The Illinois Department of Health has cited and fined Oak Park Oasis in Oak Park, IL when a 68-year-old psychiatric resident with a well-documented history of suicidal ideation was allowed unsupervised access to a razor blade, which she used to cut her own neck and face in an attempt to end her life, requiring emergency intervention and psychiatric hospitalization. The facility failed in its most basic obligation: to keep a known, high-risk resident safe in an environment it knew she could not safely navigate on her own.

The resident was a 68-year-old woman living on the facility’s dedicated psychiatric unit. Her diagnoses told a serious story: schizophrenia, major depressive disorder, bipolar disorder, PTSD, anxiety disorder, and recurring suicidal ideation. She was cognitively intact and fully aware of her own condition. Earlier that same year, she had been hospitalized after disclosing to staff that she had been hearing voices for months commanding her to end her life, and that she had a specific plan to cut her carotid artery with a razor blade. She returned to the facility following that hospitalization. Staff knew exactly who she was and what she was capable of doing to herself.

Late one evening, a nurse at the nurses’ station looked up to find the resident walking toward her with blood coming from the right side of her face and scratches visible on her neck. The resident explained what had happened in her own words, recounted to investigators: “I had a razor, took the razor apart, and used the blade to try to stab my carotid. I was having trouble because the blade was cutting my fingers, so I got even more mad, and took the blade to my face. I just wanted to die. I kept hearing voices telling me to just end my life.” The nurse immediately called 911, applied a compress to the wounds, and notified the physician and supervisors. Paramedics arrived within ten minutes and transported the resident to the hospital, where she was transferred to a psychiatric facility.

When investigators asked how the resident came to have a razor, no one could answer. Every staff member interviewed was unequivocal that she should never have had one. The nursing supervisor said: “No way! She cannot have a razor. She’s a suicide risk. I know her history. No, she should not have a razor unsupervised.” The psychiatric nurse practitioner was equally direct: “She likely should not have had access to a razor, and closer monitoring should have been in place.” The administrator acknowledged that the facility did not know how she obtained it. No one did.

The failure here was one of supervision and environmental safety. The facility’s own Suicide Observation and Prevention policy required staff to remove sharp objects from residents with suicidal tendencies, conduct continuous monitoring, and search rooms for harmful objects. Its Supervision and Safety policy required visual rounds at least every two hours with immediate removal of any hazardous items. A certified nursing aide confirmed in an interview: “We were taught that we must supervise the resident the entire time they have access to razors.” The facility knew the rules. It knew this resident’s history. And it still allowed a razor to reach her hands, unsupervised, on a psychiatric unit, at night, while she was actively hearing voices telling her to end her life. The care plan had not been updated after her prior hospitalization, and the incident had not yet been reviewed by the facility’s quality assurance committee — but the more fundamental failure was simpler than that: a vulnerable woman was not kept safe.

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. 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.

The Illinois Department of Health has cited and fined Accolade Healthcare of Savoy when staff failed to monitor and report critical warning signs for a resident with heart and kidney disease, including dangerously low blood pressures, significant weight gain, and decreased urination, resulting in acute kidney failure that required dialysis and ultimately led to her death. Despite the resident and her family repeatedly reporting concerns about decreased urination and back pain, staff delayed obtaining a urine sample for days and failed to notify providers about the resident’s deteriorating condition.

The resident in question was hospitalized for multiple serious conditions including urinary tract infection, pneumonia, heart attack, severe sepsis, and acute heart failure. When discharged back to the facility, she had significantly impaired kidney function and was on multiple heart medications including a diuretic. Her care plan required staff to monitor for side effects of diuretic therapy and report lab results. Her physician orders included instructions to notify if there was no urinary output for eight hours and to report if her systolic blood pressure dropped below 100.

Shortly after returning, the resident began experiencing concerning symptoms. She reported scanty urine overnight and worried she might be developing another infection. However, what followed was a series of delays and failures to act on clear warning signs.

The resident’s blood pressure readings were alarmingly low throughout her critical period, dropping to dangerous levels including 77/27, 89/34, 79/29, and 90/42. Despite orders to report blood pressures below 100 systolic, staff did not notify a provider about these critically low readings for days. The nurse practitioner later stated that if these low blood pressures “were reported sooner, she would have made adjustments in the resident’s medications sooner.”

The resident’s weight also increased significantly – from 144.9 pounds to 150.2 pounds over three days, a gain of over five pounds indicating fluid retention. Her medication record specified to notify the provider of a five-pound gain in one week. Despite this clear warning sign in someone with heart failure, there was no documentation that any provider was notified.

Most critically, the resident experienced decreased urination and repeatedly reported this concern, as did her family. Nursing notes documented repeated delays in collecting a urine sample with excuses including “due to lab schedule, will collect tomorrow” appearing multiple times. Staff claimed samples were contaminated with bowel movements or that the lab didn’t collect on weekends.

The nurse practitioner had ordered straight catheterization if the resident hadn’t urinated, but this order was not followed. Staff continued trying to get clean catch samples for days instead. The resident’s family member stated the resident “had reported back pain and lack of urination, which had been reported to nurses on day four, but the resident went nearly a week before anything was done.”

The medical record did not document that the resident’s urine output was routinely monitored every shift during this critical period. A urine sample was finally obtained via straight catheterization six days after initial concerns. By then, lab work revealed severe kidney failure – her blood urea nitrogen had increased from 47 to 76 and her creatinine had skyrocketed from 1.8 to 6.2. The nurse practitioner ordered her sent to the emergency room.

At the hospital, the resident’s condition deteriorated. Her labs revealed white blood cell count of 14.07 indicating infection, creatinine of 6.51, and sodium of 115 indicating dangerous hyponatremia. She was admitted to the intensive care unit with acute kidney injury, renal failure, and low oxygen levels. The hospital explained the resident had “acute kidney injury on chronic kidney disease likely prerenal from diarrhea and volume contraction” with “likely acute tubular necrosis” – actual kidney tissue damage.

Two days after admission, the resident started dialysis and was intubated due to worsening oxygen requirements. After almost 10 days on a ventilator with continued dialysis, the family opted for comfort measures and the resident died.

The nurse practitioner stated clearly the failures had serious consequences. She confirmed “staff should have been monitoring the resident’s urine output after her complaints” and “this delay in treatment could lead to complicated UTI, decreased urine output, and AKI.” She explained that “if she was made aware of these changes in the resident’s condition sooner, she probably would have sent the resident out to the hospital sooner.”

Regarding the unreported weight gain, the nurse practitioner stated “if this was reported, she would have ordered a one-time additional dose of Lasix.” She concluded that “decreased blood pressure and decreased urine output along with days without reporting could have contributed to the resident’s critical lab results, and the resident could have been sent out sooner and may not have required dialysis.”

The nurse practitioner acknowledged the resident “was very sick and had a lot of things going on, so it is hard to say if these failures and delay in treatment caused the resident’s death, it may have only prolonged things if the resident had received hospital treatment sooner.” However, the cascade of failures was clear: staff never reported dangerously low blood pressures for days, never reported significant weight gain, delayed obtaining a critical urine sample for nearly a week despite orders, and failed to properly monitor the resident’s urination despite her repeated complaints.

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. 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.

The Illinois Department of Health has cited and fined Evercare at University when nursing staff dismissed a 95-year-old resident’s severe breathing distress as a “panic attack” and failed to seek immediate medical attention despite dangerously low oxygen levels. The resident was eventually hospitalized on a ventilator after her family called 911, with emergency responders finding her oxygen saturation at a life-threatening 50 percent.

The resident in question, who was cognitively intact and on dialysis three times per week, had been readmitted to the facility after a hospital stay for pulmonary edema and was already on continuous oxygen therapy. On the evening of the incident, she began experiencing severe shortness of breath and repeatedly called out “I can’t breathe, I can’t breathe.” Multiple staff members heard her distress but repeatedly told her to “calm down” and dismissed her condition as a panic attack rather than recognizing it as a medical emergency.

The Licensed Practical Nurse on duty that evening later admitted she “got called in because another nurse did not show up” and was immediately handed medication cart keys and placed on a lengthy phone call. When the resident’s oxygen saturation was measured at 76 percent, the nurse acknowledged that “we normally send residents out to the hospital when the oxygen is 84% or less,” but chose not to do so because “it was a crazy night” and she believed the resident “was having a panic attack and just wanted someone to sit with her.” The nurse stated she was “not sure” if she contacted the doctor, violating the facility’s change of condition policy requiring immediate physician notification.

A Certified Nursing Assistant took vital signs but failed to document them in the computer system, instead writing them “down on a piece of paper” and giving them to the nurse. When asked about the specific readings, the assistant said she “can’t remember what they were.” Multiple staff members interviewed confirmed they do not routinely take or document vital signs, with one stating “the nurses usually take their own vitals” and another saying “I will take a vital if the nurse asks me to. Otherwise, I normally do not take vitals.”

The resident’s family member received a call around 7:00 PM telling them their mother was having a panic attack. Upon arriving at the facility, the family member found their mother “gasping for air” and “in distress,” describing the scene as “unimaginable.” Unable to locate nursing staff for assistance, the family member called 911 directly. The family member stated, “I don’t know why the facility did not send my mom out when she started having problems, I am at loss.”

Emergency Medical Services arrived to find the resident in severe respiratory distress with an oxygen saturation of only 50 percent, far below the normal range of 92 percent or higher. The EMS report documented that the resident’s “skin was flush and blue in extremities” and she had “shallow and rapid respirations.” When paramedics attempted to get a report from nursing staff, they were told only that the resident “has been struggling to breathe for several hours” and that the nurse “came into the patient’s room several times to tell her to calm down and slow her breathing for several hours.”

The resident required immediate advanced life support interventions, including multiple intubation attempts and the use of an emergency airway device. She was transported to the hospital where she was placed on mechanical ventilation due to “hypoxic respiratory failure and severe respiratory distress.” The hospital records confirmed she arrived “cyanotic with a SPO2 of 50% with labored breathing” and required the highest level of critical care intervention.

The facility’s Medical Director stated that he would expect “all oxygen levels to be at 92% or higher” and that if a resident was saying they could not breathe with oxygen levels at 76 percent, he would expect staff to “send them out immediately.” He emphasized that “if they were in distress, I would want them sent out immediately.” The Director of Nursing confirmed that she expects “all vitals to be charted and in the resident’s medical records” but was unaware that the resident was in distress with her oxygen levels.

The incident revealed multiple systemic failures, including inadequate staffing with nurses covering multiple units, failure to properly document vital signs, dismissal of serious medical symptoms, and violation of the facility’s own policies requiring physician notification and hospital transfer for residents with dangerously low oxygen levels. The resident’s care plan failed to address her oxygen needs or respiratory issues despite her documented pulmonary problems and recent hospitalization for fluid in her lungs.

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. 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.

The Illinois Department of Health has cited and fined Aperion Care Elgin when they failed to maintain proper emergency tracheostomy supplies for a resident with a tracheostomy tube, resulting in delayed care during a respiratory emergency. The resident suffered from acute respiratory distress and had to be transferred to the hospital for treatment of acute respiratory failure after facility staff could not properly address a tracheostomy tube obstruction.

The resident in question was admitted to the facility with multiple medical conditions including a subarachnoid hemorrhage from an intracranial artery, ruptured aneurysm, acute respiratory failure with hypoxia, and had a tracheostomy (an artificial opening in the neck with a tube inserted to help with breathing). The resident was receiving supplemental oxygen at 6 liters via a trach collar.

This incident was not the first time the resident experienced problems with his tracheostomy. Less than a week before the emergency, the resident’s entire tracheostomy tube had become dislodged. A Licensed Practical Nurse (LPN) attempted to reinsert it but was unsuccessful, resulting in the resident being transferred to the hospital. The resident returned the same day with a new, smaller tracheostomy tube (changed from a size 6 to a size 4).

On the night of the emergency, the resident began experiencing low oxygen levels. The nurse administered a nebulizer treatment and then attempted to suction the tracheostomy but encountered resistance. When the nurse tried to change the inner cannula (the removable part inside the main tracheostomy tube), she also met resistance. According to the nurse, “I was not trained in changing entire tracheostomy tubes,” so she contacted the resident’s physician who ordered transfer to the hospital.

When emergency paramedics arrived, they found the resident’s oxygen levels were worsening. They attempted to ventilate and suction but also encountered resistance. The paramedic explained, “The protocol for when resistance is met with patients with tracheostomies is to change the entire trach tube.” When the paramedic asked the nurse if she had attempted to change the tube, she responded that she “was not trained to change entire trach tubes.”

The nurse provided the paramedic with a tracheostomy kit, but it contained the wrong equipment—an uncuffed tracheostomy tube without an obturator (a guide used to help insert the tube safely). Despite having inadequate equipment, the paramedics managed to change the tracheostomy tube and ventilate the resident before transferring him to the hospital.

At the hospital, the resident was admitted for “acute on chronic hypoxic respiratory failure.” Hospital notes indicated “EMS attempted to change the inner cannula, but they did not have the proper equipment; however after the clogged inner cannula was removed his SpO2 improved.” The hospital report continued: “Upon arrival to the ED he presented with stable and appropriate vitals but he quickly became hypotensive and hypoxic. His trach was connected to mechanical ventilation.”

An inspection of the resident’s bedside supplies revealed serious deficiencies. A box of size 6 inner disposable cannulas at the bedside had expired nearly a year earlier. The nurse acknowledged that “tracheostomy equipment should be checked and disposed of when expired.” More concerning, there were no emergency tracheostomy exchange kits for the resident. The nurse confirmed that residents with tracheostomies required emergency exchange tube kits with an obturator “for emergency situations at the bedside.”

The Respiratory Therapist Manager, who provided consulting services to the facility, confirmed that residents with tracheostomies required specific emergency equipment at bedside, including “trach tube kits with the same type of trach tube and an obturator.” She specified the kits should include “one of the same size and a downsized one” and that equipment “should be checked routinely to ensure safe trach care is being provided.” She also noted that licensed nurses could change tracheostomy tubes “if there was a doctor’s order and if they were trained appropriately.”

The Director of Nursing confirmed that when the resident returned from his previous hospital visit, his tracheostomy tube had been replaced with a smaller size 4 tube. She stated the facility expects nursing staff to ensure residents with tracheostomies have the required emergency supplies at bedside, including kits with a tube of the same size, a downsized tube, and an obturator. Importantly, she stated she “expects nurses to be able to change entire trach tubes monthly as ordered and during emergencies.”

The resident’s care plan specifically included “TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside.” Furthermore, the resident’s orders clearly stated “Trach: Licensed nurse may re-insert trach tube, as needed for dislodgment” and “Trach: Change Trach tube every day shift every 1 month(s).”

The facility’s Admission Data Form for tracheostomy patients specified that equipment needed included “one same size trach and one downsized trach at the bedside at all times.” However, the facility’s Tracheostomy Care policy contradicted this by stating: “Emergency Care: If outer tube comes out, stay with resident and summon assistance. A rubber tipped hemostat maybe used to maintain opening. If necessary, suction the resident through the opening. Physician generally responsible for reinserting new tube.”

This conflicting policy may have contributed to the nurse’s belief that she was not authorized to change the tracheostomy tube, despite having physician’s orders permitting her to do so. The policy also did not provide instructions on how to perform the procedure, suggesting inadequate training for staff on this critical emergency procedure.

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. 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.

IDPH has cited and fined Bria of Elmwood Park when the facility failed to respond urgently and quickly to a resident’s respiratory distress and need for suctioning, resulting in a delay of care and ultimately the resident’s death.

Around 9:00 AM on the morning of the incident, a LPN (Licensed Practical Nurse) noticed the resident gesturing and pointing to his tracheostomy, indicating a need for suctioning. The LPN informed the Respiratory Therapist, who was working with another patient next door. Critically the LPN did not ensure that suctioning was provided immediately.

The Respiratory Therapist stated that she provided routine morning tracheostomy care, including suctioning, around 9:25 AM – 9:30 AM, noting that the resident was agitated before, during, and after the care.

At approximately 10:30 AM, a CNA found the resident unresponsive and notified the LPN, who initiated a code blue. During the resuscitation efforts, it was discovered that the resident’s tracheostomy tube was dislodged. Despite the staff’s efforts and the arrival of EMS, the resident was declared deceased at 11:07 AM.

One of the most significant shortcomings in the resident’s care was the nursing home staff’s inadequate response to his clear signs of respiratory distress. When the resident was observed gesturing and pointing to his tracheostomy, indicating an urgent need for suctioning, the LPN (Licensed Practical Nurse) failed to recognize the severity of the situation and did not take immediate action to ensure that the resident received the necessary care. This lack of urgency was a contributing factor to the delay in the resident’s treatment.

Furthermore, the Respiratory Therapist failed to prioritize the resident’s needs when informed of his distress. Instead of immediately attending to the resident, the RT continued with routine tracheostomy care for other residents, only reaching the resident nearly 30 minutes later. This delay in providing crucial suctioning support was problematic given the resident’s agitated state and the well-known risks associated with inadequate airway clearance in tracheostomy-dependent patients.

The nursing home’s substandard policies and insufficient staff training regarding respiratory care and suctioning also played a significant role in the suboptimal care the resident received. The inconsistencies in staff members’ understanding of their roles and responsibilities in responding to respiratory emergencies highlight the facility’s failure to ensure that its staff was adequately prepared to handle such critical situations. This lack of proper education and clearly defined protocols directly contributed to the confusion and delay in the resident’s care.

Moreover, the nursing home’s inadequate staffing levels and lack of proper monitoring equipment for residents with tracheostomies not connected to ventilators further compromised the resident’s safety. The facility’s decision to prioritize cost-cutting measures over resident well-being, by failing to provide sufficient respiratory therapists and neglecting to install necessary alarm systems to alert staff of potential tracheostomy dislodgement, created an environment in which the resident’s deteriorating condition went unnoticed until it was too late.

The culmination of these shortcomings in the resident’s care – the lack of urgency in care, the delay in providing necessary suctioning, the inadequate policies and staff training, and the insufficient staffing levels and monitoring equipment – resulted in the resident suffering from prolonged respiratory distress, ultimately leading to cardiac arrest and death. This tragic outcome could have been avoided had the nursing home fulfilled its fundamental duty to provide timely, competent, and attentive care to its 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. 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.

IDPH has cited and fined Caseyville Nursing & Rehab Center after a resident there suffered a slit in his penis due to poor catheter care.

The use of catheters is discouraged under federal regulations for nursing homes, in large part due to the risk of the development of urinary tract infections.  However for males especially, there is a risk of damage to the urethra from prolonged catheter use.  A catheter is a thin tube which is threaded through the urethra into the bladder to allow urine to be drained from the bladder.  The risk of tearing of the penis comes from friction from the catheter and pressure from the tubing and collection device.

The resident in question suffered from numerous health issues and ultimately needed a catheter installed to help him urinate. On a daily basis nurses would have to care for his catheter and the surrounding area.

At first, the catheter made the resident’s penis skin red and sore. There was a care plan made that instructed nurses to watch the spot daily and protect it with ointment. But over many months, the nurses failed to consistently care for the area – oftentimes days would go by without checking the resident’s catheter.

Gradually, a cut formed on the tip of the resident’s penis.  The cut grew worse over time and spread all the way down his penis, eventually becoming an open slit. Nurses applied ointment to the cut but did not measure it or keep records of how bad it was getting.

One key mistake was that a nurse incorrectly thought the resident was in hospice. Hospice is limited to comfort care for people near the end of their lives.  In hospice the goal is not to heal injuries. So that nurse claimed since the resident was supposedly in hospice, he was not sent to the ER to get the worsening penis slit the medical care it required.

In reality, however, the resident had been removed from hospice care approximately 10 months beforehand. A hospice supervisor confirmed that there was no record of any penis injury for the resident while he was receiving care in hospice. So the resident could (and should) have been sent to the hospital to fix the issue at a much earlier date.

The bottom line – months of poor catheter site care allowed the penis wound to increase in size and worsen. Ignoring internal facility rules to check and care for the catheter wound allowed the injury to grow more severe. 

Finally, after 8 months, the resident had to have surgery to implant a new catheter and fix the fully split penis. 

The situation likely could have been prevented had the nurses been aware of the resident’s hospice status and if the nurses had followed catheter care policies on a consistent basis. 

Sadly, the resident endured much needless and preventable pain and suffering.

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.