IDPH has cited and fined River Crossing of Alton nursing home after a resident there had to be hospitalized with hepatic encephalopathy after not receiving a medication as had been ordered for her.
Ammonia is a waste product that builds up in the blood as part of the digestive process. Ordinarily, ammonia is filtered through the liver where it is converted to urea which is then removed from the body through urination. When the liver is not functioning properly, ammonia builds up in the body and can be toxic to the brain and other organs. One way in which ammonia levels in the body can be brought down is through the use of a drug called lactulose.
The resident at issue had a diagnosis of cirrhosis of the liver and her admitting orders called for receiving lactulose every 8 hours, or 3 times per day. However, during the first two days of her admission to the nursing home, she received only one dose each day and then did not receive any the third day that she was in the nursing home because she was out of the facility at the time that medication was passed.
The resident’s chart reflects that a friend called the nursing home on the evening of the third day of her admission and told the nurse that he had spoken to the resident and she reported to him that she was only getting her lactulose once a day and should have been getting it two or three times a day. There does not appear to have been any action taken in response to that phone call, as the next morning when staff checked on the resident first thing in the morning, she was unresponsive.
The resident was brought to the hospital where her lab work showed that she had ammonia levels of 238 (normal range is 15-45). She was admitted to the hospital with a diagnosis of hepatic encephalopathy, which is a loss of brain function brought on by the failure of the liver to remove toxins from the blood. Here, the brain injury was caused by the failure to give the medication as ordered.
There are two major breakdowns in the care that this resident received. First, the admitting orders were not transcribed properly, resulting in her receiving one dose of lactulose per day rather than the three which were ordered. This nursing home medication error led directly to the brain injury that this resident suffered. The IDPH citation further stated that the Director of Nursing admitted that there had been some problems with accurately transcribing orders. Second, there was no apparent action from the call from the friend. It is more than likely that if the resident was raising the medication issue with the friend, she was also raising it with the staff. At a minimum this should have sparked some effort by the staff to verify that the orders were correct and to discuss the matter with the resident. Instead the call brought no apparent response, with the resident being taken to the hospital unresponsive the following morning.
This breakdown in the care that this resident received is what happens when the staff does not take the time to actually meet the care needs of the resident by doing things like checking to make sure that orders are entered properly and that concerns about the care are at least considered. When these things don’t happen, it raises questions about whether this is an understaffed nursing home. Unfortunately, understaffing a nursing home is a basic feature of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
Other blog posts of interest: