IDPH has cited and fined Aperion Care Capitol nursing home in Springfield after the nursing staff there failed to complete the admissions process for a newly-admitted resident suffering from bacterial meningitis, resulting in her not receiving any form of care for the first 42 hours she was in the facility.
Nursing homes are businesses, and well-run businesses have processes which are intended to help assure that the basic services that the business is there to provide are in fact delivered in a routine fashion. When those routine processes are not followed, then there is almost inevitably a breakdown in the provision of those services. In the case of a nursing home those are nursing services necessary to assure the health and well-being of the resident, and failing to provide those services is a form of nursing home abuse and can have catastrophic consequences.
The starting point of the process by which nursing care is provided starts when the resident is first admitted to the facility. The resident is added to the roster of residents that it is caring for. Usually these days it is an electronic record keeping system. The admission orders for the resident sent over from the hospital are reviewed with the attending doctor and the orders are entered into the system. The care planning process begins with a resident assessment and the development of a preliminary care plan.
What happened to this resident is a study of what happens when a resident is brought to the nursing home, but the admissions process is never initiated.
The resident at issue was admitted from the hospital suffering from bacterial meningitis and was to be receiving IV vancomycin. She was also a paraplegic and was unable to get out of bed on her own. The resident arrived at 5:50 p.m., but the nurse on duty did not have time to admit the resident, so she passed the resident onto the nurse on the next shift. That nurse never admitted the resident.
Due to the failure to even start the process of caring for this resident, the nursing home effectively did not know that the resident was even in the facility. Over the next 42 hours:
- The resident was not fed because there was not an order for her to receive a meal tray;
- The resident did not receive her IV vancomycin, resulting in the resident having critically low levels of vancomycin, meaning that she was not receiving the therapeutic benefit of being on the medication;
- There were not proper supplies for the resident to self-catheterize as was the usual method for her to pass urine;
- She was not turned and repositioned, setting the stage for developing bed sores;
- She did not receive pain medication, even though she complained to the staff of pain levels of 10/10;
- Isolation precautions were not put into place for staff coming in and out of the resident’s room, placing other residents at risk of infection.
Each of these items had the potential for truly catastrophic results. The real question though is how in the world could this happen?
The likely answer relates to understaffing of the nursing home. Nursing homes are one of the true for-profit sectors in the health care industry, and staffing costs are one of the largest line-item expenses for a nursing home, so management will always endeavor to keep these under control. Would admitted this resident have resulted in the receiving nurse having to work overtime when doing so was discouraged? It is a question which is worth asking.
Staff in an understaffed nursing home are often stretched to the breaking point, and the nurse on the next shift should have taken the task of admitting the resident over, but that is a time-intensive task which apparently slipped by.
Whatever the specific reasons why things happened the way that they did, the care of this resident was an apparent casualty of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced 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.
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