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.
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:
Fatal medication error at Warren Barr Oak Lawn
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
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