IDPH has cited and fined Sauk Valley Senior Living in Rock Falls after a resident was admitted to the hospital in respiratory distress due the failure of the nurisng staff provide proper care for a resident with a tracheostomy.
The resident at issue was 31 years old who suffered a severe brain injury after choking on food. As a result of this incident she was nonverbal, unable to care for herself of participate in her care, and had a tracheostomy.
A tracheostomy is a surgical hole in a person’s throat which helps a person breathe. After the surgical incision is made, there is a tub called a cannula which is placed down the person’s airway. The cannula actually has two components: an inner cannula and an outer cannula. The outer cannula hold open the site of the tracheostomy, while the inner cannula is inserted into the windipipe and can be removed for cleaning.
The cannula can become obstructed with fluids or other items. Obstruction of the cannula can result in a loss of oxygen to the patient and ultimately result in the wrongful death of the nursing home resident. One way of resolving an obstruction is by suctioning.
The orders for tracheostomy care called for the resident to receive trach care daily and as needed, to be suctioned as needed, and to have the inner cannula changed daily. This was doubtless part of her care plan.
On the night of the incident, an aide recognized that the resident was struggling to breathe, so she brought the nurse in. The nurse gave oxygen and listened to the resident’s lungs and recognized that the resident had minimal lung sounds. She admitted to the state surveyor that she did not attempt to suction the resident because she did not have much experience working with tracheostomies. She notified the doctor and obtained an order for the resident to be sent to the hospital.
When the paramedics arrived, they recognized that resident was in respiratory distress and was told by the nurse that had been going on for up to an hour. When they arrived at the hospital, the nursing staff found that the tracheostomy cannula was clogged with blood tinged sputum and hair. It was very dirty and it was obvious to the nursing staff that the cannula had not been cleaned or suctioned. They cleaned out the cannula and replaced it and the resident began breathing normally.
The obvious issue here is that the resident was not receiving the care that she needed to maintain her airway. When she was brought to the hospital, the inner cannula was clogged with hair and fluids and was very dirty. This indicates that the resident was not receiving the care that she needed and which is actually required under federal regulations.
Nursing homes are also required by federal regulations to have sufficient staff with the skills needed to assure resident safety and meet the care needs of residents. The nurse on duty at the time of this incident demonstrated that she did not have necessary skills to care for this resident as she either did not know to suction the resident or did not believe that she had the skills to do so. Either way, the most immediate step to care for the resident was not taken.
Violations of federal regulations like this are a form of nursing home abuse and neglect.
If the nursing home did not have the staff available to properly care for this resident – and it appears from the description of the cannula in the IDPH citation that this resident was not the only nurse uncomfortable caring for the tracheostomy – then the only proper course for this nursing home would have been to deline the admission. However, this is the kind of medically compromised, complex patient that tends to bring higher levels of revenue for the nursing home, so the profit model says that this resident will be accepted for admission when the wisest course action may have been to decline the admission.
One of our core beliefs is that nursing homes are built to fail due to the for-profit business model they follow and that unnecessary accidental injuries and wrongful deaths of residents are the inevitable results. 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:
Resident wanders from Good Samaritan Society in Mt. Carroll
California Gardens fails to obtain respiratory equipment
Urinary catheter injury at Marigold Rehab
Resident dies after yanking out own tracheostomy
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