IDPH has cited and fined Countryside Nursing & Rehab in Dolton after a resident there was assaulted by her roommate and sustained multiple injuries.
One of the little-known facts about the nursing home industry is that many nursing homes accept residents who suffer from significant forms of mental illness. Many times these are residents who are significantly younger than your “typical nursing home resident” and do not have the same kinds of physical limitations that many nursing home residents have. When their form of mental illness manifests itself in aggressive behavior, there is a real risk of significant abuse.
The victim in this case was a 99 year old woman who suffered from Alzheimer’s disease. Her Minimum Data Set indicated that she was rarely to never understood. She was assessed as being at risk of harm due to serious mental illness. Her care plan called for close monitoring by staff and redirecting her from situations where there is a potential for harm. According to the interviews with the staff, she was a good fit for her roommate because she rarely received visitors.
The aggressor in this case was her roommate. She was 65 years old and suffered from schizophrenia. Before this incident, she had been involved in three other instances of physical aggression against other residents, two of whom were her roommates. The staff believed that part of the reason that she had become aggressive with past roommates is that she did not like having other people in the room and her old roommates had received visitors frequently. Her care plan included assessing her behavior and intervening if her behavior became a threat to others.
In the days leading up to this resident-on-resident assault, she exhibited signs that she was experiencing delusions and had been verbally aggressive with staff. Further, she was refusing some of the medications that had been ordered by her treating psychiatrist. The staff failed to notify the psychiatrist that she was refusing medications and that she was exhibiting signs of delusional behavior.
The assault was discovered by a staff member who saw the victim on the floor with a number of bruises, cuts, and other signs of injury. The aggressor was laying in bed when the staff discovered the victim on the floor. When the aggressor got out of bed, they saw that she had a belt with her that had blood on it. The victim was brought to the hospital where in addition to receiving treatment for the beating that she had received, she also underwent x-rays which showed that she had a broken finger and a broken wrist.
The hall where these residents resided was staffed by an aide and a nurse. The aide brought the victim back to her room around 6:30 p.m. Both she and the nurse clocked out around 8:30 p.m. for their meal break, leaving the residents unsupervised. The attack was discovered shortly before 9:00 p.m. The Director of Nursing told the state surveyor that the residents should not have been left unsupervised during meals – if they were both going to go, they needed to arrange coverage.
There are a number of problems with the care that was being provided. First, the victim was assessed as being at risk for abuse, yet they chose to room her with a resident who had a demonstrated history of aggressive behavior toward her roommates. Second, the staff failed to notify the psychiatrist that the aggressor had been exhibiting signs of delusion and had been refusing her medication. This denied the doctor a chance to intervene in the resident’s behavior before it escalated. Third, the residents were left unsupervised even though this is the front-line mechanism for preventing abuse between residents.
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.
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