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Resident Falls Three Times In One Week, Fractures Hip At Hillsboro Rehab & Health Care Center

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IDPH has cited and fined Hillsboro Rehab & Health Care Center after a resident there fell three separate times during her first week at the facility, sustaining a non-operable re-fracture of her left hip.

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, fall 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 severely cognitively impaired, with behaviors such as inattention and disorganized thinking, and required assistance with Activities of Daily Living (ADLs) including bed mobility, transfers, walking in room, dressing, eating and toileting.

The day after the resident was admitted to the facility, the resident was found by a nurse on the ground at the foot of her bed, sitting on her buttocks with her left leg extended forward and right leg bent.  The resident was complaining of pain and discomfort, and was transported to the ER, where all tests for injuries were negative. 

The resident returned to the facility, only to fall again that same evening.  This time the resident was found on the floor in front of the bathroom.  She was lying on her right arm, complaining of right shoulder, back and hip pain.  Before returning to the ER a second time in one day, a nurse at the facility spoke with the ER doctor.  He stressed that he was unable to believe that the resident had fallen a second time, since he had given orders that upon returning to the facility the resident was to receive 1:1 care.  This refers to a specialized level of care provided in nursing homes where one caregiver is assigned to provide individualized care to a single resident. 

The third fall occurred approximately five days later, with the resident found on the floor near her overturned commode.  This fall resulted in another trip to the ER and a diagnosis of a non-operable re-fracture of the left hip.

The citation mentions several interviews with nurses that try to explain how the order for 1:1 care from the doctor was missed after the first fall.  Nurses also honestly confessed that this level of care would have been nearly impossible, as “if you are 1:1 with a resident, no one else would get their care.”

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.

Fall Investigation Reveals Startling Lack Of Training And Understaffing At Bella Terra Wheeling

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The Illinois Department of Health has cited Bella Terra Wheeling after a resident fell from her wheelchair in the dining room and suffered face lacerations and a fractured femur.

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.

On the day of this nursing home fall, the resident in question was in the dining room, in her wheelchair, waiting for breakfast to be served.  The nurse watching over the residents that morning claims that she was helping another resident when she heard the resident “fall hard,” landing on her right side and bleeding onto the floor.  

The resident was assessed, x-rays were ordered and the resident was sent to the hospital for further evaluation.  At the hospital it was determined that the resident had suffered an acute femur fracture.

Falls can be devastating events for seniors, and often they lead to additional falls.  While this fall is certainly a serious and sad occurrence, equally as disturbing in this case are some of the findings that the surveyor found when she went to conduct her investigation at the facility.

– When the surveyor visited the same dining room where the fall occurred, there was a different nurse watching a group of residents.  That nurse commented that “you can see there are a lot of residents here so we can’t get to all of them if they fall.”  When the surveyor counted the number of residents assembled in the dining hall, she counted 41, with just one nurse monitoring the room.  

– When the surveyor visited the nurse that was watching the resident on the day of the incident, the nurse stated that she was “with agency and I had just got there that day and they (facility) assigned me to be in charge of watching the dining room.”  

When the surveyor asked if she had returned to the facility after the day of the accident, she replied that she had not and that she had no idea that the resident was a fall risk.  “No I haven’t been back since that last time and I only was there once.  I didn’t know anything about her fall risk. Is she one because they didn’t tell me anything? All they do like every place is give you the residents and they don’t tell you anything.”

When asked if the agency had received any dementia or fall prevention training, the nurse replied “I’m with agency, they don’t do training.”

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.  Even worse, when a nursing home does not train their nurses in fall prevention, it would seem to border on negligence.  Unfortunately, insufficient training of nurses and 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.

Resident Breaks Pelvis In Fall From Bed At Bria Of Westmont

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IDPH has cited and fined Bria of Westmont after a resident fell from her bed,  sustaining a painful pelvic fracture.

Prior to the accident, the resident at issue had a Minimum Data Set (MDS) submitted to the federal government indicating that she required the assistance of two for bed mobility.  For the ability to roll left and right in bed, the resident was coded as “01”.  This code means that the dependent-helper does all of the effort and the resident does none of the effort to complete the activity.  

Importantly, this facility does not use side rails on beds.  Therefore residents that require this much assistance are not able to remain on their side without the risk of rolling over. 

The only way to safely provide incontinence care would be with two staff members, one to hold onto the resident and the other to provide the incontinence care.

At the time of this nursing home fall, an aide was providing incontinence care by herself to the resident. The aide explained that after positioning the resident on her left side, she quickly ran into the bathroom inside of the resident’s room to get more supplies, leaving the resident unattended “for no more than 10 seconds.” The aide acknowledged that she witnessed the resident fall out of the bed as she stepped out of the bathroom, landing onto her right side on the floor.

When the x-ray technician arrived in the room, the technician found the resident “in tremendous pain and screaming.”  

She was diagnosed with a closed nondisplaced fracture of the right acetabulum and a closed fracture of the right pubis.  

This is yet another instance where a resident suffers injury because one person was doing a two-person job (see here, here, here, here, and here for examples).  Generally the root cause of this kind of incident is due to understaffing of the nursing home, which is something that is inherent in 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.

Communication Failure Leads To Fall And Death At The Arc At Normal

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IDPH has cited and fined The Arc At Normal after a resident fell and died after attempting to toilet on his own.

There is a framework for providing the vast majority of routine care in a nursing home setting.  This is referred to as the care planning process.  When it is done properly, the risk of residents suffering unnecessary injuries, falls  and wrongful deaths is greatly reduced.  However, oftentimes there are serious deficiencies in the care-planning process which sets the stage for disaster.

When the resident in question was admitted to the nursing home, the initial assessment listed the resident at a moderate risk for falls.  The only fall prevention intervention documented at that time was to make sure the call light was within reach.

The resident’s family, on the other hand, informed the admitting nurse that their loved one was a high fall risk with frequent intermittent confusion and requested that he not take the ordered Eliquis (blood thinner) due to his frequent falls and prolonged bleeding. Importantly, they communicated to the admitting nurse that their loved one be toileted at 1:00 am and 4:00 am, as that is what he was accustomed to when they were caring for him at home.

When the family was leaving the facility later that night they communicated to another nurse that they were concerned about their loved one.  The nurse assured them that residents are checked on every 2 hours and toileted at those times.  Further, since the resident was confused and often tried to get up, the nurse assured the family that a nurse would check on the resident every hour to see if he needed anything.   

Critically, the admitting nurse never communicated to other nurses, including the night staff, that this particular resident needed to be toileted at 1:00 am and 4:00 am.  

Without this critical information, tragedy struck.  

An aide did stop to toilet the resident sometime between 9:00 pm and 10:00 pm, but did not return again until midnight.  When the aide saw that the resident was sleeping, she decided to let the resident sleep without toileting him.

The next interaction anyone had with the resident was at 1:15 am when the aide found the resident lying face down on the floor, behind the door and bleeding from his head. 

The resident was rushed to the hospital but passed that same night.  Cause of death was Intracranial Hemorrhage with anticoagulant used for AFib (Atrial Fibrillation).

In this case the major breakdown in the care planning process was with communication.  Once the care plan has been developed, it must be communicated to the members of the nursing home staff charged with carrying it out.  This should be a simple enough process, but in practice, nurses and other staff members often have a hard time explaining how that occurs which leaves the issue in doubt as to whether the contents of the care plan are ever communicated to the people charged with doing the work.

These systemic failures are often a sign of an understaffed nursing home.  Sadly, that is a basic part of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Aide Neglects To Attach Foot Pedals To Wheelchair, Resident Falls & Suffers Neck & Shoulder Injuries At Grove Of St. Charles

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IDPH has cited and fined Grove of St. Charles nursing home after a resident there became injured in a wheelchair accident.

Wheelchairs are one of the most common pieces of equipment used in a nursing home setting and at first blush are very simple to use safely.  However, even these simple devices can prove dangerous when not used properly.

On the morning of the injury, aides were escorting three residents on a morning walk around the facility through the parking lot.  The residents were walking side by side when the left rear wheel of one of the resident’s wheelchairs caught the edge of a manhole cover. Unfortunately for the resident, the aide had neglected to attach the foot pedals to the resident’s wheelchair.  

The use of leg pedals on a wheelchair helps to position the hips back if there is a sudden “jerk” while in motion. They keep the knees up and the person back in their seat. 

As the chair became stuck in the manhole cover, the resident lurched forward and fell out of the chair, landing on the pavement.  

The resident suffered a progression of an existing neck fracture, a shoulder dislocation, and a hematoma on her forehead.

Sadly, the resident had been mobile prior to the fall and had been able to wheel herself around the hallways but has subsequently become primarily bed bound after the injury.

A janitor, examining the manhole cover after the accident, noted that it was painted yellow and was set down three-quarters of an inch below the surrounding asphalt.  The janitor also noted that there was ample room on either side of the manhole cover and that the aide should have been able to wheel the resident around the cover, not over it.

Like all pieces of equipment in a nursing home, a wheelchair is a safe piece of equipment – when used properly.  This includes using the footrests – the use of which would have helped to prevent this kind of accident.  The misuse of the wheelchair was the immediate cause of this accident.

The fact that such an obvious safety measure was not taken raises serious questions as to whether this is an understaffed nursing home.  When the facts of an accident show that the staff was taking a shortcut which placed the safety of the resident at risk, it could be an indicator that the staff was not trained properly or that the staff simply did not have time to do things properly.  Either way, this raises questions about how the nursing home is being operated.  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.

Resident’s Requests To Fix Bed Rails Go Unheeded, Falls From Bed At Bria Of Belleville

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IDPH has cited and fined Bria of Belleville after a resident there fell out of bed and was hospitalized due to bed rails that were poorly attached to the frame.

Although the U.S. Food and Drug Administration’s (FDA) warnings on bed rail safety have prompted many manufacturers to design safer beds that minimize the risk of accidents, many nursing homes continue to place their residents in outdated beds with unsafe rail designs.

Nursing homes that do have upgraded beds often still have older models in some rooms, since there is little incentive to rid the facility of any usable bed. Adding to the risk of serious or fatal injury are rental beds from medical supply companies. Not only are the rental beds typically those with more outdated designs, but they are often sent to nursing homes with mismatched parts. In other words, the mattress and bed rails may be from different manufacturers, putting the resident at risk of getting trapped in the space between the mattress and frame.

On the day this resident was admitted to the nursing home she immediately remarked to the admitting nurse that the bed rails felt “loose and wiggly.”  The resident’s husband remarked that his wife showed how loose the bed rails were to “several staff members . . . and no one did anything about it.”  

The citation mentions that the admitting nurse acknowledged that she vaguely remembers someone making a remark about the bed rails as she was checking in the new resident, but that she was new and intensely focused on the computer and her documentation. 

It only took one day for the accident to occur. 

On her second day in the facility, while the new resident was repositioning herself in bed, the bed rail became detached and the resident fell off the bed.  She landed on top of the detached bed rail on the floor.  She was transported to the Emergency Room and was diagnosed with a frontal sinus facial fracture, mildly compressed skull fracture, and a possible subdural hematoma. 

The citation mentions that the bed appeared to be an older model with an air mattress placed on the bed frame.

After the incident, the resident’s husband returned to the facility to examine the bed.  “I got down on the floor to look at how the rails are attached to the bed, and it is only attached by a hand knob that you hand tighten. All anyone had to do was to tighten the black knob and my wife would not be in this condition. Anyone could have done that.  Their negligence is why my wife is like she is now.”

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.

Series of Failures Lands Resident At Doctors Nursing & Rehab In Hospital With Stage 4 Bed Sore And Sepsis

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IDPH has cited and fined Doctors Nursing & Rehab Center in Salem after a resident there was hospitalized due to a bed sore that became infected due to poor care.

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

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

When this resident was admitted to the nursing home, it was initially observed that there was a “wound to the Coccyx, two open areas, (area) measures 2 by 4 with a depth of 0.1, light clear serous drainage, well defined edges, with 100 percent of the wound covered by granulation tissue.”  No stage of the wound was documented. 

Over the next two months the nursing wound assessments indicate that the wound was stable for a period, then declined, then improved slightly, then declined again.  Ultimately, after approximately 8 weeks in the facility, the resident was rushed to the hospital with a Stage 4 wound that developed an infection, requiring Intravenous (IV) antibiotic therapy, and surgical debridement.  Worse, sepsis had set in.

While all wounds may fluctuate in their status, the failure of the nursing home in this case revolved around the lack of care provided by multiple staff members.

The first failure involved the wound care physician.  The resident initially received adequate care (for about four weeks).  At this four week mark however, the physician documented that “the patient’s visit has been rescheduled.  No nurse available for rounds.” 

One nurse noted in the citation that she was unsure as to why the wound doctor’s notes would read that a nurse was not available for a round, as any of the nurses could round with the wound care physician.

Unfortunately for the resident, there were no further evaluations of the wound by the wound care physician, as he was absent from the facility.  Ultimately, it was explained that the wound care physician “was on an extended medical leave and was not (and would not) be available.”

The second failure involved the primary care physician.  One nurse at the facility claims that she had reached out to the primary care physician once the wound care physician was no longer available. 

The primary care physician, however, denies having been contacted by the facility regarding the deteriorating wound.  In fact, she claims that she is always available directly by phone and was even in the facility making her rounds and could have easily examined the wound if she had been informed of the situation. 

The last failure involves the medical director at the facility.  While a nurse did contact the director, he did prescribe new treatment orders, but failed to stop by the resident’s room to examine the wound himself. 

A full month after the last visit by the wound care doctor, the night nurse reported that the resident had a fever of 104 degrees fahrenheit, and that the “urine in (indwelling catheter) bag noted to be dark and cloudy with small clots observed.”

The resident was sent to the hospital and was diagnosed with “septic shock secondary to sacral wound.”  Patients with advanced bed sores such as this resident are at high risk for going into septic shock due to open wounds created by the bedsores and the body’s inherently weakened condition as a result of the underlying wounds.

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

In this case these systemic failures are a sign of an understaffed nursing home, and border on neglect.  Sadly, that is a basic part of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Resident’s 9th Fall From Toilet Results In Left Femur Fracture And Surgery At GreenFields Of Geneva

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IDPH has cited and fined GreenFields of Geneva after a resident there was allowed to go to the bathroom without the required help and then fell while trying to transfer herself from the commode to the wheelchair, resulting in a fracture to her left femur, which required surgery and a 4-day hospital stay.

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 extensive assistance with toileting and transfers from the toilet.  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.

The resident’s progress notes indicated that in the last 12 months she had been found on the bathroom floor after falling while attempting to self-transfer no less than 8 separate times. 

On the day of this nursing home fall, the resident told a nurse that she needed to be toileted.  The nurse placed her on the commode chair in her bathroom and then left her there unattended to go assist another resident.  The nurse claimed in the citation that a separate nurse told her that it would be okay to leave the resident unattended.  The resident was alone and subsequently fell while attempting to self-transfer back to her wheelchair.

The fall resulted in a fracture to her left femur.  The resident was transferred to the hospital where she had a four day stay and underwent surgery to fix the injury.  

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.  The nurse had a feeling that she should not leave the resident alone while toileting, but needed to attend to another resident.  When the nurse asked one of her co-workers if it was okay to leave the resident unattended on the toilet, the nurse said that it was okay.  This turned out to be very  bad advice.  Because the resident was left on the toilet unattended, 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.

Bed Sore Acquired In Hospital Subsequently Neglected By Bethany Rehab Nursing Staff, Resident Dies

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IDPH has cited and fined Bethany Rehab nursing home after a resident there died due to a bed sore that went largely untreated in the nursing home and became infected due to poor care.

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

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

When the resident was admitted to the nursing home, she was coming directly from a local hospital.  The discharge summary from the hospital included, amongst other ailments, a “sacral suspected deep tissue injury hospital acquired, (adhesive foam dressing) sacrum dressing changed every 3 days and as needed.” 

Unfortunately for the resident, the admission assessment at the nursing home indicated that the new resident did not in fact have any impairment in skin integrity.  This was in direct contrast to the discharge summary from the hospital.

Two weeks later, a nursing note continued to acknowledge the hospital acquired sacral deep tissue injury.  The nursing note indicated that the resident had “no new issues” regarding her skin integrity. 

It was only approximately 5 weeks after the date of admission that a nursing note indicated “wound care provided to sacral area.” 

Every weekly skin assessment, from the date of admission, made no mention of the sacral deep tissue injury that was acquired in the hospital prior to admission. 

A few days after the first mention of the wound in a nursing note, a new note indicated that “resident found with eye open nonverbal but will track you with eyes, wound on coccyx bleeding now, dressing applied, 911 ambulance took resident to (local emergency room) for eval.”

The report from the emergency room states that there was a “quarter sized circular opening mid lower sacrum/coccyx draining serosanguinous fluid. Skin over the lower back is warm, hot, erythematous, and tender. Able to express fluid with palpation. Foul smelling drainage.”

Unfortunately, the resident was operated upon, suffered cardiac arrest, and passed away several days later.  The resident’s Death Certificate showed cause of death as sepsis, gluteal abscess necrotizing fasciitis and atrial fibrillation.

There are a couple of significant failures in the care of this resident which led to her death:

  1.  There was an initial failure to document the bed sore that was clearly mentioned in the discharge summary from the local hospital.  If the admission assessment had acknowledged the wound, steps could have been taken to address the bed sore at an early stage.

  2. Despite the existence of the hospital acquired bed sore, there was a delay in excess of five weeks before the nurses notes mention any treatment of the bed sore.  

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

These systemic failures are often a sign of an understaffed nursing home.  Sadly, that is a basic part of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.   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.

Medication Error at Wauconda Care Lands Resident In Emergency Room

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IDPH has cited and fined Wauconda Care in Wauconda after a resident there had to be hospitalized in the intensive care unit after a medication error in which the the nurse gave medications to the wrong resident.

Many nursing home residents are on multiple medications.  One of the basic tasks for members of the nursing staff is to give the medications to the resident as ordered by the doctor.

To safely do this, and avoid nursing home medications errors, nurses are supposed to check the 5 “rights” before giving medications to the resident: (1) is this the right resident, (2) is this the right medication, (3) is this the right dose, (4) is this the right route (pill, oral, etc.), and (5)  is this the right time?  Checking each of the 5 rights is a simple, but proven and effective way to avoid preventable medication errors.

The resident at issue was in his room with his wife when the nurse came by to administer his medication.  The nurse poured all of the medications into the resident’s mouth at the same time, and the resident was unable to swallow the pills or move his mouth at all. 

The resident’s wife told the nurse that something seemed wrong but the nurse kept trying to get the resident to swallow his pills and ultimately gave him Glucerna and pudding to aid the effort.  The resident’s wife said that two other nurses came into the room and one of them said to call 911 as the resident’s face was drooping like he was having a stroke. 

Upon arrival at the hospital the resident’s blood sugar was 17 in the Emergency Room.  He was admitted to the Intensive Care Unit where he received intravenous fluids with sugar. 

Blood tests for sulfonylurea ultimately revealed the presence of glimepiride, indicating that the resident had been administered the medication for a different resident who was a diabetic. 

This was a highly preventable medication error.  Giving one resident medications that were intended for another resident is the kind of medication error which should never occur – that is one of the basic “5 rights” that should be verified before giving medication. 

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.

Resident’s Pleas For Help Neglected By Nursing Staff, Dies At Chicago Ridge SNF

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IDPH has cited and fined Chicago Ridge SNF after a resident there suffered potential fluid overload in the lungs and subsequent death only three days after admission.  

Nursing home residents who are suffering from kidney failure may require dialysis, and when this is true, families often make the decision to pick one nursing home over another based upon the availability of an in-house dialysis unit in order to spare their loved one from having to be transported to an outside dialysis center.  These in-house units are usually operated by a separate company which means that coordination of care between the dialysis unit and the nursing staff is crucial to ensuring that the resident receives the care that is required. 

When this doesn’t happen, the results can be catastrophic.   When the kidneys are not functioning properly, the body cannot remove excess fluid and toxins.   Dialysis takes up that function in the absence of properly working kidneys.  When necessary dialysis sessions are missed, excess fluids and toxins can build up and cause serious problems throughout the body, most notably with the heart and lungs.

The resident at issue suffered from end stage renal disease, or kidney failure.  On the day that the resident was admitted, the internet was down from approximately 2:30 pm until approximately 1:00 am the following day.  While the in-house dialysis center was aware that the resident was arriving, they were never notified via email by the admitting nurse that the patient had actually arrived. 

Notes from the investigation highlight that this was most likely due to the initial lack of internet connectivity.  To make matters worse, the nursing staff neglected to send the email to the dialysis center once the internet was back up and running later the following morning.

The first signs of trouble appeared two days after the resident was admitted, when a nursing note documented that the resident was having trouble breathing and the blood oxygen level was 93%.  A nurse noted that to help the resident the nurse elevated the bed and the blood oxygen level rose back to 97%. 

The following afternoon the resident’s condition further deteriorated, with nurses noting that the resident was “coughing a lot and spitting up secretions.”   Nurses stated in the investigation that they were “too busy” to listen to the resident with a stethoscope and did not notify any doctors that the resident’s condition had changed for the worse, stating “I didn’t think to call the doctor at that time.  I just passed it onto the next nurse.”

Later that night notes indicate that a nurse visited the resident’s room at around 1:21 am.  The resident was reported to be talking but sounded upset.  While the residen’s breathing sounded congested and was slightly out of breath, the resident refused to be suctioned and was assisted by the nurse to lie back with head elevated.  The door was left open so that the nurse could hear if the resident needed assistance. 

The resident’s roommate, on the other hand, had a different story to tell.  The roommate claims that the resident was “screaming and yelling almost all night” and “coughing to the point of almost choking” screaming aloud “I can’t breathe.  Help me!”  The roommate claimed that a nurse visited the residence one time that night, telling the resident to “sit up and drink some water.” 

Unfortunately, at 6:45 am the morning nurse entered the resident’s room, only to find him without a pulse.   

There were a number of shortcomings in the care that this resident received:

  • When the resident initially developed shortness of breath and a low blood oxygen level, a doctor should have immediately been informed.  Further, there was no attempt to provide him with oxygen or send him to the hospital for further care.  It represented a change in condition and a real threat to the health and well-being of the resident.
  • There was no effort to regularly monitor the resident on the night before his death. Following the initial change in condition, the resident should have been checked on every two hours. The nurse on duty the night before the resident’s death admitted to not revisiting the resident after 1:21 am due to her busy schedule.  
  • There was inadequate response to possible fluid overload signs. The resident’s symptoms, such as respiratory distress, were indicative of potential fluid overload, yet no action was taken to address this.
  • Finally, when a resident is admitted needing dialysis, certain protocols must be followed.  In this case, the admitting nurse was able to order the resident’s medications, but failed to notify the in-house dialysis center, putting the patient in grave danger and contributing to the resident’s death just a few days after admittance.  

One of our basic 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.

 

Resident Receives 2x Dose of Diabetes Medication, Hospitalized At Sharon Healthcare Elms

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IDPH has cited and fined Sharon Healthcare Elms after a resident received two times the initially prescribed medication needed to treat his Diabetes Melitus leading to a drop in blood sugar that required hospitalization.

When a resident is admitted to a nursing home from a hospital, one of the things that the nursing home receives at the time of the admission is a list of prescribed medications and orders to be followed by the nursing home.  When the transfer orders are received, these are customarily entered into the resident’s chart by the admitting nurse.  In well-run nursing homes, the entry of these orders is double-checked to ensure that all of the orders are entered into the chart correctly.  Assuring continuity of care is absolutely crucial to assuring the health and well-being of nursing home residents because the failure to give ordered medications or to carry out treatments or orders can have catastrophic consequences.

The resident at issue here was admitted to the facility with a diagnosis of Type 2 Diabetes Mellitus.  Diabetes is a common ailment treated in nursing homes.  To keep blood sugar levels properly controlled, medications are commonly given.  One is Glipizide which when taken brings blood sugar levels down.  Too much Glipizide can result in excessively low blood sugar levels or hypoglycemia.  The discharge medication instructions from the hospital indicated Glipizide (XL)2.5 mg 24 hour sustained release tablets, once daily.  In this case the nursing home made a transcription mistake, resulting in the resident receiving Glipizide (XL) 2.5mg twice daily.  

Fortunately, there was a consultant pharmacy that notified the nursing home via fax on two separate occasions that there was a discrepancy in the quantity of the medication.  In well run nursing homes, the moment a nurse receives the fax, he or she addresses the mistake immediately.  Neither of the faxes that were sent directly to the nursing station were acted upon and the resident continued to receive Glipizide twice daily.  

The additional medicine resulted in the resident becoming unresponsive, hypoglycemic and requiring transfer to the hospital via ambulance.

Obviously, this nursing home medication error led to this resident experiencing a life threatening medical event. The initial transcription error is clear, but the nursing home also failed this resident by not acting upon the faxes the pharmacist sent over to the nursing station. 

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.

Resident at Dekalb County Rehab and Nursing Center Chokes in Dining Room and Dies

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IDPH has cited and fined Dekalb County Rehab and Nursing after a resident there choked on a dinner of chicken and waffles.  

One thing that families almost never envision being a possible outcome when they admit a family member to a nursing home is the possibility that their loved one could choke to death on food.  However, there are residents in nursing homes who are at risk of choking and sadly for some, that possibility comes to pass with deadly results.

There are two main factors that place residents at risk for having a nursing home choking accident.  The first of these is physical; the other is psychiatric or behavioral.  The kinds of physical issues that place residents at risk for choking would include things like poor dentition or some form of chewing or swallow dysfunction – often associated with neuromuscular issues such as movement disorders or the residual effects of strokes.  The kinds of psychiatric issues that may place a resident at risk for may include dementia or some form of behavioral disorder which results in compulsive or uncontrolled behaviors with regard to food.

There are two main shortcomings that occurred at Dekalb that resulted in the choking and subsequent death of this resident.  

First, the nursing home did not adjust the resident’s meal plan after he lost his dentures.  Specifically, the resident had misplaced his lower dentures and was in the process of being fitted for new dentures.  Importantly, the resident should have had a swallow evaluation done by a speech therapist to come up with modified diet orders or other approaches to eating which can serve to reduce the risk of choking.  The recommendations of the speech therapist should have been incorporated into physician orders and/or the resident care plan, which then should have been carried out on a day-to-day, shift-to-shift basis.  This was never done.  Even worse, multiple staff members who were interviewed about the choking death stated they did not know the resident was eating without lower dentures, even though the missing dentures had been documented as missing since the end of April.

The second shortcoming was that there were no aides in the dining hall when the choking episode occurred.  Federal regulations require that nursing homes have enough staff on hand to meet the care needs of the residents 24/7.  There had even been several discussions at resident council meetings about the lack of staff in the dining hall to assist residents with their meals.  

On the day of this nursing home choking incident, the general diet being fed to the residents consisted of a meal of waffles and fried chicken with syrup.  According to other residents at the table, the resident began coughing and was unable to respond to the other residents as they tried to communicate with him. Because they couldn’t find any staff in the dining room, a resident from the table stood up and walked out of the dining room to the nursing station to get help.

When a nurse finally came into the dining room, she could not see any blockage in the resident’s mouth. She completed back blows and the Heimlich maneuver but without success. She called in for assistance from another staff member who was out of the dining room and when that staff member arrived he took over back blows.  911 was called and paramedics took over the resuscitation efforts.  The resident was transferred to the hospital and soon thereafter passed away. 

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 AHVA Care of Winfield Chokes to Death on a Peanut Butter Sandwich 

Fondulac Rehab Resident Chokes to Death

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

Resident Breaks Leg After Wheelchair Accident at Generations at Applewood

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Generations at Applewood in Matteson was cited and fined by IDPH when a resident suffered a fractured tibia due to her foot becoming ensnared in her wheelchair.

The incident occurred during an attempt to transport the resident  from her room to a common area for an activity. The activity aide responsible for assisting the resident that day neglected to attach the necessary footrests to the wheelchair before initiating the transport. Without the footrests, the residents feet dangled freely, leaving her in a precarious position during the journey.

As the activity aide pushed the resident down the hallway, everything seemed to go smoothly until they reached a corner where the wheelchair needed to turn. Due to the resident’s difficulty in maneuvering sharp turns, she involuntarily lost her balance and attempted to catch herself, leading her right foot to get entangled under the wheelchair’s frame, causing excruciating pain. 

The resident was transported to an acute care hospital, where an examination revealed a right tibial fracture near her right knee. The fracture was deemed severe enough to warrant hospitalization for immediate treatment and care.

There was no policy at the facility regarding the use of footrests for safe transportation of residents who use wheelchairs. 

Unfortunately, the Activity staff member who pushed the resident in the wheelchair when the accident occured said that she “didn’t really pay attention” and that the resident did not have footrests. She said the resident was holding her legs up while she pushed the chair but then dropped her foot down during transport.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary injuries and illnesses and wrongful deaths of 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:

Pleasant Meadows Senior Living Resident Fractures Hip and Wrist in Fall

Unlocked Furniture Causes Fall and Broken Leg at Mount Vernon Countryside Manor

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

Vienna’s Hillview Healthcare Center Neglects to Notify Family Of Illness, Resident Dies

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IDPH has cited and fined Hillview Healthcare Center in Vienna after the facility failed to notify a resident’s family member in a timely manner of their loved ones’ dramatic decline in health.  Had the family been notified earlier, they would have acted to send her to the hospital prior to her becoming so ill that she perished in the ambulance.

Failing to follow protocol in notifying family members or Power of Attorney is an unfortunately common nursing home error. (See here, here, and here for examples). This is most often caused by an understaffed nursing home, not following appropriate steps, taking shortcuts, and ignoring the requests of its residents and family members. 

In this case, the progress notes from the first night of the incident indicate that the resident was suffering from a high fever.  Further, over the nighttime period the resident had remained in a recliner to sleep.  When passing her medications the resident was noted to be in a stupor with labored breathing and a temperature of 102.9. It was also noted that the resident was only responsive to painful stimuli of sternal rubs and deep nail press. The resident’s oxygen had dropped to 88% on room air.

The notes from the following day indicate that the resident had a large loose stool while sitting in her recliner and that the stool covered the resident “from head to toe.” That same day the resident was very slow to respond when spoken to and kept her head down while sitting in her recliner.

The facility was unable to provide documentation or reproducible evidence that any emergency contact or family members had been notified of this drastic change in condition.

In the afternoon of the second day a family member made an unannounced visit.  

At the time of the family members visit, the resident was observed to be non-responsive, and a staff member attempted a sternal rub with no response. The staff member looked at the resident’s legs, saw the mottling in her lower legs and told the family member “that concerned him.” The family member stated that the caregiver told her, “It just has me baffled. I don’t know what more to do because most of her vital signs were good.” 

The staff member stated that it was not clear to him what he was dealing with. At that point he said, “I think we need to send her to the hospital and that maybe it is something an IV could take care of”. When asked if she had spoken to the hospital yet, the staff member stated, “Not really.”

During a post incident interview, the staff stated they did not contact the family because the family had the facility number blocked. When the family contact was interviewed and asked if they had any of the facility phone numbers blocked so the facility would be unable to contact them, they stated, “I did not have my phone off and my phone number is not blocked to receive calls from the facility. Three family members’ contact information were listed in the resident’s record.

Had the facility contacted the numerous numbers available, the resident could have been transferred to the hospital hours earlier, when it was evident the resident’s health was in danger. 

Sadly, when the ambulance was finally ordered, the resident was transferred to the ER but died in transit to the hospital. Her cause of death was sepsis due to cellulitis, gastric bleed, and cardiac arrest.

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.

Resident Falls From Sling At Helia Healthcare of Belleville When Staff Use Incorrect Equipment

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The Illinois Department of Health has cited Helia Healthcare of Belleville after a resident fell from a mechanical lift when a paper transfer sheet broke mid-transfer. The resident suffered a head laceration and spent 22 days in the hospital.

Residents in healthcare facilities have different needs and require different types of assistance. For many seniors, transferring, or getting from one place to another, like chair to bed or bed to chair, can be quite difficult. In some cases, residents in facilities will need help from caregivers to safely transfer.  A mechanical lift, when used correctly, helps to keep the senior safe during a transfer as well as the caregivers. Mechanical lifts are used when the senior can bear little to no weight and require significant assistance to transfer. The lift does the heavy lifting and keeps everyone safe.

In the case at Helia, the resident needed extensive assistance getting from his chair to his bed. His care plan noted that he needed to be helped by 2 staff at a time and that those 2 staff members needed to use a mechanical lift.

After the incident, the staff interviewed said that the facility had not had enough mechanical lift slings on hand. The staff said that leadership told them they could use a paper transfer sheet in place of a sling, which clearly goes against the safety instructions and precautions for the lift.

On the day of this nursing home fall the 2 caregivers used a paper transfer sheet that was not made for the mechanical lift. When the lift was in the air, the sheet split in half and dropped the resident to the floor. The resident hit his head and began bleeding from the impact. The resident was taken to the hospital, where he remained for 22 days.

This is the kind of unnecessary injury that occurs due to taking shortcuts in providing care to residents.  Here there was a clear instruction, only use manufactured approved accessories, which was discarded for convenience sake and as a result, utterly predictable injury occurred.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.   Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

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

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

Champaign Urbana Nursing & Rehab resident admitted to ICU with untreated urinary tract infection

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

Resident Chokes To Death At Spring Creek Nursing & Rehab When Diet Is Mysteriously Changed Without An Order From A Physician

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The Illinois Department of Health has cited Spring Creek Nursing & Rehab, located in Joliet, after a resident died after choking on a meal of chicken tenders that did not meet their prescribed diet from their physician. The nurse at the community stated she changed the diet order but could not remember getting an order for the change from a physician or speech therapist. 

There are many challenges that can come with aging and with conditions that arise for older adults. Swallowing, for example, can become more difficult and lead to dangerous consequences, like choking. Physicians work with speech therapists to find food consistencies that are easier to swallow for older adults who might not be able to chew and swallow plated foods.

There are two very common types of diet consistencies for those who have difficulties swallowing safely, pureed and mechanical soft. In the case at Spring Creek, the resident was on a pureed diet after returning from a hospital stay, meaning that all food on the plate was to be pureed so that it was easier to swallow.

According to the citation report, the resident had a physician order to eat a pureed consistency general diet on March 23, 2023. On April 7, 2023, the nurse at the community stopped the pureed diet simply documenting the reason for the change as “wrong diet.” There is no documentation from the physician ordering the modification or of a speech therapy evaluation to change the diet.

It is a general protocol for speech therapy to be involved with any diet consistency changes. Best practices state that to upgrade from a pureed diet, the diet should change to mechanical soft consistency before returning to a regular consistency diet. A speech therapist would observe the person changing consistency while eating and then after eating for more than one meal to ensure the older adult was safe to make the change official.

This did not happen at Spring Creek, and the consequences were dire. Once a nurse noticed a problem, the resident was wheeled outside of the dining hall.  At that point the nurse did not hear an exchange of air and the resident started to make the universal sign for choking.  The nurse then took a spoon to do a sweep of the resident’s mouth only to find large chunks of chicken tenders.  At that point the nurse started to compress the resident’s abdomen from the front, and food started to come out of the resident’s mouth.  The nurse began to hear an exchange of air, but the resident’s eyes closed and the pulse went from thready to none.  The resident was rushed to the hospital and later died due to complications from an obstructed airway.

Unfortunately, there are a lot of questions here about how this happened, and why. Investigators spoke with multiple staff at the Spring Creek community, as well as the speech therapist and the physician who served the resident. The nurse who changed the order did not recall who she got the order from for the new diet. She just stated that she upgraded the diet to regular consistency because the resident was on the “wrong diet.”

This is a scary situation because of the forgetfulness of the nurse and the decision to upgrade a diet without following industry best practices. Senior living communities are busy places, but there is a process in place for upgrading diet orders.  Unfortunately this process was not followed at Spring Creek and the resident paid the ultimate price for the mistake. 

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

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

Champaign Urbana Nursing & Rehab resident admitted to ICU with untreated urinary tract infection

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

Grove of Berwyn Resident Violently Assaults Another Resident

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The Centers for Medicare and Medicaid Services have cited The Grove of Berwyn based on interview and record review and has determined that the facility failed to protect a cognitively impaired resident from assault from another resident with a history of violent behavior.

The injured resident was admitted to the facility in February of 2023 with a diagnosis of dementia. In April of 2023 another resident with a history of violent and criminal behavior that had often led to the requirement of restraints and security watch was allowed to walk unsupervised into another resident’s room and assaulted her. 

The assault resulted in the attacked resident falling to the ground with injuries after being violently pushed. The injured resident was emergently transferred to the hospital for care that included repair of a fractured femur requiring surgical intervention and pain management.

Upon interview of staff, the Grove of Berwyn LPN stated she did not actually see the fall, she saw the resident when she was already on the ground and that she called paramedics. When asked if she was aware of either resident having a record of a violent past, she stated “I did not, I don’t normally work here. No one told me anything about violent behavior and whether either resident should be monitored. I am from an agency and haven’t worked there since the incident.”

Progress notes contradict this interview and read “Patient was in another resident’s room when the resident pushed a patient in her back to get her out of her room. Patient landed on her knees and then laid on the floor and turned her left arm while lying on the floor and sustained abrasion to left elbow, cleaned and dry. 911 called.” Staff will continue to monitor for aggression.

The facility policy titled Abuse and Neglect reads in part: “It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment”. Based on the interviews, The Grove of Berwyn was cited for a failure to follow their policy and procedure for admissions by not ensuring the resident was protected from the resident that posed a known risk.

Failing to protect residents from injury and abuse and treat them with respect is all too commonplace in the nursing home setting. (See here, here, and here for examples). This is most often caused by an understaffed nursing home, the utilization of temporary employees that are not informed appropriately about resident needs, and lack of proper monitoring of residents. 

Unfortunately, ignoring regulations and failing to relay important information to new and existing staff regarding safety measures is the standard level of care for many nursing homes.  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.

 

Split penis the result of poor catheter care at Piatt County Nursing Home

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IDPH has cited and fined Piatt County Nursing Home after a resident there suffered a split in his penis from the tip to the scrotum due to poor catheter care.

The use of catheters is discouraged under federal regulations for nursing homes, in large part due to the risk of the development of urinary tract infections.  However for males especially, there is a risk of damage to the urethra from prolonged catheter use.  A catheter is a thin tube which is threaded through the urethra into the bladder to allow urine to be drained from the bladder.  The risk of tearing of the penis come from friction from the catheter and pressure from the tubing and collection device.  The use of a catheter should be addressed in the resident care plan.

The resident as admitted to the nursing home with a catheter in place for urinary retention.  Despite having a catheter in place on admission, there was no care plan developed with regard to the use of the catheter.  One month after admission, the staff documented a split in the tip of the resident’s measuring 1 cm x 0.5 cm.  A wound care physician was brought in to address the tear, and he issued orders which included application of petroleum jelly and consult with a urologist.

When a resident develops a wound like this, this represents a change in condition which requires physician notification (which was done).  It also requires revision of the resident care plan.  This was not done.

When the staff was interviewed by IDPH as part of its investigation, one nurse said that it appeared that the resident had issues at the nursing home where he resided previously.  If there was in fact a tear present when the resident was admitted to the facility, the fact that it went unaddressed for a month is troubling as well.  When residents are admitted to a nursing home, the undergo a head-to-toe skin assessment, and if that wound was missed not only during that assessment but also during regular catheter care during the first month of the resident’s admission to this nursing home, that is also substandard care.  It means that the wound would not have been reported to the physician, it would not have been addressed in the care plan, and there would have been no treatment for it.

The staff applied the petroleum jelly for four days but then stopped because it was causing drainage.  However, the staff did not notify the wound care physician and no order was ever issued to discontinue the use of petroleum jelly.  The urology consult was scheduled.  However, the earliest date for an appointment which could be obtained was nearly two months later.  On the day of the appointment, the resident was not able to go to the appointment because his high-backed wheelchair could not fit into the van which was to take him to the appointment.  The appointment was canceled and had not been rescheduled as of the time of the investigation by IDPH.

A month after the urology consult was canceled, the attending physician was notified that the catheter has been changed 3 times in one week due to nonpatency (there was a blockage which kept the urine from flowing through the catheter), that the resident had not yet been seen by a urologist, and that the resident’s penis was split down the the scrotum. IDPH arrived a few days later and found that the urine bag was on the floor next to resident’s bed rather than hanging from the rail.  The surveyor observed that the penis was filleted open from the tip to the scrotum.  When the surveyor asked whether it was sore, the resident replied, “Yes, more than you know.”

There were a number of shortcomings in the care that this resident received:

  • If there was in fact a tear present on admission, it was not discovered by the staff during their initial skin assessment or during subsequent care, nor was the wound addressed in the care plan or in treatment orders.
  • Care of the catheter was not addressed in the resident care plan.
  • The staff failed to follow the physician’s order for the application of petroleum jelly or advise the physician that application of it was causing additional drainage.
  • Once the wound was recognized in the facility, care of the wound was not addressed in the resident care plan.
  • The staff failed to obtain a timely appointment for the consult with the urologist, failed to make arrangements for proper transportation to the appointment, failed to advise the wound care physician or the attending doctor that the appointment was canceled, and failed to reschedule it.
  • Left the urine collection bag on the floor, resulting in additional pressure on the penile tissues.

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

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

Champaign Urbana Nursing & Rehab resident admitted to ICU with untreated urinary tract infection

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

 

Southgate Health Care Center Resident Dies When Brought To Shower Without Supplemental Oxygen

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The Centers for Medicare and Medicaid Services have cited Southgate Healthcare Center of Illinois with violations after interviews and records uncovered that the facility failed to provide prescribed oxygen therapy during a resident’s shower, leading to the residents death. 

Noncompliance in following prescribed orders is an all-too-common reason for nursing home error. (See here, here, and here for examples). 

Errors of noncompliance are most often caused by lack of training, disorganization, and failing to follow changes in the prescribed orders for the resident. This incident demonstrates that incidents occur when the staff are not properly trained and are noncompliant.

In this case, the resident was admitted to Southgate facility with diagnoses including Pulmonary fibrosis, chronic respiratory failure, COPD (chronic obstructive pulmonary disease), and continuous dependence on supplemental oxygen. The resident required 2-2.5L of oxygen continuously at the time of admission. Additionally, he was determined to require the physical assistance of one person for bathing activity due to his impaired balance, limited mobility, and the necessity of supplemental oxygen. 

During his stay, therapy notified nursing that the resident’s oxygen levels had been dropping in the 80’s when trying to work with him. The nurse checked resident tubing for kinks. The resident appeared to be anxious and holding his breath, causing his oxygen to drop into the high 80’s. 

Medication records showed that the resident had been prescribed Buspirone 10 mg. for anxiety, three times daily. Physical therapy asked if the resident could be prescribed anything additional for his anxiety. The resident’s Primary Care Physician’s office was notified of the request. The physician placed a new order for an increase to 3L of oxygen by nasal canula, active on every shift. 

During interview the CNA stated she went to the resident’s room and told him it was his shower day and stated, “I asked if he wanted a bed bath or shower. He looked at me and stated, you know I haven’t had a shower since I’ve been here, I’m sticky. I want a shower.” CNA said she then took the resident from his room without his oxygen to the shower room. She estimated that the time from his room to the time he became unresponsive in the shower room was about 10 minutes. “I did a quick one for him because I know the oxygen situation. He wanted his head washed really good. He was greasy. I know oxygen patients can’t be off of oxygen long. I’m terrified to take the oxygen machine into the shower because of electrical concerns. I monitored his 02 stats the whole time and they were “high” (mid to high 90’s). I don’t do that kind of paperwork, but I used the 02 sat monitor on his finger. He was talking with me the whole time and he said, Baby, are we about done? I told him yes and we were drying off and getting dressed. I had him out of the shower, he was in the shower chair. I turned to my left to grab his shirt and went to put his shirt on, and he had his arms up to put the sleeve holes, I got his arms in and then his arms fell into his lap. I called for help immediately. I stuck my head in the hall and a CNA was right there in the hall (we were using that shower room because they were working on skilled back shower room water). I told him to get the nurse STAT that the resident was unresponsive I never left him alone in the shower. Not even a minute later the nurse came in. I’m pretty sure someone took his vital signs, but I don’t remember. I think that someone could stay off oxygen for 10 minutes, but in my experience, I didn’t think 10 minutes would be that long. What scared me was that he had been talking to me.” 

When asked what electrical concerns one might have with portable oxygen, the staff member said she was not aware she could take a portable with her to the shower and stated, “I did not know that this resident was required to be on continuous oxygen. We have residents who take their oxygen off to go to the dining room, but I was assuming he was the same way. This was the second time I had ever worked with him, and it was never conveyed to me he was continuous oxygen.” When asked if the resident had ever sustained a fall, the CNA stated not that she was aware of.

Facility notes read, “This nurse was on hall passing medicines when a CNA came to get me telling me they need a nurse. I went into the hall shower room and found the resident non-responsive. I immediately called 911. The LPN stated when she entered the shower room the resident was sitting in the shower chair just outside the shower itself. His dentures were protruding from his mouth. The CNA relayed to the nurse that she was drying the resident off, and he started not breathing very well. It was noted that the resident’s oxygen was not in the shower room and the nurse immediately instructed “the male staff” to go and get his oxygen, then called 911. 

When asked if the resident had experienced a fall at any time, the LPN said she was told he had not, that he remained in the shower chair. LPN continued that she asked what the resident’s code status was, but that the CNA did not know how to read the board. At this time the nurse was able to confirm the code status was DNR. 2-3 minutes later, the male staff returned with resident’s portable oxygen. The resident’s oxygen per nasal cannula was administered at 2L and, according to records, his color returned. LPN stated she kept calling the resident’s name and he would gasp but did not speak. “He was still in distress, and I was praying the ambulance would get there quick.” She added that prior to this incident, the resident was cognitive with confusion, but could hold a conversation with her and could tell her exactly how he liked his pills. When asked if any vitals were taken during the incident, she stated no, she had been on the phone with 911. She said EMS took vitals on arrival. “Had I realized he was being taken down to the shower room, I would have suggested he have his 02 with him. I would have rather he stayed in bed and had a bed bath because he gets out of breath with movement, but he has that right to a shower. 

The nurse confirmed if a resident requires a continuous 02 you would take the portable to the shower and work around it. You would never not take the 02 with them to the shower, stating, “they could meet Jesus on the way.” When asked how a CNA would determine whether a resident required oxygen and whether it would be intermittent, as needed, or continuous, both the CNA and nurse stated the easiest thing would be to ask the nurse and that’s what they would do. When asked how they would handle a situation in which a resident who was ordered continuous oxygen for all activities asked for a shower, both nurses stated they would take the portable oxygen tank. The portable tanks do not need to be plugged in.

EMS facility notes staff state that they were told the patient went to go take a shower and the staff found him unresponsive on the shower floor. According to EMS the CNA sat him up and then noticed that he was still unresponsive, so they called 911. 

Upon arrival to Southgate, the staff brought EMS to the bathing room where they found the patient sitting in shower chair with CNA holding patient up with nasal cannula with oxygen delivered at 2L. 

Staff stated patient had been taking a shower and talking with no problem. CNA stated she turned around to grab a towel and turned back and patient head was slumping down and not responding to stimuli. Resident was transported and the family notified.

Based on interview and record review the facility failed to ensure this resident received continuous oxygen therapy as required during a shower. This failure resulted in the resident becoming unresponsive requiring emergent care with subsequent hospitalization.

Upon admission to the ER the patient was found unresponsive but had a pulse. Patient was in acute respiratory failure requiring intubation. Upon reassessment after treatment, the resident began to become more awake and started pulling at his tube. He was left on the ventilator to reduce carbon dioxide levels. The patient was extubated to a non-invasive high-flow respiratory support system and ultimately the decision to extubate and provide comfort measures was made. He remained in the company of family and passed away two days later. The cause of death was determined to be Acute Chronic Respiratory Failure with a duration of two days and Community Acquired Pneumonia.

The interview and review of records concluded that post incident, the resident suffered an elevated troponin level, indicating heart muscle damage not due to acute coronary syndrome, weakness, pulmonary fibrosis but from respiratory failure due to the lack of oxygen (hypoxia) and subsequently developed pneumonia.

When the Director of Nursing was asked about the resident’s hospital records documenting his history that was taken by EMS indicating that the resident was found on the floor unresponsive. The director reiterated that the resident never sustained a fall, especially on the date of the shower incident and that the information obtained was either misunderstood or recorded incorrectly in the report.

During the interview the director stated if a resident required continuous oxygen, you would make sure to take the portable 02 with the resident in the shower and only remove while washing the face to ensure the oxygen was off as short a time as possible because some residents have COPD and “things like that”.

The facility stated that access resident information is available at the kiosk or tablet Kardex where charting is performed but was not sure if their information would define whether a resident required continuous 02, but that most CNAs would ask the nurse. The facility confirmed if a resident required continuous oxygen for all activities, a portable tank would be taken to the shower room. The male staff member stated they would be afraid to take a resident out of their room for the fear they may become short of breath, but if they requested a shower, he would not take them without some form of 02.

This facility estimated the resident was without his oxygen for approximately 10 minutes from the time he left his room for the shower until the time he became unresponsive, and oxygen was started again 2-3 minutes later. When asked if he felt being off oxygen during this time would have contributed to an acute respiratory distress event, the staff member stated, “In my mind the main thing with the resident was he had end stage lung disease/pulmonary fibrosis and if he was without oxygen longer than 10 minutes, he would definitely think that could trigger an event and that anything less than 10 minutes would not contribute to acute respiratory distress. When asked if he thought this could have contributed to the resident’s death while in the hospital, the facility did not think the incident would directly relate to his death. He reiterated the time frame involved and stated the resident was oxygen dependent, and he had a terminal illness.

Unfortunately, noncompliance with physician orders and poor training is the standard level of care for many nursing homes. 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.

 

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.

 

 

 

 

 

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