The Illinois Department of Health has cited and fined Ahva Care of Stickney when, according to state investigators and facility records, a newly admitted resident found unresponsive did not receive effective continuous cardiopulmonary resuscitation, and emergency medical services were not promptly called, contributing to what investigators described as a delayed and compromised emergency response before the resident was transferred to the hospital, where she was later pronounced deceased. The state issued an Immediate Jeopardy citation, the most serious level of violation.
The resident had been admitted to the facility the previous day with diagnoses including hypertension, chronic obstructive pulmonary disease, type 2 diabetes, and an anxiety disorder. She had a tracheostomy in place. According to the citation, the facility’s admission paperwork was inconsistent regarding her code status. One section of the paperwork referenced “No CPR.” Another admission-related assessment contained no documented code status. There was no physician order documented for code status, and the facility’s electronic medical record contained no clear advance directive information. According to subsequent staff interviews, the admitting nurse documented she was a DNR based on information she received in report but could not recall from whom and acknowledged she had not verified the code status. The social services representative stated she did not verify the resident’s code status, and the family member she did speak with was not the designated power of attorney.
The Director of Nursing later told investigators that under facility practice, if the facility does not have the paperwork documenting DNR then the resident is considered a full code until paperwork is confirmed and received. The Director of Nursing also stated that family members confirmed the resident’s DNR status the day after she was found unresponsive — after the emergency response had already occurred.
In the early morning hours, a nurse making rounds found the resident unresponsive. The nurse reported she checked for pulses, found none, called for a certified nursing aide, and began chest compressions. According to video footage reviewed by investigators, the resident was without continuous basic life support measures for substantial periods during the response, including separate gaps of approximately one minute and eleven seconds and approximately one minute and three seconds. Another nurse who entered the room later told investigators she did not perform any CPR or use the ambu bag — a device used to provide breathing assistance — and was observed at multiple points exiting the room, including once while on her personal phone. A certified nursing aide and another nurse were observed in the hallway demonstrating chest compressions to the responding nurse who was inside the room with the resident.
The responding police officer, who arrived before EMS, reported that when she entered the room there was one nurse attempting CPR “but not effectively.” She took over chest compressions immediately. The officer told investigators that no staff member was using an ambu bag on the resident or providing any other direct care when she arrived. The ambulance report documented that, according to a certified nursing aide on the scene, the resident may have been down for approximately 15 minutes before 911 was contacted. The emergency room record indicates the resident’s approximate downtime prior to compressions was approximately 9 minutes. The resident was transported to the hospital, where despite continued resuscitation efforts she was pronounced deceased.
The facility’s own CPR policy required staff to provide basic life support including chest compressions and ventilations unless a valid DNR or POLST order indicated otherwise, to activate the facility’s emergency response system immediately, to retrieve the crash cart, and to call 911 without delay. The facility could not produce a current CPR certification card for the responding nurse. The family member later told investigators she did not recall ever signing a DNR or POLST form and stated she would have expected staff to provide all care to the resident. The family member also reported that the resident had texted her at 1:38 AM saying “I need help” — less than an hour before staff documented finding the resident unresponsive.
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 Illinois 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.
