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

Feeding tube error puts Burgess Square resident into heart failure

September 21, 2021 By Barry G. Doyle Leave a Comment

IDPH has cited and fined Burgess Square Health Center nursing home in Westmont after a resident there was given tube feedings well in excess of that ordered by the physician, causing her to experience acute congestive heart failure and requiring hospitalization.

One of the basic functions of nurses in a nursing home setting is to provide care in accordance with physician orders. Each resident will have a diet order. Some residents have an order for a general diet, other residents have a modified diet such as a mechanical soft diet which is intended to reduce the risk of nursing home choking accidents. Still other residents receive their nutrition through tube feedings, and this is something which requires the help of the nursing staff.

When a resident receives nutrition through a feeding tube, the order will usually include what kind of formula should be given and how much. Failing to give the right kind of formula can cause medical problems for the resident, while failing to give as much as ordered can lead to malnutrition and other illnesses for the resident. Here, we have a situation where the resident was given far more than ordered.

The order that was in place called for the resident to receive a 275 ml of formula three times a day. Typically, that amount would be given over two to three hour period. Instead of providing the tube feeding as ordered, the nurse gave the resident 275 ml of formula per hour for five hours. This means that the resident received a far greater amount than was ordered, far faster than was ordered.

The net result of this was that the resident experienced fluid overload which led to acute congestive heart failure. The resident experienced severe abdominal pain from overfeeding. She also experienced significantly elevated blood sugars. All of this led to an unnecessary hospitalization for her.

The root cause of this feeding tube accident was that the order was not followed. The order was for a 275 ml bolus (single dose), rather than 275 ml per hour continuously. In much the same way that medication errors in nursing homes can be prevented by making the proper checks, this incident could have been easily avoided by checking the physician order before administering the tube feedings.

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

Other blog posts of interest:

Aperion Care Wilmington resident suffers ruptured colon due to fecal impaction

Burbank Rehab resident hospitalized due to missed dialysis sessions

Failure to obtain treatment for congestive heart failure at Avantara Long Grove

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

Resident at Chateau nursing home in Willowbrook suffers spinal fractures in wheelchair accident

September 19, 2021 By Barry G. Doyle Leave a Comment

IDPH has cited and fined Chateau Nursing & Rehabilitation Center nursing home in Willowbrook after a resident there suffered spinal fractures due to falling from her wheelchair after being pushed forward by the staff when there were no leg rests on her wheelchair.

Wheelchairs are a common sight in nursing homes, and as long as they are used properly, they are generally safe, helpful equipment for the care of nursing home residents who need that level of assistance. The key of course is that they are used properly, and proper use of a wheelchair requires that the leg rests to the wheelchair be applied when the wheelchair is being pushed by staff.

The reason that leg rests are required to be used when the resident is being pushed forward in the wheelchair is that without the leg rests in use, there is a chance that the resident’s feet will drop to the floor while the wheelchair is being pushed forward. When this happens, one of two things are likely to occur: (1) that the resident’s legs will get pulled underneath the chair, resulting in a twisting mechanism which can produce fractures or tears to ligaments and cartilage or (2) that the resident can be thrown forward out of the chair, resulting in the kinds of injuries you might see if a resident falls forward while walking – except that this fall will happen at a higher speed.

The resident at issue was wheelchair bound. She suffered from Parkinson’s which left one arm contracted against her body. However, she was able to self-propel in her wheelchair using her feet, meaning that she was able to move throughout the nursing home in her wheelchair by walking her feet forward. For many wheelchair-bound residents, this is an important part of maintaining some degree of independence.

This resident experienced not one, but two nursing home falls due to staff pushing her in her wheelchair with no leg rests applied. The first occurred two months before the fall at issue. In that fall, she was being pushed forward by staff with no leg rests on the wheelchair. She dropped her feet to the floor and was thrown forward out of the wheelchair. Fortunately, there were no injuries from this fall.

After the fall, there was a care planning meeting held with the family. The family agreed to obtain leg rests for the wheelchair and a bag for them to be kept on the back of the wheelchair. The resident’s care plan was updated to include using leg rests while pushing the resident in her wheelchair and the staff was given in-service training on the use of leg rests while pushing the resident in her wheelchair. The change in the care plan was noted on the care card which advises staff of the contents of the care plan.

On the day of the fall, the resident was being pushed forward into the dining room by an activity aide. There were no foot rests applied to the wheelchair even though they were in the bag that was hanging on the back of the chair. Even though she attended the in-service training, the aide explained to the state surveyor that she did not know that the leg rests needed to be applied according to the care plan and that she could not see the bag because the resident was seated on top of a mechanical lift sling and the bag with the leg rests was was hidden by the sling.

While the resident was being pushed into the dining room, the resident’s feet dropped to the floor and the resident was thrown forward out of the wheelchair, and hit her head on the floor. This is of course a near-replay of the fall two months earlier. It is also one of the truly predictable mechanisms of injury when a nursing home resident is pushed in a wheelchair that has not foot rests.

Sadly, in this fall the resident did not escape injury. She was brought to the hospital where it was determined that she suffered a fracture of the C1 vertebra, the bone at the top of the spinal column. She had a previous compression fracture of the T4 vertebra, located in the upper portion of the mid-back. It was decided that she was not a good surgical candidate, so she was placed in a hard cervical collar. Because she actively tried to remove it while in the hospital, restraints were used. Once she was discharged to the nursing home, she received supervision from a 1:1 sitter whose job was to keep her from removing the hard collar and causing further injury to herself.

The obvious and basic cause of this fall is the failure to place the foot rests on the wheelchair while pushing her forward. It resulted in a very predictable injury to the resident. Even though the staff and this aide specifically were in-serviced to use the foot rests, this should be a basic part of the training that staff receives in caring for every resident in the facility. This resident was not the only one put at risk from being pushed in a wheelchair with no footrests.

Past that, the aide explained to the state surveyor that the care card which indicated that foot rests were required was in the resident’s room, and as an activity aide, she did not go into resident rooms. However, part of the care planning process is communicating the contents of the care plan to the staff charged with carrying it out. The care plan is supposed to guide the actual provided, and if the staff delivering the care does not know what is required, the plan is nothing more than paperwork.

These breakdowns, especially the failure to train staff, are sadly common in the long-term care industry. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

Good Samaritan of Pontiac nursing home resident suffers multiple fractures in wheelchair accident

Wheelchair accident at Avanti Wellness

Assisi at Clare Oaks resident suffers broken neck in fall from wheelchair

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

Warren Park Health & Living Center resident suffers brain bleed in fall down stairwell

September 18, 2021 By Barry G. Doyle Leave a Comment

IDPH has cited and fined Warren Park Health & Living Center nursing home in Chicago after a resident there accessed the stairwell and suffered a fall in which she suffered a brain bleed.

Federal regulations regarding nursing home falls provide that the nursing home environment should be as free of accident hazards as possible. For nursing home residents, stairwells pose a serious risk of falls and injury. This is because many nursing home residents have strength and/or balance problems which make the use of stairs especially hazardous.

Compounding the risk associated with the use of stairs is the fact that stairs are usually out of the line of sight for staff members, so they will not be in a position to offer help to residents who need help and attempt to go up and down the stairs. Additionally, if a fall occurs, the fall and any injury that occurs may not be timely discovered which can result in delaying the receipt of care. This can have fatal consequences where a resident suffers an injury such as a brain bleed.

To alleviate the risk of stairwell falls in a nursing home setting, access to the stairwells by residents should be restricted. The most common means by which this is accomplished is either: (1) locking the stairwells so you can only get in the stairwell with a key or (2) more commonly, they are secured with a key pad access system which limits access to the stairwell or sounds an alarm when someone uses the stairwell without the proper code. However, as we have seen in situations where the resident has eloped or wandered from the nursing home, the alarm system is ineffective where the key pad is disabled or the access code is commonly known among the residents (see here, here, here, and here for examples of this).

The resident at issue lived on the second floor of this nursing home and had a friend who she liked to visit who lived on the third floor of the nursing home. She would frequently use the stairwell to get from the second to the third floor. She was a fall risk, as she had a history of falls, and we know that having one nursing home fall tends to beget additional falls.

On the day of this nursing home fall, she was in the stairwell when she either lost her balance or tripped and fell. She hit her head and was knocked unconscious. She suffered a laceration to the head which required surgery, but more significantly, suffered a brain bleed when she fell. This is an injury which can progress, and if left untreated can have catastrophic consequences.

The investigation into this incident showed that the key pad access system for the stairwell had been disarmed, so residents were able to freely access the stairwell, and thereby be exposed to the hazards of going up and down the stairs. Exposing residents to risk of harm this way is a violation of federal regulations.

Other blog posts of interest:

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

Grosse Pointe Manor resident falls and breaks hip after being left unattended

Generations Oakton Pavilion resident falls and fractures hip

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

Tuscola Health Care Center resident dropped from lift, breaks ankle

September 3, 2021 By Barry G. Doyle

IDPH has cited and fined Tuscola Health Care Center after a resident there suffered a fractured ankle after she was dropped from a lift during transfer.

Used properly, a mechanical lift is a wonderful tool for use in a nursing home. It saves from wear-and-tear on the staff and keeps them from getting hurt. It allows safe transfers of residents who need that level of assistance.

The phrase in the sentence above is “used properly.” Proper use of a mechanical lift requires the assistance of two staff members during transfers (see here, here, and here for examples of what happens when one person does a two-person job), the lift and its accessories must be properly maintained (see here and here for examples of that not occurring), the right accessories must used.

The nursing home fall that is the subject of this citation is what occurs when proper accessories are not used.

The resident issue had a history of stroke with residual weakness on one side. Transfers from bed to wheelchair, wheelchair to chair and so forth were done by lift.

On the day of the fall, the resident was being transferred by two staff from bed to wheelchair using a lift. The sling for the lift was not the right size. Because of this, the straps that pass underneath that resident could not be criss-crossed as normal. Because the transfer was a short distance, the staff decided to attempt it.

As they did so the resident slipped out of the sling, landing on the floor on top of her ankle. X-rays were taken and she was sent to the hospital where she was diagnosed with a fractured ankle. The treating orthopaedic surgeon attributed the fracture to the fall and stated that the resident would have some chronic discomfort in the ankle despite her limited weight bearing status.

This was a highly preventable injury. The right number of people for the transfer were there, but the right accessories to the lift were not. This led directly to the resident’s fall and injury. Had the proper sling been used, this resident likely would not have been injured at all.

The fact that the staff decided to go ahead with the transfer raises questions about whether this is an understaffed nursing home. Whenever there are shortcuts taken in the care of residents, it is an indicator that they do not have time and space to deliver care the way that it needs to be. Sadly, short-staffing is a part of the nursing home business model.

Other blog posts of interest:

Resident at Hickory Point Christian in Forsyth suffers multiple fractures in fall

Casey Healthcare resident breaks hip in fall due to violation of care plan

Taylorville Skilled resident sustains fractured hip after multiple falls

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

Sunset Rehab resident chokes to death

September 1, 2021 By Barry G. Doyle

IDPH has cited and fined Sunset Rehabilitation & Health Care nursing home in Canton after a resident there choked to death while eating lunch.

The resident at issue here had a history of having had a traumatic brain injury. One way in which this manifested itself was in behavior disturbances which manifested itself by eating very rapidly, not chewing, and walking around while eating. These behaviors placed the resident at risk for choking.

When a resident is at risk for harm, it is incumbent on the nursing staff to develop a care plan outlines a series of steps which are to be taken on a day-to-day, shift-to-shift basis to prevent the harm from occurring. It also recommended that he be given “finger foods” to eat. In this case, the steps incorporated into the resident care plan was to provide one person assistance with eating – a level of care which was also documented on the resident’s Minimum Data Set (MDS).

On the day of this nursing home choking accident, the resident was given a slice of ham, sweet potatoes, and a vegetable to eat. He got up from the table while still eating and began to choke, collapsing in a nearby hallway. The staff attempted to clear the airway and perform CPR, but the resident died before he could be brought to the hospital. Cause of death was brain hypoxia, or loss of oxygen to the brain.

IDPH’s investigation of the incident uncovered a number of troubling findings:

Even though the use of finger foods was a part of the resident’s care to address his risk of choking, there was no diet order to that effect. In fact on the day that he died, he was served ham and sweet potatoes – things that can hardly be characterized as finger foods. Further the ham was not cut into smaller pieces to mitigate the risk of choking. The facility cook stated that he was not aware of the resident’s care plan and never looked at resident care plans.
The resident’s care plan called for one person assistance with eating while he was only receiving supervision that day. The difference between the two is getting some physical help versus cues and reminders to slow down while eating. The net difference here was that there was no one to cut his food into smaller pieces which very easily could have been the difference between having a fatal choking accident and surviving this event.
Many of the staff had expired CRP certifications, including several of the staff members who responded to the emergency. Beyond having expired certifications, the ambu-bag (a device which uses a bag to force air into the lungs during CPR) was never employed until the paramedics arrived, the staff did not know how to determine the resident’s code status, or whether CPR should be attempted on a resident who is DNR (it should).

This is a classic example of a situation where the nursing has failed the resident for a long period of time, but avoided catastrophe only by sheer luck. Good luck is not a substitute for good care. The resident had a care plan which did not correlate with the diet orders, the process by which that care plan would be implemented (having the kitchen prepare meals which complied with the car plan) didn’t work because the kitchen staff didn’t review care plans, and the staff was ill-trained and without required certifications. This is an accident which could have occurred to any number of residents on any number of days.

Other blog posts of interest:

Aperion of Spring Valley resident chokes to death

Resident at Aspen Rehab in Silvis chokes to death due to failure to follow care plan

Fatal choking accident at Spring Creek in Joliet

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

Westminster Village resident suffers multiple fractures in fall

August 29, 2021 By Barry G. Doyle

IDPH has cited and fined Westminster Village nursing home in Bloomington after a resident there sustained multiple fractures in a fall.

The resident involved was admitted for rehabilitation following a urinary tract infection and for age-related debility. However, less than 2 weeks after being admitted to the nursing home, the resident was discharged from physical therapy. The therapy discharge summary stated that the resident required stand by assist for all functional mobility due to decreased awareness of limitations. It also stated that the resident had limited potential for further gains and that resident would likely not achieve independent levels of function.

The resident was assessed as being at risk for falls and a fall prevention care plan was put into place. This called for assistance with activities of daily living and supervision with toileting and transfers. However, her Minimum Data Set showed a more extensive level of assistance being required: supervision with toileting, transfers, personal hygiene, and walking in her room.

On the night of this nursing home fall, the aide assigned to care for the resident set things up for the resident to get ready for bed including brushing her teeth. He left to attend to other residents because he believed that she was independent with those activities. He was unable to return for a while because other resident’s call lights were sounding.

After the resident got done brushing her teeth, she pushed the door to leave the bathroom and lost her balance, falling forward and hitting her face on the floor. She was complaining of chest pain, so she was sent to the hospital where she was diagnosed as having rib fractures, a fractured sternum, and multiple fractures of the jaw. The jaw fractures were significant enough that she required transfer to another hospital for a higher level of care.

There was a disconnect between what the resident needed and what the resident required in the way of care. The discharge summary from physical therapy called for the resident to get stand-by assist with all functional mobility, while the CNA assigned to the resident believed that she was independent. The care plan only called for supervision with activities of daily living. Clearly there was a breakdown in what was needed and was being provided. This resident needed someone in the room helping at the time of the accident, but did not get that help, and as a result sustained serious injuries in this fall.

The injuries that this resident sustained are significant above and beyond the pain which she experienced from the broken bones. Rib fractures and a fractured sternum make it difficult to inhale and exhale normally which can set the stage for developing pneumonia. The jaw fractures will result in decreased oral intake, which can set the stage for the resident to develop bed sores.

The fact that the aide was not able to return to the room in a timely fashion because of the needs of other residents raises a question of whether this is an understaffed nursing home. Unfortunately, not having enough staff on hand to meet the care needs of the residents is a common feature in the long-term care industry. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

Resident breaks hip in fall at McLean County Nursing Home

Fall results in fractured kneecap at Country Health in Gifford

Failure to assist resident to bathroom leads to fall at Heritage Health in Peru

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

Alden Estates of Huntley fails to follow orders to give antibiotic

August 28, 2021 By Barry G. Doyle

IDPH has cited and fined Alden Estates Courts of Huntley nursing home after a resident there had to undergo surgery to replace an artificial knee after developing an infection brought on by the failure of the nursing home to obtain and give antibiotics that had been ordered for the resident.

The resident at issue had a history of chronic discitis bacteremia, which mean that her low back was colonized with infectious organisms In this case it was staph bacteria. To combat this and prevent the bacteria from spreading to other parts of her body, the resident had been permanently placed on an antibiotic called doxycycline prophylactically, meaning that she was to receive the mediation on an ongoing basis to keep her from getting critically ill with sepsis. Once the body is colonized with infection-causing bacteria, they can cause infection in other parts of the body. Implants such as artificial joints, stents, and pacemakers are often places where infection results.

When the resident was admitted to the nursing home from the hospital with orders on the discharge papers to receive an antibiotic doxycycline, 100 mg twice per day. However, when the resident was admitted to the nursing home, the order was never transcribed onto the physician order sheet, and as a result, the medication was never ordered from the pharmacy. With the orders never transcribed onto the order sheet and the medication never obtained, the resident did not receive any of the antibiotic that was ordered for her for the first 13 days of her admission to the nursing home.

After missing the first 13 doses, the resident suffered an episode of chest pain and was admitted to the hospital for a total of 13 days. When she was discharged from the hospital, she again had orders for doxycycline, 100 mg twice per day. Once again, the order was never entered into the physician order sheet and the medication was never ordered.

The net effect of this nursing home medication error is that the resident did not receive a total of 52 doses of the medication that was ordered to suppress the bacteria and prevent her from suffering a serious infection.

Due to not receiving the medication that had been ordered for her, the resident developed an infection and was sent to the hospital in a critically ill condition. She was suffering from septic shock and had an infection of her artificial knee. Due to the infection of the knee prosthesis, she had undergo surgery to remove the prosthesis and have a new one implanted. The orthopaedic surgeon attributed the infection to the bacteria which were intended to be controlled by the antibiotic which the resident did not receive.

Assuring continuity of care is a critical part of helping nursing home residents maintain their health and well-being. Nursing home resident are almost always admitted suffering from some condition of ill-being whether it is acute, as may the case with patients admitted for short-term rehabilitation, or may suffer from long-term chronic medical conditions, as was the case here. The common thread between them is that these conditions are being managed by a physician who is relying upon the nursing home home staff to implement the care that they have ordered. When they do not, catastrophe can result.

Nursing homes are businesses, and well-run businesses have systems in place to carry out their basic functions. Admitting residents to the nursing home and assuring continuity of care is one of those basic functions. Here there was clearly a problem with the system that the nursing home was operating under, as the antibiotic ordered for this resident was not given after two separate admissions. The fact that this was a common thread between the two admissions speaks to a larger problem than a simple breakdown of the system due to human error. Once could be a mistake, twice could be a larger issue.

Other blog posts of interest:

Failure to notify physician leads to death of resident at Alden Estates of Barrington

Accolade of Paxton fails to give resident post-operative antibiotics

Medication error leads to hospital admission at Arista Healthcare

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

Aperion Care Wilmington resident suffers ruptured colon from fecal impaction

August 24, 2021 By Barry G. Doyle

IDPH has cited and fined Aperion Care Wilmington nursing home after a resident there developed fecal impaction which led to a ruptured colon which required multiple surgeries.

The resident at issue suffered from mental illness and was receiving several psychotropic medications. One of the risks associated with the use of these kinds of medications is that the resident will suffer from constipation. When a resident is receiving psychotropic medications, one of the steps typically included in the resident care plan is to monitor the resident for signs and symptoms of constipation as well as tracking their bowel movements.

Prolonged periods of constipation increases the risk that the resident will experience fecal impaction. When someone suffers from fecal impaction, there a hard balls of feces in their digest tract which are hard to push through to the end of the digestive tract. The presence of a fecal impaction can cause abdominal pain and other digestive issues, and in advanced cases can cause perforation of the structures of the digestive tract.

Perforation or rupture of structures in the digestive tract results in the contents of the digestive tract leaking out into the abdominal cavity. The causes a type of infection known as peritonitis. Peritonitis is very painful and can be a life-threatening condition. It is also a very difficult condition to treat and often requires a prolonged course of IV antibiotics and may require multiple surgeries to remove portions of the digestive tract.

The resident was discovered in bed with blood coming from his rectum the day that he was taken to the hospital. Additional blood was found in the toilet. At the hospital, the resident underwent a CT scan which showed the presence of free air in the abdominal cavity. This is a sign of rupture of one of the structures in the digestive tract.

The resident was brought to surgery where it was discovered that the resident’s colon had ruptured, that there were digestive contents throughout the abdominal cavity, and that there was extensive evidence of infection throughout. Several large balls of feces were found within the digestive tract. There was also evidence of necrosis (tissue death) of the colon. All of this indicated that this was a condition which was present for several days.

Ultimately, the resident underwent several surgeries, including removal of his colon and placement of an ileostomy, which is similar to a colostomy except that it removes waste matter from the end of the small intestine rather than the colon. Besides being an issue of dignity, this has significant negative impacts on the nutrition of the resident.

When IDPH went to investigate this incident, they questioned the staff about the tracking of the resident’s bowel movements in the chart. The answers made it apparent to the surveyor that there was no meaningful tracking of the resident’s bowel movements. As a result this led to the resident suffering prolonged periods of constipation.

Had the resident’s bowel movements truly been tracked in a regular, systematic way, the resident’s constipation could have been addressed in a number of fairly simple ways, ranging from diet changes, use of a laxative or stool softener, or digital removal. This was not done, leading to a catastrophic outcome for this resident.

Additionally, the resident was suffering from necrosis of the colon and from a significant infection at the time he was brought to the hospital and this had likely been present for a long time before this. This is a strong indicator that the staff was not monitoring the condition of the resident and did not notify the resident’s physician of changes in the resident’s condition.

Other blog posts of interest:

Failure to monitor anticoagulant levels at Greentree of Bradley

Hillside Rehab resident suffers brain bleed due to failure to obtain lab work

Failure to follow orders at Generations at Applewood

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

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

August 22, 2021 By Barry G. Doyle

IDPH has cited and fined Glenview Terrace nursing home after resident sustained multiple fractures to her back and sacrum when a mechanical lift toppled over during a transfer.

Used properly, a mechanical lift is a useful tool for caring for residents in a nursing home setting. It allows residents to be transferred safely from one place to the other with minimal risk of injury. It also reduces the risk of injury to staff members by eliminating the lifting that has to be done by staff in manual transfers. However, the key to this is that the lift must be used properly, and proper use of a mechanical lift requires two staff members to assist in transferring a resident from one place to the other. Having on person do a two-person job when it comes to transfers is a formula for disaster, as we have written about many times on this blog (see here, here, here, here, and here for examples).

The resident at issue was wheelchair bound and had a medical history which included a stroke with residual weakness on one side. Her care plan called for transfers to be done with a mechanical lift with the assistance of two staff members. Two staff members are needed for transfers with a lift because one staff member is needed to operate the lift while the other staff member keeps the resident steady in the sling.

On the day of this nursing home fall, the resident was being transferred from wheelchair to bed by a single aide using the mechanical lift. After the resident was placed in the sling to the lift and was lifted up from the chair, the resident began to sway in the sling. This resulted in the center of gravity shifting and the lift itself toppling over. The resident landed on the floor on her back. She was brought to the hospital where she was diagnosed with multiple fractures to the vertebrae in her lower back as well as to her sacrum.

The obvious cause of this mechanical lift accident was the aide failing to follow the terms of the care plan and failing to follow generally recognized safe practices regarding the use of the lift. The deeper question is, why did he not get assistance before attempting the transfer. The answer to this likely relates to the understaffing of the nursing home – he was too rushed to get the extra help needed to accomplish a safe transfer of this resident. Alternatively, it could simply be poor training of the aide.

Either option – understaffing or poor training of the staff – implicates the choices made regarding the management of this nursing home. Sadly, failing to invest in the staff so as to help assure that residents receive the care they need and deserve is 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:

Niles Nursing & Rehab resident suffers fatal brain bleed in fall

Resident suffers broken hip in unsafe transfer at Pearl of Rolling Meadows

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

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

Victorian Village resident develops pressure ulcer from orthotic boot

August 20, 2021 By Barry G. Doyle

IDPH has cited and fined Victorian Village Health & Wellness nursing home in Homer Glen after a resident there developed a pressure ulcer on her heel from her orthotic boot.

“Pressure ulcers” are commonly referred to as bed sores because they frequently develop on persons who are unable to get out of bed and are caused by pressure from the weight of the body against the bony prominences. This is why some of the most common parts of the body for bed sores to develop are the buttocks, hips, sacrum, and heels.

However, pressure from the weight of the body is not the only way that pressure ulcers can develop. One common way for bed sores to develop is pressure against the body from medical devices and equipment such as casts, catheters, immobilizers. The risk associated with the use of these devices is well-known in long-term care industry and should be addressed in the care planning process. The risk from these devices can be mitigated by frequent skin inspections; checking the device for fit, condition, and positioning; and obtaining doctor orders permitting removal when appropriate.

The resident at issue was admitted to the nursing home for rehabilitation after suffering a fall at home. One of the complications that she had as a result of the surgery was that she had a drop foot on one side for which she was given an orthotic boot to wear. On admission to the nursing home, she underwent a full skin inspection and there were no pressure ulcers.

After being admitted to the nursing home, she would periodically complain of a burning sensation in the heel. However, no one would take the boot off to inspect the underlying skin or the condition of the boot; they would simply loosen the boot for a period of time. Further, no one notified the doctor that the resident was complaining of a burning sensation in the heel.

The pressure ulcer was not discovered until the resident had been admitted to the nursing home for about 10 days, at which point a staff member removed it to clean the foot. At this point, the wound was considered an unstageable pressure ulcer which is by definition at least a Stage 3 or possibly a Stage 4 pressure ulcer. According to the citation, the wound had extended up to the Achilles tendon of the resident.

Why did the resident develop the pressure ulcer? Inspection of the boot revealed that even though it was lined, a portion of the lining had worn away so that the heel of the resident was laying directly on the frame of the boot. This is exactly the kind of thing that causes pressure ulcers to develop with the use of medical devices and equipment – prolonged pressure from an inadequately padded device.

What should the nursing home have done? For starters, the regular inspections of the skin and the device were not done. Had the boot been removed and the condition of the skin and the boot been observed, the relationship between the resident’s complaints about a burning sensation in her heel would have been readily apparent. Beyond that, the frequent appearance of a burning sensation in the heel also should have resulted in physician notification. This was not done.

Other blog posts of interest:

Resident at Christian Nursing Home in Lincoln develops pressure ulcer from brace

Oak Brook Care Center resident develops pressure ulcer from immobilizer

Pressure ulcer from surgical boot at Amberwood Care Center

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

Resident at Hickory Point Christian Village in Forsyth suffers multiple fractures in fall

August 18, 2021 By Barry G. Doyle

IDPH has cited and fined Hickory Point Christian Village in Forsyth after a resident there suffered a fractured arm and fractured hip in a fall.

The resident at issue had a history of repeated falls, including two falls within a 24 hour period, the last of which resulted in a fractured right hip which brought about the admission to the nursing home. On admission the resident was noted to have strength and mobility deficits and suffered from dementia and confusion. Having a history of falls is a significant fall risk factor, as are strength and mobility deficits and dementia/confusion.

On the day of this nursing home fall, the resident was brought to the bathroom by an aide. The aide did not consult the Kardex for the resident and was unaware of the resident’s history of falls and fall risk status. He requested some privacy so she closed the door to leave him in the bathroom. When he was done, she realized that she did not have supplies for cleaning him up, so she left him unattended in the bathroom while she went to get them. While she was gone, the resident got up from the toilet and fell, suffering fractures to the left arm and left hip.

This was a fall that likely would have been avoided had the aide checked the Kardex for the resident’s fall risk status and/or had the aide brought the necessary supplies to clean up after the resident. Neither of these things occurred, and as a result, a very preventable fall occurred.

Given that this resident had a fracture to the right hip from which he was recovering, an additional fracture to the left hip will make recovery from the two injuries much more difficult. These fractures were compounded by the fact that the resident suffered a fracture of the left arm as well, which would complicate any effort to have the resident engage in any form weight bearing using a walker or in the parallel bars in physical therapy. If the resident does not regain his ability to walk, this has serious negative consequences for his quality of life as well as his risk of developing additional complications such as bed sores.

Other blog posts of interest:

Cumberland Rehab resident suffers brain bleed due to fall from toilet

Auburn Rehab resident suffers hip fracture in fall

Heritage Health Pana staff violates care plan leading to fall and fractured hip

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

Cedar Ridge resident breaks both legs in fall from bed

August 16, 2021 By Barry G. Doyle

IDPH has cited and fine Cedar Ridge Health & Rehabilitation Center nursing home in Lebanon after a resident suffered fractures to both legs in a fall from bed.

The resident at issue had an extensive medical history which included a below the knee amputation, morbid obesity, and a host of other medical issues. Her Minimum Data Set (MDS) reflected that she required the extensive assistance of two persons with transfers and bed mobility. The entry of that information on the MDS is significant because the MDS is completed under oath since it forms part of the basis of payment for the nursing home. The resident care plan also called for assist of two with bed mobility. The resident was regularly transferred with the use of a Hoyer lift, which requires two staff for safe operation.

On the day of this nursing home fall, the resident was getting ready to be transferred from bed to her wheelchair using the Hoyer lift. As part of the transfer process the sling of the lift had to be placed underneath the resident, requiring her to roll from side to side while the sling is positioned underneath her.

During the process of getting the sling positioned underneath her, the resident rolled to one side. Once the sling was positioned beneath her she rolled to the other side, but rolled off the edge of the bed, landing on her knees. She felt and heard a pop in both knees. X-rays showed that there were fractures to both femurs which required her to be transferred to a teaching hospital for further care.

We frequently write on this blog about mishaps that occur when you have one person doing a two person job, as that is often a formula for disaster (see here, here, here, here, and here for examples). Here it was unclear whether there was one or two staff people in the room at the time of the fall. The resident quite clearly described there being only a single aide involved. The aide claimed that there was agency staff in the room at the time but that the agency staff was not near the bed at the time of the fall. Whether there was one or two staff people on the room, if only one was involved in repositioning this resident, then the resident was not receiving the level of assistance required to keep her safe – a violation of federal regulations and a violation of the resident care plan.

While the care plan violations was most clearly the cause of this resident’s fall, there is potentially a deeper level to this: the understaffing of the nursing home. The resident related here that there would normally be only a single aide involved in getting her on to the sling for transfers even though two was required. When there is one person doing a two person job, that raises a fair question about understaffing. Sadly this is a feature and not a bug 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. 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:

Sling breaks during transfer at University Nursing & Rehab

Hitz Memorial resident dropped from lift

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

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

Oak Brook Care resident develops bed sore from immobilizer

August 12, 2021 By Barry G. Doyle

IDPH has cited and fined Oak Brook Care Center nursing home after resident there developed a Stage 4 bed sore from an immobilizer.

“Bed sores” are also known as “pressure ulcers” because one of the main factors that cause these wounds is pressure. Most often the pressure that causes them is pressure brought about by immobility which is why you normally see bed sores develop on the bony prominences such as the hips, buttocks, sacrum, or heels. However, immobility-related pressure is not the only type of pressure which can cause skin breakdown as pressure from medical devices and equipment such as braces, immobilizers, catheters, casts, bed pans, and other devices and equipment can cause bed sores or pressure ulcers to develop as well.

Because the risks of developing pressure ulcers from medical devices and equipment is well-recognized, interventions such as regular skin checks should be included as part of the care-planning process and should be incorporated into the nursing home’s policies and procedures. When early signs of a skin breakdown are identified, physician notification is required so that the physician can determine whether there are suitable alternatives to the device that is causing the pressure, whether the use of the device is necessary, or whether there are ways in which the use of the device can be modified so as to eliminate or reduce the pressure caused by the device. It also allows the physician to enter orders for treatment.

The resident at issue was admitted to the nursing home with an immobilizer in place for treatment of a fractured kneecap. At the time that the resident was admitted to the nursing home, there were no bed sores present, according to her Minimum Data Set (MDS). Federal regulations provide that when a resident is admitted to a nursing home with no pressure ulcers present, they must receive care consistent with standards or professional practice such that the resident does not develop pressure ulcers unless they were unavoidable.

Within two weeks of her admission to the nursing home, the resident developed some redness to the calf, likely caused by some rubbing by the brace. The nursing staff noticed the wound and referrals for treatment by a wound care nurse and a wound care physician were obtained. However, the family was not notified and the treating orthopaedic surgeon was not notified for over a week.

When the treating orthopaedic surgeon was notified of the presence of the wound, he gave instructions that the immobilizer could be removed when the resident was in bed but that it needed to be left on during transfers and while the resident was in her wheelchair. Limiting the time that the resident was in the immobilizer would have helped with healing the wound on the calf by reducing the exposure of skin to the pressure from the use of the immobilizer. However, compliance with this order was not tracked in any meaningful way.

By the time that the wound care physician saw the resident for the first time over a week after when the wound was first seen, the wound was characterized as a full thickness wound and was much larger in size. It also had slough and necrotic tissue, indicating that there was dead tissue from the wound. This represented a significant decline in the condition of the wound from when the wound was detected. There was no notification to the family of the decline in the wound.

The wound care physician issued orders for the treatment of the wound. However, there were multiple days when those treatment orders were not carried out. The wound continued to decline and worsened to a Stage IV pressure ulcer with exposed tendon. Additionally, the facility failed to keep multiple telehealth appointments with the treating orthopaedic surgeon who was also unaware of the continued decline in the condition of the wound.

Approximately 8 weeks after the wound on the calf was first detected, the resident was transferred to the hospital for a urinary tract infection. The hospital recognized that the wound had a cellulitis infection and began to treat it with a bedside debridement and use of a wound vac. The care of the wound was being managed by a plastic surgeon. The treating orthopaedic surgeon told the state surveyor that the nursing home did not advise him of the decline in the condition of the wounds and that the wound would not have declined to the point that it did had his instructions to remove the brace been followed.

For their part, the administrator and Director of Nursing blamed agency staff for failing to complete ordered wound treatments and stated that it had been an ongoing issue with agency staff. Of course, the nursing home remains responsible for the provision of care and the administration of the nursing home is responsible for the operation of the nursing home. The failure to hire or retain qualified staff or get agency staff in who will get the job done will inevitably have consequences for the health and well-being of the residents. 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 Christian Nursing Home in Lincoln develops pressure ulcer from brace

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

Victorian Village resident develops pressure ulcer from orthotic boot

Pressure ulcer from surgical boot at Amberwood Care Center

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

University Rehab Northmoor resident suffers fractured hip in fall from bed

August 11, 2021 By Barry G. Doyle

IDPH has cited and fined University Rehab Northmoor nursing home in Peoria after a resident there suffered a fractured hip as a result of a fall from bed.

The resident at issue here suffered from cerebral palsy, cognitive deficits, and paraplegia. This is someone who would have had a great deal of difficulty assisting in her care due to her physical and cognitive challenges. There was a care plan put into place which called for assist of two with bed mobility, keeping the bed in the lowest position, and use of bilateral floor mats. When a care plan is put into place, it falls to the staff charged with caring for the resident to implement it on a day-to-day, shift-to-shift basis.

On the day when this nursing home fall, there was a single aide who was providing incontinence care to the resident. While doing so, the aide had raised the bed and moved one of the floor mats to get better access to the bed. In the process of providing incontinence care to the resident, the aide recognized that she needed a bed pan. She left the room with the bed still in a raised position, the resident unattended, and one of the floor mats moved out of position. When she returned to the room, she found that the resident had fallen from bed.

X-rays were done, which showed that the resident suffered a fractured hip requiring surgical repair.

There were at least three violations of the care plan that took place that resulted in the fall. First, the aide was providing incontinence care to the resident by herself instead of with two people. The care plan called for the assist of two with bed mobility. Bed mobility refers to the ability to change and maintain a position in bed, something that is necessary when a resident is receiving incontinence care. Two people should have been assisting with this rather the one who was actually providing this care. Having one person do a two-person job is a well-recognized formula for disaster (see here, here, here, here, and here for examples). Second, the care plan called for the bed to be in a low position. The bed was in a raised position when the resident fell. Third, it also called for floor mats on both sides of the bed, and the floor mats had been removed so that the aide could get at the resident to provide care, but then the aide left the resident unattended with a floor mats out of position. As a result, we have the resident falling, hitting the floor and suffering a broken hip.

At one level, those violations of the care plan are the cause of this resident’s injuries. However, there is a deeper level to that, and that relates to the understaffing of the nursing home. When the aide was questioned by the state surveyor as to what happened, the aide explained to the surveyor that she just didn’t have time to ask for help in providing this care. When you have a staff that is describing not having time to ask for help, when you have staff that are taking shortcuts in the care that’s being provided to the resident, then that’s a sign of a nursing home which is understaffed, and that’s a nursing home which places residents at increased risk for adverse events, such as falls, bedsores, nursing home choking accidents, medication errors, and so forth.

Unfortunately, understaffing is part of how nursing homes are run. 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:

Farmington Country Manor resident breaks leg due to failure to follow care plan

Resident at The Clayberg breaks arm due to failure to use gait belt

Aperion Spring Valley resident suffers fatal brain bleed in fall

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

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

August 10, 2021 By Barry G. Doyle

IDPH has cited and fined Sharon Health Care Elms nursing home in Peoria after a resident there suffered seizures due to not receiving anti-seizure medications as ordered.

Treating seizures is a difficult task but must be done. Prolonged seizures can cause brain damage but even shorter seizures can cause injury and have lasting effects. The most effective way to prevent seizures is through the use of medication, often given in combination. Nursing home medication errors which result in residents not receiving their medications as ordered can result in significant seizures with serious resulting injuries.

The resident at issue had a diagnosis of epilepsy as well other neurologic disorders which affected the brain. She was prescribed multiple medications, including Keppra and Depakote to help prevent seizures.

Over a period of approximately 6 hours, the resident experienced four seizures. The shortest of these was 90 seconds, the longest approximately 5 minutes. Two occurred in the nursing home, one in the ambulance on the way to the hospital, and the last in the emergency room.

When the resident arrived in the emergency room, labs were drawn. These showed that the resident’s Depakote levels were 13 mcg/ml (normal range 50-100) and that Keppra could not be detected at all. The conclusion was that the resident’s seizures were due to subtherapeutic (below normal) levels of these anti-seizure medications.

Investigation into this incident showed that the Keppra had been discontinued due to a clerical error by a member of the nursing staff. An error had been made in entering the order for the Keppra. The wrong order was discontinued; however the correct order was not entered. The net result was that no Keppra was being given to the resident. This is of course consistent with lab results showing that Keppra could not be detected at all.

The issue with the Depakote is more difficult to determine how the resident ended up with subtherapeutic levels of the medication. However, the last delivery of Depakote was made to the nursing home from the pharmacy a little less than a month and a half prior to the date that the seizures occurred. However, the container only had enough medication to last 18 days. Clearly there was not enough medication on hand for the resident to be receiving the medication as ordered, resulting in the below-normal levels of this medication as well.

Giving medications as ordered is one of the basic tasks in a nursing home, and this incident demonstrated two clear but critical breakdowns in the delivery of medication to this resident. One, relating to the Keppra, was the result of simple clerical error. However, in well-run nursing homes, entries as to medication orders are normally double checked after the order is entered by a nurse on the floor. The other medication error, relating to the Depakote, was likely multi-factorial but likely involves some element of false charting by the nursing home staff.

Other blog posts of interest:

Medication error at Sunset Rehab in Canton

Failure to give anti-coagulant medication at H&J Vonderlieth Living Center

Resident given wrong medication at Villa Health Care East

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

Rochelle Rehab resident breaks leg due to unsafe use of wheelchair

August 9, 2021 By Barry G. Doyle

IDPH has cited and fined Rochelle Rehabilitation & Health Care Center nursing home after a resident there suffered a broken leg in a fall caused by the failure of the staff to use footrests while pushing the resident in a wheelchair.

On the surface, a wheelchair is a safe, simple piece of equipment to use. However, like all equipment in a nursing home setting it must be used properly. When it is being pushed by staff, that includes the use of foot rests. Foot rests are required when the wheelchair is being pushed by staff because the failure to use foot rests requires residents to keep their feet up off the ground while they are being pushed forward. If residents are unable to do so because of physical or cognitive limitations, one of two things happen when the residents are no longer able to keep their feet up: (1) the resident’s feet get pulled underneath the wheelchair, resulting in twisting injuries to the leg which can cause fractures or torn ligaments and cartilage or (2) the resident can be thrown forward out the wheelchair, resulting in injuries such as a brain bleed, facial fractures, or broken collarbones, or wrists.

Sometimes, a fall from a wheelchair causes both. And that was the case here.

The resident involved had cognitive impairments and was wheelchair bound. She was being pushed by an aide in a wheelchair with no foot rests. According to the aide, the resident stomped her foot job and sprang out of her seat “like a jack in the box.” She landed on the floor and had a large laceration to the forehead that was immediately apparent. She was sent to the hospital where she was also diagnosed with a fractured femur and additional scans showed two fractured vertebrae in the neck which were age indeterminant.

This is exactly the kind of nursing home fall which is going to result from pushing a nursing home resident in a wheelchair with no foot rests. The failure to take these very simple steps raises a couple of questions about the operation of the nursing home, specifically with regard to the training of the staff and whether this was an understaffed nursing home. Either one of these speaks to the investment that nursing home management is making in ensuring that the care needs of the residents are being met. 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:

Good Samaritan of Pontiac nursing home resident fractures leg and ankle in wheelchair accident

Resident breaks leg in wheelchair accident at Heritage Health in Dwight

Fall from wheelchair at LaSalle County Nursing Home

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

Sling breaks during transfer at University Nursing & Rehab

August 9, 2021 By Barry G. Doyle

IDPH has cited and fined University Nursing & Rehabilitation Center nursing home in Edwardsville after a resident there suffered a broken hip and broken shoulder after falling during a transfer with a mechanical lift when the sling to the lift broke during transfer.

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

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

The resident at issue here required the use of a mechanical lift for all transfers. On the day of this nursing home fall, she was being transferred from a shower chair to her bed. There were two staff present, but during the course of the transfers, the loop that attaches the sling to the lift device itself tore, causing the resident to fall to the ground. The staff member who was assisting the resident during the transfer kept the resident’s head from hitting the floor, but the resident complained of leg pain and back pain. The resident was sent to the hospital where she was diagnosed as suffering from a fractured hip and fractured shoulder.

The investigation into this mechanical lift accident revealed two things. First is that the type of sling in use at the time of the accident was manufactured by a different company than the lift itself. Neither the manufacturer of the lift nor the manufacturer of the sling recommended mixing their products with those made by other companies. Second, the sling had been in use for two years and five months, and the sling manufacturer recommended that its product be replaced after a year. The bottom line is that the sling was being used well past the end of its useful life in a manner that neither the manufacturer of the lift or the manufacturer of the sling recommended.

Past that, there was no set protocol for inspecting the slings to ensure that they were in good condition for use. The administrator told the state surveyor that there was a laundry aide who was good about inspecting the slings but they did not have a protocol for inspecting the slings otherwise. If the laundry aide did not do an inspection, there was no one who regularly did one or was trained to do so. Without having enough trained eyes on the condition of the sling, this was allowed to fall into disrepair, leading to the failure of the sling and injury to this resident.

Other blog posts of interest:

Fall from mechanical lift at Hillcrest Retirement Village

Cornerstone Rehab resident falls from lift, breaks leg

Hitz Memorial resident dropped from lift

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

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

August 6, 2021 By Barry G. Doyle

IDPH has cited and fined Aspen Rehabilitation & Health Care nursing home in Silvis after a resident there choked to death on a sandwich due to a violation of the resident care plan.

The resident involved in this nursing home choking accident was a long-term resident of the nursing home. He suffered from schizophrenia, anxiety, and dementia. Some people afflicted with this set of conditions tend to eat very quickly, shoving food into their mouth and swallowing without chewing.

This is something that places the resident at risk for choking, and this had proven to be the case for this resident. Prior to being admitted to the nursing home, the resident had a choking incident which led to an admission to the hospital intensive care unit. He also had at least three other known choking incidents at the nursing home before the fatal one. This was a resident who was clearly at risk for choking.

When there are threats to the health and well-being of nursing home residents, this must be addressed in the care planning process. There are six basic steps to the care planning process: (1) an assessment of the risks to the well-being of the resident, (2) development of a written care plan consisting of a series of steps or interventions that must be taken to address those risks, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) ongoing evaluation of the effectiveness of the care plan, and (6) revision of the care plan if there are changes in the resident’s condition or if it proves to be ineffective in practice.

The nursing home recognized that that the resident was at risk for choking, and consulted with a speech therapist for recommendations to help ensure that the resident was able to eat safely. These steps included obtaining an order for a modified diet to mechanical soft and mositening bread before serving. It also included supervision of the resident while eating, cutting food into small pieces, cueing the resident to eat nore slowly and to take sips of water in between bites. These steps were all incoporated into the resident care plan.

The resident’s family was permitted to bring food in for the resident periodically, but it had to be prepared and served by the staff. On the day of the incident, the resident’s family brought in a tuna melt sandwich. The sandwich was microwaved in the kitchen but not moistened. Due to the pandemic, the residents were all eating in their individual rooms. The resident’s meal was brought to him in his room by an aide who then left the room to pass additional meals. She returned to the room about 5 minutes later to assist the resident’s roommate.

When she got to the room, she heard a gasping sound coming from the resident and realized that he was choking. She called for help and began resuscitation efforts. However, the resident’s airway was filled with food which they were not able to successfully clear. The resident’s heart beat was lost and they were not able to regain it. An emergency room physician instructed the paramedics and staff to cease resuscitation efforts and the resident was declared deceased. Cause of death per the death certificate was anoxia due to choking on food.

There were a number of failures that led to the death of this resident.

First is that the resident was not being supervised while he was eating. The nursing home properly recognized that he was at risk for choking and took reasonable steps to identify a number of steps which could be taken to mitigate that risk. The key one here was supervision of the resident while eating – and this was not done here and was a violation of the resident care plan.

Why was there a violation of the care plan?

The simple answer is that the aide who served the meal did not know that he was supposed to be supercised while eating. She did not know this because no one told her. The resident care plan is more than paperwork – it is the game plan for the delivery of routine but necessary care for the resident. If the staff charged with carrying out the care plan doesn’t know what they are supposed to be doing, the effort in coming up with the care plan is wasted. More than that it represents a breakdown in the basic system that is intended to assure the safety of residents throughout the facility. It is a major systems failure.

The second reason was that the kitchen staff failed to follows the orders for mositening of the bread. The mechanical soft diet is supposed to help residents who have swallow difficulties and the moistening of the bread is intended to reduce the choking risk associated with bread. This step which was intended to mitigate the risk of choking was also not followed.

In the end, these failures resulted in the very preventable death of this resident.

Other blog posts of interest:

Aperion of Spring Valley resident chokes to death

Fatal choking accident at River Bluff nursing home

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

Sunset Rehab resident chokes to death

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

Resident at Christian Nursing Home in Lincoln develops pressure ulcer from brace

August 5, 2021 By Barry G. Doyle

IDPH has cited and fined Christian Nursing Home in Lincoln after a resident there developed an infected pressure ulcer from an immobilizer that was being used to treat a broken leg.

Bed sores are also known as pressure ulcers because one of the main factors that lead to the development of these wounds is pressure. Most often that pressure is caused by immobility associated with some form of debility. However, that pressure can also be produced by the use of medical devices and equipment such as braces, casts, tubing, or catheters.

When residents are at risk for developing pressure ulcers due to the use of medical devices or equipment, this must be addressed through the resident care plan. Most often, this would include the use of padding on pressure points, periodic removal of the device to check the condition of the skin, and regular assessments of the fit and positioning of the device.

The resident here was admitted as a short-term rehab patient after breaking the lower end of his femur (thigh bone) in a fall. He was placed in an immobilizer for the fracture and was supposed to be receiving care and therapy in the nursing home.

When the resident was admitted to the nursing home, he was assessed as being at risk for developing bed sores, which makes sense because he was suffering from immobility related to the fractures. A care plan was put into place which addressed the risk of the resident developing the usual kind of bed sores that you see with nursing home residents who suffer from immobility. There was no part of the care plan that specifically addressed the risk of developing pressure ulcers related to the use of the immobilizer.

The failure to care plan specifically for the development of pressure ulcers related to the use of the immobilizer was substandard care. Done properly, care planning addresses the risks of harm specific to that resident. Here, the resident faced a specific risk of harm related to the use of the immobilizer. However, that risk was never addressed in the care plan. The point of care planning is to help ensure that the risks of harm to the resident are addressed in a thought-out, systematic way and that the care needed is delivered on day-to-day, shift-to-shift basis and not left to the random decisions of nurses who may have varying levels of skill, knowledge, and work loads.

Within a week of the resident’s admission to the nursing home, there were reports made to the nursing staff by occupational therapy and physical therapy about concerns regarding the condition of the resident’s skin. The resident was finally assessed at the end of that first week as having developed deep tissue injuries to the leg where the immobilizer was applied. He alose had developed multiple bed sores on his hips and sacrum,

After the pressure ulcers developed, the care plan was revised to account for the presence of the immobilizer and the presence of the wounds. Revision of the care plan to account for the presence of the bed sores was appropriate, but at that point, the damage from poor care planning had been done. Making matters worse, the resident here also had peripheral vascular disease or poor circulation to the lower extremities which would make recovery from the wounds all the more difficult.

The resident was sent to the hospital within two weeks of admission to the nursing home suffering from sepsis related to the pressure ulcers from the immobilizer. Poor care planning all too often leads to poor outcomes and that proved to be the case here.

Other blog posts of interest:

Flanagan Rehab resident suffers infection from bed sore

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

Pressure ulcer from surgical boot at Amberwood Care Centre

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

Good Samaritan of Pontiac resident suffers fractured leg and knee in wheelchair accident

August 4, 2021 By Barry G. Doyle

IDPH has cited and fined Good Samaritan nursing home of Pontiac after a resident there suffered a fractured kneecap and femur due to being pushed in a wheelchair with no foot rests.

Wheelchairs are one of the basic pieces of equipment in use in nursing homes, and when used properly, they are very safe things to use for nursing home residents. However, the key is safe use – and when wheelchairs are being pushed by staff, this includes using the foot rests. It is acceptable for wheelchairs to be used without foot rests when residents are propelling themselves by walking their feet forward. However, when staff is pushing a resident, use of foot rests is required for safe use. The facts of this incident demonstrate why.

The resident at issue was admitted to the nursing home after suffering a fall at home in which she suffered a fractured pelvis. The resident’s Minimum Data Set (MDS) indicated that she was wheelchair bound and required assist of one staff members with transfers.

On the day of the incident, the resident was brought to the dentist’s office using the facility’s transportation van. The transportation aide did not place the foot rests on the wheelchair before leaving the facility. When they arrived outside the dental office, there was a handicapped ramp available to push the wheelchair up.

As the aide was pushing the resident up the ramp, her feet dropped and her legs got pulled underneath her. The resident experienced immediate pain at the knee. They got into the dentist’s office where the resident asked the staff for Tylenol. The aide told the staff that they could not give the resident the medication. The aide reported the incident and after the appointmenet was done, brought the resident back to the nursing home.

The staff obtained orders for x-rays which showed that the resident suffered a fracture to the knee cap and a fracture to the femur which extended down the through end plate of the bone. The resident was placed in a cast, but some two months after the incident, the resident was still in an immobilizer and she told the state surveyor that her doctor said that she would likely never be able to walk again.

The failure to use foot rests while pushing a wheelchair leads to a very predictable accident: the resident is not able to keep their feet elevated off the floor while being pushed forward. When their feet drop to the floor, the wheelchair keeps moving forward, pulling the resident’s legs underneath. Once that happens, one of two things happens: (1) there is a twisting mechanism which results in fractures to the legs or tears to the cartilage and ligaments; or (2) the resident is thrown forward out of the wheelchair.

Federal regulations pertaining to nursing home falls require that nursing home residents receive supervision and assistive devices necessary to prevent accidents. And while those regulations most commonly pertain to nursing home falls, they also apply to this set of circumstances. The failure to use the foot rests at the time of this accident led to this resident’s injury and was a violation of federal regulations.

The failure of the aide to know that this was necessary for safe use of the wheelchair speaks to poor training of the staff. 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:

Rochelle Rehab resident suffers multiple injuries in fall from wheelchair

Assisi at Clare Oaks resident breaks neck in fall from wheelchairs

Resident breaks leg in wheelchair accident at Heritage Health in Dwight

Fall from wheelchair at LaSalle County Nursing Home

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

Bella Terra Streamwood resident suffers multiple fractures after falling out of bed

August 3, 2021 By Barry G. Doyle

IDPH has cited and fined Bella Terra Streamwood nursing home after a resident there sustained a fractured tibia and femur after falling from bed.

One piece of information that our firm looks at very closely in investigating nursing home abuse and neglect cases is the Minimum Data Set (MDS). The MDS is a summary of the results of a series of assessments done as to the care needs of the resident. It is supposed to reflect the levels of care that the resident requires. It forms part of the basis by which the nursing home is paid for providing care to the resident and must be signed under oath by the staff members completing it.

The results of the MDS trigger a process called the Care Area Assessment which is essentially a prompt for the nursing home staff to initiate the care planning process for various areas. Because the MDS triggers the Care Area Assessment, there should be a high degree of congruency between the MDS and what is reflected on the resident care plan.

Here, the resident’s MDS indicated that she required a two-person assist to turn and reposition in bed. Her care plan also called for assist of two with bed mobility.

On the day of this nursing home fall, the resident was receiving incontinence care from a single aide. She was in a position lying on her side and asked the aide to apply some additional lotion before turning her back from her side. As the aide reached for the lotion, the resident rolled off the side of the bed and landed on the floor. The resident was sent to the hospital where she was diagnosed with fractures of the tibia (shin bone) and the femur (thigh bone).

Here, the resident was properly assessed as requiring a two-person assist with bed mobility. This was because she had strength and mobility deficits which made it hard for her to maintain position in bed. There was a care plan in place which called for the proper level of care – two staff with bed mobility – but that care plan was not followed because you had one person doing a two-job with predictably disastrous results.

When you have staff taking shortcuts in the care of residents, it raises questions about three larger questions than the immediate shortcomings in care. One is the possibility that the this is an understaffed nursing home – did the aide feel that she did not have time to wait for extra help to keep the resident safe? Second, is this a poorly trained staff given that the aide did not know to follow the care plan? Third, is there a breakdown in the delivery of care where the staff on the floor is not properly instructed as to the contents of the care plan? All of these possibilities deserve a closer look.

Other blog posts of interest:

Niles Nursing & Rehab resident suffers fatal brain bleed in fall

Warren Barr North Shore resident rolled from bed, suffers fractured ankle

Alden Valley Ridge resident rolled from bed, breaks both legs

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

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

July 30, 2021 By Barry G. Doyle

IDPH has cited and fined Heartland of Moline nursing home after a resident there developed aspiration pneumonia due to the failure of the staff to follow orders for a modified diet.

One common condition that nursing home resident suffer from is dysphagia, or a swallowing dysfunction. This condition is commonly associated with the residual effects of a stroke, some neurological condition, generalized weakness, or advanced dementia. Swallow dysfunction can be a deadly condition in that it places the resident at risk for having a nursing home choking accident or developing aspiration pneumonia. Aspiration pneumonia occurs when foreign materials such as food, liquids, or saliva enter the lungs and cause an infection in the lungs.

When a resident is recognized as having a swallow dysfunction, evaluation by a speech therapist is necessary. The speech therapist will then make recommendations regarding the resident’s eating and diet. These recommendations are intended to combat the risks to the health and well-being of the resident, and will often include supervision and assistance with eating as well as modifications to the diet such as a puree or mechanical soft diet and/or thickened liquids. The recommendations of the speech therapist should be incorporated into an order by the physician and into the resident care plan.

The resident at issue suffered from dysphagia and was referred to a speech therapist. The speech therapist confirmed the presence of the swallow dysfunction and determined that a puree diet and moderately thickened liquids was necessary for the safety of the resident. Those recommendations were accepted by the resident’s doctor who issued the appropriate order.

However, shortly after these recommendations were made, the resident was seen with a half finished glass of regular water at lunch. Regular water is considered a thin liquid and giving this to the resident would be a violation of the recommendations of the speech therapist and of the doctor’s orders.

The following day, the resident was running a fever, was disoriented, and had crackling sounds in the lungs. The physician was notified, and he was sent to the hospital where x-rays confirmed the diagnosis of aspiration pneumonia. The resident was suffering from sepsis due to the pneumonia and was placed on comfort care measures only by his family.

This horrific outcome could have been easily prevented. The whole point of having a speech therapy evaluation done is to find out what has to be done to keep the resident safe while eating. When those recommendations (and the corresponding physician orders and care plan) are ignored, this subjects the resident to unnecessary risks of harm. In this case, the recommendation for thickened liquids was not followed by the staff, with a deadly pneumonia being the end result.

Other blog posts of interest:

Aperion of Spring Valley resident chokes to death

Fatal choking accident at River Bluff nursing home

Feeding tube error puts Burgess Square resident into heart failure

Fatal choking accident at Spring Creek in Joliet

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

Alden Valley Ridge resident breaks leg in fall

July 29, 2021 By Barry G. Doyle

IDPH has cited and fined Alden Valley Ridge nursing home in Bloomingdale after a resident there suffered a broken leg in a fall due to an aide’s failure to use a gait belt.

Properly run nursing homes invest significant effort into determining what kind of help and assistance residents require to assure their safety and well-being. When the required levels of care are properly identified but then not provided, unnecessary injuries are the very predictable result.

The resident at issue had weakness associated with a prior stroke and was considered a fall risk. Her Minimum Data Set indicated that she required extensive one person assist with ambulation, transfers, and toileting. “Extensive assist” includes actually physically assisting and supporting the resident during the activity.

When a resident requires extensive physical assist, use of a gait belt is required to perform the activity safely. A gait belt is a canvas strap which is applied to the midsection of the resident and used by the aide while assisting the resident. It allows the aide to effectively provide physical support to the resident and to either help the resident maintain and upright position or control the fall should a resident begin to fall or lose their balance. The nursing home’s policies and procedures required the use of a gait belt on residents who required physical assistance.

On the day of this nursing home fall, the aide had brought the resident to the bathroom and was assisting her in getting an adult brief on. The resident was standing by the toilet holding onto a grab bar. The aide had a gait belt, but it was not on the resident. It was in the aide’s pocket. The aide explained to the state surveyor that it was a matter of judgment as to whether to use the gait belt, and that it was her judgment that this resident did not need one.

The resident told the aide that she could not maintain her standing position and that her legs were giving out. The aide tried to get the resident to the toilet or to get a wheelchair over to help the resident, but the resident fell to the floor. She later complained of leg pain and when x-rays were done, they showed a fractured femur.

The whole point of performing assessments and determining the level of care that a resident receives is so that it is not left to random chance. The same would be true of having policies and procedures. When staff decides that providing the level of care that a resident truly needs is a matter of judgment, the residents’ care is left to random chance – what did a particular staff member see and what did they think about what they saw on a particular day? When a staff member provides substandard care but avoids injury, that becomes part of the basis for judgments made down the line – not realizing that the lack of a catastrophic outcome was a matter of good luck, not good care. And having gotten lucky once, that becomes a tempting option in providing care going forward. The net result though is that residents are exposed to unnecessary risk of harm.

Unfortunately, that was what happened here. A staff member disregarded what the assessments had said about the resident’s care needs, disregarded the facility’s policies and procedures, and substituted her own judgment, much to the detriment of the resident.

Other blog posts of interest:

Alden Valley Ridge resident rolled from bed, breaks both legs

Failure to use gait belt leads to fall and fractured kneecap at Friendship Village in Schaumburg

Assisi at Clare Oaks resident breaks neck in fall from wheelchair

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

River Bluff nursing home in Rockford resident suffers multiple fractures in fall

July 28, 2021 By Barry G. Doyle

IDPH has cited and fined River Bluff nursing home in Rockford after a resident there suffered multiple fractures in a fall.

Here, the resident at issue was involved in a nursing home fall in which she suffered a fractured pelvis and a fractured humerus. There was a care plan in place which called for the use of a bed alarm and a chair alarm, both of which were in place when the fall occurred. However, the resident had shut the chair alarm off when she got up to go to the bathroom and was returning from the bathroom when the fall occurred.

You may be asking yourself how this is the nursing home’s fault? The answer goes to the fundamentals of the care planning process.

Care planning is an ongoing process. It is not something that is done once and then forgotten about. There are in fact six steps to the care planning process: (1) the assessment of the risks to the health and well-being of the resident, (2) the development of a written care plan, (3) communication of the care plan to the members of the staff charged with carrying it out, (4) implementation of the care plan on a day-to-day, shift-to-shift basis, (5) evaluation of the effectiveness of the care plan, and (6) revision of the care plan if it proves to be ineffective in practice or if the care needs of the resident change.

The breakdown here occurred in the sixth and final step of the care planning process. The point of the fall prevention care plan was to prevent falls by avoiding having the resident up and about unattended which was when she was at highest risk for falls. However, this resident had a known behavior of disarming the alarm when she wanted to get up on her own. The nursing home staff was aware of this, but did not make any changes even though what they were doing was being shown to be ineffective in practice.

What should have been done instead?

A chair alarm or bed alarm essentially consist of two main components: the alarm box and the alarm device. The alarm device is either a pressure-sensitive pad (which was what was in use here) or a clip which is affixed to the resident’s clothing, usually between the shoulder blades where it is difficult to remove with a short cord which goes to the alarm box. If the pressure alarm is in use, the alarm sounds when the resident gets up off the pad; if the clip is used, the alarm sounds when the cord is pulled away from the alarm box.

Here the staff placed the alarm box in easy reach of the resident who simply shut it off before getting up. This was a known behavior on the part of the resident which had been shown on a number of occasions before this nursing home fall. All that would have been required to prevent this fall would have been to modify the resident care plan to include placing the alarm box out of the reach of the resident and making sure that this was communicated to the staff charged with caring for this resident. However, due to a lack of effort and critical thought, this change was never made. A care plan which is ineffective in practice is not one that meets the care needs of the resident. Making that simple change would likely have prevented this injury.

Other blog posts of interest:

River Bluff resident fractures elbow in fall from wheelchair

Fall from toilet at Alden Park Strathmoor

Waverly Place of Stockton resident breaks hip in unsafe transfer

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

Psych med usage leads to bed sores at Eastview Terrace

July 28, 2021 By Barry G. Doyle

IDPH has cited and fined Eastview Terrace nursing home in Sullivan after a resident there suffered significant weight loss and developed bed sores due to lethargy associated with the use of psychotropic medications.

The use of restraints is strongly discouraged in the long-term care industry for a number of reasons, but most particularly, they pose a serious risk of harm to nursing home residents and are also an affront to their right to dignity. Tying a resident into a bed or chair is something which is generally not acceptable nursing practice. Use of a chemical restraint – that is medicating a resident in such a way that the resident is so sedated to the point that their movement or freedom is restricted – also carries serious risks to the health and well-being of nursing home residents and is an affront to their right to dignity.

Certain medications especially psychotropic medications carry a high risk of becoming chemical restraints by sedating nursing home residents to the point that they are unable to move. Federal regulations limit the use of psychotropic medications to the extent necessary to treat the symptoms and prohibit the use of unnecessary drugs. Regulations also require monitoring for the presence of side effects.

The resident at issue was initially admitted to the nursing home with a diagnosis of dementia with behavioral disturbances. He weighed 184 pounds and was ambulatory. Ten days after admission, he was transferred to a geripsych facility after attacking a staff member.

When he returned there were dramatic changes in the resident’s condition. He was no longer ambulatory, required extensive assist of two staff members for activities of daily living, and was largely nonverbal. He was on a regimen of six psychotropic medications, including receiving some more than once daily. A week after admission, the staff called the doctor with concern about the resident’s lethargy. The nurse practitioner came to the facility and ordered a lab check for levels of one medication and ordered that the medication be held if the resident appeared sleepy. It did not appear as though the medication was ever held.

The resident continued to demonstrate lethargy, requiring extensive assistance from the staff with activities of daily living including eating. He did not demonstrate much appetite, and when he did try to eat independently, he often missed his mouth. He was discharged from both physical and occupational therapy due to inability to participate. he was wheelchair bound and was using a high-backed wheelchair to aid in positioning.

There was nothing in the citation that suggested that his behaviors were being tracked or monitored for the side effects of the psychotropics, even though the care plan called for monitoring of somnolence and to notify the doctor if the side effects outweigh the benefits. There was no further notification to the resident’s doctor even though he was seen twice via telehealth during which the staff advised that there were no concerns. There was no apparent referral to a psychiatrist to modify the drug regimen.

What was done with this resident is a near classic example of a chemical restraint. While the resident’s behavior was absolutely a source of concern, there was no meaningful attempt to monitor for side effects to eliminate potentially unnecessary medications. The net result of this was that the resident was so sedated that he was unable to move independently to the point that he was unable to feed himself, unable to participate in therapy, unable to care for himself, and unable to stand and move independently.

There are a number of dangers associated with chemically restraining a resident, including having nursing home falls and developing bed sores. There are three main risk factors for developing bed sores: (1) incontinence, (2) immobility, and (3) poor nutritional status.

The citation demonstrated two of the three factors clearly. The resident had immobility based on the inability to participate in the therapy, the well-documented lethargy, and the change from being ambulatory to needing a high-backed wheelchair for positioning. He also had poor nutritional status in that poor appetite and an inability to eat were explicitly documented. He also had documented significant weight loss in that his weight decreased from 185 pounds when he was initially admitted to 172 pounds after being readmitted from the geripsych unit to 159 pounds a month later. He also likely had some element incontinence given that he was dependent on staff for activities of daily living and would have been dependent upon them for toileting.

It should be small surprise then that this resident ended up developing bed sores. He developed a deep tissue injury on his coccyx and pressure ulcers on his sacrum and on his left and right buttocks.

These injuries are the predictable results of employing a chemical restraint on a resident. Lethargy with an inability to move and loss of appetite with associated weight loss predictably led to the development of multiple bed sores. Recovering from them will be very difficult without any modification of his psychotropic medication regimen.

While the staff was rightly concerned about the resident’s aggressive behavior, the solution to that is not to sedate the resident into total inactivity without making any effort to minimize the side effects of the psychotropics that the resident was receiving, Yet, that is what occurred here.

Other blog posts of interest:

Resident undergoes electroconvulsive therapy after staff at Palm Terrace fails to give antipsychotic medication

Resident develops bed sore at Nokomis Rehab

Moweaqua Rehab resident suffers worsening bed sores

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

Feeding tube error puts Burgess Square resident into heart failure

Resident at Chateau nursing home in Willowbrook suffers spinal fractures in wheelchair accident

Warren Park Health & Living Center resident suffers brain bleed in fall down stairwell

Tuscola Health Care Center resident dropped from lift, breaks ankle

Sunset Rehab resident chokes to death

Westminster Village resident suffers multiple fractures in fall

Alden Estates of Huntley fails to follow orders to give antibiotic

Aperion Care Wilmington resident suffers ruptured colon from fecal impaction

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

Victorian Village resident develops pressure ulcer from orthotic boot

Resident at Hickory Point Christian Village in Forsyth suffers multiple fractures in fall

Cedar Ridge resident breaks both legs in fall from bed

Oak Brook Care resident develops bed sore from immobilizer

University Rehab Northmoor resident suffers fractured hip in fall from bed

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

Rochelle Rehab resident breaks leg due to unsafe use of wheelchair

Sling breaks during transfer at University Nursing & Rehab

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

Resident at Christian Nursing Home in Lincoln develops pressure ulcer from brace

Good Samaritan of Pontiac resident suffers fractured leg and knee in wheelchair accident

Bella Terra Streamwood resident suffers multiple fractures after falling out of bed

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

Alden Valley Ridge resident breaks leg in fall

River Bluff nursing home in Rockford resident suffers multiple fractures in fall

Psych med usage leads to bed sores at Eastview Terrace

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