The Illinois Department of Health has cited and fined Doctors Nursing and Rehab when the facility repeatedly failed to administer physician-ordered antibiotics and wound treatments to a resident with serious leg infections, and failed to complete ordered lab work and medications for a second resident with congestive heart failure — failures that contributed to both residents developing life-threatening conditions and ultimately dying. The state issued an Immediate Jeopardy citation, the most serious level of violation, finding that these failures caused or were likely to cause serious injury or death.
The first resident had been living at the facility for years and had serious, complex wounds on both lower legs caused by venous insufficiency and lymphedema — conditions that cause fluid to build up and skin to break down. Her wounds were infected with dangerous bacteria including MRSA and pseudomonas, and she was under the care of an outside wound specialist who visited her regularly and sent detailed treatment orders back to the facility. The story of what went wrong is one of repeated, compounding failures over several months.
The wound specialist originally ordered a powerful intravenous antibiotic to be given twice a day. The facility told him they could not do it — they did not have registered nurse coverage at night to administer IV medications on that schedule. The order was reduced to once a day. The wound specialist later said that if the antibiotic could have been given twice daily as originally ordered, the blood levels could have become therapeutic and the sepsis might have been avoidable. When the once-daily dose failed to bring the antibiotic to effective levels in her blood, the dosage was increased — but by then, time had already been lost.
Over the following months, the wound specialist sent additional antibiotic orders to the facility that were simply never entered into the medication system and never given. Orders for three separate oral antibiotics sent in October went completely unimplemented — there was no record of them in the medication administration records and no evidence they were ever given. When a subsequent antibiotic was ordered and the facility raised a concern about a possible allergy, the wound specialist’s office clarified the order and sent it back — but that antibiotic was never given either. When yet another antibiotic was ordered for a dangerous drug-resistant urinary tract infection that had developed alongside the wound infections, nursing staff noted the order, passed it between shifts, called the pharmacy — and then let it drop. The pharmacy had never received the order. Multiple nurses acknowledged in interviews that they never saw the resident receive it.
Meanwhile, the wound treatments themselves were frequently not done as ordered because the facility routinely ran out of basic supplies — Dakin’s solution, kerlix gauze wrap, and specialized wound products. Nurses documented substituting whatever they had on hand rather than what was ordered. Several nurses admitted in interviews that even when they did not have the correct supplies, they would sign off in the medical record that the treatment had been done as ordered. The wound specialist stated that Dakin’s solution was critical because it is one of the few agents that kills pseudomonas — the specific bacteria infecting her wounds — and that not using it likely contributed to the wound infection worsening. He stated directly that if all the antibiotics that were ordered had been given and the wound treatments had been performed per order using the Dakin’s solution, he did not think the resident would have deteriorated the way she did. He added that the wound infection was the primary cause of her deterioration and that she deteriorated rapidly due to the facility not following orders, ultimately leading to sepsis and her death.
The second resident had congestive heart failure — a condition in which the heart cannot pump blood efficiently, causing fluid to build up in the body — along with a range of other serious diagnoses. When lab work showed her BNP level, a marker of heart stress, was critically elevated at more than eight times the upper limit of normal, her physician ordered an increased diuretic dose for five days and a repeat lab test the following Monday to check if the treatment was working. The repeat lab was never done. The increased diuretic was entered into the system with an end date one day too early, so she only received four of the ordered five days of treatment. The physician later stated that not completing the full course of diuretic could have contributed to the resident retaining extra fluid and ultimately led to an exacerbation of her heart failure.
When the second resident returned from a brief hospitalization for heart failure, a nurse received a discharge order from the hospital to “increase” the diuretic — but the dose specified was the same as what the resident was already taking. Rather than calling the hospital or the physician to clarify what was clearly an inconsistency, the nurse simply entered the order as written and moved on. The physician stated that if the nurse had called to clarify, a higher dose could have been ordered that might have slowed the resident’s decline. Over the weeks that followed, multiple nursing staff observed the resident becoming increasingly lethargic, refusing to eat, and showing signs of worsening fluid overload — including facial and limb swelling and declining oxygen levels. These warning signs were not reported to the physician in a timely manner. One nurse stated she thought the resident would get better. The physician stated that if she had been notified of the declining condition earlier, she could have put interventions in place that could have slowed the decline and ultimately delayed the resident’s death by preventing an exacerbation of congestive heart failure. The resident was eventually transferred to the hospital in an unresponsive state, required intubation, and died.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Illinois 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.
