The Illinois Department of Health has cited and fined Accolade Healthcare of Savoy when staff failed to monitor and report critical warning signs for a resident with heart and kidney disease, including dangerously low blood pressures, significant weight gain, and decreased urination, resulting in acute kidney failure that required dialysis and ultimately led to her death. Despite the resident and her family repeatedly reporting concerns about decreased urination and back pain, staff delayed obtaining a urine sample for days and failed to notify providers about the resident’s deteriorating condition.
The resident in question was hospitalized for multiple serious conditions including urinary tract infection, pneumonia, heart attack, severe sepsis, and acute heart failure. When discharged back to the facility, she had significantly impaired kidney function and was on multiple heart medications including a diuretic. Her care plan required staff to monitor for side effects of diuretic therapy and report lab results. Her physician orders included instructions to notify if there was no urinary output for eight hours and to report if her systolic blood pressure dropped below 100.
Shortly after returning, the resident began experiencing concerning symptoms. She reported scanty urine overnight and worried she might be developing another infection. However, what followed was a series of delays and failures to act on clear warning signs.
The resident’s blood pressure readings were alarmingly low throughout her critical period, dropping to dangerous levels including 77/27, 89/34, 79/29, and 90/42. Despite orders to report blood pressures below 100 systolic, staff did not notify a provider about these critically low readings for days. The nurse practitioner later stated that if these low blood pressures “were reported sooner, she would have made adjustments in the resident’s medications sooner.”
The resident’s weight also increased significantly – from 144.9 pounds to 150.2 pounds over three days, a gain of over five pounds indicating fluid retention. Her medication record specified to notify the provider of a five-pound gain in one week. Despite this clear warning sign in someone with heart failure, there was no documentation that any provider was notified.
Most critically, the resident experienced decreased urination and repeatedly reported this concern, as did her family. Nursing notes documented repeated delays in collecting a urine sample with excuses including “due to lab schedule, will collect tomorrow” appearing multiple times. Staff claimed samples were contaminated with bowel movements or that the lab didn’t collect on weekends.
The nurse practitioner had ordered straight catheterization if the resident hadn’t urinated, but this order was not followed. Staff continued trying to get clean catch samples for days instead. The resident’s family member stated the resident “had reported back pain and lack of urination, which had been reported to nurses on day four, but the resident went nearly a week before anything was done.”
The medical record did not document that the resident’s urine output was routinely monitored every shift during this critical period. A urine sample was finally obtained via straight catheterization six days after initial concerns. By then, lab work revealed severe kidney failure – her blood urea nitrogen had increased from 47 to 76 and her creatinine had skyrocketed from 1.8 to 6.2. The nurse practitioner ordered her sent to the emergency room.
At the hospital, the resident’s condition deteriorated. Her labs revealed white blood cell count of 14.07 indicating infection, creatinine of 6.51, and sodium of 115 indicating dangerous hyponatremia. She was admitted to the intensive care unit with acute kidney injury, renal failure, and low oxygen levels. The hospital explained the resident had “acute kidney injury on chronic kidney disease likely prerenal from diarrhea and volume contraction” with “likely acute tubular necrosis” – actual kidney tissue damage.
Two days after admission, the resident started dialysis and was intubated due to worsening oxygen requirements. After almost 10 days on a ventilator with continued dialysis, the family opted for comfort measures and the resident died.
The nurse practitioner stated clearly the failures had serious consequences. She confirmed “staff should have been monitoring the resident’s urine output after her complaints” and “this delay in treatment could lead to complicated UTI, decreased urine output, and AKI.” She explained that “if she was made aware of these changes in the resident’s condition sooner, she probably would have sent the resident out to the hospital sooner.”
Regarding the unreported weight gain, the nurse practitioner stated “if this was reported, she would have ordered a one-time additional dose of Lasix.” She concluded that “decreased blood pressure and decreased urine output along with days without reporting could have contributed to the resident’s critical lab results, and the resident could have been sent out sooner and may not have required dialysis.”
The nurse practitioner acknowledged the resident “was very sick and had a lot of things going on, so it is hard to say if these failures and delay in treatment caused the resident’s death, it may have only prolonged things if the resident had received hospital treatment sooner.” However, the cascade of failures was clear: staff never reported dangerously low blood pressures for days, never reported significant weight gain, delayed obtaining a critical urine sample for nearly a week despite orders, and failed to properly monitor the resident’s urination despite her repeated complaints.
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. 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.
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