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Vandalia Rehab cited for understaffing

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IDPH has cited Vandalia Rehabilitation & Health Care Center for failing to have enough staff on hand to meet the care needs of the residents.

Nursing homes are regulated by both the federal government and the State of Illinois.  Both have regulations regarding minimum staffing levels.  The state regulation sets a mathematical formula for the minimum number of staff required, and it is rare to see nursing homes out of compliance with that regulation.  The federal regulation is a more flexible but demand standard.  It requires nursing homes to have enough trained staff on hand to meet the care needs of the residents on a 24/7 basis.

One of our core beliefs is that the root cause of many of the catastrophes that befall nursing home residents is actually due to understaffing of the nursing home – the staff simply does not have the ability to provide the care and critical thought the residents require because they are stretched so thin due to the choices that management made in how to staff the nursing home.

With that said, it is exceedingly rare for a nursing home to be explicitly for understaffing a nursing home, but that is what happened here.  The local ombudsman received a call from the residents complaining that there was only one nurse and one CNA on duty caring for twenty-five residents.  Upon arriving at the facility, the ombudsman found that the complaints from the residents were accurate.  The appearance and odor of the residents demonstrated that they were not being showered on any regular basis or provided incontinence care in a timely way.

Proving good care in a nursing home is a labor-intensive business, and without having adequate staff on hand, residents get placed at risk of harm in multiple ways:

  • Residents who require the help of a mechanical lift for transfers might receive manual transfers rather than with the use of the lift or have a single staff member operate the lift when doing so is a two-man job;
  • Residents who are risk for nursing home falls due to musculoskeletal issues and some degree of cognitive impairment will not receive the supervision called for under federal regulations to prevent falls;
  • Residents who suffer from incontinence will not receive timely incontinence care, placing them at higher risk for developing bed sores;
  • Residents who have a care plan which calls for turning and repositioning as means of preventing bed sores will not get the necessary turning and repositioning, increasing the chances of getting bed sores;
  • Residents who already have bed sores will not receive dressing changes and other care necessary to promote healing and prevention of infection;
  • Residents who are experiencing some change in condition are less likely to have the staff recognize it.  The staff are the eyes and ears of the doctor and understaffing can lead to a delay in notifying the doctor of a change in condition;
  • It increases the chance that medication errors will occur;
  • Residents may not receive their meal trays and needed fluids in a timely way, increasing the odds that residents will suffer from malnutrition and dehydration, with all of the complications that follow from that;
  • Residents are unlikely to receive the care called for in their care plans;
  • Residents who are risk of choking may not receive the supervision they need while eating, increasing the risk of a nursing home choking accident;
  • And the list goes on ….

None of this is to serve as a criticism of the staff who stayed on trying to provide care for the residents in that nursing home.  When the nursing home is chronically understaffed, they are really fighting a losing battle and deserve more help from management to provide the residents with the care that they are entitled to.

COVID has obviously made operating a nursing home harder than it used to be, but management must find a way to provide the necessary care to 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:

Sharon Health Care Elms resident suffers brain bleed in fall while on smoking patio

Cedar Ridge resident breaks both legs in fall from bed

Understaffing at Generations at Rock Island leads to fall and hip fracture

 

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

 

 

Resident at Park Pointe in Morris suffers multiple fractures down unlocked stairwell

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IDPH has cited and fined Park Pointe Healthcare and Rehab nursing home in Morris after a resident there suffered multiple fractures due to falling down a stairwell.

The resident involved in this fall down the stairwell had a care plan for wandering. Wandering is also known as elopement in the long-term care industry and is a serious risk of harm to the resident. Residents who wander can find themselves in situations where they are faced with hazards which due to physical or cognitive limitations, they are unable to safely face or address. This resident was also a fall risk because she was wheelchair-bound and had musculoskeletal deficits as well as significant cognitive deficits.

For residents which are at risk of harm due to wandering/elopement or falls, there are a number of steps that can be taken to mitigate that risk.  One of the principal steps is to keep the resident under close supervision.  Doing this reduces the risk from injury for both falls and wandering, and is consistent with the requirements of federal regulations.

On the day of this nursing home fall, the staff noticed that a plastic curtain, which went to an otherwise-empty COVID unit, had been disturbed. The staff checked the rooms in the COVID unit for  residents but did not find any. They returned to their own unit and discovered that the resident involved in this incident was missing.

They looked throughout the facility but were unable to locate her and returned to the COVID unit.  Upon return to the COVID unit, they re-inspected all of the rooms and were unable to find the missing resident. Coming to the end of the hallway, they noticed that the door to the stairwell was closed, but the green light for alarm was flashing. This was an indication that the alarm was not armed.

The staff opened the door and found the resident down at the bottom of the stairwell, with her wheelchair two or three steps down the stairwell. She apparently had begun to fall down the stairs. The wheelchair stopped, and she was ejected from the wheelchair. An ambulance was called. The resident was brought to the hospital where she was diagnosed as having a fracture to her clavicle, as well as broken ribs.

There were two major shortcomings in the care that this resident received. First, any resident who is at risk for falls and is also known as a wanderer and at risk for elopement should be a resident who is closely supervised. The citation issued by IDPH indicates that the staff was well aware of her history of wandering and that she wandered actively throughout the facility, often looking for her husband, who is in fact, not a resident at the facility.  Keeping her under close observation would have likely prevented this injury, especially given the amount of time that it would have taken her to travel that distance and open not only the door to the stairwell, but also the curtain to the COVID unit.

The other major shortcoming in the care that this resident received is that the stairwell was not secured with either a lock or an alarm. Stairwells pose a special risk of harm to nursing home residents.  This is partially due to the fact that many are simply not able to negotiate them safely as well as the fact that stairwells are an area where they are out of view of the staff.  Once a fall occurs in a stairwell, it is likely that the resident will endure a prolonged period of time before the fall is discovered and care for any injuries from the fall can be offered.

In this particular case, the practice at the nursing home was that the maintenance staff would check the alarms throughout the facility during weekdays, but there was no one specifically assigned to check the alarms on weekends – which is when this fall occurred. As a result, the stairwell was not secured with locks or alarm leading to the fall and injuries sustained by this resident.

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

Other blog posts of interest:

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

Accolade of Pontiac resident fractures hip in fall after call light left out of reach

Resident breaks both legs in fall from bed at Grove of Fox Valley

 

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

 

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

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IDPH has cited and fined Prairie Manor Nursing & Rehabilitation Center in Chicago Heights after a resident there suffered a brain bleed due to being rolled out of bed while receiving incontinence care from a single staff member rather than the two that were needed.

In the long term care industry, the term “bed mobility” refers to the ability of the resident to change and maintain position in bed.  This is an important area for assessing a resident’s abilities because the resident’s ability to change positions in bed is crucial for things like incontinence care and turning and repositioning, all of which are important for the prevention of bed sores.

The resident’s abilities with regard to bed mobility are recorded on the Minimum Data Set (MDS) which is a document which is submitted under oath to the federal government and is part of the basis for calculating the payments to the nursing home for the care that the resident receives.  When the MDS indicates that a resident requires extensive assist of two staff members for bed mobility, this indicates that the resident has little to no ability to change or maintain position in bed.  When two staff are providing care in bed to the resident, one staff member should be on each side of the bed with the staff member on the side of the bed in which the resident is turning being charged with making sure that the resident does not fall from the bed.  To assist the staff in knowing which residents require the assistance of two staff, the staff is provided with a care card which spells out the requirements for care of that resident.

On the day of this nursing home fall, the resident was receiving incontinence care from a single aide.  As the aide turned resident away from her, the resident slid off the edge of the bed, hitting her head on the floor.  She had immediate bleeding and was sent to the hospital where scan showed that she suffered a brain bleed.

Besides this being a situation where you had one person doing a two-person job – which is almost always a formula for disaster (see here, here, here, here, and here for examples), the aide compounded the problem by rolling the resident away from her instead of bringing her toward her while positioning the resident.

The deeper question is of course why did this aide attempt to do a two-person job by herself?  The likely answer relates to understaffing of the nursing home.  The aide explained to the supervising nurse that she could not find anyone to help her.  Not having staff available to meet the care needs of the resident is characteristic of an understaffed nursing home.  Unfortunately, understaffing of the nursing home is a feature, and not a bug, in the nursing home business model.  The net effect of understaffing is that it doesn’t give the staff the ability to provide proper care for the residents – and the net result of that is unnecessary injuries such as this one.

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

Other blog posts of interest:

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

Manorcare of Palos Heights East resident breaks hip in fall

Resident rolled from bed at South Suburban Rehab

 

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

 

Piatt County Nursing Home resident breaks hip in fall

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IDPH has cited and fined Piatt County Nursing Home after a resident there fractured a hip in a fall due to the failure of an aide to provide needed supervision and assistance.

Falls are a major issue in the long-term care industry due to the serious negative effects that they have on the mortality and quality of life of nursing home residents.  Therefore, fall prevention is always a specific area of focus in the care planning process.

The care planning process begins with an assessment of the resident’s fall risk.  Nursing homes use a variety of tools to assess fall risk, but one common feature in almost all tools is that (1) some form of musculoskeletal weakness, balance issue, or gait dysfunction and (2) some form of dementia, forgetfulness, intermittent or constant confusion, poor safety awareness or judgment, or some other form of cognitive impairment are major factors in weighing the resident’s fall risk.  The reason that cognitive impairment contributes to fall risk is that the resident cannot be counted on to follow instructions or make good decisions for their own safety.  Where cognitive impairments are a contributing factor to fall risk, close supervision is a mainstay of fall prevention – consistent with the requirements of federal regulations.

The resident at issue was properly assessed as being a fall risk.  Among the factors that made the resident a fall risk were having mobility impairments, poor balance, an unsteady gait, a history of falls, and according to the resident’s Minimum Data Set (MDS) he required extensive assist of the staff with transfers and to stabilize.  On the cognitive side, he was noted to have long and short term memory problems.  He further had a known history of attempting to self-transfer and forgetting to use the call light.  He was considered a fall risk because of his impaired gait and forgetting and/or overestimating his limits.

On the day of this nursing home fall, the resident activated the call light for assistance to use the commode.  The aide arrived to assist the resident.  He provided the resident his walker and then turned and went to close the privacy curtain for the resident.  As the aide was closing the privacy curtain, the resident attempted to stand using the walker.  As he did so, he lost his balance and fell to the floor.  The resident’s leg was rotated outward with a leg length discrepancy – obvious signs of a fractured hip.

The resident was brought to the hospital where the fractured hip was confirmed.  The resident was transferred to a larger hospital where he underwent surgery to repair the fractured hip.

The facts of this fall show how quickly small failures in the care that the resident is provided can have catastrophic consequences.  The aide responded to the call light (something that does not always happen) and attempted to provide the resident with a measure of dignity by closing the privacy curtain.  However, he did so after providing the resident with the walker.  He was not in a position to provide the resident with the needed assistance with transferring and stabilizing when he rose from the position seated at the edge of the bed.  Further, he had his back turned to a resident whose known history and behaviors spoke to a need for close supervision.  The Director of Nursing admitted as much, telling the state surveyor that simply closing the privacy curtain when he entered the area could have prevented this fall.

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:

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

Westminster Village resident suffers multiple fractures in fall

Moweaqua Rehab resident fractures hip in fall

 

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

 

 

Inverness Health & Rehab resident suffers multiple fractures in fall

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IDPH has cited and fined Inverness Health & Rehabilitation nursing home after a resident there suffered multiple fractures in a fall due to violations of the resident care plan.

The resident care plan is one of the building blocks by which much of the routine care a resident in a nursing home requires is provided.  Once a care plan is put into place, it falls the to the staff charged with carrying out the various steps in the care plan to actually implement the care plan on a day-to-day, shift-to-shift basis.

For the resident at issue, her Minimum Data Set (MDS) showed that she required the extensive assistance of two staff members with all transfers.   This means that the resident required the hands-on help from two people to move from bed to wheelchair, wheelchair to chair or toilet, and so forth.  The data in the MDS is certified under penalties of perjury to the federal government and the care needs shown on the MDS should be reflected in the resident care plan.

On the day of this nursing home fall, the resident was being transferred to the toilet by a single aide, not two staff members as called for by the resident care plan.  Having one person do a two-person job is a formula for disaster, as we have written about many times on this blog  (see here, here, here, here, and here for examples).  In attempting to complete the transfer, the resident fell to the floor.  As a result of the fall, the resident suffered fractures to the kneecap and to the tibia and fibula (the long bones of the lower leg) – but these injuries would not be discovered or treated for over a day.

When an aide is involved in a resident fall, it must be reported to the nurse so that the nurse can do an assessment on the resident.  It then falls to the nurse to report the fall to the resident’s  family and the resident’s doctor so that he can make orders about further care for the resident.

However, after this fall the aide simply helped the resident from the floor before reporting the fall to the nurse, exposing the resident to risk of injury from being moved when it was not safe to do so.  Further the failure to report the nurse delayed the onset of care because nothing was done about the injuries until the following morning when the resident refused to get out of bed due to the pain she was experiencing.

The nursing staff then called the physician and the doctor’s physician’s assistant ordered STAT x-rays.  The portable x-ray company advised that it could not make it the facility in a timely way, so the staff called the PA back and were advised to send the resident to the hospital.  However, that did not actually happen for nearly 9.5 hours.  Most nursing home staff members would agree that subjecting a resident to unnecessary pain is a form of nursing home abuse.

The immediate cause of the injuries to this resident was a violation of the resident care plan.  The deeper question is why this occurred the way that it did.  It likely relates to understaffing of the nursing home and the training of the staff.  Having staff take dangerous shortcuts in the care of the resident (such as attempting a transfer with one when two are required) is a sign of an understaffed nursing home.  Failing to invest in training of the staff so that the staff knows to follow the care plan and report falls when they occur is also something that reflects the choices that management makes regarding the nursing home.  Sadly, understaffing the nursing home and failing to invest in the staff is consistent with the core features 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:

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

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

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.

 

Pekin Manor resident suffers brain bleed due to fall

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IDPH has cited and fined Pekin Manor nursing home after a resident there sustained a brain bleed in a fall.

Falls are a significant issue in the long term care industry because of the serious adverse effects they have on the mortality rate and overall quality of life for nursing home residents.  Because of this, falls are a specific area of focus in the care planning process.  There are six steps to the care planning process: (1) an assessment of the risks to the health and well-being of the resident, (2) development of a care plan which spells out specific steps (or interventions) to be taken to address the risks to the resident’s health and well-being, (3) communication of the care plan to the staff members 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 on an ongoing basis, and (6) revision of the care plan if proves to be ineffective in practice of if changes in the resident’s condition warrant it.  An effective care plan is one that meets the risks of resident and are tailored to that particular resident.

When it comes to falls there is no “gold standard” risk assessment tool similar to the Braden Scale used for assessing the risk of developing bed sores.  However, there are two major fall risk factors which appear in just about every well-designed fall risk assessment tool.  The first of these is some form of balance or musculoskeletal dysfunction which leaves the resident at risk of falling.  The second major fall risk factor is some form of cognitive deficit such as constant or intermittent confusion, dementia, forgetfulness, or general poor safety awareness or judgment.  The reason that cognitive deficits contribute to fall risk is that the resident cannot be counted on to follow instructions or make good decisions for their own safety.  When the cognitive deficits are significant contributors to fall risk, the care plan should reflect this.

The resident was admitted to the nursing home as a short-term admission for rehabilitation and strengthening.  Her preliminary care plan assessed her as being a fall risk.  The care plan called for “call light education” as an intervention to address her fall risk.  During the days that followed, the full extent of her cognitive impairments became apparent.  Her Minimum Data Set (MDS), which is submitted under oath to the federal government, documented her as having severe cognitive impairments.  The nursing home social worker told the state surveyor after the fall that she suffered from cognitive impairments to the point that she was unable to recognize family members.  Her roommate told the state surveyor that she would forget things that she had been told five minutes earlier.

In light of this, call light education was an inadequate care plan.  She simply could not be relied upon to use the call light, completely undermining that as a fall prevention strategy.  Federal regulations call for residents to receive supervision and assistance as necessary to prevent accidents, and falls are a form of accident.  As the extent of her cognitive impairments became apparent, her care plan should have been revised to include supervision as a primary means of fall prevention, rather than depending on her to use the call light.

On the day that this nursing home fall occurred, the resident was found on the floor of her room with bruising to the back of her head.  She was sent to the emergency room where a CT scan showed that she suffered a brain bleed as a result of the fall.

Sadly, the basic step of having an adequate care plan was not taken in this case.  Both her doctor and the director of nursing told the state surveyor that the care plan was not proper in light of her cognitive impairments.  Without an adequate care plan, fall prevention was left to random chance.

Pointing to an inadequate care plan providers an easy answer as to why this resident fell and was injured, but the deeper question is why this happened.  The real answer to that question probably relates to the management of the nursing home – the staff was so stretched and stressed that they did not have the time or ability to give this resident’s needs to the critical thought and attention they required.  Unfortunately, that is typical of how nursing homes are operated.   One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Accolade of Pontiac resident suffers fractured hip in fall after call light left out of reach

Christian Nursing Home resident suffers severe leg injury in fall

University Rehab Northmoor resident suffers broken hip in fall from bed

 

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

 

Chicago Ridge Nursing & Rehab resident chokes to death

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IDPH has cited and fined Chicago Ridge Nursing & Rehab nursing home after a resident there choked to death on a sandwich.

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

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

When a resident is at risk for choking, this should be addressed in the care planning process.  This may include having a swallow evaluation done by a speech therapist to come up with modified diet orders or other approaches to eating which can serve to reduce the risk of choking.  The recommendations of the speech therapist should be incorporated into physician orders and/or the resident care plan, which then must be carried out on a day-to-day, shift-to-shift basis.

One of the kinds of records that are unique to the nursing home industry is the Minimum Data Set, or MDS.  The MDS collects information regarding the resident’s condition, care needs, and the levels of assistance needed.  The MDS forms part of the basis by which the reimbursement (or payment) levels for the nursing home are set, so there is a requirement that the MDS be completed under oath.  Because the MDS is certifying that the resident needs and is receiving a given level of care, the care shown on the MDS is usually incorporated into the resident care plan.

The resident at issue had a number of medical issues, including suffering from dementia and having had a history of stroke.   There was a physician order in place for a puree diet.  The resident had a series of know n behaviors, including frequently goin into other resident’s rooms and stealing food from other residents.  Her care plan included one person assistance and supervision while eating and supervision related to her dementia. The staff interviewed after this choking incident however told the state surveyor that she was able to eat without supervision and was alert and oriented to person, time, and place.

Her Minimum Date Set (MDS), however, told a different story.  It described her as having severe cognitive impairments.  With regard to eating, it stated that she required supervision of one while eating,  that she experienced loss of food or liquid from the mouth while eating, and that she showed signs of a swallowing disorder in the form of pocketing while eating.  This is very clearly the picture of a resident who was at risk for choking and required supervision.  This is also consistent with the care plan.

On the day of this nursing home choking accident, the resident was found unresponsive in bed with a piece sandwich in her mouth.  She was not breathing.  Paramedics were called, but since she was a DNR, they did not attempt to resuscitate her and did not bring her to the hospital.  Case of death per the death certificate was asphyxia due to choking on a food bolus.

There were a number of shortcomings in the care that this resident received which led to her death:

  • The staff was not aware of what the care plan called for – they believed that the she was capable of eating independently when she required supervision due to her swallow difficulties and cognitive impairments.  Communicating the contents of the care plan to the staff charged with carrying it out is a basic part of the delivery of care via the care planning process;
  • The care plan did not address her known behavior of taking food from other residents.  The physician’s order called for a puree diet and consumption of anything that was not pureed would be a violation of that order.  As part of the care planning process, the care plan must be revised when it prove inadequate in practice.  If the resident was taking food from other residents which placed her at risk for choking, this is a risk to the health and well-being of the resident which must be addressed in the care plan.  Sadly, it was not.
  • The care plan called for supervision of the resident, but we know that leading up to the choking incident, she obtained a sandwich from somewhere, began to eat it, and choked on it – all without the knowledge of the staff.  As noted above, the staff should have been monitoring this resident specifically for the taking of food which she was not supposed to have, but that was not being done – and it also appears that the more general supervision was lacking as well.

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

Other blog posts of interest:

Winston Manor resident chokes on peanut butter sandwich

Bella Terra Wheeling resident chokes to death

Alden Poplar Creek resident chokes to death

 

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

 

Accolade of Pontiac resident fractures hip in fall after call light left out of reach

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IDPH has cited and fined Accolade Healthcare of Pontiac nursing home after a resident there suffered a hip fracture in a fall.

Fall prevention is a major focus of care in nursing homes because falls have such a devastating effect on the mortality and overall quality of life for nursing home residents.  One mainstay of fall prevention is encouraging the use of a call light and leaving personal items such as books, glasses, phones, and so forth in easy reach of the resident.   The basic idea of having things in easy reach is that residents don’t have to get up and down from a seated position and walk across the room to get anything.

Another mainstay in fall prevention is use of a call light.  Call lights can be effective in summoning the staff for assistance.  However, for that to happen, the call light must also be left in easy reach of the resident – just as with personal items.

The resident at issue was a very clear fall risk.  She suffered from moderate cognitive impairments (and thus could not be relied upon to consistently make good judgments for her own safety) and had difficulty walking, using a walker or a wheelchair for mobility.

On the day of this nursing home fall, the resident was found on the floor.  Her left leg was rotated, a common sign of a hip fracture.  The resident did not have on nonskid footwear and had not activated her call light.  However, the nurse on duty noted that the call light was hanging on the call light box on the wall.  The resident was brought to the hospital where she was diagnosed as suffering from a hip fracture.

This fall was due to the failure to take the simple step of leaving the call light in a place where the resident could easily reach it without getting up.  However, the call light had been placed on top of the call light box, out of reach.  Besides being a common-sense failure in care, it was also a violation of the facility’s own policies and procedures which called for the call light to be in easy reach of the resident.

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

Other blog posts of interest:

Westminster Village resident suffers multiple fractures in fall

Resident breaks hip in fall at McLean County Nursing Home

Piatt County nursing home resident breaks neck in fall from power recliner

 

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

 

 

 

Sharon Health Care Elms resident suffers brain bleed in fall while on smoking patio

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IDPH has cited and fined Sharon Health Care Elms nursing home in Peoria after a resident there suffered a brain bleed and a compression fracture of a vertebra in her neck after a fall that occurred while she was left unsupervised on the smoking patio.

People unfamiliar with nursing homes are sometimes surprised that nursing home residents are permitted to smoke.  Even though nursing homes are health care institutions, they are also truly the homes of the people who live there, so people are permitted to smoke.  Due to restrictions on indoor smoking, smoking must be done outdoors, usually on a deck or patio which has been designated as a smoking area.

However, beyond just the well-known negative health effects of smoking, there are additional risks associated with smoking for nursing home residents.  This principally includes the risks of fires or getting burned, mainly due to careless handling of smoking materials by residents suffering from confusion or dementia or due to movement disorders such as Parkinson’s or due to smoke near compressed oxygen equipment.

A lesser known, but still present risk is a risk of falls.  This is primarily associated with residents not paying attention to what they are doing due to anxiety or distraction associated with the desire to smoke.

Whatever risks are present associated with residents who smoke, this should be addressed through the resident care plan.  Once a care plan is put into place it must be carried out on a day-to-day, shift-to-shift basis.  One of the principal forms of addressing risk associated with smoking is by supervision of residents on the smoking patio.  To facilitate this, many nursing homes set certain hours during which the smoking deck is open for use.

The resident at issue here was assessed as being a fall risk, in part because of diminished safety awareness and apparent significant visual deficits (per the citation, she told a fellow resident that she was going blind) which affected her ability to see and perceive things around her.  Before the fall at issue, over the last year or so, she had four nursing home falls, all on the smoking patio.  Her care plan included being supervised on the smoking patio as a fall prevention measure.

The resident fell at approximately 6:30 a.m. while on the smoking patio.  She was on the patio unsupervised, having followed another resident who would sometimes give her cigarettes out onto the patio.  There was no staff present.  While she was out of the smoking deck, she tripped over a decorative landscaping and hit her head.  There was immediate bleeding, including from the nose, so the other residents went into the facility and altered the nursing staff.  When the nursing staff was unable to stop the nosebleed, they sent her to the hospital.  There scans showed that she had a brain bleed and a fracture in her cervical spine.  She was transferred to another hospital for advanced care.

This fall was a result of the resident not being supervised on the smoking patio.  The lesson that should have been drawn from the prior falls is that her visual deficits and distraction while on the smoking patio left her particularly susceptible to falls.  The resident care plan called for it, but there was a clear violation of the resident care plan.

Part of the reason that she was not supervised on the smoking patio is that even though there were supposed to be a set of scheduled hours when the patio was permitted to be used, there was no consensus as to when those hours were, not apparently, on who was supposed to be supervising residents on the patio.

The deeper question is of course why there was no supervision, and the root answer to that question is likely understaffing of the nursing home.  More than one of the residents interviewed by IDPH told the surveyor that there was not enough staff on hand to provide regular care to the residents, let alone supervise them when they are smoking.  Unfortunately, understaffing of nursing homes is a featured component 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:

Pekin Manor resident suffers brain bleed in fall

Christian Nursing Home resident suffers severe leg injury in fall

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

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

 

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

 

 

Dehydration leads to hospital admission for resident at Mattoon Rehab

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IDPH has cited and fined Mattoon Rehabilitation & Health Care Center nursing home after a resident there had to be sent to the hospital suffering from encephalopathy and acute kidney injury due to dehydration.

One of the basic commitments that nursing homes make when they accept a resident for admission is that they will do what is required to help maintain the resident’s basic health.  Many people are therefore shocked to hear of  nursing home residents suffering from conditions like dehydration and malnutrition.

This resident was admitted for treatment with IV antibiotics, including vancomycin and cephapime, for treatment of osteomyelitis and discitis.  Her medical history included congestive heart failure for which she was receiving a diuretic (commonly known as a “water pill”).  One of the effects of taking a diuretic is that you urinate frequently (hence the term “water pill”), which can lead to dehydration.  Because this is a known risk of use of a diuretic, it is something that should be addressed in the resident care plan.

The care planning process is the road map for providing much of the routine care that resident’s receive in a nursing home.  It begins with the resident assessment which identifies the known risks to the health and well-being of the resident.  From there, a care plan is developed.  This includes a series of steps, or interventions which must be taken on a day-to-day, shift-to-shift basis to minimize the risks to the health and well-being of the resident.  Once a care plan is put into place it must be communicated to the staff charged with carrying it out and then actually implemented on a day-to-day, shift-to-shift basis.

When a resident is at risk for dehydration due to the use of a diuretic, this is something that should be addressed in the resident care plan.  This would include simple measures such as encouraging fluids, monitoring fluid intake, and monitoring signs and symptoms of dehydration.  These would include a dry mouth, diminished urine output, darker colored urine, and increased lethargy and confusion.

Having and executing a care plan to address the risk of dehydration is especially critical in residents who are receiving the antibiotic vancomycin.  Vancomycin is known to have adverse effects on the kidneys, made worse when the patient is suffering from dehydration.

When the resident was admitted to the nursing home, she was assessed as having no cognitive issues, was alert and oriented, and able to make her needs known.  Over the first few days of her admission to the nursing home, she was not eating much and was only taking a few sips of water.

One the sixth and seventh days after she was admitted to the nursing home, the staff noted that the resident was having disorganized thinking, difficulty with finding words, and slowed response times.  The resident chart further recorded that had poor appetite and was tired.  These were signs and symptoms of dehydration.  The onset of these signs and symptoms represented a change in resident condition which should have prompted physician notification.

On the eighth day after she was admitted, a nurse returned from vacation and cared for this resident for the first time.  She was advised by the staff that the resident was able to make her needs known and was alter when she was admitted.  The nurse contacted the resident’s physician who ordered labs drawn the next day.

Unfortunately, the evening, the resident experiencing muscle jerking and twitching and was sent to the hospital.  Labs drawn there showed elevated BUN and creatine levels – markers of dehydration and diminished kidney function.  The resident was diagnosed with acute kidney injury and encephalopathy (brain dysfunction) all related to her dehydration.  She had to be admitted to receive fluids – something which is dangerous for a patient suffering from congestive heart failure as this resident was.

Additionally, the resident was discovered to have developed multiple bed sores.  When the resident was admitted to the facility, she did not have any skin breakdowns.  Federal regulations require that resident receive care, treatment, and services necessary to prevent the development of bed sores.  Dehydration is a known risk factor for the development of bed sores.  Immobility is another one, something that was likely true for this resident as she became weak and lethargic due to her dehydration.

These issue – the dehydration and all of its complications, as well as the bed sores – are the simple result of routine care not being provided to this resident.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Arcadia of Danville resident dies due to improperly treated urinary tract infection

Failure to report changes in condition at Heritage Health in Carlinville

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

 

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

 

Medication error at River Crossing of Alton leads to hospitalization

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IDPH has cited and fined River Crossing of Alton nursing home after a resident there had to be hospitalized with hepatic encephalopathy after not receiving a medication as had been ordered for her.

Ammonia is a waste product that builds up in the blood as part of the digestive process.  Ordinarily, ammonia is filtered through the liver where it is converted to urea which is then removed from the body through urination.  When the liver is not functioning properly, ammonia builds up in the body and can be toxic to the brain and other organs.  One way in which ammonia levels in the body can be brought down is through the use of a drug called lactulose.

The resident at issue had a diagnosis of cirrhosis of the liver and her admitting orders called for receiving lactulose every 8 hours, or 3 times per day.  However, during the first two days of her admission to the nursing home, she received only one dose each day and then did not receive any the third day that she was in the nursing home because she was out of the facility at the time that medication was passed.

The resident’s chart reflects that a friend called the nursing home on the evening of the third day of her admission and told the nurse that he had spoken to the resident and she reported to him that she was only getting her lactulose once a day and should have been getting it two or three times a day.  There does not appear to have been any action taken in response to that phone call, as the next morning when staff checked on the resident first thing in the morning, she was unresponsive.

The resident was brought to the hospital where her lab work showed that she had ammonia levels of 238 (normal range is 15-45).  She was admitted to the hospital with a diagnosis of hepatic encephalopathy, which is a loss of brain function brought on by the failure of the liver to remove toxins from the blood.  Here, the brain injury was caused by the failure to give the medication as ordered.

There are two major breakdowns in the care that this resident received.  First, the admitting orders were not transcribed properly, resulting in her receiving one dose of lactulose per day rather than the three which were ordered.  This nursing home medication error led directly to the brain injury that this resident suffered.  The IDPH citation further stated that the Director of Nursing admitted that there had been some problems with accurately transcribing orders.  Second, there was no apparent action from the call from the friend.  It is more than likely that if the resident was raising the medication issue with the friend, she was also raising it with the staff.  At a minimum this should have sparked some effort by the staff to verify that the orders were correct and to discuss the matter with the resident.  Instead the call brought  no apparent response, with the resident being taken to the hospital unresponsive the following morning.

This breakdown in the care that this resident received is what happens when the staff does not take the time to actually meet the care needs of the resident by doing things like checking to make sure that orders are entered properly and that concerns about the care are at least considered.  When these things don’t happen, it raises questions about whether this is an understaffed nursing home.  Unfortunately, understaffing a nursing home is a basic feature of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Failure to give HIV Medications at Bria of Belleville

Aperion Care Capitol fails to give medication to resident suffering from bacterial meningitis

Rushville Nursing & Rehab resident suffers from untreated surgical wound infection

 

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

 

 

Failure to give anti-seizure medications at Generations at Rock Island

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IDPH has cited and fined Generations at Rock Island nursing home after a resident had to be hospitalized due to seizure activity after not receiving his anti-seizure medications for 36 hours after admission.

The resident at issue had been admitted to the facility from home.  He had a history of a brain injury and seizures and was to receive two anti-seizure medications (levetiracetam and oxcarbazepine) twice per day, at 8 am and 8 pm.  Before being admitted to the nursing home, his seizures were being managed by a neurology clinic which had prescribed these medications.

Before a resident is admitted to the nursing home, there is a process by which the resident is screened to determine whether the nursing home can meet the care needs of the resident.  If the nursing home cannot meet the care needs of the resident, then the proper course of action is to decline the admission.  Part of the screening process is obtaining information about the resident’s medical history, their active diagnoses, and the medication and other treatment orders.

Once the resident is admitted to the nursing home, the resident must have an attending physician for manages the overall medical care of the resident, including signing orders for medications and other treatment orders as needed.  Obtaining the signed orders for medications is important in assuring proper care for the resident because there are some medications which the nursing home will not keep on hand and the pharmacy will not dispense to the nursing home without a signed order.  Anti-seizure medications fall into that category.

When the resident arrived at the nursing home during the middle of the afternoon, the admitting nurse asked a nurse practitioner who was in the facility to sign off on the orders for the anti-seizure medications, but she declined to do so.  The admitting nurse then contacted the medical director, but could not speak with him and left a message.  He did not return the call until 1:55 p.m. the following afternoon, and the medication orders were not entered into the resident’s electronic medical record until after 4 p.m.  As a result, the medications did not arrive in the facility during the resident’s second day in the nursing home.  Because of this, the resident missed three doses of each of the two anti-seizure medications he was due to receive – the 8 pm dose the first day he was in the facility, and both doses the second day.

At about 8:30 p.m. on the second day, the resident was able to speak normally with an aide.  About 10 minutes later, that same aide walked by the resident’s room, looked in and saw that the resident was having a seizure.  The resident had wet himself, the right side of his body was limp, but he was shaking violently, nonresponsive, and had his eyes rolled back into his head.

911 was called and the resident was brought to the hospital to receive care for the seizures.  His treating doctor attributed the seizures to the missed doses of medication.

Making sure that medications are given as ordered is crucial to ensuring the well-being of nursing home residents.  When the nurse practitioner refused to assume care of the resident, the admitting nurse did the right thing by reaching out to the medical director to get orders for the medication.  However, when she could not reach him, simply waiting for a return call was not acceptable practice given the importance of the medication in the overall care of the resident.  Follow-up phone calls to the medical director or contacting the regular prescribing doctor was what was required.  This nursing home medication error to a critical lapse in the care of this resident.

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

Other blog posts of interest:

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

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

Resident suffers from flesh-eating disease from untreated skin tear at Regency of Sterling

 

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

 

 

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

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IDPH has cited and fined Barry Community Care Center nursing home after a resident who was a known fall risk was left unattended at the nurse’s station and fell, refracturing a recently broken hip.

Falls are a major issue in the long-term care industry because they have such significant implications for the well-being of residents.  Fall risk is one of the areas which is specifically assessed during resident assessments during the care planning process.  There are a number of tools that are used at different facilities, but the two common threads to assessing a resident’s fall risk are (1) some type of gait, neurologic, or musculoskeletal dysfunction which makes it difficult for a resident to walk, stand, or transfer safely, and (2) some type of cognitive deficit such as dementia, intermittent or constant confusion, or simple poor safety awareness or judgment.

The reason that cognitive deficits contribute to a resident’s fall risk is that the resident cannot be counted on to follow instructions or take basic precautions for their own safety.  Because of this, keeping the resident under close observation is a mainstay of fall prevention.  In fact, federal regulations pertaining to nursing home falls require nursing homes to provide supervision and assistance necessary to prevent accidents.  Usually, this takes the form of keeping residents who are at risk for falls near the nurse’s station, the dining room, the activity area or some other common area where the staff can keep an eye on what the residents are doing.

The resident at issue here was admitted to the nursing home after suffering a fractured hip which was surgically repaired.   The resident was assessed as being at risk for falls.  The assessment included findings that the resident was oriented to person only – indicating significant cognitive deficits.  Before the fall at issue, the resident had two prior falls, and the occurrence of a fall is a predictor of additional falls in the future.

On the day of this nursing home fall, the resident was brought to the nurse’s station so that the staff could keep her under direct observation.  However, she apparently decided to stand on her own and fell, pulling the wheelchair down on top of her. It was recorded as being an unwitnessed fall, indicating that even though the resident was brought to the nurse’s station to be kept under observation, she was left unattended and the fall resulted.

The resident was brought to the hospital where scans showed a fracture around the prosthesis from the original hip fracture.  The citation did not recite what was done to repair the fracture, but any surgical repair would necessarily be a difficult and complex operation and would result in loss of whatever recovery had been made from the original fracture.  Without surgery, the chances of the resident being able to regain any significant measure of ability to bear weight would be minimal which in turn has serious negative long-term consequences for the overall health and well-being of the resident.

Whenever there is a report that staff which were required were not present, this raises a question of whether the nursing home is understaffed.  Sadly, understaffing of nursing homes is a feature, not a bug of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Failure to use gait belt leads to fall at Clayberg Nursing Center in Cuba

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

Pittsfield Manor resident suffers fatal fall

 

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

Mar Ka Nursing Home resident breaks both legs in fall

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IDPH has cited and fined Mar Ka Nursing Home in Mascoutah after a resident there broke both legs in a fall while being readied for a shower.

One of the kinds of records that are unique to the nursing home industry is the Minimum Data Set, or MDS.  The MDS collects information regarding the resident’s condition, care needs, and the levels of assistance needed.  The MDS forms part of the basis by which the reimbursement (or payment) levels for the nursing home are set, so there is a requirement that the MDS be completed under oath.  Because the MDS is certifying that the resident needs and is receiving a given level of care, the care shown on the MDS is usually incorporated into the resident care plan.

So, when the MDS states that a resident requires the assistance of two staff with transfers, that is telling the federal government that this resident requires the help of two staff members moving bed to wheelchair, wheelchair to chair, and so forth.  When a resident requires extensive assist, that means that the staff must physically hold and support the resident during the transfer movement.

To do this safely, use of a gait belt is required.  A gait belt is a sturdy canvas strap that is applied to the midsection of the resident.  It provides the staff with a firm place to get a hold of a resident without trying to grab on to the resident’s body (many residents suffer from osteoporosis or brittle bone disease, which leaves the them susceptible to fractures from being grasped that way) or their clothing which is not designed for that kind of use and susceptible to tearing.

On the day of this nursing home fall, the resident was brought to the shower by a single aide.  The aide was in the process of transferring the resident from her wheelchair to a shower chair and was undressing her.  The aide was not using a gait belt.  While she was doing this resident’s leg slipped on the wet floor.  The aide could not control the resident and was lowered to the floor.  There was an obvious deformity to one leg.

The resident was brought to the hospital where x-rays showed that there were fractures to the femur in both legs, with a fracture just above the resident’s prosthetic knee on the left side.  The resident had to undergo surgery to repair both fractures.  These injuries will have serious long term implications for the health and well-being of the resident, including by placing her at increased risk for developing bed sores or suffering pneumonia.  Additionally it is unlikely that she will regain even her prior limited level of function after this injury.

There were a number of shortcoming in the care that this resident received which led to serious injuries with significant long term consequences for this resident.  The resident was being transferred at the time of her injury by a single aide when two were required.  Capping it off, that aide was not using a gait which was necessary to make the transfer safely.  Finally, federal regulations require that the resident environment remain as free of accident hazards as possible.  The loss of balance here was brought on by the slippery floor of the shower – a condition which could have been easily alleviated by the use of anti-skid strips on the floor of the shower.

When you have one person dong a two-person job it raises questions of understaffing of the nursing home.  Unfortunately, failing to provide adequate staffing levels is a planned feature of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Sling breaks during transfer at University Nursing & Rehab

Red Bud Regional Care staff fails to respond to call light, leading to fall

Broken ankle from fall at Aperion of Mascoutah

 

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

 

 

 

Feeding tube error at Aperion of Westchester

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IDPH has cited and fined Aperion Care of Westchester nursing home after a resident there developed pneumonia due to improper care while being fed through a feeding tube.

At a minimum pneumonia is a serous illness for senior citizens and other medically fragile individuals, and can prove fatal in some cases.  One of the common causes of pneumonia in a nursing home setting is aspiration of foreign substances into the lungs.  This can occur when things like food, saliva, or digestive tract contents are inhaled.

Aspiration pneumonia is one of the recognized risks of tube feeding.  Essentially, the risk is that the feeding solution will make its way up into the respiratory tract before being digested.  To help combat this risk, the person receiving the tube feeding should be kept with the the head of the bed elevated to at least 30 degrees while the tube feeding is underway and then for another 30-60 minutes after the tube feeding is completed.  Here, the resident’s care plan included those precautions.

On the day of the incident, the nurse completed giving the resident their feeding via the feeding tube and flushed the tube.  She left the room with the head of the resident’s bed elevated at 30 degrees.  Approximately an hour later, the nurse was summoned to the room by an aide who was not assigned to the resident but happened to be going down the hallway and could tell that the resident needed assistance.

When the nurse arrived in the room, she found the resident laying flat in her bed.  There were yellowish secretions consistent with the feeding tube solution coming from the resident’s mouth.  The resident was in apparent distress with elevated heart and respiratory rates, but her oxygen saturations having dropped to 78.

The paramedics were called.  They found the resident in severe visual, respiratory distress with foreign matter coming from the mouth.  The paramedics reported that they were told by the staff that the resident had been receiving her g-tube feeding while laying flat.  The resident was brought to the hospital to receive care for severe respiratory distress.

The investigation into the incident by IDPH did not reveal how the head of the bed ended up in a flat position, although the statements made by the staff to the paramedics suggest that it was in a low position throughout.  At a minimum the condition of the resident was such that it could not have been lowered by her, so someone else did this.  This amounts to a violation of the care plan and is evidence of poor training of the staff seeing as this is a fundamental when it comes to providing care to residents with feeding tubes.

Sadly, training the staff properly requires making investments in the staff.   The choice to not invest in the training of the staff is unfortunately a part of the nursing home business model.

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

Other blog posts of interest:

Feeding tube error puts Burgess Square resident into heart failure

Failure to follow feeding tube orders leads to hospice admission for Parker Nursing & Rehab resident

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

 

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

 

Failure to supervise Westmont Manor resident leads to fall and broken hip

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IDPH has cited and fined Westmont Manor & Rehabilitation nursing home after a resident who was a known fall risk there was left unsupervised at the nurse’s station, and a result fell and suffered a fractured hip which required surgery.

When a resident is considered a fall risk, developing and implementing a fall prevention care plan is required.  One of the mainstays of a good fall prevention care plan is keeping residents who are at risk for falls in an area where they can be easily supervised by staff.  In fact federal regulations require that residents receive supervision and assistance necessary to prevent accidents, and falls are definitely accidents.  In practice, this means that residents who are at risk for falls are placed in areas like the dining room, the activities area, or by the nurse’s station so that staff can keep them under direct observation.  This of course requires staff to actually be present in those areas.

The resident at issue was a known fall risk, and in fact before the fall at issue, had three prior falls.  One of the truisms about nursing home falls is that the occurrence of a fall is a predictor for additional falls and is a factor considered in almost all high-quality fall risk assessment tools.  Other crucial factors include some type of musculoskeletal or gait dysfunction and some form of cognitive impairment such as confusion, dementia, or poor safety awareness of judgment.  The reason that cognitive impairments feed into fall risk is that the residents cannot be counted on to make good judgments for their own safety or follow instructions from the staff intended to minimize fall risk.

This resident was wheelchair bound and required the extensive assistance of two staff with transfers and suffered from dementia.  She also had poor trunk control and had a history of stroke.  With the history of multiple falls and her physical and cognitive impairments, she was properly assessed as being a fall risk, and a fall prevention care plan was put into place.  One of the steps in that fall prevention care plan was to  keep her in an area where she could be supervised while up.

On the day of this nursing home fall, the resident was brought to the nurse’s station in her wheelchair.  The nurse was due for his break, so he went into the dining room – just a short distance from the nurse’s station.  While he was on break, an aide was assigned to monitor the residents at the nurse’s station.  However it was also the time for shift change for the CNA’s, so the aide was down at the other end of the hallway getting ready to end her shift.  As a result no one was monitoring the residents at the nurse’s station.

While he was sitting in the dining room on break, the nurse heard a thud.  He went to the nurse’s station and found the resident on the floor.  He went and got the aide who was getting ready to leave and returned to the resident.  He assessed the resident and then got her off the floor.  The resident had a bump on the forehead and was complaining of pain in the left hip, so the resident was sent out to the hospital.

At the hospital, scans showed that the resident had a femoral fracture extending into the intertrochanteric space – in lay terms, a fractured hip.  She underwent surgery with the placement of nails to repair the fracture.

This fall was the direct result of a violation of the resident care plan.  The whole point of having the resident in a location where she could be monitored is so that someone would be watching and in a position to intervene if she attempted to get up unassisted – a known behavior for this resident.  However, when the nurse assigned took his break and the aide left the nurse’s station to get ready to go home, the resident was left unsupervised.  Care plans need to be implemented on a 24/7 basis – and this is the result when they are not.

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:

AHVA Care of Stickney resident suffers hip fracture in fall

Alden Courts of Shorewood breaks both legs in unsafe transfer

Improper transfer leads to broken leg at Springs at Monarch Landing in Naperville

 

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

 

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

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IDPH has cited and fined Bria of Palos Hills nursing home after a resident there fell and suffered a broken arm due to the failure of staff to provide care called for by the resident care plan.

Care planning is a process by which risks to the health and well-being are identified and measures are put into place and carried out on a day-to-day basis to prevent those risks from coming to fruition.  One of the ways that proof of nursing home abuse and neglect is proven is by showing violations of the resident care plan.  Delivery of the care called for in the care plan is fundamental to providing quality care to residents in a nursing home setting.

There are six steps to the care planning process: (1) an assessment of the risks to the health and well-being of the resident; (2) a written care plan is developed which identifies a series of steps or interventions intended to reduce the risks to the resident.; (3) communication of the care plan to the staff who are charged with carrying it out; (4) implementation of the care plan on a day-to-day, sift-to-shift basis; (5) ongoing evaluation of the effectiveness of the care plan; (6) revision of the care plan if it proves to be inadequate in practice or if the care needs of the resident change.

The resident at issue was identified as being a fall risk, and a fall prevention care plan was put into place.  Among the steps that were to be taken was extensive assist of one staff with toileting and ambulation.  “Extensive assist” generally means provided physical support with weight bearing during the activity, including the use of a gait belt.

One the day of this nursing home fall, the nurse on duty had been told that the resident was not feeling well and went to the room.  As she approached the room, she saw that the call light was on.  She looked into the room and saw that there was an aide in the room already and that the resident was standing, walking toward the bathroom.  Assuming that the aide was there to assist the resident, she left to care for other residents.

Moments later she heard the resident call out the she had fallen and returned to the room and found the resident on the floor of the bathroom.  She told the staff that she lost her footing and fell.  She was bleeding from a wound from the head and was complaining of pain to her arm.  She was brought to to the emergency room where she was diagnosed with a comminuted fracture of the surgical neck of the humerus (upper arm).

There was a care plan in place which was intended to prevent just this kind of injury.  The resident was a fall risk and the care plan called for the assistance of one staff member to prevent falls, which can be so devastating to nursing home residents.  Care plans must be communicated to the staff so that they can actually be implemented.  Here, there were two staff members – the aide who was already in the room and the nurse who looked into the room – who saw that the resident was up without assistance.  Neither helped this resident, and as a result, the fall occurred.  The failure to carry out the care plan led directly to this injury.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  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 Chateau Nursing Home in Willowbrook suffers spinal fractures in wheelchair accident

Manorcare of Palos Heights East suffers hip fracture in fall

Mechanical lift accident at South Holland Manor

 

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

 

Failure to follow care plan results in fall with broken arm for resident at Heritage of Hoopeston

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IDPH has cited and fined Heritage Health of Hoopeston after a resident there suffered a broken arm in a fall brought on by the failure to follow the resident’s care plan.

The care planning process is how much of the routine care provided in nursing homes gets delivered.  There are six steps to the care planning process.  First there is an assessment of the risks to the health and well-being of the resident.  Second a care plan is developed which identifies a series of steps or interventions which are to be done to reduce the risks to the resident.  Third, the care plan is communicated to the staff who are charged with carrying it out.  Fourth, the care plan must be implemented on a day-to-day, sift-to-shift basis.  Fifth, the effectiveness of the care plan must be evaluated on an ongoing basis.  Sixth, the care plan must be revised if it proves to be inadequate or if the care needs of the resident change.

The resident at issue was identified as being at risk for falls.  Two of the interventions that were listed in her care plan were: (1) transfer the resident with two staff when suffering from acute illness and (2) place non skid strips on the floor.

In the days leading up to the nursing home fall, the resident was diagnosed as suffering from cellulitis of the right leg and from covid.  As a consequence of her covid diagnosis, she was placed in another room.  According to her care plan, the nonskid strips should have been placed on the floor of her room, but were not.  On the day of her fall, she was being transferred from her recliner to the bathroom with the assistance of a single aide.  As the aide was transferring the resident, the resident’s feet began to slide out from under her due to the lack of nonskid strips on the floor.  The aide attempted to support the resident by holding her from under her armpits, but there was a loud cracking sound and the resident experienced immediate pain and was unable to move the arm.  She was brought to the hospital where x-rays showed that she suffered a broken arm and a separated shoulder.

The two elements of the care plan discussed above were violated, and the fall and the injury to this resident were the result.  Even though the resident was placed in a new room due to her covid diagnosis, the nonskid strips on the floor were still required.  The lack of the nonskid strips on the floor led to the resident’s feet sliding out from under her, leading to the loss of balance.  When the one aide attempted to stop the fall she was working alone and was not able to.  Having a second staff member present for the transfer likely would have prevented the injury to the resident.

The most direct and obvious cause of the injury to this resident was the violation of the care plan.  However, understaffing of the nursing home is a likely culprit as well.  The aide involved admitted to the state surveyor that she knew that there was supposed to be a second aide assisting with the transfer but she tried to get it done on her own.  When you have staff taking shortcuts in the care of residents, understaffing is a likely culprit.  Sadly, understaffing 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:

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

Gardenview Manor resident suffers broken hip during unsafe transfer

Fall results in fractured kneecap at Country Health in Gifford

 

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

Heartland of Galesburg resident dies due to untreated urinary tract infection

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IDPH has cited and fined Heartland of Galesburg after a resident there died due to sepsis brought on by an untreated urinary tract infection.

One of the basic truisms of care in a nursing home setting is that doctors are not there on a 24/7 basis.  Because of this, nurses must be the “eyes and ears” of the doctors and let them know when there has been a change in the condition of a resident.  The nurse does not need to know what the change represents (though they often have a good idea) or how to treat it.  It is up to the doctor to make a diagnosis and decide how to treat the resident.  The nurse simply needs to be able to identify the change in condition, notify the resident’s physician, and give the doctor sufficient information for the doctor to make good decisions.

The presence of a urinary catheter places a resident at increased risk for developing a urinary tract infection.  There are a number of reasons for this, including the fact that the presence of the catheter opens up the body for entry of infecting organisms; bacteria can colonize the catheter itself; and the placement of the catheter can cause trauma to the urinary tract  and/or obstructions to the outflow of urine.  Because the risk of urinary tract infections is increased, their use is discouraged by federal regulations.  There must be medical justification for the use of a catheter in a nursing home, including a physician order for it.  Nursing homes are required to evaluate the use of a catheter on an ongoing basis and obtain orders for its removal when possible.  Catheter care, including monitoring for signs and symptoms of urinary tract infections, must be addressed in the resident care plan.  A well-done care plan will include monitoring for signs and symptoms of infection.

Nurses must know and be able to identify signs and symptoms of a urinary tract infection.  These may include: burning while urinating; foul-smelling, cloudy, or bloody urine; back or flank pain; mental status changes such as confusion or delirium; fever; and weakness or lethargy.  When a resident demonstrates signs and symptoms of a urinary tract infection, the nurse must notify the doctor who then must decide whether to order treatment over the phone (usually in the form or ordering a urinalysis and prescribing an antibiotic), come to the nursing home to evaluate the resident, or send the resident to the emergency room.  Left untreated, a urinary tract infection can cause sepsis leading to multi-organ failure and death.

The resident at issue was admitted to the nursing as a short-term admission to undergo rehabilitation after suffering a nondisplaced hip fracture at home (i.e., one that did not require surgery).  While she was in the emergency room, the staff there placed a catheter so that she would not have to get up to urinate.  Before that, there was no need for a catheter.  When she was transferred to the nursing home the following day, the catheter was left in place.  However, there were no orders entered for the use of the catheter and no assessment made of the suitability of removing the catheter.

Just over a week after the resident was admitted to the nursing home, the nurses noted on consecutive days that the resident had cloudy urine.  This is one of the signs of a urinary tract infection.  However, there was no notification of the doctor.  There were two additional days in which there was no note at all. However, aides told the state surveyor that in the interim, the urine had gained a foul odor and that there was

On the afternoon of the fourth day after the urine turned cloudy, the resident became lethargic.  It was recognized by the physical therapist, who reported it to the nurse on duty.  The nurse also noted that the resident was less talkative.  That evening, the nurse on duty also noted that the resident was lethargic, so she sent a fax to the resident’s doctor at 9:40 p.m.  Because the information was faxed to the doctor rather than the subject of a phone call, the doctor was not aware of the change in condition until the resident was already in the hospital the following afternoon.

Over the next day, the resident continued to decline until by early afternoon, the nurse on duty called 911 to have the resident transferred to the hospital.  The paramedics report stated that the resident had been sick since the day before and became unresponsive in the morning.  Upon arrival at the hospital, the resident was obviously ill – her appearance was described as “toxic”.  The collection bag for the catheter was described as being filled with dark brown urine with clumps of pus in it.  The urine was foul-smelling to the point that it made the nurse in the emergency room nauseous.  The catheter was changed out, but very little urine came out once the new catheter was placed.  This was an indication that the resident was in kidney failure due to sepsis.

The resident passed away approximately 12 hours after arriving in the emergency room.  Cause of death was multi-organ failure due to sepsis from the urinary tract infection.

There were multiple failures in the care of this resident that led to her death:

  • The nursing home allowed the resident to remain catheterized without a physician’s order for it use;
  • The nursing home allowed the resident to remain catheterized when there was no medical justification for the use of the catheter;
  • There was no assessment as to whether the resident’s condition actually required the use of a catheter;
  • The care plan for the use of the catheter included monitoring the resident for signs and symptoms of infection and notifying the physician of the onset of such.  This was not done;
  • Failed to notify the physician of the initial development of cloudy urine, which would have likely led to a urinalysis being done – and just as likely, an order for the removal of the catheter, since the doctor was familiar with the patient outside the nursing home and knew that she did not need a catheter;
  • Failed to recognize the development of a foul odor to the urine and the presence of pus in the urine – clear markers of infection;
  • Failed to report the onset of lethargy to the doctor to the doctor when it was reported by physical therapy;
  • When the staff finally notified the doctor of the onset of the change in condition, they did so by fax rather than calling the doctor, resulting in the doctor not receiving the communication from the nursing home;
  • Failed to notify the doctor the morning that the resident was transferred to the hospital of the declines that occurred overnight; and
  • The nursing home did not have policies and procedure in place regarding catheter use and care.

Ordinarily urinary tract infections are easily treated with antibiotics.  However, when there are substantial delays in the treatment of a urinary tract infection and can lead to sepsis, multi-organ failure, death – as happened here.  There were many opportunities for this tragic outcome to be avoided and to allows this resident to return home.  Sadly, they were all missed, over a period of several days and multiple shifts.

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

Other blog posts of interest:

Champaign-Urbana Rehab resident admitted to ICU due to untreated urinary tract infection

Rushville Nursing & Rehab resident suffers untreated surgical wound infection

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

 

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

Failure to activate chair alarm leads to fall and brain bleed at Pleasant Meadows Senior Living in Chrisman

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IDPH has cited and fined Pleasant Meadows Senior Living nursing home in Chrisman after a resident who was a known fall risk suffered a brain bleed due to a fall caused by the failure of the staff to activate his chair alarm.

Chair alarms and bed alarms are useful tools in preventing falls.  These alarms come in two basic forms – one is a pressure sensitive strip which is placed in the chair or bed.  When the pressure on the strip is lifted, this causes an alarm to sound.  The other kind of alarm is referred to as a mobility alarm.  It has a length of cord that is affixed to the resident’s clothing (usually between the should blades to make it difficult to remove) at one end.  On the other end of the cord is a alarm box.  When the cord is pulled away from the alarm box, the alarm sounds.  The sounding of the alarm serves two functions: (1) it alerts the staff that the resident is up unattended – and they should respond immediately and (2) reminds the resident that they should not be up on their own.

Of course for the alarm to have an use as a fall prevention tool, the alarm has to be activated.  This citation tells the story of what happens when the alarm is not activated.

The resident at issue was a recognized fall risk.  His Minimum Data Set (MDS) recorded that she suffered from severe cognitive impairments, required the assistance of two staff with transfers, was not steady and was only able to stabilize with the assistance of staff, and had a history of falls with injury.  His care plan called for the use of bed and chair alarms.  The staff reported to the state surveyor after the fall at issue that the alarms were an effective fall prevention tool for this resident and that they were frequently going off.

On the day of this nursing home fall, the resident was brought to physical therapy.  When the resident was taken from the room to go to physical therapy, the resident was in his recliner, but when he was assisted from the chair, the alarm did not go off.  Upon his return to the room from physical therapy, the alarm was not activated.

Shortly after this, the resident got up from his chair and began to make his way to the hallway.  As he reached his door he lost his balance, striking his head on the door frame on the way down. 911 was called and the paramedics reported in their notes that the staff reported physical therapy had not turned on the alarm.  The resident was brought to the hospital where he was diagnosed as suffering a brain bleed and a fractured hand.

Here there was a clear violation of the resident fall prevention care plan.  The care plan called for the use of a chair alarm.  This sort of fall prevention measure is only effective if it is carried out on a day-to-day, shift-to-shift basis.  The failure of the physical therapist to ensure that it was on was a violation of the care plan, likely sparked in part by the fact that it was apparently not on when the resident was taken from his room to therapy.

There were also shortcomings in the actual care planning itself.  The staff told the state surveyor that the alarm was going off “all the time,” indicating that the resident was frequently up.  While catastrophic falls had apparently been avoided, that was a matter of luck, not good care.  Additional interventions such as keeping the resident in common areas, frequent rounding, and having a room near the nurse’s station were additional steps which could and should have been taken.

From a legal perspective, the involvement of physical therapy is an important issue because physical therapists are often not direct employees of the nursing home but are employees of an outside company which bears responsibility for the poor care of its employees.  This adds an extra layer of complexity to any nursing home abuse and neglect case.

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:

Loft of Rock Spring resident suffers hip fracture in fall

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

Fatal brain bleed after fall at Pleasant Meadows Senior Living in Chrisman

 

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

 

Moweaqua Rehab resident fractures hip in fall

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IDPH has cited and fined Moweaqua Rehabilitation  & Health Care Center nursing home after a resident there suffered a fractured hip in his second fall in as many days.

Falls are a major issue in the long-term care industry.  Virtually all of the patient population in nursing are either elderly or medically frail (or both).  The statistics are that a significant portion of the senior citizens who suffer hip fractures die within 6 months of the injury due to either intra-operative or post-operative complications or due to complications brought on by debility from the injury.

Because falls represent such a risk to the health and well-being of nursing home residents, they are a major focus of the care planning process.  The care planning process is fundamental to the delivery of routine care in nursing homes.  In short, it is a process by which the risks to the health and well-being of the resident are identified and steps, or interventions, are put into place to prevent that harm from coming to fruition.

There are 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.

When a resident experiences a fall, even one with no injury, this is a major event which requires physician notification and evaluation of the care plan.  The reason the reevaluation of the care plan is required is because (a) it may not be effective, seeing as a fall just occurred and (b) it is well-recognized that falls tend to beget additional falls, so that after a fall has happened, the resident’s fall risk is actually higher than it was even the day before.

The resident at issue suffered from multiple conditions and had been assessed as a high fall risk.  The first fall occurred just after 2:00 p.m. when the resident was found on the floor of his bathroom with his pants around his ankles.  The cause of the fall was specified as resident actions with no further description or revision of the care plan.  The next fall occurred at 7 am the following morning where the resident was again found on the floor of his bathroom.  The investigation revealed that the resident was tryin to pull his pants up and lost his balance.  The Director of Nursing reported to the state inspector that the resident required assistance but would refuse to use the call light at times.

The citation revealed a couple of important points.  First, the staff knew that the resident had behavior of getting up without using his call light.  This kind of behavior is a powerful contributor to fall risk – and to the extent that it was a known behavior, it should have been accounted for in the care plan.  Second, there was apparently no consideration given to revising the care plan in light of the fall.

There were a number of steps which could have been taken to help prevent this fall.  Putting the resident on amore aggressive rounding schedule would likely have been of help.  The other measure would be to put the resident on a toileting schedule.  How this works is that the resident’s bathroom habits are observed over a period of days, and when this happens, certain patterns are likely to emerge.  Once the pattern is identified, the resident is assisted to the bathroom and through going to the bathroom.  The net result of this should be that the resident is not left unattended in the bathroom.

Of note, one of the fall prevention measures taken was that a sign was placed in the resident’s room reminding him to call, not fall.  Unfortunately, the resident was blind, leaving this of questionable value.

After this nursing home fall was discovered, the resident was brought to the hospital where he was diagnosed with a fractured hip and a collapsed lung.

The injuries to this resident could have been prevented with the application of critical thought about his care needs.  However, nurses in a nursing home setting are often given too little opportunity for this given the demands of the residents they care for.  Sadly, this is a direct result of the nursing home business model.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Loft of Rock Spring resident suffers hip fracture in fall

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

Fall with broken hip at Heritage Health in Mt. Zion

Failure to activate chair alarm leads to fall and brain bleed at Pleasant Meadows in Chrisman

 

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

 

 

Failure to follow feeding tube orders leads to hospice admission for Parker Nursing & Rehab resident

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IDPH has cited and fined Parker Nursing & Rehabilitation Center in Streator after a resident there developed sepsis from aspiration pneumonia due after vomiting because his orders for administering nutrition through his feeding tube were not followed, leading to him be admitted to hospice for end of life care.

One of the basic truisms in the nursing home industry is that a nursing home should not accept the admission of a resident when they are not able to meet the care needs of the resident.  This is what happens when that fundamental is not followed.

When a resident is admitted to a nursing home from a hospital, the discharge planner from the hospital forwards information to the nursing home regarding the medical history and care needs of the resident.  Those records are reviewed by a senior member of the nursing staff to determine whether or not the resident is suitable for admission to the nursing home.  If so (and the financial portion of the admission is worked out), then the resident can be admitted to the nursing home.

The resident at issue was admitted to the nursing home for rehabilitation after experiencing a stroke.  He had a tracheostomy and a feeding tube.  However, the admission screening information from the hospital stated that he was a “short stay” admission.  The discharge orders included continuous infusion of the solution for the feeding tube at 75 mg per hour.  Delivery of the solution would ordinarily require use of a pump to ensure that the resident received the solution at the desired rate.

The decision to accept a resident at this nursing home would ordinarily be made the quality assurance nurse, who at this facility was a LPN.  However, she was gone on vacation at the time that the admission was being considered and her role was being covered by another nurse, the MDS Coordinator.  This nurse okayed accepting the resident into the facility, apparently unaware that they did not have a pump for use for this resident.

There were other members of the staff who were aware that there was no pump available for this resident.  However, no one called the resident’s doctor to notify him that they could not carry out the doctors’ orders due to the lack of a feeding pump.  The resident’s doctor told the state surveyor that he should have been notified and that had the staff done so, he would have changed the orders.

Without a pump to regulate the flow of feeding tube solution to the resident, the rate of the feeding tube was left to gravity – in other words, the bag with solution was left to hang on an IV pole and simply empty out.  The problem with this is that the rate at which the solution was delivered to the resident was not controlled, which in this case meant that the solution was delivered to the resident far too quickly.  The net result of this is that the resident was badly overfed and began to vomit, with vomit coming from the resident’s mouth and out of the tracheostomy.

Vomiting from a resident represents a change in condition which requires physician notification.  However, the doctor was not notified.  Further, the nurse did not shut off the tube feeding, resulting in the resident continuing to be overfed.   As the resident continued to receive more and more solution, he continued to vomit.

The nurse reported to the state surveyor that she did not suction the resident initially, but did so later.  Even then, it was a superficial suctioning, not a deep suctioning which would have been necessary to clear the airway.  Suctioning was necessary to clear the airway because when a person inhales foreign substances into the lungs, this causes aspiration pneumonia.

Aides assigned to care for the resident reported to the state surveyor that throughout the night they advised the nurse on duty that the resident was continuing to vomit and that the resident did not look good.  Despite this, the nurse did not go to check on the resident and did not suction the resident’s airway.

Some 5 hours after the resident began to vomit, the nurse called for an ambulance to take the resident to the hospital.  There, the resident was diagnosed with severe sepsis due to aspiration pneumonia caused by overfeeding.  The resident was admitted to hospice to receive end-of-life care.

There were multiple failures in the care that this resident received:

  • The nursing home accepted the resident for admission when it did not have the equipment necessary to treat him consistent with physician orders;
  • They did not advise the doctor that they did not have the pump necessary to control the delivery of feeding tube solution to the resident, precluding the doctor from issuing other orders for the feeding of the resident;
  • They failed to advised the doctor that the resident was receiving far more feeding solution than was ordered;
  • They failed to advise the doctor of the onset of vomiting by the resident;
  • Once the resident began to vomit, they failed to stop the delivery of the feeding tube solution;
  • The nurse on duty failed to suction the resident’s airway once he began to vomit, setting the stage for him to develop aspiration pneumonia;
  • The nurse on duty failed to assess the condition of the resident despite being advised by aides that the resident was continuing to vomit and did not look good.

All of these failures set the stage for the resident to be admitted to hospice to receive end-of-life care.  This is a resident who despite his recent medical issues, was admitted to the nursing home as a rehabilitation patient – in other words, there was an expectation that he would eventually return home.  This was not be be due to the failures in the care that this resident received.

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:

Feeding tube error at Aperion of Westchester

Aperion Care of Wilmington resident suffers ruptured colon due to fecal impaction

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

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

 

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

 

Christian Nursing Home resident suffers severe leg injury in fall

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IDPH has cited and fined Christian Nursing Home in Lincoln after a resident there suffered a serious injury to her leg after a fall after experiencing two falls during the first three days she was in the nursing home.

The resident at issue was admitted to the nursing home for rehabilitation after having a stroke which left her with some left-sided residual weakness.  Before that, she was living in the community and had 24-hour care because she had some issues with dementia.

When a resident is admitted to a nursing home, a care plan must be developed.  There are six basic steps to  the care planning process.  First there is an assessment of the risks to the health and well-being of the resident.  Second, a care plan outlining the various steps, or interventions, which must be taken by the staff on a day-to-day, shift-to-shift basis to address the risks identified during the assessment.  These must be tailored to the specific needs of the resident.  Third, the care plan must be communicated to the staff.  Fourth, the care plan must in fact be implemented on a day-to-day, shift-to-shift basis.  Fifth, the effectiveness of the care plan must be evaluated on an ongoing basis.  Sixth, it must be revised when it proves to be inadequate in practice of due to changes in the condition of the resident.

One area that is always assessed in the care planning process is the resident’s fall risk.  This is because falls are a well-recognized threat the life and well-being of nursing home residents and because there are federal regulations on falls.  There are no gold standard tools for assessing fall risk in nursing homes like how the Braden scale is used for the risk of developing bed sores, but almost all of the assessment tools have some features in common.

Two of the commonly recognized risk factors includes (1) some degree of musculoskeletal, gait, or balance dysfunction and (2) dementia, intermittent of constant confusion, and/or poor safety awareness or judgment.  The physical aspect relates to the resident’s ability to safely walk, stand, transfer, or even maintain a seated position.  The cognitive aspects come into play because where a resident has cognitive deficits or poor safety awareness or judgment, they cannot be counted upon to make good decisions for their own safety or follow safety instructions.  These are factors which must be taken into account in developing the resident’s care plan.

On admission, the resident was assessed as being at high risk for falls.  Findings in the assessment included: unsteadiness while walking, use of a wheelchair, rushing to use the bathroom due to incontinence of bladder, significant cognitive impairments, and impaired functional problem solving and safety awareness.  The care plan included frequent checks and assistance with transfers.

The first nursing home fall occurred during the evening of the second day of her admission.  The resident had been changed into clothes for bed, but within an hour was found on the floor dressed in her normal clothes.  She told the staff that she wanted to get changed before her husband came home, obviously showing a significant degree of disorientation and cognitive impairment.

The occurrence of this fall was a significant event.  First, it showed that the resident had more significant cognitive impairments than was perhaps initially recognized.  Second, it is well-recognized in the long-term care industry that falls tend to beget more falls.  For this reason, revision of the care plan was required.  And it was – to add in a sign to remind the resident to call, not fall.

The second fall occurred the following day.  An aide was going down the hall, shutting off lights at bed time and checking on residents.  When she got to this resident’s room, she saw that the resident was not in bed.  She went into the bathroom and found the resident on the floor, not wearing shoes, just socks.  There were obvious signs of injury to her left leg, so she was sent immediately to the hospital.  There she was diagnosed with dislocation of the hip and a fractured femur.   She was then transferred to another hospital for surgery.

The investigation into this revealed a number of shortcomings in the care that this resident received.  As a starting point, they failed to take into consideration the fact that the resident had 24-hour care at home and had significant cognitive deficits even though those items of information were a part of the information that the nursing home received from the hospital at the time of transfer.  Had they been taken into account, the Director of Nursing admitted to the state surveyor that the resident would have been admitted to the dementia unit where the staffing patterns would have allowed for increased supervision which may have prevented the fall.

Past that there were a number of shortcomings in the care that this resident received.  First there was no effort at implementing a toileting schedule for an incontinent resident who suffered from significant dementia and was a high fall risk.  Second, the care plan did not include use of proper footwear – a key point since the resident was found on the floor at the time of her second fall wearing only socks.  Finally, the revision to the care plan after the first fall was wholly inadequate.  That first fall was her dementia and poor safety awareness/judgment in action and relying on her to read and heed a sign was foolish.

The net effect of all these is that this resident suffered a serious and unnecessary injury.  One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  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 left unsupervised on smoking patio at Sharon Health Care Elms falls and suffers brain bleed

Resident breaks hip in fall at McLean County Nursing Home

Piatt County Nursing Home breaks neck in fall from power recliner

University Rehab Northmoor resident suffers fractured hip in fall from bed

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

Grove of Elmhurst resident dies due to delay in physician notification

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IDPH has cited and fined the Grove of Elmhurst nursing home after a resident there died due to a 30-hours delay in notifying the resident’s physician about a fever exceeding 104 degrees.

One of the basic truisms of care in a nursing home setting is that doctors are not there on a 24/7 basis.  Because of this, nurses must be the “eyes and ears” of the doctors and let them know when there has been a change in the condition of a resident.  The nurse does not need to know what the change represents (though they often have a good idea) or how to treat it.  Those things are the role of the doctor.  The nurse simply needs to be able to identify the change in condition, notify the resident’s physician, and give the doctor enough good information about what is happening to allow good decision-making.  Once the doctor is informed of the problem, then the doctor must decide to come to the nursing home, issue orders over the phone, or order the resident transferred to the hospital.

The resident at issue had been admitted to the nursing home with a number of medical problem, including: multiple rib fractures, chronic respiratory failure, encephalopathy, a tracheostomy, and anoxic brain damage.  He was in a comatose state and dependent on staff for care.  At the time of admission, he had been running low-grade fevers (98-101), so the attending doctor requested consultations with an infectious disease physician who assigned a nurse practitioner to the patient.

On the morning of the fourth day after admission, the resident’s temperature rose to 104.5 degree.  This represented a change in condition for the resident, and should have triggered notification of the resident’s physician or the infectious disease nurse practitioner.  The resident’s temperature was taken 7 times during the course of that day, yielding temperatures of 102 degree or higher 5 times.   Neither the resident’s physician or the infectious disease nurse practitioner were notified of the rising temperatures.

The following day, the resident’s temperature was taken at 6:30 a.m. and was 102 degrees, but dropped down to 99.9 at 8:53 a.m. However, it climbed back to 104.5 degree by 10:57.  After the temperature climbed back up over 104 degrees, the staff called the doctor but he was not available so they had him paged.  No effort was made to reach the infectious disease nurse practitioner.

At 12:55 p.m., the respiratory therapist was treating the resident and noted a heart rate of 120-130 after suctioning.  The nurse assessed the resident and found that the resident had a temperature of 101.4 and a heart rate of 118.  Fevers and an elevated heart rate are signs of sepsis.  The primary care physician was paged again, although no effort was made to reach the infectious disease nurse practitioner.

The attending physician was paged again at 3 pm and this time the doctor was reached.  He was informed of the resident’s condition and ordered the resident be sent to the emergency room.  The staff first called a private ambulance service and was told that it would be 90 minutes for an ambulance to arrive.  The nurse went to assess the resident again and noted shallow breathing.  The nurse and the respiratory therapist began to do CPR using an ambu-bag.  911 was called, and the paramedics arrived 8 minutes later.  On arrival the resident had no pulse and was in respiratory arrest.  They were able to regain a pulse twice  in their resuscitative efforts, but the resident died less than an hour after the paramedics arrived.  The apparent cause of death was pneumonia – a condition which could have been better addressed in a hospital setting.

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

  • When the resident initially developed temperatures in excess of 104 degrees, no one was notified of the development of that high a fever.  It represented a change in condition and a real threat to the health and well-being of the resident.
  • There was no effort to notify the infectious disease nurse practitioner.  The fever and rapid heart rate were signs of sepsis and seeing as this specialist was brought in to help manage this aspect of the resident’s care, notifying the nurse practitioner was a reasonable option when the 104 degree fever developed and/or the attending could not be reached.
  • There was inadequate follow up when the attending physician could not be reached.  Once a doctor is paged and is not responding, additional follow-up efforts are required to actually reach the doctor to get his guidance.
  • Finally, when a doctor cannot be reached, the facility medical director should be contacted to obtain orders if necessary.  It is simply not acceptable to not get some medical direction when the resident’s situation calls for it.

The net result of all of this is that there was a 30 hour delay in getting the instructions that were required when the resident first developed the 104 degree fever.  This was a medically complex, medically fragile individual for whom timely care was required.  When a resident suffers from an infection like pneumonia, delays in receiving care can contribute to the development of complications like sepsis which can in turn feed other complications.

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

Other blog posts of interest:

Feeding tube error at Aperion of Westchester

Lack of wound monitoring leads to infection at Regency Care of Morris

Fall leads to brain bleed and death at Regency Care of Sterling

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

 

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

 

Marshall Rehab resident fractures back in van accident

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IDPH has cited and fined Marshall Rehabilitation after a resident there suffered a fracture to her lumbar spine in an accident while a passenger on board a van from the nursing home.

Many nursing homes operate passenger vans which are used to transport residents to and from doctor appointments or community events.  When the nursing home uses a van that way, it is responsible for three things: (1) that the van is operated in a safe manner, (2) that the residents who are passengers in the van are handled and secured properly within the van, and (3) that the staff is properly trained on both of the other points.  This citation was about what happens when neither is true.

The resident was in a wheelchair in the facility van returning from a doctor appointment in Champaign.  There was road construction on the way back.  While passing through the road construction zone, the driver hit a large bump in the road.  The impact with the bump caused the resident to be jolted up and down in her wheelchair.  When she came down, she felt a pop in her lower back and began to have significant ongoing pain in the low back which persisted even with the use of strong pain killers.  Her doctor eventually ordered an MRI which showed an acute compression fracture in the lumbar spine.  the doctor ordered that she be placed in a LSO brace (turtle shell brace) for six weeks.

The investigation into this incident showed that even though the van was equipped with a restraint system, it was not in use because the aide who was driving the can had not been trained in how to use it.

This was a highly preventable injury has the nursing home and its staff adhered to the three basic principles outlined above.  First, safer driving in the form of reduced speed and keeping a safer lookout in a construction zone would have likely reduced the violence of the impact with the bump.  Second, the resident was not in the restraint system which would have kept her from being thrown up out of her seat.  Finally, the aide admitted that she had not been trained in the use of the restraint system.

Of the three failures, the last is the one which is most predictable given the basic nursing home business model, which includes failing to invest in the training of 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:

Transportation van accident at Generations of Rock Island

Resident falls from van at Casey Healthcare

Hilltop Skilled resident breaks leg in fall from bed

 

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

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