Nursing Home Abuse Blog - Page 20 of 35 - The Law Offices of Barry G. Doyle, P.C.

Dialysis patient bleeds to death at Warren Barr North Shore

May 27, 2019 By Barry G. Doyle

IDPH has cited and fined Warren Barr North Shore nursing home in Lincolnshire after a resident bled to death after she manipulated her dialysis port.

The resident at issue was a long-term resident of the nursing home and received dialysis three times a week. In addition to the medical issues which required dialysis, she was on blood thinners and suffered from advanced dementia. She had a fistula for dialysis in her left upper arm. The fistula would allow the blood to drawn out of the body, have the waste filtered out, and the blood returned to the body.

Before the incident that resulted in the wrongful death of this nursing home resident, there were two other incidents where the resident experienced bleeding related to her dialysis site. The first of these took place approximately three months earlier, when an aide found the resident in bed with the resident’s sheets soaked with brown, hardened, coagulated blood. The fistula site was identified as the source of the bleeding. Approximately a month and a half later, a wound was found on the resident’s arm next to the fistula and the staff documenetd that the resident was known to scratch at the area.

During the survey process conducted by IDPH, other staff members and health care professionals acknowledged that the resident frequently scratched at the dialysis site. There was speculation that tape that held the port into place was an irritant.

At 11 pm the day before the resident died, the nurse took her hand away from the fistula site. She was checked on twice that night before being found the next morning around 4 am. The citation describes a horrific scene – the resident covered head to toe in blood, blood saturating the sheets and blankets, blood on the floor and wall. The resident was already deceased. Cause of death per the death certificate was exsanguination, meaning that she had bled to death.

This case demonstrates a breakdown in the care planning process and delivery of care is impacted by the nursing home business model. The underlying premise of the care planning process is that the risks to the health and well-being of the resident are identified and steps are taken to address the risks.

The staff here knew of a behavior which represented a threat to the health and well-being of the resident – her behavior of scratching at the fistula site. In fact, they got a preview of how serious an incident that could be in April when she had a significant bleeding incident caused by scratching at the fistula site. Further the staff had at least a notion of the underlying cause of the resident scratching at the fistula site: irritation of the skin from the tape.

There were at least a couple of simple solutions available to address this risk. One would be to use a different type of adhesive which did not cause the irritation. Without the irritation, there would be no scratching at the fistula site and this incident would not have occurred. The other option would have been to protect the fistula site with a dressing which would have kept the resident from dislodging it. Neither of these options appear to have been pursued and there is no indication in the citation that the risk of this kind of bleed-out was ever addressed in the care planning process.

The likely reason that this was never addressed in the care planning process is that it is not one of the specific areas that is part of the standard care planning process like the risks of nursing home falls, developing bed sores, or elopement (or wandering). One of our beliefs is that the nursing home business model stretches staff so far that little critical thought is given to the health and well-being of residents. This was a situation that called for a little extra critical, outside-the-box thought and consideration which never happened.

Order our FREE report, Built to Fail, to learn more about how the nursing home business model ends up causing unncessary injuries and deaths to nursing home residents. 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:

Forest City Rehab fails to send resident to dialysis

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

Resident rolled from bed at Warren Barr in Lincolnshire

Wheelchair fall at Hillcrest Retirement Village

Medication errors results in severe bleeding at Fairmont Care Centre

Short-staffing leads to fall at Warren Barr North Shore

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

PA Peterson resident breaks both legs in fall

May 26, 2019 By Barry G. Doyle

IDPH has cited and fined PA Peterson at the Citadel nursing home in Rockford after a resident broke both legs in a fall from bed.

The resident at issue was a hospice patient. She had earlier been assessed as being a high fall risk due to a history of falling, poor balance, anbd forgetting her limitations. In the days leading up to this nursing home fall, she was attempting to transfer on her own and get out of her wheelchair unassisted and telling the staff that she wanted to leave the facility. She was also suffering from a urinary tract infection which in a senior citizen population can cause increased confusion.

Two days prior to the nursing home fall at issue, she she suffered another fall from her wheelchair and sustained a laceration to her head. The fall prevention nurse was notified and recommended that the resident be given a reclining wheelchair to assist with trunk support and that she not be left in her room unattended if she was awake.

On the day of the fall, the resident was given a bath by a hospice CNA and then brought to bed. The resident was discovered on the floor with the bed in the highest position and the controller for the bed on top of the bed. She left the resident alone, unaware that the resident was supposed to not be left unattended and failed to notify other staff members.

The resident was brought to the hospital where scans showed that she had comminuted, severely angluated fractures of both femurs.

This fall demonstrates what happend when members of the care team are unaware of what needs to be done to care for the resident properly. The fall prevention nurse came up with a reasonable plan to address the resident’s fall risk after she had the fall from her wheelchair – not leaving her alone. This was necessary after she was demonstrating increased agitation and poor judgment for her own safety, especially in light of her urinary tract infection. It is unlcear whether this was formally included in her fall prevention care plan, but one basic step to delivering quality care in a nursing home setting is making sure that everyone knows what needs to be done. The hospice aide was not aware of the added fall prevention measures, and as a result this fall occurred.

The hospice aide is clearly that most responisble for this fall. However, federal regulations also place the responsibility on the nursing home to provide the supervision necessary to prevent accidents, including falls. This means that even though the hospice agency would have some liability for this fall, the nursing home would as well.

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:

River Bluff nursing home resident suffers multiple fractures in fall

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

Brain bleed from fall at Alpine Fireside

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

Pine Acres resident breaks neck in fall from bed

Fall from toilet at Alden Park Strathmoor

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

Brain bleed from fall at Landmark of Des Plaines

May 24, 2019 By Barry G. Doyle

IDPH has cited and fined Landmark of Des Plaines Rehab nursing home after a resident sustained a brain bleed due to a fall from bed.

The resident at issue had a movement disorder which left her a total assist with all activities of daily living and bed mobility. She was an assist of two with bed mobility. On the day of the accident, she was being changed by a single aide after an episode of incontinence. She was positioned on her side but was moving her arms involuntarily which brought her closer to the edge of the bed. She started to slide off, and the aide was unable to stop the fall. She hit her head on the legs to the bedside table and began to bleed. She was sent to the emergency room where a CT scan showed that she had a brain bleed. A repeat scan was done which showed that the bleeding had advanced to the point that the doctor declared that it was likely a fatal hemorrhage. Assuming that was the case, this nursing home fall would be the basis for a wrongful death lawsuit.

The conclusion of the IDPH investigation was that this resident required the assist of two with incontinence care, but as with some of the other IDPH citations we have written about (see here, here, here, and here), there was a single aide changing a resident who needed the help of two.

What was unclear from the citation is why there was only one aide. The resident was assessed as required the assistance of two with bed mobility. However, the aide who was changing the resident was the regular aide who cared for her and said that she was assist of one for changing. If that was the case, then there was an inadequate care plan in that it did not provide for assist of two with incontinence care for a resident whose condition called for that. On the other hand, if the aide did not know that the assist of two was required, there were breakdowns in how the contents of the care plan were communicated to the staff. It also means that this resident would have been receiving care in a manner inconsistent with the care plan for week or months on end, and the nursing home had just gotten lucky that there had not been an injury from a fall earlier. There is a difference between dodging bullets and providing good care, and this resident paid the price for a staff that had been dodging bullets for weeks instead of providing the care that was needed.

Other blog posts of interest:

Moorings staff fails to notify doctor of symptoms of GI bleed

Bella Terra Streamwood resident suffers multiple fractures in fall

Niles Nursing & Rehab resident suffers fatal brain bleed in fall

Care plan violation at Central Nursing Home

Wheelchair fall at Hillcrest Retirement Village

Generations Oakton Pavilion resident falls and fractures hip

Resident suffers brain bleed after third fall at Bria of Chicago Heights

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

Resident burned by hot pack at Miller Health Center

May 24, 2019 By Barry G. Doyle

IDPH cited and fined Miller Health Center in Kankakee after a resident sustained burns from a hot pack that required debridement.

The resident at issue was 82 years old and was suffering from neck pain. The nurse practitioner for his primary care physician issued an order for use of icy hot cream and a hot pack 3 times a day. The purpose of this was to loosen the muscles and provide him with pain relief. There were no instructions about how hot the hot pack should be or how long it should be applied. The nurse practitioner told the state surveyor that she assumed that there was a facility protocol that would be followed.

Unfortunately for this resident, that assumption was wrong. There were no policies, procedures, or protocols for this. The aide who was assigned to give the resident the hot packs warmed a wet washcloth up in the microwave, placed it in a plastic bag and then placed it in a pillow case. She did not know how hot it was, did not know how long it was applied to the resident’s skin, or who removed it. The resident told the surveyor that he fell asleep with it on and woke up with the burn from the hot pack. When the resident awoke he had a 6 cm x 3.5 cm burn where the pack had been applied. Ultimately, this wound required debridement.

This particular resident suffered from diabetes which tends to impair circulation. Further, at 82 years of age, this resident’s skin was thin and fragile. It is one of the reasons that bed sores are a serious issue in nursing homes. And the nursing home left it to the discretion of the aide – the least medically trained person providing care to residents – to decide whether the hot pack was too hot or cold, how it was prepared, and how long it would be applied. That is a formula for disaster. When medical care has the potential for injury to residents, the staff must be guided through training, policies, and procedures as to what must be done. The nursing home here failed to do that.

This is not to completely excuse the nurse practitioner. She provided no guidance about how the care she ordered was to be delivered and assumed that there were standard procedures at the nursing home when there were none. In practice, it h as been surprising to hear how often from doctors who have large nursing home practices have no real idea about how the care is actually delivered in the nursing and how much they defer to the nursing home staff.

Other blog posts of interest:

DuPage Care Center resident burned by hot packs during therapy

Facility acquired bed sores at Gilman Healthcare

Untreated pressure ulcer at Aperion Care of Bradley

Failure to treat pressure ulcer at Franciscan Village in Lemont

Meadowbrook Manor resident suffers Stage 4 bed sore

Resident burned by hot pack at University Nursing & Rehab

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

Improper transfer at Southgate nursing home

May 22, 2019 By Barry G. Doyle

Southgate Health care Center in Metropolis has been cited and fined by IDPH after a resident sustained multiple fractures due to falling during a transfer in which the aide was not using a gait belt.

The resident at issue was 88 years old and suffered from Parkinson. She had contractures and had been non-weight bearing for a long time. The staff was transferring her from her bed to her wheelchair. She was care planned as a two-person assist due to the extensive weakness she had due to the Parkinson’s. The aide had the resident seated on the edge of the bed while she waited for another aide to come help her with the transfer.

Suddenly the resident began to slide off the edge of the bed. Because there was no gait belt on the resident the aide was left to try to stop the fall by grabbing under her arms. She could not stop the fall and the resident fell to the floor. A nurse was called into the room, and they lifted the resident to the bed by her arms after checking for signs of injury.

After being brought to the dining room, the resident began to complain of shoulder pain, so she was brought to the emergency room where a CT scan showed that she had a fractured clavicle and a fractured sternum.

This nursing home fall was a very preventable accident. First this resident should not have been placed on the edge of the bed. The resident was not able to bear her own weight due to the contractures and the Parkinson’s so leaving her on the edge of the bed was simply an invitation for a fall to occur. Second, the aide did not have a gait belt on the resident. Use of a gait belt is a key safety messure when a resident needs asssitance with walking or being transferred because it allows the aide to control the resident without grabbing onto limbs or clothing as happened here. This resident’s injuries were to her chest and shoulders which were not directly impacted in the fall, but which were manhandled in the effort to break her fall and then get her back into bed.

Other blog posts of interest:

Resident falls from lift at Oregon Living & Rehab

Failure to use mechancial lift results in ankle fracture

Fall results in fractured hip at Daystar

Multiple fractures at Rolling Hills Manor

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

Resident develops bed sore at Nokomis Rehab

May 22, 2019 By Barry G. Doyle

IDPH has cited and fined Nokomis Rehabilitation & Health Care Center in Nokomis after a resident was discovered to have an unstageable pressure ulcer.

Bed sores are a major issue in the long term care industry. This is an area which is specifically addressed in federal regulations. Nursing homes are charged with responsibility for preventing bed sores in residents who enter the nursing home without any and with providing necessary care, treatment, and services to promote healing and prevent infection and the development of new bed sores in residents who have them.

Bed sores are a specific area of resident assessment when a resident is admitted to the nursing home, usually using the Braden scale. Many residents have specific care plans to address prevention of bed sores. When a resident is at risk for a bed sore, regular skin checks are part of the routine. Development of a bed sore is a significant change in condition which requires the nurse to notify the doctor to obtain treatment orders and requires revision of the care plan.

When the resident at issue was admitted to the nursing home in July, 2018, he was scored at a 19 on the Braden scale, which corresponds to a moderate risk of devloping bed sores. The nursing home’s policies and procedures called for daily skin checks. When the bed sore on his buttocks was first documented in late October, it was 4×7 cm with a 2×2 cm necrotic area.

This is considered an unstageable pressure ulcer because the area of necrotic tissue concealed the base of the wound, so its true depth could not be determined. By definition, an unstageable pressure ulcer is at least a Stage 3 or Stage 4 bed sore. Necrotic tissue is dead tissue which suggests that the bed sore had been present for some time before and should have been seen earlier. This was the conclusion of the doctor and the director of nursing.

When we look at cases involving bed sores, it is always important to look at both aspects of the care that the resident received. One part looks at what was done to prevent the development of the bed sore to begin with, but the more often overlooked aspect of the case is what was done after the resident developed the bed sore. Many times, we find that when a resident leaves a facility to go to another nursing home or to the hospital, the staff at the next place is documenting a sore that is in far worse condition than the records from the nursing home reflect.

Bed sores which are not reported and treated in a timely way are often set up for the inset of infection like cellulitis or osteomyelitis and these can in turn lead to sepsis are ultimately result in the wrongful death of the nurisng home resident.

Other blog posts of interest:

Unstageable pressure ulcer to heel at Willow Rose in Jerseyville

Call light not being answered at Aperion of Mascoutah

Maggots discovered in bed sore at Manor Court of Clinton

Aperion Care Capitol fails to obtain equipment to treat bed sore

Moweaqua Rehab resident suffers multiple declining bed sores

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

Spinal fracture from fall from bed at Pine Acres

May 20, 2019 By Barry G. Doyle

IDPH has cited and fined Pine Acres Rehabilitation & Living Center nursing home in Dekalb after a resident there suffered a spinal fracture in a fall from bed.

The resident at issue was 77 years old and suffered from Parkinson’s and dementia. She had a care plan in place which called for extensive assist assist of two with bed mobility. This means that two aides would be required from any activity which involves repositioning the resident in bed.

On the day in question, an aide checked the resident and discovered that she had suffered an episode of incontinence of bowel and began the process of cleaning her. The resident raised her legs up and she was moved to her side. The aide went to get a wash cloth and other supplies for cleaning the resident. As she did so, the resident slid from bed.

The resident was brought to the hospital where a CT scan showed a fracture at the C2 level, at the top of the neck. The citation references a neurosurgical consultation being obtained, but does not specify whether the resident underwent surgery or whether this nursing home fall resulted in the wrongful death of this nursing home resident.

This episode represents a simple matter of the failure of the nursing staff to implement a care plan. The resident suffered from Parkinson’s Disease which would have robbed her of much of her ability to control the movement of her body and would have left her with extensive musculoskeletal weakness. With this kind of chronic condition, extensive assist of two would have been appropriate with the kind of repositioning that is required to prevent the development of bed sores. The care plan was also communicated to the direct care staff as the need for a two person assist was apparently posted. The only reason that this resident was injured is that a reasonable care plan was not followed.

Sadly, this has been the same story told in several other recent blog posts involving falls from bed – like here, here, here, and here. Two people were needed to help the resident, one tried to handle the task alone.

Besides the simple story of a single aide trying to do a two person job by herself, the other level to this story is the question of whether or not this nursing home was understaffed. When you see an aide do something like this which they should know better than to try doing alone, the question is “why?” Sometimes the answer is that the nursing home did not have enough people to provide the care that the residents really needed, so the aide did the best they could to try to help that resident and all the other residents they were charged with caring for, and the gamble they took in trying to do a two-person job alone was lost in a big way — for the resident.

Other blog posts of interest:

Cornerstone Rehab resident falls from lift, breaks leg

Failure to obtain urinalysis at Sandwich Rehab

Broken leg in fall at Generations at Neighbors

Fall during transfer results in broken ankle at Sandwich Rehab

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

Diabetes medication not given at Alden Estates of Orland Park

May 19, 2019 By Barry G. Doyle

IDPH has cited and fined Alden Estates of Orland Park nursing home after the failure of the nursing staff to provide insulin to a diabetic resident resulted in the admission of the resident to the hospital with critically high blood sugar levels.

The resident at issue was a new admission to the nursing home who had orders in place for a long-acting insulin dose at bedtime, plus an additional order for sliding scale insulin where if the resident’s blood sugar testing showed elevated blood sugar levels, then the resident would be given units of insulin to reduce her blood sugar levels.

When the resident was initially admitted to the nursing home, she was given a room on the second floor, but was transferred within a matter of hours to a room on the first floor. When the transfer occurred, the nurse receiving the patient did not get a report on the resident from the prior nurse. With her shift coming to an end, she instructed the nurse coming on duty to get a report from the nurses on the second floor.

Communication is one of the keys to delivering quality care in a nursing home setting. “Report” among nurses is a conversation among the nurses where they discuss the residents who are coming under their care. It is one of the keys to ensuring continuity of care. Nursing homes operate in part on the basis of communications systems such as the resident chart, 24-hour sheets, and care plans. When members of the nursing home staff fail to communicate, errors are made in caring for the resident which can be seen in blog posts here, here, and here.

In this case, the failure to communicate resulted in this resident not receiving her dose of long-acting glucose at bed time, not having her blood sugar testing done, and not receiving whatever additional insulin which would have been required based on the results of the testing. As a result, she was transferred to the hospital the next morning with an elevated blood sugar level (kyperglycemia) of 525, when the normal range is 70-99. This kind of medication error can have serious consequences for a diabetic resident, including diabetic ketoacidosis, diabetic coma, or even cause the wrongful death of the nursing home resident.

Other blog posts of interest:

Medication error leads to hospital admission at Arista Healthcare

Improper administration of medication at Landmark of Des Plaines

Failure to give diabetes medications at Bridge Care Suites

Alden Estates Huntley fails to give ordered antibiotic

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

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

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.

Urinary catheter injury at Friendship Manor

May 17, 2019 By Barry G. Doyle

IDPH has cited and fined Friendship Manor nursing home in Nashville, Illinois after a resident suffered injury due to improper insertion of an indwelling catheter.

The resident at issue was a 36 year old quadraplegic who had a neurogenic bladder as a result of his injuries, meaning that due to his spinal cord injury, he was unable to control his bladder. Part of his regimen of care for the neurogenic bladder was use of an indwelling catheter which would drain urine from his bladder into a bag.

One of the risks associated with the use of an indwelling catheter is an increased chance of developing a urinary tract infection. In the days immediately prior to the injury, the resident was showing signs and symptoms of a urinary tract infection, so his doctor ordered replacement of the indwelling catheter and a urinalysis.

An indwelling catheter has a balloon at the end which is inflated once the catheter is inserted into the opening of the bladder. The inflation of the balloon allows the urine to drain from the bladder down the catheter and into a bag.

The nurse who was responsible for replacing the catheter did not use proper technique in placing the new catheter. Instead of inflating the balloon after the catheter had entered the bladder, she inflated the balloon while the catheter tip was still within the urethra – in other words, she inflated the balloon too early. Other staff members were not able to resolve the issue, so they contacted the resident’s doctor who ordered the resident sent to the hospital.

At the hospital, a CT scan was done which confirmed that the catheter balloon was inflated within the urethra. A determination was made to transfer the resident to another hospital where a urologist would have to perform an open surgical procedure to resolve the problem.

The fundamental issue in this case is an issue of poor nursing technique. The signature of a proper placed catheter is a flow of urine from the bladder into the bag. The nurse in this case claimed “maybe a dribble” of urine entered the bag and nurses who attempted to resolve the issue were unable to verify that there was any urine in the bag at all. When nurses fail to follow proper technique, this is a form of nursing home abuse and neglect and can be the basis for a civil lawsuit.

Other blog posts of interest:

Urinary catheter injury at Marigold Rehab

Diabetes care mismanaged at Aperion Care Capitol

Maggots discovered in bed sore at Manor Court of Clinton

Fall from toilet at Leroy Manor

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

Fatal Choking Accident at Iona Glos

May 17, 2019 By Barry G. Doyle

IDPH has cited and fined Iona Glos Specialized Living Center in Addison, Illinois after a fatal choking accident involving a resident there.

Iona Glos is a facility that primarily serves adults with developmental disabilities. The resident at issue had devlopmental delays which manifested itself in part by the resident “shoveling” food into his mouth while eating. His diet included only soft or ground meat, soft moist bread with no crusts, and soft vegetables. He also a mealtime protocol (a care plan) which was designed to help him eat safely by providing monitoring during mealtimes with cueing and prompting to eat slowly and to swallow before taking another bite.

On the morning of the accident, the resident was being served oatmeal and banana bread in the dining room. There was an aide in the room who had worked the overnight shift and was assisting another resident. The aide was not watching the resident at issue eat and did not know what the mealtime protocol for the resident was. He did not see the resident eat the three by four inch piece of banana bread because he was not watching.

Suddenly, the resident got up from the table and hurried to the bathroom. The aide followed him into the bathroom because the resident was known to play with feces in the toilet and he did not want the resident to get his outfit dirty for a planned family visit. The resident suddenly fell to the floor without hitting his head. The resident was unresponsive, so the aide called nurses over to assist, but did not initiate CPR or check his airway because he was concerned about a head or neck injury and because the resident did not give off any sign of choking such as gagging or coughing.

When the nurse arrived, she began CPR and noticed that there was something mushy in his mouth and attempted to clear the airway. Police arrived shortly thereafter and attempted abdominal thrusts. Finally, the paramedics arrived and cleared the airway with forceps and was able to intubate him. Despite vigorous efforts at resuscitation, the resident died that afternoon.

The nursing home here had done a reasonable job under the circumstances of identifying the issues and coming up for a care plan to avoid a nursing home choking accident. The resident had been properly identified as being at risk for choking by virtue of his known behavior of shoveling food into his mouth (which is a relatively common behavior in nursing home residents with some forms of mental illness or dementia). There was also a reasonable plan in place: keeping him under observation during mealtimes and cuing him to eat in a safe manner.

The problem here came from the fact that the aide who was there when the accident happened didn’t know that was what the plan was. When a care plan is put into place, it is up to the nursing home staff to carry out the care plan on a day-to-day, shift-to-shift basis. There are some items in care plans which if neglected once may not have catastrophic events (such as with bed sores), but there are other such as with choking or nursing home falls which can have truly catastrophic conseuqences if the care plan is neglected even once. In order for the direct care staff to do that, the care plan must be communicated to them. This aide simply did not know what the care plan for this resident was and as a consequence, the resident stuffed a whole piece of banana bread down his throat, resulting in the wrongful death of this nursing home resident.

Other blog posts of interest:

Fatal choking accident at River Bluff nursing home

Resident chokes to death at Glenwood Nursing Home

Another fatal choking accident at Glenwood Nursing & Rehab

Fatal choking accident at Grove at the Lake

Resident chokes to death at Presence Villa Franciscan

Moorings resident chokes to death

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

Resident rolled from bed at Villa of South Holland

May 17, 2019 By Barry G. Doyle

IDPH has cited and fined the Villa of South Holland nursing home after a resident suffered a head injury after being rolled from bed by staff.

The resident at issue suffered from advanced multiple sclerosis and had contractures and muscular weakness of her extremities. Because of her disease process, she could not hold a side-lying position. Her care plan included assist of two with personal care and turning and repositioning.

On the day of the incident, an aide was providing incontinence care to the resident without any assistance. She was new to caring for the resident, and was not aware that a two-person assist was required to care for the resident. While she had the resident laying on her side the resident fell from the bed, suffering a head injury which was treated at the hospital.

There are two basic issues with this nursing home fall: (1) a breakdown in the care planning process and (2) understaffing of the nursing home.

One of the basic steps to the care planning process is communication of the care plan to the staff charged with caring for the resident. After all, having a great care plan is no good at all if the people providing the care don’t know about it. Here, the needs of the resident were properly identified and a plan put into place to address those needs, but the plan was not carried out because the aide charged with caring for the resident did not know what the plan was.

A well-run nursing home will have a system in place for communicating the plan to the persons charged with implementing it. If the fall here happened because the plan was not communicated to the aide, it begs the question, how many residents are not receiving the care they need because the staff charged with caring for them do not know what they are supposed to do?

During the investigation of this fall, the Director of Nursing acknowledged to the surveyor that root cause of the accident was not enough staff the care was being provided. This speaks to understaffing of the nursing home, which has serious implications for the overall quality of care at this facility.

Other blog posts of interest:

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

Resident breaks in leg in failed mechanical lift transfer at South Holland Manor

Fractured hip from fall at Villa of South Holland

Resident rolled from bed at South Holland Manor

Two serious falls at Holy Family Villa

Resident rolled out of bed at Generations at Applewood

Brain bleed from being rolled from bed at Bria of Palos Heights

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

Fall from commode at Pekin Manor

May 11, 2019 By Barry G. Doyle

IDPH cited and fined Pekin Manor in Pekin after a resident suffered a head injury in fall from the commode.

The resident at issue was unable to walk independently and was brought to the toilet by an aide. After the resident was place on the toilet, the aide left the room, and at some point thereafter, went on break – leaving the resident sitting on the toilet unattended. The resident activated the call light, but go not response – after all the aide was on break. After 25 minutes of waiting the resident decided to get down from the toilet and crawl to her bed. In so doing, she hit her head on the floor suffering a head injury which required care at the hospital.

One of the staples of just about every care plan for nursing home residents who are at risk for experiencing nursing home falls or who have musculoskeletal issues is encourage use of the call light. The idea is that when the resident asks for help, the staff will provide it. The important thing about it is that use of the call light requires some degree of faith on the part of the resident – a belief that if I hit the call light, someone will come help me.

What happens when there is a breach of that faith on the part of the staff? What does it teach residents when they hit the call light and no one answers? Failing to respond to or acknowledge call lights teaches residents that they are not going to get the help that they need when they hit the call light, and and as a result, residents will either stop using call lights or will give staff less of an opportunity to respond because the belief that help is on its way has already been undermined.

Why do you get poor response times to call lights? Understaffing is a likely culprit, combined with a nursing staff that is struggling just to keep up with the needs of the residents. It is all a part of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

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

Failure to obtain treatment supplies at Pekin Manor

Hospitalization from medication error at Fon Du Lac Rahabiliation in East Peoria

Fall from toilet at Leroy Manor

Fractured neck from fall at Manor Court of Peoria

Cornerstone Rehab resident falls from lift, breaks leg

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

California Gardens fails to obtain respiratory equipment

May 9, 2019 By Barry G. Doyle

IDPH has cited and fined California Gardens nursing home in Chicago after it failed to obtain necessary respiratory equipment for a newly admitted resident, resulting in the resident suffering respiratory failure and requiring hospitalization.

The resident at issue suffered from respiratory failure due to neuromuscular weakness. His admission to the nursing home was a planned one, and the transfer orders, included the use of a BiPAP machine. This is a piece of respiratory equipment which helps force oxygen into the patient’s lungs.

When the resident was admitted to the nursing home, the machine had not yet been ordered from the supplier. The staff called the supplier, but failed to specify that this was a STAT order because they had a resident already in the facility who needed that piece of equipment. The difference: a regular order arrives in 24 hours; a STAT order arrives in 2-4 hours.

The order for the machine was placed at 2:30 in the afternoon. By 12:30 a.m., the resident was visibly struggling to breathe and requested the BiPAP. The nurse placed him on supplemental oxygen when she was unable to reach the doctor. There was no documentation of monitoring of the vital signs or blood oxygen levels. By the following morning, the resident was transferred to the hospital where he was shown to be suffering from hypoxemia (low levels of oxygen in the blood) and admitted for treatment of respiratory failure.

There are at least three major issues with what occurred here:

The BiPAP machine that this resident needed was not ordered. There are specific federal regulations relating to the provision of care for residents who need respiratory services, and these regulations place the obligation on the nursing home to provide the care. When that care requires the use of specialized equipment, failing to timely obtain that equipment is unacceptable. This is a form of nursing home neglect.
Ordering that kind of equipment in advance of the resident showing up at the nursing home is the kind of thing that should be handled as a matter of routine in a nursing home. Nursing homes are businesses, and well-run businesses have systems in place to provide the services that hold themselves out as offering. When a simple matter like this is mishandled, it raises real questions about how many systems are either not in place or not functioning as they should. It is a broader, more worrisome sign of trouble than the one simple error that was made for this one resident.
When the right equipment was not present and the resident began to experience significant problems, it was the nurse’s job to notify the doctor of the decline in the resident’s condition. Nurses are the eyes and ears of the doctors and the doctor is unable to do anything to help the resident if they don’t know that there is a problem. If they were unable to reach the doctor, then the medical director should have been contacted, and worst case scenario, ongoing monitoring of the resident’s vital signs and blood oxygen saturation levels was mandatory with a call placed to 911 if a doctor could not be reached and the resident’s vital signs continued to deteriorate. Letting the issue go overnight was dangerous and could have easily resulted in the wrongful death of the resident.

Other blog posts of interest:

Resident dies after yanking out tracheostomy tube at California Gardens

Resident suffers from respiratory failure at Mid America Care Center

Sauk Valley Living Center fails to care for tracheostomy

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

Resident wanders from Good Samaritan Society in Mount Carroll

May 7, 2019 By Barry G. Doyle

IDPH cited and fined the Good Samaritan Society nursing home in Mt. Carroll after a resident wandered from the facility and suffered a heart attack.

One of the common reasons that families make the decision to admit a loved one to a nursing home is that they are suffering from a form dementia and have been known to wander and either get lost or put themselves in dangerous situations. In the nursing home industry, this form of wandering is known as elopement, and it is a serious threat to the health and well-being of the resident.

The resident at issue was admitted to the nursing home with his wife shortly before the incident which resulted in the citation. He suffered from dementia, but did not need assistive devices, and had a known history of wandering. During his first few days in the facility, he was seen pushing his wife around in her wheelchair. There were attempts that were documented to leave the nursing home – once by leaving through an exit door which was alarmed with a wanderguard and once by attempting to leave through the front door with a group of visitors.

The resident was properly assessed as a fall risk, and staff members interviewed in connection with this incident acknowledged that they needed to keep an eye on him.

On the day of the incident, staff saw him walking up and down the halls wearing a fall weight jacket, a sweatshirt, and shoes. He went into an unoccupied room, opened up the window, and popped the screen out. He climbed out the window and walked away from the facility. Once the staff realized that he was not in the building, the director of nursing was contacted, and she pulled up security video from her home computer and saw the resident going into the unoccupied room and not leaving. Staff entered the room, saw the window open and footprints in the snow leading away from the building. The staff called 911.

He was located by the sheriff’s department approximately two and a quarter hours after he was last seen, trying to climb a fence on a farmer’s field a short distance away. He was brought to the hospital where he was diagnosed as suffering from hypothermia and had suffered a cardiac injury which the doctor believed was due to he exertion associated with leaving the facility and walking that distance.

This is a situation which could have had a far worse result as it is not hard to envision a set of circumstances where the resident might have fallen and suffered a fractured hip or ended up suffering a wrongful death either from accidental injury or from simple exposure to the cold.

The nursing home did some things right: they properly recognized that this resident was an elopment risk and they put a care plan into place to address the elopement risk. Their shortcoming was in allowing him into an area where he would not be supervised given that he made at least two active attempts to leave the facility during the very short period of time he was in the nursing home before this. The other area was in the failure of the staff to address the fact that the resident was up with a coat on for outdoors before 6:00 a.m. The staff was well aware by that time that he was a risk for elopement and his dress at that time of day should have caused more concern than was in fact generated.

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

Other blog posts of interest:

Resident wanders from Alden Long Grove

Police fracture skull of resident who wandered from Integrity of Smithton

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

Unsafe transfer at Alden Courts of Shorewood

May 6, 2019 By Barry G. Doyle

IDPH has cited and fined Alden Courts of Shorewood after a resident suffered a fractured tibia and fibula due to an improper transfer.

The resident at issue had significant cognitive impairments, required extensive to total assist with all activities of daily living, and had functional limitations in range of motion in the bilateral upper an lower extremities. There was an order in place for transfers with the assist of two using a slide board for transfer to/from bed and wheelchair.

A slide board is a device which is essentially used as a bridge that the resident is slid across from one surface to another. It is an appropriate way to transfer residents such as this one who are unable to bear weight with their legs.

On the day in question, the nurse assigned to the resident and an aide attempted to transfer the resident using a pivot transfer technique. A pivot technique is one which is accomplished by using a gait belt to support a portion of the residents weight while the resident stands and pivots from one surface to another. Neither the nurse nor the aide were familiar with the resident. The nurse was aware that there was an order for use of the slide board but she did not see one, so she elected to proceed with the pivot transfer.

As the began the pivot transfer, the resident’s legs were unable to bear her own weight and she was lowered to the ground. They later discovered that the resident suffered a tibia/fibula fracture.

This incident is a textbook example of the consequences that can follow when staff is unfamiliar with a resident and then fail to follow orders or the care plan for the resident. Neither of the people involved in the the attempted transfer here were familiar with the resident and thus unaware that she could not bear weight with her legs. Had they known this, they would have recognized that there was a high risk of a nursing home fall in attempting a pivot transfer. However, that does not excuse the fact that following physician’s orders is not optional. The fact that the slide board was immediately available is not a reason to violate a physician’s orders, and the fact that the nurse attempted to try something else rather than get the equipment needed to comply with the doctor’s orders speaks to a strong likelihood of understaffing.

Other blog posts of interest:

Resident fall from bed at Spring Creek in Joliet

Failure to use gait belt during transfer at Jacksonville Skilled Nursing & Rehab

Resident sustains multiple fractures in fall at Chateau Nursing & Rehab

Failure to follow care plan at Tower Hill in Elgin

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

Unsafe transfer at Alden Estates of Orland Park

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

Resident chokes to death at Glenwood nursing home

May 5, 2019 By Barry G. Doyle

IDPH cited and fined Glenwood Healthcare & Rehabilitation Center after a resident choked to death.

The resident was 59 years old and had a diagnosed swallowing disorder and suffered from severe mental impairments. There was a physician order in place for a mechanical soft diet. A mechanical soft diet is provided to nursing home residents who have chewing or swallowing disorders to help prevent nursing home choking accidents.

On the day in question, the resident was provided with a fried chicken sandwich. This was what was being provided that day to residents on a general diet, not the mechanical soft diet, and in any event is something that is completely inconsistent with the mechanical soft diet. An aide saw that there was no one there to supervise the resident and he was stuffing food into his mouth – a behavior that the aide told the surveyor that “all the staff knew about.” The aide went over to tell him not to do that and he accidentally spit some of the food out onto her face. She left to go wash off her face without taking the tray away from him and without telling another staff member to watch him.

When she returned from the bathroom, she recognized that he was choking. She alerted a nurse and they attempted the Heimlich, getting some food out of his mouth and then started CPR. Paramedics came to the nursing home and he was taken to the hospital where he was declared deceased in the emergency room.

There are several levels of failures which led to the wrongful death of this nursing home resident:

The resident was obviously at risk for choking based on his well-known behavior of stuffing food in his mouth. He suffered severe mental impairments which made relying on him to act in a manner which assured his own safety was folly. He was not able to control his own behavior. This risk required a specific care plan to address a known safety risk. This is the kind of resident for whom the kind of supervision that is provided at a feeder table was intended. Yet, that was either not a part of his care plan or the care plan was not being followed.
He was provided with food that was not consistent with his physician-ordered diet. Each resident has a diet card which specifies what they are supposed to be getting. This resident was provided with the wrong meal.
Once the aide saw that he was eating food which was not mechanical soft diet foods and that he was eating unsupervised, the right move at that point was to take the tray away, make sure that the resident’s mouth was clear, and make sure that he was being supervised. From a human behavior standpoint, wanting to get food that was spit on you cleaned up is understandable, but at that moment, the aide was the only thing standing between the resident and a potentially fatal hazard. She needed to make sure that he did not have food that he could choke on and that he was being supervised before getting cleaned up.

One thing that we see often in nursing home abuse and neglect lawsuits, especially accidents like nursing home falls, is that the injury producing event has roots that were planted weeks, if not months earlier. Had this resident been care planned for an obvious choking risk and assigned to a feeder table, he would never have been allowed to start eating that fried chicken sandwich and there would have been supervision on hand. Even with that failure of care planning early on, the staff knew about behaviors which showed a choking risk. Nonetheless there was apparently no care plan in place to address that choking risk. The aide who left to clean up played an immediate, obvious role in producing this man’s wrongful death, but there were many contributors to this over the days, weeks, and months leading up to this incident.

Other blog posts of interest:

Fatal choking accident at Spring Creek in Joliet

Another fatal choking accident at Glenwood Nursing & Rehab

Resident chokes to death at Grove at the Lake

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

Unsafe transfer at Alden Estates of Orland Park

Fatal choking accident at Iona Glos

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

Wheelchair accident at Generations at Lincoln

May 3, 2019 By Barry G. Doyle

IDPH cited and fined Generations at Lincoln nursing home in Lincoln after a resident suffered a torn meniscus when his leg got caught underneath his wheelchair.

The resident had been admitted to the nursing home for rehab after breaking his fibulea in a fall at home. He was wearing a heavy boot to stabilize the fracture and was largely wheelchair bound.

On the day of the injury, he was sitting in his wheelchair when an aide came to take him to get showered. He asked the aide to put on the footrests because the boot was heavy. She explained that she did not have time to put om the footrest and told him to keep his legs raised. She began to push him quickly toward the shower, but he could not keep his legs up the whole way. As he legs touched the ground, his leg rolled under the wheel of the wheelchair.

Following the accident, he was no longer able to bear weight. He was sent for an MRI which confirmed that he had a torn meniscus, or torn cartilage, in his knee. Additional surgery for that may be required.

The nursing home here had a policy here requiring that foot rests be used when staff is transporting a resident in a wheelchair. The purpose of that policy was simple – to prevent these kind of very preventable accidental injuries to residents. The aide violated the policy and the injury that the policy was intended to prevent occurred.

What was interesting about the citation was the reason that the aide gave to the resident is the explanation she gave the resident as to why the footrests could not be used – she was too busy. That is something that is emblematic of a nursing home that is understaffed. When a nursing home is understaffed, simple steps like putting footrests on a wheelchair or using two aides instead of one on a mechanical lift do not get followed and injury to residents is the inevitable result.

It is also important to keep in mind that this was a short-term rehab resident who was not suffering from dementia. That meant that he was able to give a full, accurate accounting of what happened and why. There are many times when the staff takes a shortcut due to understaffing where they get away with it in the sense that nothing bad happens and there are other times where something bad happens and the staff is able to attribute what happened to something else because the resident is unable to speak for themselves.

Other blog posts of interest:

Failure to use footrests on wheelchair leads to broken leg at Lexington of Orland Park

Fall from wheelchair at Hillcrest Retirement Village

Wheelchair accident at Avanti Wellness

Wheelchair accident at LaSalle County Nursing Home

Resident falls from lift at Oregon Living & Rehab

Mechanical lift accident at Mennonite Meadows in Chenoa

Resident breaks leg in wheelchair accident at Heritage Health in Dwight

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

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

Diabetes care mismanaged at Aperion Care Capitol

May 3, 2019 By Barry G. Doyle

IDPH cited and fined Aperion Care Capitol after its staff mismanaged the diabetes care of a resident which resulted in the wrongful death of the resident.

The resident was a 73 year old man who was a long-time diabetic who was cognitively intact and had a good understanding of how his diabetes should be managed. He was transferred into the facility on October 17 from another nursing home. On admission, there was an order in place for sliding scale insulin. This admitting order was adjusted by his attending physician two days after admission. The records indicate that this regimen was followed by the staff without any evidence of adverse effects.

On November 5, the resident was seen by a nurse practitioner who was employed by an outside company – not by the doctor, not by the nursing home. The nurse practitioner ordered the insulin regimen that the doctor had ordered discontinued and a new regimen put into place. The doctor was not notified of the changes made in the insulin regimen. On November 6, the resident complained of having blood in his urine social services. There was no record of that in the nurse’s notes and no indication that the doctor had been notified. On November 7, the nurse practitioner again changed the insulin regimen – and again the doctor was not notified of the changes in the insulin regimen. That same day, the doctor also issued an order for a change in the sliding scale regimen. The difference between the two regimens was essentially that the resident would receive higher doses of insulin when the resident has lower blood sugar level readings.

From November 5 through November 10, the nursing staff followed the sliding scale regimen put in place by the nurse practitioner, not the doctor, and never resolved the differences between the two sliding scale orders. As a result, the resident received higher doses of insulin at lower blood sugar levels which would have the effect of further depressing his blood sugar levels. There was nothing in the chart to suggest that the nurses were monitoring his response to the new sliding scale orders or determine why the resident was experienced below normal blood sugar levels.

On the morning of November 10, the resident was found unsresponsive with a blood sugar level of 12, a very low level. 911 was called and the resident was given an injection of glucagon which is intended to treat severe hypoglycemia, or low blood sugar. The resident coded while the paramedics were working on him and was taken to the hospital with the paramedics continuing to administer CPR. At the hospital, he was diagnosed with respiratory failure secondary to severe hypoglycemia and cardiac arrest. He was also diagnosed with severe sepsis due to a urinary tract infection. He was placed on a ventilator and died after the family consented to the removal of the ventilator.

The investigation by IDPH into this incident revealed several disturbing findings:

The nurse practitioner kept a separate set of notes on his treatment of the resident which were kept on his own computer which was not networked into the computer system of the nursing home or even able to be printed at the nursing home. The chart is an important communication tool among the various health care professionals involved in the care of the resident. There were no systems in place to ensure that the nurse practitioner’s notes were included in the resident’s chart.
He was unable to justify to the surveyor the orders he entered for ordering insulin to be given to the resident at lower blood sugar levels and told the surveyor that he was thinking an error occurred, but that the nurses should have known better than to follow his order.
The nurses here failed to resolve the inconsistencies between the orders given by the nurse practitioner and the doctor on November 7.
The nurse practitioner agreed that infections can cause a fluctuation in blood sugar levels. The fact that the resident had blood in his urine was never addressed by anyone caring for the resident. The doctor was not notified, and the nurses appear to have been unaware of the blood in the resident’s urine that he reported to social services. The resident was suffering for severe sepsis when he arrived at the hospital. The resident also had some cellulitis on his finger for which the nurse practitioner ordered an antibiotic. The role of this infection in affecting the resident’s blood sugar levels appears to have never been considered.
The most concerning findings come from the interview of the resident’s doctor, in part because he is also the medical director of the nursing home. He stated that he nurse practitioner is in the facility every day, but he is not privy to the orders that the nurse practitioner entered regarding his resident unless the facility tells him, which they do not always do. He sent his nurse to the nursing home for a meeting to discuss this, and the facility refused to give her access to the medical records regarding his patients.
The doctor further described when he rounds at the nursing home, he is accompanied by a nurse from the facility who is not always the nurse who cares for a resident and is often unfamiliar with the resident.
The doctor related to the inspector that he had standing orders regarding diabetes management, but the nurses don’t follow them. When the inspector asked the facility’s director of nursing for a copy of the doctor’s standing orders, she could not find a copy. She had to have the doctor’s office fax a copy over after the inspector asked.
When he was asked about nurses giving insulin to residents with low blood sugar, the doctor stated that the facility has nurses on staff who don’t follow standards of practice and that the facility uses agency nurses who are not familiar with the residents and as a result there are a lot of problems with continuity of care.

This is one of the more damning citation reports I have read, which is revealing a whole series of systemic problems with how this facility is operated. The fact that some of the harshest criticisms are coming from the medical director of the facility is eye-opening and reveals some deep dysfunction about how the facility is operated.

In the end, this resident died because his insulin regimen was mismanaged. On the surface, this is a simple story to understand. Looking at this incident on a deeper level, there were a whole series of failures which shows how the way in this nursing home is managed ended with this result. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary injuries and illnesses 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:

Anticoagulant medication not given at H & J Vonderlieth Living Center

Failure to give diabetes medications at Bridge Care Suites

Aperion Care Capitol fails to obtain equipment to treat bed sore

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

Alden Estates of Orland Park fails to give insulin

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

Failure to give HIV medications at Bria of Belleville

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

Fall in shower at Champaign County Nursing Home

May 2, 2019 By Barry G. Doyle

The Champaign County Nursing Home was cited and fined by IDPH after a resident suffered multiple facial fractures and a dislocated jaw as a result of a nursing home fall while getting a shower.

The resident had severe cognitive impairments and required the assistance of two for bathing due to generalized weakness and immobility. However, even though she required that level of assistance, that was not incorporated into her care plan.

On the day of the fall, the resident was brought to the shower room, transferred to the shower bed and was being showered with a single aide. The aide turned his back after providing pericare to the resident and as he did so, the shower bed tipped over and the resident fell forward lading on her face. She was taken to the hospital where testing showed multiple painful facial fractures and a dislocated jaw.

This is a simple case where there was a clear breakdown in the care planning process. This is a resident who was assessed as requiring assist of two with bathing. The next step in the care planning process is to incorporate the care needs of the resident into the care plan. That was not done, so even though the aide claimed to have reviewed the care plan, it didn’t tell him that two were required for bathing the resident.

Incorporating that into the care plan was something that was clearly necessary as has been the case in several other incidents we have covered in our blog – here, here, and here, for instance – where the resident was rolled out of bed when a single aide was providing care to the resident with one rather than the two that was called for in the care plan. The reason for this is that the resident has so little control over their body that they are at high risk for falling from the bed when moved onto a side-lying position. I also recognized that the aide apparently accomplished the transfer of the resident to the showed bed using a mechanical lift by himself – something that has come to grief as often as not, such as was seen here, here, and here.

Obviously, there was a clear issue going on that led to this fall relating to the breakdown in the care planning process, but the fact that there was also a transfer with the lift accomplished speaks to possible issues relating to staff training and understaffing. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary injuries and illnesses 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:

Fall results in fractured kneecap at Country Health in Gifford

Fall from shower chair at Charleston Rehab

Gardenview Manor resident fractures hip during unsafe transfer

Fall with head injury at University Rehab

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

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

May 1, 2019 By Barry G. Doyle

IDPH cited and fined Bria of Palos Hills nursing home after a resident was rolled out of bed during care and suffered a brain injury. Compounding the neglect on the part of the staff, they failed to timely summon EMS to take the resident to the hospital.

The resident suffered from a variety of conditions, including hemiplegia (weakness on one side of the body), dementia, and generalized weakness. She was known to have poor trunk control which means that she had great difficulty controlling her body. She required two person assist for activities of daily living which includes incontinence care and was dependent on staff for all aspects of care.

This nursing home fall occurred while the resident was getting care with only one aide, not the two that was required. The aide reportedly looked away and the resident rolled out of bed, landing on the floor. A nurse was brought into the room, noted a hematoma near the eye and bleeding from the nostrils. A lift was brought into the room and she was returned to bed. The doctor was paged and the family was notified. The family requested that the staff call 911 to have the resident brought to the hospital.

The fall occurred at approximately 7 pm, but the paramedics were not called until 9:25 pm. There was no documentation of what care the resident received during the interim period of time. When they arrived, no one was available to let them in through the door that the nursing home had designated for paramedics. They waited 5 minutes before someone let them into the nursing home. When they got to the resident, there was no nurse available to brief them and the aides were unable to tell them what happened. They were told by the family that the resident had fallen and was placed back to bed by the staff. The paramedics saw that the resident was bleeding from the mouth and that there was blood on the floor.

They brought the resident to the hospital where a CT scan showed an acute subdural hematoma with a midline shift. She was transferred to a higher level of care. The citation from IDPH did not describe what the final outcome for the resident was, but those kind of findings in a resident with as many pre-existing medical problems is obviously grim.

There are a number of issues that are readily apparent in this situation.

First, the underlying accident is one which should not have happened. The resident required assist of two for what was being done at the time she fell from bed, but there was only one aide in the room at the time. This is a resident who was at high risk for falling from bed due to the combination of dementia, hemiplegia, generalized weakness, and poor trunk control. Once her momentum began to carry her toward the edge of the bed, she was not likely to stop moving in that direction. The fact that a single aide was working with her at the time is an indicator that understaffing is likely an issue at this facility. In all likelihood, the care plan was not being followed.

Second, once a resident falls, a 72-hour fall watch is customary with frequent neuro checks to monitor for signs of a brain bleed. This resident clearly suffered one, but the chart did not contain any documentation of these checks having been done. The fact that there was still blood on the floor some two and a half hours later makes me wonder what was being done during that almost two and a half hour window. Did anyone check on the resident?

Third, when the paramedics arrived at the facility, not only was no one there to bring them to the resident, they could not get inside. And once they did, there was no one to provide them with the crucial information they needed to properly care for the resident.

This is a case where failures abounded and were ultimately visited on the resident.

Other blog posts of interest:

Two serious falls at Holy Family Villa

Resident rolled from bed by staff at Generations at Applewood

Brain bleed from fall at Heritage Healthcare in Bloomington

No fall prevention care planning at South Suburban Rehab

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

Resident rolled from bed at Village at Victory Lakes

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

Unsafe Transfer at Alden Town Manor Results in Broken Hip

April 30, 2019 By Barry G. Doyle

Alden Town Manor nursing home in Cicero was cited by IDPH after a resident suffered a broken hip during a transfer that was being performed by a single aide rather than the required two aides.

The resident at issue had been properly evaluated as a fall risk with need to extensive assist for mobility and the use of a mechanical lift with assist of two for transfers. This means that there were two aides that were supposed to participate in every transfer. It was part of the facility’s policies and procedures, it was incorporated into the resident’s care plan. It was clear that this is what was supposed to be done when a resident was being transferred.

However, on the day of the fall at the nursing home, only a single aide was assisting the resident while using the lift to move her back to bed after a shower. What happened next is exactly why the assist of two was needed for transfers: the aide lost control of the resident and she suffered a fractured hip. Hip fractures have devastating consequences for nursing home residents and often set the stage for the wrongful death of the resident. This resident survived – at least for the short term – and was able to describe what happened to both the nursing home administration and the surveyors from IDPH.

What happened in the immediate aftermath of the fall was a fascinating slice of life: one aide asked another to cover for her and say that they were both in the room and the sling to the lift just snapped mid-transfer and that was the cause of the fall. The story unraveled when inspection of the sling showed that there was nothing wrong with it …. and the resident returned to the facility to tell the administration that there was only one aide involved in the transfer. This of course begs the question, what else are they doing that they are not supposed to be doing and covering for one another? Why did the aide who was not in the room feel compelled to agree to the cover story?

This is a common tale, sadly. Many of the episodes we have covered involving failed transfers like this one have involved this exact same scenario – the transfer that was supposed to be with the assist of two was done with one. You can read about that here, here, here, and here. The root cause of this tends to be understaffing which is something that we cover in detail in our fee Built to Fail report, available for order through this web site. 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 down front stairs at Alden Town Manor

Infection from skin tear at Eldorado Rehab

April 20, 2019 By Barry G. Doyle

Eldorado Rehab and Healthcare in Eldorado was cited and fined by IDPH after a resident developed an infection due to improper treatment of a skin tear.

The initial injury occurred when the when the legs to the resident’s wheelchair were being moved. It was a significant skin tear measuring 12 cm, or just under 5 inches in length. The nurses on duty closed the skin tear with steri-strips. The nursing progress note entered that day described how the skin tear occurred and reflected that the doctor entered orders for treatment. However, that order was never entered into the Physician’s Order Sheet, and the resident’s attending physician and the facility’s wound care doctor both denied having been advised that the resident suffered a skin tear.

One of the reasons that skin tears are concerning is that any breach in the skin opens up the body to infecting organisms – that is one of the reasons that bed sores are such an issue of concern in the long term care industry. And indeed, this is just what happened to this resident. She developed a cellulitis infection which led to am 8-day hospital admission.

There are three real problems with the care that was provided to this resident:

First, when a resident suffers a skin tear, it is an event which requires the nurse to notify the physician. The doctor should be the one to make the determination about what should happen after a skin tear occurs. A skin tear of this size really required a trip to the emergency room to have the wound closed more effectively than trying to pull it back together withe steri-strips. The doctor denies that this occurred, which raises the next issue.

Second, the progress note indicates that the doctor issued an order. The doctor denies that this occurred, which would be an example of false charting. One of the items that supports the doctor’s account of this is that there was no entry on the physician order sheet. Many times nurses will call the doctor and get an order over the phone, in which case there still needs to be an entry on the resident’s chart for the order which the doctor will sign off on the next time he/she is in the nursing home.

Third, one of the things that nurses should be doing when a resident has a wound, whether it is a skin tear or a pressure ulcer, is checking it for sign and symptoms of infection. By the time that this resident was brought to the hospital, there were obvious signs of infection which should have been recognized much earlier.

Other blog posts of interest:

Surgical wound infection at Presence Villa Franciscan

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

Failure to obtain treatment orders leads to surgical wound infection at Loft of Canton

Resident dies from sepsis at St. James Manor in Crete

Fatal infection at Alden Northmoor

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

Maggots discovered in bed sore at Manor Court of Clinton

April 17, 2019 By Barry G. Doyle

IDPH has cited and fined Manor Court of Clinton nursing home after a resident developed heel and hip pressure ulcers.

The resident was admitted to the nursing home for a short-term rehab stay. This means that whatever long-term chronic conditions he suffered from, there was an expectation that he would return home and whatever long-term medical problems he had would not keep him in the nursing home indefinitely.

On admission, the nursing staff did the usual head-to-toe body assessment and found that he did not have any pressure ulcers. This meant that according to federal regulations, he was entitled to receive care and services to prevent pressure ulcers (or bed sores) and that he should not develop them unless they were unavoidable. This was not some pipe dream for this man because of part of the care planning process, his risk of developing bed sores was measured using the Braden Scale and he was determined to be not at risk.

However, within 3 weeks, he developed a bed sore on his left heel. It was a Stage 2 pressure ulcer. Once the bed sore developed, federal regulations required that he be provided care, treatment and services to promote healing, prevent infection, and prevent the development of new pressure ulcers. Over the next several weeks, the wound continued to decline and he developed a second wound on his right hip. The resident’s son asked that he be referred to a wound clinic to be treated by a specialist.

During an early visit to the wound clinic, there was an order entered that he be provided with a low air-loss mattress. This is a pressure-relieving device which is intended to be used to prevent bed sores from developing and to help existing wounds heal. The low air loss mattress was not obtained until after he returned from the hospitalization that followed further decline of the wounds.

As the weeks passed, the records showed that the wound showed further signs of decline in terms of the size of the wound, the appearance of the wound, and the development of an odor. The presence of an odor is often a sign the bed sore has become infected with cellulitis. Beyond the signs of infection, the wound was become ever more painful for the resident.

Shortly before the resident was sent to the hospital, one of the nurses went to do a dressing change on the heel wound and found that the dressing was loosely intact and that there were maggots on the dressing and in the wound.

As both wounds continued to decline, the resident’s doctor ordered him transferred to a hospital where he underwent a surgical debridement of the wounds and treatment for sepsis from the infections of the wounds.

Capping all of this off, after the resident returned to the nursing home from the hospital, the state surveyors were in the facility and they saw that the resident was not being repositioned, that the low air loss mattress was not being used properly, and that orders for care were not being carried out.

This is a resident who was admitted to the nursing home with an expectation of a short term rehab stay and was not considered at risk for developing bed sores. The heel wound developed shortly after admission and continued to decline. Before the situation spiraled out of control leading to the hospital admission, there is clear evidence that physician’s orders were not being followed. Once he returned there was additional evidence that this was continuing to happen and even the routine care which is required to prevent bed sores and promote healing was not being done. All of this speaks to chronic problems with the delivery of care at this facility.

Other blog posts of interest:

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

Unstageable bed sore at Nokomis Rehab

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

Residents injured in falls at Manor Court

Manor Court resident breaks neck in fall

Four residents develop bed sores at Morton Villa

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

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

Fall from toilet at Leroy Manor

April 14, 2019 By Barry G. Doyle

The Illinois Department of Public Health cited and fined Leroy Manor in Le Roy after a resident sustained a head injury in a fall from the toilet.

The underlying facts leading to the nursing home fall which injured this resident are simple enough: the resident was cognitively impaired and requires extensive assist of two with toileting and was only able to stabilize herself with staff assist moving off and on the toilet. Her fall risk assessment scored as suffering from muscle wasting and atrophy. The staff was aware that she should not be left on the toilet unattended.

On the day of the accident, she was brought to the toilet by two aides and then the aide which was supposed to stay with her left to get toileting supplies. While she was gone, other staff members heard the fall and found the resident on the floor. She was brought to the emergency room for treatment of a head injury.

This is a case where the nursing home had in place a fall prevention care plan which would have prevented this accident: there was supposed to be a staff member attending to the resident while she was on the toilet. It may have only taken a moment for this aide to get the toileting supplies, but that was all that it took for this resident to be injured.

Understanding why a resident is a fall risk is helpful in keeping a resident safe. This resident was noted to have muscle atrophy and weakness, which is an indicator she likely had poor trunk control. Residents with poor trunk control are at higher risk for falls from chairs, wheelchairs, and from the commode (as happened here) because their lack of control over their trunk is likely to lead them to lean forward far enough that a fall can occur. The staff had this figured out – they just didn’t do what was needed to keep this resident safe.

Sadly, this is not the first time that Leroy Manor has made this blog because of nursing home falls involving its residents: see here and here.

Other blog posts of interest:

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

Taylorville Skilled nursing home resident falls and breaks hip

Brain bleed from fall at Heritage Healthcare in Bloomington

Bria of Palos Hills cited after resident rolled from bed

Fall from commode at Pekin Manor

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

Fall from wheelchair at Hillcrest Retirement Village

April 11, 2019 By Barry G. Doyle

The Illinois Department of Public Health cited and fined Hillcrest Retirement Village in Round Lake Beach after a resident there fell forward from her wheelchair and suffered a broken neck.

The resident at issue was a stroke survivor with right sided hemiplegia. During the care planning process, she was assessed as being a high fall risk. She was given a wheelchair with a reclined back to help reduce her fall risk. A family member and a friend who visited the resident separately earlier on the day of the accident both saw the resident lean forward in her chair to the point that they were concerned that she would fall from her wheelchair.

The friend who visited told the nurse on duty on her way out of the facility that she was worried about the resident’s leaning forward and possibly falling out of her wheelchair. The nurse went into check on her, adjusted her in her wheelchair and left her to watch TV. A few minutes later a visitor to the nursing home informed the nurse that the resident had fallen.

The resident was brought to the hospital where scans showed that she had fractures at the C1 and C2 levels – the highest levels up on the neck. Due to the resident’s age, surgery would not be pursued, meaning that she would have to remain in a cervical collar for the rest of her life. These are very dangerous injuries, according to the resident’s neurosurgeon and can in fact be fatal injuries.

The Director of Nursing at the nursing home told state inspectors that the resident had been trying to get out of the chair from Day 1 and that she should have been placed in a well-supervised area.

Many times, when families come to see us after a nursing home fall, one of the concerns that they have is that their family member should have been restrained so that the accident could not have happened. That is actually the wrong tack to take because restraints can result in even more serious accidents.

Rather, the right approach is what the Director of Nursing indicated: that the resident should have been brought in an area where she could be closely supervised, especially given the concerns voiced by the resident’s friend. Not only would this provide her with the right kind of supervision in the moment, it would also give the nursing staff better data with which to revise the resident fall prevention care plan if that was called for.

It was interesting to see that a reclined wheelchair was in use. These can be effective for helping to prevent falls in residents with poor trunk control (as was apparently the case here), but they also carry the risk of developing bed sores. The use of this kind of wheelchair needs to be a carefully considered nursing judgment.

Our law firm serves nursing home residents who have been injured in falls and their families. Contact our experienced Chicago nursing home lawyers to learn more about what can be done after a fall and what your rights are. There is no charge for contacting us, and you are not obligated to hire us if you do call.

Other blog posts of interest:

Fall from mechanical lift at Hillcrest Retirement Village

Fatal injuries in fall from wheelchair at Rosewood of Elgin

Poor trunk control leads to fall at Charleston Rehab

Fatal consequences from fall at Forest Villa

Wheelchair accident at Avanti Wellness

Resident falls from wheelchair at Meadowbrook Manor

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

Dialysis patient bleeds to death at Warren Barr North Shore

PA Peterson resident breaks both legs in fall

Brain bleed from fall at Landmark of Des Plaines

Resident burned by hot pack at Miller Health Center

Improper transfer at Southgate nursing home

Resident develops bed sore at Nokomis Rehab

Spinal fracture from fall from bed at Pine Acres

Diabetes medication not given at Alden Estates of Orland Park

Urinary catheter injury at Friendship Manor

Fatal Choking Accident at Iona Glos

Resident rolled from bed at Villa of South Holland

Fall from commode at Pekin Manor

California Gardens fails to obtain respiratory equipment

Resident wanders from Good Samaritan Society in Mount Carroll

Unsafe transfer at Alden Courts of Shorewood

Resident chokes to death at Glenwood nursing home

Wheelchair accident at Generations at Lincoln

Diabetes care mismanaged at Aperion Care Capitol

Fall in shower at Champaign County Nursing Home

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

Unsafe Transfer at Alden Town Manor Results in Broken Hip

Infection from skin tear at Eldorado Rehab

Maggots discovered in bed sore at Manor Court of Clinton

Fall from toilet at Leroy Manor

Fall from wheelchair at Hillcrest Retirement Village

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