IDPH has cited and fined Forest City Rehabilitation & Nursing Center nursing home in Rockford after a resident had to be sent to the intensive care unit at a local hospital after the nursing home failed to send the resident to dialysis for three consecutive scheduled sessions.
When a nursing home resident suffers from kidney failure and is on dialysis, the resident must receive all of their scheduled sessions. The failure to send a resident to dialysis as ordered can result in the resident suffering high levels of potassium which can cause the death of the resident.
While some nursing homes have in-house dialysis units, other nursing homes have to send residents to outside dialysis centers for their schedules sessions. When this is the case, reliable transportation must be arranged. In this particular instance, the resident was supposed to receive services at an outside center. The contract with the nursing home placed responsibility on arranging for transportation on the nursing home, and there was a staff member who was specifically responsible for arranging for the transportation.
The resident was readmitted to the nursing home after a short hospital admission and was due to get dialysis the following day. Her schedule called for three dialysis sessions per week. However, she was not brought to dialysis that day as scheduled or for the next two sessions either. This meant that the resident did not receive dialysis for a week.
After missing the third session, one nurse noticed that the resident was less alert than normal and appeared puffier – likely because she was retaining fluid due to the missed dialysis sessions. The nurse practitioner was notified and ordered the resident sent to the hospital. There labs showed that the resident had critically high potassium levels. She was admitted to the intensive care unit and received dialysis.
There are three shortcomings in the care that this resident received. First, the nursing home was responsible for arranging transportation, and even if the outside company failed to provide the services it promised, the nursing home was still obligated to get the resident to her scheduled dialysis sessions. Second, when the resident did not receive the care that was ordered, this was a situation where physician notification was required. The failure to get the ordered dialysis is a very serious situation which can have severe adverse health consequences for the resident and the judgment and expertise of a physician as tow to how to address this is necessary. Third, the citation revealed that the staff did not have a good understanding of what dialysis services the resident needed. Because dialysis is so essential to the health and well-being of residents, the dates for dialysis and its completion should be clearly documented in the resident chart. Taken together, these failings led to the unnecessary critical illness of this resident.
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