Nursing Home Abuse and Neglect Archives - The Law Offices of Barry G. Doyle, P.C.

Moweaqua Rehab resident develops pressure ulcer from fracture brace

January 28, 2023 By Barry G. Doyle Leave a Comment

IDPH has cited and fined Moweaqua Rehabilitation & Healthcare Center nursing home after a resident there developed a pressure ulcer from a fracture brace.

The resident at issue was admitted to the nursing home after suffering a fracture to her femur. The resident was sent to the nursing home with a brace which was intended to immobilize the fracture.

One of the times that is fraught with risk for a nursing home resident is when a resident is admitted to a nursing home from the hospital. Typically, there are specific orders sent with or in advance of the resident’s arrival at the facility for the resident’s general medical needs as well as the specific medical issues that had the resident in the hospital to begin with. The reason that this is a time of high risk for the resident is that orders may be omitted or mis-transcribed. This can lead to things like nursing home medication errors or needed care not being delivered.

When the resident arrived in the nursing home, there were no orders in place with regard to the fracture brace – where it should be positioned, how long it should be on, how it should be padded, how skin checks should be performed. Bed sores are also known as “pressure ulcers” or “pressure sores” because one of the main causative factors is pressure from the skin. With bed sores, that is usually pressure put on the skin by the weight of the body against the resting surface (usually a bed or chair). When a resident is wearing a brace, cast, or other medical appliance, the pressure is between the skin and the medical device. With things like a splint, brace, or cast which is being used to treat a fracture, this is especially true because the device is intended to be on tight enough to immobilize the fracture site.

Two days after the resident was admitted to the nursing home, an aide saw that the brace was on the resident’s lower leg and that there was blood. She brought in the nurse who removed the brace and saw that there was an indentation from pressure from the brace. There was a wound just above the ankle and measured 10.5 cm x 4 cm with drainage and a foul odor. This wound was caused by misapplication of the brace. Eventually the wound declined to the point that there was exposed muscle and ligaments.

Due to the her immobility, the resident was also supposed to have been placed on a turning and repositioning schedule, but was not. As a result, she also developed bed sores to her heel and sacral area.

The proper course of action when this resident was admitted to the facility would have been to call the doctor to obtain orders for care. The resident was admitted with a readily obvious medical device in place. This should have prompted the nurses to ask, “What do we need to do to take care of this?” This simple question was not asked, and as a result, necessary care – proper placement of the brace, proper padding and pressure relief, inspection of the skin – was not done with disastrous results.

When nursing home staff does not have time to think to ask basic questions needed for proper care of the residents, that is a sign of an understaffed nursing home. 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 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:

Mattoon Rehab resident dies from infected bed sore

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

Oak Brook Care resident develops pressure ulcer from immobilizer

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

Staff at Bella Terra Schaumburg knowingly uses broken lift, resulting in brain bleed for resident

January 25, 2023 By Barry G. Doyle Leave a Comment

IDPH has cited and fined Bella Terra Schaumburg nursing home after the staff there knowingly used a mechanical lift with a broken attachment to the sling. This led to a resident being dropped from the lift during transfer and suffering a brain bleed.

Used properly, a mechanical lift is a useful tool for caring for nursing home residents. They allow residents to be moved safely from bed to wheelchair, wheelchair to chair or toilet, etc. They allow residents to be moved safely while being bathed. They also prevent injuries from being twisted while being moved manually. They save wear and tear on the backs, knees, shoulders, and so forth of the staff and help prevent injury to staff as well. Useful tools indeed!

The key phrase in that first sentence of the paragraph above is “used properly.” When not used properly, they set the stage for serious injury to the resident. Proper use includes having two staff members operate the lift (see here, here, here, here, and here for examples of what happens when one person does a two-person job); it includes safe operation of the lift itself (see here and here for examples of what happens when the lift isn’t used properly); and it includes making sure that the lift itself is in good condition and that all of the slings and accessories are in good condition and appropriate for use (see here, here, and here for examples for when that is not true).

The only proper course of action when the lift and all of its equipment is not in proper shape is to take it out of service. This is what happens when the staff decides to soldier on using equipment it knows was defective.

The resident at issue had multiple long term conditions and required all transfers to be done with a mechanical lift. One week before this nursing home fall, the staff on the third floor (where this resident was housed) saw that the clip which attached the sling to the lift arm was broken. They notified the Director of Nursing who inexplicably told them to continue using the lift.

According to the citation, there were 13 residents on the third floor who required mechanical lift transfers. Each of these residents likely required several transfers each day. And for each transfer, the staff made a choice to continue using equipment which it should have recognized as being unsafe for use with the residents. And for a time, they got away with it.

But good luck is no substitute for good care, and eventually the luck ran out, and it was this resident who paid the price.

The resident was being transferred when the slings lipped loose from the lift arm, causing the resident to fall to the ground. She was taken to the hospital where a head wound was closed with staples and the resident was diagnosed as having suffered a brain bleed.

This injury was highly preventable, and worse the hazard which caused the injury here was known not just to staff, but management as well. And management ordered the lift to continue to be used. This is utterly inexcusable.

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 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:

Symphony of Buffalo Grove resident has catastrophic fall from lift

Glenview Terrace resident suffers multiple fractures when lift topples over during transfer

Grove of Skokie resident breaks leg due to violation of care plan

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

Resident left unattended in dining room at Ascension Saint Anne Places suffers fractured hip in fall

January 22, 2023 By Barry G. Doyle

IDPH has cited and fined Ascension Saint Anne Place nursing home in Rockford after a resident there suffered a fractured hip in a fall after he was left unattended in the dining room.

Falls are a major concern in the long-term care industry because of the serious negative effects they have on mortality and the long-term quality of life for nursing home residents. Because of this, they are a regular focus in the care planning process.

Nursing homes use a variety of tools to assess a resident’s fall risk. Some of the major factors are a recent history of falls, as it is well-recognized in the long-term care industry that falls tend to beget additional falls; balance, gait, or musculoskeletal dysfunction; and some form of cognitive impairment, dementia, constant or intermittent confusion, or general poor judgment or awareness for one’s own safety or limitations. The cognitive impairment factor is crucial because this means that a resident cannot be counted on to follow instructions or to make good judgments or decisions for his or her own safety.

Federal regulations pertaining to falls in nursing homes provide that residents must receive supervision and assistance necessary to prevent accidents. Falls are considered accidents under the regulations.

Close supervision of the resident is a mainstay of any fall prevention strategy in a nursing home. One of the common ways of providing supervision to residents is to gather them in areas where several residents who require supervision can all be watched at the same time by a limited number of staff people. Common examples of this would be to gather residents in an activity room, near the nurse’s station, or in the dining room.

The resident at issue was admitted to the nursing home after suffering a subdural hematoma in an earlier fall. Once at the facility, he was assessed as a fall risk due to cognitive impairments, and the need for extensive assistance of staff with transfers and the use of a wheelchair and a walker for ambulation.

After arriving in the nursing home, he had two unwitnessed falls, both of which occurred in his room. The circumstances surrounding each of these falls suggested that the resident got up from his wheelchair unassisted while left in his room alone. After the second of the two falls, the resident’s fall prevention care plan was updated to include, “resident should not be left alone in his room in his wheelchair.”

On the day of this nursing home fall, one of the nurses was looking for the resident in order to check his blood sugar. She was initially unable to locate the resident on his unit, but was able to determine that he had been brought down to the dining room. She checked his blood sugar levels and found that they were 269 (elevated blood sugar levels – above 140 – are known to be a potential cause of confusion. The nurse told the aide in the dining room to not leave the resident alone because he was a fall risk.

Shortly after this, the resident’s wife and son entered the facility. His wife went to use the public restroom while his son went to the resident’s room. On her way to the resident’s room, the wife passed by the dining room and saw a man laying on the floor and she recognized that it was her husband. He later told her that he got up because everyone else in the dining room had left, so he thought that he should too.

A dietary aide discovered that the resident was on the floor and called for help. The facility dietician responded and upon entry to the dining room discovered that there were no aides in the dining room. The nurse was summoned to the dining room and encountered the aide that she had spoken to earlier. That aide explained that he had taken another resident to their room and left the resident unattended in the dining room.

Paramedics were called to the facility and the resident was brought to the hospital where it was revealed that the resident had a fractured hip.

This is a case where the extent to which dementia/confusion plays into fall risk is clearly demonstrated. The resident was not able to walk independently – he used a walker of a wheelchair as a matter of routine – but because of his cognitive impairment, he thought that it was appropriate for him to try to leave the dining room on his own when he was clearly not able to do so safely. This is why close supervision of residents who have cognitive impairments is so crucial – because they cannot be relied upon to follow instructions or make good decisions for their own safety. Sadly, the admonition from the burse to the aide to not leave the resident alone was not followed, and this fall and injury was the result.

Other blog posts of interest:

Addolorata Villa resident fractures hip in fall

Failure to use gait belt leads to fall and fractured hip at Fair Oaks rehab in South Beloit

Rochelle Rehab resident breaks leg sue to unsafe use of wheelchair

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

Infection results from failure to provide care for surgical wound at Arcadia Care of Morris

January 17, 2023 By Barry G. Doyle

IDPH has cited and fined Arcadia Care of Morris nursing home after a resident there developed an infection of a surgical wound for a hip fracture, requiring IV antibiotics and a surgical debridement.

The resident at issue was admitted to the nursing home for post-operative care after suffering a broken hip in a fall. There was a surgical wound incision that had been closed with staples, and the resident was supposed to be seen in the surgeon’s office for removal of the staples in 1-2 weeks.

That didn’t happen – because the nursing home staff seems to have failed to recognize that there was a surgical wound, despite the fact the resident was being admitted for post-operative care.

When a resident is admitted to a nursing home from a hospital, there are a number of steps that must be taken. One of these is to take the discharge instructions and orders and have them added to the resident’s chart with the resident’s attending physician giving orders for care. This helps assure continuity of care – that the resident continues to get the care in the nursing home that the doctors in the hospital wanted them to get. The order is a head-to-toe inspection of the resident’s skin. Part of this is to ensure that the resident is not arriving at the nursing home with bed sores that the nursing home might otherwise be blamed for, but also to ensure that if there is some defect in the skin, that proper orders are obtained for caring for that.

When this resident was admitted to the nursing home, that comprehensive skin assessment was apparently not done, as there was no documentation of that. There were also no orders for wound care obtained from the resident’s physician. The resident’s 1-2 week follow up appointment was not set. The resident care plan, which is supposed to address all of the risks to the health and well-being of the resident, did not address wound care. A single note, done a month after admission by the wound care nurse, documents that there was no injury to the skin.

Two days after the note was generated by the wound care nurse, and more than five weeks after the surgery, the resident was brought to the orthopaedic surgeon’s office. He removed the staples and sent the resident to the hospital because there was evidence that the surgical wound was infected, likely due to the length of time that the staples were left in place and the lack of dressing changes. The resident was admitted to the hospital to get IV antibiotics for the infection and to have a surgical debridement done of the infected tissue. The orthopaedic surgeon told the state surveyor, “I have had problems with that facility lately and am thinking of mot letting my patients go there anymore.”

There were a number of failures in the care that this resident received. First, there was a basic breakdown of the systems which assure continuity of care. Second, the admitting nurse and almost every nurse after that failed to assess the wound or recognize that treatment was not being provided for it. Third, residents’ skin is normally checked by aides during baths or showers and defects are reported on “bath sheets”. Either this was not done or no action was taken with regard to that. Fourth, the care planning process is intended to be a comprehensive review of the resident’s care needs, and yet, in the process of doing the care plan, the need for wound care and skin assessments was completely missed. The net result of this is that the resident suffered a surgical wound infection, which can be a very grim condition indeed if it requires removal of the orthopaedic hardware. Yet, this is the risk that this resident is being subjected to due to a lack of basic care provided here.

Other blog posts of interest:

Flanagan Rehab resident develops infection from bed sore

Surgical wound infection at Regency of Morris

Untreated pressure ulcer at Aperion Care of Bradley

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

Promedica Skilled Homewood resident falls and breaks hip

January 15, 2023 By Barry G. Doyle

IDPH has cited and fined Promedica Skilled Homewood nursing home after a resident there suffered a fractured hip in a fall.

Federal regulations pertaining to falls in nursing homes provide that residents are entitled to receive supervision and assistive devices necessary to prevent accidents. Falls are a type of accident.

Because falls are addressed in the regulations this way and because falls have such a detrimental affect on the quality of life and well being of nursing home residents, they are a specific point of focus in the the care planning process. There are a six basic steps to the care planning process: (1) an assessment of the risks to the health and well-being of the resident, (2) development of a written care plan, (3) communication of the contents of the care plan to those members of the care team charged with carrying it out, (4) actual implementation of the care plan, (5) evaluation of the effectiveness of the care plan on an ongoing basis, and (6) revision of the care plan if it proves to be ineffective in practice or if the resident’s care needs change.

Nursing homes use various tools to assess a resident’s fall risk, but there are two main factors that feed into fall risk: (1) some form of musculoskeletal weakness or gait, strength, or balance dysfunction and (2) intermittent or constant confusion, dementia, or general poor safety awareness or judgment. These type of cognitive deficits feed into fall risk because the resident cannot be counted on to follow instruction or make good decisions for their own safety. A third, important risk factor is the occurrence of falls in the recent past, as it is well-recognized in the long-term care industry that falls tend to beget additional falls.

The resident at issue here was one who was clearly at risk for falls – she had well-documented musculoskeletal strength deficits, had significant cognitive deficits, and had another fall just days before the one at issue here. Further, on the day of this fall, she was telling the staff that she wanted to leave.

The fall prevention care plan did include a number of interventions or steps intended to prevent falls, but none of them specifically addressed the issue of supervision of the resident. Further, when asked by the state surveyor what steps were in place to prevent falls for this resident, the staff was unable to9 explain what interventions were actually in place. For a care plan to work, it must have steps which are specifically tailored for the resident and the staff must know what those steps are. Unless this is true, the staff is left to improvise what care is being provided to the resident where the care plan process is designed to provide the necessary care is a systematic, routine manner. Poor care plans lead to poor outcomes, and that was the case here.

On the night of this nursing home fall, the resident was given dinner and placed in bed by an aide who left the resident in her room with the TV on. Normally, a sitter would be present, but the sitter was a no-show the night of this fall. There was no provision for that added level of supervision, especially in light of the resident’s earlier comments that evening that she wanted to leave

The aide left to provide care to other residents. While she was providing care to other residents, she was notified that the resident had fallen and was in the hallway. The resident had apparently left her room by the nurse’s station and walked halfway down the hallway before her legs gave out from her, as had happened in her earlier fall and as has been seen during physical therapy earlier. The resident was brought to the hospital where she was diagnosed with a fractured hip.

There were a number of shortcoming in the care that this resident received. First the care plan did not provide for the regular, systematic supervision and observation that was necessary for a resident who this set of known behaviors and risks. Second, the fact that this resident had been verbalizing a desire to leave the nursing home was a warning sign that she was likely to get up and try to act on that, but nothing was done to mitigate the risks that were present that night. Third, the sitter who was a regular part of the care team was not present. Fourth, even minimal supervision was not provided as this resident was able to get up out of bed, walk out of her room, and then go halfway down the hallway before she was discovered – to say nothing of how long she was on the floor before she was actually discovered.

When a nursing home is unable to provide residents with the necessary supervision, that is a sign that this is likely an understaffed nursing home. Unfortunately, short-staffing a nursing home is a basic 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 nursing home 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:

Landmark of Richton Park resident dropped from lift, breaks both legs

Failure to provide required assistance leads to fall and broken arm at Bria of Palos Hills

Prairie Manor resident suffers brain bleed after being rolled out of bed by staff

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

Unsupervised resident at Odd Fellow Rebekah Home falls and suffers brain bleed

January 7, 2023 By Barry G. Doyle

IDPH has cited and fined Odd Fellow Rebekah Home in Mattoon after a resident there was left unsupervised and fell, suffering a brain bleed.

Federal regulations pertaining to falls in nursing homes provide that resident must receive supervision and assistive devices necessary to prevent falls. Supervision is a key factor because one of the main factors that place nursing home residents at risk of falling and suffering injury is dementia, cognitive deficits, or general poor safety awareness. This leads to falls because residents with these issues cannot be counted on to follow instructions or make good decisions for their own safety.

One of the basic strategies for providing the necessary supervision is to keep the resident in an area where their actions can be easily monitored. Often this is by the nurse’s station or in a dining room or activity room where one or more staff members may be assigned to watch over several residents at once. This strategy is often incorporated into the resident’s fall prevention care plan. However for this strategy to be effective, the supervision must in fact be provided.

The resident involved was recognized as a fall risk due to a number of factors, including cognitive impairments, unsteadiness of his feet, gait and mobility abnormalities, and muscle weakness. He used a wheelchair. The resident’s Minimum Data Set (MDS) recorded that the resident was unsteady when rising from a seated to a standing position. The resident also had two falls in the first week of his admission to the nursing home, and one well-recognized fact about nursing home falls is that falls tend to beget more falls. In short, this resident was at serious risk for having a fall.

To address this risk, the staff moved the resident in his wheelchair to the nurse’s station. This was a solid strategy for fall prevention. In this facility, the nurse’s station was across the hall from the physical therapy gym, which has a window. The physical therapist on duty at the time saw the resident’s head pop into view through the window and disappear rapidly. Concerned that there was a nursing home fall, the therapist went out into the fall and saw the resident on the floor, bleeding from a wound on the head. There was no staff at the nurse’s station or anywhere nearby.

The resident was sent to a local hospital where scans showed that he had a brain bleed. He was immediately transferred to another hospital to receive a higher level of care.

Here, the staff took the right first steps in recognizing that the resident was a fall risk and bringing him to be watched at the nurse’s station. However, there was no one actually watching him when he fell. This is a violation of federal regulations which require that the resident receive supervision necessary to prevent falls. Sadly because the necessary supervision was not in fact being provided, this resident had a very predictable fall with serious injuries resulting.

This is all the more unfortunate because this is the second time in the last few months that a resident at this facility has suffered a fall with a brain bleed as a result. 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 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:

Unlocked furniture causes fall and broken leg at Mt. Vernon Countryside Manor

Moweaqua Rehab resident fractures hip in fall

Charleston Rehab resident suffers brain bleed and fractured hip in fall

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

Unlocked furniture causes fall and broken leg at Mount Vernon Countryside Manor

January 4, 2023 By Barry G. Doyle

IDPH has cited and fined Mount Vernon Countryside Manor after a resident there suffered a fall with a fractured leg after he leaned against his bed which rolled away from him due to the wheel locks not being applied.

The resident at issue was admitted to the nursing home after falling and suffering a fractured hip at home. He underwent surgical repair of the fracture and entered the nursing home as a short-term rehab patient with the expectation that he would be returning home after recovering from his injury and the surgery.

During the course of his admission, he became ill and was also diagnosed with covid. He was sent to the hospital and upon discharge was assigned to a new room where he was under quarantine due to the recent hospital admission and the covid diagnosis.

In preparation for this, the housekeeping staff was instructed to move a bed into the resident’s new room. However, after the bed was put into place, the wheel locks were not applied.

Having furniture in a nursing home setting locked into place is a key safety measure as many nursing home residents with strength, gait, or other mobility deficits will use pieces of furniture to support themselves and maintain balance. Further, nursing home resident are far less likely to recover their balance if it is lost when a piece of furniture they were relying on for balance rolls away from them.

Not only is keeping furniture locked and in place a common-sense safety measure, it is also consistent with federal regulations. Federal regulations pertaining to falls require that nursing homes be kept as free of accident hazards as possible, and unlocked wheels on a piece of furniture represents a significant safety hazard.

On the day of this nursing home fall, the resident had just returned that day from the hospital admission. He was alone in his room in a wheelchair. he got up from the wheelchair to put his mail on the nightstand and leaned on the bed as he did so. Because the wheels were not locked, the bed rolled away from him and he fell.

Initially he refused to go to the hospital, so x-rays were done at the nursing home which showed that he had a fracture of the femur just below the prosthesis from his recent hip fracture. The resident refused to have additional surgery on it and elected to be admitted to the nursing home for comfort care.

This was a highly preventable injury with devastating consequences. Keeping wheels locked in place is a basic, common-sense safety measure, but this was not done here. As a result, the resident suffered a fracture which was especially significant due to his recent injury at home as well as its location. Its location near the prosthesis meant that the surgery to repair the fracture would be complex and difficult. It is unlikely that this resident will ever bear weight again in any meaningful way and will be subject to a host of complications that are associated with immobility including a general acceleration of his decline, pneumonia, and bed sores.

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.

Other blog posts of interest:

Aperion Care Fairfield resident injured by falling television set

Resident rolled from bed, breaks leg at Stonebridge Nursing & Rehab in Benton

Odd-Fellow Rebekah Home resident suffers fatal brain bleed due to fall

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

Sharon Heath Care Elms resident develops bone-deep bed sore

January 2, 2023 By Barry G. Doyle

IDPH has cited Sharon Health Care Elms nursing home in Peoria after a resident there developed a Stage 4 bed sore on her ankle due to the failure of the staff to apply protective boots as called for in the resident care plan.

There are a number of factors which predispose nursing home residents to developing bed sores, also known as pressure ulcers. Chief among these is immobility. Lack of movement over a prolonged period of time creates pressure on the small blood vessels which supply the skin. This pressure is produced by the squeezing of the skin in between the bony prominences and the resting surface, usually a bed, chair, or wheelchair. One of the chief strategies for preventing the onset of bed sores is the relief of pressure through frequent turning and repositioning through the use of pressure-relieving or other protective devices.

Bed sores are a significant issue in the long-term care industry and are a specific focus in the care planning process. During the care planning process, the risks to the health and well-being of the resident are identified, and a series of specific steps, or interventions, are developed to address those risks and then assigned to various members of the staff to carry those out on a day-to-day, shift-to-shift basis.

The resident at issue has severe cognitive impairments and quadriplegia with spasticity. She was bedbound and her lower legs were contracted due to inactivity. One of the complications that results from a nursing home resident developing contractures is that the legs lay on the bed differently than they might otherwise, exposing different portions of the legs to pressure than might be the case if the resident was laying flat in bed. In this case, the way that the resident’s legs lay on the bed resulted in her inner ankle resting on the bed.

To address the risk of the resident developing pressure ulcers to the ankle, there was a physician order in place for use of protective boots. Use of these boots was incorporated into the resident pressure ulcer prevention care plan. Between the order and the care plan, it was incumbent on the staff to make sure that the protective boots were used with regard to this resident. However, the facility wound care nurse told the state surveyor that these were used for the resident until after the bed sore on her ankle developed.

Due to the failure of the staff to use the protective boots, the skin on the resident’s inner ankle was exposed to pressure (from her unusual lying position) and friction (associated with her spasticity), all of which led to the development of a Stage 4 bed sore on the resident’s ankle. A wound care physician had to be brought into the nursing home to treat the resident, including doing a surgical debridement of the wound. This was the exact scenario that the care plan and the physician order were intended to prevent.

When interviewed by the state surveyor, the Director of Nursing admitted that there was a problem with residents developing bed sores in the facility. She further admitted that the skin assessments were being done only weekly by a wound care nurse and that rather than doing doing daily skin assessments, the floor nurses had been instructed to give the resident’s skin “a good look.” When pressed as to why this resident did not have the protective boots on, she also admitted that there were issues getting the staff to implement physician orders or care plans intended to prevent the development of pressure ulcers. The fact that this is occurring at scale in this nursing home is a massive failure of the care that the residents at this facility are entitled to.

Other blog posts of interest:

Sharon Health Care Willows resident undergoes surgery for bed sore

Resident suffers pressure ulcers to both knees at Royal Oak Care Center

Resident develops pressure ulcers at Eastside Health & Rehab

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

Resident at Fondulac Rehab in East Peoria catches fire in smoking accident

December 26, 2022 By Barry G. Doyle

IDPH has cited and fined Fondulac Rehabilitation & Health Care Center nursing home in East Peoria after a resident there caught fire in a smoking accident.

People unfamiliar with the nursing home industry may be surprised to hear that nursing home residents are permitted to smoke – they are in a health care institution after all. However, nursing homes are the homes of residents, and they are adults who are permitted to smoke if they so choose. However, the right to smoke is not unrestricted. Smoking is permitted only within designated areas of the nursing home home and under terms that are set by the nursing home.

There are a couple of dangers associated with smoking for nursing home residents that are not large issues with the general population, but are certainly important with nursing home residents. The first of these is smoking near concentrated oxygen equipment, as the oxygen equipment can cause a flash fire. The second of these is fires resulting from the mishandling of smoking materials, such as when a resident is not able to handle a lighter safely or drops lit cigarettes onto the themselves or their clothing. This can happen when the resident has some type of movement or musculoskeletal disorder. The dangers of all these are worse when the resident suffers from cognitive or memory impairments or from poor safety awareness.

Like any risk to the health and well-being of a nursing home resident, the risks associated with smoking should be addressed in the resident care plan. There are six basic steps in the care planning process: (1) an assessment of the risks to the resident, (2) the development of a care pan to address those risks, (3) communication of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) evaluation of the effectiveness of the care plan, and (6) and revision of the care plan if it proves to be ineffective in practice or if the care needs of the resident changes. Care plans should be be reviewed at least quarterly and changes made as needed.

The resident at issue here suffered from emphysema for which he was prescribed supplemental oxygen. When he was last assessed, he had the physical ability to smoke and did not have cognitive impairments which kept him from smoking. However, that assessment was not current, and there had not been an assessment of his smoking risk in the current quarter. The failure of assess was important here because there had been declines in both his cognitive abilities and in his ability to use a lighter safely.

On the morning of this nursing home smoking accident, the resident stopped by the nurse’s station to get a fresh tank of oxygen and then went to the smoking patio with a another resident. The other resident told the state investigator that they knew the code to exit the building onto the smoking patio and that they routinely smoked without staff present, despite facility policies requiring staff supervision of smoking.

The resident was unable to light his lighter himself, so the other resident went to start the lighter for him. Unfortunately, his supplemental oxygen was on and this started a flash fire, setting the residents beard and face on fire. The other resident grabbed the tubing and threw it to the ground and stomped out the fire, but it was too late.

The resident suffered superficial and deep partial thickness burns to his face, lips, and eye. Soot was found in his nasopharynx and oropharynx. He had to be intubated and placed on a ventilator and was placed under the care of a wound care physician.

There were at least failures that resulted in the injuries to this resident. The first is that the smoking risk assessments were not kept current, and the declines in the is resident’s cognitive state and ability to safely handle smoking materials was not addressed in his care plan as a result. Second the facility policies regarding supervision of smoking activities was not followed. There was no staff present. Staff would have known to make sure that the supplemental oxygen was turned off before attempting to light the resident’s cigarette. Other residents may not know that, and responsibility for that cannot be handed off from the staff to someone else. Clearly, the facility policies were no being followed as a matter of routine, much to the detriment of this resident.

Other blog posts of interest:

Resident suffers third degree burns in smoking accident at Elevate Care in Waukegan

Fondulac Rehab resident suffers fatal injuries in fall

Sharon Health Care Elms in Peoria fails to give anti-seizure medication to resident

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

Mattoon Rehab resident dies from infected bed sore

December 26, 2022 By Barry G. Doyle

IDPH has cited and fined Mattoon Rehabilitation & Healthcare Center nursing home after a resident there died due to a bed sore that developed in the nursing home and became infected due to poor care.

“Bed sores” are the commonly used term for pressure ulcers, which are breakdowns in the skin which can lead to infections and other serious negative health consequences. There are specific federal regulations which address the development and care of bed sores, so they are a source of intense focus in the long-term care industry.

There are actually two separate federal regulations which address the topic of bed sores. The first relates to what is required when a resident is admitted to a nursing home without bed sores. This provides in essence that a resident should receive care necessary to prevent the development of pressure ulcers unless the clinical condition of the resident demonstrates that they were unavoidable – which is a very high standard to meet. The second addresses what happens after a resident has a bed sore. In essence it provides that a resident must be provided care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new bed sores.

There are a number of factors which place a resident at risk for developing bed sores. The most common are immobility, incontinence, and poor nutritional status. There are other factors as well, and these are wrapped into an assessment tool known as the Braden Scale, which measures the resident’s risk of developing bed sores.

When this resident was admitted to the nursing home, she did not have a skin breakdown on her sacral area and was assessed as being at moderate risk for skin breakdown. The citation does not describe a care plan having been created to address the resident’s risk of developing bed sores. Since the resident was at risk, there should have been one created. Some of the common steps would have included a turning and repositioning schedule to relieve pressure on the resident’s skin. It should have also included a plan for prompt incontinence care as the chemicals in urine and feces as well as the associated moisture contribute to the breakdown of the skin. These steps were necessary because the resident was dependent on the staff for bed mobility and toileting.

The resident’s record reflected that during 31 days she was in the nursing home, she was toileted two or more times on only 12 days. During the first three weeks the resident was in the facility, she was only bathed twice. This lack of incontinence care means that the resident’s skin was being subject to breakdown from urine and feces. This was consistent with the observations of the family who told later treating health care professionals that the resident was often soaked in urine.

Nine days after admission, the resident was first identified as having a skin breakdown. When a skin breakdown occurs in a nursing home resident, this is a change in condition requiring physician notification. The purpose of notifying the doctor is to allow the doctor to either issue treatment orders over the phone, come in to see the resident, or have the resident sent to the hospital. Beyond this, the wound must be described in the medical record, including the size and depth of the wound as well as its other characteristics. This allows the care team to determine whether the wound is getting better or worse and whether the treatment being provided is effective or not. It also should have triggered either the development of a care plan for pressure ulcers or a revision in the existing one, if there was one.

Even though these are basic, well-established first steps, neither were taken when the resident first showed signs of skin breakdown. In fact neither of these steps were taken for another two weeks. When the physician was notified, he gave orders for care and for consultation with the wound care physician. However, that consultation was never obtained. When there was finally a description of the wound in the chart, it was described as being 8.2 cm x 5.5 cm with 80% covered in slough (soft, dead tissue). It was further noted that the pressure ulcer was acquired in-house.

Five days later, the resident’s chart showed that there a foul-smelling discharge coming from the wound. This is a sign of infection. A call was placed to the physician who ordered an antibiotic. Later that same day, the resident fell from her wheelchair. She had complaints of pain, so she was sent to the emergency room.

The emergency room staff recognized that the wound was in poor condition and had a surgical consult done in the emergency room. These resident was brought into surgery two days later where the surgeon described the wound as being 21 cm x 10 cm (8×4 inches) with exposure of the periosteum (the layer of nerves and blood on the outer layer of the bone).

Given the severity of the wound combined with urinary and stool incontinence, the surgeon recommended that the resident be placed on hospice. She died five days later. Cause of death was a Stage IV decubitus ulcer (pressure ulcer).

There are a number of failure in the care of this resident which led to her death:

There was a failure to provide routine preventative care, including turning and repositioning and prompt incontinence care. If there was a care plan (and the citation in silent on that issue), these are steps which should have been included and carried out. If there was no care plan, that is a separate failure.
Once the bed sore developed, there was a delay in excess of two weeks in notifying the physician. This resulted in the resident not receiving treatments over that period.
The development of the bed sore should have triggered either the development of a care plan or revision of one. Clearly whatever steps were being taken was not sufficient to prevent the breakdown of this resident’s skin, so a new course of action was required.
The consultation with the wound care physician was not obtained.
The condition of the wound was not being tracked by the facility staff. This wound deteriorated rapidly, but there were only two time that the condition of the wound was documented – when the first set of measurements were taken and when there was foul discharge from the wound.

There are likely a long list of other failures. The sad fact about bed sores is that these are injuries which do not occur in a flash moment of time such as with a nursing home fall or a choking accident. Rather these were failures that spread across multiple days, multiple shifts, multiple staff members.

These systemic failures are often a sign of an understaffed nursing home. Sadly, that is a basic 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 nursing home 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:

Dehydration leads to hospitalization for resident at Mattoon Rehab

Resident at Bridge Care Suites dies from infected bed sore

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

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

Non-functional alarm leads to fall and fractured hip at Sunset Home in Quincy

December 24, 2022 By Barry G. Doyle

IDPH has cited and fined the Sunset Home nursing home in Quincy after the failure to use a working pressure alarm led to a resident fall causing a fractured hip.

The care planning process dictates how much of the routine care in nursing home setting is delivered. It is a multi-step, multidisciplinary process which is intended to address the risks to the health and well-being of the resident in an organized, systematic way.

There are six basic steps to the care planning process: (1) an assessment of the risks to the health and well-being of the resident, (2) the development of a care plan which is intended to address those risks, (3) communication of the care plan to the members of the care team who are assigned to carry out the various elements of the care plan, (4) actual implementation of the care plan; (5) evaluation of the effectiveness of the care plan; and (6) revision of the care plan if it proves to be ineffective in practice or if the care needs of the resident change.

The resident at issue here was properly assessed as being at risk of falls. She had musculoskeletal weakness and cognitive deficits – a common reason for a resident to be considered at risk for falls. She also had a history of falls, and one of the well-recognized truisms in the long-term care industry is that falls tend to beget additional falls.

Due to her fall risk, a fall prevention care plan was put into place which called for the use of a pressure alarm on her chair. A pressure alarm is a strip which is placed underneath the resident and when the pressure on the strip is released, a loud, audible alarm would sound. That sound of that alarm would serve two purposes – first to alert the staff that the resident was up without assistance and second, to remind the resident that they should not be up without assistance.

On the day of this nursing home fall, the resident was alone in her room when she decided to get up out of her chair and walked toward the door without using her walker. When she turned around to return to her chair, she lost her balance and fell to the floor, suffering a fractured hip.

Investigation into this fall revealed that although there was an alarm in place, it was not functioning. Because of that, there was no alarm that sounded when the resident got up from her chair. There were no facility policies requiring checks of the alarm on any regular basis. Of course, because the alarm was not functioning, there is no knowing how many times the resident was up unassisted and it was pure good luck that the resident did not fall. Of course, good luck is not a substitute for good care, and good luck is eventually bound to run out.

Here the resident was properly assessed as being a fall risk based on her functional and cognitive deficits. A reasonable care plan was put into place. Yet that care plan failed because the equipment being used didn’t work. A simple practice of regular checks on the pressure alarm for function would have prevented this fall and the resulting injury.

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.

Other blog posts of interest:

Failure to monitor leads to fall and re-fracture of broken hip at Barry Community Care

Hope Creek resident suffers fractured hip in fall from toilet

Monmouth Nursing Home resident suffers multiple falls leading to brain bleed

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

Staff at Lutheran Home in Peoria drops resident from lift, resulting in fractured hip

December 23, 2022 By Barry G. Doyle

IDPH has cited and fined the Lutheran Home nursing home in Peoria and a resident there suffered a fractured hip after being dropped from a mechanical lift.

Lift slings come in different forms and sizes. There are different sizes to ensure that the sling is appropriate for use with a particular resident. For example a very small resident is likely to slip out of a sling sized for a very large person and vice versa. There also slings for different uses. There are general lift slings, slings that are used for toileting, slings that are used for showers. The type of sling must also be appropriate to the use to which it is being put.

This mechanical lift accident is what happens when the wrong type of sling is put to use and is not used properly.

The resident involved in this nursing home fall required transfers via a mechanical lift. She also was incontinent of bowel and bladder and as a result, would not have been toileted. Nonetheless the aides transferring the resident this day selected a toileting sling to transfer the resident from her recliner. A toileting sling has a hole in the bottom so that the resident can go to the bathroom once placed on the toilet, with the resident’s legs supported by straps that go around the thighs. There are attachments that go from the sling to the lift arms.

As the transfer got underway the buckles from the sling came detached, and the resident was dropped back down to her recliner, purportedly a distance of only an inch. Nonetheless, the resident began to experience pain in the hip which was not alleviated by medication and worsened over time. X-rays were ordered which showed that the resident had a fractured left hip which required surgical repair.

There were a number of failures in the care of this resident which contributed to this fall. First, the wrong type of sling was used. This resident was incontinent so there wasn’t any set of circumstances where she would have been brought to the toilet so the general lift sling should have been used. The general lift sling provides more support to the resident such that the resident likely would not have been dropped when the buckle came detached. Second, the buckle was not secured properly to the lift. When buckled properly, these should be secure for the type of transfer that was being performed. That it failed shortly after the lift got underway serves as evidence that it was not secured properly.

The failure of the staff to use the proper sling is the result either of a failure to adequately train the staff or the nursing home being understaffed such that the staff felt compelled to take a shortcut in the care of the resident. Either way is consistent with the 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 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 Crossing of East Peoria resident suffers brain bleed due to unsafe use of lift

Mason City Area Nursing Home resident suffers fatal brain bleed in fall

Failure to follow care plan leads to fall and fractured hip at Piatt County Nursing Home

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

Avantara Lake Zurich resident suffers lower leg wound during unsafe transfer to bed

December 22, 2022 By Barry G. Doyle

IDPH has cited and fined Avantara Lake Zurich nursing home after a resident there suffered a 7.5 inch long lower leg wound while being transferred from his wheelchair to bed.

One of the basic tasks performed by aides in a nursing home is transferring residents. Some of those transfers are done with a lift; others are done manually. Either way, these transfers have to performed properly, with the right help or right equipment or disaster is the likely result. Most often, the net result is a nursing home fall resulting in a brain bleed or hip or other fracture. Here the net result was a skin tear, 7.5 inches long which required 35 staples and 9 stitches to close .

How did this occur?

The resident was being transferred from his wheelchair to his bed with the assistance of a single aide. The resident had been assessed on his Minimum Data Set (MDS) as requiring maximum assist of two staff with transfers. Facility policies also required the use of a gait belt with assisted transfers, but none were in use on the day of this resident’s injuries.

As the resident was being moved into position, he told the aide that he was not in the right place, but she assured him that it was okay to proceed anyway. No gait belt was in use. As he was being moved into the bed, his leg got caught on a portion of the bed frame of bed rail, resulting in the skin tear. As we age, our skin becomes thinner (which is one of the reasons that nursing home residents are susceptible to developing bed sores).

There was immediate bleeding, and the resident was sent to the emergency room where the wound was closed. However, by the time that the survey was conducted by the State, it was apparent that the wound was not closing properly, and is requiring the care of a wound care specialist.

Why did this happen?

There are the immediate reasons, and then the deeper reason. The resident was assessed as requiring two person assist with transfers and this was the level of care that the nursing home certified to the federal government was being provided. The MDS forms part of the basis by which the nursing home is reimbursed, so it must be completed under penalties of perjury. Here, the was one person doing what the nursing home said was a two-person job. Further, the resident gait belt was not in use despite a facility policy requiring its use. The gait belt allow the staff to better control the movements of the resident and would have helped avoid the contact with the bed frame. Finally, the aide ignored the resident when he said he wasn’t in the right position. Many nursing home residents who do not have cognitive deficits are well aware of what their care requirements are, even if they can’t manage it themselves. Ignoring the warnings of the person most knowledgeable about the resident’s care needs is setting yourself up for failure.

The deeper reason is that the nursing home was likely understaffed. When you see the staff take shortcuts like going without a gait belt or having one person do a two-person job (a well-recognized formula for disaster- see here, here, and here for examples), that is a sign of an understaffed nursing home. When there is not enough help, the net result is that shortcuts are routinely taken in the delivery of care, with the avoidance of disaster being good luck rather than good care. Relying on luck is not a substitute for proper care.

Sadly, understaffing a nursing home is a basic 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 nursing home 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:

Symphony of Buffalo Grove resident has catastrophic fall from lift

Addolorata Villa resident fractures hip in fall

Grove at the Lake resident suffers multiple injuries in mechanical lift accident

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

Macomb Post Acute Care Center resident thrown from wheelchair during van ride, suffers multiple fractures

December 17, 2022 By Barry G. Doyle

IDPH has cited Macomb Post Acute Care Center nursing home after a resident there suffered a fractured hip one one side and fractured tibia and fibula on the other when she was thrown from her wheelchair while being driven back to the facility by an aide.

Some nursing homes have vans available for transporting residents to and from doctor appointments, planned outings, and so forth. These vans are often specially equipped with lifts to help residents get in and out of the van safely and with special restraint systems to make sure that all residents, especially those in wheelchairs, are safe while the van is in operation.

Like any piece of equipment in a nursing home, a van is only safe for use when used properly, which requires the staff to be trained on its proper use. The nursing home in fact had a policy in place which required those operating the van to obtain permission to use the van and to do so in a manner which was consistent with their training.

There are three primary components of a restraint system for a wheelchair: (1) a tethering system for the wheels to the chair to ensure that it stays locked in place while the resident is in the van, (2) a shoulder harness system, and (3) a pelvic/lap restraint system. The details obviously vary, but the lap and shoulder systems essentially act like a seat belt in a car. All of these components need to be in place and used properly for the resident to be moved safely in the van.

On the day of this nursing home fall, the resident was being brought to a local homecoming parade by an aide. The aide did not get permission from any supervisor to take the resident from the facility in the van. She borrowed keys from a nurse to get into the office where the keys for the van were locked.

The aide brought the resident to the parade and was on her way back to the facility when the accident occurred. When the resident was loaded onto the van, the tethering system was in place and the shoulder harness, but not the lap restraint. It was bot in use because the aide could not find it – meaning that the resident was brought to the parade without it also. Fortunately no injury occurred on the way, but good luck is no substitute for good care.

The resident was injured when the aide hit a bump in the road while returning to the facility. The jolt from hitting the bump caused the resident to fly up in the air from her seat. She came down, she slid off the edge of her wheelchair cushion and onto the floor of the van.

The resident had immediate pain, and according to the aide, “her right ankle looked messed up.” Rather than call 911, the aide first put the resident back into the wheelchair and then called the nursing home who told her to return to the nursing home. After the nurse had a chance to assess the resident, 911 was called and the resident was sent to the hospital.

There she was diagnosed with a displaced fracture of the left hip, a comminuted fracture of the right tibia and a fracture of the right fibula. She underwent surgery on the left hip and was placed in a cast for the tibia and fibula fractures. The fractures on the lower right leg will probably impede any recovery she was likely to make from the hip fracture which will have long-term negative effects on her health and well-being.

While the motive for taking the resident from the facility was pure (taking her to the homecoming parade), a pure heart does not excuse an empty head. Not only did the aide take the resident from the facility without permission, she did so without having received the necessary training on how to do so safely. As a result, the resident was not properly restrained in the van and fell from her wheelchair and was badly injured.

Other blog posts of interest:

Non-functional alarm leads to fall and fractured hip at Sunset Home in Quincy

Transportation van accident at Generations of Rock Island

Resident falls from van at Casey Healthcare

Marshall Rehab resident breaks back in van accident

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

Second fatal choking accident at Aperion of Spring Valley in two years

December 12, 2022 By Barry G. Doyle

IDPH has cited Aperion of Spring Valley Nursing Home after a resident there choked to death while eating. Sadly this was the second fatal choking accident at that nursing home in the last two years.

In the earlier choking incident, the resident was given food which was not consistent with her dietary restrictions. She was not being supervised while eating, even those this was called for in her care plan because she was not able to eat safely due to her dementia and diagnosed dysphagia, or difficulty with swallowing. Sadly, the nursing home failed to learn or apply some of the lessons that should have been learned from this earlier fatality.

The resident involved in this incident had a number of diagnoses that would have placed him at risk of choking. First, he suffered from dysphagia, or difficulty in swallowing. He also suffered from dementia, intellectual disability, postural kyphosis (hunching of the back). When someone has diagnoses which place them at risk for choking, they are customarily referred to speech therapy, who evaluates the resident’s risk of choking and makes diet and other recommendations intended to minimize the risk of choking.

Here, the resident was in fact seen by speech therapy who determined that the resident was at risk for choking and was given a diet of mechanical soft foods with nectar thickened liquids. The recommendations also included one for constant supervision. This was backed up by physician order which in addition to the diet restrictions, also called for giving no more than a ounce of fluid at one time due to impulsivity, take small bites of food and small sips of liquid due to dysphagia, have the resident drink liquids after 2-3 bites of food.

The care planning process is a multi-step process by which risks to the health and well-being of the resident are addressed. These steps include: (1) assessing the risks to the health and well-being of the resident, (2) developing a care plan which reduces to writing the steps which must be taken to address those risks, (3) communicating the care plan to the staff members charged with carrying it out, (4) actually implementing the care plan, (5) evaluating the effectiveness of the care plan, and (6) revising the care plan if it proves to be ineffective in practice or the care needs of the resident change.

When a speech therapist issues recommendations for safe eating or a physician issues standing orders regarding diet, these are customarily included in the resident care plan. However, these were not included in the care plan for this resident.

Why? The director of nursing told the state surveyor who investigated this incident that she did not know that diets should be included in the care plan. As a result, the steps which should have been taken to keep this resident safe were not communicated to the staff.

Despite this, the staff was aware of the need for supervising the resident. They were aware that the resident would try to eat too quickly and shove more food into his mouth than was safe (something that is fairly common among nursing home residents suffering from dementia). They knew that he needed cueing to slow down and to drink water and that at times he would need assistance with the eating. They also knew that he should not be left unattended his meal tray.

On the day of this fatal nursing home choking accident, the resident was brought to lunch and seated at a feeder table with aide. The residents were being feed ground beef stew, biscuits, soft cooked vegetables, cake, and a beverage. These are items which are consistent with the mechanical soft diet.

While the residents were being lunch, the aide at the table was called out of the dining room to deal with a crisis with another resident. When she left the dining room, the tray with the food was left with the resident. There was no one supervising the resident.

Less then 5 minutes later, a family member of another resident saw that the resident was choking and yelled out that this was happening. Other staff responded and pulled the resident away from the dining room in his wheelchair. Staff at first attempted to perform the Heimlich maneuver with the resident still in the chair, but this was unsuccessful, so the resident was removed from the chair and placed on the floor. A nurse attempted to clear the resident’s airway with a finger sweep, but was only able to remove a small potion of the biscuit.

The crash cart was brought to the resident, but where he was placed on the floor was far enough away from an outlet that the suctioning device could not be plugged in, so maintenance had to be called to bring an extension cord.

In the interim, 911 had been called, and the paramedics arrived. When they arrived, the staff was still trying to clear the airway. They used a suction device and forceps and were able to remove more biscuit from the resident’s airway. However, by the time that the resident’s airway was cleared the resident had lost his pulse. There was a DNR in place, so the paramedics inquired of the hospital whether they should continue resuscitative efforts. They were instructed to continue to do compressions and bring the resident to the emergency room. However, once they arrived, the staff there determined that the resident could not be treated in a manner consistent with the DNR, so efforts were stopped and the resident was pronounced dead.

During its investigation, IDPH determined that only one nurse was in the building who had a current CPR certification, and she was not involved in the care of this resident because she was assigned to work the COVID wing of the building. The aides involved were not certified, either. This was despite a facility-wide policy requiring all staff to have current CPR certifications. The director of nursing explained to the state surveyor that there had been changes in the human resources department and the certifications were not being tracked.

The key issue here is that the resident was not being supervised while eating despite a well-recognized need for doing so. The resident was left unattended with his meal tray while the aide left to help elsewhere. While this was going on the resident ate too much biscuit too quickly (a behavior which was well-known to the staff) which he was not able to swallow because of his dysphagia. The aide simply should not have left him unattended and with his meal tray. If helping with the other resident was absolutely necessary, then the tray should have been taken out of the reach of the resident. Instead, he was left unattended to the point that it fell to a visiting family to recognize that the resident was choking.

After one previous fatal choking accident, the nursing home should have learned a hard lesson about failing to supervise residents who were at risk of choking, but that lesson was not absorbed. Sadly, failing to learn hard lessons seems to be too often true in the long-term care industry. 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 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:

Aperion of Spring Valley resident chokes to death

Fatal choking accident at River Bluff nursing home

Heartland of Moline resident develops pneumonia due to failure to follow diet orders

Sunset Rehab resident chokes to death

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

Failure to follow care plan leads to fall and fractured hip at Piatt County Nursing Home

November 17, 2022 By Barry G. Doyle

IDPH has cited and fined Piatt County Nursing Home after a resident there fell and suffered a fractured hip due to the failure of the staff to comply with the resident care plan which called for the use of a bed alarm and a chair alarm.

The care planning process is how much of the basic care is provided to nursing home residents on a day-to-day basis. There are six steps in the care planning process: (1) a resident assessment where the risks to the health and well-being of the resident are identified, (2) the development of a care plan which identifies steps or interventions to be taken to address the risks to the resident and assigns various staff to carry out those steps, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) evaluation of the effective of the care plan on an ongoing basis, and (6) revision of the care plan if the resident’s needs change or if the care plan proves to be in ineffective in practice.

The resident involved was properly assessed as being at risk for falls. She had a number of fall risk factors. One of these was a history of falls, as it is well-recognized in the long-term care industry that falls tend to beget additional falls. Another risk factor was an impaired gait. Finally, the resident suffered from cognitive impairments which caused her to overestimate or forget limits. This means that she could not be counted on to follow instructions or make good decisions for her own safety.

A fall prevention care plan was put into place to address the resident’s risk of injury due to falls. Among the steps that were put into place was the use of a bed alarm and a chair alarm. These are devices which are designed to sound an alarm when the resident attempts to get out of bed or their chair or wheelchair. The sounding of the alarm serves two purposes: it alerts the staff that the resident is getting up and it reminds the resident that they should be waiting for help. The requirement for use a bed alarm or chair alarm was backed by a physician order for the staff to check that the alarm was in place and functioning.

On the day of this nursing home fall, the resident involved was suffering from a urinary tract infection. For senior citizens, urinary tract infections are well-known to cause increased confusion, and indeed earlier on the day of the fall, the resident had been noted to have increased episodes of confusion. To address the resident’s increased confusion, the resident was placed in her wheelchair and brought out into the hallway where she could more easily be monitored by staff. However, when she was moved to the hallway, the chair alarm was not taken from her room chair and placed on her wheelchair, so there was no alarm in place.

The aide who discovered the fall exited another resident’s room and saw the resident standing in front of her wheelchair. She was unsteady and fell to the floor. She was diagnosed with a fractured hip.

During interviews with the staff by the state surveyor, the aide acknowledged that the chair alarm should have been placed on the wheelchair when the resident was moved to the hallway, but that she did not know this was supposed to be done. This is a breakdown in the communications portion of the care planning process – there was a reasonable care plan in place (backed by a physician order to boot), but the staff charged with carrying it out did not know what was supposed to be done. All staff acknowledged that the use of the alarm would have alerted them that the resident was getting up and would have given them an opportunity to try to prevent the fall.

Beyond that, the whole purpose of bringing the resident out in the hallway was to keep her under direct observation. This was a reasonable thing to do given that increased confusion should have been anticipated and was in fact observed due to the urinary tract infection. The problem with this is that this was not assigned to anyone in particular, and she was left unattended in the hallway. This gives proof to the adage in business, “When it’s everyone’s job, it’s no one’s job.” Since it was no one’s job, the plan to keep her under direct observation (a good plan) was not executed, with the fall and broken hip a result.

Other blog posts of interest:

Lutheran Home resident dropped from lift during transfer, breaks hip

Piatt County Nursing Home resident breaks neck in fall from power recliner

Westminster Village resident suffers multiple fractures in fall

Piatt County Nursing Home resident breaks hip in fall

Mason City Area Nursing Home resident suffers fractured hip in fall due to failure to use gait belt

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

Resident rolled from bed, breaks leg at Stonebridge Nursing & Rehab in Benton

November 13, 2022 By Barry G. Doyle

IDPH has cited and fined Stonebridge Nursing & Rehabilitation nursing home in Benton after a resident there was rolled from bed, suffering a fractured leg which required surgical repair.

In the nursing home industry, the term “bed mobility” refers to the ability of a resident to change and maintain position in bed. When residents have deficits in bed mobility, it places them at increased risk for developing bed sores. Bed mobility is one of the areas which is assessed during the process of preparing the Minimum Data Set (MDS) and if the resident has deficits, they must provided assistance with one or two staff members. The level of assistance is recorded on the Minimum Data Set form and submitted to the federal government under penalties of perjury because the data submitted in the MDS forms part of the basis by which the nursing home is paid for the care it provides.

As a general rule, side rails are discouraged in the nursing home industry due to the risks associated with entrapment between the side rail and the mattress. There is also a risk of falls associated with residents trying to climb over the top of them. However, they may be used as a aid in bed mobility where the resident can use the upper rails to hold onto in changing and maintaining position in bed.

The resident involved in this nursing home fall suffered from a multitude of long-term conditions, including general weakness. She had been coded on her MDS form as requiring the assistance of two with bed mobility. She also had one upper side rail to assist with bed mobility.

On the day of this nursing home fall, a single nurse came into the room to provide care for skin breakdowns on the resident’s sacrum. The resident was positioned on her side, facing away from the one side rail that was in place to assist with bed mobility. The wheels to the bed were not locked in place. As the nurse went to get her supplies, the bed slid away from the wall and the resident rolled off the bed in between the wall and the bed, landing on the floor.

The resident had immediate pain in the left leg. An ambulance was called, and the resident was brought to the hospital where she was diagnosed with a comminuted fracture of the femur. She underwent surgery to repair the fracture.

There were at least four failures in the care that this resident received. First, she was repositioned in bed by a single staff member, rather then the two which were indicated by her MDS. Having one person do a two-person job is a well-recognized formula for disaster (see here, here, and here for examples). Second, the nurse left her unattended in a side-lying position, so there was actually no one available to help her maintain her position in bed. When two staff members are used to reposition a resident in bed, one is on each side of the bed to ensure that the resident does not continue rolling over the edge of the bed, such as happened here. Third, the resident was turned away from the side rail that was in place so that she had nothing to help her maintain her position in bed. Finally, the wheels to the bed were not locked in place. This in turn led to the bed rolling while the resident was in the side-lying position and contributing to her falling from bed.

Other blog posts of interest:

Resident dies from brain bleed after fall at Elmwood Nursing & Rehab in Maryville

Aperion Care St. Elmo breaks hip in fall

Mar-Ka Nursing Home resident breaks both legs in fall

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

Swansea Rehab resident fractures hip in fall

September 15, 2022 By Barry G. Doyle

IDPH has cited and fined Swansea Rehabilitation & Health Care Center nursing home after a resident there suffered a fractured hip in a fall after she was left unattended while going to the bathroom.

The resident at issue was recognized as being at risk for falls. She suffered from cognitive impairments, was not steady on her feet and only able to stabilize with staff assistance while walking. This combination of physical and cognitive impairments is a leading indicator of fall risk because they are not able to walk safely, but at the same time cannot be counted on to follow instructions or make good decisions for their own safety.

Due to her fall risk, a fall prevention care plan was put into place. The fall prevention measures included one person assist with use of a gait belt for all ambulation.

On the day of this nursing home fall, the resident was brought to the bathroom by an aide to use the toilet before dinner. While the resident was using the toilet, the aide left the resident to get a washcloth. When she returned, she found the resident in a seated position on the floor of her room. The aide admitted to the state surveyor that she knew that she should not have left the resident alone on the toilet. She also admitted to the state surveyor that she told the nurse on duty that she was in the room when the resident fell when actually was not because she did not want to get into trouble.

The aide reported the fall to the nurse who in turn notified the resident’s physician. The doctor ordered x-rays which showed that there was an acute fracture of the hip. The resident was then sent to the hospital for further care.

The cause of this fall and injury to the resident is readily apparent – the aide admitted that the resident should not have been left unattended while on toilet, but she was. The aide told the surveyor that she thought she would be gone for 30 seconds, but it was clearly longer than that, given that the resident finished going to the bathroom, got up from the toilet, and walked into her room where the fall occurred. More troubling than this is the fact that the aide lied to the nurse about what happened, which raises questions as to exactly what was really being done to care for this resident.

Other blog posts of interest:

Resident rolled from bed, breaks leg at Stonebridge Nursing & Rehab in Benton

Resident dies from brain bleed after fall at Elmwood Nursing & Rehab in Maryville

Aperion Care St. Elmo breaks hip in fall

Mar-Ka Nursing Home resident breaks both legs in fall

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

Arcadia Care Bloomington resident suffers broken hip and back due to defective wheelchair

September 12, 2022 By Barry G. Doyle

IDPH has cited and fined Arcadia Care Bloomington nursing home after a resident there suffered a broken hip and a fracture to her mid back after she suffered a fall due to a defective wheelchair brake.

Wheelchairs are one of the most commonly used pieces of equipment in a nursing home. However, for them to be used safely, they must be properly maintained and all of the accessories used as well. The brakes on a wheelchair are critical to the safe use of the chair. When residents attempt to get out of the wheelchair, the brakes must hold firmly or the wheelchair will roll out from under them while they are in the process of rising. This will almost certainly result in a fall. In most nursing homes, the maintenance department are the ones called upon the fix and maintain the residents’ wheelchairs.

On the day of this nursing home fall, the physical therapist entered the room only to find that the resident was half-in, half-out of the wheelchair. She summoned an aide who helped get the resident from the floor, but the resident was in too much pain to participate in therapy. The aide noted that the left side brake was loose so that the chair would still move even with the brake on. She was sent to the emergency room where she was diagnosed with a fractured hip and a fracture of the T-12 vertebra (lower middle back) which required the use of a back brace.

The investigation of this incident revealed that there were at least three staff members who were aware that the brake was loose. Two were aides – including the one who helped the therapist. The other was the maintenance man, who found that the brake was “wiggly” when he installed an anti-rollback device but thought it was sufficient to hold and elected to not repair the brake at that time.

Federal regulations require that nursing homes be kept as free of accident hazards as possible. The defective brake on the wheelchair is something that should have been readily recognized as a hazard by staff given that they had doubtless been trained to make sure that the wheelchair was locked in place with the brakes before attempting to transfer a resident. The failure to correct a known hazard was the direct cause of this fall and the resident’s injuries.

Other blog posts of interest:

Failure to follow care plan leads to fall, fractured hip at Piatt County Nursing Home

Good Samaritan at Pontiac resident suffers fracture knee and leg in wheelchair accident

Piatt County Nursing Home resident breaks hip in fall

Resident breaks hip in fall at McLean County Nursing Home

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

Odd Fellow-Rebekah Home resident suffers fatal brain bleed due to fall

September 9, 2022 By Barry G. Doyle

IDPH has cited and fined the Odd Fellow-Rebekah Home nursing home in Mattoon after a resident suffered a fatal brain bleed due a fall that occurred after she was left unattended while going to the bathroom.

The resident involved had a complex medical history, including diagnoses of atrial fibrillation, abnormalities of gait and mobility, unsteadiness on her feet, and generalized muscle weakness. The diagnosis of atrial fibrillation was significant because she received a blood thinner commonly known as Eliquis in order to prevent blood clots brought on by the atrial fibrillation. Blood thinners are obviously an important part of preventing blood clots that can lead to stroke and other cardiac and circulatory events. However, one of the risks of the use of blood thinners is the risk of internal bleeding with trauma. In particular, brain bleeds are known to occur after falls, even in the absence of a direct blow to the head.

The resident was also well-recognized as being a fall risk. Her fall risk assessment showed her to be at high risk for falls. The Minimum Data Set (MDS) completed by the nursing home staff showed that she had cognitive impairments, required staff assistance with all activities of daily living, that she was not steady during transitions and while walking, and that she needed the staff with her to stabilize her while toileting. The Minimum Data Set is a form which is completed by the staff and certified under as being an accurate statement of the care the resident requires and is receiving. The reason that is certified under oath is that it forms part of the basis by which the nursing home is paid for the care

In the week prior to the fall at issue, she two other falls. The occurrence of falls is significant because it is well-recognized in the long-term care industry that falls tend to beget more falls. After each of the two prior falls, the staff investigated the fall and determined that the first was caused by her legs becoming weak while walking and that the second was caused by a loss of balance while trying to get to the bathroom unassisted. After each, the staff checked a box for “no” on the form which read, “Independent for Toileting.” After each of the two falls, the resident fall prevention care plan was upgraded.

On the day of this nursing home fall, the aide assigned to the resident was told by another aide who had been in the resident’s room that the resident was on the toilet with clothes on. The aide went into the room and found the resident laying sideways on her bed undressed with resident’s walker turned over on the floor. The aide got the resident positioned in bed and notified the nurse.

The following morning, aides getting the resident from bed saw that the resident had a large (10.5 cm x 12 cm) bruise on her face. The nurse notified the resident’s physician. The doctor happened to be in the nursing home and upon seeing the resident ordered her sent to the emergency room for evaluation. A CT scan at the hospital showed that there was a large (22 cm), acute brain bleed. She was transferred to another hospital where she died a week later. Her cause of death, per her physician, was brain bleed due to the fall.

Following the fall, the director of nursing conducted an investigation and concluded that the cause of the fall was the resident being left unattended on the toilet and attempting to return to bed without assistance.

This was a highly preventable fall. The nursing home staff clearly recognized that she was a fall risk due to her generalized weakness. However, her cognitive impairments were a substantial barrier to her being able to make good decisions for her own safety and to heed warnings and instructions. After each of the two earlier falls (one of which happened when she was on her way to the bathroom unattended), the investigation showed that she was no independent for toileting. Nonetheless, the aide left her on the toilet on her own and left her to get off it and back to bed on her own. In short, her well-recognized care needs were not met. This led directly to her fall and death.

Other blog posts of interest:

Unsupervised resident at Odd Fellow Rebekah Home has fall, suffers brain bleed

Aperion Care St. Elmo resident breaks hip in fall

Charleston Rehab resident suffers fractured hip and brain bleed in fall from bed

Tuscola Health Care Center resident dropped from lift, breaks ankle

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

Mishandling of resident results in broken shoulder at Havana Health Care Center

August 29, 2022 By Barry G. Doyle

IDPH has cited and fined Havana Health Care Center nursing home after a resident there suffered a broken shoulder due to being mishandled by staff while she was repositioned in bed.

“Bed mobility” refers to the ability of a resident to change and maintain their position in bed. When a resident has deficits in bed mobility, it is up to the nursing staff to help change their position in bed. When a resident needs to be moved toward the head or the foot of the bed, a lift sheet is used to help reposition the resident.

A lift sheet is laid on top of the fitted sheet and staff lifts the resident up part way and moves them up and down in bed. Besides being helpful in repositioning the resident, the use of a lift sheet reduces the amount of friction and shear to the resident’s skin, something that increases the risk of developing bed sores. Use of a lift sheet in repositioning residents was called for in the nursing home’s policies and procedures.

The resident at issue had a medical history which included chronic lower back pain and a stroke with residual right-sided weakness. Her Minimum Data Set (MDS) certified that she required extensive assistance of staff with bed mobility.

On the day of this resident’s injury, the lift sheet was underneath the resident in a position where the staff could not easily access it. Because it was a busy time with a lot of call lights going off, the aides decided to lift the resident from under her armpits. As they did so, there was a pop heard coming from the resident’s shoulder and she had immediate pain. However, it was not until the next shift that a nurse notified the doctor. An order was placed for an x-ray which showed that she had a fracture of the proximal humerus (the portion of the upper arm which inserts into the shoulder socket).

The treating orthopaedic surgeon confirmed for the state surveyor that this kind of fracture is “a very painful injury, especially initially.” The resident’s physician ordered Norco the following day. However, the resident did not receive the medication due to the nursing home failing to obtain the necessary authorizations for the pharmacy to release a controlled substance, resulting in the resident experiencing unnecessary pain.

There are a number of issues with the care that this resident received. The first level relates to the mishandling of this resident. Use of a lift sheet was called for by facility policies and procedures, but the staff instead mishandled the resident, resulting in the injury. Second, once the injury occurred, she did not receive the prescribed pain medication, resulting in her experiencing unnecessary pain.

These are of course the superficial reasons why. The deeper reason is likely understaffing of the nursing home. This is shown by the fact that the staff took shortcuts in the care of this resident because it was so busy – a sign that there are not enough hands on deck to meet the care needs of the residents. Sadly, understaffing is a core feature 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 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:

Heritage – Mt. Sterling resident breaks leg in fall

Mason City Area Nursing Home resident suffers broken hip in fall due failure to use gait belt

Fondulac Rehab resident suffers fatal injuries in fall

Mason City Area Nursing Home resident suffers fatal brain bleed in fall

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

Symphony of Buffalo Grove resident has catastrophic fall from lift

August 25, 2022 By Barry G. Doyle

IDPH has cited and fined Symphony of Buffalo Grove nursing home after a resident there suffered multiple injuries in a fall from a lift that led to the resident being placed on hospice.

One commonly used piece of equipment in a nursing home setting is a mechanical lift, and used properly, it can be one of the most useful pieces of equipment in the nursing home. It allows the staff to easily move residents with significant mobility deficits from bed to wheelchair, wheelchair to chair, and so forth. Used properly, it minimizes the risk to residents and staff alike during manual transfers.

Of course like any piece of machinery, the risks of injury increase when it is not used properly. Proper use of a mechanical lift has at minimum three main parts: 1) the staff is properly trained in the use of the device, 2) the lift and all of its components parts and accessories are in good condition and used properly, and 3) two staff are used to complete the transfer – one to manage the controls to the lift, the other to supervise and assist the resident through the transfer.

Having one person doing a two-person job is a well-recognized formula for disaster (see here, here, here, here, and here for examples), and this event proved to be no different.

The resident involved had a long list of significant medical conditions, and had been declining since a hospital admission earlier in the year. She was dependent on staff for all care and required the assistance of two staff for all transfers, and her care plan called for use of a mechanical lift with two person assist for all transfers.

On the day of this nursing home fall, the resident was being transferred by a single aide from bed to her wheelchair so that she could receive assistance with eating lunch. The aide admitted to the state surveyor that she knew that there were supposed to be two staff members for all lifts but she did not get a second staff member to assist because they were busy due to it being lunch time.

When the aide went to get the resident up in the lift, she saw that there were six straps to the lift sling, not the four that the aide was accustomed to. She attached the sling to the lift just as she normally would have, ignoring the additional two straps that were a part of the sling. The aide then attempted to maneuver the lift into position, but as she did so, the resident’s foot bumped the arm rest of the wheelchair. The resident began to sway in the sling and then suddenly slid out of the sling onto the floor, landing feet first, but then hitting her head on the floor.

There was immediate bleeding from the back of the resident’s head. The aide got the nurse who tried to bring the bleeding under control and then called for an ambulance. The resident was brought to the hospital, where she was diagnosed with a brain bleed, a fractured skull, a fractured clavicle, and a fractured humerus. Surgery was not attempted and the resident was placed on hospice.

There are a number of causes of this very preventable injury. First the aide was not trained in the use of this lift and this sling, resulting in the sling not being attached to the lift properly. Second, the aide violated the resident care plan which called for two staff with all transfers via lift. Third, the aide attempted to transfer the resident on her own, not with the assistance of a second staff member as required by her training and the facility’s own policies. Had a second staff member been involved in the transfer, there is a reasonable chance that the sling would have been attached properly, but just as importantly, there would have been another staff member to help control the resident so that the contact with the wheelchair would have been avoided, as this is what led to the resident swaying in the sling and eventually being dumped from the lift onto the floor.

These are the obvious reasons for this fall, but there is a second level to this, and it relates to the overall management of the facility. The aide had not been properly trained in the use of the sling and the lift, and then proceeded with the transfer on her own because the staff was busy due to it being lunchtime. Being “too busy” to get the required number of people to provide proper care to a resident is a sign of an understaffed nursing home. Sadly, poor training and understaffing are a result 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 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:

Addolorata Villa resident fractures hip in fall

Inverness Health & Rehab resident suffers multiple fractures in fall

Glenview Terrace resident suffers multiple fractures when lift topples over during transfer

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

Resident suffers broken ankle in unsafe transfer at Loft Rehab of Rock Springs

August 24, 2022 By Barry G. Doyle

IDPH has cited and fined Loft Rehab of Rock Springs nursing home in Decatur after a resident there sustained a fractured ankle while being transferred from her wheelchair to her bed with the assistance of a single aide rather than the two which were required.

Used properly, a mechanical lift is a helpful piece of equipment in a nursing home. It allows residents to be safely transferred from bed to wheelchair, wheelchair to chair, and so forth. It also spares the staff the task of moving residents manually, which reduces the incidence of injury to the staff from lifting injuries and to residents from rough or improper handling while being moved.

The key phrase in the paragraph above is “used properly.” This is because when the lift is not used properly, the potential for disaster lurks. Proper use of the lift includes the staff being properly trained in the use of the lift, two staff involved in the transfer (one to handle the resident, the other to manage the controls), and all of the equipment and accessories on the lift itself being in good working condition. One of the more common types of accidents we see with the use of lift is having one person doing a two-person job (see here, here, and here for examples).

On the day of this nursing home fall, the resident was being transferred from her wheelchair to her bed using a lift. There was only a single aide involved in the transfer. While the resident was being lifted from her wheelchair to her bed, her lower leg became entangled in the foot rests to the wheelchair. The aide completed the completed the transfer and put the resident to bed. The following morning, the resident was complaining of pain, and the nurse on duty found that the resident’s ankle was bruised, swollen, and painful to touch. The resident was sent to the hospital where CT scans showed that there were multiple fractures of the ankle. However, because the resident was nonweight bearing, they elected to proceed without surgery.

This was a highly preventable injury. All that had to be done was for a second aide to participate in the transfer. The very purpose of that second aide is to help handle the resident and this would have likely avoided the entanglement with the wheelchair footrests and the resulting injury. Although the resident was nonweight bearing, this kind of fracture does have serious negative implications for her activity level and her overall quality of life.

The deeper and more important questions is why did the aide skip the step of having a second staff member there? She told the state surveyor that she was in a hurry that evening. Being in too much of a hurry to provide safe care is a hallmark of an understaffed nursing home. Sadly, understaffing a nursing home is 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 nursing home 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:

Tuscola Health Care Center dropped from lift, breaks ankle

Loft of Rock Springs resident suffers fractured hip in fall

Charleston Rehab resident suffers brain bleed and fractured leg in fall from bed

Unlocked furniture results in fall and fracture at Mount Vernon Countryside Manor

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

Park Place Christian Community resident rolled from bed by staff

August 20, 2022 By Barry G. Doyle

IDPH has cited and fined Park Place Christian Community nursing home in Elmhurst after a staff member there rolled a resident out of bed and onto the floor, resulting in the resident suffering fractures which led to the resident being placed on hospice.

“Bed mobility” in the long-term care industry refers to the ability of the resident to change and maintain position in bed. This includes things like being able to turn to the side and maintain that position. This is something that is important for having the staff provide incontinence care to help prevent the development of bed sores or to get a sling into position for transfers with a mechanical lift.

When residents have deficits in bed mobility, this is something that requires the assistance of staff. The extent of the resident’s deficits and the need for staff assistance should be recorded on the resident’s Minimum Data Set (MDS). The MDS is information which is submitted to the federal government and forms part of the basis by which the nursing home is reimbursed for providing care. Because of the financial implications of this, the data on the MDS is certified as being true and an accurate reflection of the care that the resident is in fact receiving.

This resident had a long medical history and was largely bedbound. Her MDS specified that she had deficits in bed mobility and required the assistance of two staff members with bed mobility. When two staff members are providing help with bed mobility and the resident is being positioned on her side, one should be positioned on each side of the bed. This way, when the resident is turned to one side, one staff member can do what is necessary (e.g., provide incontinence care, position the sling for the lift etc.) while the other assures the position of the resident on the bed and makes sure that the resident does not roll out of bed.

On the day of this nursing home fall, the aide was attempting to position the resident onto the sling for the lift. Even though this was designated on the MDS as a two-person assist, the aide was attempting to do this on her own. Having one person attempt a two-person job is a well-recognized formula for disaster (see here, here, and here for examples). Making the task all the more difficult, the resident was on a low-air loss mattress for the prevention of bed sores. This surface can make the mattress more slippery than it would be otherwise.

As the aide attempted to place the resident into the sling, she moved the resident’s legs away from her. The resident’s legs went over the edge of the bed, pulling the resident with her. The resident landed on her hands and knees. X-rays confirmed that she sustained fractures of the femur (the high bone) and the humerus (the bone of the upper arm). Rather than attempt surgery, the resident’s family elected to have the resident placed on hospice.

This was a highly preventable accident. All that it would have taken is for the resident to receive the care that the nursing home certified was necessary – two persons assisting with bed mobility. Had that been done, the resident’s legs would not have pulled her off the edge of the bed in the way that this happened and she would not have been injured and placement in hospice for necessary pain control would not have been required.

When staff takes shortcuts in the care that a resident needs – such as having one person doing a two-person job – this is an indication that the nursing home may be understaffed. Sadly, understaffing is a core component of the basic 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 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:

Grove of St. Charles resident fractures hip after being rolled out of bed by staff

Westmont Manor resident suffers brain bleed after being rolled out of bed

Addolorata Villa resident fractures hip in fall

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

Heritage – Mt. Sterling resident breaks leg in fall

August 16, 2022 By Barry G. Doyle

IDPH has cited and fined Heritage of Mt. Sterling nursing home after a resident there suffered a broken leg in a fall which occurred due to the failure to use a gait belt while providing care and failing to provide care with two qualified staff members as required.

One useful tool in the care of nursing home residents is the Minimum Data Set (MDS). The MDS serves as repository of data regarding the abilities and care needs of nursing home residents. One unusual feature of the MDS is that the data contained on it is certified to the federal government as being accurate, as it forms part of the basis by which nursing homes are reimbursed for the care that they provide to residents.

This resident’s MDS included findings that she required extensive physical assistance of two staff with dressing, bed mobility, and transfers. During the care planning process, the resident was assessed as a fall risk due to a history of falls, poor cognition, and overestimating or forgetting her limitations. Her medical history also included a diagnosis of muscle weakness. The care plan called for two staff to assist with all transfers.

The nursing home also had standing policies which the staff was to follow in the care of residents. One of those was a policy regarding the use of gait belts. A gait belt is a woven strap that is applies around the midsection of residents while residents are receiving assistance with transfers or walking. It allows the staff member to better control the balance of the resident and either stop or slow down the rate of falls when the resident loses their balance.

On the day of this nursing home fall, the resident was seated on the edge of the bed while being dressed by an aide. There was no gait belt applied. The resident moved toward the edge of the bed to stand to transfer her from the bed to her wheelchair, but the resident’s legs gave out from underneath her, and she fell to the ground.

At the time of the fall, there was a second staff member called a unit assistant. However, that person was not trained to provide direct patient care to residents and was two feet away when the fall occurred. The administrator and director of nursing both told the state surveyor that a unit assistant did not qualify as a second staff person when the resident required the assistance of two staff with dressing and transfers.

The resident had immediate pain by the knee and was sent to the hospital where she was diagnosed as having a displaced periprosthetic fracture of the distal femur – meaning that there was a fracture of the thigh bone near the resident’s artificial knee where the two sides of the fracture were no longer in alignment. The team at the hospital elected against surgery, and the resident was placed in an immobilizer.

This injury will likely have significant impacts on the well-being of this resident, as her period of immobility will likely result in her no longer having even the limited ability to bear weight on the lower extremities. This in turn can set the stage for issues like the onset of pneumonia or the development of bed sores.

There are two obvious causes of this resident’s injury. One is the failure to use the gait belt as required by the facility’s own internal policies. The second is the failure to have two qualified staff people participating in the transfer as called for in the resident care plan – seeing as the unit assistant was not qualified to participate in helping with the transfer.

There is a deeper level to this, and it likely is that the nursing home was understaffed. When you see shortcuts being taken in the resident care such as not applying a gait belt or there not being two staff available when needed, these are signs of an understaffed nursing home. Sadly, understaffing is 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 nursing home 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:

Mason City Area Nursing Home suffers fatal brain bleed in fall

Fondulac Rehab resident suffers fatal injuries in fall

Monmouth Nursing Home resident sustains multiple falls leading to brain bleed

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

Moweaqua Rehab resident develops pressure ulcer from fracture brace

Staff at Bella Terra Schaumburg knowingly uses broken lift, resulting in brain bleed for resident

Resident left unattended in dining room at Ascension Saint Anne Places suffers fractured hip in fall

Infection results from failure to provide care for surgical wound at Arcadia Care of Morris

Promedica Skilled Homewood resident falls and breaks hip

Unsupervised resident at Odd Fellow Rebekah Home falls and suffers brain bleed

Unlocked furniture causes fall and broken leg at Mount Vernon Countryside Manor

Sharon Heath Care Elms resident develops bone-deep bed sore

Resident at Fondulac Rehab in East Peoria catches fire in smoking accident

Mattoon Rehab resident dies from infected bed sore

Non-functional alarm leads to fall and fractured hip at Sunset Home in Quincy

Staff at Lutheran Home in Peoria drops resident from lift, resulting in fractured hip

Avantara Lake Zurich resident suffers lower leg wound during unsafe transfer to bed

Macomb Post Acute Care Center resident thrown from wheelchair during van ride, suffers multiple fractures

Second fatal choking accident at Aperion of Spring Valley in two years

Failure to follow care plan leads to fall and fractured hip at Piatt County Nursing Home

Resident rolled from bed, breaks leg at Stonebridge Nursing & Rehab in Benton

Swansea Rehab resident fractures hip in fall

Arcadia Care Bloomington resident suffers broken hip and back due to defective wheelchair

Odd Fellow-Rebekah Home resident suffers fatal brain bleed due to fall

Mishandling of resident results in broken shoulder at Havana Health Care Center

Symphony of Buffalo Grove resident has catastrophic fall from lift

Resident suffers broken ankle in unsafe transfer at Loft Rehab of Rock Springs

Park Place Christian Community resident rolled from bed by staff

Heritage – Mt. Sterling resident breaks leg in fall

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