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

2 Residents At Carriage Rehab Suffer Untreated Bedsores; Doctor’s Orders Ignored

May 3, 2021 By Barry G. Doyle

IDPH has cited the nursing home Carriage Rehab & Healthcare in Rockford, IL after they failed to follow doctor’s orders for the bedsores of not one but two residents.

Bedsore care and treatment are supposed to be a top priority at long-term care facilities. Also known as pressure sores, these lesions or wounds are anticipated among residents who have reduced mobility, as they tend to stay in one position for long periods of time. We have federal regulations that entitle nursing home residents to proper care that promotes the healing of existing bed sores, prevents their infection, and prevents the development of new ones.

When a resident develops a bedsore, the nursing home staff is required to notify the doctor, and the doctor then enters orders for treatment. These treatment instructions typically have to be carried out by the staff on a daily basis. Haphazard treatment for bed sores could lead to worsening wounds and serious infection of surrounding tissues.

In this case at Carriage Rehab, one resident had a bedsore on her heel, and another resident on the side of her foot. The wound care doctor ordered daily dressing changes for each of them. It is standard procedure to write the date of the dressing so that people know when it was last changed.

As the doctor was making his weekly rounds, he discovered that the dressing on one resident had been left unchanged for an entire week, as indicated by the date on it. The next week, he found that the same had happened to the other resident.

The doctor went to the nursing home administrator to explain that this was unacceptable and needed to be reported to the State of Illinois.

The two residents had to undergo debridements or the removal of dead tissue from their wounds. This process would likely have been unnecessary if their bedsores were encouraged to heal with daily dressing changes. Likewise, the prolonged pain of these residents might have been mitigated had the nursing staff followed the doctor’s instructions.

It speaks volumes that the doctor’s orders were skipped not just for a couple of days but for a whole week, and in two separate cases within the same facility. Citations like this are strong indicators of the quality of care that each individual resident receives in a nursing home.

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

Other blog posts of interest:

Lexington of Orland Park resident suffers Stage 4 bed sore

Sharon Health Care Willows resident undergoes surgery for bed sore

Integrity of Smithon resident develops infected pressure ulcer

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

Thank you for reading.

Lack Of Wound Monitoring Leads To Resident’s Infection At Regency Care of Morris

April 14, 2021 By Barry G. Doyle

IDPH has cited the nursing home Regency Care of Morris after a resident there developed a wound infection that required surgical removal.

Wounds and wound infections are major concerns at long-term care facilities. One of the basic responsibilities of nursing home staff is to monitor any of the residents’ wounds and look out for signs of infection. When a symptom of infection is present, the staff must then bring it to the attention of the doctor. The physician then decides whether to instruct the nursing staff on appropriate treatment, to come to the facility and administer the treatment himself/herself, or to have the resident brought to a hospital.

It is crucial to have wound infection treated early. Allowing it to fester could lead to more serious conditions involving various body tissues.

The resident in this case had a wound from a hip replacement surgery. Upon her admittance to the nursing home, it would have been part of the staff’s job to monitor this wound. The resident had staples on the wound when she was admitted to the nursing home, but these staples were subsequently removed during her initial postoperative visit at the hospital. Unfortunately, there was no documentation that the wound was assessed after that postoperative appointment.

Eight days after that visit, the resident asked a nurse at the Regency facility for shower assistance. It was only then that the nurse saw bloody drainage coming from the resident’s surgical wound, and called the doctor.

The resident was brought to the hospital, where wound infection was recognized. She told the doctor and the Department of Public Health surveyor that she had reported the drainage to the nursing home staff a few days earlier, yet nothing was done about it.

By the time the resident was sent to the hospital, she had to undergo surgical debridement of the wound. Doctors had to cut away portions of her gluteus muscle and trochanter, a part of the femur or hip bone. This indicated some level of osteomyelitis, a type of bone infection.

Deep-tissue infections like this happen when a wound infection is left untreated for a time. This resident’s wound was left unchecked and untreated for at least several days. Had the nursing home staff been more diligent in carrying out their wound monitoring duty, and had they called for treatment sooner, the resident’s infection would not have reached a costly and dangerous extent. In short, this resident’s horrible experience could have been avoided.

Other blog posts of interest:

Lexington of Orland Park resident suffers Stage 4 bed sore

Sharon Health Care Willows resident undergoes surgery for bed sore

Flora Gardens staff fails to give antibiotic, leading to death of resident

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

Thank you for reading.

Resident Left Without Gait Belt Fractures Arm at Clayberg Nursing Center

March 30, 2021 By Barry G. Doyle

The Illinois Department of Public Health cited the Clayberg Nursing and Rehabilitation Center in Cuba, Illinois due to an injurious fall that ended up in a broken arm.

Patient Had a Recognized Fall Risk

The injured resident had a recognized fall risk marked by her history of falling alongside unsteadiness and some weakness in her legs. Specifically, she had been designated to require extensive assistance when doing transfers and using the toilet.

When a nursing home resident has this requirement, a staff member has to physically ‘lay a hand’ on them to assist them with their movements, as opposed to just watching them and letting them move on their own.

In this particular case, the Clayberg resident had an aide that assisted her in showering, bathing, and getting dressed. However, as the aide was picking up towels, the resident was left in a standing position without a gait belt on and without someone physically assisting her as she stood. The resident lost her balance and suffered a fall that resulted in her arm fracture.

Most Nursing Home Falls can Be Prevented

In many cases, nursing home residents require the use of a gait belt, a wide canvas strap that wraps around the midsection of their body and is held by the nursing home aide. This allows the aide to keep the residents upright and help them control their movements. Additionally, if the resident loses their balance, the aide can maneuver the fall to minimize the chances of injury on the resident.

This incident highlights the responsibility of nursing homes and their staff to follow care protocols to the letter. Even just a momentary deviation from gait belt use can lead to painful injuries, especially for older or impaired residents. An incident like this could just as easily result in life-threatening conditions like head trauma or spine injuries.

It also illustrates that many nursing home injuries could be prevented, if only the facility upholds its obligations towards residents. Often, injuries on residents are chalked up as accidents when they are a direct result of the facility’s or their staff member’s failure to do their duty.

Call an Illinois Nursing Home Abuse Lawyer

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.

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

Thank you for reading.

Other blog posts that might be of interest:

River Bluff resident fractures elbow in fall from a wheelchair

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

Southpoint Nursing & Rehab resident breaks leg in an improper transfer

Resident Breaks Hip After Fall in McLean County Nursing Home

March 2, 2021 By Barry G. Doyle

IDPH has cited the McLean County Nursing Home in Normal, Illinois after one of its residents with a high “fall risk” suffered a hip fracture from falling in the home.

Staff Was Aware of High Fall Risk

On the evening of the fall, a nursing home aide had brought the resident to her bathroom at 5 p.m. The resident was then seen at 6:45 p.m., seated on her wheelchair by the foot of her bed. Then about an hour later, staff heard her calling for help. They found her on the floor with obvious signs of injury. They brought her to the hospital, where she had to undergo surgery for her broken hip.

Prior to this incident, there were obvious signs that the resident needed protection from falls.

Her quarterly assessments showed that her risk of falling went from “moderate” to “high.” She was also specifically assessed to be unsteady when standing from a seated position. These should have prompted revisions to her care plan, with proactive steps for the staff to reduce her fall risk. For instance, her unsteady motion when trying to stand up meant that she needed extensive assistance when using the toilet.

This is especially important because the resident had a known behavior of frequently getting up to go to the bathroom on her own. Staff members themselves were well aware of this. They described to the state surveyor that she would get up from her wheelchair and try to go to the bathroom unassisted.

Worse, they would find her walking down the hallway with her Depends around her ankles after she had used the bathroom on her own, unable to lift the sanitary garments back into place. An impediment around the ankles is dangerous for someone who has a high fall risk.

On top of all these, the resident was known to have dementia.

Nursing homes must take into account that residents with dementia might not be able to follow instructions well, recognize their physical limitations, or make good decisions for their safety. This should be factored into a resident’s care plan.

However, for this particular resident, the main intervention that was planned was to have the resident use the call light. This is an instruction that a person with dementia might not be able to follow. It was not likely to be an effective intervention for this resident who had dementia and a high fall risk.

Proactive Care Was Required but Not Undertaken

Considering her profile, the resident needed more proactive care around her. This could have included a toileting schedule that is developed from her observed bowel and bladder patterns.

This nursing home could have noted the usual times when she needed to use the toilet, then provided her with an aide to assist her during those times. Other measures could have included regular rounding and placing the resident in common areas instead of by herself.

Her painful fracture might not have occurred if she was given more appropriate attention and care at the nursing home.

Call an Illinois Nursing Home Abuse Lawyer

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.

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

Thank you for reading.

Other blog posts of interest:

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

Heritage Health Pana staff violates care plan, resident falls and breaks hip

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

After a Series of Falls, Resident Suffers Broken Hip at Tower Hill Nursing Home

February 16, 2021 By Barry G. Doyle

The IDPH has issued a citation to Tower Hill Nursing Home in Elgin, following a broken hip injury sustained by one resident. The injurious fall is the most recent in a series of falls that the resident had suffered, which could have been prevented had the care plan been updated and adhered to.

Nursing Home Care Planning and Fall Risk

It is standard procedure at nursing homes to revisit a resident’s care plan once the resident suffers a falling incident. This is because “a fall begets more falls,” meaning that if a resident falls once, it is a sign that they are at higher risk of falling again. One fall should trigger a revision of their care plan to determine what measures should be implemented to reduce the risk of subsequent falls.

However, this particular resident at Tower Hill was not protected by appropriate preventive measures, even after she experienced three falling incidents leading up to her injury.

Patient Suffered Several Falls

The first fall was an unwitnessed incident in her room. Her care plan was actually updated after this, referring her to physical therapy. However, for some reason, this was not carried out.

She fell again five weeks later, also unwitnessed in her room. This time, she was referred to physical therapy, but was discharged quickly because her dementia prevented her from participating in a meaningful way.

The physical therapy clinic instead recommended that she be supervised. She was found to require contact guard assist, which meant that an aide should physically put hands on her to help steady her movements. The clinic also recommended restorative care for her ambulation or walking about.

These recommendations were not incorporated into her care plan.

Two months later, the resident fell again in an unwitnessed incident, and this time, she broke her hip. She had to be sent to the hospital to undergo surgery.

Care Plan Diligence is Crucial for Injury Prevention

This injury might have been avoided if significant updates to the patient’s care plan were implemented and followed through.

Any long-term care facility should have recognized that a resident with her profile needed aggressive fall preventive measures. She had balance issues, mobility issues, dementia, and a previous diagnosis of traumatic brain injury. She also now had a history of falls that the nursing home was well aware of.

The contact guard assist that was recommended after her second fall would have helped to keep her steady and might have prevented her third and injurious fall. There are also other strategies to prevent such incidents. One is to place the resident in common areas where the staff can supervise her. The nursing home could also implement frequent rounding, or having somebody check on the resident at regular intervals, perhaps every 15 minutes.

The fact that she was not protected by relevant anti-fall measures points to substandard care.

Contact an Illinois Nursing Home Lawyer for Legal Support

Falls are a major consideration in the long-term care industry. At the very minimum, nursing homes are supposed to have explicit care plans for this particular issue, plus vigilant reassessments and meticulous implementation of these plans.

Without these, it’s a matter of good luck rather than good care that a resident doesn’t suffer serious injuries. And residents’ safety should not be left to luck.

We believe that most 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 results. 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.

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

Thank you for reading.

Other blog posts that might be of interest:

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

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

Heritage Health Pana staff violates care plan, resident falls and breaks hip

Center Home Resident Suffers Broken Arm, Requires Surgery After Fall

January 22, 2021 By Barry G. Doyle

IDPH has cited the Center Home for Hispanic Elderly in Chicago after one of its residents broke her arm in a fall, requiring surgery.

Nursing homes must have measures to avoid injurious falls among their residents. One of these measures is the fall risk assessment, which is the first step in every resident’s care planning process. Upon admittance to a nursing home, the resident goes through this evaluation to see whether they should be tagged as someone with a “fall risk” and should have a fall prevention care plan. The whole process is then redone every 90 days to ensure that the resident’s care plan is up-to-date.

Several factors are examined to determine a person’s risk for suffering falls. Two major factors are gait or balance dysfunction and intermittent or constant confusion.

In this particular case at Center Home, the resident underwent an incomplete fall risk assessment. Specifically, her gait assessment was never completed by the restorative nurse assigned to the task. Thus, the resident was not flagged for fall risk, and she did not have a fall prevention care plan.

Had the gait analysis been completed, the resident would likely have shown a risk of falling due to her polyneuropathy, a nervous condition that affects one’s gait and balance. In fact, she was already largely dependent on a wheelchair due to her physical weakness. Though her balance and gait were clearly compromised, the lack of a complete fall risk assessment meant that there was no fall prevention plan for her at the nursing home.

Five months after she was admitted, the resident suffered a fall that broke her arm. She was initially hospitalized for immediate treatment, and then a second time for surgical repair of the fracture.

It’s additionally notable that she had been in the home for five months and within that time, her care plan had not been revised to include fall prevention. Each resident’s care planning is supposed to be reviewed every 90 days, which means that this particular resident should have had at least one review during her stay. A proper review of her care plan would have shown her fall risk and hence put in place a fall prevention plan that might have prevented her injurious accident.

In short, this injury was avoidable at two different points: first, during the resident’s admittance and initial care planning, and second, during the quarterly review of the care plan. Yet in both instances, the nursing home failed to provide the fall prevention plan she needed.

Other blog posts of interest:

River Bluff resident fractures elbow in fall from wheelchair

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

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

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

Thank you for reading.

Lexington of Orland Park resident suffers Stage 4 bed sore

December 17, 2020 By Barry G. Doyle

IDPH has cited and fined Lexington of Orland Park nursing home after a resident there was found with a Stage 4 bed sore on her sacrum.

Bed sores are an area of intense focus in the long-term care industry for a number of reasons, not the least of which is that the development of bed sores has serious adverse consequences for the quality of life of a resident who suffers one. Federal regulations provide that a resident who enters a nursing home without a bed sore (or pressure ulcer) should receive care, treatment, and services necessary to prevent one from occurring unless the resident’s condition shows that they are unavoidable. The regulations also provide that after a resident develops a bed sore, they are entitled to care, treatment, and services which are necessary to promote healing, prevent infection, and prevent the development of new pressure ulcers.

It is an area which is specifically addressed during the care planning process. It begins with an assessment of the resident, usually using the Braden scale to determine the resident’s risk level of developing pressure ulcers. There are a number of risk factors, but they key risk factors are immobility, incontinence of bowel or bladder, and poor nutritional status. If a resident is at risk for developing bed sores, this must be addressed in the resident care plan with steps that should be taken on a day-to-day, shift-to-shift basis. If a resident does develop a bed sore or has a decline in an existing one, this is something that requires physician notification and revision of the care plan.

The resident at issue was admitted for short terms rehab after a fall in which she suffered a broken back with no bed sores present. However, she was at risk for developing bed sores due to immobility associated with the fractures and incontinence of bowel and bladder. The care plan which was put into place including daily monitoring of the skin. Usually this is a task which is done by the aides which assisting a resident with getting dressed, bathing, or providing incontinence care. If an aide sees an area of concern, it is the aide’s responsibility to notify the nurse who can then make a determination what it is and notify the doctor if need be.

Bed sores or pressure ulcers are rated as Stage 1 through Stage 4. A Stage 4 is the most severe, involving exposed muscle and bone. However, advancing from a Stage 1 to a Stage 4 takes time, and treatment can and should slow the progression, if not actually heal the wound once it is discovered. This is why physician notification is required after a resident is discovered to have a bed sore. Without treatment, further decline is almost a certainty.

When the staff first reported that this resident had a bed sore, it was a Stage 4 bed sore on her sacrum with sloughing and exposed bone. In other words, this was an advanced wound, and the presence of sloughing is often associated with dead, bacteria-laden tissues which can set the resident up for complications such as cellulitis or osteomyelitis infections. The resident was referred to a wound care doctor for treatment.

The fact that this wound was so advanced when it was first documented says that one of a number of things, but either the aides did not realize that this was a resident for whom daily skin inspections was required; they did not realize what they were looking at when they were dressing, showering, or providing incontinence care to the resident; or they did not know that skin defects needed to be reported to the nursing staff. None of these reflect well on the quality of care that was being provided at this nursing home.

Other blog posts of interest:

Grove of Berwyn fails to treat bed sore

Failure to treat pressure ulcer at Franciscan Village in Lemont

Untreated pressure ulcer at Aperion Care of Bradley

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

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

December 15, 2020 By Barry G. Doyle

IDPH has cited and fined Warren Barr North Shore nursing home in Highland Park after a resident there was rolled out of bed while receiving incontinence care, suffering multiple fractures of the tibia and fibula.

Bed mobility is a term that generally refers to a resident’s ability to move and change position in bed. Some residents, due to musculoskeletal issues, need the assistance of one or more staff members with bed mobility. This is important for changing positions to prevent bed sores, for example. It also is important when a resident needs incontinence care so that they can get into a side-lying position to allow staff members to clean them and apply barrier cream.

When a resident requires assistance with bed mobility, this is something that should be addressed in the care plan and recorded in the Minimum Data Set. Depending on the degree to which assistance is needed in safely positioning the resident, this may require the help of two staff members.

Having two staff members on hand for assistance with bed mobility is critical for the safety of the resident in order to prevent injuries from rough handling, or as here, being rolled out of bed.

The resident at issue had significant musculoskeletal deficits and had been care planned as requiring the extensive assistance of two staff members with bed mobility. On the day of this nursing home fall, there was a single aide providing incontinence care to the resident. While this was happening the resident rollled over the edge of the bed. The aide attempted to slow the descent of the resident, but she still landed on her ankle. She was brought to the hospital where a CT scan showed that there were four separate fractures of the tibia and fibula (bones of the lower leg).

For regular readers of this blog, it is part of the familiar story of what happens when you have one person doing a two-person job (see here, here, here, and here for examples) with predictably disastrous results.

One person doing a two-person job is also consistent with a understaffed nursing home, something that was a specific issue raised in a citation involving a fall at this nursing home last year. Sadly, understaffing is a part of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

Improper use of sit-to-stand lift results in fractures at Radford Green

Resident rolled out of bed at Warren Barr – Lincolnshire

Short-staffing leads to fall at Manorcare – Libertyville

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

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

December 12, 2020 By Barry G. Doyle

IDPH has cited and fined Palm Terrace nursing home in Mattoon after staff there failed to give a prescribed antipsychotic medication to one of the residents, leading to a breakdown of the resident which required the resident to be hospitalized and undergo electroconvulsive therapy.

The resident at issue had a history of mental illness and was discharged from the hospital to the nursing with an order to receive an injection of an antipsychotic medication called Invega approximately two weeks after admission to the nursing home. The nursing home apparently failed to order the medication, and by the time that the due date for giving the medication came, the pharmacy which supplied the medication informed the nursing home that the medication was not covered by the resident’s insurance. As a result, the resident did not receive the medication.

About two weeks after the missed dose of the medication, the resident experienced a psychiatric breakdown which involved him being threatening to the staff and refusing to keep his clothes on. The resident was brought to the hospital and admitted to the psychiatric unit where he underwent three rounds of electroconvulsive therapy in an effort to resolve the breakdown.

There were at least two major breakdowns in the care that this resident received.

First was the medication error which resulted in the resident not receiving the Invega which was prescribed for him. When a resident is going to be admitted to a nursing home, the admissions staff receives and reviews information about the resident to ensure that they can meet the care needs of the resident. If they can’t, the proper course is to deny the admission. One of the pieces of information that they receive is a list of the medications which have been prescribed so that they can order the medications to have them ready or on order when the resident is admitted. There was clearly a breakdown in this process – otherwise, the medication that the resident needed would have been on order when the resident arrived. If it could not be obtained, then other measures had to be taken.

Second was the failure of the nursing staff to notify the doctor that the medication which he prescribed was not being given to the resident. Doctors generally work on the assumption that their orders will be followed and that prescribed medications will be given. If this medication could not be obtained and was not given to the resident as ordered, the doctor was required to be notified so that he could determine what other course of action to take. Simply not giving the resident critical medications and hoping for the best was never an acceptable course of action.

Other blog posts of interest:

Taylorville Skilled fails to obtain anticonvulsant medication for resident

Flora Gardens staff fails to give antibiotic, leading to death of resident

Medication error at Palm Terrace leads to hospitalization

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

River Bluff resident fractures elbow in fall from wheelchair

December 10, 2020 By Barry G. Doyle

IDPH has cited and fined River Bluff Nursing Home in Rockford after a resident there suffered a fractured elbow in a fall from her wheelchair.

For residents who are a fall risk, staying in a seated position is often the safest place to be. However, when a resident has poor trunk control as a result of weak core muscles, that is not always true. When a resident has poor trunk control, their torso can move well outside the center of the body, bringing their center of gravity forward or over to the side, resulting in them falling forward out of the chair or over the sides of the chair. To address this, a resident with poor trunk control may be seated in a chair or wheelchair that tilts backwards or with high arms to prevent falls.

This resident apparently had poor trunk control which was combined with a behavior of frequently bending forward to adjust the footrests on her wheelchair. Because of this behavior, part of her fall prevention care plan called for her to be seated in a tilted position in her wheelchair. However, due to poor maintenance of the wheelchair, she was not tilted back on the day of her fall. Further, the nurse on duty believed that since she was not demonstrating the behavior of bending forward to adjust the footrests it was not necessary to place her in a tilted position.

The net result? The nurse on duty left her in a regular seated position and then went to attend to other residents. After she did so, the resident leaned forward and fell out of her wheelchair. As a result of this nursing home fall, the resident suffered a broken elbow and a significant laceration to the head.

There are at least two issues with the care that this resident received. First, federal regulations provide that a resident receive care, treatment, and services necessary to prevent accidents, which includes falls. This includes making sure that the equipment that they use is well maintained and in good working order. Second, care plans are intended to be carried out on a day-to-day, shift-to-shift basis, and leaving the resident in a regular seated position when the care plan called for the resident to be tilted backwards was a violation of the care plan.

Other blog posts of interest:

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

PA Peterson resident breaks both legs in fall

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

Flora Gardens staff fails to give antibiotic, leading to death of resident

December 9, 2020 By Barry G. Doyle

IDPH has cited and fined Flora Gardens Care Center nursing home in Flora after a resident there died after the staff failed to give her the antibiotics which had been prescribed for a urinary tract infection.

One of the places where failures in the delivery of care can occur in nursing homes is in transitions in care – generally from the hospital to the nursing home. This is because residents are often re-admitted to the nursing home after a hospital visit with new prescriptions for medications and new orders for treatment. When the nursing home fails to give the new prescriptions or follow the new orders, disaster is the likely result.

This resident was brought to the emergency room with a urinary tract infection. Urinary tract infections are unpleasant for anyone, but for nursing home residents they can prove fatal if they go unchecked. Fortunately, they are often treated successfully with front-line antibiotics.

And that was the plan for this resident. She was brought to the emergency room and returned later that day with a prescription for the antibiotic levaquin which was to be given once a day for 7 days. The hospital faxed the order for the antibiotic over to the nursing home and returned the resident back to the facility the same day. However, the resident did not receive the antibiotic as ordered and the medication error went undiscovered for three days until a family member called the nursing home to get an update as to how the resident was doing. At that point the medication error was discovered. The medication was then ordered from the pharmacy and the resident’s doctor was notified.

Five days after the medication started to be given the resident was returned to the hospital. There she was diagnosed as suffering from severe sepsis and was discharged back to the nursing home to receive end of life care. The resident’s physician told the state surveyor that he believed that the delay in starting the antibiotic contributed to cause the death of the resident in that it permitted the infection to enter the bloodstream and become systemic whereas it had been a localized infection at the time the resident left the hospital.

A nursing home is a business and a well-run business has systems in place to ensure that the routine operations of the business get done without fail. Making sure that orders for treatment and medication get carried out when a resident is admitted or re-admitted to a nursing home or after a doctor or hospital visit. Obviously, the systems that were supposed to ensure that this resident received the medication she was prescribed broke down – ultimately with fatal consequences.

Topping all this off was what happened after she was returned to the nursing home to receive end-of-life care. She was prescribed a scolpamine patch to help her stay comfortable up through the time that she passed, but this medication was not given either. She died about 6 hours after returning to the nursing home. Her family placed multiple calls to find out what her condition was like but no one took or returned their calls until after she had died, denying them a chance to see her in her last moments even through the nursing home window.

Other blog posts of interest:

Taylorville Skilled fails to obtain anticonvulsant medication for resident

Failure to give HIV medications at Bria of Belleville

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

Medication error at Palm Terrace leads to hospitalization

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

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

December 6, 2020 By Barry G. Doyle

IDPH has cited and fined Generations at Rock Island nursing home after a resident there sustained a fractured hip caused in part by the understaffing of the nursing home.

In this blog, we often discuss the importance of the care planning process in delivering the routine care that is absolutely necessary to assure the health, safety, and well-being of residents (see here, here, here, and here for recent examples). However, even the best care plan is of no use if there is not enough staff around to actually carry it out.

There are two basic regulatory standards that have to be met in terms of staffing levels at nursing homes. One is the state standard which uses a mathematical formula to determine appropriate staffing levels. The second standard is the federal regulation which is more flexible, yet more demanding. It provides that the nursing home must have enough appropriately trained staff on hand to meet the care needs of the residents on a 24/7 basis.

Understaffing has always been a part of the nursing home business model. It is part of why we believe that nursing homes are inherently built to fail and why we wrote a free report with the same name. In essence, nursing homes are one of the few explicitly for-profit sectors in the health care industry. They generate revenue per resident, per day and maximize revenue by filling as many beds as possible with as many ill people as they can. On the expense side, staff is the biggest expense item and to maximize profits, you need to keep staffing expense to a minimum.

The net result of this is that resident suffer poor care because there is not enough staff on hand to meet the care needs of the resident. Residents are not turned and repositioned and do not receive prompt incontinence care, leading to bed sores. Residents don’t get help and/or supervision while eating, leading to malnutrition and dehydration as well as nursing home choking accidents. Nurses get distracted while doing medication pass, leading to medication errors. And finally as here, staff is unable to answer call lights, leading to nursing home falls.

The citation that IDPH issued to this nursing home is long (130 pages) and covered a multitude of issues involving several different residents, but we are focusing here on the staffing issue and how it related to this resident’s fall. As a starting point, one of the things that the nursing home was explicitly cited for was understaffing. Understaffing is a common feature of care in nursing homes and is often the root cause of many unnecessary deaths and injuries to nursing home residents, but it is rarely the explicit subject of a citation issued by IDPH.

How bad was the understaffing that IDPH found? In one portion of the citation, a nurse described having 43 residents to care for with her and one aide. There is simply no way that residents can get the care they need with that kind of resident to staff ratio. The pandemic has clearly made things more difficult for nursing homes, but ending up with staffing levels like that is a failure of management.

What was the impact of the short-staffing on this resident?

She was assessed as being a fall risk due to difficulty walking and dementia. Dementia is a key factor is a resident’s fall risk because residents suffering from dementia cannot be relied upon to follow instructions or make good decisions for their own safety. Before the fall in which she broke her hip, she had a fall in which she suffered a bump on the head. One of the truisms in the nursing home industry is that the occurrence falls tend to beget additional falls, and her care plan was revised to include 15 minute checks on the resident.

Frequent checks on residents who are fall risks is an excellent step for preventing falls – if it is actually done. However, we know that this nursing home was understaffed and this was something that was not feasible for the staff given the staffing levels. However, the care planning process requires more than writing down good ideas on paper; it requires actually carrying them out.

On the day of this nursing home fall, the resident sounded the call light to get help to go to the bathroom. Her roommate told the state surveyor that the call light hand been on for about a half hour. The resident leaned against her table while going toward the bathroom. The table broke and she fell to the ground, suffering a fractured hip.

This is a situation where the is an explicit link between understaffing of the nursing home and a resident injury. The resident was supposed to be checked on every 15 minutes. That didn’t happen, as the roommate told the state surveyor that she had been waiting a half hour after sounding the call light, so the care plan was clearly not being implemented. This was also likely not the first time that this had happened, and when there are repeated instances of not getting a timely response to a call light, the residents are essentially trained that no one is coming when they sound a call light, so they are ever more likely to take risky actions.

The net result for this one resident is that she suffered a serious injury that has real long-term consequences, assuming that this not a case where the hip fracture ends up being an ultimately fatal injury.

Other blog posts of interest:

Generations at Rock Island fails to care for pressure ulcers

Aperion of Spring Valley resident suffers fatal brain bleed in fall

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

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

December 2, 2020 By Barry G. Doyle

IDPH has cited and fined Red Bud Regional Care Center nursing home after a resident there fell after getting out of bed to shut the lights off because the staff did not respond to her call light.

There are a number of factors which can contribute to a resident being a fall risk. Among these are musculoskeletal, balance, or gait deficits; a history of falls; and poor safety awareness. When the resident is at risk for falling, then a fall prevention care plan must be developed and implemented. Well-constructed fall prevention care plans will generally include as elements of it anticipating the resident’s needs and promptly responding to call lights. The reason that these are commonly included in the fall prevention care plan is so that residents don’t get up unassisted when they actually need help with walking or transferring.

The resident at issue had been admitted to the nursing home for rehabilitation after a fall at home in which she broke her clavicle and her left hip. She was considered a fall risk due to poor balance, a weak gait, her history of falls, and poor safety awareness.

On the night of this nursing home fall, the resident had been put to bed. Normally, she liked the lights off when went to bed, but for whatever reason the staff left them on when they left the the room. She activated her call light to have the staff turn the lights off, but no one responded for a half hour. Tired of waiting, she got her walker went over to turn the lights off herself, and as she turned to head back to bed, she lost her balance and fell to the floor. She called for the staff to come help her, but when no one responded for over 20 minutes, she called her son with her cell phone, who in turn called the nurse’s station. The staff then went to the room and found the resident on the floor.

She was brought to the hospital where she was diagnosed with a femoral neck fracture. This is the bridge of bone that connects the femur (or thigh bone) to the ball of the hip. Even though it is described as a fracture of the femur, it is really a fractured hip. Since this was the same hip that she had broken earlier, this will undoubtedly be a complicated recovery from this injury which may leave her with additional mobility deficits.

This is case where simple failures of care led to a significant injury. Had the lights been shit off when the staff left the room (that would be an example of anticipating the resident’s needs), the resident would not have been up. Had the staff responded to the call light, the resident would not have been up. Often in a nursing home setting, these simple breakdowns in the delivery of care lead to horrific results.

When we investigate this kind of case where the use of the call light is at issue, one step we take is to find out what make and model the call light system was. Many call light systems record data regarding the time the call light was sounded until when it was shut off. This can provide really accurate data as to how long the call light had gone unanswered for any particular event. Past that, data can usually be obtained for that resident over the course of the admission, for the resident’s room, for the hall she lived on, or for the facility itself. If the data shows that the staff frequently left residents waiting for extended periods of time, this is essentially trains the residents that no one is coming for them when they sound the call light, reducing the chances that they will wait for assistance. This increases the risk of falls and catastrophic injury, such as broken hips or brain bleeds.

Other blog posts of interest:

Red Bud Regional Care resident breaks hip and leg in fall

Hitz Memorial Home resident dropped from lift

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

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

Bella Terra Wheeling resident chokes to death

December 1, 2020 By Barry G. Doyle

IDPH has cited and fined Bella Terra Wheeling nursing home after a resident there choked to death while eating dinner without supervision.

We have written in this blog many times about the significance of the care planning process, and the tragic results that can come from a lack of care planning, poor care planning, or the failure to actually implement the resident care plan. This incident arises from failing to understand what the interventions in the care plan are.

The care planning process begins with an assessment which is intended to identify the risks to the well-being and safety of the resident. At the same time, the Minimum Data Set (MDS) is completed which records the results of a comprehensive assessment of the resident. The MDS helps form the basis by which the nursing home is paid for services provided to the resident, so this must be completed under penalties of perjury. From the assessment, a care plan is completed which must then be communicated to the staff who in turn must carry out the care plan on a day-to-day, shift-to-shift basis. Finally the effectiveness of the care plan must be evaluated on an ongoing basis and then revised if it proves to be ineffective in practice.

For this resident, the MDS recorded that he required supervision with eating, and his care plan also showed he required supervision with eating due to dementia with behaviors. The speech therapist told the state surveyor that “supervision” meant having the resident in view while eating.

On the day of this nursing home choking accident, the aide brought the resident’s dinner tray into the room. The resident did not want to get out of bed, so the aide left tray with the resident after elevating the head of the bed to 90 degrees and then left the room. About five minutes later, the nurse was making her rounds and saw that the resident was slumped over, blue in the face, and gasping for air. She attempted the Heimlich, but was unable to clear the airway. The resident was pronounced dead by the paramedics who were called to the nursing home.

Staff interviewed by the state surveyor told the surveyor that “supervision” while eating meant reminding the resident to take small bites or that the food is on front of them and then periodically checking on them. The speech therapist explained that what the staff though was “supervision” was actually “cueing,” and that supervision meant keeping the resident within sight.

Here, this resident choked to death because there was a disconnect between what the care plan called for and what the staff thought it meant. This speaks to a lack of training of the staff. This shows a lack of interest in investing in the staff on the part of the ownership and management of the nursing home. Sadly, this is a common theme in the choices management makes in how to operate a nursing home. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

Resident chokes at Grove at the Lake

Hillcrest Retirement Village resident chokes to death

Resident chokes to death at the Moorings in Arlington Heights

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

Sharon Health Care Willows resident undergoes surgery for bed sore

November 28, 2020 By Barry G. Doyle

IDPH has cited and fined Sharon health Care Willows nursing home in Peoria after a resident there developed a bed sore on his buttocks which declined to the point that it required surgery and treatment with IV antibiotics.

Federal regulations provide that when a resident enters a nursing home without having a bed sore, he should receive care, treatment and services such that the resident will not develop them unless they are clinically unavoidable. Further, once a resident does develop a bed sore, he must receive care, treatment and services necessary promote healing, prevent infection, and prevent the development of new sores.

Because they are so specifically addressed in the federal regulations, prevention of bed sores is a specific area of focus in the care planning process at every nursing home. The care planning process begins with an assessment of the resident’s skin condition and then their risk of developing beds sores, most often using a standardized risk assessment tool called the Braden Scale. If a resident has bed sores or is at risk for developing bed sores, a care plan is developed which includes a series of steps that are to be taken to reduce the risk of having a resident actually develop bed sores. That pressure ulcer prevention care plan must then be communicated to the staff who then must carry it out on a day-to-day, shift-to-shift basis. Finally, the care plan must be evaluated on an ongoing basis to see whether it is effective in practice or whether it is meeting the care needs of the resident, taking into consideration any changes or declines in the resident’s condition.

Aides are responsible for regularly checking the skin of the residents they care for while dressing them, providing incontinence care, or giving showers. If they identify an area of skin breakdown, it is their job to alert the nurse. Nurses are also responsible for periodic skin checks as well. if a skin breakdown is identified, it is the nurse’s job notify the doctor of the bed sore so that the doctor can enter orders for treatment. Further, the development of a bed sore or the decline of an existing one is an event that requires revision of the care plan.

This citation tells the story of what happens when there are multiple breakdowns in this process because staff members do not know what their responsibilities are.

When the resident at issue was admitted to the nursing home, he had no skin breakdowns. This means that he should not have developed any unless they were clinically unavoidable. A Braden assessment was performed which showed that he was at moderate risk for developing bed sores. Even though the resident was at risk, no pressure ulcer prevention care plan was put into place. A well-thought out care plan would have included a turning and repositioning schedule, use of pressure relieving device, use of barrier creams, and regular skin inspections.

Just over two weeks before the resident was sent to the hospital, an aide discovered a skin breakdown on the buttocks. However, none of the aides reported the skin breakdown to the nurse. The treatment nurse was responsible for doing weekly skin inspections. However, she never identified the area of skin breakdown because the resident was in a low bed (as a fall prevention measure) making it difficult to see the area of the buttocks where the skin breakdown occurred, which was in between the folds of the buttocks. The treatment nurse further reported to the state surveyor that the skin checks which were supposed to be done each shift by the aides was documented as being done, but were not in fact done, and on other shifts the skin checks were not completed at all.

A week before the resident went to the hospital, the treatment nurse did a quarterly reassessment of the resident’s Braden score to measure pressure ulcer risk. This showed that the resident’s condition had declined and was now at high risk – notwithstanding the fact that resident already had a bed sore that she was unaware of. Of course, the resident’s condition had probably declined to the point where the resident was at high risk well before that, but that did not trigger any of the nurses on the floor to suggest revision of the care plan.

Even though the treatment nurse now recognized that the resident was at high risk for skin breakdowns, she did not revise the care plan. She expected that the care plan coordinator would revise the care plan. The care plan coordinator acknowledged getting the Braden scores showing that the resident was now at high risk, but told the state surveyor that she didn’t know what to do with them.

On the day that the resident was sent to the hospital, the treatment nurse was helping an aide clean up the resident after an episode of incontinence. While she was doing so, she saw two necrotic areas on the resident’s buttocks. She alerted another nurse and they contacted the doctor who ordered the resident sent to the hospital.

T o summarize the areas where the care of this resident broke down, we have:

The resident was assessed as being at moderate risk of skin breakdown, but no care plan was put into place.
Multiple shifts in which skin inspections were supposed to be completed by aides which were not done or which were documented as having been done but were in fact not done.
When the skin breakdown was discovered it was not reported to the nurse by the aide who discovered it, nor by multiple other aides during later shifts over the next two weeks plus. Due to the failure of the aides to notify the nurses, the doctor was not notified of the skin breakdown for over two weeks, resulting in a delay in the resident receiving the care he needed.
The skin breakdown was not noticed by the treatment nurse during her weekly skin inspections for at least two weeks, in part due to the resident being in a low bed which made seeing the wound difficult.
The resident’s condition declined to the point that he was at high risk for skin breakdowns, yet none of the nurses recognized that this was the case so as to suggest revision of the care plan based on the change in his condition.
The treatment nurse conducted a Braden assessment without recognizing that the resident already had a skin breakdown.
Once the Braden was done showing that the resident’s risk of skin breakdown had increased from moderate to high risk, there was still no revision of the care plan.

So – what was the consequence of all this?

The resident was brought to the hospital, where the wounds were assessed as being Stage 4 bed sores. Surgery was performed, and the resident was started on IV antibiotics because there was evidence that the infection of the soft tissue had worked its way into the bone (osteomyelitis). These wounds would not have necessarily progressed to that point with proper steps being taken to prevent the bed sores or with the timely initiation of treatment for these wounds.

The failure of the aides, the treatment nurse, and the care plan coordinator to recognize what their roles are in the prevention and treatment of bed sores speaks to a nursing home which fails to invest in the training of its staff. Unfortunately, failing to make this kind of investment in the people who work for them is common in the nursing home industry. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

Resident suffers from multiple pressure ulcers at Parker Rehab

Bed sore requires surgery for Timbercreek resident

Resident develops bed sores to both heels at McLean County Nursing Home

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

Alden Valley Ridge fails to give resident anti-seizure medications

November 27, 2020 By Barry G. Doyle

IDPH has cited and fined Alden Valley Ridge Nursing Home in Bloomingdale after a resident there had to be hospitalized after experiencing grand mal seizures brought on by a failure to give prescribed anti-seizure medications.

The resident at issue had a history of epilepsy with seizures. When he was discharged from the hospital to the nursing home, there were orders in place and prescriptions written for at least three anti-seizure medications which were to be given twice per day: dilantin, onfi, and keepra. When the resident arrived at the facility, these medications were not on hand and had to be obtained from the pharmacy. These medications were not obtained during the first 36 hours of the resident’s admission to the facility, and as a result, he did not receive his anti-seizure medications.

As a result, the resident experienced two grand mail seizures. The doctor was not notified about the first, and as a result, was not sent to the hospital. After the second occurred, the doctor was notified and the resident was sent to the hospital where labs showed that he had critically low levels of dilantin. He was admitted to to the hospital for several days to stabilize his condition.

Before a resident is accepted for admission to a nursing home, the facility receives a package of materials about the resident which includes a medication list. This is so that the nursing home can determine whether it can meet the care needs of the resident and if they decide to accept the resident, they can order necessary medications. Well-run nursing homes have processes in place to ensure that routine items such as this get handled properly so that critical medications such as this are on hand when the resident arrives. Past that, when there is a critical medication like an anti-seizure medication that is unavailable for a resident, there are processes in place to ensure that the medication is delivered in a timely fashion.

Past that, there were events during this admission which required physician notification. The first of these was the fact that there was a medication error because these was no medication available and that there were multiple missed doses of medication. Had the doctor been notified, the doctor would have had the option of ordering other medications or taking other steps to help the resident maintain his dilantin levels to prevent the seizures. The second of these was the occurrence of the first seziure. When a resident experiences a significant event like that, it requires care regardless. It is also an indication that the missed doses of the anti-seziure medication are having adverse effects on the health and well-being of the resident.

Other blog posts of interest:

Failure to obtain anti-seizure medication at Gilman Healthcare Center

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

Failure to give anti-seizure medication at Lexington of Orland Park

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

Heritage Health Pana staff violates care plan, resident falls and breaks hip

November 25, 2020 By Barry G. Doyle

IDPH has has cited and fined Heritage Health – Pana nursing home after a resident there was left unattended in her wheelchair in violation of her care plan. The resident tried to get up from her wheelchair on her own and fell, breaking her hip.

The care planning process is the foundation for much of the routine care that gets delivered in a nursing home setting. Fall prevention is a special area of emphasis in the nursing home setting because falls tend to beget additional falls and any fall tends to have serious long-term consequences for nursing home residents.

The care planning process starts with an assessment of the resident’s fall risk. The tools that nursing homes use to measure fall risk vary widely, but there are a number of factors that tend to be given weight: balance, gait, or musculoskeletal dysfunction; dementia or intermittent or constant confusion; incontinence; and a history of prior falls. If the resident is assessed as being a fall risk, then a fall prevention care plan must be developed which includes a series of steps or interventions that should be performed . That care plan must be communicated to the staff charged with carrying it out, and then it must in fact be implemented on a day-to-day, shift-to-shift basis. The care plan must be evaluated for effectiveness on an ongoing basis and then revised if it is either ineffective or there are changes in the resident’s condition.

Of course, it all comes down to the care plan being carried out on a day-to-day, shift-to-shift basis. The best assessments and the best care plans have no value if they are not actually implemented, and that was the source of this nursing home fall.

This resident had a history of a prior fall with a broken left hip. The Minimum Data Set (MDS) showed that the resident required extensive assistance from two staff members for transfers and had severe cognitive impairments. The assessment also noted a behavior of getting up unassisted. In short, she was a clear fall risk and was assessed as such. Part of her care plan was that when the resident was up in her wheelchair, she should be placed in a high traffic/highly visible area (in the common room or by the nurses’ station would be examples). This is a very common intervention to address this form of fall risk. The care plan was recorded on the kardex which was stored on the back of the door to the resident’s room.

On the day of this nursing home fall, the staff reported finding the resident trying to crawl from her bed to her wheelchair. They assisted her into her wheelchair. Then, rather than bring her out to an area where she could be kept under observation, she was left unattended in her room. Shortly after being left in the room, the resident attempted to get up unassisted, and fell. She was brought to the emergency room, where x-rays showed that she had fractured her left hip – the same one which had been broken before.

The obvious cause of this nursing home fall and the injury sustained by this resident was the failure of the aide to care out the care plan. The resident was left unattended in her room in her wheelchair. This was a violation of the care plan, and the Director of Nursing conceded as much to the state surveyor. For her part, the aide told the state surveyor that she did not know that the resident needed to be supervised.

In situations such as this, where the staff cannot take the time to access readily available information to know how to properly care for a resident, this is a strong indicator that this is an understaffed nursing home. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

Other blog posts of interest:

Taylorville Skilled nursing home resident falls and breaks hip

Repeated resident falls at Heritage Health in Springfield ends with broken arm and brain bleed

Failure to train staff leads to broken hip and death at Heritage in Jacksonville

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

Southpoint Nursing & Rehab resident breaks leg in improper transfer

November 22, 2020 By Barry G. Doyle

IDPH has cited and fined Southpoint Nursing & Rehab nursing home in Chicago after a resident there suffered a broken leg as a result of an improper transfer.

The Minimum Data Set (MDS) is a report which is submitted under oath to the federal government and describes the level of care that a resident is receiving. It is supposed to be based upon the information in the resident chart, discussions with staff members and the resident and family, and on the assessment of the individuals signing off on it.

The reason that the MDS is completed under oath per federal regulations is that the response in the MDS can change the acuity level for the resident which in turn can affect the payment that the nursing home receives for caring for the resident. In short, there is money involved, so honest reporting on the MDS is required.

The responses on the MDS in turn trigger something called a Care Area Assessment (CAA) which is an indication to the care planning staff that particular areas should be considered in the care planning process. This helps assure that the resident is receiving the care he or she needs on a day-to-day basis.

The resident at issue was coded on the MDS as requiring extensive assistance with transfers and bed mobility from two staff members. She was totally dependent on staff members for activities of daily living. Given that was how she was coded, per facility policies, this should have been reflected in the care plan and in the care that the resident was receiving on a day-to-day, shift-to-shift basis.

On the day of this nursing home fall, the resident was being transferred from her bed to a wheelchair by a single aide using a gait belt. The resident’s leg buckled and the aide was forced to lower her to the edge of the wheelchair and then after obtaining some additional help, to lower her to the floor. The resident was brought to the hospital where x-rays showed that she had a broken femur. She underwent surgery to repair the fracture.

At first blush, this appears to be a common case of one person doing a two-person job, as we have often discussed on this blog (see here, here, for examples). While this is true, it is also not the whole story.

When the state surveyor interviewed the staff at the facility, the aide explained that she regularly cared for the resident and knew that the resident was a one-person transfer because there was a note above the resident’s bed that said “B-1” which meant that the resident was a one-person transfer. The surveyor then went and interviewed the floor nurse, who is supposed to be supervising the aide, and the nurse told her she followed along with what the aides told her because they know what to do for each resident. Finally, the surveyor was told by the restorative nurse that “B-1” meant one person assist for bed mobility – which is of course not what the MDS indicated.

To summarize: the MDS and the care plan called for two-person extensive assist with transfers. The aide charged with providing that care had not been providing that care as a matter of routine because she misunderstood the significance of the sign over the resident’s bed. That sign did not even track the level of care that the resident was supposed to receive. Topping it all off, the nurse who was supposed to be supervising the aide simply relied on the aide to know what to do – an assumption that was not borne out by what was happening all around her.

Having this many levels of breakdowns in care might be called a comedy of errors – if it were not for the fact that a resident suffered a significant injury which will likely have longer term consequences which will place her at risk of a premature death.

Sadly, having a staff that has not been properly trained and having a nursing home claiming to be providing a higher level of care than is actually being delivered is all too typically 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:

Resident fractures leg in improper transfer at Woodbridge Nursing Pavillion

Broken ankle from unsafe transfer at Aperion Care International

Multiple injuries from fall at Symphony of Midway

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

Stephenson Nursing Center resident undergoes surgery for bed sore

November 19, 2020 By Barry G. Doyle

IDPH has cited and fined Stephenson Nursing Center nursing home in Freeport after a resident from that nursing home had a bed sore decline due to bad care that the resident required surgery to treat it.

There are three main factors which place a resident at risk for developing bed sores: immobility, incontinence, and poor nutritional status. A resident’s risk of developing bed sores is supposed to be addressed through the care planning process. Once a resident develops bed sores, this is an event which requires physician notification and a revision of the resident care plan, as federal regulations relating to bed sores require that once a resident develops a bed sore that the nursing home provide care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new sores.

When this resident was admitted to the nursing home, he did not have bed sores. This meant that he was entitled to receive the care necessary to prevent the development of bed sores unless they were clinically unavoidable. Although the citation does not recite what his Braden score was, he was very clearly at risk for developing bed sores, as he suffered from quadriplegia and neurogenic dysfunction of the bladder, which means that he was immobile and incontinent. When the care planning process is implemented properly, a resident such as this would have had a care plan put into place once the resident was determined to be at risk for developing bed sores. However, this was not done until four and a half months after the resident’s admission and over a month and a half after the first bed sore developed.

The first bed sore, located on the left buttocks, was noted approximately 3 months after the resident entered the nursing home and about two months before he was eventually sent to the hospital. The resident’s doctor was notified but the care plan was not changed to reflect the fact the resident’s had greater care needs due to the onset of this new bed sore. Over the course of the next month and a half, the wound continued to decline, growing larger in diameter and gaining additional depth with necrotic tissue appearing in the wound bed. The continuing decline of the bed sore is also something that called for physician notification, as that indicates that the care which was being provided was not successful in resolving the bed sore. The treatment orders were not changed at all until about two and half weeks before the resident went to the hospital.

At the same time that the condition of the bed sore was declining, the resident was experiencing significant weight loss. This means in addition to having immobility and incontinence as risk factors for bed sores, he also now had poor nutrition to go along with this. Having good nutrition is important for preventing bed sores but is really crucial when attempting to heal a pressure ulcer. How significant was the weight loss? According to the citation, during period beginning just over two months before he was admitted to the hospital up through the date he went to the emergency room, the resident’s weight dropped from 240 pounds t0 212 pounds. Part of that was due to the loss of a tooth and difficulty eating associated with that, but the bottom line is that this resident was not receiving the intake of nutrients necessary to recover, and contrary to facility policies, his intake was not tracked for the vast majority of the meals that he was served.

It is also worth noting that the nursing home recorded his weight as being 235 pounds only four days before he went to the hospital. Obviously, that is an example of false charting. Being able to pinpoint examples of false charting in a nursing home chart is valuable in nursing home abuse and neglect lawsuits because the presence of false chart entries undermines the reliability of other chart entries which tend to reflect that care was provided in the right way and undermines the credibility of the individual staff members.

On the day the resident was sent to the emergency room, he told the staff that he was dying and asked to go to the hospital. Permission was given by the attending doctor, and he was brought to the hospital. There, his blood sugar level was taken and it was 407, a severely elevated blood sugar level. Elevated blood sugar levels are often associated with the presence of an infection. Inspection of the skin revealed a second bed sore, this one on his sacrum, which measured approximately 2 cm in diameter but was bone deep. The left buttocks wound was 10×13 cm with 2 cm of depth. About half of the surface area of the buttocks ulcer was necrotic. He underwent surgery to debride both of the bed sores. He was diagnosed with osteomyelitis at the location of the sacral wound. This ordinarily would have been addressed surgically, but he was not a surgical candidate, so the doctors were going to try to bring the infection under control with antibiotics.

The level of failure in the care of this resident is staggering. Here is a short rundown of the failure of the care that this resident endured:

He was on obvious risk for developing bed sores based on his immobility and incontinence. Yet, there was never a pressure ulcer prevention care plan developed for him.
Once he did develop the left buttocks wound, the care plan was never revised to include the care needs associated with attempting to heal an existing pressure ulcer.
The resident suffered significant weight loss during the period of his residency at this nursing home. At a time when his nutritional needs were at their maximum level to sustain wound healing, he was likely suffering from malnutrition.
The left buttock wound continued to decline, but the doctor was not notified that the treatments he ordered for the resident were not effective and the wound was getting worse, not better. Similarly, there was nothing done until the very end with regard to care planning for pressure ulcer healing.
The facility staff failed to recognize the presence of the sacral wound at all. As a result there were no treatment orders obtained and no revisions made to the care plan to account for this new bed sore.
The wounds became infected, but the staff failed to recognize signs and symptoms of the infection and failed to notify the doctor, delaying the start of care allowing the infection to progress.
The family was not notified about the declines in the resident’s condition.

These are only the very high-level failures in the care that this resident received. A detailed review of the resident chart would likely show dozens of individual failures of the care of this resident.

Other blog posts of interest:

St. Anthony’s nursing home resident requires surgery for bed sore

Bed sore requires surgery for Timbercreek resident

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

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

St. Anthony’s nursing home resident requires surgery for bed sore

November 17, 2020 By Barry G. Doyle

IDPH has cited and fined St. Anthony’s Nursing & Rehabilitation Center in Rock Island after a resident there was required to undergo surgery due to worsening in the condition of the sore.

Bed sores or pressure ulcers are a major focus of care in the long-term care industry. The development and/or decline of a bed sore is a serious health event in the course of care for a nursing home resident, often leading to other complications.

Federal regulations relating to be sores provide that when a resident enters the nursing home, they should receive care consistent with professional standards necessary to prevent the development of bed sores. The regulations further provide that once a resident develops bed sores, they must receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new wounds.

Once a resident develops a bed sore or a bed sore declines, two things must happen. First, the doctor must be notified so that new treatment orders must be carried. Second, the care plan must be evaluated and likely revised. Both the doctor’s orders and the steps outlined in the care plan must be carried out on a day-to-day, shift-to-shift basis.

The resident at issue was admitted to the nursing home with a Stage 4 bed sore measuring 3×3.5 cm with a depth of 1.7 cm. Over the course of a month, the wound declined in that it grew in size to 10×8 cm with a depth of 3.5 cm with necrotic tissue in the wound bed and involvement of the fascia. At that point the resident was transferred to the hospital to undergo surgery to remove the dead tissue.

How did things go so badly for this resident? The answer, as is often true with bed sores, was in many ways:

The Stage 4 bed sore that he was admitted with was not addressed in the resident care plan. In addition to physician orders, there are a number of nursing interventions that can be taken to improve the resident’s chances of healing. Without having those steps included in the resident care plan, having those things done is left to chance.
The physician orders were not followed. The initial orders were for dressing changes once per day, but then were changed early in the second week that the resident was there to twice daily. The changed orders were not reflected on the Treatment Administration Record, so the resident only got dressing changes daily – on the days that there were dressing changes at all – and there were days when there were no dressing changes at all. Skin audits that were ordered were not done. Measurements were not taken regularly of the wound.

Bed sores are a different kind of injury than those that might be sustained in a nursing home fall or a nursing home choking accident in that there is usually not a clearly defined time when the injury took place. Instead this is an injury which really reflects the cumulative effects of breakdowns in the delivery of care. The records here show that there are small breakdowns in the care happening over and over – and as a result this resident’s bed sore decline swiftly to the point that surgery was needed.

The real question is of course why these breakdowns happen, and the answer frequently comes back to this being an understaffed nursing home. The staff in understaffed nursing homes have a hard time keeping up with basic needs of the residents, and this has a direct impact on the residents. Unfortunately, understaffing the nursing home is a key 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:

St. Anthony’s fails to treat resident’s pain during wound care

Bed sore requires surgery for Timbercreek resident

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

Stephenson Nursing Center resident requires surgery for bed sore

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

Champaign-Urbana Nursing & Rehab resident breaks hip in fall

November 15, 2020 By Barry G. Doyle

IDPH has cited and fined Champaign-Urbana Nursing & Rehabilitation nursing home in Savoy after a resident there suffered a fractured hip after being left unattended in the courtyard.

Assessing fall risk is one of the standard assessments which is completed as part of the care planning process. For assessing fall risk, there are few standardized scales similar to the Braden scale (which is used to assess risk of developing bed sores), so nursing home use a variety of standardized tools. However, virtually all of them give major weight to two factors: (1) musculoskeletal weakness of dysfunction and (2) cognitive impairment which renders the resident unable to comply with safety instructions or make good decisions for their own safety.

While musculoskeletal dyfunction is obviously an important factor in determining fall risk, cognitive impairment is at least as significant, if not more. A resident with really significant musculoskeletal issues is not terribly likely to suffer injury in a fall, if they can understand and follow instructions that must be followed to keep themselves safe. On the other hand, a resident with relatively minor musculoskeletal issues but with real issues with intermittent or constant confusion which renders them unable to follow instructions or make good decisions regarding their own safety may have really significant risks of sustaining a catastrophic fall.

The resident at issue here has well-recognized cognitive impairments. She had in fact been assessed by the speech therapist (in addition to doing swallow assessments which play such an important role in keeping residents safe from choking accidents, they also do assessments and treatment of residents suffering from cognitive issues) shortly before this injury and found to have deficits in reasoning and judgment with impulsive, unsafe confused behaviors. She also had a history of falls – another key factor for determining whether a resident was a fall risk.

On the day of this nursing home fall, the resident walked out to the courtyard unassisted and began to pick dead flowers out of a flower pot. Staff saw her out in the courtyard, and brought her wheelchair to her, locked the wheelchair in place, and placed it next to a bench where they placed the flower pot. Staff then left the resident unattended in the courtyard. About ten minutes later a family member of another resident came in and reported that the resident at issue was on the ground.

She was brought to the hospital where x-rays showed that she had sustained a broken hip in the fall. She underwent surgical repair of the fracture.

So what did the nursing home do wrong? The basic answer is that this resident was left unattended. She was very clearly a fall risk with a history of falls, musculoskeletal issues, and documented cognitive impairments. If there was no fall prevention care plan in place, that would be a serious shortcoming in the care that this resident received. If the care plan did not call for keeping the resident under close observation, that is equally problematic. If the care plan called for that and the resident was left alone in the courtyard, that would be a violation of the care plan. The bottom line with residents who have cognitive impairments which leave them unable to be counted on to make good decisions for their own safety is that they must be kept under observation. That was not done here, with catastrophic results.

Other blog posts of interest:

Gardenview Manor resident suffers broken hip during unsafe transfer

Fall results in fractured kneecap at Country Health in Gifford

Brain bleed from fall at Gibson Community Hospital Annex

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

Assisi at Clare Oaks resident breaks neck in fall from wheelchair

November 14, 2020 By Barry G. Doyle

IDPH has cited and fined Assisi Health Care Center at Clare Oaks nursing home in Bartlett after a resident suffered a broken neck in a fall from a wheelchair.

Wheelchairs are like every other piece of equipment in a nursing home setting – usually safe, helpful, and beneficial if well-maintained and used properly. For a wheelchair, this includes things such as having the wheels working properly, functioning wheel locks, a properly fitting seat cushion, and foot rests in place. Without all of those things being true, something as simple as a wheelchair can add an extra level of hazard for a nursing home resident.

The resident at issue here was wheelchair bound, but was able to eat independently, and needed only limited assistance with her activities of daily living. She was able to wheel herself about the facility, something which gave her some degree of independence and added to the quality of her life.

On the day of this nursing home fall, the resident was being wheeled out of the shower. The aide pushing the wheelchair had noticed that the seat cushion was too long for the seat. The foot rests were also not being used. As the resident was being pushed forward, the resident slid forward out of the seat onto the floor. There was immediate bleeding, and the aide left to get a nurse.

The resident was brought to the hospital where she was diagnosed with a fracture of the C2 vertbera (the second one from the base of the skull). She successfully underwent cervical fusion surgery to stabilize and repair the fracture and returned the to the nursing home. However, where she was able to feed herself, wheel herself about the facility, and needed only minimal assistance with her activities of daily living, now she is a total assist with everything.

There were two notable shortcomings in the care that this resident received. First, she was being wheeled about in a chair with a cushion that was too large. How the too-large cushion got there was not addressed in the citation, but the fact is that it was recognized as such before the resident was taken from the shower. Having an ill-fitting cushion leads to an unstable seating surface which creates the potential for this kind of accident to occur. Second, the resident was being pushed without the foot rests in place. Use of footrests would have helped stabilize the resident in the wheelchair and likely prevented the fall. It is also impossible based on the contents of the citation to exclude the possibility that the resident’s feet dropped to the floor, resulting in her being propelled forward out of the chair. Lack of footrests is far more dangerous than would appear at first glance.

The failure to recognize the danger which was which being created here is an indication of a poorly trained staff. Having a poorly trained staff shows a lack of investment in the personnel working at the nursing home. Sadly, this is consistent with 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:

Wheelchair accident at Avanti Wellness

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

Alden Valley Ridge resident rolled from bed and breaks both legs

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

Taylorville Skilled fails to obtain anti-convulsant medication for resident

November 12, 2020 By Barry G. Doyle

IDPH has cited and fined Taylorville Skilled nursing home after a resident there went six days without his anticonvulsant medication, resulting in seizures that led to the resident being admitted to hospice.

Fundamentally, nursing homes are businesses, and well-run businesses have systems in place to ensure that the routine delivery of necessary services occurs, and those services are critical, that there are back-up or fail safe systems that can kick in when things break down to avert catastrophe. Giving medications is one of those routine services that nursing home provides. But in order for that to happen, the prescribed medications must be on hand.

Nursing home medication errors like this are what happens when the medication prescribed for a resident is not on hand and nothing is done to address the situation.

The resident at issue had a complex medical history including epilepsy. His neurologist prescribed a medication called Vimpat to be twice daily to control seizures. Epileptic seizures in adults can have long-term serious effects.

Nursing homes rely on pharmacies to supply medication to the facility. These medications are delivered on a regular basis to the nursing home, and the nursing home relies on timely delivery of the medications to ensure the health and well-being of the residents. The nursing home here switched pharmacies, and in the process of making the switch, the new pharmacy did not deliver the medication because it wanted a new prescription from the doctor.

In the meantime, over a 6-day period the resident did not receive the anticonvulsant medication. The staff duly noted on the resident chart that the resident did not get the medication because they were awaiting delivery from the pharmacy. However, they did not notify the doctor, the director of nursing or the administrator, or the resident’s family. As a result, the resident experienced significant seizures which were difficult to bring under control even in a hospital setting. Due to the consequences of the seizures, the resident has been placed on hospice.

There are a number of breakdowns in the care that this resident received. A large part of that relates to the breakdown in the delivery of medications and the failure to resolve the issue once it occurred. This is a staff training issue since apparently among multiple staff members who cared for the resident over that 6-day window, none of them knew what to do when the medications were not being delivered. At a minimum the doctor and resident’s family needed to be notified that his patient was not receiving critical medications. This is a critical issue of which the nursing home administration should have been notified.

The failure to properly train the staff is consistent with a lack of investment in the staff. Failing to make investment in the personnel on the floor is consistent with how the nursing home business model operates. 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:

Taylorville Skilled resident sustains fractured hip after multiple falls

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

Flora Gardens staff fails to give antibiotic, leading to death of resident

Resident given wrong medication at Villa Health Care East

Taylorville Skilled nursing home resident falls and breaks hip

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

Aperion of Spring Valley resident chokes to death

November 9, 2020 By Barry G. Doyle

IDPH has cited and fined Aperion of Spring Valley nursing home after a resident there choked to death on a peanut butter and jelly sandwich.

Having their mom or dad choke to death in a nursing home is one of those things that is too horrible for children to imagine happening when their loved one is admitted to a nursing home. Sadly, given declining physical and mental conditions, it is a risk that some nursing home residents face.

The basic tool for addressing known risks to the health and safety of nursing home residents is the care planning process. The care planning process is a series of steps which must be taken to address the risks to the safety and well-being of nursing home residents. Choking risk can be addressed in the care planning process.

There are six basic steps to the care planning process: (1) an assessment of the threats to the safety and well-being of the resident, (2) development of the care plan which is an actual written document which outlines the steps or interventions that must be taken to address those threats, (3) communication of the care plan to the staff members charged with carrying it out, (4) implementation of that 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 in the event that there are changes in the resident’s condition or needs or if the care plan as written proves to be ineffective.

When it comes to choking risk, the person who customarily evaluates the resident’s risk of choking is the speech therapist. There are a number of conditions which can place a resident at risk of choking. Dysphagia is the medical term for difficulty swallowing. Regardless of the medical condition which produced the difficulty with the swallow function, this is a prime driver of increased risk of choking. When combined with dementia, this can result in a high risk of choking because the resident may not be able to adjust his/her behavior in a way to minimize choking risk.

Besides outright choking, difficulty with swallowing can lead to aspiration pneumonia as food particles entering the airway and make their way into the lungs. The body’s reaction to having food enter the lungs is to cough in an effort to expel the foreign substance. Observation of coughing while eating may be a sign that the resident has swallow deficits.

When the speech therapist determines that a resident is at increased risk of choking, there are a number of recommendations that are normally a part of the care plan. These include therapy, supervision while eating, behavioral cues, and modifications to diet.

The resident at issue had a diagnosis of dysphagia and suffered from dementia. She had a history of multiple episodes of aspiration pneumonia. She was well-known to the staff to someone who could not follow swallow strategies to take small bites and eat at a slow pace. While she was being fed, she could often be heard coughing. Her care plan included supervision while eating, to serve the resident a prescribed diet, and to monitor the resident while eating for difficulties with swallowing.

On the day of this nursing home choking accident, the residents were not able to eat in common areas due to COVID restrictions, so they would be brought to their doorways while being fed. Each resident had a specific snack that was supposed to be provided to them. This resident was supposed to receive a pudding snack, but the aide passing the snacks did not see that the resident had been provided with a designated snack, so she provided the resident with a peanut butter and jelly sandwich per the resident’s request.

After passing the peanut butter and jelly sandwich to the resident, thee aide continued to pass snacks to other residents, leaving the resident unattended and unsupervised. About 10-15 minutes after the resident was given the sandwich, a physical therapy assistant working with a resident across the hall looked out the door and saw that there was something wrong with the resident. He went over to the resident and asked what was wrong, and she said, “I am choking.”

The physical therapist pounded the resident on the back and went and got the aide, who in turn summoned a nurse. A code was called, and efforts were made at clearing the airway and doing the Heimlich. The resident lost consciousness and was placed on the floor while CPR was performed. However, she lost her pulse, and by the time that paramedics arrived, she could not be revived. She was declared deceased without being brought to the hospital. Cause of death per the death certificate was asphyxiation ands choking on a sandwich.

There are a couple of shortcomings in the care that this resident received.

The first is that she was not given the snack that had been selected for her by the dietary staff. Pudding (the selected snack) is much less thick than a peanut butter and jelly sandwich and is less likely to cause an airway obstruction. Instead of verifying what should be given to the resident, the aide left that in the hands of the resident who likely never understood what her needs were.

Second, the resident was not supervised while consuming the snack. This resident had a well-known risk of choking starting with her dementia and dysphagia, her history of having episodes of aspiration pneumonia, her well-known behavior of not following safe eating practices, and her documented history of coughing while eating. This was a resident who required close supervision while eating and that level of supervision called for in her care plan was simply not provided. No doubt that COVID made this more difficult, but it needed to be done to assure the safety of this resident.

Delivery of good care in a nursing home isn’t always easy, but it is possible. However, it is that much harder when there is not enough staff on hand to get the job done. Sadly understaffing a nursing home is a feature and 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:

Resident chokes to death at River Bluff nursing home

Fatal choking accident at Spring Creek in Joliet

Aperion of Spring Valley resident suffers fatal brain bleed in fall

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

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

November 8, 2020 By Barry G. Doyle

IDPH has cited and fined Grosse Point Manor nursing home in Niles after a resident there fell and suffered a fractured hip after being left unattended in the dining room.

Falls are a major focus in the long-term care industry because as a whole nursing home residents are more susceptible to suffering serious injuries in falls which can easily prove fatal or have serious adverse effects on the resident’s quality of life.

Because falls are a focus, they are specifically addressed in the care planning process. There is no commonly adapted tool for measuring fall risk the same way the Braden Scale is used to measure risk of developing bed sores. However, there are two major factors that are used in just about every fall risk assessment tool I have seen. The first of these is some form of musculoskeletal, gait, or balance dysfunction or deficit. This contributes to fall risk for obvious reasons. The other is some degree of dementia, impaired judgment, or intermittent or constant confusion. This is because the resident then cannot be counted on to follow instructions, heed safety precautions, or make good decisions about their own safety.

When a resident is considered a fall risk, there are a couple of mainstay interventions or steps that can be taken to address fall risk. The first of these is to keep the resident under observation in the common areas or by the nurse’s station during hours when the resident is awake. The other is a use of a bed alarm or a chair alarm which sounds when a resident gets up out of bed or out of his/her chair. It serves two purposes: one to alert the staff that the resident is up and moving; the other to remind the resident that they should not be up unattended.

The resident at issue was 91 years of age and suffered from confusion and musculoskeletal weakness. She used a walker with the assistance of one staff member. Before the fall that led to this citation, she experienced 7 falls in a year and a half. Her care plan called for the use of a bed alarm (but no chair alarm) and for her to be closely monitored in the dining room.

On the day of this nursing home fall, the resident was in the dining room and an aide was assigned to monitor the residents in the dining room. However, the aide assigned to the dining room left to care for the other residents she was assigned to care for. While she did that, the resident got up to leave. As she walked away from the dining room unattended, her legs gave out from under her and she fell, suffering a fractured hip which required surgery.

There are a few levels of failures in the care that this resident received. First, the aide violated the care plan by leaving the resident unattended and unsupervised in the dining room. That supervision was absolutely necessary in light of the resident’s known behavior and history of prior falls. Second, this is a facility which used alarms, and chose to use a bed alarm but not a chair alarm. If the use of a bed alarm was appropriate for this resident, the use a chair alarm likely was also, especially with the number of prior falls this resident had experienced. Finally, the aide reported to the state surveyor that the nursing home was short staffed and that was why she left the residents in the dining room unattended while she went to care for others.

Federal regulations require nursing homes to have enough staff on hand to meet the care needs of the residents on a 24/7 basis. Clearly that was not the case here. Sadly, understaffing is a common 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:

Niles Nursing & Rehab resident sustains fatal brain bleed due to fall

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

Grosse Pointe Manor resident breaks leg in unsafe transfer

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

Patient Had a Recognized Fall Risk

Most Nursing Home Falls can Be Prevented

Call an Illinois Nursing Home Abuse Lawyer

Staff Was Aware of High Fall Risk

Proactive Care Was Required but Not Undertaken

Nursing Home Care Planning and Fall Risk

Patient Suffered Several Falls

Care Plan Diligence is Crucial for Injury Prevention

Contact an Illinois Nursing Home Lawyer for Legal Support

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