her morning medications.  At 10:30 a.m., her blood sugar levels read 517.  The resident was sent to the hospital around lunchtime where the resident’s family reported that she was more confused than normal, and the lab work-up showed that she was suffering from diabetic ketoacidosis.  Diabetic ketoacidosis is a result of your body not producing enough insulin.  Some of the potential complications associated with diabetic ketoacidosis include swelling of the brain, kidney failure, and respiratory distress.  The resident was admitted to the intensive care unit.

At first blush, this would seem to be am issue where there may be some shared liability between the pharmacy and the nursing home for this medication error, but further investigation revealed that it was really a training issue.  The nursing home had an automated backup medication dispensing system.  If the resident needed medications that were not on hand or medications were needed on an emergency basis, the nurses could reach out to the pharmacy and get a code which when entered would result in the medication being dispensed.  The medications that this resident needed were available through the backup dispensing system.  The nurse charged with caring for this resident did not know about this system and did not ask other nurses on the floor about what to do, did not contact a supervisor about what to do, and failed to notify the resident’s doctor about the unavailability of the medication.  Further, the nurse did not notify the doctor’s office right away about the 568 reading at 7:30 a.m. which is a critically high reading.

Making all of this worse is the fact that the resident also experienced a nursing home fall that day.  One of the things that happens after a resident experiences a nursing home fall is that the undergo a 72-hour fall watch which includes performing serial neuro checks to evaluate whether a resident suffered from a brain bleed after the nursing home fall.  This means that the resident’s declining mental condition should have been front and center for the nurse on duty.

One of the basic things that nurses are responsible for is giving residents their physician-ordered medications.  The nursing home here a system in place to deal with the possibility that necessary medications might not be delivered by the pharmacy, but failed to train the nurse on duty as to the fact that it was available or how to use it.  This is a failure which comes from a lack of resources devoted to staff training which is as much a feature of the nursing home business model as understaffing of the 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:

Multiple medication patches lead to seizures at Seminary Manor in Galesburg

Resident given wrong medication at Villa Health Care East

Failure to give HIV medication at Bria of Belleville

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

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

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

Diabetes care mismanaged at Aperion Care Capitol

 

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

 

 

Mechanical lift accident at Meadows Mennonite Home in Chenoa

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IDPH has cited and fined Meadows Mennonite Home in Chenoa after a resident there fell during a mechanical lift transfer and suffered a fractured pelvis.

The resident at issue was one who needed to be transferred with a mechanical lift.  Per facility policy, transferring a resident with a mechanical lift is always a job that is supposed to be done with two staff members.  This is a crucial safety measure as it allows one staff member to operate the lift while the other is in position to manage the resident during the transfer.  Having two staff members participate in a mechanical lift transfer is an issue which we have covered here on this blog repeatedly (see here, here, here, here, and here just as a few examples) and one which the Department of Public Health regularly issues citations when mechanical lift accidents result in injuries to residents.

This is yet another example of one person trying to do a two-person job.  The aide who was doing the transfer reported that the other aide assigned to that area of the nursing home was busy with another patient and the nurse on the floor was not available to help, so she attempted the transfer by herself.  The resident was being transferred from bed to her wheelchair and was in position over her wheelchair when the sling aparently came off the hook and the resident slid out of the sling and onto the floor.

The resident was taken to the hospital where it was determined that she suffered a fractured pelvis.  This is an injury for which there are very few treatment options which means that the resident will simply have to deal with the pain each time she is turned and repositioned in bed, that the resident will have more difficulty standing even for short periods of time, which can lead to the development of bed sores.

There is an obvious immediate cause of an accident like this: the aide tried to transfer the resident by herself when it was a two-person job.  There is a deeper level, and that likely goes to understaffing of the nursing home which is a common feature of the nursing home business model.   It also speaks to an issue of culture in the nursing home: this was a risky decision made by this aide, but she went ahead and did it anyway.  Well-run nursing homes put the safety of the residents as top priority, and making this kind of decision was a line which should not have been crossed.

This nursing home fall also raises an issue of the training of the staff.  The explanation offered for the fall was that the sling came off the hooks for the lift.  When used properly, a machanical lift is generally a safe device to use, but that requires that the sling be attached to the lift properly.  When the sling is not attached properly, the device doesn’t work as intended, and accidents result.  Besides the fact that the aide didn’t follow the basic safety precautions of having two staff members participate in this transfer, the other root cause of this accident was likely a failure of staff training.

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 falls from van at Casey Healthcare

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

Resident falls from mechanical lift at Oregon Living & Rehab

Failure to follow care plan result in fall with broken arm for resident at Heritage of Hoopeston

River Crossing of East Peoria resident suffers brain bleed due to unsafe transfer

Presence St. Anne resident breaks neck in fall from lift

Severe head injuries in fall at Heritage Health in Bloomington

 

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

 

 

Failure to use gait belt results in fall and fractured knee at Friendship Village

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IDPH has cited and fined Friendship Village nursing home in Schaumburg after a resident there fell and suffered a fractured knee due to the failure of an aide to use a gait belt in transferring a resident from his wheelchair to bed.

On the day of the accident, the resident was visiting with his wife in his room when he became tired and asked to be out to bed.  The aide came into the room to transfer the resident from his wheelchair to his bed.  His wife saw that the aide had her gait belt in her pocket and told the aide that she was going to need to use the gait belt to help transfer him because he was feeling tired and weak.

The aide ignored her instructions and tried to transfer him using the elastic from his shorts instead.  The elastic broke and he fell forward to the ground.  He was sent to the hospital where x-rays showed that he had a nondisplaced fracture of the kneecap.  His leg was placed in an immobilizer brace, but he has recurrent pain in the knee such that he is no longer able to stand on his own.

The nursing home had a policy in place at the time of the incident which required the staff to use gait belts during transfers.  A gait belt is a canvas starp that is applied around the midsection which allows staff members to control a resident during transfers and to help prevent falls from occurring or when the resident does lose balance to keep the fall under control in order to minimze the chances of injury.

The failure to use the gait belt under these circumstances was a violation of the nursing home’s own policies and would be a reasonable basis for a nursing home abuse and neglect lawsuit.  The whole point of the policy is to avoid preventable nursing home falls like this one, and while the injury itself is one which a defense lawyer may minimze (“it’s a nondisplaced fracture”), a broken kneecap is a serious injury.  And this same set of facts could just have easily yielded a truly catastrophic injury like a fractured hip or a brain bleed.  As is, this gentleman lost the ability to stand and this going to have serious, long-term consequences for his overall state of health and well-being and will at a minimum put him at increased risk for developing bed sores.

The real question to this though is why did the aide fail to use the gait belt even when she was explicitly asked to use it?  The answer will likely take some form of feeling rushed and with too much work to do and too little time to get it done.  This is of course a consequence of understaffing of the nursing home which is a part of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Resident suffers shoulder injury during improper transfer at Addolorata Villa

Failure to use gait belt at Jacksonville Skilled Nursing & Rehab

Brain bleed from fall at Gibson Community Hospital Annex

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

Alden Valley Ridge resident rolled from bed, breaks both legs

Unsafe transfer at Alden Courts of Shorewood

 

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

Fall with head injury at University Rehab in Urbana

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IDPH has cited and fined University Rehab in Urbana after a resident there had a fall and suffered a head injury.

The nursing home fall that sparked this citationg was troubling enough, but the things that the surveyor found and reported were even more disturbing.

The resident at issue was weakness on one side due to residuals from a stroke.  He was able to control his bowels, but needed help to get to the toilet.  On the day of the accident, he recogninzed that he needed to use the bathroom, so he sounded the call light for help.  Staff came to his room, shut off the call light and said that they would be back.  While he was waiting, he had an episode of incontinence of bowel and because in his words “I don’t like to sit in it,” he went to clean himself up.  While he was doing so, he lost his balance and fell over backwards.  He suffered a laceration to the back of his head which required staples to close.

Falls like this have a potential for serious injury.  It is a matter of luck, not good care, that this gentleman did not suffer a more significant injury like a fractured hip or brain bleed, both of which could have easily happened in this kind of fall.

What made this citation especially interesting is what the resident had to say:

[He gets up by himself] because the staff don’t come to help and when your pants are dirty, you don’t want to just sit in it.  They take a long time to answer the light, and then they tell you they will come back to assist and then they never do.  I’m not like a dog, I’m potty trained.  I just can’t hold it and definitely don’t like sitting in it.

Each nursing home home has a Resident Council where the residents are able to give feedback to the administration on the things that they like and don’t like.  They keep meeting minutes, and the minutes of the Resident Council meetings at this nursing home tell a story about why this fall occurred.  They document complaints at multiple meetings of long response times to call lights and of staff coming and shutting off the call lights withotu actually helping the resident who activated the call light.

The things that happened in this particualr incident and what is being documented in the Resident Council meeting minutes is indicative of a nursing home that is either understaffed or that has a poor culture of delvering care to residents.  These are systemic problems that lead to very predictable bad outcomes for residents in this facility.  Understaffing at nursing homes is a feature of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Auburn Rehab resident suffers fractured hip in fall

Call lights not being answered at Aperion of Mascoutah

Resident burned by hotpack at University Rehab

Fall in shower at Champaign County Nursing Home

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

Critical medication error at Gardenview Manor

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IDPH has cited and fined Gardenview Manor nursing home in Danville after a resident there ended up in intensive care due to being given another resident’s medications.

One of the basic functions that a nurse carries out day to day in a nursing home is passing of medications.  When a nurse passes medications, there are supposed to be multiple checks that are made – is this the right patient?  Is this the right medication?  Is this the right dose?  Is this the right dose?  Is this the right time?  The medication is not supposed to be given without those checks being made.

Of all of these, perhaps the most important of these is making sure that the medication is being given to the right patient.  If the medication is given to the wrong person this has the potential for disaster.  To help combat the potential for error, some nursing homes actually have the picture of the resident on the container for the medication.  Nonetheless, these kinds of nursing home medication errors do occur, and can have significant medical consequences.

In this incident, one resident was given a set of medications that were intended for another resident.  The citation from IDPH didn’t spell out why the medication error occurred, but it was clear that the resident was given someone else’s medications.  These included: Clonidine, Coreg, Losartin, Hydralazine, Coumadin, Nepro, Vitamin C, Phosio, Calcium Carbonate and Vitmain D3.

To their credit, the nursing home staff promptly recognized the error and took reasonable steps in reaction to that.  They notified the resident’s doctor, they contacted poison control, and closely monitored the resident.  When the resident’s blood pressure began to drop, they called for an ambulance and had the resident transported to the hospital where he was placed in the intensive care unit as part of a 5-day hospital admission.

The real question of course is why this medication error occurred.  The citation doesn’t address that, but having the critical safety measures that are part of passing medications become “routine” is probably a part of the problem.  The other likely root cause would be understaffing of the nursing home which may have resulted in the nurse being rushed or distracted during medication pass.  Understaffing of a nursing home is one of the features of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of 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:

Gardenview Manor resident fractures hip during unsafe transfer

Failure to notify doctor of abnormal lab results at Momence Meadows

Diabetes medication not given at Alden of Orland Park

Medication error leads to hositalization at Palm Terrace

Diabetes care mismanaged at Aperion Care Capitol

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.

Resident falls from bed at Spring Creek

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IDPH has cited and fined Spring Creek nursing home in Joliet after a resident there suffered a fractured femur in a fall from bed.

Care planning is one of the fundamental building blocks for the delivery of care in a nursing home setting.  In the care planning process, the resident’s needs are assessed, a series of steps or interventions are set out in the care plan to help assure the safety and well-being of the resident, and those steps are supposed to be carried out on a day-to-day, shift-to-shift basis.  When the staff fails to follow the care plan, that sets the stage for disaster to strike.

This resident was assessed as needing the assist of two for bed mobility, which means turning from side to side and moving in bed.  This is something that often needs to be done in connection with incontinence care and for turning and repositioning to prevent bed sores.  The reason that she was assessed as needing the assist of two is because she had cognitive impairments, musculoskeletal weakness, and was a larger person which would make it harder to a single person to safely control her while moving her in bed. When a person is designated as assist of two with bed mobility one staff member should be positioned on either side of the bed to help ensure that the resident doesn’t roll out of bed.

On the day of the accident, a single aide was providing incontinence care to the resident.  In doing so the resident was turned onto her side.  As the aide was cleaning the resident, she reached for her purse which was on a bedside table. Once she did that, the resident began to roll over away from the aide and over the side of the bed.  The aide was able to slow her fall by grabbing at her shirt, but the resident’s legs still went over the side of the bed and the resident suffered a fractured femur.

Proof of neglect on the part of the nursing home should be easy to come by: the care plan called for the assist of two, but only one a single aide was caring for the resident when the incident occurred.  The point that we would drive home here is: on days when the care plan was followed, there was no injury to the resident; one days when it was violated, a nursing home fall occurred and the resident suffered a broken leg.

Of course, the larger question would be, why was the aide going it alone?  The answer to that question likely lies in understaffing of the nursing home which is a feature of how nursing homes are operated.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Fatal choking accident at Spring Creek in Joliet

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

Lakeshore Rehab resident rolled from bed, breaks leg

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

Aperion Care International resident fractures ankle in unsafe transfer

Resident rolled from bed at Villa of South Holland

Alden Courts of Shorewood resident breaks both legs during unsafe transfer

 

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

 

 

Resident falls from lift at Oregon Living & Rehab

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IDPH has cited and fined Oregon Living & Rehabilitation Center after a resident there suffered a broken leg after falling from the sling of a mechanical lift.

Done properly, a mechanical lift is a safe way to transfer residents who are unable to participate in moving from a bed to wheelchair, wheelchair to chair or toilet, and so forth.  Using the lift takes the potential for accidents occurring due to loss of balance away and greatly reduces the risk of injury to the staff.

The key of course is the first part – “done properly,” and we have seen a number of incidents where residents have sustained major injuries due to unsafe practices in the use of a lift, most commonly where a single aide attempts to transfer a resident where the help of two is required, as happened here and here.  The other area where errors might occur is where the resident is either not positioned in the sling properly, the sling itself is in disrepair, or the straps to the sling were not attached to the lift properly.

And this bring us to the situation involving this resident.  This resident had a care plan which called for a two-person assist with transfer with a mechanical lift.  On the day of the accident, there were two aides participating in doing the transfer.  However, as they lifted the resident, she fell out of the side of the sling, landing on the ground and breaking her femur.

When interviewed by the state surveyor, the staff was not able to fully explain how the resident ended up falling out of the sling, but they agreed that there was no way that this should occur if the lift is being used properly.  Based on the circumstances, it appears that the straps were not properly placed on the lift before the transfer was attempted.

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 results in brain bleed and death at Regency Care of Sterling

Presence St. Anne resident breaks neck in fall from lift

Failure to follow care plan at Tower Hill Healthcare

Spinal fracture in fall from bed at Pine Acres

Resident suffers unexplained broken arm at Oregon Living & Rehab

 

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

 

Resident chokes to death at Rosewood of St. Charles

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IDPH has cited and fined Rosewood of St. Charles nursing home after a resident there choked to death during dinner.

One of the fundamenentals of delivering care in a nursing home is that when there are steps identified in the resident care plan that have to be taken to assure the safety and well-being of the resident, these need to be carried out on a day-to-day, shift-to-shift basis.  When nursing home staff fails to carry out a resident care plan, disaster can result – and that is what happened here.

The nursing home here actually did many things right in carting for this resident.  The resident was suffering from Alzheimer’s and was known to the staff to be someone who ate very fast.  The staff in various parts of the citation described her as “gobbling” or “scarfing” her food down while she ate, noting that sometimes she chewed her food and sometimes she didn’t.  The aides and other staff described frequently needing to remind her to slow down while she was eating.  They referred her to a speech therapist who noted issues with chewing, swallowing, and pocketing of food while she ate.  She was downgraded to a mechanical soft diet with thin liquids and an order was obtained for four weeks of speech therapy to work on swallowing.  Her care plan  called for her to to eat in an assisted dining room at a feeder table and to be monitored during meals.

These are all reasonable steps to take – as long as they are taken.  And that was where the problem here arose.

In the assisted dining room, there were usually at least three aides in the dining room during meals.  One of them would be seated at the feeder table to provide direct supervision and assistance to the residents who were seated there.  The speech therapist told the state surveyor that the resident at issue needed to be under direct eye contact supervision while she ate because of her chewing and swallowing issues.

On the night of the incident, there were were only two aides in the assisted dining room because the others were running late.  The aides instructed the dietary aide to start passing the trays eve though no one was seated at the feeder table.  While the aides were pouring drinks to the other residents, the resident began to eat and started to choke.  The staff attempted the Heimlich and was able to get a small piece of meat out, but the resident was stil not breathing and began to turn blue.

Paramedics happened to be in the building because they were returning another resident from a doctor appointment.  The offered to help and were able to clear more food from the aiway doing the Heimlich.  They began to try to resuscitate the resident and brought her to the emergency room.  However, her heart stopped while she in transit to the emergency room.  There was already a DNR in place, so further efforts at resuscitation were stopped, and the resident was declared deceased.

This resident’s death was a direct result of failing to carry out a reasonable care plan.  This resident required direct, eyes-on supervision while she was eating because of her habit of eating very quickly when she had known swallowing and chewing problems.  The combination of the two are a formula for a nursing home choking accident which is why that level of supervision was needed.  However, the assisted dining room was not fully staffed when the instruction was given to start passing the trays, and as a result, the resident did not get the level of supervision she needed, with disastrous results.

The deeper question of course is why the aides who were supposed to be in the assisted dining room that evening were running late.  A possible answer to that would be that they had to much other work to get done for them to make it into the assisted dining room in time.  That in turn raises questions about understaffing of the nursing home which is a feature of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Fatal choking accident at Warren Barr North Shore

Resident chokes to death athe Moorings at Arlington Heights

Fatal choking accident at Iona Glos

Resident chokes to death at Grove at the Lake

Riverview Rehab resident chokes to death

 

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

 

 

 

Resident bleeds to death at Aperion of Forest Park

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IDPH has cited and fined Aperion Care of Forest Park after a resident there bled to death following the removal of a wound vac device.

Many nursing home residents take anticoagulant (or blood thinner) medications to prevent serious medical issues such as a stroke, heart attack, or pulmonary embolism, all of which can be fatal or cause serious, long-lasting, debilitating problems.  They work by inhibiting the blood’s ability to form clots.  The risk and the downside of taking these medications is that by inhibiting the blood-clotting ability of the body, when the resident experiences a bleed, it may go unchecked which can cause its own serious set of problems.  This is one of the reasons that residents on anticoagulants require close monitoring after experiencing a nursing home fall – they may be experiencing a brain bleed which can prove fatal or seriously debilitating if allowed to continue.

The resident at issue was admitted to the nursing home after undergoing a vascular bypass surgery on January 8 to improve circulation to the left lower extremity.  During the hospital admission, he also underwent amputation of the fourth and fifth toes of his left foot.  There were orders in place for continuous use of wound vac to help close a non-healing wound where the toes had been amputated.  The resident was also taking aspirin and Plavix to help prevent blood clots.  The resident was to return to see the doctor on the morning of January 23.

The practice at the nursing home was that when a resident had an early morning doctor appointment, the wound vac would be removed the prior afternoon.  This was because if the medical transport team arrived to take the resident to the doctor’s office before the wound care nurse arrived at the nursing home, there was a risk that the resident would be admitted to the hospital from the doctor’s office and the wound vac machine might not be returned to the nursing home.  Therefore, to avoid the risk of loss of the wound vac machine, the wound vac would be disconnected the afternoon before the appointment at the doctor’s office.

On the afternoon of January 22, in keeping with the practice at the nursing home, the wound care nurse removed the wound vac and applied a dry dressing before leaving for the day.  She told the state inspector that there was no active bleeding when she left the resident.  However, less than an hour later, a staff member observed a pool of blood on the floor coming from the wound where the toes had been amputated and the resident was unresponsive and in cardiac arrest.  911 was called and the resident was brought to the emergency room, but the staff there was unable to revive the resident and he was declared deceased.

The state investigation revealed that the facility had no policy in place for monitoring residents after removal of the wound vac.  Further they relied on representatives from the various manufacturers of the different types of wound vacs in use at the nursing home to train the staff, but they were unable to show what training had in fact been provided to the staff, although the operations manual to the wound vac called for special precautions for residents who are on anticoagulants.

Making matters worse, the resident’s doctor said that the wound vac should not have been removed to begin with, as his order was for continuous use and removing the wound vac denied the resident of the additional hours of treatment with it.  He told the surveyor that the removal of the sponge that covered the wound when the wound vac was disconnected could have caused the bleeding which resulted in the death of this resident.

What this shows is that the nursing home did not train or have policies in place on monitoring residents after a wound vac was removed, but removed the wound vac in violation of doctor’s orders in order to guard against the possible loss of the wound vac in the event that the resident was admitted to the hospital from the doctor’s office.  Good for the nursing home, not good for the resident, even without the tragic and avoidable outcome that we had here.

The practice of removing the wound vac to guard against the risk of it being lost is an example of how dollars and cents decisions adversely effect care for nursing home residents. 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:

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

Dialysis patient bleeds to death at Warren Barr North Shore

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

California Gardens fails to obtain respiratory equipment

Aperion Care Wilmington resident suffers ruptured colon due to fecal impaction

 

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

 

 

Generations at Rock Island fails to provide care for pressure ulcers

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IDPH has cited and fined Generations at Rock Island nursing home after an inspection there found that two residents were not receiving treatment for bed sores as ordered.

Bed sores are a major issue in the nursing home industry.  Once a resident develops a bed sore, whether it started in the nursing home or not, the nursing home is obligated by federal regulations to provide care, treatment, and services necessary to promote healing, prevent infection, and prevent new bed sores from developing.  When the nursing home fails to provide the care that is ordered to treat bed sores, it leaves the resident in need of care vulnerable to further decline of the wound, the onset of infections like cellulitis and osteomyelitis, and other complications.  These things can spiral out of control and result in the wrongful death of the nursing home resident.

This of course underlines the importance of providing care as ordered.  And this citation shows that the nursing home failed these two residents.

The first resident had multiple bed sores, including on her coccyx and right ischium.  The orders in place called for daily cleansing of the wound and application of dressings and a foam.  During the period between February 1 and March 22, the nursing home staff failed to provide care on 27 days.  For those keeping score at home, that is just over 50% of the time that the resident did not receive the care ordered.  The weekly wound reports, skin assessments, and shower sheets that were to have been completed by the nursing home during that period were not completed.  When confronted by the surveyor, the facility Director of Nursing admitted that the wound care was not being provided as ordered and that the documentation and reporting was not being done either.

The second resident has a single stage 4 pressure ulcer on the left ischium.  The wound measured 1.0 x 0.3 x 0.5 cm with no tunneling or undermining.  The wound care orders included packing the wound with Medihoney, use of a barrier cream, and giving nutritional supplements.  The Director of Nursing also verified to the surveyor that during the month of February, the treatments were not provided on 12 out of 28 days in February, the barrier cream was not being used, and the nutritional supplements were not being given.  At the time the inspection was completed by the state that same wound was now 5.0 x 3.0 x 2.0 cm with three separate areas of tunneling under the wound.  This represents a substantial decline in the condition the wound.

We know that the treatments for these wounds were not being provided as ordered – the DON admitted that.  The real question is why, and the answer to that likely lies in understaffing of the nursing home.  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:

Transport van accident at Generations at Rock Island

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

Failure to notify doctor of bed sore at Aperion of Moline

Maggots found in bed sore at Manor Court of Clinton

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

 

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

Grove of Berwyn fails to treat bed sore

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IDPH has cited and fined the Grove of Berwyn nursing home after the staff there failed to treat a resident who developed a pressure ulcer.

The resident at issue was admitted to the nursing home on March 21 without any bed sores present.  The resident was sent back to the hospital and was readmitted on April 5 with a Stage 3 pressure ulcer on her buttocks.  There was a physician order sheet which included orders for treatment of the bed sore.  However, those orders were never transcribed onto the resident’s Treatment Administration Record on the resident’s chart and there was no care for the wound provided through April 24.  On April 24, the facility’s wound doctor arrived at the nursing home and performed a sharp debridement of the the now unstageable bed sore and issued additional orders.

One of the basic items that must happen any time a resident is admitted or readmitted to a nursing home is that the orders for treatment be entered into the resident chart and then carried out.  This resident apparently developed a bed sore while at the hospital and returned to the nursing home with orders for their treatment.  The failure to include these orders in this resident’s chart led directly to the resident not receiving the treatment ordered.

Past that, when a resident is admitted or re-admitted to a nursing home, that should re-start the care planning process.  The care planning process includes a full assessment of the resident including a full body check which should have revealed the presence of the bed sore and notfication of the doctor for treatment orders.  The facility also had a policy in place calling for weekly skin checks which were apparently never done.

Federal regulations require nursing homes to provide care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new bed sores when a resident is admitted to the nursing home with a bed sore.  Here, there were at least three breakdowns in the delivery of care: the failure to transcribe the orders from the hospital, the failure to do the full body check which is part of the care planning process, and the failure to do the weekly skin inspections.  Each of these failures resulted in this resident going nearly three weeks without care and in the decline of the bed sore which led to the debridement of the wound.

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 develops bed sore at Avantara of Elgin

Residents develop bed sores at Elmwood Terrace

Providence Downers Grove fined after multiple residents suffer bed sores

Fatal choking accident at Grove at the Lake

 

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 Eden Village

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IDPH has cited and fined Eden Village Care Center nursing home in Glen Carbon after a resident there developed bed sores on both heels.

Federal regulations provide that when a resident is admitted to a nursing home without bed sores that they receive care consistent with professional standards of practice to prevent bed sores and that they do not develop bed sores unless the resident’s clinical condition demonstrates that they were unavoidable.  Once a resident develops a bed sore, federal regulations require that the resident receive treatment and services necessary to promote healing, prevent infection, and to prevent new sores from developing.

Bed sores occur most often on the bony prominences.  One of those areas is the heels.  This is because the weight of the body and the creates a “pinch point” between the bony prominence and the resting surface (usually a bed or chair) where the small blood vessels that supply oxygen and nutrients to the skin can be compressed.  This is why immobility is a major risk for the development of bed sores and a huge impediment to their healing.  The regular means of combating immobility is pressure relief which consists of turning and repositioning the resident and floating the heels off the bed.

The resident at issue was admitted without any skin breakdowns but assessed (likely using the Braden scale) as being at risk for skin breakdowns.  The resident had a pressure ulcer prevention care plan put into pace which included daily skin checks, turning and repositioning every two hours, and floating the heels while in bed.  The resident developed a pressure wound on her left heel approximately three and a half weeks after being admitted to the nursing home.  The flow sheets indicated that the daily skin checks were not done on just under half of the days before the wound on the left heel developed.  At that point, the doctor entered an order for the heels to be floated, among other orders for treatment.

Approximately six weeks after the wound of the left heel developed, an unstageable pressure ulcer was discovered on the right heel.  When the surveyor reviewed the resident chart, she discovered that there were multiple days where the floating of the heels did not occur.  The nurse practitioner interviewed by the suveyor (likely the wound care nurse) stated that the bed sores to the heels were likely avoidable had the heels been floated as called for in the resident care plan and the treatment orders.

Unlike incidents such as nursing home falls or choking accidents in nursing homes, the development of bed sores does not usually occur in a flash moment of time.  In other words, the development of bed sores is most often the product of days if not weeks of the resident failing to receive the kinds of routine care (such as repositioning and floating the heels) which is necessary to prevent the development of bed sores and to promote the healing of existing wounds.  When that routine care is not done, this is the kind of outcome that you have.

The question of course is why is this routine care not being done?  Frequently it relates to understaffing of the nursing home, which is an issue which I would certainly examine in a nursing home abuse and neglect lawsuit.  Understaffing of is one of the key features of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Resident develops bed sores at Eastside Nursing & Rehab

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

Bed sore caused by leaving resident sitting on bed pan at Mar Ka Nursing Home in Mascoutah

Medication error at Eden Village

Call lights not being answered at Aperion of Mascoutah

Resident develops bed sore at Nokomis Rehab

 

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

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

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IDPH has cited and fined Heritage Health nursing home in Jacksonville after a resident fell forward out of specialized postural positioning chair, suffered a fractured hip, and died.

One of the factors that contributes to fall risk in residents who are bedbound or chairfast is poor trunk control.  Lack of having even minimal core strength can lead to the resident not being able to control their own torso when in a seated position or in bed.  This can lead to rapid loss of control when the resident is being moved and result in the resident falling from bed or from a chair.

That was what happened in this situation.  The resident at issue had poor trunk control and part of her care plan called for the use of a specialized postural positioning chair which would tilt back while the resident was being moved.  Tilting the resident back in the chair would have the effect of preventing the resident from suddenly leaning forward and falling forward out of the chair.

Of course, for that care plan to work properly, the staff charged with carrying out needed to be trained in the use of this specialized piece of equipment.  Sadly, that was not the case here.

On the day of this nursing home fall, the resident was being brought back from the bathroom seated in the postural positioning chair.  However, the chair was not tilted back and the resident fell forward from the chair.  She was brought to the hospital where she was diagnosed as having suffered a fractured hip.  She died two days later, apparently from complications from the broken hip.

During the inspection by the state surveyor, the aide told the surveyor that she had never been trained on how to use the chair.  The state surveyor also determined that there were no facility policies in place regarding the use of this piece of equipment.  Bottom line: a reasonable care plan which could not be effectively carried out because the staff did not know how to use the equipment needed to deliver the care this resident needed.

The net result: a fall with a fractured hip leading to the wrongful death of this nursing home resident.

Nursing homes are required to have staff on hand with the necessary competencies to deliver the care required to meet the resident’s needs on a 24/7 basis.  When the staff is not trained on how to use the equipment specified in the resident care plan, that is a violation of federal regulations.

The real question is of course, why was the staff not properly trained?  That comes down to time, attention, and money, and the nursing home business model cuts away at all of those things when it comes to delivery of care to the residents.  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:

Taylorville Skilled nursing home resident falls and breaks hip

Fractured eye orbit from fall at Integrity of Alton

Fall from edge of bed leads to broken leg at Jerseyville Manor

Fractured femur due to failure to use lift at Granite Rehab

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

Broken ankle in fall at Aperion of Mascoutah

 

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

 

Resident fractures hip in fall at Caseyville Nursing & Rehab

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IDPH has cited and fined Caseyville Nursing & Rehab after a resident fell and fractured a hip while going to the bathroom unattended.

The fact pattern which is described in this citation is a distressingly familiar one: a resident with musculoskeletal issues and impaired safety judgment attempts to go to the bathroom unattended and falls, suffering a hip fracture.

There were a number of issues with the care which this resident was provided leading to this nursing home fall which were immediately apparent:

  1.  The resident was well-recognized as a fall risk and that she had impaired safety judgment.  When a resident has impaired safety judgment, they cannot be relied upon to do things (such as wait for staff to go to the bathroom) which are necessary to assure their safety.  Federal regulations relating to nursing home falls require nursing homes to provide supervision and assistance necessary to prevent accidents such as falls.  When a resident cannot be relied upon to simply follow instructions to wait for staff, monitoring and supervision are required to address the deficits in their judgment for the own safety.
  2. Before the fall which resulted in the fractured hip, there were at least two prior falls involving this resident in the nursing home.  Having one fall tends to beget additional falls and is also an indicator that the existing care plan is not working as well as hoped, so revision of the resident fall prevention care plan is required.  This did not occur.  The fact that there were no injuries in the first two falls in good luck, not good care.  An improved care plan is a far better tool for assuring the safety and well-being of the residents than relying on good luck.
  3. At the time of the fall, her doctor had issued an order for a change in her psychiatric medications.  These medications do have a role in fall risk and when medications are being changed (as opposed to when residents have been long-time users), the effect of these medications is not entirely certain, so it is a time when increased vigilance is required.
  4. She was also suffering from a urinary tract infection at the time of the accident.  This is significant because urinary tract infections often have the effect of increasing confusion in a geriatric patient population which is a contributing factor to fall risk.  It also has the effect of making a resident weak which increases fall risk.  UTI’s are treated with antibiotics which can also cause digestive problems which can result in urgency to use the bathroom.  All of these factors taken together draws the picture of a resident who requires the additional supervision.
  5. The most telling part of the citation was the comment which the resident made to the state surveyor – that she always has to “wait, and wait, and wait, so I just take myself.”  This is one of the indicators that nursing home may be understaffed, which is something that leads to an increased rate of falls and a higher incidence of residents suffering bed sores.

Understaffing of a nursing home is one of the products 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:

Taylorville Skilled resident suffers fractured hip after multiple falls

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

Fractured femur due to failure to use lift at Granite Rehab

Broken ankle in fall at Aperion of Mascoutah

Fall from edge of bed at Integrity of Alton

 

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

 

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

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IDPH has cited and fined Lexington of Orland Park nursing home after a resident there suffered a broken leg while being pushed in her wheelchair.

When it comes to wheelchair-bound residents, the term “self-propelling” means that the resident is able to move themselves in the wheelchair without staff assistance.  Usually this is done primarily through the resident using their feet to walk the wheelchair forward with some use of the arms for steering.  It is something which promotes the independence and dignity of the resident as it allows them move throughout the facility without having to wait on or depend upon the staff to push them.  To improve the resident’s ability to self-propel, the footrests are usually removed from the wheelchair so that they don’t interfere with the resident’s ability to self-propel or cause skin tears or other injury to the resident by striking the resident’s legs.

The downside to self-propelling is that it is a slow process, and staff often doesn’t have time to wait for a resident to self-propel.  When the staff needs to get the resident moved more rapidly, they can simply push the resident where they need to go.

This was the situation here – the resident was able to self-propel, but it was meal time so an aide began to push the resident toward the dining room.  Because the resident usually self-propelled, her wheelchair had the footrests removed.  Instead of placing the footrests back on the wheelchair, the aide simply had the resident hold her legs up.  On the way to the dining room, the aide heard a loud popping sound and saw that one of the resident’s legs had gone under the wheelchair.

The resident was brought to the hospital where x-rays showed that she had a broken leg.  The resident was placed in an immobilizer. The failure to use footrests on the wheelchair led directly to this injury.

This was a highy preventable injury.  All that was required to transport this resident to the dining room safely was to place the footrests on the wheelchair, but the aide failed to do so, either due to the pressure of having to get too much work accomplished in too little time to get it done  due to inadequate staff levels, or due to lack of training.  Neither reflects well on the nursing home.

As a result, this resident sustained a broken leg which required the application of an immobilizer.  This will eliminate her ability to self-propel while it is on, and due to disuse, she may end up losing that ability to self-propel all together.  Loss of strength may lead an increased risk of suffering a nursing home fall.  Past that, her immobility will also place her at increased risk of developing bed sores as immobility is a prime risk factor for that.

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 at Lexington of Orland Park results in facial fractures

Wheelchair accident at LaSalle County Nursing Home

Resident breaks leg in wheelchair accident at Heritage Health in Dwight

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

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

Wheelchair accident at Avanti Wellness

 

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

 

Fall results in broken vertebra at Heritage Health of Mendota

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IDPH cited and fined Heritage Health nursing home in Mendota after a resident there experienced two falls in two days, the second resulting in a fractured lumbar vertebra.

The resident at issue had been admitted to the nursing home for rehabilitation following a knee replacement surgery.  She was assessed as having cognitive issues which increased her fall risk  including confusion, memory problems after 5 minutes, and overestimating or forgetting her limits.  This combination of factors made her a high fall risk – there are orthopaedic issues which create a risk of falls and cognitive issues which can lead to behaviors that increase fall risk, specifically getting up without assistance or supervision.  The fall prevention care plan only called for assist of two using a gait belt and walker for walking and assist of two with transfers.

The first fall actually occurred on the day of her admission.  She thought that she heard her daughter’s voice in the hallway and got up from her recliner using her walker and walked out into the hallway where she lost her balance and fell, bumping her head.

One of the truisms regarding nursing home falls is that a first fall tends to beget additional falls.  When a resident experiences a fall, that is a situation which requires physician notification and revision of the care plan.  The occurrence of a single fall is a strong indicator that the current care plan is inadequate for addressing fall risk and needs to be revised.

The second fall occurred the following day.  The resident was again in her recliner in her room when she got up and walker without her walker to the doorway of her room without her walker when she lost her balance and fell landing on her back.  She complained of significant lower back pain and was sent to the emergency room where x-rays showed a fracture of the L4 vertebra.

When a resident suffers from cognitive issues such as dementia, intermittent or constant confusion, or poor safety judgment, this is a significant factor in a resident’s fall risk profile.  It means that they cannot be counted on to do the things that would help assure their own safety like calling for and waiting for help.  Federal regulations relating to nursing home falls require that residents receive supervision and assistive devices necessary to prevent accidents.

In the past this kind of resident would have been provided with a bed alarm which would have served to alert the staff and remind the resident to wait for help.  However, even with federal regulations discouraging (but not prohibiting) the use of bed alarms, the nursing home still has an obligation to provide supervision necessary to prevent accidents.

The cognitive difficulties that this resident was plainly experiencing (and which tend to be at their worst when first admitted to a nursing home) needed to be specifically addressed in the resident care plan, but was not.  Most often, the care plan would include keeping the resident in a common area or at the nurse’s station so that they can be supervised by staff.   The failure to include specific interventions in the care plan to address the cognitive issues, especially in light of the fall on the day of admission, was a significant failure on the part of the 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:

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

Fall due to failure to assist resident to bathroom at Heritage Health of Peru

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

Waverly Place of Stockton resident fractures hip in unsafe transfer

Third degree burns from fall at Sauk Valley Senior Living

Spinal fracture from fall from bed at Pine Acres in DeKalb

 

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

Fractured femur due to failure to use lift at Granite Rehab

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IDPH has cited and fined Granite Nursing & Rehabilitation nursing home in Granite City after a resident suffered a fractured femur due to an unsafe transfer.

The resident at issue had been assessed as needing assist of two with all transfers.  This was incorporated into her care plan, which specified that all transfers were to be accomplished using a mechanical lift.

On the day of the accident, the resident was being transferred manually (not with a lift) by a single aide (not two) when the aide tripped on the resident’s night stand, causing a fall.  The resident was brought to the hospital where she was diagnosed as having a fractured fenur which required surgery.

Having an implementing a reasonable care plan, combined with thoughtful, diligent nursing care, gives nursing home residents the best chance at maintaining their quality of life and avoiding accidental and/or unnecessary injuries.  The flip side to that of course, is that violating the care plan exposes nursing home residents to risk of unnecessary, preventable injuries.

In this case, there was a reasonable care plan put into place which called for the resident to be transferred using a lift with the help of two aides.  That care plan was not be followed when this nursing home fall occurred.  The aide was attempting to transfer the resident manually and by herself.  The aide’s loss of balance led directly to the resident’s injury.

This is of course the obvious answer to the question of why did this injury occur.  There is likely a deeper answer which relates to understaffing of the nursing home where there simply was not enough help available to meet the care needs of the residents.  As a result of this, the aide, feeling the pressure to get on with everything else that needed to be done, chose to not wait for the lift to be brought to the room and chose to not wait for a second aide to help her.  She chose to gamble with the resident’s safety instead, and the resident lost.

The issue of understaffing goes back to the basic choices about how nursing homes operate.

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:

Use of improper sling leads to resident being dropped from lift at Carlinville Rehab

Resident falls from lift at Oregon Living & Rehab

Failure to use gait belt at Jacksonville Skilled Nursing & Rehab

Hitz Memorial Home resident dropped from lift

Fractured femur from improper transfer at Frankfort Healthcare & Rehab

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

 

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

 

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

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IDPH has cited and fined Rosewood of Inverness nursing home after a resident there had both ankles broken as a result of an unsafe transfer using a mechanical lift.

The resident at issue had a history of having suffered a stroke with residual weakness.  She had poor trunk control and general muscular weakness.  She was coded as needing extensive assist with a mechanical lift for transfers to and from her wheelchair.  The facility protocols called for two aides to be involved in all mechanical lift transfers.  This is necessary to ensure that there is one aide to operate the controls of the lift and another to keep the resident steady and safe within the lift during transfer and to make sure that the resident is safely positioned at the end of the transfer.

In this incident, the resident was being transferred from her bed to her wheelchair by a single aide.  When the resident was placed into her wheelchair, she was too far forward and slid forward out of the wheelchair.  In all likelihood, her poor trunk control and general weakness kept her from being able to position herself far enough back in the chair to prevent her from having the fall.  This is of course exactly why a second aide was required to do the transfer to start with.

The resident was brought to the hospital where x-rays showed that both ankles were fractured as a result of this nursing home fall.

The aide involved in this incident was fired for violating the facility’s policies and procedures, but the records from the facility showed that he had been trained on the proper use of the lift, including the need for the two aides to participate in every mechanical lift to transfer.  The practice by aides of doing a two-person job with only one has been a recurrent theme in many of the accidents which we have covered in this blog (see here, here, here, here, and here just as a few examples).  Since we know that this aide knew better than two try to do the job by himself (his training records showed that), the question is why did this accident happen?

The answer to that question likely relates to understaffing of the nursing home, which is a direct by-product of the business decisions that management makes about how to operate a nursing home.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

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

Failure to use gait belt leads to fall and fractured knee at Friendship Village in Schaumburg

Bedbound resident at Elevate Care of Waukegan suffers broken arm

Resident suffers shoulder injury during improper transfer at Addolorata Villa

Short-staffing leads to fall at Manorcare of Libertyville

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

 

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

 

Failure to notify doctor of pressure sore at Aperion of Moline

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IDPH has cited and fined Aperion Care of Moline nursing home after a resident there developed a pressure sore on her heel but failed to notify the doctor to obtain proper treatment orders.

One of the basic facts of nursing home care is that doctors are not there on a 24/7 basis, so the nursing staff has to serve as the eyes and ears for the doctors as to what is happening with the residents who are under their care.  That means that when the nursing staff must notify the resident’s doctor when there is a change in condition, when the resident experiences a nursing home fall, and so forth.  This allows the doctor to decide whether to issue orders for the staff to carry out over the phone, to come into the nursing home himself, or to order the resident to be sent to the hospital.

One of the situations where physician notification is absolutely required is when a resident develops a new bed sore, also referred to as a pressure ulcer or pressure sore.  One of the things that needs to be determined early on is what is the stage of the bed sore, as that will drive what kind of treatment the resident receives.  Nurses don’t get to determine what kind of treatment should be ordered for a particular type of wound unless they are a wound care nurse, and even then, that is subject to the doctor issuing the order for care.  Unfortunately for this resident, failing to notify the doctor and initiating treatment without orders is exactly what occurred to this resident.

The resident at issue had a Stage 4 deep tissue injury on her heel.  The first time it was noted in the resident chart was when the nurse practitioner who treated wounds at this nursing home saw it.  Before that, no nurse had documented in the resident’s chart the presence of this wound, its condition, the notification of the doctor, or the doctor’s orders for treatment of the bed sore  – all things which would have occurred in well-run nursing homes.

On the day that the bed sore was discovered by the nurse practitioner, there was a foam dressing in place.  A foam dressing was not appropriate for this type of wound, and there were no markings on the dressing itself to indicate who put the dressing on or when.  The resident said that it had been put on a few days earlier, and there was  enough drainage on the dressing to indicate that it had been at least a few days since it had been applied.   Further, the resident was not getting a pressure-reliving boot, a crucial step to ensure that the wound healed.

Federal regulations require that nursing home residents receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new pressure sores.  When nurses fail to notify the doctor and fail to obtain proper treatment orders, violation of these regulations is the almost certain 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:

Untreated pressure ulcer at Aperion Care of Bradley

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

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

Resident develops bed sore at Nokomis Rehab

Aperion Care Capitol fails to obtain equipment to treat bed sores

 

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

 

 

Unsafe transfer at Heartland of Galesburg results in dislocated hip

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IDPH has cited and fined Heartland of Galesburg nursing home after a resident there suffered a dislocated hip after an aide attempted to transfer her with a mechanical lift by herself instead of with a second aide.

The resident at issue had been admitted to the nursing home for rehabilitation following a hip replacement surgery.  On the day of this nursing home fall, she sounded a call light to be taken to the bathroom.  An aide brought a sit-to-stand mechanical lift to bring her to the bathroom and began preparations to bring the resident to the bathroom.  As she did so, the resident asked her whether two aides should be used for the transfer.  The aide told her that it wasn’t necessary.  After placing the straps around the resident, the aide began to bring her to the bathroom, but the resident’s legs gave out from under her and she fell to the floor, landing on her buttocks.

The resident initially thought that she was okay, but as they brought her back into bed, she hard a sharp pain in the hip that had just been operated upon.  She was sent to the the hospital where it was determined that she had a dislocated hip.

At the time of this mechanical lift accident, there was a facility policy in place what called for the use of two aides in making transfers.  This was obviously violated by the aide in trying to do this herself.  Making matters worse, the investigation into the incident indicated that the straps for the sling were not applied appropriately.

Aides attempting to do the job of two people by themselves has been a recurrent theme in many of the blog posts we have written (see here, here, here, here, and here just as a few examples).  This is often due to aides feeling the pressure of all of the work that needs to be done to care for the residents assigned to them and the wait for help just puts them that much further behind.  Failing to apply the straps properly also speaks poorly to the quality of the training that the aide received.

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:

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

Heartland of Galesburg fined for nursing home falls

Improper use of lift at Danville Care Center

Seminary Manor resident suffers fatal brain bleed in fall

 

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

 

Multiple injuries in fall at Symphony at Midway

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IDPH has cited and fined Symphony at Midway Nursing Home in Chicago after a resident there suffered multiple injuries in a fall.

Care planning is the basic process by which the care needs of nursing home residents are met.  It is a multi-step process which starts with an assessment which identifies the risks to the health and well-being of the resident.  From the there, steps or interventions are put into place and assigned to various staff members to carry out on a day-to-day, shift-to-shift basis.  The interventions then must be communicated to the staff who then must implement the care plan.  Finally, it must be evaluated and revised if it proves inadequate in practice or if there are further declines in the resident’s condition.

It all starts with the assessment – if you have a bad assessment that understates the risks to the resident, you end up with a care plan that doesn’t meet the needs of the resident.  That is what happened in this case.

Nurisng home falls present a serious risk to the health and well-being of residents.  Even if a resident doesn’t sustain a major injury like a hip fracture in a nursing home fall, that is a matter of luck, not skill.  Past that one nursing home fall tends to be a predictor of additional falls to come.  Therefore, fall risk is a standard part of every nursing home assessment.  There are few standardized, tested scales used to predict fall risk in the long-term care setting the way that the Braden Scale is used to assess the risk of developing bed sores.

In our view, there are two major factors which contribute to fall risk.  The first of these is some type of muskuloskeletal issue which affects strength and/or balance to the point that the resident is unable to sit, stand, or walk safely.  The other major risk facor is behavioral, meaning either poor safety judgment, impulsivity, constant or intermittenty confusion, and/or dementia which makes it more likely that the resident will so things that are not safe for them to do or fail to wait for or obtain help from the staff.  To be sure, there are other factors such as incontinence or medication usage which can contribute to fall risk, but muskuloskeletal issues and behavioral issues are the major ones.

Care planning must be redone periodically.  Federal regulations require that it be done every quarter, but should also be done where there are declines in the resident’s condition.

The resident at issue suffered from impairments in strength and range of motion and also suffered from dementia and had documented impulsive behaviors.  In short, this is a resident who was a classic fall risk.  The last time that this resident was assessed for fall risk was in June, 2017 and was at that time assessed as being at low risk for falls.  No interventions were put in place.  Between then and when the resident had the fall at issue in the citation on February 2, 2019 (yes, more than a year and a half later), there were no other documented fall risk assessments.  Needless to say, there should have been several done in the interim.

On the day of the resident’s injury, an aide was called to the resident’s room and found the resident on the floor bleeding from the head apparently having fallen from bed.  The aide reported that the resident would frequently move from side to side, but there were no interventions in place to keep the resident from falling from bed.  The resident was brought to the hospital where testing showed that he had brain bleeds on both sides of the brain as well as a possible fractured hip.

This is exactly the kind of thing that happens when care planning is not done as needed.  This resident was clearly at risk for falls, yet nothing was done in a regular systematic, way to prevent the kind of accidental injuries that result from falls.  This was a complete failure on the part of the 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:

Symphony of Midway resident suffers fatal fall from window

Care plan violation at Central Nursing Home in Chicago

Two serious falls at Holy Family Villa

Fall down steps at Alden Town Manor in Cicero

 

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

 

 

 

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