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Generations at Applewood Cited After Ten-Tooth Extraction Proceeds Without Notice to Resident’s Providers, Requiring Emergency Transfusions

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The Illinois Department of Health has cited and fined Generations at Applewood in Matteson, Illinois when, according to state investigators and facility records, the facility failed to notify the resident’s attending physician and cardiology provider that an extensive dental extraction had been scheduled, and failed to communicate with those providers and obtain and implement appropriate orders concerning the multiple blood-thinning medications the resident was taking. Ten teeth were extracted, the resident began hemorrhaging from his gums after returning to the facility, and he was emergently transferred to the hospital and admitted with oral hemorrhage requiring transfusion of multiple blood products.

The resident was documented as moderately cognitively impaired and was taking two blood-thinning medications — apixaban, a prescription anticoagulant, and aspirin. Months before the extraction, a cardiology nurse practitioner had given clearance for a dental procedure with specific instructions: hold the apixaban for two days beforehand and the aspirin for five days beforehand. At the time she gave that clearance, no extraction date had been scheduled. She repeated those same instructions weeks later when the attending physician’s nurse practitioner contacted her about clearance for the extraction at the request of the resident’s power of attorney.

According to the citation, the cardiology provider was never told when the procedure was finally scheduled. She told investigators that no one from the facility informed her a date had been set, that it was her expectation the facility would do so, and — significantly — that she had understood the plan to involve a single tooth. She considered that a low-risk procedure. Multiple extractions, she said, would have been high-risk. She stated that had she known the date of the extraction appointment, she would have definitely continued with the order to hold the anticoagulant medication before the procedure.

The resident’s attending physician told investigators he was likewise never made aware of the scheduled date, and that his expectation was for the facility to inform him. He said that had he known, the facility has a protocol for placing anticoagulant medication on hold before a procedure, and that he would have ordered the apixaban held for three days and the aspirin for seven days before an extraction of multiple teeth. He added that “one tooth extraction is more than enough to cause bleeding, and so it is important to hold blood thinner medication prior to procedure.” The nurse practitioner working with him gave investigators the same account, stating she was aware of a possible tooth extraction but not of multiple teeth, and was never told a date had been set.

The dentist told investigators the dental office was aware the resident was taking anticoagulant medications, and that it is the facility’s physician who can order those medications held. He acknowledged the dental office did not communicate any recommendation, pre-procedure guidance, or instruction to either the facility or the resident’s physician. He stated the facility already knew the reason for the appointment was tooth extraction and should have communicated that to the physician. According to the citation, the resident consented to new dentures and to the extraction of ten teeth.

Ten teeth were extracted. The dental notes record that bleeding had been brought under control before the resident was released back to the facility. Once he returned, staff could not control the bleeding from his gums, and emergency services were called. Hospital records document that he arrived by ambulance with oral bleeding, that pressure was applied with gauze, which provided some initial relief but slowed the bleeding only a small amount, and that given the volume of blood loss described at the facility and observed in the emergency department, the decision was made to transfuse him with red blood cells, platelets, and fresh frozen plasma. His anticoagulation was reversed using a medication containing blood clotting factors. He was admitted with a diagnosis of oral hemorrhage. His attending physician separately told investigators the resident required at least one or two units of blood transfusion during the hospital stay, and the nurse practitioner working with him said the resident received at least one unit of blood and plasma to help reverse the hemorrhaging.

The Director of Nursing told investigators that once an appointment is scheduled, nurses are to notify the resident’s family and attending physician, and that doing so gives the facility and physicians the opportunity to review the resident’s records and issue orders to hold or discontinue anything necessary. The resident’s physician order sheet contained no order to hold any medication before the dental procedure. The facility’s own policy required the nurse to notify the attending physician when there is a need to significantly alter a resident’s treatment.

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 Illinois 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.

Nurse Misjudges Resident In Crisis, Fails To Notify Physician Or Call 911 To Save Resident From Death At Zahav of Des Plaines

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IDPH has cited and fined Zahav of Des Plaines nursing home after the staff failed to notify the resident’s doctor of a critically low lab value, with the resident ultimately going into cardiac arrest and dying.

Doctors are not present in a nursing home on a 24/7 basis and when they are not there, one of the roles that the nurses play is to serve as “the eyes and ears” of the doctor.  In that role, it is their job to notify the doctor when things occur like nursing home falls, the development of bed sores, and significant changes in the resident’s condition.  One of the things that they are also responsible for is reporting when lab results show abnormal values.  This allows the doctor to make a decision to issue orders over the phone, come into the nursing home to see the resident, or order the resident sent to the hospital.

In this nursing home death case, a nurse was notified by an outside lab of a resident’s critically low sodium level of 119 (normal 138-147).  In addition to the abnormal lab value, the resident was exhibiting multiple signs of decline – including lethargy, poor appetite, cool skin, blue discolored fingertips, slowed speech and glazed over eyes.

A change in condition such as this, accompanied by critically low lab values, should have warranted the nurse reaching out to the resident’s physician for further direction. 

In this case however, the resident’s physician stated the decline in the resident’s health was never communicated to him by any nurse at the nursing home.  If he had known, the physician acknowledged “…he would have sent the resident to the hospital for further evaluation.”

The next day a CNA noted that the resident had not eaten his breakfast or lunch.   Critically, a new nurse that was caring for the resident failed to review the lab report from the prior day that documented the low sodium level. 

At 4pm that day, a CNA informed the nurse that the resident “was not looking well.” The nurse subsequently went to assess the resident and only increased the resident’s oxygen, then left him alone to check another resident.

Around the same time, the Director of Nursing came to the unit and made the call for EMS after seeing the resident’s condition.

The Nurse admitted that there were not any staff continuously monitoring the resident until EMS arrived. The EMS run report noted it was 30 minutes from when the resident was last seen to when the 911 call was made. The resident was found in cardiac arrest and resuscitation efforts were not successful.

The nurses caring for the resident failed to adequately assess, document or report his deterioration to his physician. Prior to his death he was left completely unattended for at least 30 minutes when in distress before 911 was called, which delayed medical intervention.

The facility’s delayed emergency response and lack of monitoring most likely contributed to the resident’s death.

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.

Resident’s Pleas For Help Neglected By Nursing Staff, Dies At Chicago Ridge SNF

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IDPH has cited and fined Chicago Ridge SNF after a resident there suffered potential fluid overload in the lungs and subsequent death only three days after admission.  

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.  On the day that the resident was admitted, the internet was down from approximately 2:30 pm until approximately 1:00 am the following day.  While the in-house dialysis center was aware that the resident was arriving, they were never notified via email by the admitting nurse that the patient had actually arrived. 

Notes from the investigation highlight that this was most likely due to the initial lack of internet connectivity.  To make matters worse, the nursing staff neglected to send the email to the dialysis center once the internet was back up and running later the following morning.

The first signs of trouble appeared two days after the resident was admitted, when a nursing note documented that the resident was having trouble breathing and the blood oxygen level was 93%.  A nurse noted that to help the resident the nurse elevated the bed and the blood oxygen level rose back to 97%. 

The following afternoon the resident’s condition further deteriorated, with nurses noting that the resident was “coughing a lot and spitting up secretions.”   Nurses stated in the investigation that they were “too busy” to listen to the resident with a stethoscope and did not notify any doctors that the resident’s condition had changed for the worse, stating “I didn’t think to call the doctor at that time.  I just passed it onto the next nurse.”

Later that night notes indicate that a nurse visited the resident’s room at around 1:21 am.  The resident was reported to be talking but sounded upset.  While the residen’s breathing sounded congested and was slightly out of breath, the resident refused to be suctioned and was assisted by the nurse to lie back with head elevated.  The door was left open so that the nurse could hear if the resident needed assistance. 

The resident’s roommate, on the other hand, had a different story to tell.  The roommate claims that the resident was “screaming and yelling almost all night” and “coughing to the point of almost choking” screaming aloud “I can’t breathe.  Help me!”  The roommate claimed that a nurse visited the residence one time that night, telling the resident to “sit up and drink some water.” 

Unfortunately, at 6:45 am the morning nurse entered the resident’s room, only to find him without a pulse.   

There were a number of shortcomings in the care that this resident received:

  • When the resident initially developed shortness of breath and a low blood oxygen level, a doctor should have immediately been informed.  Further, there was no attempt to provide him with oxygen or send him to the hospital for further care.  It represented a change in condition and a real threat to the health and well-being of the resident.
  • There was no effort to regularly monitor the resident on the night before his death. Following the initial change in condition, the resident should have been checked on every two hours. The nurse on duty the night before the resident’s death admitted to not revisiting the resident after 1:21 am due to her busy schedule.  
  • There was inadequate response to possible fluid overload signs. The resident’s symptoms, such as respiratory distress, were indicative of potential fluid overload, yet no action was taken to address this.
  • Finally, when a resident is admitted needing dialysis, certain protocols must be followed.  In this case, the admitting nurse was able to order the resident’s medications, but failed to notify the in-house dialysis center, putting the patient in grave danger and contributing to the resident’s death just a few days after admittance.  

One of our basic 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.

 

Vienna’s Hillview Healthcare Center Neglects to Notify Family Of Illness, Resident Dies

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IDPH has cited and fined Hillview Healthcare Center in Vienna after the facility failed to notify a resident’s family member in a timely manner of their loved ones’ dramatic decline in health.  Had the family been notified earlier, they would have acted to send her to the hospital prior to her becoming so ill that she perished in the ambulance.

Failing to follow protocol in notifying family members or Power of Attorney is an unfortunately common nursing home error. (See here, here, and here for examples). This is most often caused by an understaffed nursing home, not following appropriate steps, taking shortcuts, and ignoring the requests of its residents and family members. 

In this case, the progress notes from the first night of the incident indicate that the resident was suffering from a high fever.  Further, over the nighttime period the resident had remained in a recliner to sleep.  When passing her medications the resident was noted to be in a stupor with labored breathing and a temperature of 102.9. It was also noted that the resident was only responsive to painful stimuli of sternal rubs and deep nail press. The resident’s oxygen had dropped to 88% on room air.

The notes from the following day indicate that the resident had a large loose stool while sitting in her recliner and that the stool covered the resident “from head to toe.” That same day the resident was very slow to respond when spoken to and kept her head down while sitting in her recliner.

The facility was unable to provide documentation or reproducible evidence that any emergency contact or family members had been notified of this drastic change in condition.

In the afternoon of the second day a family member made an unannounced visit.  

At the time of the family members visit, the resident was observed to be non-responsive, and a staff member attempted a sternal rub with no response. The staff member looked at the resident’s legs, saw the mottling in her lower legs and told the family member “that concerned him.” The family member stated that the caregiver told her, “It just has me baffled. I don’t know what more to do because most of her vital signs were good.” 

The staff member stated that it was not clear to him what he was dealing with. At that point he said, “I think we need to send her to the hospital and that maybe it is something an IV could take care of”. When asked if she had spoken to the hospital yet, the staff member stated, “Not really.”

During a post incident interview, the staff stated they did not contact the family because the family had the facility number blocked. When the family contact was interviewed and asked if they had any of the facility phone numbers blocked so the facility would be unable to contact them, they stated, “I did not have my phone off and my phone number is not blocked to receive calls from the facility. Three family members’ contact information were listed in the resident’s record.

Had the facility contacted the numerous numbers available, the resident could have been transferred to the hospital hours earlier, when it was evident the resident’s health was in danger. 

Sadly, when the ambulance was finally ordered, the resident was transferred to the ER but died in transit to the hospital. Her cause of death was sepsis due to cellulitis, gastric bleed, and cardiac arrest.

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.

Failure to treat infection leads to resident death at Elevate Care South Holland

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IDPH has cited and fined Elevate Care of South Holland nursing home after a resident there died as a consequence of an infection of his dialysis fistula going untreated.

One of the basic truisms of care in a nursing home is that doctors are not present in a nursing home 24/7 the way that they are in a hospital.  Therefore, in the absence of physicians being in the building, nurses must act as “the eyes and ears” of physicians with regard to the residents who are under their care.  In that role it is part of their job to notify physicians of changes in the condition of the residents who are under their care as well as events such as the development of bed sores, medication errors, choking incidents, and falls.  After a doctor is notified of one of these things, the doctor has the option to issue orders for care over the phone, come into the nursing home to see the resident, or order the resident sent out to the hospital.

One of the types of conditions that nurses must notify doctors about is the onset of signs and symptoms of infection.  Nurses do not need to know whether what they are seeing is actually an infection, what kind of infection it is, or how to go about treating it – although experienced nurses often have a solid idea about all of these issues.  The most common course of action is to start an antibiotic and to obtain a relevant culture (for example, a urine culture if a urinary tract infection is suspected) to confirm the presence of the infection and whether the antibiotic ordered is appropriate for the type of infecting organism.

The resident at issue was a dialysis patient and had an AV fistula (the port through which dialysis is done) on his right upper arm.  The facility wound care nurse performed a routine readmission skin assessment on the resident and saw that there was purulent drainage coming from an abscess on the right upper arm.  The wound care nurse notified the resident’s nurse practitioner via text message and advised her that there was a wound with some drainage and that a wound culture had been obtained.  The wound care nurse also claims to have notified the wound care physician, but according to the citation, he denied knowing about the abscess until he was in the facility three days later.

The resident was scheduled for dialysis the following day but did not receive it for reasons that are not clear from the citation.  However, the nephrologist stated that had he been made aware of the presence of an abscess near the dialysis fistula, he would have obtained a wound culture and started an IV antibiotic through the dialysis fistula immediately.

The wound care physician arrived in the nursing home three days after the abscess was first noted.  He ordered Keflex, an oral antibiotic, and a consult with an infectious disease physician.  However, the nursing home did not have the antibiotic in stock and when they attempted to reach the infectious disease doctor, they only reached his answering service.  The antibiotic did not get delivered before the resident was sent to the hospital.  Therefore, neither of the orders were actually implemented before the resident was sent to the hospital the following morning.

The next morning the nurse on duty recognized that the resident’s condition was declining and his vital signs were troubling, so she called 911 to have the resident sent to the hospital.  The preliminary diagnosis there was that he suffered a stroke, so an MRI of his brain was ordered and this should evidence of septic emboli and a cerebral abscess – signs that the infection had migrated to his brain.  It was determined that he had a poor chance of neurological recovery and that he was a poor surgical candidate, so the family opted for comfort measures only, and he died five days later.

There are a number of issues with the care that this resident received:

  • The skin assessment where the abscess was discovered was a readmission assessment.  Where was he being readmitted from and why was the infection not addressed there?  The citation does not give any indications on this issue.
  • It is unclear whether the wound care physician was in fact notified of the presence of the infection – the wound care nurse from the nursing home yes, the doctor says no.  There are a number of ways of resolving that issue.  One way would be to see who issued the orders for the wound culture and dressing.  Otherwise it becomes an issue of getting into phone records and the electronic medical record if it had a electronic messaging platform integrated with it.
  • Assuming that both the nurse practitioner and the wound care doctor were timely notified, the discussion ended without an order for an antibiotic.  An experienced nurse would have recognized that the usual course is to initiate antibiotics before the results of the culture are received.  In her role as a patient advocate, the nurse should have asked whether they wanted one started.
  • There were no clear lines of responsibility for who was managing this portion of the patient’s care.  It is a common adage that when everyone is responsible, no one is responsible.  Sadly, no one appears to have taken charge to ensure that the resident had an antibiotic started.
  • It appears that the resident did not go to dialysis as scheduled the day after the abscess was discovered.  The dialysis fistula is something that directly impacts the care that a nephrologist gives, but no one alerted the nephrologist about the apparent infection in the area.  It is clear from the citation that the nephrologist would have addressed the abscess with a good deal more urgency than either the wound care physician or the nurse practitioner.
  • When the antibiotic was ordered but not available, no one advised the wound care physician of this.  Many nursing homes carry a “house stock” of commonly used medications, and the one ordered would have likely fallen into that category.  When it was not available, the failure of the staff to notify the wound care doctor that they could not give the antibiotic as ordered denied the wound care doctor the opportunity to choose a different course of action – such as a different medication or ordering the resident to the hospital.  When an infection is left untreated, it can only be expected to worsen the in medically compromised population found in nursing homes.

This series of failures in the care that the resident received ultimately ended up causing his death.

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:

Lemont Nursing & Rehab cited for failure to notify doctor of abnormal lab results

Heartland of Galesburg resident dies due to untreated urinary tract infection

Resident suffers flesh-eating infection due to untreated skin tear at Regency of Sterling

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Forest City Rehab fails to send resident to dialysis

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IDPH has cited and fined Forest City Rehabilitation & Nursing Center nursing home in Rockford after a resident had to be sent to the intensive care unit at a local hospital after the nursing home failed to send the resident to dialysis for three consecutive scheduled sessions.

When a nursing home resident suffers from kidney failure and is on dialysis, the resident must receive all of their scheduled sessions.  The failure to send a resident to dialysis as ordered can result in the resident suffering high levels of potassium which can cause the death of the resident.

While some nursing homes have in-house dialysis units, other nursing homes have to send residents to outside dialysis centers for their schedules sessions.  When this is the case, reliable transportation must be arranged.  In this particular instance, the resident was supposed to receive services at an outside center.  The contract with the nursing home placed responsibility on arranging for transportation on the nursing home, and there was a staff member who was specifically responsible for arranging for the transportation.

The resident was readmitted to the nursing home after a short hospital admission and was due to get dialysis the following day.  Her schedule called for three dialysis sessions per week.  However, she was not brought to dialysis that day as scheduled or for the next two sessions either.  This meant that the resident did not receive dialysis for a week.

After missing the third session, one nurse noticed that the resident was less alert than normal and appeared puffier – likely because she was retaining fluid due to the missed dialysis sessions.  The nurse practitioner was notified and ordered the resident sent to the hospital.  There labs showed that the resident had critically high potassium levels.  She was admitted to the intensive care unit and received dialysis.

There are three shortcomings in the care that this resident received.  First, the nursing home was responsible for arranging transportation, and even if the outside company failed to provide the services it promised, the nursing home was still obligated to get the resident to her scheduled dialysis sessions.  Second, when the resident did not receive the care that was ordered, this was a situation where physician notification was required.  The failure to get the ordered dialysis is a very serious situation which can have severe adverse health consequences for the resident and the judgment and expertise of a physician as tow to how to address this is necessary.  Third, the citation revealed that the staff did not have a good understanding of what dialysis services the resident needed.  Because dialysis is so essential to the health and well-being of residents, the dates for dialysis and its completion should be clearly documented in the resident chart.  Taken together, these failings led to the unnecessary critical illness of this resident.

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:

Forest City Rehab resident murders roommate

Burbank Rehab resident hospitalized due to missed dialysis sessions

Failure to notify doctor of abnormal labs at Momence Meadows

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Lemont Nursing & Rehab cited for failing to notify doctor of abnormal lab results

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IDPH has cited and fined Lemont Nursing & Rehabilitation Center nursing home in Lemont due to the failure of the staff to notify the resident’s doctor of abnormal lab results.

One of the basic facts of care in a nursing home is that there are not doctors on hand on a 24-7 basis.  However, members of the nursing staff are, and one of their functions is to serve as “the eyes and ears of the doctor” when the doctor is not actually in the nursing home.  Nurses are required to notify the doctor of significant events in the care of the resident, such as the occurrence of a fall, the development or a bed sore or its decline, abnormal lab or test results, and of any changes in the condition of a resident.

One thing that requires physician notification is the onset of signs and symptoms of infection.  Nurses are not required to be able to determine exactly what the infection is or how to treat the infection, but they do need to know when a resident is showing signs and symptoms of infection.  When a resident is showing signs and symptoms of an infection, the nurse is required to notify the doctor and the doctor can use that information to decide whether to issue orders for treatment over the phone, come into the nursing home to examine and treat the resident, or to have the resident sent to the emergency room.

The use of an indwelling catheter is something that predisposes nursing home residents to develop urinary tract infections.  There are a number of reasons for this, and as a general proposition, nurses working in a nursing home setting are well-schooled on what the signs and symptoms of a urinary tract infection are.  These might include: lethargy, confusion or other changes in mental status; fever; back or flank pain; burning while urinating; and changes in the color or appearance of the urine itself such as it becoming cloudy or darker, having pus or blood in it, or having a foul odor.  When those signs and symptoms occur, then physician notification is required.

The resident at issue here had an indwelling catheter.  He began to show increased confusion and the urine draining from catheter was cloudy.  These are signs of a urinary tract infection.  The physician was notified and he ordered a urinalysis and urine culture to determine whether the resident was suffering from a urinary tract infection and if so, what antibiotics would be most effective against it.

The resident also had a regularly scheduled Complete Blood Count (CBC) done the next day.  When the results of that came back that afternoon it showed that the white blood cell count was significantly elevated.  An elevated white blood cell count is an indicator that there is an infection present.  This abnormal lab result should have been reported to the doctor.  However, it was not.  In the context of this resident’s reported confusion and cloudy urine, the failure of the nursing staff to notify the doctor of the abnormal lab results deprived the doctor of a critical piece of information in medical decision-making.

Three days after the CBC test results came back, the results of the urinalysis came back.  These showed that the resident did in fact have a urinary tract infection.  The doctor was properly notified and started the resident on an antibiotic.  However, the following day the resident had to be sent to the hospital due to decreased urine output.  The resident was admitted to the intensive care unit with a diagnosis of elevated white blood cell count and sepsis.  After the family had the resident placed on comfort care only, the resident died a week later.

Here, there was a simple failure to follow standard nursing practices.  The doctor was notified when there was a change in the resident’s condition initially, resulting in the urinalysis being ordered.  The doctor was also notified when the results of that test came back with abnormal findings.  However, the staff failed to notify the doctor of the blood test showing the elevated white blood cell count.  This piece of information would likely have led to early administration of antibiotics and may have yielded a different outcome, as delay in the initiation on effective antibiotics increases ill-effects of infections.

One of our basic 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:

Untreated infection leads to resident death at Elevate Care South Holland

Grove of Elmhurst resident dies due to delay in physician notification

Aperion Care of Wilmington resident suffers ruptured colon due to fecal impaction

Resident at Arcadia Care in Danville dies due to improperly treated urinary tract infection

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Dehydration leads to hospital admission for resident at Mattoon Rehab

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IDPH has cited and fined Mattoon Rehabilitation & Health Care Center nursing home after a resident there had to be sent to the hospital suffering from encephalopathy and acute kidney injury due to dehydration.

One of the basic commitments that nursing homes make when they accept a resident for admission is that they will do what is required to help maintain the resident’s basic health.  Many people are therefore shocked to hear of  nursing home residents suffering from conditions like dehydration and malnutrition.

This resident was admitted for treatment with IV antibiotics, including vancomycin and cephapime, for treatment of osteomyelitis and discitis.  Her medical history included congestive heart failure for which she was receiving a diuretic (commonly known as a “water pill”).  One of the effects of taking a diuretic is that you urinate frequently (hence the term “water pill”), which can lead to dehydration.  Because this is a known risk of use of a diuretic, it is something that should be addressed in the resident care plan.

The care planning process is the road map for providing much of the routine care that resident’s receive in a nursing home.  It begins with the resident assessment which identifies the known risks to the health and well-being of the resident.  From there, a care plan is developed.  This includes a series of steps, or interventions which must be taken on a day-to-day, shift-to-shift basis to minimize the risks to the health and well-being of the resident.  Once a care plan is put into place it must be communicated to the staff charged with carrying it out and then actually implemented on a day-to-day, shift-to-shift basis.

When a resident is at risk for dehydration due to the use of a diuretic, this is something that should be addressed in the resident care plan.  This would include simple measures such as encouraging fluids, monitoring fluid intake, and monitoring signs and symptoms of dehydration.  These would include a dry mouth, diminished urine output, darker colored urine, and increased lethargy and confusion.

Having and executing a care plan to address the risk of dehydration is especially critical in residents who are receiving the antibiotic vancomycin.  Vancomycin is known to have adverse effects on the kidneys, made worse when the patient is suffering from dehydration.

When the resident was admitted to the nursing home, she was assessed as having no cognitive issues, was alert and oriented, and able to make her needs known.  Over the first few days of her admission to the nursing home, she was not eating much and was only taking a few sips of water.

One the sixth and seventh days after she was admitted to the nursing home, the staff noted that the resident was having disorganized thinking, difficulty with finding words, and slowed response times.  The resident chart further recorded that had poor appetite and was tired.  These were signs and symptoms of dehydration.  The onset of these signs and symptoms represented a change in resident condition which should have prompted physician notification.

On the eighth day after she was admitted, a nurse returned from vacation and cared for this resident for the first time.  She was advised by the staff that the resident was able to make her needs known and was alter when she was admitted.  The nurse contacted the resident’s physician who ordered labs drawn the next day.

Unfortunately, the evening, the resident experiencing muscle jerking and twitching and was sent to the hospital.  Labs drawn there showed elevated BUN and creatine levels – markers of dehydration and diminished kidney function.  The resident was diagnosed with acute kidney injury and encephalopathy (brain dysfunction) all related to her dehydration.  She had to be admitted to receive fluids – something which is dangerous for a patient suffering from congestive heart failure as this resident was.

Additionally, the resident was discovered to have developed multiple bed sores.  When the resident was admitted to the facility, she did not have any skin breakdowns.  Federal regulations require that resident receive care, treatment, and services necessary to prevent the development of bed sores.  Dehydration is a known risk factor for the development of bed sores.  Immobility is another one, something that was likely true for this resident as she became weak and lethargic due to her dehydration.

These issue – the dehydration and all of its complications, as well as the bed sores – are the simple result of routine care not being provided to this resident.  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:

Mattoon Rehab resident dies from infected bed sore

Arcadia of Danville resident dies due to improperly treated urinary tract infection

Failure to report changes in condition at Heritage Health in Carlinville

Failure to notify physician leads to resident death at Alden Estates of Barrington

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Heartland of Galesburg resident dies due to untreated urinary tract infection

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IDPH has cited and fined Heartland of Galesburg after a resident there died due to sepsis brought on by an untreated urinary tract infection.

One of the basic truisms of care in a nursing home setting is that doctors are not there on a 24/7 basis.  Because of this, nurses must be the “eyes and ears” of the doctors and let them know when there has been a change in the condition of a resident.  The nurse does not need to know what the change represents (though they often have a good idea) or how to treat it.  It is up to the doctor to make a diagnosis and decide how to treat the resident.  The nurse simply needs to be able to identify the change in condition, notify the resident’s physician, and give the doctor sufficient information for the doctor to make good decisions.

The presence of a urinary catheter places a resident at increased risk for developing a urinary tract infection.  There are a number of reasons for this, including the fact that the presence of the catheter opens up the body for entry of infecting organisms; bacteria can colonize the catheter itself; and the placement of the catheter can cause trauma to the urinary tract  and/or obstructions to the outflow of urine.  Because the risk of urinary tract infections is increased, their use is discouraged by federal regulations.  There must be medical justification for the use of a catheter in a nursing home, including a physician order for it.  Nursing homes are required to evaluate the use of a catheter on an ongoing basis and obtain orders for its removal when possible.  Catheter care, including monitoring for signs and symptoms of urinary tract infections, must be addressed in the resident care plan.  A well-done care plan will include monitoring for signs and symptoms of infection.

Nurses must know and be able to identify signs and symptoms of a urinary tract infection.  These may include: burning while urinating; foul-smelling, cloudy, or bloody urine; back or flank pain; mental status changes such as confusion or delirium; fever; and weakness or lethargy.  When a resident demonstrates signs and symptoms of a urinary tract infection, the nurse must notify the doctor who then must decide whether to order treatment over the phone (usually in the form or ordering a urinalysis and prescribing an antibiotic), come to the nursing home to evaluate the resident, or send the resident to the emergency room.  Left untreated, a urinary tract infection can cause sepsis leading to multi-organ failure and death.

The resident at issue was admitted to the nursing as a short-term admission to undergo rehabilitation after suffering a nondisplaced hip fracture at home (i.e., one that did not require surgery).  While she was in the emergency room, the staff there placed a catheter so that she would not have to get up to urinate.  Before that, there was no need for a catheter.  When she was transferred to the nursing home the following day, the catheter was left in place.  However, there were no orders entered for the use of the catheter and no assessment made of the suitability of removing the catheter.

Just over a week after the resident was admitted to the nursing home, the nurses noted on consecutive days that the resident had cloudy urine.  This is one of the signs of a urinary tract infection.  However, there was no notification of the doctor.  There were two additional days in which there was no note at all. However, aides told the state surveyor that in the interim, the urine had gained a foul odor and that there was

On the afternoon of the fourth day after the urine turned cloudy, the resident became lethargic.  It was recognized by the physical therapist, who reported it to the nurse on duty.  The nurse also noted that the resident was less talkative.  That evening, the nurse on duty also noted that the resident was lethargic, so she sent a fax to the resident’s doctor at 9:40 p.m.  Because the information was faxed to the doctor rather than the subject of a phone call, the doctor was not aware of the change in condition until the resident was already in the hospital the following afternoon.

Over the next day, the resident continued to decline until by early afternoon, the nurse on duty called 911 to have the resident transferred to the hospital.  The paramedics report stated that the resident had been sick since the day before and became unresponsive in the morning.  Upon arrival at the hospital, the resident was obviously ill – her appearance was described as “toxic”.  The collection bag for the catheter was described as being filled with dark brown urine with clumps of pus in it.  The urine was foul-smelling to the point that it made the nurse in the emergency room nauseous.  The catheter was changed out, but very little urine came out once the new catheter was placed.  This was an indication that the resident was in kidney failure due to sepsis.

The resident passed away approximately 12 hours after arriving in the emergency room.  Cause of death was multi-organ failure due to sepsis from the urinary tract infection.

There were multiple failures in the care of this resident that led to her death:

  • The nursing home allowed the resident to remain catheterized without a physician’s order for it use;
  • The nursing home allowed the resident to remain catheterized when there was no medical justification for the use of the catheter;
  • There was no assessment as to whether the resident’s condition actually required the use of a catheter;
  • The care plan for the use of the catheter included monitoring the resident for signs and symptoms of infection and notifying the physician of the onset of such.  This was not done;
  • Failed to notify the physician of the initial development of cloudy urine, which would have likely led to a urinalysis being done – and just as likely, an order for the removal of the catheter, since the doctor was familiar with the patient outside the nursing home and knew that she did not need a catheter;
  • Failed to recognize the development of a foul odor to the urine and the presence of pus in the urine – clear markers of infection;
  • Failed to report the onset of lethargy to the doctor to the doctor when it was reported by physical therapy;
  • When the staff finally notified the doctor of the onset of the change in condition, they did so by fax rather than calling the doctor, resulting in the doctor not receiving the communication from the nursing home;
  • Failed to notify the doctor the morning that the resident was transferred to the hospital of the declines that occurred overnight; and
  • The nursing home did not have policies and procedure in place regarding catheter use and care.

Ordinarily urinary tract infections are easily treated with antibiotics.  However, when there are substantial delays in the treatment of a urinary tract infection and can lead to sepsis, multi-organ failure, death – as happened here.  There were many opportunities for this tragic outcome to be avoided and to allows this resident to return home.  Sadly, they were all missed, over a period of several days and multiple shifts.

One of our basic 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:

Champaign-Urbana Rehab resident admitted to ICU due to untreated urinary tract infection

Rushville Nursing & Rehab resident suffers untreated surgical wound infection

Resident suffers from flesh-eating disease due to untreated skin tear at Regency of Sterling

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Failure to follow feeding tube orders leads to hospice admission for Parker Nursing & Rehab resident

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IDPH has cited and fined Parker Nursing & Rehabilitation Center in Streator after a resident there developed sepsis from aspiration pneumonia due after vomiting because his orders for administering nutrition through his feeding tube were not followed, leading to him be admitted to hospice for end of life care.

One of the basic truisms in the nursing home industry is that a nursing home should not accept the admission of a resident when they are not able to meet the care needs of the resident.  This is what happens when that fundamental is not followed.

When a resident is admitted to a nursing home from a hospital, the discharge planner from the hospital forwards information to the nursing home regarding the medical history and care needs of the resident.  Those records are reviewed by a senior member of the nursing staff to determine whether or not the resident is suitable for admission to the nursing home.  If so (and the financial portion of the admission is worked out), then the resident can be admitted to the nursing home.

The resident at issue was admitted to the nursing home for rehabilitation after experiencing a stroke.  He had a tracheostomy and a feeding tube.  However, the admission screening information from the hospital stated that he was a “short stay” admission.  The discharge orders included continuous infusion of the solution for the feeding tube at 75 mg per hour.  Delivery of the solution would ordinarily require use of a pump to ensure that the resident received the solution at the desired rate.

The decision to accept a resident at this nursing home would ordinarily be made the quality assurance nurse, who at this facility was a LPN.  However, she was gone on vacation at the time that the admission was being considered and her role was being covered by another nurse, the MDS Coordinator.  This nurse okayed accepting the resident into the facility, apparently unaware that they did not have a pump for use for this resident.

There were other members of the staff who were aware that there was no pump available for this resident.  However, no one called the resident’s doctor to notify him that they could not carry out the doctors’ orders due to the lack of a feeding pump.  The resident’s doctor told the state surveyor that he should have been notified and that had the staff done so, he would have changed the orders.

Without a pump to regulate the flow of feeding tube solution to the resident, the rate of the feeding tube was left to gravity – in other words, the bag with solution was left to hang on an IV pole and simply empty out.  The problem with this is that the rate at which the solution was delivered to the resident was not controlled, which in this case meant that the solution was delivered to the resident far too quickly.  The net result of this is that the resident was badly overfed and began to vomit, with vomit coming from the resident’s mouth and out of the tracheostomy.

Vomiting from a resident represents a change in condition which requires physician notification.  However, the doctor was not notified.  Further, the nurse did not shut off the tube feeding, resulting in the resident continuing to be overfed.   As the resident continued to receive more and more solution, he continued to vomit.

The nurse reported to the state surveyor that she did not suction the resident initially, but did so later.  Even then, it was a superficial suctioning, not a deep suctioning which would have been necessary to clear the airway.  Suctioning was necessary to clear the airway because when a person inhales foreign substances into the lungs, this causes aspiration pneumonia.

Aides assigned to care for the resident reported to the state surveyor that throughout the night they advised the nurse on duty that the resident was continuing to vomit and that the resident did not look good.  Despite this, the nurse did not go to check on the resident and did not suction the resident’s airway.

Some 5 hours after the resident began to vomit, the nurse called for an ambulance to take the resident to the hospital.  There, the resident was diagnosed with severe sepsis due to aspiration pneumonia caused by overfeeding.  The resident was admitted to hospice to receive end-of-life care.

There were multiple failures in the care that this resident received:

  • The nursing home accepted the resident for admission when it did not have the equipment necessary to treat him consistent with physician orders;
  • They did not advise the doctor that they did not have the pump necessary to control the delivery of feeding tube solution to the resident, precluding the doctor from issuing other orders for the feeding of the resident;
  • They failed to advised the doctor that the resident was receiving far more feeding solution than was ordered;
  • They failed to advise the doctor of the onset of vomiting by the resident;
  • Once the resident began to vomit, they failed to stop the delivery of the feeding tube solution;
  • The nurse on duty failed to suction the resident’s airway once he began to vomit, setting the stage for him to develop aspiration pneumonia;
  • The nurse on duty failed to assess the condition of the resident despite being advised by aides that the resident was continuing to vomit and did not look good.

All of these failures set the stage for the resident to be admitted to hospice to receive end-of-life care.  This is a resident who despite his recent medical issues, was admitted to the nursing home as a rehabilitation patient – in other words, there was an expectation that he would eventually return home.  This was not be be due to the failures in the care that this resident received.

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:

Feeding tube error at Aperion of Westchester

Aperion Care of Wilmington resident suffers ruptured colon due to fecal impaction

Sharon Health Care Elms in Peoria fails to give anti-seizure medication to resident

Heartland of Moline resident develops aspiration pneumonia due failure to follow diet orders

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Grove of Elmhurst resident dies due to delay in physician notification

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IDPH has cited and fined the Grove of Elmhurst nursing home after a resident there died due to a 30-hours delay in notifying the resident’s physician about a fever exceeding 104 degrees.

One of the basic truisms of care in a nursing home setting is that doctors are not there on a 24/7 basis.  Because of this, nurses must be the “eyes and ears” of the doctors and let them know when there has been a change in the condition of a resident.  The nurse does not need to know what the change represents (though they often have a good idea) or how to treat it.  Those things are the role of the doctor.  The nurse simply needs to be able to identify the change in condition, notify the resident’s physician, and give the doctor enough good information about what is happening to allow good decision-making.  Once the doctor is informed of the problem, then the doctor must decide to come to the nursing home, issue orders over the phone, or order the resident transferred to the hospital.

The resident at issue had been admitted to the nursing home with a number of medical problem, including: multiple rib fractures, chronic respiratory failure, encephalopathy, a tracheostomy, and anoxic brain damage.  He was in a comatose state and dependent on staff for care.  At the time of admission, he had been running low-grade fevers (98-101), so the attending doctor requested consultations with an infectious disease physician who assigned a nurse practitioner to the patient.

On the morning of the fourth day after admission, the resident’s temperature rose to 104.5 degree.  This represented a change in condition for the resident, and should have triggered notification of the resident’s physician or the infectious disease nurse practitioner.  The resident’s temperature was taken 7 times during the course of that day, yielding temperatures of 102 degree or higher 5 times.   Neither the resident’s physician or the infectious disease nurse practitioner were notified of the rising temperatures.

The following day, the resident’s temperature was taken at 6:30 a.m. and was 102 degrees, but dropped down to 99.9 at 8:53 a.m. However, it climbed back to 104.5 degree by 10:57.  After the temperature climbed back up over 104 degrees, the staff called the doctor but he was not available so they had him paged.  No effort was made to reach the infectious disease nurse practitioner.

At 12:55 p.m., the respiratory therapist was treating the resident and noted a heart rate of 120-130 after suctioning.  The nurse assessed the resident and found that the resident had a temperature of 101.4 and a heart rate of 118.  Fevers and an elevated heart rate are signs of sepsis.  The primary care physician was paged again, although no effort was made to reach the infectious disease nurse practitioner.

The attending physician was paged again at 3 pm and this time the doctor was reached.  He was informed of the resident’s condition and ordered the resident be sent to the emergency room.  The staff first called a private ambulance service and was told that it would be 90 minutes for an ambulance to arrive.  The nurse went to assess the resident again and noted shallow breathing.  The nurse and the respiratory therapist began to do CPR using an ambu-bag.  911 was called, and the paramedics arrived 8 minutes later.  On arrival the resident had no pulse and was in respiratory arrest.  They were able to regain a pulse twice  in their resuscitative efforts, but the resident died less than an hour after the paramedics arrived.  The apparent cause of death was pneumonia – a condition which could have been better addressed in a hospital setting.

There were a number of shortcomings in the care that this resident received:

  • When the resident initially developed temperatures in excess of 104 degrees, no one was notified of the development of that high a fever.  It represented a change in condition and a real threat to the health and well-being of the resident.
  • There was no effort to notify the infectious disease nurse practitioner.  The fever and rapid heart rate were signs of sepsis and seeing as this specialist was brought in to help manage this aspect of the resident’s care, notifying the nurse practitioner was a reasonable option when the 104 degree fever developed and/or the attending could not be reached.
  • There was inadequate follow up when the attending physician could not be reached.  Once a doctor is paged and is not responding, additional follow-up efforts are required to actually reach the doctor to get his guidance.
  • Finally, when a doctor cannot be reached, the facility medical director should be contacted to obtain orders if necessary.  It is simply not acceptable to not get some medical direction when the resident’s situation calls for it.

The net result of all of this is that there was a 30 hour delay in getting the instructions that were required when the resident first developed the 104 degree fever.  This was a medically complex, medically fragile individual for whom timely care was required.  When a resident suffers from an infection like pneumonia, delays in receiving care can contribute to the development of complications like sepsis which can in turn feed other complications.

One of our basic 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:

Landmark of Richton Park resident dies due to mishandling of tracheostomy tube

Lemont Nursing & Rehab staff fails to notify doctor of abnormal labs

Feeding tube error at Aperion of Westchester

Lack of wound monitoring leads to infection at Regency Care of Morris

Untreated infection leads to resident death at Elevate Care South Holland

Heartland of Moline resident develops pneumonia due to failure to follow diet orders

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

Champaign Urbana Nursing & Rehab resident admitted to ICU due to untreated urinary tract infection

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IDPH has cited and fined Champaign Urbana Nursing & Rehab nursing home in Savoy after a resident there had a urinary tract infection go untreated for over a week due to the failure of the nursing staff to timely notify the resident’s doctor of changes in the resident’s condition and carry out orders for a urine culture.

When it comes to the relationship between nurses and doctors in a nursing home setting, nurses are responsible carrying out two major functions.  First, because doctors are not present in the nursing home on a 24/7 basis, they must serve as the “eyes and ears” of the doctor and report changes in the resident’s condition, including the presence of signs and symptoms of infection.  Second, nurses must timely carry out orders by the doctor for treating the resident.

The presence of a urinary catheter places a resident at increased risk for developing a urinary tract infection.  There are a number of reasons for this, including the fact that the presence of the catheter opens up the body for entry of infecting organisms; bacteria can colonize the catheter itself; and the placement of the catheter can cause trauma to the urinary tract  and/or obstructions to the outflow of urine.  Because the risk of urinary tract infections is increased, their use is discouraged by federal regulations.  Catheter care, including monitoring for signs and symptoms of urinary tract infections, must be addressed in the resident care plan.

Nurses are not required to be able to diagnose urinary tract infections or determine how to treat them, but they do need to know and be able to identify signs and symptoms of a urinary tract infection.  These may include: burning while urinating; foul-smelling, cloudy, or bloody urine; back or flank pain; mental status changes such as confusion or delirium; fever; and weakness or lethargy.  When a resident demonstrates signs and symptoms of a urinary tract infection, the nurse must notify the doctor who then must decide whether to order treatment over the phone, come to the nursing home to evaluate the resident, or send the resident to the emergency room.

The resident at issue had an enlarged prostate.  This caused him to experience urinary retention which is a risk factor for developing urinary tract infections.  To alleviate the urinary retention, use of a catheter was ordered.  The risk of developing a urinary tract infection was something that was specifically addressed in the resident care plan and physician orders.

The resident initially developed signs and symptoms of a urinary tract infection in the form of a fever and pain and burning with urination during the early morning hours on a Saturday.  The doctor was properly notified and ordered a urinalysis and culture and sensitivity test.  The nurse collected the urine sample.  However, the lab with whom the facility had a contract did not do pick ups on the weekend, so it was not brought to the lab until Monday.

When the results of the urinalysis were returned that same Monday, the nurse called the results over to the doctor.  However, the culture and sensitivity results were not available, so the doctor did not order any antibiotics.  Those results were not received until Wednesday.  However, no one called the doctor to inform him of the results of the the culture and sensitivity.  Usually, this testing is used to help determine what antibiotics the infection is susceptible to.  Without those results, there were no antibiotics ordered.

On Friday (one week after the signs and symptoms of the infection first appeared), the resident complained of painful urination which was producing bloody, cloudy, foul-smelling urine.  These are all signs of a urinary tract infection.  The nurse on duty called the nurse practitioner who ordered a urinalysis and culture and sensitivity.  However, given that this was a Friday and the lab had already come for the day, the nurse put in the order for the testing to be done the next day that the lab was in the building which would be the following Monday.

The urine culture was done the following Monday and the results arrived on Tuesday.  Based on the results, the nurse practitioner ordered an antibiotic for the resident.  However, the resident’s condition continued to decline, and he was brought to the emergency room two days after starting the antibiotic suffering from severe sepsis.  The infectious disease specialist noted that the resident had been having pain with urination for two weeks and that the catheter appeared to be infected.  The resident was sent to the Intensive Care Unit due to the severity of the infection.

There were a number of shortcomings in the care that this resident received leading to him developing severe sepsis requiring the admission to the Intensive Care Unit:

  1.  Neither the doctor nor the nurse practitioner were informed that the urine sample they ordered taken could not be delivered to the lab until the following Monday.
  2. The doctor was not informed of the result of the culture and sensitivity, delaying the start of antibiotic therapy.
  3. The catheter was described as having an infected appearance, indicating that there was poor catheter care throughout.
  4. The resident doubtless continued to have signs and symptoms of the a urinary tract infection after the signs first appeared, but there were only two notifications made to medical providers outside the nursing home.

All of these delayed the start of effective care for the urinary tract infection, resulting in the resident to experience such severe sepsis.  It is well-established that early intervention in an infection helps yield better outcomes and prevents the worsening of the infection into the kind of severe sepsis that this resident experienced.  Multiple chances a better outcome were let go by the wayside.

One of our basic 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:

Lack of wound monitoring leads to infection at Regency Care of Morris

Dehydration leads to hospital admission for resident at Mattoon Rehab

Aperion Care of Wilmington resident suffers ruptured colon from fecal inpaction

Failure to notify doctor of abnormal labs at Momence Meadows

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Resident suffers flesh-eating disease from untreated skin tear at Regency of Sterling

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IDPH has cited and fined Regency of Sterling nursing home after a resident underwent surgery for a infected skin tear which had not been treated while at the nursing home.

One basic fact of life is that as we age, our skin gets thinner and more susceptible to injury.  This is why bed sore prevention is a focus of care in nursing homes.  With senior citizens, one form of injury to the skin that they are susceptible to skin tears.  A skin tear is a traumatic injury to the skin which results in the separation of the skin, frequently with peeling back of the skin.

Most often skin tears can be treated relatively easily by bringing the edges of the skin together and using steri-strips and dressings to promote healing of the wound.  However, as with any wound, the occurrence of a skin tear is something that requires physician notification and ongoing monitoring for healing and signs and symptoms of infection is absolutely required.  Intact skin is the most effective barrier to having infecting organisms enter the body, and having a skin tear is a breach of the integrity of the skin.

The resident at issue sustained a skin tear to her left lower outer leg while being assisted into bed by staff.   The resident had been recognized as being at risk for skin tears, and care should have been taken by the staff to avoid injury to the skin in transferring the resident to bed.

Once a skin tear occurs, the staff is then required to care for it properly and monitor for signs and symptoms of infection.  This nursing home had specific policies and procedures in place which were intended to set forth what should be done in the event of a skin tear.  These required notification of the physician after a skin tear occurs to obtain treatment orders, following the wound orders, and ongoing monitoring by the wound care nurse.  In practice the wound care nurse would do rounds on patients with wounds weekly and she would be notified by the nursing staff that there was a new patient with a wound that required care.

The first problem that occurred here is that the first step – notifying the physician and obtaining treatment orders never happened.  There was no record in the chart of the physician being notified.  There were no orders from the doctor recorded in the resident chart.  The resident was not added to the roster of patients who required care from the wound care nurse.  The Treatment Administration Record did not show that there was monitoring of the wound or care being provided.  The basic steps to initiate care were simply not taken.

The facility policies called for an incident report to be completed – and it appears from the text of the citation that an incident report was in fact completed.  However, in a well-run facility, incident reports are more than paperwork which is finished.  They should be a catalyst for the administration to investigate and make sure that proper follow-up was being done.  The records of this resident seem to indicate that was not the case here.

The failures of the nursing home in this case do not end there, however.  Even with a wound care nurse on staff, this does not absolve the nurses and staff on the floor of their responsibility to serve as the “eyes and ears” of the doctors and to notify the doctor when a resident is demonstrating signs and symptoms of an infection.  Nurses do not need to know how to treat an infection, but they do have to be able to recognize the signs and symptoms, which can include: fever, redness and warmth of the affected area, blistering of the skin, drainage, and changes in mental status, among other signs.

Five days after the resident sustained the skin tear, the resident demonstrated increased confusion.  After the nurse on the floor did an assessment, she paged the on-call nurse practitioner who ordered the nurse to call 911 and have the resident sent to the emergency room.

Once the resident was brought to the emergency room, her temperature measured 102.6 degrees.  Her leg showed large fluid filled blisters from her ankle up to mid calf with tenderness and red and blue discoloration.  The infectious disease physician diagnosed her as suffering from necrotizing fasciitiis, or flesh-eating disease.  He recommended antibiotics and immediate surgical debridement.

There were a number of issues with the care that this resident received:

  • Depending on the facts and circumstances, the skin tear itself could be evidence of improper technique or potential understaffing of the nursing home;
  • There was no notification to the doctor or even the wound care nurse, which resulted in inadequate treatment and monitoring of the wound;
  • There was no follow-up to the incident report which was generated concerning the incidence of the skin tear;
  • There was inadequate care by the staff on the floor after the skin tear occurred, as there were likely signs and symptoms of the infection days before the nurse practitioner was notified;
  • There were multiple violations of facility policies and procedures.

All of these failures together led to the resident experiencing a devastating infection which will require significant medical care, all of which could and likely would have been avoided with routine follow-up care to the kind of injury that happens fairly frequently in a nursing home setting.  Simple steps not taken led to disaster.

One of our basic 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:

Lack of wound monitoring leads to infection at Regency Care of Morris

Fall leads to brain bleed and death at Regency Care of Sterling

Heartland of Moline resident develops pneumonia due to failure to follow diet orders

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

 

Rushville Nursing & Rehab resident suffers untreated surgical wound infection

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IDPH has cited and fined Rushville Nursing & Rehabilitation Center nursing home after a resident there suffered significant complications from an untreated surgical wound infection.

One of the common reasons that people are admitted to nursing homes is for rehabilitation after a hospitalization.  This may include post-surgical care.  One of the basic functions of the nursing staff in caring for residents who are admitted for post-surgical care is to monitor for signs and symptoms of infection.  Signs and symptoms of infection may include abnormal white blood cell counts; foul-smelling purulent drainage (pus); fever; redness and warmth around the surgical site; the presence of slough and necrotic tissue; confusion; increased respiratory rate and pulse; and low blood pressure.

Nurses do not need to know how to treat an infection – that is for the doctors to determine.  However, because doctors are not present in an nursing home 24/7, the nursing staff is the “eyes and ears” of the doctors and must notify the doctor when signs and symptoms of infection are present.  The doctor then can decide to come to the nursing home himself to treat the patient, issue orders over the phone, or order the resident sent to the hospital to receive care there.

The resident involved was admitted to the nursing home after undergoing a complicated abdominal surgery which resulted in multiple surgical wounds, the placement of abdominal mesh, a surgical drain, and the need for the use of a wound vac.  However, there was no evidence of a wound infection at the time the resident was admitted to the nursing home, and the day before the resident was transferred, her lab work showed that there was a normal white blood cell count.  The orders were for dressing changes every Monday, Wednesday, and Friday and to return to the wound care clinic two weeks later.

The first 10 days after the resident was admitted to the facility were relatively unremarkable.  However, two days before she was to go to the wound clinic, the floor nurse noted a very foul odor to the would.  She notified the wound care nurse, who was scheduled to see the resident and do a dressing change that day.  The wound care nurse noted tunneling in the surgical wound, purulent drainage, a foul odor, reddened skin on the edges of the wound, moderate slough and necrotic tissue.  These were obvious signs of infection.  She faxed a note to the doctor’s office asking for an order to give an antibiotic.  In response, the physician’s nurse practitioner called and asked the floor nurse to check for warmth around the edges of the wound.  The floor nurse reported back that there was no warmth present, so the nurse practitioner decided to assess the wound herself the following day.

When the nurse practitioner arrived the following day, the wound vac and dressing were in place.  She chose to not take down the wound vac and the dressing to assess the wound itself. Seeing no signs of infection on the exterior and with the resident not running a fever, she decided to let the wound clinic address things when the resident went in for her appointment the following day.

The next day, the resident had her scheduled appointment with the wound care clinic.  However, when the transportation aide arrived in the resident’s room to take her to her appointment, she discovered that the resident was not dressed and could not be make the scheduled time at the wound clinic.  The staff told the aide that they did not get the resident dressed because they were unaware of the appointment at the wound clinic.  The clinic advised that they could not get her in later that day, so the appointment was rescheduled for five days later.  Later that same day, lab work for the resident showed an elevated white blood cell count.

Three days later the notes in the resident’s chart show that there was a foul odor and slough in the wound bed with edges of the wound being reddened.  However, there was no notification of the doctor of this.  The following morning, there as foul smelling drainage coming from the drain, but the doctor was not notified.  That evening, there was additional foul-smelling drainage from the drain, so the nurse on duty faxed a note to the doctor’s office after hours.

The next day was the rescheduled appointment at the wound clinic.  That morning the staff at the nursing home noted that the drain was producing thick, brown drainage.  The nurse practitioner was in and noted that the fax the day before had been received after hours and that the resident was scheduled to go to the wound clinic later that day.

On arrival, the staff at the wound clinic noted that the resident did not look well.  They took her blood pressure and found that it was low.  Inspection of the wound revealed that the abdominal wall had separated and that there was fecal matter in the wound and draining into the drain.  They concluded that the wound was badly infected and had the resident transferred to the hospital.  The nurse practitioner at the wound clinic later told that the state surveyor that the wound had not been cared for appropriately at the nursing home and that the wound did not deteriorate to that extent overnight.  She also said that the nurse practitioner at the nursing home told her that the staff at the nursing home did not tell her of the extent of the deterioration of the wound and that she had only looked that he exterior of the wound with the wound vac and dressings still in place.

At the hospital, lab work showed that the resident’s white blood cell had increased further.  She was diagnosed as suffering from low blood pressure, a necrotic wound of the abdominal wall with surgical site dehiscence, fecal matter draining into the surgical wound, and an intrabdominal infection.

As a general proposition, early intervention with an infection yields better outcomes.  There were a number of times when earlier intervention would have been appropriate, but the infection went unchecked for a week after the first signs of infection were present.  This allowed the infection to spread and worsen.  This resident will likely have to undergo multiple surgeries to try to resolve this infection and undergo a lengthy course of antibiotics.  Once the infection is clear, there will likely be extensive surgical wounds which will be difficult to close, leaving this resident at risk for further infections and complications.

There are a number of places where earlier action should have been taken which would have led to an improved outcome for this resident:

  • When the floor nurse first recognized that there was a foul odor to the wound, this was a sign of infection.  This in itself required physician notification, not just referral to the wound care nurse.  The wound care appropriately asked for an order for antibiotics.  The nurse practitioner should have likely given the order.  However, the content of what was communicated to the nurse practitioner is important because it was apparently not enough to justify a phone order for the necessary antibiotics.  Nurses need to communicate enough information to provide a basis for medical decision-making.
  • When the nurse practitioner came in the following day, she assessed the wound without taking down the wound vac and the dressing, making it impossible to see what was actually underneath.  This deprived her of vital information for her decision-making.  The supervising physician for the nurse practitioner reportedly told the administrator that he did not condone the practice of trying to assess the wound without removing the wound vac and dressing.
  • On the day of the scheduled appointment, the resident was not dressed and ready to go resulting in the cancellation and rescheduling of the appointment.  The resident was not ready to go because the staff was reportedly not aware that she had an appointment.  Getting residents to scheduled doctor appointments is a basic function in providing care in this setting.  There was a clear breakdown in that process.
  • Once it became apparent that the resident was not going to make the appointment as scheduled, the urgency of the resident being seen was not communicated to the wound care clinic.  The staff already had concerns about the resident having an infection and part of the thought process for the nurse practitioner the day before had been that there was a pending wound care clinic appointment.  When that was not going to happen, the clinic needed to know that there was some urgency for them to see the resident, and why.
  • During the days leading up to the rescheduled wound clinic appointment, the resident doubtless continued to show signs and symptoms of infection, most of which were not noted by the staff.  The few times that there notes suggestive of the presence of infection, there was no notification to the doctor until the after-hours fax was sent the evening before the rescheduled appointment.  When a resident is demonstrating the kind of advanced signs of infection that this resident was showing, simply faxing a note over was not sufficient – a call or page was required.  Why?  Because we know that no one responded to the fax sent the evening before – resulting in additional delay and spread of the infection.

There were multiple missed opportunities to drive a better outcome for this resident, spread across several days and several health care providers, including the nurse practitioner.  The net result is that this resident will experience significant, needless suffering and complications.

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:

Heartland of Galesburg resident dies due to untreated urinary tract infection

Aperion Care of Wilmington resident suffers ruptured colon due to fecal impaction

Failure to notify physician leads to resident death at Alden Estates of Barrington

Failure to adequately report changes in condition at Heritage Health in Carlinville

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

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