IDPH has cited and fined Burbank Rehabilitation Center nursing home after a resident there had to be hospitalized for fluid overload after not being brought to dialysis as ordered.
Nursing home residents who are suffering from kidney failure may require dialysis, and when this is true, families often make the decision to pick one nursing home over another based upon the availability of an in-house dialysis unit in order to spare their loved one from having to be transported to an outside dialysis center. These in-house units are usually operated by a separate company which means that coordination of care between the dialysis unit and the nursing staff is crucial to ensuring that the resident receives the care that is required. When this doesn’t happen, the results can be catastrophic. When the kidneys are not functioning properly, the body cannot remove excess fluid and toxins. Dialysis takes up that function in the absence of properly working kidneys. When necessary dialysis sessions are missed, excess fluids and toxins can build up and cause serious problems throughout the body, most notably with the heart and lungs.
The resident at issue suffered from end stage renal disease, or kidney failure. She was admitted to the nursing home from the hospital with orders to receive dialysis three days a week (Tuesday, Thursday, and Saturday). The orders are also called for the nursing staff to checks vitals after dialysis and to check the dialysis access site for signs of redness, bleeding, or swelling. The nursing home staff documented that the resident received dialysis as ordered for the first three scheduled sessions and that the post-sessions checks of vitals and of the access site were all done.
However, on the same day as the scheduled third session, the nursing staff noted that the resident was suffering from pitting edema, required supplemental oxygen, and was lethargic. The staff could not obtain her vital signs. Due to this change in condition, the nursing staff notified the resident’s doctor who ordered the resident sent to the hospital.
At the hospital, based on the resident’s presentation and abnormal labs, the resident was diagnosed as suffering from volume overload due to missed dialysis sessions. She was hospitalized for twelve days in order to resolve the condition.
The investigation into this incident revealed that the facility had policies and procedures in place for coordinating the care between the nursing home and the dialysis center for new admissions to the nursing home who required dialysis. However, even with the policy in place, the resident was not added to the list of residents who would be receiving dialysis on the days on which it was ordered. This breakdown in the process led to the missed dialysis sessions and the resident not receiving the care as ordered.
Beyond that, the nursing staff on the floor signed off on the resident as receiving dialysis on the days when it was ordered when it was in fact not done. Had the nursing staff realized that the care ordered had not been provided instead on simply checking off that it had been done, this situation would not have escalated to the point that it did.
One of the things that out firm does very carefully in prosecuting nursing home abuse and neglect cases is go through the chart very carefully for evidence of false charting – that is, documenting care that was never provided. We have seen examples of where the staff was documenting care being provided when the resident was in the hospital or in one case, after the resident was dead. When we find this evidence, it undermines the credibility of the other entries made on the chart and makes it very difficult for the nursing home to defend the care that was provided.
This is a situation where there were clear breakdowns in the basic operations of the nursing home. The process that was in place wasn’t followed and the staff was documenting care that was never provided. 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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