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.
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