Nursing Home Abuse Blog - Page 18 of 35 - The Law Offices of Barry G. Doyle, P.C.

No fall prevention care planning at South Suburban Rehab

September 13, 2019 By Barry G. Doyle

IDPH has cited and fined South Suburban Rehab nursing home in Homewood after a resident there sustained multiple injuries in a fall.

One thing commonly seen is a push to get hospital patients out the door over the weekend. There are a host of reasons that hospitals prefer to get discharges done before the close of business Friday, Saturday at worst. The problem that comes up from the perspective of the new nursing home resident is that the transition doesn’t always go so smoothly. And that was the case for this resident.

The resident at issue was admitted to the nursing home from the hospital at 6:30 p.m. on a Saturday evening. The report from the hospital was that he was a fall risk, and his family also described him as a fall risk with a history of falls at home. The staff promised that a floor mat would be put down.

Fall prevention care planning is a discipline which helps assure that the care the resident needs to stay safe and healthy is delivered on a day-to-day, shift-to-shift basis. One of the things that makes care planning work is that the care plan is reduced to writing. Having a written care plan means that everyone knows (or should know what needs to be done). Not having it in writing reduces the crucial to-do’s that must be done to keep a resident safe to handful of things said from one staff member to another during change of shift. It is a formula for dropping the ball, and that is what happened here.

When the nurse came on duty for the morning shift, she saw that the resident’s legs were very stiff. She helped him to a wheelchair, put a floor mat down, and brought him to the dining room where he remained for the rest of the shift. When the CNA came in for the afternoon shift, she helped the resident to bed. Unaware that he was a fall risk, she moved the floor mat away, thinking that it was for use by his roommate. Shortly thereafter, the resident fell from bed, sustaining a cut to the forehead, a broken nose, and a separated shoulder.

He was brought to the hospital, but had ongoing complaints of intractable pain and was eventually placed on morphine and discharged home on hospice.

When the state surveyor arrived, it was clear that the staff did not know who should be preparing a care card to tell the aides what needed to be done when the restorative nurse (the one who normally did it, but was there only Monday through Friday) was not available. As a result, no care card was prepared, and the care that this man received was random chance nursing. This is a formula for disaster that ended badly yet predictably – with an utterly preventable nursing home fall.

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

Other blog posts of interest:

Resident rolled from bed at South Suburban Rehab

Third fall at Bria of Chicago Heights results in brain bleed

Two serious falls at Holy Family Villa

Resident rolled out of bed at South Holland Manor

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

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

September 12, 2019 By Barry G. Doyle

IDPH has cited and fined Presence St. Anne Center in Rockford after a resident there fell from a mechanical lift, suffered a broken neck, and died.

The resident at issue was dependent on staff to transfer him to and from bed with a mechanical lift. At this nursing home, the aides were provided with resident care cards which were located on the inside of the door. The care card called for an assist of two while transferring the resident with the mechanical lift.

On the morning of this nursing home fall, the resident was being transferred with a single aide. The resident slid from the sling and fell to the ground, hitting his head against the base of the lift. He was taken to the hospital where a CT scan showed that he had an unstable fracture at the C4-5 level.

The resident and his family elected to forego surgery and simply treat the fracture with a hard collar, knowing that further neurolgic complications could follow. The resident failed a swallow test, raising the risk that he could choke on his own saliva. He was intubated briefly to allow his son to return from out of the country, and after his son returned, the resident was extubated and placed on comfort measures only. He died three days after the fall.

When interviewed, the aide who was doing the transfer at the time of the fall stated that it was a busy morning and that she did not review the care card on the inside of the resident’s door. She further stated that the resident had been there as long as she had and that she was just doing as she was trained. The restorative nurse, who made the determination that an assist of two was required for mechanical lift transfers, told the surveyor that this was necessary because the resident suffered from contractures and that she would have never made him an assist of one with transfers.

The pattern which we see here is one which we see often with nursing home falls: doing a two-person job with only one person (see here, here, here, here, and here just as a few examples). There are at least three issues that are apparent with this particular unsafe transfer and the resulting injury and wrongful death of this nursing home resident:

Understaffing – When interviewed, the aide described the morning of the fall as a busy morning and told the surveyor that she did what she was trained to do with regard to this resident. The fact that it was a “busy morning” raises the question of whether the aide rushed through the process of placing the resident in the sling to the lift because of the need to move on to the next resident. Past that, she told the surveyor that she did not read the care card, but did what she was trained to do, which raises the question as to whether this resident was routinely being transferred by a single aide when two were required, and if that was happening to him, how many other residents were/are being transferred in an unsafe manner?
Training – A mechanical lift, used properly (and with enough staff) is a device which is suitable for accomplishing safe transfers. However, when the resident is not placed in the sling properly, a resident can very easily fall from the lift. This aide was attempting the transfer by herself which made proper placement of the resident in the lift all the more important. The fact of the fall raises fair questions about whether the aide knew how properly position the resident in the lift.
System breakdown – There was a system in place at this nursing home to communicate the care needs of the resident: there was a card on the inside of the door stating what the needs were. All that had to be done was for the aide to review that. The aide admitted that she did not do so. Well-run businesses run on systems to ensure the delivery of the services that have to be provided day-in-day-out. When a system breaks down in such a spectacular fashion, wholesale retraining and enforcement of these basic systems is a necessity to prevent the same kinds of breakdowns and the same kinds of disastrous results from recurring.

Other blog posts of interest:

River Bluff nursing home resident suffers multiple fractures in fall

PA Peterson resident breaks both legs in fall

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

Broken leg in fall at Generations at Neighbors

Three falls at Provena Cor Mariae in Rockford

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

Failure to obtain anti-seizure medication at Gilman Healthcare Center

September 10, 2019 By Barry G. Doyle

IDPH has cited and fined Gilman Healthcare Center nursing home after a resident there did not receive his required anti-seizure medications, resulting in the resident experiencing multiple seizures.

The resident at issue was admitted to the nursing home on a Friday with orders which included the administration of two anti-seizure medications (Onfi and Vimpat) two times daily. The two medications were not kept on hand at the facility and had to be obtained through the nursing home’s pharmacy. In order to get those medications, the nursing home needed a hard copy of the prescriptions from the doctor who ordered the medications at the hospital. The hard copy prescription did not arrive at the nursing home with the resident, however.

Faced with this situation, the nurse who admitted the resident did not call the hospital to have the hospital send over the hard copies of the prescriptions. Instead, she faxed a request over to the attending doctor at the nursing home, who did not respond to the fax all weekend long. As a result, the resident did not receive his anti-seizure medications Friday or over the weekend. Reason listed in the Medication Administration Record of the resident’s chart was Drug Unavailable.

On Monday morning, the Director of Nursing contacted the attending physician’s office again at 8:30 a.m. The doctor’s office staff informed her that it may be a while before they get a response because they needed to sort through some 50 (!) faxes that came in over the weekend and the doctor would not be in until 10:45 a.m.

What happened as a consequence of this resident not receiving his anti-seizure medication? Over the course of the weekend, the staff documented the resident experiencing multiple seizures. Throughout the course of the day Monday, the resident had several additional seziures while the nursing home staff waited for a return call. Shortly after 1 pm, the nursing home had the resident sent to the hospital, after which time the doctor called back saying he was not comfortable issuing the prescription for the anti-seizure medications. At the hospital, the resident was sedated and intubated and given an EEG which confirmed that the resident had multiple seizures. Transfer to a larger hospital was recommended to treat the seziures caused by this nursing home medication error.

There are multiple issues with what transpired with this resident:

When the hard copy of the prescription needed to order the medication did not arrive with the resident, the simplest course of action would have been to follow up with the hospital, but this was not done. Instead, they looked to the attending doctor from the nursing home (who, if you read the citation from the nursing home, was probably not expected to be very responsive) and who ultimately declined to get involved;
When they could not get a response from the doctor, they failed to contact the medical director or the hospital to get assistance;
Once the resident began to experience seizures, they failed to notify the doctor to get orders or instructions to get the resident to the hospital. As a result, the resident remained in the nursing home experiencing additional seizures.

Obtaining medications for nursing home residents who need them is a basic part of the services that nursing homes provide. Well-run businesses run on systems that provide the basic level of service without fail. The nursing home here quite clearly failed that task, much to the detriment of the resident.

Other blog posts of interest:

Anticoagulant medication not given at H & J Vonderlieth Living Center

Medication usage leads to fall at Gilman Healthcare Center

Failure to obtain anti-seizure medication at Alden of Orland Park

Medication error at Palm Terrace leads to hospitalization

Two medication errors at Alden Town Manor

Resident given wrong medications at Manor Court of Freeport

Failure to obtain anti-seizure medications at Gilman Healthcare Center

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

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

Infection goes unnoticed at Helia of Belleville

September 8, 2019 By Barry G. Doyle

IDPH has cited and fined Helia Healthcare of Belleville after a resident there suffered complications from an untreated infection at the surgical site for a pacemaker.

The resident at issue was admitted to nursing home after having surgery to have a pacemaker installed. When surgery is done to install a pacemaker, there is a surgical wound where the pocket for the pacemaker is located. Like any surgical wound, it requires regular skin checks for signs of infection. One of the basic skills of a nurse working in a long term care setting is being able to identify signs and symptoms of infection – and in the case of surgical wounds, cellulitis is one of the principal forms of infection to be concerned about. When signs of infection are present, it is the responsibility of the nurse to notify the doctor so that the doctor can either issues order for treatment over the phone, come into the nursing home himself, or have the patient transferred to the hospital.

In this case, the patient was brought into the doctor’s office for a post-op check about 5 months after the surgery was done. When the nurse practitioner saw the condition of the wound, she had the resident sent to the emergency room immediately. In the emergency room, the doctor saw an open wound with erythema, swelling, and very tender to touch. Wound cultures were taken which showed multiple multiple drug-resistant organisms in the wound. The resident was admitted to the hospital to have the pacemaker removed and a new one placed.

When the state surveyor asked the nurse practitioner how long the pacemaker wound was in that condition, she estimated 2-4 weeks before the patient came into the office. The surveyor then checked with multiple staff members all of whom had some responsibility for checking the condition of the resident’s skin. All of them denied noticing anything abnormal about the resident’s skin. The normal course of a cellulitis infection is that it starts off as a fairly mild redness around the edges of the wound which can treated fairly easily. Serious problems result though when the infection is left untreated which was apparently the case here given the severity of the infection and the appearance of the surgical wound. This means one of two thins is true: either the staff did not know what they were looking for (which is really a basic nursing skill), the checks were not being done (most likely), or that the abnormal findings were just not being reported to the doctor. None of these scenarios represent acceptable nursing care.

Other blog posts of interest:

Rushville Nurisng & Rehab resident suffers untreated surgical wound infection

Surgical wound infection of Presence Villa Franciscan

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

Moorings staff fails to notify doctor

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

Resident chokes to death at The Moorings in Arlington Heights

September 4, 2019 By Barry G. Doyle

IDPH has cited and fined The Mooring nursing home in Arlington Heights after a resident there choked to death. Topping that off, when the state inspectors were at the facility a month and half later, the same systems failures were evident for other residents who were at risk of choking.

Nursing homes are businesses, and well-run businesses have systems in place to deliver the basic services that they are supposed to provide. In a nursing home setting, that is the care that is needed to provide for the safety and well-being of the residents. Sometimes those systems are the nursing home’s internal policies and procedures; other times, those services are delivered through the care-planning process. Either way, the care that needs to be delivered on day-to-day, shift-to-shift basis needs to have some system in place to ensure that the care is in fact delivered.

What is not acceptable is to have care that is crucial for the safety and well-being of residents provided on a catch-as-catch-can basis. Sadly, that is what was occurring at The Moorings, and this resulted in the wrongful death of one nursing home resident.

The resident at issue had a physician order for thin liquids. This is usually ordered for residents who have swallow difficulties. She also required supervision with the assistance of one while eating. Earlier on the day of the choking accident, the resident was observed by an aide to be coughing and choking while drinking water. The aide reported this to a nurse and the speech therapist. One of the main functions of the speech therapist in a nursing home is to address a resident’s risk of choking by making dietary recommendations and offering services to reduce the risk of choking.

The usual practice for this speech therapist would be to downgrade the resident’s diet order to a different consistency intended to reduce the risk of choking. However, the speech therapist told the surveyor that was not done and said that it should have been done. She also said that she did not speak to the nurse assigned to the resident before leaving work that day. The speech therapist also explained that at this nursing home there was no system for informing staff who is at risk for choking other than word-of-mouth communication. She explained that the meal tickets show what kind of diet the resident is on, but do not identify which residents are at risk of choking or what strategies should be employed to reduce the risk of choking.

Later that night, she was eating dinner when she began to choke. Her husband yelled for help. The staff came, attempted the Heimlich, but that was not effective. She lost consciousness and was taken to the hospital where she died 5 weeks later of complications related to the choking accident.

The state surveyor also interviewed other staff members. One aide described having witnessed a choking incident a week earlier and having told the nurses about it. The other three staff members (one aide, two nurses) all denied know that she had a history of choking or of needing any supervision or assistance with eating.

The death of this nursing home resident is the very definition of catch-as-catch-can nursing, and is a formula for disaster. Here is a resident who obviously had some swallow difficulty (hence the order for thin liquids) and had a specifically observed episode of choking observed, but there is no care planning done to address that risk. The whole point of the care planning process is to identify risks to the health and well-being of the resident and to identify measures that can be taken to address that risk. Instead of taking a series of systematic routinized steps to keep a resident safe, it was left to word of mouth and the judgment of the nurses and staff that particular day. In short, necessary care is being delivered by random chance, and that is a formula for failure.

Having sustained a fatal choking accident, one would hope that this would spur the nursing home administration to change their approach to residents who are risk of choking. Unfortunately, the state surveyor found otherwise. One resident with a history of Parkinson’s Disease and stroke, both of which can cause swallow problems and contribute to choking risk and had a swallow study done which showed he was at high risk for choking. He was observed eating unsupervised and unattended. Another resident with a history of dementia, stroke, and a diagnosis of dysphagia (swallowing disorder), and a prior choking incident was observed eating in a large dining room but the aides there were unaware that the resident was at risk for choking.

The failure of this nursing home to change how it addresses choking risk after a fatal choking accident is dumbfounding, but doing do is the kind of thing that requires attention and focus. Nursing homes have that in short supply because of how they 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:

Riverview Rehab resident chokes to death

Fatal choking accident at River Bluff nursing home

Resident chokes to death at Rosewood in St. Charles

Winston Manor resident chokes on peanut butter sandwich

Resident chokes at Grove at the Lake

Mooring staff fails to notify doctor

Fatal choking accident at Warren Barr North Shore

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

Failure to obtain treatment supplies at Pekin Manor

September 2, 2019 By Barry G. Doyle

IDPH has cited and fined Pekin Manor nursing home after a resident there had to be hospitalized with respiratory failure due to the failure of the staff to order necessary medical equipment.

The resident at issue was admitted to the nursing home with orders from his doctor to have his chest tube drained daily until draining the chest tube returned less than 100 cc’s of fluid, at which point the frequency with which the chest tube had to be drained less frequently. On Wednesday, February 27, the nurses treating this resident recognized that they were running low on the bottlesg necessary to drain the chest tube. A request was made internally at the nursing for an order to be placed, but the order was never placed. By Friday, March 1, they were down to the last bottle, so a request was made to have the supplies delivered on a 24-hour basis. However, the medical equipment supplier did not made 24-hour deliveries on weekends, so the resident did not get the chest tube drained over the weekend.

The resident was taken to the emergency room Sunday night suffering from respiratory failure. When he was in the emergency room, the doctors there drained 800 cc of fluid from the resident’s chest. The resident was admitted to the hospital.

One of the basic tasks that nursing homes are charged with are carrying out physician orders. In this case, that included doing daily drainage of the chest tube. In order to do that, the necessary supplies had to be on hand.

Nursing homes are businesses, and well-run businesses have systems in place to deliver the basic services that are supposed to be provided. In the nursing home setting that means having systems in place to ensure that supplies are on hand to deliver the care that the residents need. Here there was a system that simply failed: the supplies that were needed were not ordered. As a resulty, the nursing home failed to provide necessary care.

However, once the staff was aware that there were not going to be supplies on hand to provide the resident with the care that the doctor ordered, simply skipping it and hoping for the best was not a real option. This was a situation where physician notification was required, as it was not the nurse’s role to decide whether it would be okay for the resident to go without the care that was needed.

Other blog posts of interest:

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

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

California Gardens fails to obtain respiratory equipment

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

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

September 1, 2019 By Barry G. Doyle

IDPH has cited and fined Manorcare of Arlington Heights nursing home after a resident there fell from a shower chair, suffered a brain bleed, and died.

Providing basic personal care, like bathing and showering residents, is one of the basic tasks that needs to be done in a nursing home. However, like any task in a nursing home, it needs to be done safely.

The resident at issue suffered from a number of conditions, most notably Alzheimer’s and her care plan called assistance of two for transfers and bathing. On the day of the accident, the resident’s husband asked the staff to give her a shower. She was brought to the the shower with two aides, but the one of the aides left because the family did not want to have her showered by male aides. The resident was placed in a regular shower chair and the one aide gave her a shower. When it was time to get her out of the shower, the aide was calling for other aides who were on their way when the resident fell forward out of the shower chair and hit her head on the floor.

She was brought to the hospital where a CT scan showed that she suffered a subdural hematoma. She died two and a half weeks later. Cause of death listed on the death certificate was closed head injury and fall.

There are a number of issues which led to this nursing home fall and the wrongful death of this nursing home resident.

First, the care plan called for the assist of two while bathing the resident. While two aides were used to bring her to the shower and the aide was calling for help after the shower was over, the fact remains that the aide gave the resident a shower by herself. This resident obviously had issues with poor trunk control which means that she could not be counted on to remain in an upright position without assistance. That was one of the reasons why two aides were needed to give this resident a shower. Going it alone was a violation of the resident’s care plan and a gamble with the resident’s safety – one which obviously had disastrous results.

Second the aide, used an upright shower chair rather than one that reclined. When a resident is unable to maintain an upright position due to a lack of trunk control (which is consistent with advanced Alzheimer’s), then using a device like a reclining shower chair is the right way to eliminate the lack of trunk control as a safety hazard for the resident.

Simple measures not taken led to this nursing home fall and the wrongful death of this nursing home resident. There are likely reasons that, when pressed, this aide would likely admit to being the reasons the aide did not take these simple steps – no time to wait for a second aide, no time to get the reclining shower chair – all of which amount to the nursing home being understaffed.

Other blog posts of interest:

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

Fall from shower chair at Charleston Rehab

Resident fractures leg due to unsafe transfer at Ascension Nazarethville in Des Plaines

Shower room fall at Champaign County Nursing Home

Fall leads to fractured skull at Arlington Rehab

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

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

Failure to monitor anticoagulant levels at Greentree of Bradley

August 31, 2019 By Barry G. Doyle

IDPH has cited and fined Greentree of Bradley nursing home after a resident was hospitalized with a gastronintestimal bleed caused by the failure of the nursing home staff to monitor the resident’s levels of anticoagulant medication.

Blood thinning medications, or anticoagulants, are an important tool in the doctor’s toolbox for maintaining the health of nursing home residents. Nursing home residents who are at risk for developing blood clots are generally given these medications to reduce the risk of things like stroke, deep venous thrombosis, pulmonary embolism, and other serious medical issues.

To determine whether the resident is receiving the right level of anticoagulant, doctors rely on a lab test called a PTT/INR. When the lab shows a score which is too low, that is called subtherapeutic which means that there is an increased risk of developing blood clots. When the score is too high, that means that the blood, that means that there is an increased risk of uncontrolled bleeding. Depending whether the score is too high or too low, the doctor can adjust the order to get the PTT/INR in the desired range. For that to happen, the labs must be done and the doctor notified of any abnormal lab results.

That is where things went wrong in this case.

The resident at issue was admitted to the nursing home with orders to receive warfarin (coumadin) 5.0 mg per day for atrial fibrillation (an irregular heartbeat which can produce blood clots which cause strokes) and left leg deep venous thrombosis (blood clotting which can cause pulmonary emboli, which are almost always fatal). The labs when discharged from the hospital showed a PTT/INR level of 3.0 with a target level of 2.0 – 3.0.

After being admitted to the nursing home, no labs were obtained. The resident continued to receive the ordered warfarin with no lab work being done to check whether the levels were appropriate. Approximately one month after being admitted, the staff discovered large anounts of blood on the bed linens with large clots. The resident was sent to the hospital at a PTT/INR score over 11. This is referred to as being supratherapeutic and is associated with a risk on uncontrolled bleeding. The resident was admitted to the intensive care unit with uncontrolled bleeding.

At this facility, the doctor had standing orders regarding the lab work and there were policies in place regarding doing lab work on all residents admitted with an order for anticoagulants. This lab work was never done, and as a result, the resident’s anticoagulant levels climbed dangerously high, resulting in the gastrointestinal bleed and the transfer to the intensive care unit.

Simple steps not taken, leading to disastrous results.

Other blog posts of interest:

Failure to follow medication orders at Generations at Applewood

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

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

Failure to notify doctor of abnormal lab results at Momence Meadows

Medication error leads to hospital admission at Arista Healthcare

Diabetes medications not given at Alden of Orland Park

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

Failure to obtain anti-seizure medications at Gilman Healthcare Center

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

Bed sore requires surgery for Timbercreek Rehab resident

August 30, 2019 By Barry G. Doyle

IDPH has cited and fined Timbercreek Rehab nursing home in Pekin after a resident’s bed sore declined to the point that surgery was required.

“Bed sores” are sometimes referred to as “pressure ulcers” because one of the main components in causing these painful wounds is pressure from the resident’s own body weight over the bony prominences, such as the hips, heels, and tailbone. This is why these are the most common places for nursing home residents to develop bed sores. In essence, what happens is that due to muscular weakness, residents in nursing homes do not move as frequently, and the resident’s body weight squeezes the tiny blood vessels that supply the skin, causing injury and death to the skin. This results in the wound that is commonly known as a “bed sore.”

Because pressure from the bony prominences is a well-known risk factor for developing bed sores, one of the main tactics used to limit the development of bed sores and promote the healing of bed sores once they occur is frequent turning and repositioning. Typically, this is done every two hours, but with certain residents, this is done every hour. Repositioning the resident relieves the pressure and helps prevent injury to the resident. Failing to do that is something which causes bed sores to develop and worsen once they occur. The difficulty with this is that this is something that needs to be done consistently, day-to-day, shift-to-shift. Failing to do so one time will usually not cause a bed sores, but the cumulative effect of not doing so multiple times usually will. Failing to provide this kind of care after a bed sore develops will almost certainly keep from healing and leads to further decline of the wound.

On February 12, the resident at issue had an area of skin that was excoriated (meaning it was red, raw, irritated) but was almost resolved. The resident’s pressure ulcer care plan called for him to be turned and repositioned every 2 hours. On February 21, the resident had an area of skin that was described as a pressure wound measuring 1 cm x 0.7 cm x 0.1 cm. This corresponds roughly to a Stage 2 pressure ulcer. The resident was sent to the hospital for an unrelated issue and the staff there measured the wound as being 2.5 cm x 2.5 cm. When he was returned to the nursing home on March 14, it was described as being the same size.

The resident was returned to the hospital on April 7 due to confusion and lethargy. The wound was described as being 6 cm x 8 cm x 0.5 cm with the wound being completely necrotic, or consisting of dead tissue. The resident’s doctor determined that the wound required surgical debridement to remove the dead tissue. Post-operatively the wound was measured at 7.5 cm x 7.5 cm with 13 cm of tunneling and bone exposed. Having bone exposed increases the risk of developing an infection called osteomyelitis.

When interviewed by the state surveyor, the surgeon told the surveyor that pressure ulcer was the direct result of prolonged pressure on the one area and sitting in that one position too long. The wound care nurse told the surveyor also told the surveyor that this bed sore was preventable with timely repositioning and proper care. The resident’s son described for the surveyor visiting his parent at the nursing home and that prolonged periods of time would pass without any repositioning by the staff.

This is a classic example of how a bed sore declines and causes serious medical consequences for a nursing home resident. Turning and repositioning residents is a staple of the work that aides in nursing homes do, but the press of the many things that they have to do often keeps them from getting this crucial work done. The root cause of this is understaffing of the nursing home, which is one the ways in which the failure of the nursing home to deliver on the care that residents require is baked right into the nursing home business model.

Other blog posts of interest:

Generations at Rock Island fails to treat bed sores

Resident suffers from pressure ulcers at Parker Rehab

Maggots discovered in bed sore at Manor Court of Clinton

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

Failure to obtain treatment supplies at Pekin Manor

Flanagan Rehab resident develops infection from bed sore

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

Short-staffing leads to fall at Warren Barr North Shore

August 26, 2019 By Barry G. Doyle

IDPH has cited and fined Warren Barr North Shore nursing home in Highland Park after a resident sustained a head injury in a fall that was caused by short-staffing of the nursing home.

People who reside in nursing homes need help. That’s why they are there. Federal regulations require the nursing home to have staff on hand necessary to meet the care needs on a 24/7 basis. When nursing homes don’t have enough staff on hand, there are all sorts on negative consequences which ultimately come back on the residents:

Residents don’t get turned and repositioned or have timely incontinence care provided, which can lead to the development of bed sores;
Residents who need supervision at meal times may not get it, which can lead to choking accidents;
Aides may not have time to wait for the help of another aide to use a mechanical lift to transfer a resident which can cause a Hoyer lift accident;
Residents may not get bathed or showered as they should, which is a form of nursing home abuse — and is one of the things that IDPH cited the nursing home here for. Some residents had gone 10 days without being bathed because there was not enough help to get it done.

One of the most immediate risks brought on by understaffing is the risk of nursing home falls. Essentially what happens is the is that residents who need assistance with walking or transfers will get tired of waiting, will decide that they don’t wish to soil themselves, and will get up without the assistance the need — and a fall will result.

That is exactly what happened in this particular situation. The resident at issue was on a wing which should have been staffed by 4 aides, but one – just one – was on duty. The resident was at high risk for falls, and was looking for some assistance with lower back pain. He activated his call light, waited an hour, and then walked to the nurse’s station to get some help. Unfortunately, he did not get any help there either, and as he stood there, his legs gave out and he fell to the ground, suffering a fractured wrist. He was found crawling down the hallway by staff and was sent out to the hospital.

This is exactly the kind of fall which is all too predictable when the nursing home is understaffed. And even if this kind of of short-staffing were a one-off kind of event, having that kind of understaffing erodes the effectiveness of call lights as a fall prevention measure because it trains the residents that even if they activate their call light, no one is coming to help them.

Sadly, this kind of short-staffing was not a one-off kind of event because the citation issued by IDPH contains an admission by the Director of Nursing that they were not meeting their staffing target levels. Further the resident council minutes going back three months before the fall all request additional aides. The short-staffing at this facility has led to residents not having their basic needs for human dignity being met as some are going more than a week without being bathed or showered due to the lack of available help.

This happens to be an extreme example, but is a clearly a situation where the nursing home business model is causing the residents at this facility to not get the care they need and deserve. 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:

Dialysis patient bleeds to death of Warren Barr North Shore

Short-staffing leads to fall at Manorcare of Libertyville

Fractured hip in fall at Heartland of Casey

Vandalia Rehab cited for understaffing

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

Moorings staff fails to notify doctor

August 24, 2019 By Barry G. Doyle

IDPH has cited and fined The Moorings nursing home in Arlington Heights after the nursing staff failed to notify the doctor that a resident was having coffee ground emesis (a sign of internal bleeding) resulting in a delay in the resident obtaining care and the wrongful death of the nursing home resident.

One of the basic truisms about nursing home care is that there is not a doctor in the facility 24/7 like there is in a hospital. Therefore, one of the basic functions of a nurse in a nursing home is to serve as the “eyes and ears” of the doctor. When something happens with one of the doctor’s patients, it is the job of the nurse to notify the doctor that a resident has experienced a change in condition. It isn’t their job to diagnose what the problem is or determine what the right course of treatment for it is; it is just their job to present the problem to the doctor so that the doctor can decide whether to issue orders over the phone, come in to see the patient, or order the patient sent to the hospital. When there is a true emergency situation, the staff should bypass the doctor and

The problem arises when there is a failure on the part of the nursing staff to carry out this function. Without the nurse telling the doctor that something is happening with the patient, the doctor has not reason to know that anything needs to be done to help. When no one steps up to get a nursing home resident help when things go wrong, the situation can escalate rapidly – and that is a formula for disaster in a medically fragile patient population.

The resident at issue had a history of atrial fibrillation which is an irregular heartbeat. This can cause blood clots which can cause a host of complications, most notably a stroke. To combat the development of blood clots and thereby reduce the risk of stroke, people suffering from atrial fibrillation are commonly treated with a blood thinner or anticoagulant, in this case coumadin. He was also on antibiotics for an infection. When patients are getting both antibiotics and coumadin, they are at increased risk of gastrointestinal bleeding or bleeding in the stomach. One of the signs of this is so-called “coffee-grounds emesis” which is essentially blood-tinged vomit. This is an emergency situation and 911 should be called.

On the morning of June 2, paramedics were called to the nursing home for vomiting. The crew was informed that the resident had 4-5 episodes of coffee ground emesis the night before. The resident then vomited in front of the ambulance crew, this time vomiting bright red blood. He lost a pulse, and CPR was initiated, but the resident died that day. One cause of death on the death certificate was gastrointestinal bleeding.

This case presents a fairly simple instance of the nursing staff failing to recognize that a resident was experiencing a medical expergency and failing to take appropriate steps in response. Coffee grounds emesis is a sign of something serious, and even if the nursing staff did not recognize the full implications of a resident having that, a doctor would have. Either way — calling a doctor or calling 911 — this resident would have been sent to the hospital where there would be a real chance of avoiding this tragic outcome.

Other blog posts of interest:

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

Failure to notify doctor of abnormal lab results at Momence Meadows

Fatal choking accident at The Moorings in Arlington Heights

Dialysis patient bleeds to death of Warren Barr North Shore

Injury from catheter placement at Marigold Rehab

Surgical wound infection at Presence Villa Franciscan

Failure to monitor anticoagulant medication at Greentree of Bradley

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

Broken ankle from fall at Aperion of Mascoutah

August 20, 2019 By Barry G. Doyle

IDPH has cited and fined Aperion of Mascoutah nursing home after a resident there slipped on ice that was on the floor.

One of the basic beliefs that I have as a nursing home lawyer is that nursing home fall cases are not slip-and-fall cases, and lawyers who look at nursing home falls like they are the same kind of slip-and-fall cases are doing their clients a real disservice by looking at fall accidents in nursing homes that way. A traditional slip-and-fall case looks to see if there is some defect in the property or some foreign substance or object on the floor which was the cause of the fall. A nursing home fall case views falls involving nursing home residents as being a breach of the basic commitment a nursing home makes to keep your parents safe when they accept them as a resident in their facility.

To keep residents safe from falls, nursing home use a process known as the care planning process to idenitfy which residents are at risk for falling and then sets forth a set of steps or interventions to prevent falls. This process is baked right into the federal regulations relating to nursing home falls. Most often, what we find are breakdowns in the care planning process where the steps necessary to prevent falls are either not put into place or not taken. Applying that set of lenses in viewing nursing home fall cases has served us and our clients very well.

Of course, there are some nursing home falls that are very much like traditional slip-and-fall, but even then that kind of nursing home fall is still different from a traditional slip-and-fall case. This situation is one of those instances.

This resident at issue was assessed as being a high fall risk because she was not steady while walking and would often try to walk without assistance. On the day of her injury, the resident was walking without assistance in the dining room when she slipped in water that was on the floor next to an ice chest that was placed in a cubby in the dining room that the staff would make use of. X-rays showed that she suffered a fractured ankle as a result of the fall. A fractured ankle is not as grim for seniors as a hip fracture, but is still as significant injury in that loss of mobility often sets the stage for the development of bed sores and further decline in the overall level of function.

The vast majority of falls in nursing homes don’t involve a substance or object being the cause of a fall, likely in part because federal regulations require the facility be kept as free of accident hazards as possible, and water or ice dropped from the ice chest onto the dining room floor is an obvious example of an accident hazard. One of the routine steps included in virtually every nursing home fall prevention care plan is to keep the resident environment free of slipping or tripping hazards. That obviously was not done in this case.

Other blog posts of interest:

Mar-Ka Nursing Home resident falls, breaks both legs

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

Resident fractures hip in fall at Caseyville Nursing & Rehab

Failure to recognize infection at Helia of Belleville

Call lights not being answered at Aperion of Mascoutah

Fall resulting in brain bleed at Good Samritan Home in Quincy

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.

Failure to assist resident to bathroom results in fall at Heritage Health in Peru

August 19, 2019 By Barry G. Doyle

IDPH has cited and fined Heritage Health nursing home in Peru after a resident fell and suffered a knee injury when an aide failed to provide needed assistance to the bathroom.

The resident at issue was assessed as being at high risk for falls and required the extensive assist of two for transfers and the extensive assist of one for toileting. These requirements were incorporated into the resident’s fall prevention care plan.

On the day of the incident, the resident was seated in the dining room when she realized that she needed to use the restroom. She got an aide to bring her to the bathroom, but once there, the aide left her alone. Realizing that she was likely to soil herself, the resident stood and attempted to get her own pants down. While she was doing so, her legs gave out and she fell to the ground. She was taken to the emergency room where a knee injury was diagnosed and she was advised to follow up with an orthopaedic surgeon.

This nursing home fall is the very definition of a preventable fall. The resident was properly assessed as a fall risk, there was a reasonable care plan in place to address the care she required for transfers and for toileting. When it came time to deliver that care, the aide caring for her utterly failed to do. Fall prevention care plans are put into place so that the care necessary to keep residents safe gets delivered on a day-to-day, shift-to-shift bases. When the care needed to assure the safety of the residents is not provided, falls result, often with more catastrophic injuries such as brain bleeds or hip fractures the end result.

Other blog posts of interest:

Multiple fractures from fall at Accolade of Pontiac

Fall results in broken vertebra at Heritage Health – Mendota

Cornerstone Rehab resident falls from lift, breaks leg

Third degree burns from fall at Sauk Valley Senior Living

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

PA Peterson resident breaks both legs in nursing home fall

Head injury in fall from toilet at Heritage Health in Bloomington

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

Multiple residents victimized by fellow resident at Winning Wheels

August 18, 2019 By Barry G. Doyle

IDPH has cited and fined Winning Wheels nursing home in Prophetstown after multiple residents were victims of physical and sexual assaults by a fellow resident.

The word “home” in the term “nursing home” is there for a reason – it is the home of each of the residents there, and each and every nursing home resident deserves to feel safe in their home. That is part of the reason that assaults on nursing home residents by staff members are addressed so aggressively – usually with the swift discharge of the offender, followed by criminal charges.

However, the staff is not the only source of risk to nursing home residents. At times, fellow nursing home residents are the perpetrators of assaults upon their fellow residents, and that is clearly the case in this situation.

The resident at issue in this situation suffered a brain injury as a result of an assault in 2017 and was admitted to the nursing home on October 11, 2018. As we will see, the brain injury obviously affects his ability to control his behavior, but it is still the obligation of the nursing staff to provide supervision necessary to keep other residents safe.

The citation reflects that this resident is wheelchair-bound, but is able to get around the facility independently in his wheelchair. In doing so, he has terrorized a number of staff members and fellow residents. The citation itself is worth review, but these are some of the incidents described in the citation, some of which were noted in the resident chart (keeping in mind that there may very well be several other incidents involving other residents or staff members which were either not charted or otherwise unknown to staff):

He grabbed the breasts of multiple residents and staff members;
He repeatedly exposed his penis to staff members and fellow residents;
He punched multiple staff members and fellow residents;
He punched and grabbed another male residents by the genitals. This resident’s father reported to the surveyor that his son then tried to choke himself with an eye toward committing suicide. This resident is in a nursing home due to a brain injury from a failed suicide attempt;
He would masturbate in front of staff.

To say the least, other residents are aware of this resident and are terrified of him. One resident reported to the surveyor that she did not want him to know where her room was; another reported getting a door stop so that he could not get into her room.

These behaviors are well-known to the staff and have been since he was admitted, as his initial care plan included care planning for sexually inappropriate behaviors. Part of that care plan included 1:1 supervision which was not done because the staffing is not available. Failing to follow a care plan may serve as basis for a nursing home abuse and neglect lawsuit. Unfortunately for the nursing home, this does not relieve the facility of the burden of meeting the federal regulations which require the nursing home to have staff on hand to meet the care needs of the residents on a 24/7 basis. If 1:1 supervision is required to keep other residents safe from a fellow resident, then that is what must be done.

Past that, there needs to be serious consideration of whether the nursing home acted appropriately in accepting this resident into the facility. Nursing homes should only accept residents into the facility when they can meet the care needs of the resident. These behaviors are likely not new and were likely known to the nursing home when he was being considered for admission, seeing as he was care planned for sexually inappropriate behavior as part of his baseline care plan which is done immediately after admission.

Nursing home residents who are the victims of assaults (physical or sexual) have the right to pursue a nursing home abuse and neglect lawsuit for the failure to keep them safe in their home. At times, the surest way to grab the attention of a nursing home operator and to effect change at a facility is to file a lawsuit. This is one of those times that cries out for it.

There should also be some consideration as to whether the nursing home is acting properly in continuing to keep him as a resident. As resident can be involuntarily discharged from a nursing home when they endanger the safety of others in the nursing home. Another option would be to have him transferred to a psychiatric facility which is better equipped to deal with his behaviors. Allowing staff and residents to continue to be vicitmized by this resident has gone on far too long.

Other blog posts of interest:

Resident assaulted by roommate at Countryside Nursing & Rehab

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

Resident sexually assaulted by fellow resident at Dixon Rehab

Broken hip from assault by fellow resident at Stephenson Nursing Center

Fatal beating in Oak Park nursing home

Residents terrorized by fellow resident at Carmi Manor

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

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

August 17, 2019 By Barry G. Doyle

IDPH has cited and fined Lexington of Orland Park nursing home after the failure to give anti-seizure medications resulted in a resident requiring a lengthy admission to the intensive care unit of the hospital.

One of the basic functions that a nursing home carries out is the administration of medications as ordered by a physician. With some medications, it is absolutely critical that the medication be given as ordered. Anti-seziure medications fall under that category, as the failure to get needed anti-seziure medications can result in the resident experiencing seizures which may cause brain damage.

The resident at issue suffered from seziures after contracting encephalitis as a child in 2001. He was on a regimen of six anti-seizure medications which he and his mother managed at home. He was admitted to the nursing home on March 19 for strengthening after a hospital admission. The transfer orders included giving all six anti-seizure medications. The hospital delayed transferring him to the nursing home until he had received his last medication for the day.

To say the least, the nursing home did poorly in giving him the medications that had been ordered for him:

Medication #1 was to be administered twice per day at 9:00 a.m. and 9:00 p.m. The 9:00 a.m. dose was given at 1:50 p.m. on March 20, nearly 5 hours late, and the evening dose was not given.
Medication #2 was to be given twice per day, the first dose was supposed to be 1 tablet, the second dose 1.5 tablets. The resident never received these medications on March 20 or March 21 because the medication was not avsilable.
Medication #3 was to be given 1 tablet in the morning and 1.5 in the evening. The resident did not receive any of this medication on March 20 and on March 21 and 22, the medications were given in backwards order (1.5 tablets in the morning and 1 in the evening).
Medication #4 was supposed to be administered each night. It was not given on March 20.
Medication #5 was supposed to be given every 12 hours. It was not given on March 20.
Medication #6 was supposed be given with a dose of 2.2 ml twice daily for 1 week then increased to 4.4 ml twice daily. On March 20, he received only a single dose at 2.2 ml. On March 21, he received a dose of 2.2 ml at 5 pm and a 4.4 ml dose at 10 pm. On March 22, he was given three doses: 2.2 ml at 9 am and 5 pm with a 4.4 ml dose at 11 am. On March 23, he again received three doses: 2.2 ml at 9 am and 5 pm with a 4.4 ml dose at 11 am.

For those keeping score at home, there were six anti-seizure medications that were ordered to be given in a set way. None of the six anti-seizure medications were in fact given to the resident as ordered. In short, a series of serious nursing home medication errors.

What happened as a result?

On March 22, the resident had seizure activity for 5-10 minutes which was observed by a CNA and reported to the nurse, but the nurse apparently failed to notify the resident’s doctor. The following morning, the resident’s chart reflected that he had altered mental status due to seizure activity the day before. That afternoon, the resident’s mother was visiting him and he had another seizure. This time, paramedics were called and he was brought to the hospital where he was stablized, then transferred to another hospital where he was admitted directly to the intensive care unit where he was unresponsive for 11 days. His mother reported to the surveyor that after the seizures he was now incontinent.

When interviewed by the state surveyor, the resident’s neurologist stated that following the regimen of anti-seizure medication was critical and that administering medication late by as little as 90 minutes is “pushing it” and that the levels of anti-seizure medicstions drop very quickly. In his opinion, the failure to give the medications as ordered played a role in the resident’s seizures.

There are obvious medication errors that occurred, but beyond that, there is a larger story to be told. The nursing home did not have all of the medications needed on hand when the resident was admitted to the facility. When a resident is admitted to a nursing home, one of the things that the nursing home receives in advance of the resident showing up on their doorstep is the list of the medications that the resident is supposed to receive. If the resident requires medications that are not on hand at the nursing home, then there needs to be a system in place to ensure that they are on hand when the resident needs them. That system either does not exist or failed badly in this case.

Past the nursing home medication error, the nursing home staff failed this resident once the seizure activity began. The occurrence of seizure activity represented a significant change in condition requiring physician notification. There is nothing in the citation which indicated that this occurred. The following morning, the resident had a change in mental status which was attributed to the seizure. Again, no physician notification is reflected in the citation. It wasn’t until he had an additional seizure in the presence of his mother that he was sent to the hospital. Earlier action to have the resident sent to the hospital very well could have prevented the second seizure.

Other blog posts of interest:

Failure to obtain anti-seizure medications at Gilman Healthcare Center

Bella Terra Wheeling resident receives roommate’s diabetes medications

Diabetes medication not given at Alden of Orland Park

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

Medication error at Palm Terrace leads to hospitalization

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

Failure to follow medication orders at Generations at Applewood

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

Glenwood Healthcare & Rehab resident chokes to death

August 14, 2019 By Barry G. Doyle

IDPH has cited and fined Glenwood Healthcare & Rehab after a resident there choked to death despite being on aspiration precautions. Incredibly, this is the second choking incident at Glenwood in a year where the nursing home has been cited and fined by IDPH.

One of the base level commitments that nursing homes make to families of the residents admitted to the facility is that we will do the things that are necessary to keep your loved one safe. In turn, families place their trust in the nursing home and its staff to do just that. At times, that trust is broken in the most egregious way. This incident is one of those times.

The resident at issue had been a long term resident of the nursing home apparently due to a brain injury which left his with hemiplegia (weakness on one side) and difficulty with swallowing. On June 11, 2018, he had a choking incident where the staff recognized that he was choking, did the Heimlich menuver, and had him sent to the hospital, where he was admitted for nine days for treatment of aspiration pneumonia (pneumonia caused by foreign objects such as food entering the lungs).

Following his return to the nursing home, there was a physician order for aspiration precautions, and he was referred to speech therapy. One of the things that speech therapists do is work with people who have difficulty with their swallow function. After the completion of speech therapy, he remained on aspiration precautions. He was assessed as needing one-on-one assistance with feeding. At this facility, residents who are on aspiration precations should be brought to the dining room (where they are likely seated at a feeder table) or are fed one-on-one in their rooms. There is never a set of circumstances where they should be left to eat alone.

Like with nursing home falls, the occurrence of a nursing home choking accident tends to forecast the occurrence of additional ones unless proper precautions are taken. Sadly, that it is exactly what occurred in this instance.

On February 1, 2019, a CNA responded to the resident’s call light. When she entered the room, she saw that the resident was choking and that there was a dinner plate on the bedside table. The CNA called for help. The staff was unable to access the resident’s airway because the resident;s jaw was so tightly clenched. 911 was called and the paramedics retrieved a large amount of food from the resident’s airway. The paramedics took the resident to the hospital where he was died shortly after arrival.

If I were investigating this incident as a nursing home wrongful death lawsuit, there are a number of issues that would be a source of concern to me:

This resident was admitted to the nursing home with an order for a puree deit which was upgraded to a mechanical soft diet. It is possible to choke on a mechanical soft diet, so the issue of whether the resident was appropriate for an upgrade to mechanical soft diet is one worth examining. Doctors customarily rely on the judgment of the speech therapist in upgrading a resdient’s diet from puree to mechanical soft, so the role of the speech therapist in this choking incident is worth close examination.
How did the resident get this tray and how did he come to be unattended at meal time? This was a resident who required assistance with eating and was not supposed to be left unattended at meal time, yet this is exactly what happened. The kind of risks that this resident faced of choking is not the most common safety hazard for nursing home residents, but is far from rare. Well-run businesses (and nursing homes are a business) run on systems which make ensure that the services promised get delivered every time – as long as the system is followed. Did this nursing home really have a system for making sure that aspiration precautions were followed or was there a simple breakdown in the system and this resident paid the price? These are the questions that I would try to see answered in a nursing home abuse and neglect lawsuit.
The director of nursing admitted that the facility had no policies and procedures regarding aspiration precautions, just practices that were followed. Were the aspiration precautions that this resident needed actually incorporated into a care plan addressing the risk of aspiration or choking or was the delivery of this crucial care item left to random chance?

Other blog posts of interest:

Chicago Ridge Nursing & Rehab resident chokes to death on sandwich

Resident chokes to death at Glenwood nursing home

Fatal choking incident at Iona Glos

Resident chokes at Grove at the Lake

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

Cumberland Rehab resident suffers brain bleed in fall from toilet

August 12, 2019 By Barry G. Doyle

IDPH has cited and fined Cumberland Rehab in Greenup after a resident fell from the toilet suffering a brain bleed as a result.

The resident at issue was assessed as having moderate cognitive impairments, and needed extensive assistance with transfers and toileting. The resident was assessed as being at high risk for falls and was on the anticoagulant (blood thinner) Xarelto. The resident’s fall prevention care plan called for supervision and monitoring in providing care.

On the day of the fall, the resident was on the toilet being attended to by an aide. The aide realized that he gloves were soiled so she left the resident unattended on the toilet to get new gloves. A call light was available to her to have a co-worker give her assistance, but she chose not to use it. While she left the resident unattended, the resident fell from the toilet and suffered a lcaeration to the head and skin tears to the elbow. The resident was sent to the emergency room where a CT scan showed that were multiple brain bleeds. The laceration to the head was closed, and the resident was transferred to a trauma center for treatment of the brain bleeds.

Xarelto is a powerful anticoagulant, or blood thinner. It is usually prescribed to prevent the development of blood clots. It is often prescribed to nursing home residents who suffer from atrial firbrillation (irregular heartbeat) or who have had a history of suffering embolisms. It is a very effective drug for preventing complications relating to blood clots. However, the risk associated with its use is that when nursing home residents suffer falls, there is an increased risk of major injuries such as brain bleeds, uncontrolled internal bleeding, and severe bleeds asscoauted with fractures. This is why special vigilance needs to be exercised to prevent falls in residents who are on blood thinners such as Xarelto or Coumadin.

We often look at a resident’s care plan as a starting point of determining whether the nursing home bears any responsibility when a resident suffers injury from a nursing home fall. Here, there was a reasonable assessment done (resident was a high fall risk) and a reasonable care plan put into place (provide supervision with care). Once a care plan is developed, it needs to be carried out day-to-day, shift-to-shift. Any time the care needed is not being provided, there is a risk that the bad outcome (in this case, a fall) will occur.

Sadly, that is just what happened here. The resident who needed supervision on the toilet was left unattended and as a result, had a fall with a serious injury. This is a pretty predictable outcome, as this happens often (see here, here, and here).

One issue that we would carefully examine is why the aide left the resident unattended on the toilet. One likely reason is that she knew that it woiuld place a huge imposition on other staff members who were stretched as thin as can be because the nursing home was understaffed. 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 from commode at Pekin Manor

Hilltop Skilled resident breaks leg in fall from bed

Leroy Manor resident suffers head injury in fall from toilet

Head injury in fall from toilet at Heritage Health in Bloomington

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

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

Fall resulting in brain bleed at Good Samaritan Home in Quincy

August 10, 2019 By Barry G. Doyle

IDPH has cited and fined the Good Samaritan Home in Quincy after a resident there experienced ten (!) falls in less than 2 weeks, the last resuting in a brain bleed which led to the resident being placed on hospice care.

One of the truisms regarding nursing home falls is that the occurrence of one fall tends to forecast the occurrence of additional falls. There are a number of reasons that this is true: the resident loses confidence in their ability to stand or walk; the resident has some injury which makes weight bearing more challenging; or it is a demonstration that the resident is unable to control their actions or make good judgments for their own safety. This is why the occurrence of a fall is a serious event that requires notification of the physician and revision of the resident care plan.

The resident at issue was admitted to the nursing home on February 5. She was assessed as being at high risk for falls due to advanced dementia, incontinence, unsteady balance, and needing the assistance of staff for transfers. During the period between February 7 and February 17, the resident experienced 9 falls. Following the ninth fall, she the care plan was revised to include 1-to-1 supervision.

The last fall happened on February 20. It occurred at 6:00 a.m. and was described as an unwitnessed fall occurring after the resident got up from a recliner at the nurse’s station. The reisdent had a golf-ball sized lump and a laceration on her head and was unable to form sentences that made sense. Her pupils were uneven, so she was sent to the hospital. A CT scan was done there which showed the presence of a brain bleed. She was lethargic and unarousable and was placed on hospice.

Federal regulations require that residents receive supervision and assistive devices necessary to prevent accidents, and a fall is one of the types of accidents covered by the regulations. This resident was properly assessed as a high fall risk and experienced multiple falls, all of which made the occurrence of an additional fall predictable. To address that risk, the care plan called for 1-to-1 supervision.

A care plan is more than just a piece of paper that is in a nursing home resident’s chart – it is a guide to the care that must be delivered to keep a resident safe. If the fall was unwitnessed, that tells us that the 1-to-1 care that was supposed to be provided was in fact not being provided. Leaving a resident at risk for falls near the nurse’s station is a common fall prevention measure, but that is not the same as 1-to-1 supervision. Violation of a care plan is a basis for a nursing home abuse and neglect lawsuit, and in this case if the injuries from the fall were a contributing cause to the death of this resident, that would be a basis for a nursing home wrongful death lawsuit.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of 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:

Non-functional alarm leads to fall and fractured hip at Sunset Home in Quincy

Heritage – Mt. Sterling resident breaks leg in fall

Pittsfield Manor resident suffers fatal fall

Care plan violation at Central Nursing Home

Fall from toilet at Leroy Manor

Brain bleed from fall at Pontiac Healthcare

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

Resident wanders from Alden Long Grove

August 9, 2019 By Barry G. Doyle

IDPH has cited and fined Alden Long Grove nursing home after a resident wandered from the facility on March 7 only to be discovered over two miles away walking through a busy intersection during the pre-dawn hours.

The resident at issue suffered from Huntington’s Disease which caused him to experience delusions. He also suffered from cognitive impairments, and was not steady with walking and required assistance with mobility. On March 1, he demanded to go home with his family and pushed his mother in an effort to get out the front door of the facility. On March 2, he was assessed as being at high risk for elopement, or wandering from the facility unsupervised and he was placed on 1:1 supervision. He again expressed a desire to leave the facility on March 4. On March 6, the 1:1 supervision was terminated in favor of checks every 15 minutes. However, the staff admitted to the surveyor the 15 minutes checks could not always be performed because they were caring for other residents.

At approximately 4:30 a.m. on March 7, another resident who was playing with his phone in the front lobby saw the resident at issue walk right out the front door of the facility. The resident alerted staff members who checked the interior and exterior of the building for the resident and then called police. The staff member assigned to care for the resident at the time said that he last saw the resident at 4:00 a.m. The police received a call reporting seeing a man walking through a busy intersection over 2 miles away and sent a patrol car. It was the missing resident and he was brought back to the facility before being brought to the hospital for examination due to exposure to the cold. The resident told the reporting officer that he had fallen backwards while he was out and hit the back of his head and that he wanted to got his home in Round Lake Beach, some 17 miles away. The surveyor described the route to the point where the resident was picked up by police as being filled with heavy traffic, ice, uneven ground, and road construction.

The hazards that this resident was exposed to underlines why avoiding incidents with elopement or wandering from a nursing home is so important. Along the way to the point where he was picked up by police in a busy intersection, the resident actually fell (and fortunately avoided severe injury like a hip fracture or a brain bleed) and was at risk for getting hit by a car the entire time. Due to the length of time that he was outside in below freezing temperatures, he was at risk for developing pneumonia, frostbite, or hypothermia, all of which can turn out be deadly conditions for nursing home residents.

So – the question is, how did this come to pass? There are at least three explanations:

1. The 15 minute checks which were not in fact done. The staff member assigned to care for the resident told police that he last saw the resident at 4:00 a.m. and was not aware that the resident was gone until sometime after 4:30 when another resident told him that the resident at issue went out the front door. This means that at least 2 checks were skipped, which raises an issue as to whether there was understaffing at this nursing home.

2. The 1:1 supervision was likely terminated prematurely in favor of the 15 minute checks. When a resident is actively verbalizing an intent to leave the facility and is acting on it, there is a high risk that the resident will in fact exit the facility with all of the risks that go along with that.

3. The front door alarm was disarmed. The investigation revealed that the facility had a front door alarm that was supposed to be armed when the front desk receptionist left for the day at 8 pm. Another resident had been out on pass and returned at 12:30 a.m. A nurse let her back into the building and failed to re-arm the alarm, so that when the resident at issue went out the front door, the alarm did not sound. When the safety of residents depend on staff supervision of the residents, there is always a risk of a breakdown which must be addressed by passive devices such as alarms. They act as a safety net for the residents. When the alarms are disarmed, the necessary safety net disappears.

This was a highly preventable incident which could have had a much more tragic outcome. The fact that it didn’t was good luck, not good care. Relying on good luck is no substitute for providing proper care.

Other blog posts of interest:

Resident wanders from Claridge Healthcare Center

Resident missing for 6 days from Villa at Windsor Park

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

Niles Nursing & Rehab resident wander from facility, suffers fractures

Resident-on-resident assault at Alden Long Grove

Resident suffers fatal injuries after wandering from Alden Town Manor

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

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

Resident fractures leg in improper transfer at Woodbridge Nursing Pavilion

August 8, 2019 By Barry G. Doyle

IDPH has cited and fined Woodbridge Nursing Pavilion nursing home in Chicago after a resident suffered a broken leg during an unsafe transfer.

The citation that was issued in connection with this incident was eye-opening because it showed how little the staff knew about how to properly care for this resident.

The injury to this resident occurred when the resident’s psychologist found the resident sitting on the edge of the bed. An aide had left her sitting on the edge of the bed while she went to get a mechanical lift to transfer her to her wheelchair. The psychologist attempted to transfer her to a wheelchair, but in the process of doing so, lost control of the resident and had to call for help. A nurse came to his aid, but in the process of getting the resident to her wheelchair, she suffered a broken leg just above the knee.

Leaving a resident sitting on the edge of the bed is an invitation for disaster, as it can very easily lead to a nursing home fall, such as happened here. The resident was a known fall risk due to right-sided weakness and required a mechanical lift for transfers.

When the surveyor arrived at the nursing home to do her investigation into the injury to this resident, she spoke to the staff and learned:

The nurse who was assigned to care for the resident the day of the inspection was unable to tell her anything about the resident, explaining that it was her second day on the job. She denied having been giving any special instructions about the care of the resident, denied that the previous nurse has given her any endorsement of the care of that resident, denied knowing whether there were any instructions for that resident to stay in bed, or whether that resident was a fall risk.
The CNA assigned to care for the resident that day denied knowing whether the resident was a fall risk or whether there were special instructions for how to get her out of bed.
The CNA assigned to care for her the day of her injury said that she left the resident sitting at the edge of her bed because that was what she always did and denied knowing that there were any special instructions as to how to transfer the resident.

Care for residents in a nursing home needs to be provided in an organized, systematic way. That is what the care planning process does – it determines what the basic care needs of the resident are and how those care needs will be met on a day-to-day, shift-to-shift basis. Staff caring for a resident need to know how to meet those needs – avoiding disaster is simply a matter of a good luck. Good luck is no substitute for good care. When the staff doesn’t know that a resident is a fall risk or what needs to be done to get her safely from bed, it is relying entirely on good luck. Sadly for this resident, good luck ran out.

Other blog posts of interest:

Femur fracture from unsafe transfer at Lexington of Streamwood

Broken hip in unsafe transfer at Pearl of Rolling Meadows

Resident falls from edge of bed at Manorcare of Libertyville

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

Short-staffing results in fall at Manorcare of Libertyville

August 6, 2019 By Barry G. Doyle

IDPH has cited and find Manorcare of Libertyville nursing home after a resident fell from bed and suffered a broken leg.

There are certain residents who require the assist of two with bed mobility – meaning being rolled onto their side, usually for incontience care as part of assuring the dignity of residents and preventing bed sores. However, we have written on this blog about multiple incidents ( such as here, here, here, and here) where the resident was being handled in bed by a single aide and rolled out of bed, usually resulting in a significant injury such as a brain bleed or a hip fracture.

This is the story that we have to tell at Manorcare of Libertyville – but with a twist this time.

The resident at issue suffered from a variety of issues including rheumatoid arthritis, muscle weakness, and hemiplegia from a stroke. She was deficits relating to both legs and one arm. She was noted as requiring extensive assist of two with bed mobility. On the day of the accident, a single aide was in the room changing her diaper after an episode of incontinence. When she did so the resident’s legs began to shake and she rolled off the edge of the bed, landing on her knees.

Because the resident was non weight bearing and had contractures due to her pre-existing issues, the decision was made to not proceed to surgery even though she suffered a displaced fracture of the femur in the fall. Due to the injuries from the fall she now had chronic pain which she did not have before which requires the use of pain medication to control.

What makes this incident a little different from the many others like it that we have covered on this blog is that the staff came clean as to the root cause of this nursing home fall: understaffing of the nursing home:

The aide on duty told the surveyor “… that day we were short-staffed, and I was pressed for time so I did it myself.” She also told the surveyor that having a second person there would have prevented the resident from falling from the bed.
Another aide told the surveyor that it is safer to change that resident with 2 people, but that staffing is a struggle sometimes so ytou have to do it yourself.
The unit manager acknowledged that having two people help with changing would have prevented the fall.

It is worth noting that the one aide who was present at the time of the fall admitted that short staffing was an issue at that particular moment. However, the other aide’s statement more clearly suggests that short-staffing is a chronic issue at that nursing home.

Other blog posts of interest:

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

Resident suffers shoulder injury during improper transfer at Addolorata Villa

Resident falls from bed at Spring Creek in Joliet

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

Brain bleed from fall from bed at Landmark of Des Plaines

Resident rolled out of bed at Warren Barr – Lincolnshire

Resident falls from edge of bed at Manorcare of Libertyville

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

Medication error at Palm Terrace leads to hospitalization

August 4, 2019 By Barry G. Doyle

IDPH has cited and fined Palm Terrace nursing home in Mattoon after a medication error resulted in the hospitalization of a resident there.

One of the basic tasks that a nurse does in a nursing home is pass medications. Generally, the “med pass” is done by the nurse stocking a medication cart with the medications to be given to the residents under their care. To make sure that the medication is delivered to the intended resident, nurses are required to do a series of “right” checks before actually giving the medication.

Failing to give medication to the intended resident can be a complete disaster. It means that the resident receiving the medication will be receiving medication that is not intended for them, may be entirely unsuitable for them, may have drug interactions with other medications that they are taking, and at minimum, they will not be receiving the medications that they were ordered.

This is exactly what happened in this incident. The nurse doing med pass dispensed medications for two residents, placed the medications into the medication cart and began the process of verifying the identity of the resident who would be receiving the medication. Before actually giving the medication, as the nurse described it, chaos broke loose with six (6!) nursing home falls occurring in a short period of time. She left to assess the residents who fell and get vital signs, and when she returned to give the resident she was caring for her medication, she took the medication for another resident off the cart and gave it to the resident.

This nursing home medication error was discovered a few minutes later when she went to administer medication to the resident whose medication had been dispensed in error. The nurse got vital signs and notified the doctor of the medication error. The medication that was provided in error had the potential to cause respiratory depression, so the staff was ordered to send the resident to the emergency room if the resident’s blood pressure or her oxygen saturation level dropped below a certain level. That was exactly what happened, resulting in the resident being taken to the hospital and being admitted to the critical care unit and placed on a ventilator due to respiratory failure.

There were obviously simple steps which if taken would have prevented this medication error. However, the chaos surrounding the multiple falls occurring during the medication pass prevented those measures from being properly taken. This is a prime example of how simple steps not taken in a nursing home setting can have disastrous consequences.

Other blog posts of interest:

Diabetes medication not given at Alden of Orland Park

Fall at Palm Terrace in Mattoon

Diabetes care mismanaged at Aperion Care Capitol

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

Care plan violation at Central Nursing Home

August 3, 2019 By Barry G. Doyle

IDPH has cited and fined Central Nursing Home in Chicago after a resident was rolled out of bed by an aide and suffered a fractured elbow.

The resident at issue had a number of diagnoses, including a history of stroke, quadraplegia, and epilepsy. She was assessed as being a high fall risk and required the total assistance of two for side positioning. Her care plan called for the assistance of two with activities of daily living, which would include incontinence care.

On the day of the accident, a single aide was providing incontinence care to the resident. The resident’s body weight caused her to begin to slide out of bed, and the aide could not stop the fall. She fell to the floor. X-rays taken later at the hospital showed that she had a fractured elbow.

This is a classic scenario (as shown here, here, here, and here as well as elswhere on this blog) of how doing something simple like providing incontinence care can result in a nursing home fall. The resident here was clearly at risk for falls due to her underlying medical conditions. There was a care plan in place which called for two aides to provide incontinence care to the resident, but that care plan was not being followed that night as the aide was working on the resident alone. This kind of fall could have easily had more significant consequences such as a fractured hip or a brain bleed.

Past the obvious care plan violation, there were two fascinating statements in the citation issued by IDPH:

The aide told the state surveyor that she always provided incontinence care to this resident alone. This means the care plan was being violated not just that day, but on a routine basis. The whole point of a care plan is to set out the care that a resident is supposed to be receiving day-to-day, shift-to-shift. It isn’t just some piece of paper in the chart, and when it is being ignored on a routine basis, having an acceptable outcome (incotinence care provided without injury to the resident) is a matter of getting luck rather than providing quality care.
The nurse on duty told the state surveyor that they were short-staffed that night. This kind of nursing home falls is the kind of thing that results when a nursing home is understaffed because the staff feels the need to cut corners to keep up with the pace of the residents’ needs. Yet … the aide told the surveyor that this was done all the time. Looking into the issue of understaffing would be a critical issue in any civil lawsuit arising from this fall.

Other blog posts of interest:

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

Resident rolled from bed at Warren Barr – Lincolnshire

Niles Nursing & Rehab resident suffers fatal brain bleed in fall

Fall from bed at Landmark of Des Plaines results in brain bleed

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

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

August 1, 2019 By Barry G. Doyle

IDPH has cited and fined Lexington of Streamwood nursing home after a resident there suffered a fractured leg as a result of an improper transfer involving a mechanical lift.

The resident at issue was 92 years old and suffered from advanced dementia with mobility and strength deficits. He was wheelchair bound and required transfers to be done with a mechanical lift with an assist of two. However, on the night of his injury, his was transferred to bed from his wheelchair by an aide who did the transfer alone and not with the assist of a second staff member.

Later that night, he was noted to have a red mark and swelling on his thigh. Despite this change there was no assessment done until the following morning when he complained of pain as well. Orders were obtained for x-rays done there which showed that there was an acute complete displaced spiral fracture of the femoral shaft. This was an injury which required surgery with the placement of hardware to repair.

This is a secenario which we have covered in this blog repeatedly (here, here, and here, for example) because IDPH writes citations on this over and over again. It is simply not safe to use a mechanical lift to transfer a resident, as it places the resident at risk for experiencing nursing home falls and other mishaps, such as occurred here.

If doing this is something that is so obviously dangerous, the question is, why do staff members continue to do this in nursing homes all over the state? The likely answer is understaffing – as staff members wait for a second to assist with the transfer, they can feel themselves slipping further and further behind on the tasks that they need manage, and they decide to take the risk … and the resident ends up paying the price.

Why do we have nursing homes that have staffing issues when federal regulations require them to have sufficient staff on hand to meet the care needs of residents on a 24/7 basis? Nursing homes are for-profit business where decisions are driven by businessmen not healthcare professionals as is the case everyhwere else in the healthcare sector. 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:

Bella Terra Streamwood resident suffers multiple fractures in fall

Improper use of lift at Danville Care Center

Fatal wheelchair fall at Rosewood of Elgin

Fall from bed at Landmark of Des Plaines results in brain bleed

Fall at Lexington of Orland Park results in facial fractures

Presence St. Anne resident breaks neck in fall from mechanical lift

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

Fractured hip in fall at Heartland of Casey

July 30, 2019 By Barry G. Doyle

IDPH has cited and fined Heartland Nursing & Rehabilitation in Casey after a resident there suffered a fractured hip due to falling from the commode as a nurse was attempting to care for two residents at the same time.

Juggling is a skill I very much admire, but if you are juggling something like fine china and let one drop, it is going to shatter into a thousand pieces. When you are juggling the care of two nursing home residents at the same time, there is a chance that you are going to let something drop, and due to their delicate condition, the result could be a nursing home fall that results in a fractured hip. That is bascially what this citation from IDPH describes.

The nurse caring for the resident at the time of the fall described the work load – they had about 50 residents spread over 4 halls with 2 CNA’s (sometimes 3) and one nurse, and she told the state surveyor that “most of the time that is enough” … more on that later.

The night that fall occurred, the two CNA’s were on one hall, leaving the nurse to care for two separate residents. Resident number 1 was a high fall risk due to a series of diagnoses relating to musculoskeletal weakness and cognitive deficits. She also had a history of 7 separate falls before that day. Resident number 2 was in the room across the hall. She was also a high fall risk with a history of prior falls – in this case, 11 prior falls.

What happened is that Resident 2 sounded her call light to go to the bathroom and was placed on a commode stool in her room. While she was seated on the commode, Resident 1 also needed to be toileted. The nurse brought Resident 1 to the toilet and was attending to her while she was on the toilet when she saw across that hall that Resident 2 was getting up from the commode stool on her own. The nurse left Resident 1 on the toilet and rushed across the hall and helped resident 2 to the edge of the bed of the bed. When she turned around to attend to Resident 1, she fell from the toilet.

There were obvious skin tears, and the nurse attended to these, helped Resident 1 back to bed with the help of an aide, and then helped resident 2 back to bed.

The next morning, when the aide assigned to Resident 1 attempted to get her dressed, she complained of pain in the left leg. Ultimately, she was sent to the emergency room where a fractured hip was diagnosed. This fractured hip will require surgical repair.

Providing continence care to residents is an important task for members of the nursing staff. It helps promote the dignity and comfort of the residents, and is an important step in preventing bed sores. However, there was a series of gambles that were taken with the safety of the residents – and not just Resident 1. When she took Resident 1 to the bathroom while Resident 2 was seated on the commode stool, there was a risk that Resident 2 would fall from the commode stool or would get up unattended, which is of course what happened. When she reacted to Resident 2 getting up unattended, there was a risk that Resident 1 would fall from the toilet which is of course exactly what happened. When she left Resident 2 on the edge of the bed to take care of Resident 1, there was a risk that Resident 2 would fall from the edge of the bed (such as happened here).

To say the least, the nurse here made a poor choice to try to juggle the needs of two residents at the same time. Gambling with the safety of nursing home residents is never acceptable.

The real question is why the nurse felt compelled to take that gamble. The answer to that question is found in the statement that the nurse made to the state surveyor – that “most of the time” the staffing was adequate to meet the needs of the residents. “Most of the time” is not what is required – federal regulations require the nursing home to have enough staff on hand to meet the care needs of the residents on a 24/7 basis. The work load of this crew (50 residents over 4 halls) was likely high enough that this crew was stretched to the breaking point on a nightly basis. My guess: that the nurse involved in this incident took gambles like this more often than she would have liked because caring for the residents sequentially (finishing toileting Resident 2 before dealing with Resident 1) would have resulted in Resident 1 having an episode of incontinence that would have had to be cleaned up which would have put her behind in caring for other residents, all in a vicious cycle.

This kind of nursing home fall is exactly the kind of accident that understaffing a nursing home causes.

The choice of staffing levels lies with the management of the nursing home, not the nurses charged with the care of 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 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

Resident fractures hip in fall at Caseyville Nursing & Rehab

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

Fractured eye orbit from fall at Integrity of Alton

Improper use of safety devices at Casey Healthcare

Fall from toilet at Leroy Manor

Cumberland Rehab resident suffers brain bleed in fall from toilet

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

No fall prevention care planning at South Suburban Rehab

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

Failure to obtain anti-seizure medication at Gilman Healthcare Center

Infection goes unnoticed at Helia of Belleville

Resident chokes to death at The Moorings in Arlington Heights

Failure to obtain treatment supplies at Pekin Manor

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

Failure to monitor anticoagulant levels at Greentree of Bradley

Bed sore requires surgery for Timbercreek Rehab resident

Short-staffing leads to fall at Warren Barr North Shore

Moorings staff fails to notify doctor

Broken ankle from fall at Aperion of Mascoutah

Failure to assist resident to bathroom results in fall at Heritage Health in Peru

Multiple residents victimized by fellow resident at Winning Wheels

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

Glenwood Healthcare & Rehab resident chokes to death

Cumberland Rehab resident suffers brain bleed in fall from toilet

Fall resulting in brain bleed at Good Samaritan Home in Quincy

Resident wanders from Alden Long Grove

Resident fractures leg in improper transfer at Woodbridge Nursing Pavilion

Short-staffing results in fall at Manorcare of Libertyville

Medication error at Palm Terrace leads to hospitalization

Care plan violation at Central Nursing Home

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

Fractured hip in fall at Heartland of Casey

“A” Cause Is All You Need to Show in a Worker’s Comp Case ….

“Tell them it happened some other way …..”

10 Common Medication Errors

10 Questions to Ask Your Potential Chicago Medical Malpractice Attorney

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

4 Things a Chicago Truck Accident Attorney Will Do For Your Claim

5 Things Joliet, Illinois Motorcycle Accident Lawyers Can Do For You

A Spy in Your Camp – The Nurse Case Manager

A Third Party Could be at Fault in Your Chicago Trench Accident

A Wheaton, IL Dog Bite Attorney Can Provide Evidence of Dog Bite Damages

Location

Skokie, IL

Practice Areas