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.
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