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Bella Terra Elmhurst resident fractures hip, dislocates knee in fall

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IDPH has cited Bella terra Elmhurst nursing home after a resident there suffered a fractured femur and dislocated knee in a fall.

One of the well-worn paths for injury to nursing home residents is having one person do a two-person job (see here, here, here, here, and here for examples).  Most often, this occurs because the staff member involved is taking a shortcut in the care of the resident, usually because the nursing home is understaffed.  This incident shows that this can also happen when there is a breakdown in the process by which the care needs of the residents are communicated to the staff on the floor.

The resident at issue suffered a dislocated shoulder and underwent a course of physical therapy.  At the time the resident was discharged from physical therapy, there was a recommendation by the therapy for the resident to have transfers with the assistance of two staff members using a gait belt.  The nursing home incorporated that recommendation into the resident’s care instructions which were kept in a binder at the nurse’s station.

On the day of this nursing home fall, there was an aide from a staffing agency who was assigned to care for the resident at issue.  It was that aide’s first time caring for the resident, so she asked the nurse assigned to the resident what her transfer status was, and was told that the resident required assist of one with a gait belt.  The aide was unaware of the existence of the binder.  The nurse, who was caring for the resident for only the second time, claims that she was told during the nurse-to-nurse report during change of shifts that the resident was assist of one with transfers.  However, she did not verify this in the binder.

Acting on the information provided, the aide attempted to transfer the resident from her bed to her wheelchair without the assistance of another staff members.  Immediately after the resident stood up from the bed, her legs gave out from underneath her, and the resident was lowered to the floor using the gait belt.  The aide  got a nurse who helped the resident get back into bed using a lift.

The resident had persistent complaints of pain before she was sent to the hospital where x-rays showed a subcapital femur fracture (a type of hip fracture) and a dislocated knee as a result of the fall.

One of the interesting points about this is that the aide and nurse who were charged with caring for this resident were both agency staff, meaning that they were not necessarily people who regularly worked in the facility.  When agency staff is brought on board, they must be trained sufficiently in how things are done in the nursing home.  The aide did the right thing by asking what the transfer status was of the resident, but was unaware that there was a clear answer in the binder – because she did not know that the binder existed.

The use of agency staff and the failure to invest the minimal time necessary to properly train them is a sign of a nursing home that takes shortcuts in the care of the resident.  Sadly, this is consistent with 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:

Failure to supervise Westmont Manor resident results in fall with hip fracture

Park Place Christian Community resident rolled from bed by staff

Sunny Hill resident suffers fractured leg after lift tips over

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

 

Violation of care plan at Generations Oakton Pavillion leads to fall and fracture

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IDPH has cited and fined Generations Oakton Pavillion after a resident there suffered a fractured leg in a fall which occurred due to staff attempting to manually transfer her from wheelchair to bed without using a lift, in violation of the resident’s care plan.

Much of the routine care that residents receive in a nursing home setting is shaped by the resident care plan.  In the care planning process, an assessment is done to identify the resident’s care needs and risks to the health and well-being of the resident.  A series of steps, or interventions, are then put into place which are intended to meet the resident’s needs.  The staff members assigned to carry out those interventions then must do so on a day-to-day, shift-to-shift basis.

The resident at issue was morbidly obese and had left-sided weakness from having had a stroke in the past.  She was unable to bear weight, so her care plan called for transfers with a mechanical lift with the assistance of two staff members.

On the day of this nursing home fall, the sling for the lift that normally would have been left underneath the resident as she sat in her wheelchair was not in place.  Because there was no sling readily available, the aides attempted to transfer the resident manually without using a gait belt.  As they attempted to pivot to turn from the wheelchair to the bed, the resident’s legs gave out and she fell to the ground, landing on her knees.  She was helped from the floor to bed by the aides.

After the fall, the resident had complaints of pain in the knee and swelling and bruising below the knee.  The resident was transferred to the hospital where x-rays showed that the resident had a fracture of the upper portion of the tibia, extending into the knee joint, and a patellar tendon avulsion.  The resident underwent surgery to repair the injuries from the fall.

The nursing home had a reasonable care plan in place for this resident – the problem was that the staff did not implement it.  The care plan called for transfer with a lift, which was appropriate given her inability to bear weight.  Rather than follow this care plan, the staff attempted to transfer the resident manually.  This was never likely to succeed given her inability to bear weight – and the chances of ensuring an injury-free transfer dropped when they elected to not use a gait belt, either.

The fact that the staff plowed ahead with trying to transfer the resident manually raises a question of whether this is an understaffed nursing home.  This is true anytime you see the staff taking shortcuts which sacrifice resident safety and there were two such shortcuts taken – attempting the transfer without the lift and then not using a gait belt.  Sadly, understaffing a nursing home 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:

Unsupervised resident falls and fractures hip at Lutheran Home for the Aged

Resident fractures leg in unsafe transfer at Ascension Nazarethville in Des Plaines

Addolorata Villa resident fractures hip in fall

 

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

 

Fairhaven Christian Retirement Center resident dropped from lift, breaks hip

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IDPH has cited and fined Fairhaven Christian Retirement Center nursing home in Rockford after a resident there suffered a fractured hip when she was dropped from a lift during a transfer.

Used properly, a mechanical lift is a great tool for providing care for nursing home residents with severe mobility deficits.  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.

Of course, 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).

This incident shows what happens when you have one person doing a two-person job.

The resident at issue had significant cognitive and mobility impairments such that she required assistance of two staff members with transfers.  Further, the resident care plan called for the use of a mechanical lift with two staff assist.  Having the care plan call for two staff members to participate in transferring the resident with a lift is consistent with prevailing safety practices in the long term care industry, as safe operation of a lift requires one staff member to operate the controls of the lift while the other staff member keeps the resident safe and properly positioned in the sling.

On the morning of this nursing home fall, an aide was walking down the hallway when she heard a loud noise come from the resident’s room.  She entered the room to find the resident on the floor lying on the top of the legs of the lift with blood coming from her head.  The only other person in the room was another aide.  The aide explained that she was transferring the resident from her wheelchair to bed by herself.  While the transfer was in progress, the resident rolled to the right and fell from the sling.  Because there was only a single staff member involved in the transfer, there was no one who was able to help keep the resident in the sling.

The resident was transferred to the hospital where she was diagnosed with a fractured hip.  Surgical repair was attempted, but the fracture was complicated and proved to be nonrepairable.  The resident was returned to the nursing home for comfort measures, including pain management.

This is another example of the disaster that results when one person attempts to do a two-person job.  Not only was this a violation of the resident care plan, there were also facility policies in place which required the use of two staff for transfers with a mechanical lift.  And the nursing home not only had a policy in place, but also provided the staff with radios to call for help with transfers.  The aide involved clearly knew that this was not something she should be doing, as she told the first person to enter the room, “I always ask for help.”  Sadly she didn’t do so this time, and the resident paid the price.

When you have staff taking shortcuts in the care of residents, this raises the question as to whether this is an understaffed nursing home.  Unfortunately, understaffing a nursing home is a 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:

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

Waverly Place of Stockton resident breaks hip in unsafe transfer

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

 

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

Use of improper lift at Sunset Home leads to intensive care unit admission

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IDPH has cited and fined Sunset Home nursing home in Quincy after a resident there had to be admitted to the intensive care unit at the hospital due to internal bleeding caused by the use of an improper lift by staff.

There were three key variables in this incident: use of blood thinner medication, a mechanical lift, and violation of the resident care plan.

Blood thinner medications are one of the useful tools in maintaining the health and well-being of nursing home residents.  They can be used to help prevent blood clots, strokes, and a host of other circulatory problems.  However, one of the risks associated with their use is that of uncontrolled internal bleeding which is a reason why residents are customarily placed on a 72-hour fall watch after experiencing a nursing home fall.

Mechanical lifts are also great tools in a nursing home setting when used properly.  They allow residents who have mobility deficits to be transferred from bed to wheelchair, wheelchair to chair, etc. with greatly reduced risk of injury to both the resident and staff.  They phrase, though, is “used properly.”  This includes using an appropriate type of lift and properly sized, well-maintained, suitable accessories for the  lift.

The resident care plan is the tool by which much of the routine care in a nursing home setting is delivered. The care planning process has six steps: (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.

When a resident uses a mechanical lift, this is covered by the resident care plan.  It will specify the reasons why the resident needs the use of a lift, what kind of lift should be used, and how many staff members should be involved in transfers with the lift.  (Hint: it should always be two, because having one staff member try to transfer a resident with a mechanical lift is a formula for disaster – see here, here, here, here, and here for examples).

The resident at issue had a medical history which included atrial fibrillation.  This is an irregular heart beat which causes the formation of blood clots in the heart which can lead to stroke or heart failure.  It is one of the conditions for which a blood thinner is commonly prescribed, and in this case the resident was receiving Elliquis (a blood thinner medication).  The resident was also morbidly obese and had significant strength and mobility deficits.  The resident also had a documented inability to stand for long.  The resident used a full mechanical lift, but a sit-to-stand lift would be used for toileting.

There are differences between a full mechanical lift and a sit-to-stand lift.  With a full mechanical lift, the resident has a sling placed underneath them and their whole body is lifted using the lift.  With a sit-to-stand lift, the resident’s feet are placed on a plate at the base of the lift, the resident’s shins are placed against a support pad, and a sling is placed under the resident’s armpits and around their chest and the device lifts them up into a standing position.  One of the key differences between the two kinds of lifts is that with a sit-to-stand lift, the resident must be able to bear some weight in a standing position, whereas the full mechanical lift requires no physical input from the resident.

On the morning of this incident, two aides went to get the resident out of bed and dressed for the day.  Normally this would have been done using the full mechanical lift, but there were no lift slings available for the full mechanical lift.  The aides instead elected to use a sit-to stand lift while trying to get the resident dressed.  The sling that they used was a regular sized sling, rather than a larger sling which this resident needed.  While the aides had the resident in a standing position while trying to get on his pants, the resident was unable to maintain himself in a standing position and his legs gave out.  The aides lowered the resident to the floor.

Over the next three days, large, hard, dark bruises appeared under the resident’s armpits and he began to complain of pain especially when the bruised areas were touched.  When the bruising began to extend into the back, the resident was transferred to the hospital.  At the hospital, the resident was determined to be anemic from acute blood loss to the point that a blood transfusion was required.  A CT scan of the chest multiple large hematomas of the left side of the chest.  The resident was transferred to the ICU and remained hospitalized as of the time that the state surveyors arrived at the nursing home, some 9 days after the resident was sent to the hospital.

The issue in the care that this resident received is that the aides attempted to use the sit-to-stand lift for a purpose which was not suitable for this resident.  The resident was not able to maintain a standing position for a long period of time, yet they elected to use the sit-to-stand lift to attempt to dress him.  The key difference between the two kinds of lift is that the sit-to-stand lift does require some physical input from the resident – which this resident was not able to provide.

Compounding the poor decision to use an unsuitable lift, the lift sling (the strap that goes under the armpits) was regular size rather than the large one this resident needed.  This likely resulted in there being additional trauma to the resident when the resident’s legs gave out.

These decisions, together with the resident’s use of a blood thinner, caused the serious injuries that this resident suffered.

When you see staff taking shortcuts in the care of residents, this is a mark of a nursing home which is probably short-staffed.  Rather than find a sling to use with the full mechanical lift for the resident, they used the sit-to-stand lift.  Rather than ask a nurse whether this would be okay, they went ahead anyway.  Rather than find a large sling for the sit-to-stand, they used a regular sized sling.  These decisions are examples of poor care -and they would have likely avoided serious consequences had this resident not been on a blood thinner.  Of course, there could have been other issues that resulted from this – and avoiding those would have been a matter of good luck, not good care.

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:

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

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

Sling breaks during transfer at University Nursing & Rehab

 

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

 

Bethany Rehab resident suffers brain bleed and seizures due to medication error

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IDPH has cited and fined Bethany Rehabilitation and Health Care Center nursing home in DeKalb after a resident there suffered a brain bleed and seizures due to a medication error regarding the administration of his coumadin.

Many nursing home residents take anticoagulant or “blood thinner” medications.  Used for a variety of purposes such as a history of blood clots, atrial fibrillation, stroke prevention, and management of other circulatory and cardiac conditions, this class of medication can be crucial for maintaining the health and well-being of the resident for whom the medication was ordered.

However, the use of this medication has to be carefully managed.  If the blood is considered “too thick,” or subtherapeutic, it can lead to blood clots which can have catastrophic consequences; if the blood is “too thin,” or supratherapeutic, this can lead to uncontrolled bleeding.

To ensure that the resident remains in the desired or therapeutic range, the resident must receive regular blood testing called a PT/INR test which measures whether the blood is in the therapeutic range.  If the blood is outside the therapeutic range, then the nurse must contact the doctor to notify him that the resident had an abnormal lab result.  From there, it would be up to the doctor to make adjustments in the dosing of the blood thinner medication or to take other steps to treat the condition.

The resident at issue had a medical history which included atrial fibrillation, a stroke, and a pulmonary embolism – all conditions for which use of a blood thinner was warranted.  The blood thinner which was used for him was coumadin and was being managed by a coumadin clinic.

The resident was seen at the coumadin clinic which gave orders that the resident should receive 5 mg of coumadin on Mondays and 2.5 mg of coumadin every other day with a PT/INR test to be done in weeks.  When he was seen in the coumadin clinic, his INR level was 3.0, which was the high end of the normal range.

However, when the orders were entered into the record at the nursing home, it provided for the resident to receive 5 mg of coumadin on Monday and 7.5 mg of coumadin all other days.  This means that the resident received three times the prescribed dose 6 days a week for a two-week period.

When the PT/INR test was scheduled to be performed at the end of the two weeks, the machine would not give a reading.  A call was placed to the doctor and an order was received to redraw the blood the following morning.  When the test was run again the following day, the lab called back stating again that the results were inconclusive.  Plans were made to redraw the lab again the following morning.

The next morning, the resident started to show slurring of his speech which was getting progressively worse.  The nursing staff paged the physician and nurse practitioner, but when they were not able to get a response, they called 911 and had the resident sent to the hospital.  There labs were drawn which showed a prothrombin time (PT) of 181.5 (normal is 19.7 – 28.8) and an INR score of 21.54 (normal is 2.00 – 3.00).  A CT scan of the head showed that the resident had a left-sided subdural hematoma.  Following this, the resident demonstrated loss of cognitive function and suffered seizures.

Continuity of care is a critical issue in the long-term care setting.  Residents are often seen by outside providers who issue orders for the ongoing care of the resident with the expectation that those orders will be carried out as specified.  When that does not happen, disaster awaits.  Here, the order were for the resident to receive 2.5 mg of coumadin every day other than Monday when he was supposed to receive 5 mg.  The issue arose when the orders were not entered into the record correctly and the resident received 7.5 mg dose the other 6 days of the week.  This led directly to the brain bleed sustained by the resident with catastrophic results for him.

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:

Failure to give blood thinner leads to death of resident at Warren Barr Oak Lawn

Pearl Pavilion resident dies of pulmonary embolism after not receiving blood thinner

Hillside Rehab resident dies of brain bleed due to failure to obtain lab work

 

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

 

 

 

 

 

Newman Rehab resident suffers burns to leg from radiator

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IDPH has cited and fined Newman Rehab & Health Care Center after a resident there suffered burns to his right lower leg and both feet due to his bed being placed directly against a hot electric baseboard heater.

The resident at issue suffered from multiple conditions, including dementia, Parkinson’s, myofascial pain, lumbar radiculopathy, and  history of stroke.  He had frequent falls, so as a fall prevention measure, his bed was kept in the lowest position which brought it down almost to the floor.  However, because he was known as a difficult resident, the staff would at times skip rounding on him if he was sleeping to avoid “waking the bear” and also moved his bed right up against the radiator so that they could monitor him by keeping the door open without waking him up.

In each of the rooms at this nursing home, there was an electric baseboard heater which was originally installed in 1973.  It allowed the temperature to be controlled in each room individually.  When the temperature would be set at its highest setting (over 80 degrees), it was well-known to the staff that the baseboard radiator units would get very hot.  Staff told the state surveyor that when beds were pushed directly against the radiators, it would be very difficult to pull them apart.  They further told the state surveyor that when they came into contact with the radiator, they would have to move away quickly to avoid being burned.

During the inspection by IDPH, the regional maintenance director told the state surveyor that when the temperature is turned all the way up, the internal heating element for the radiator will run full speed until the target temperature is reached.  When this happens. the heating element can reach 450 degrees.  The nursing home no longer had the manuals for the heaters but some were located online which stated that there should be at least 6 inches between the radiator and any furniture.  The regional maintenance director further told the state surveyor that they determined that at the maximum temperature  setting, the metal covers could reach 175 degrees.

On the night that this resident was injured, the temperature was set at above 80 degrees – the highest possible temperature setting.  The CNA on duty rounded on the resident between midnight and 1:00 a.m. but had to leave at 2:00 a.m. when another aide came on duty to replace her.  The resident was not rounded on again until approximately 4:30 a.m., at which time she found that the resident’s bed was directly against the radiator with his right lower leg and left foot laying directly on the radiator.  The resident’s room was very hot and he was in bed with a blanket and sheet and he had moved his legs out from underneath the blankets.  The resident’s right calf was blistered and the outer portion of his foot was very red.  There was skin peeling off the great toe of the left foot.  Another aide who entered the room said the room smelled of hot burning flesh.

The resident was sent out to the emergency room where he was admitted for wound care and pain control.  The wound on the resident’s right leg measured 27 x 9 cm, while the foot wound measured 5 x 3 cm, and the left foot wound measured 6 x 3 cm. He ultimately underwent surgery for skin grafting.  The podiatrist who did the procedures reported to the state surveyor that there was some bleeding of the right leg wound when the procedures were done which indicated that there was some perfusion to the tissue which was a favorable sign for healing.  However, the wounds to both feet did not have any bleeding which indicated poor circulation which placed the resident at risk for more debridements, more skin grafting procedures, infections, and possible amputations.

This was a very preventable injury – indeed much of the staff at the nursing home attributed the resident’s injuries to a lack of “common sense” – that a dementia resident’s bed should not be placed directly against the radiator and have the heat turned all the way up.  The staff was well aware from their own experiences that even brief contact with the radiator would burn and that the heat was enough that after the beds were pushed up against the radiators it would be hard to pull them apart.  Nursing home residents often have thin skin as a consequence of aging – this is one of the reasons that they are prone to developing bed sores – which also places them at risk for horrific burns from exposure to a hot radiator.  When this is coupled with a mobility deficit, it sets the stage for just the kind of injury that was suffered here.

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

Odd Fellow Rebekah Home resident suffers fatal brain bleed in fall

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

 

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

 

Resident dropped from lift due to use of improper sling at Carlinville Rehab

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IDPH has cited and fined Carlinville Rehabilitation & Health Care Center nursing home after a resident there suffered a fractured humerus after being dropped from a lift because the staff used a sling which should not have been used with that lift – in violation of manufacturer’s specs.

Used properly, a mechanical lift is a very beneficial piece of equipment for use in a nursing home.  It allows residents who have significant strength and mobility issues to be transferred from bed to wheelchair, wheelchair to chair, and so forth safely while at the same time reducing the risk of injury to residents and staff.

The key part of that statement is of course, the “used properly” part.  Proper use of a mechanical lift includes making sure that there are two staff members involved in all transfers because having on person do a two-person job is a formula for disaster (see here, here, here, here, and here for examples).  The other part of “proper use” is that the lift itself and all of the associated equipment is in condition for safe use and is used properly in accordance with manufacturer specifications.

The resident involved suffered from muscle wasting and atrophy and had a care plan which called for mechanical lift transfers with two staff.  On the day of this nursing home fall, two aides were transferring the resident to bed when the sling came off the arm to the lift, causing the resident to fall to the floor.  he was taken to the hospital where he was diagnosed as having suffered a fractured humerus.

The cause of this nursing home fall was not readily apparent, as the lift was brand new and the sling itself was in good shape.  However, further investigation revealed that the owner’s manual for the lift stated that only slings made by that manufacturer should be used with that lift.  The manual went on to warn that use of slings made by a different manufacturer was unsafe and may result in injury to the resident or caregiver.  The sling in use was not made by that manufacturer, and in fact, the nursing home did not have any slings made by that manufacturer.

Very clearly, the warning contained in the owner’s manual was not heeded, and the very outcome predicted in the owner’s manual came to pass.  There are several levels of failure to this, including the failure to obtain the necessary accessories to the lift; failure to review the owner’s manual, and the failure to train the staff on the proper use of the new lift.

Sadly, failure to invest time in training the staff and in proper equipment is one of the hallmarks 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:

Use of improper lift at Sunset Home leads to admission to intensive care unit

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

Sling breaks during transfer at University Nursing & Rehab

Farmington Country Manor resident breaks leg in unsafe transfer

 

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

Michaelsen Health Center resident rolled from bed, suffers brain bleed

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IDPH has cited and fined Michaelsen Health Center nursing home in Batavia after a resident there suffered a brain bleed after being rolled out of bed.

In the nursing home industry, the term “bed mobility” refers to the ability of a resident to change and maintain position in bed.   Bed mobility is one of the areas which is assessed during the process of preparing the Minimum Data Set (MDS).  The MDS form records the resident’s physical abilities and deficits and records the amount of assistance that a resident requires.  The information on the MDS form is submitted to the federal government under penalties of perjury because that information forms part of the basis by which the nursing home is paid for the care it provides.

Beyond that the information gathered during the MDS process is often incorporated directly into the resident care plan.  The care planning process has six steps: (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 at issue here had a cervical collar on due to a cervical spine fracture.  She also had right-sided weakness which was a residual from having had a previous stroke.  Her bed had a low air loss mattress, likely as a means of preventing bed sores.

On the day of this nursing home fall, the resident was receiving a bed bath from a single aide.  The aide had the resident move onto her left side and cross her right leg over her body so that the aide could clean her back.  At the time that was happening the aide was on the side of the bed where the resident was turning away from her.  When the resident crossed her leg over her body, the momentum from that movement carried her leg over the edge of the bed.  Due to her weakness from her stroke, the resident was not able to stop that momentum and this carried her over the edge of the bed.  Because the aide was positioned such that the resident was moving away from her, the aide was unable to stop the fall as well.  The resident crashed to the floor, hitting her head and leaving a bump on the back of the right side of her head.

The resident was brought to the hospital where a CT scan was performed which showed that she had a subdural hematoma of the left temporal lobe (the front front side of her brain).  The doctor described this a contrecoup injury – a type of brain injury which occurs when the brain strikes the inside of the skull opposite the direction of a blow to the head.  The resident was eventually returned to the facility where her care plan was upgraded to include assist of two with activities of bed mobility.

There were a number of shortcomings in the care of this resident.  First, the aide turned the resident away from her so that the aide was in a position to stop the momentum which carried the resident over the edge of the bed.  This is a fundamental skill which aides should have and exercise of this was necessary especially since the resident was on a low air loss mattress which can be a difficult support surface for bed mobility activities.  Second, to the extent that the aide did not know that the resident should be turned toward her, this is an issue with staff training.  Third, the care plan was revised upon the resident’s return to include two staff with bed mobility activities.  An effective care planning process includes ongoing review of the effectiveness of the care plan and revision if it proves to be ineffective in practice.  The fact that the care plan had to be revised after the fall suggests that a revision may have been required earlier but no critical thought was given to the actual care needs of this resident.

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:

Bella Terra Elmhurst resident fractures hip, dislocates knee is fall

Staff at Bella Terra Schaumburg knowingly uses broken lift, leading to fall and brain bleed for resident

Park Place Christian Community resident rolled from bed

Westmont Manor resident suffers brain bleed after being rolled from bed

 

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

 

Violation of care plan and orders leads to broken leg at Meadowbrook Manor in Bolingbrook

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IDPH has cited and fined Meadowbrook Manor nursing home in Bolingbrook after a resident there suffered a broken leg while being transferred to bed manually by a CNA rather than with a lift as called for by the resident care plan and by the orders from her doctor.

In a nursing home, the Minimum Data Set (MDS) is a tool which assesses the overall function of the resident and the care needs of the resident.  One of its uses is that it forms part of the basis by which the nursing home is paid for services so it must be completed under penalties of perjury when it is submitted to the federal government.  For this resident, her MDS stated that she was cognitively intact but that she needed extensive assist of two staff with all activities involving transfers, likely due to a history of past strokes.  The resident care plan was reflective of this in that it called for assist of two using a mechanical lift for transfers, as did the orders from her physician.

On the night of this nursing home fall, the resident was being transferred to bed by a single aide from an agency, rather than being transferred to bed with a lift being operated by two aides.  During the transfer, the resident tripped and the aide fell on top her.  The aide got the resident into bed and then reported to the nurse on duty that the resident had lower extremity pain after being transferred to bed using a mechanical lift with the assistance of another aide from that same agency.  However, when that second aide was questioned about the incident she denied having transferred any resident with a lift, denied having been asked to help with a transfer by the first aide, and stated that she worked on a different hallway that evening.

Following the incident, the resident remained in bed for three days before being sent to the hospital due to discoloration of her lower leg.  There, an x-ray showed an acute comminuted fracture of the proximal tibia (a new fracture of the shin bone closer to the knee with the fracture having many fragments).  Her physician told the state surveyor that it was a recent fracture and was the kind of fracture that was caused by an impact and did not just happen spontaneously.

During the hospitalization, the resident experienced a hypotensive event (a drop in blood pressure) which in turn led to increased confusion due to encephalopathy.  Her family elected against aggressive treatment and she returned to the nursing home to be placed on hospice.

The obvious cause of this fall was the failure of the aide to follow the care plan and the physician orders to transfer the resident with two staff members using a mechanical lift rather than transferring her manually by himself.  A likely deeper cause would be the use of agency staff and the failure to adequately train them and orient them to the care needs of the residents.  And while the staffing agency and the nursing home are directly responsible for this fall and injury, the management choices made at the nursing home are a likely culprit as well.

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:

Promedica Skilled Homewood resident falls and breaks hip

Park Place Christian Community resident rolled from bed by staff

Westmont Manor resident suffers brain bleed after being rolled from bed

 

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

 

 

Resident at AHVA Care of Winfield chokes to death on a peanut butter sandwich

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IDPH has cited and fined AHVA Care of Winfield nursing home after a resident there choked to death on a peanut butter sandwich.

The risk of choking on food is a risk that residents in nursing homes are often at increased risk for as compared to the general population.  There are a handful of factors which may play into that.  Key risk factors that contribute to this may include (1) physiologic factors – there may be issues with chewing, or otherwise breaking the food up for safe eating or impairments to the actual swallow function from neurologic or muscular dysfunction, (2) behavioral – residents may eat too rapidly, overstuff their mouths, or have a compulsion to eat things which are not theirs or not safe for them to consume, or (3) dementia – this may cause people to eat inattentively so that they end up trying to swallow things that are not safe for consumption.

When a resident is at risk for choking this must be addressed during the care planning process, often with the help of a speech therapist.  There are six basic steps with 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 here had a number of diagnoses, including a traumatic brain injury and dry mouth.  His care plan stated that he at time would overstuff his mouth with food.  One of the identified measures intended to address that was to have the resident take small bites.  However, the resident was not added to the list of resident with swallowing difficulties or at risk for choking.

On the night of this nursing home choking accident, the resident came out of his room at approximately 3:00 a.m.  He went to the nurses station and asked for a peanut butter sandwich.  He sat on a chair by the nurse’s station and one of the nurses saw him take an enormous bite of the sandwich – she told the state surveyor that it was almost half the sandwich.  When he was done eating, he began walking back to his room.  The nurses noticed that he was walking unusually, and stopped and sat down in a chair in the hallway outside his room.  After he sat down, he fell from the chair.

The nurses rushed over and saw that he was not breathing.  They saw food particles in his mouth and lips and realized that he was choking.  They attempted to resuscitate him by sweeping his mouth and doing the Heimlich maneuver, but that failed to clear his airway.  Paramedics were called.  When they arrived, there was no heart beat.  They placed an endotracheal tube, but efforts to revive him were unsuccessful and he was declared deceased.  When the tube was removed, there was peanut butter on it.  Cause of death per the coroner was choking on peanut butter.

Here, there was a basic breakdown of the care planning process.  This resident had been assessed as being someone who overstuffed his mouth – a behavioral risk for choking.  This was addressed in the resident care plan.  However, the nurses on duty were apparently unaware of this risk or the steps that had been outlined in the care plan itself, as they watched him consume half the sandwich in a single bite.  Further, the resident was not on the list of residents who had swallow issues or were at risk for aspiration/choking, denying the nurses an easy way to identify him as a choking risk.

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:

Resident at Aspen Rehab in Silvis chokes to death due to violation of care plan

Winston Manor resident chokes to death on peanut butter sandwich

Resident chokes to death at Warren Barr North Shore

 

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

 

Failure to follow orders leads to wound infection at Generations Oakton Pavillion

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IDPH has cited and fined Generations Oakton Pavillion nursing home in Des Plaines after a resident there developed an infection of a bed sore after the staff failed to use a wound vac on a bed sore as ordered.

There are two federal regulations which address the topic of bed sores.  In essence, these provide (1) that a resident who enters a nursing home without bed sores should not develop them unless they are clinically unavoidable and (2) once a resident does have a bed sore, residents must receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new bed sores.  Once a resident develops a bed sore, this requires the nursing staff to notify the physician to get treatment orders and revision of the resident care plan.

Bed stores are staged or rated as Stage 1 through 4, with Stage 4 being the worst.  Stage 4 bed sores involve exposed muscle or bone.  Because these are so deep and involve major breaches of the integrity of the skin, these place the resident at risk for suffering infections such as cellulitis or osteomyelitis.

One of the tools that is available to treat Stage 4 bed sores is a device known as a wound vac.  The wound vac is a device in which a dressing (usually impregnated with substances to help promote healing) is placed in the wound bed and a seal is applied over the borders of the wound.  When the seal is not good, the wound vac will make a beeping noise which alerts the nursing staff of that. The wound vac is then applied to the dressing and it removes drainage from the wound bed.  This helps promote healing and prevent infection.

The resident as issue was admitted to the nursing home with a Stage 4 bed sore to his sacrum measuring 11 cm x 8 cm x 2 cm.  There was no odor to the wound and it had heavy serosanguinous drainage (a clear or bloody drainage that is present in a healthy, healing wound).  There were orders in places for use of a wound vac or alternatively for use of an antiseptic soaked gauze if the seal on the wound vac would not be achieved.  Wound vacs should be run continuously unless there is a dressing change being done, and in this nursing home, all wound vacs have signs on them saying to not shut it off.

On the fourth day after the resident was admitted to the nursing home, when the day shift nurse arrived on Monday morning, she went into the resident’s room and noticed a foul odor in the room.  She went to check the resident’s dressing and found that the wound vac had been shut off.  She then notified the wound care nurse who then assessed the resident and found that there was no seal, that the dressing was soaked, that the wound bed had a foul odor with maceration and erythema of the wound edges – all potential signs of infection.  There was no documentation as to how long the wound vac was off, but the day shift nurse told the wound care nurse that there had been problems with the machine beeping, so they shut the machine off.

A wound culture was done which showed that the wound was in fact infected.  The resident was then sent to the hospital for further treatment which would have likely included the use of IV antibiotics and/or surgical debridement of the wound.

The key issue here is the failure to know what to do when there is not a good seal on a wound vac.  There are a few options: (1) attempt to place a new dressing in the wound bed and put a new seal over the wound, (2) follow facility protocols and notify the wound care nurse that the machine is beeping and allow to try to resolve the issue, or (3) follow the orders that were in place an apply the antiseptic dressing to the wound.  Instead of pursuing any of those options, the staff on duty simply shut the machine off despite a sign on the machine saying not to do so.  That resolved the problem with the beeping noise but denied the resident the care that he needed with infection of the wound being the net 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:

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

Victorian Village resident develops pressure ulcer from orthotic boot

Failure to treat pressure ulcer at Franciscan Village in Lemont

 

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

 

 

Multiple falls leads to fractured hip and brain bleed at Monmouth Nursing Home

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IDPH has cited and fined Monmouth Nursing Home after a resident there experienced eight (8) falls in a two and half month period, the last resulting in a fractured hip and a brain bleed, both of which required surgical intervention.  This is the second citation that IDPH has written to this nursing home for a resident who experienced significant injuries after having multiple falls in the nursing home.

Falls are a major cause of death and diminished quality of life for nursing home residents.  They are also addressed in the federal regulations, so the issue of fall prevention is a major area of focus in the long-term care industry.

Fall prevention is an area which is addressed in the care planning process.  Most of the routine care that is provided in nursing homes is addressed through the care planning process.  This process has six steps: (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.

There is no tool for assessing fall risk that is considered “gold standard” the way that the Braden scale is for assessing the risk of developing bed sores.  However, any decent fall risk tool will account for the two main factors which place a resident at risk for having falls.  These are:  These include (1) some form of musculoskeletal, gait, or balance dysfunction which place a resident at risk for losing balance or falling and  (2) some form of cognitive impairment, dementia, confusion, or general poor safety awareness.  Cognitive issues feed into fall risk because the resident cannot be counted on to follow instructions or make good decisions for their own safety.  Further, it is also well-recognized that falls tend to beget additional falls – so a history of falls tends to be a precursor for additional falls.

The resident at issue had all of these factors at play.  She had a history of multiple falls at home which preceded her admission to the nursing home, the last of which resulted in compression fractures in her thoracic spine.  Further, she had a history of stroke with residual left-sided weakness as well as Parkinson’s.  Her Minimum Data Set showed that she required assist of two staff members for most mobility activities.  She further had a diagnosis of dementia and the staff recognized that she experienced confusion and was impulsive.  In short, this resident was at high risk for falls and was properly assessed at the start of her admission as being at high risk for falls.

Having assessed her as being at high risk for falls, the care plan consisted of placing a “Call, Don’t Fall” sign in her room, placing the call light and personal items within reach, use of appropriate footwear and/or gripper socks, and a referral to physical therapy and occupational therapy.

Prior to the fall at issue, the resident experienced seven falls without serious injury.  Additionally, there were at least three times where the staff found her transferring herself without assistance.  Havin incidents such as these where there are falls and residents self-transferring without help but with no injury resulting is good luck, not good care.  Reliance on good luck to assure the safety and well-being of nursing home residents is not a formula for success.

When a nursing home resident sustains a fall this should trigger some additional steps: a 72-hour fall watch, physician notification, and revision of the fall prevention care plan.  Only one of these falls resulted in an updating of the care plan, and this consisted of placing additional “Call, Don’t Fall” signs within her room.  Needless to say, this was not an effective measure, given her level of confusion and impulsivity.

On the morning of this nursing home fall, the resident was woken up by a nurse who was passing medication.  The nurse told the resident to open her eyes because breakfast was coming soon.  The nurse went on to the room next door.  While she was there, she heard screaming coming from the resident’s room.  The resident had gotten out of bed to go to the bathroom.  Urine was found soaking the bed and the floor nearby.  The resident told staff that she was trying to get clothes from her closet.

The resident was brought to the hospital where she was diagnosed with a fractured hip and a brain bleed.  The fractured hip required an open reduction and internal fixation surgery, and the brain bleed required the placement of a drain to remove the blood which was putting pressure on the brain.

The overall picture here shows a failure of the nursing home to respond in an effective way to the falls that occurred.  The final steps of the care planning process are evaluating the effectiveness of the care plan and revising it if it proves ineffective in practice.  When a resident has seven falls and three other incidents where they were known to self-transfer when they required higher levels of assistance, this is a sign that the care plan in place was not working and the only revision made to the care plan was to place additional signage which the resident was not heeding anyway.

Further, waking the resident up and then not being in a position to assist with one of the basic needs one has upon waking up in the morning (going to the bathroom) was foolish and likely led directly to the resident’s fall and injuries.  Effective rounding on residents includes not only checking on them, but assuring that their needs are met.  This was clearly not done in this instance.

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:

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

Heritage – Mt. Sterling resident leg 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.

 

Assault by fellow resident yields fractured hip at Bria of Smithton

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IDPH has cited and fined Bria of Smithton nursing home after a resident there suffered a fractured hip after being pushed down for the second time by a fellow resident.

One of the basic expectations that families have when they admit a loved one to a nursing home is that their loved one will be kept safe from violence or what would be criminal behavior elsewhere.  In fact, the risk of being exposed to criminal behavior is one of the reasons that IDPH fines nursing homes when residents wander from their nursing home (this is technically referred to as “elopement“). Sadly, nursing home residents are at times the victims of criminal behavior by staff or more often, the victims of assaults by fellow residents, as was the case here.

The most common scenario in which this occurs is that the assailant suffers from some form of mental illness or other behavior disorder and acts out physically against the victim.  It often follows periods of noncompliance with psychiatric medications.  Nursing homes have an obligation to keep their residents safe from abuse.  In the context of nursing homes, “abuse” includes actions taken by fellow residents.  This is usually addressed through the care planning process – both for the victim and the perpetrator.

Here, the assailant had a well-documented history of mental illness, including diagnoses of psychotic disturbances, mood disturbances and anxiety, major depressive disorder, and schizophrenia.  He had been noncompliant with orders for psychiatric medications and had refused psychiatric for several months before the incident at issue.  He liked to stay in his room and felt threatened when others came into it.  In the words of the family, “He does not play well with others.”

There were at least two prior incidents of physical aggression by the assailant described in the citation.  In one, he hit the social services director while she was attempting to perform an assessment on him.  In the other, four weeks before the incident at issue, the victim in this case entered the assailants room and was pushed out of the room and to the floor in the hallway.  Following this incident, he was placed on 1:1 supervision by staff.  However, it was stopped before the date of this incident.  The resident medical chart did not document when or why it was terminated and the resident care plan was not updated to address this act of aggression against a fellow resident.

On the day of this nursing home fall, the assailant emerged from his room to return his meal tray to the kitchen.  The victim was nearby.  The assailant began yelling, threw his tray to the floor, and pushed the victim to the floor.  As a result of this assault, the victim suffered a fractured hip which required surgical repair.

The nursing home was well aware of the propensities of the assailant for physical aggression.  He had previously assaulted both the victim here and a member of the staff.  They were further aware that he was noncompliant with his medications and psychiatric care, so there was no chance that his behavior could be modified through therapy.  This meant that it had to be addressed through the care planning process and that all of the staff needed to be made aware of the potential for acting out when the assailant was out of his room as well as when others entered his room.  The failure of the nursing home address this known risk led directly to the injuries sustained by the victim.

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:

Resident sexually assaulted by fellow resident at Dixon Rehab

Assault by fellow resident leads to broken hip at Stephenson Nursing Center

Multiple residents victimized by fellow resident at Winning Wheels

 

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

 

 

Pleasant Meadows Senior Living resident fractures hip and wrist in fall

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IDPH has cited and fined Pleasant Meadows Senior Living nursing home in Chrisman after a resident there was allowed to go to the bathroom without the required help and then fell while trying to get dressed, resulting in fractures to her eye orbit, her hip, and her wrist and a laceration to her head.

Nursing homes track a great deal of data concerning their residents.  Much of it is strictly for internal use, but one piece – the Minimum Data Set, or MDS – is reported outside the facility.  It is submitted under penalties of perjury to the federal government because the information that is in there forms part of the basis by which nursing homes are paid.  It tracks information concerning the physical abilities and deficits of residents, as well as the levels of care that the nursing home is in fact providing to the resident.

For this resident, the MDS showed that the resident required the assistance of one staff member with transfers, walking, dressing, and toileting.  It further reflected that the resident was not steady, used a walker, and was only able to stabilize with the assistance of staff while turning around, moving off/on the toilet, and for surface to surface transfers.  The MDS also showed that she had severe cognitive impairments.  This is a resident who was clearly at high risk for falls – she had well-documented issues with balance and mobility and also had severe cognitive impairments where she could not be counted on to follow instructions or make good decisions for her own safety.

On the day of this nursing home fall, the resident was walking to the dining room for lunch with an aide.  The resident told the aide that she needed to use the bathroom.  The aide allowed her to go the restroom unattended and unassisted.  Shortly thereafter, a scream was heard and the resident was found on the floor of a different resident’s room with another resident’s pants half on.  The resident’s own pants were found on the floor of the bathroom.  Apparently the resident needed to change pants after using the bathroom and went into an adjoining room and took another resident’s pants and fell while putting them on.

When she was discovered on the floor, there was blood pooling on the floor from a cut to the head.  The resident was sent to the hospital where she was diagnosed with a fractured orbital bone, a fractured hip, and a fractured wrist.

The basic issue with the care that was provided is that the resident required assistance with transfers, toileting, and walking.  She was also unsteady when moving off and on the toilet.  She required assistance with getting dressed.  The aide knew that she was going to the bathroom – a time when she needed help getting on and off the toilet.  She also needed help with dressing – something that was necessary after she apparently got her pants dirty or was otherwise unable to get them back on after going to the bathroom.  Because the resident was left to handle all of these tasks without help when she needed, the fall and injury resulted.

When you have staff that is stretched too thin to provide necessary supervision and help to residents to avoid accidents, this raises fair questions as to whether this was an understaffed nursing home.  Unfortunately, understaffing a nursing home is a basic 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:

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

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

Unsupervised resident at Odd Fellow Rebekah Home in Mattoon suffers brain bleed in fall

 

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

 

Fondulac Rehab resident chokes to death

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IDPH has cited and fined Fondulac Rehabilitation & Healthcare Center nursing home in East Peoria after a resident there was fed the wrong kind of diet and left unsupervised during dinner.

One of the lesser known risks to the health and well-being of nursing home residents is the risk of choking while eating.  There are a variety of reasons that a resident may be at risk for choking including advanced dementia, behavioral issues that lead the resident to cram food in their mouths, or neuromuscular issues which impair the swallowing process.  Most often, these are diagnosed following an assessment by a speech therapist.  They are then addressed through the care planning process and physician orders which call for supervision while eating and therapeutic diets which which are intended to reduce the risk of choking.

The resident involved was initially admitted to the nursing home with orders for a general diet.  However, after a hospital visit, she was readmitted to the nursing home with transfer orders for a therapeutic diet consisting of a mechanical soft diet with nectar thick liquids.  Her care plan called for assistance of one while eating due to poor safety awareness, cognitive deficits, forgetfulness, and poor mobility.  The care plan did not include the therapeutic diet.  Further, the her diet orders did not include the therapeutic diet, so she continued to be fed a general diet.

On the night of this fatal nursing home choking accident, the general diet being fed to residents consisted of Salisbury Steak and other items.  Due to covid precautions, all of the residents were being fed in their rooms, rather than in the dining room.  The aide assigned to the resident brought the tray to the room, cut up her food, fed her a bite, and then went to deliver meal trays to other residents.  As the aide came back up the hallway, she saw that the resident was blue.  She got a nurse, and they pulled the resident from bed and began CPR.  911 was called and paramedics took over the resuscitation efforts, but those efforts were unsuccessful and the resident was pronounced deceased.

An autopsy was performed, and the cause of death listed on the death certificate was aspiration of food.

There are at least four issues with the care that this resident received:

  1.  Continuity of care – We have written several times about how critical it is for the well-being of residents that the transfer orders that were in place for the resident upon discharge from the hospital be carried forward into the nursing home (see here, here, here, and here for examples).  Nursing homes are businesses, and well-run businesses have systems in place to make sure that the routine and necessary operations of their business are carried out.  Ensuring continuity of care is one of those operations, and this was not done here as the order for the therapeutic, mechanical soft diet was not implemented.  As a result, the resident was fed the Salisbury Steak that she choked on.
  2. Failure to implement care plan – This resident’s care plan called for assistance of one with eating.  After the tray was served to her she was left unattended and unsupervised.  While she was alone, she choked.  The whole point of incorporating the supervision while eating was to prevent just this kind of accident.
  3. Understaffing of the nursing home – All of the residents in the facility were eating in their rooms as a covid precaution, and aides were forthright with the state surveyor that they simply did not have enough people on hand to supervise all of the residents who needed help eating while they were all being served with in their rooms.  Federal regulations require that nursing homes have enough staff on hand to meet the care needs of the residents 24/7.  As a one aide put it, “We do not have enough staff to accommodate all those people that are being quarantined in tehri rooms that need assistance while eating.  We normally only have about one or two people available to watch over the residents that need supervision with eating.  None of the nurses or management staff help us, and it would be nice if they did.”
  4. Quarantine – The policy in place at the time was that is there was a positive case in the building (which there was), then all of the residents were quarantined, regardless of covid positive status.  Not only is that sort of isolation harmful to residents, but in the case of residents who require supervision, it makes it difficult to impossible to provide the necessary supervision.  Had the resident involved been allowed to eat in the dining room, she likely would have been seated at a feeder table where she would be fed under the direct supervision of staff, and this fatal accident would have been avoided.

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 treat infection leads to resident death at Elevate Care South Holland

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IDPH has cited and fined Elevate Care of South Holland nursing home after a resident there died as a consequence of an infection of his dialysis fistula going untreated.

One of the basic truisms of care in a nursing home is that doctors are not present in a nursing home 24/7 the way that they are in a hospital.  Therefore, in the absence of physicians being in the building, nurses must act as “the eyes and ears” of physicians with regard to the residents who are under their care.  In that role it is part of their job to notify physicians of changes in the condition of the residents who are under their care as well as events such as the development of bed sores, medication errors, choking incidents, and falls.  After a doctor is notified of one of these things, the doctor has the option to issue orders for care over the phone, come into the nursing home to see the resident, or order the resident sent out to the hospital.

One of the types of conditions that nurses must notify doctors about is the onset of signs and symptoms of infection.  Nurses do not need to know whether what they are seeing is actually an infection, what kind of infection it is, or how to go about treating it – although experienced nurses often have a solid idea about all of these issues.  The most common course of action is to start an antibiotic and to obtain a relevant culture (for example, a urine culture if a urinary tract infection is suspected) to confirm the presence of the infection and whether the antibiotic ordered is appropriate for the type of infecting organism.

The resident at issue was a dialysis patient and had an AV fistula (the port through which dialysis is done) on his right upper arm.  The facility wound care nurse performed a routine readmission skin assessment on the resident and saw that there was purulent drainage coming from an abscess on the right upper arm.  The wound care nurse notified the resident’s nurse practitioner via text message and advised her that there was a wound with some drainage and that a wound culture had been obtained.  The wound care nurse also claims to have notified the wound care physician, but according to the citation, he denied knowing about the abscess until he was in the facility three days later.

The resident was scheduled for dialysis the following day but did not receive it for reasons that are not clear from the citation.  However, the nephrologist stated that had he been made aware of the presence of an abscess near the dialysis fistula, he would have obtained a wound culture and started an IV antibiotic through the dialysis fistula immediately.

The wound care physician arrived in the nursing home three days after the abscess was first noted.  He ordered Keflex, an oral antibiotic, and a consult with an infectious disease physician.  However, the nursing home did not have the antibiotic in stock and when they attempted to reach the infectious disease doctor, they only reached his answering service.  The antibiotic did not get delivered before the resident was sent to the hospital.  Therefore, neither of the orders were actually implemented before the resident was sent to the hospital the following morning.

The next morning the nurse on duty recognized that the resident’s condition was declining and his vital signs were troubling, so she called 911 to have the resident sent to the hospital.  The preliminary diagnosis there was that he suffered a stroke, so an MRI of his brain was ordered and this should evidence of septic emboli and a cerebral abscess – signs that the infection had migrated to his brain.  It was determined that he had a poor chance of neurological recovery and that he was a poor surgical candidate, so the family opted for comfort measures only, and he died five days later.

There are a number of issues with the care that this resident received:

  • The skin assessment where the abscess was discovered was a readmission assessment.  Where was he being readmitted from and why was the infection not addressed there?  The citation does not give any indications on this issue.
  • It is unclear whether the wound care physician was in fact notified of the presence of the infection – the wound care nurse from the nursing home yes, the doctor says no.  There are a number of ways of resolving that issue.  One way would be to see who issued the orders for the wound culture and dressing.  Otherwise it becomes an issue of getting into phone records and the electronic medical record if it had a electronic messaging platform integrated with it.
  • Assuming that both the nurse practitioner and the wound care doctor were timely notified, the discussion ended without an order for an antibiotic.  An experienced nurse would have recognized that the usual course is to initiate antibiotics before the results of the culture are received.  In her role as a patient advocate, the nurse should have asked whether they wanted one started.
  • There were no clear lines of responsibility for who was managing this portion of the patient’s care.  It is a common adage that when everyone is responsible, no one is responsible.  Sadly, no one appears to have taken charge to ensure that the resident had an antibiotic started.
  • It appears that the resident did not go to dialysis as scheduled the day after the abscess was discovered.  The dialysis fistula is something that directly impacts the care that a nephrologist gives, but no one alerted the nephrologist about the apparent infection in the area.  It is clear from the citation that the nephrologist would have addressed the abscess with a good deal more urgency than either the wound care physician or the nurse practitioner.
  • When the antibiotic was ordered but not available, no one advised the wound care physician of this.  Many nursing homes carry a “house stock” of commonly used medications, and the one ordered would have likely fallen into that category.  When it was not available, the failure of the staff to notify the wound care doctor that they could not give the antibiotic as ordered denied the wound care doctor the opportunity to choose a different course of action – such as a different medication or ordering the resident to the hospital.  When an infection is left untreated, it can only be expected to worsen the in medically compromised population found in nursing homes.

This series of failures in the care that the resident received ultimately ended up causing his death.

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:

Lemont Nursing & Rehab cited for failure to notify doctor of abnormal lab results

Heartland of Galesburg resident dies due to untreated urinary tract infection

Resident suffers flesh-eating infection due to untreated skin tear at Regency of Sterling

 

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

Unsupervised resident falls and fractures hip at Lutheran Home for Aged in Arlington Heights

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IDPH has cited and fined Lutheran Home for the Aged nursing home in Arlington Heights after a resident there suffered a fractured hip in a fall.

Falls are a major source of mortality and loss of quality of life for the nursing home population.  They are also addressed in federal regulations which require that nursing home residents receive supervision and assistance necessary to prevent accidents.  A fall is a form of accident.  Because of this, falls prevention is a serious area of focus in the long-term care industry.

There are two major factors that make residents at risk for falls.  These include (1) some form of musculoskeletal, gait, or balance dysfunction which place a resident at risk for losing balance or falling and  (2) some form of cognitive impairment, dementia, confusion, or general poor safety awareness.  Cognitive issues feed into fall risk because the resident cannot be counted on to follow instructions or make good decisions for their own safety.

The resident at issue was wheelchair bound and had a history which included cognitive impairments due to developmental delay.  He had a history of falls and it is well-recognized in the long term care industry that falls tend to beget additional falls.  It was also well-known to the staff that reminding the resident to use the call light, to not try to stand unassisted, or to ask for help did not work due to his cognitive impairments, as there had been multiple incidents where he did not heed reminders which did not result in falls.

On the day of this nursing home fall, the staff heard the resident screaming in room.  When they responded, they found him on his floor in obvious pain.  The medical record notes he either slid from his wheelchair trying to get his mask off the floor or he stood to get the mask.  In either event, he fell to the floor.  He was sent to the emergency room where he was diagnosed with a fractured hip and underwent surgery.

The basic shortcoming in the care that this resident received was an issue of inadequate supervision.  It was well-known to the staff that he resident could not be relied upon to ask for assistance, use a call light, or otherwise follow instructions.  Despite this, the resident was placed in a room far from the nurse’s station when placing residents who need closer levels of supervision are customarily placed in rooms closer to the nurse’s station.  Further, residents who need closer supervision are commonly placed in common areas such as the hallway adjacent to the nurse’s station, the dining room, or a activity/common room where one staff member can watch several residents at once.  Short of that a rigorously followed rounding schedule is the fallback.  Without these measures being taken, the safety of the resident is at the mercy of the cognitive impairments of the resident, as they cannot be counted on to make good decisions for their own safety.

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 suffers fractured hip in fall

Resident suffers jaw, facial fractures in fall at Dimensions Living in Prospect Heights

Inverness Rehab resident suffers multiple fractures in fall

 

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

 

Failure to give blood thinner leads to death of resident at Warren Barr Oak Lawn

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IDPH has cited and fined Warren Barr Oak Lawn nursing home after a resident there died from a massive pulmonary embolism caused by the failure to give a blood thinner medication as ordered.

Maintaining continuity of care from a hospital to a nursing home is critical for the safety and well-being of a resident.  When someone is admitted to a nursing home from the hospital, they are generally recovering from a significant injury, illness, or surgery and have significant near-term and long-term needs.  Special care has to be taken to make sure that the care needs that the doctors and staff at the hospital have determined that the resident requires are being met during the initial stages of the resident’s admission.

When a resident is admitted to a nursing home from a hospital, the nursing home receives a list of medications that the resident is supposed to be receiving.  That list is supposed to be verified with the providers at the hospital and then double-checked by a second nurse at the nursing home to ensure that all orders, including medications, are correctly entered into the resident’s chart.  When this process does not happen, there is an increased risk that the resident will either not receive a necessary medication or be given a wrong medication or the incorrect dose of a medication that was ordered.

This kind of nursing home medication error can have catastrophic consequences, and that was the case here.

The resident at issue was admitted to the nursing home after having spinal surgery following a fall at home.  When the resident was discharged from the hospital to the nursing home, there was an order in place for him to receive heparin, a blood thinner.  Many patients will receive a blood thinner after a major surgery to prevent the developments of blood clots – a complication which is known to occur following major operations.  This is especially true when the patient has significant mobility deficits, as was the case here.

However, when the resident was admitted to the nursing home, the order for heparin was not copied from the discharge papers onto the patient’s medical record.  As a result, during the twelve days that the resident was in the nursing home, he did not receive a single dose of the blood thinner that was ordered.

On the twelfth day of his admission, the resident had episodes of vomiting and had a fixed stare.  The nursing home staff had the resident sent to the hospital, where it was discovered that he had a massive pulmonary embolism, or a blood clot that became lodged in the lung.  A pulmonary embolism can lead to cardiac arrest and death.  Sadly, that was exactly what happened in this case, as the resident died later that day.  Cause of death according to the death certificate was massive pulmonary embolism and cardiopulmonary arrest.

Well-run businesses run on systems, and a nursing home is a business.  This nursing home actually had a system in place similar to the one described above.  Unfortunately, it was not followed, leading to this very preventable medication error.

The obvious reason that this medication error occurred was the failure to follow the system that was in place.  The deeper question is why the system wasn’t followed.  Investigation by IDPH revealed that the nurse who made the mediation error was an agency nurse, or a temp.  We tend to see a lot of agency nurses in facilities where they have hiring and retention problems, generally due to low pay and heavy work loads.  Temporary staff can help address this, but there is little chance to ensure that they are trained in the systems and processes that must be followed for the consistent delivery of routine care.

In the end, this was a death that was a product of the nursing home business model, where understaffing of the nursing home and lack of investment in the staff are cardinal features – and this is because those kinds of expenses cut into the bottom line. 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:

Catastrophic brain injury results from medication error at Alden Town Manor

Diabetes medications not given at Alden Estates of Orland Park

Failure to give anticoagulant medication at H&J Vonderlieth Living Center

 

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

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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:

Newman Rehab resident suffers burns to leg from hot radiator

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

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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:

Bella Terra Elmhurst resident fractures hip, dislocates knee is fall

Resident falls and fractures hip and Lutheran Home for Aged in Arlington Heights

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

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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.

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

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

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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.

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:

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

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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

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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

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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.

 

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