The Illinois Department of Health has cited and fined The Clayberg in Cuba, Illinois when, according to state investigators and facility records, a resident’s significant change in condition went unreported to her physician for eight days after staff first documented foul-smelling, discolored urine, with the Director of Nursing instructing staff not to notify the physician because the resident had kidney failure and was 93 years old. The resident was ultimately transferred to the hospital, diagnosed with sepsis, dehydration, acute renal failure, and a urinary tract infection, and died four days later.

The resident had lived at the facility for more than five years. An assessment completed weeks before the events documented her as cognitively impaired and dependent on staff for all activities of daily living. Her diagnoses included chronic kidney disease, hypertension, dementia, and heart failure.

According to the citation, a registered nurse documented in an overnight note that the resident’s urine was malodorous and discolored, described as gray or green, and that the resident appeared pale. Her recorded vital signs included a pulse of 111 and respirations of 28. That note contains no documentation that the resident’s physician or family was notified. Investigators found no record of physician or family notification in the following days, and no vital signs recorded at all on several dates over the following week.

Multiple staff members reported the change. A certified nursing aide told investigators she observed the urine turn gray or green with a strong odor and reported that the resident appeared very pale and did not look well. A second aide said the urine became thick and gray with a much stronger odor and that the resident drank very little fluid despite encouragement, adding that she often felt concerns reported by nursing assistants “were not followed up appropriately.” The nurse who received the initial report said she passed it to the day shift nurse because she believed it was abnormal, and was told the finding was normal given the resident’s kidney failure. That day shift nurse told investigators she did not assess the resident on either of the days she worked.

An agency registered nurse, noting there was no documentation the physician had been told, documented that she faxed the physician requesting orders for a straight catheterization and urinalysis. No response was received. She told investigators she later received a text message from the Director of Nursing stating the resident had Stage IV kidney failure and that the urine appearance was expected, and that she did not follow up with the physician because she relied on that instruction. Another nurse gave investigators the same account, saying she was told by the Director of Nursing that the changes were expected because of renal failure and the physician did not need to be notified, and that standard nursing practice would have been to follow up within 24 hours if no response was received.

The Director of Nursing told investigators directly that she was made aware of the abnormal urine and instructed staff not to notify the physician because the resident had kidney failure and was 93 years old. According to the citation, she acknowledged that facility practice requires nurses to immediately assess a resident experiencing a change in condition, notify the physician, and document that notification — but said she instructed staff not to do so because she did not feel this was a change in condition. The facility’s own policy on changes in resident condition required notification of the physician and the resident’s representative within twenty-four hours except in emergencies.

A family member told investigators she visited and found the resident unusually sleepy, and on a later visit found her slumped over, lethargic, and minimally responsive. She said she asked nursing staff to contact the physician because something was wrong, and that neither the resident’s declining condition nor the earlier urinary changes had ever been reported to the family. According to her account, the resident was transferred to the emergency department after the family contacted the physician directly. The physician’s office told investigators the facility made contact that same afternoon. Laboratory testing showed an elevated white blood cell count, and a catheter specimen returned concentrated, milky urine. She was diagnosed with a urinary tract infection and started on intravenous antibiotics, and was admitted with sepsis, dehydration, acute renal failure, and a urinary tract infection. Two days later the family elected to transition her to comfort-focused care, and she died two days after that with family at her bedside. Her death certificate lists the cause of death as sepsis and urinary tract infection.

The physician’s office gave investigators an account that conflicted with the Director of Nursing’s stated rationale. A nurse at the office said their records showed the facility first made contact on the day the resident was sent to the emergency department, to report altered mental status and minimal responsiveness, and that there was no record of any facility contact regarding the resident’s abnormal urine or condition changes during the preceding week. She further stated the physician’s records contained no documentation that he did not want to be notified of the urinary changes, and confirmed that a urinary tract infection or sepsis is not an expected or normal finding in a resident with renal failure.

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.

The Illinois Department of Health has cited and fined Aliya of Glenwood when nursing staff failed to regularly monitor vital signs, blood sugar levels, and follow treatment protocols for a resident with multiple chronic conditions who eventually developed respiratory distress and had to be hospitalized with septic shock and pneumonia. The facility’s staff missed critical warning signs, failed to properly document assessments, and did not administer needed medication despite the resident showing clear signs of deterioration over several days.

This case involves a 67-year-old male resident with multiple serious medical conditions including dysphagia following cerebral infarction, type 2 diabetes, hypertensive heart disease, systemic lupus erythematosus, and hepatitis C. The resident was on a specific care plan requiring monitoring of vital signs, blood sugar levels, and watching for signs of cardiovascular distress.

Despite clear signs of deterioration, facility staff failed to provide appropriate care in the days leading up to the resident’s hospitalization. Progress notes indicate that the resident was observed with “poor appetite for breakfast and lunch and diminished lung sounds with rumbling upon auscultation” at one point. The physician was notified and ordered a respiratory panel and chest x-ray. However, the laboratory reported that the sample was canceled due to being unlabeled.

Even more concerning, there was no documented follow-up to this canceled test. The medical record contained no assessments or vital signs for the resident for more than 24 hours following this incident. When a repeat test was finally performed, results showed the resident had tested positive for Respiratory Syncytial Virus (RSV).

A licensed practical nurse documented hearing “congestion during breathing in the resident” and contacted the primary doctor to alert them of symptoms. The doctor ordered cough medication, but the nurse did not document any assessment or vital signs after making this observation. When interviewed later, this nurse admitted, “Resident should have gone out the same day but she followed the order.”

Another registered nurse documented that the resident “refused to communicate with him when asked a question, he looks confused, refuses to take his medication and dinner.” The nurse recorded vital signs showing a blood pressure of 166/85 and oxygen saturation of 87%, which is dangerously low. The nurse documented that oxygen was administered and that they would “continue to monitor.” However, when interviewed, this nurse admitted, “I did not know that the resident have such medication [for high blood pressure], I don’t really know the resident because I hardly work that set.”

The medication administration record showed the resident was supposed to receive hydralazine as needed for elevated blood pressure (systolic over 160 or diastolic over 100), but staff only administered one dose despite documented high blood pressure. Additionally, blood glucose monitoring was ordered twice daily, but records showed no documented blood sugar checks for more than a week before the emergency.

The situation reached a crisis point when a night shift nurse documented the resident as “sweating, lethargic, not verbally responsive with labored breathing” with vital signs showing a blood pressure of 160/89. Emergency services were called, and the resident was transported to the hospital. Hospital records documented that the resident arrived “unresponsive and diaphoretic with shallow respirations” and was diagnosed with “septic shock and health care associated pneumonia.” The resident had to be intubated upon arrival at the hospital.

When interviewed, the Director of Nursing confirmed that “nurses are supposed to check blood sugar and vital signs as ordered and it should be documented.” The facility’s own job description for nurses states they are responsible for administering “prescribed medications and treatments according to policy and procedure,” recognizing “significant changes in the condition of residents and take necessary action,” and documenting “nursing care rendered, resident response, and all other pertinent and necessary data.”

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 Stearns Nursing & Rehab Center when staff failed to properly assess, monitor, and respond to a resident’s significant medical decline over several days, culminating in the resident being found unresponsive with foam coming from their mouth and nose. The resident suffered cardiac arrest during emergency transport to the hospital, required CPR, and was placed on a ventilator.

The resident in question was documented as cognitively intact, requiring some assistance with daily activities, and had advance directives indicating full code status with a request for all life-sustaining measures. The resident’s care plan confirmed they were “a full code and requests life sustaining measures.”

For approximately 3-4 days prior to the emergency, multiple Certified Nursing Assistants (CNAs) observed significant changes in the resident’s condition and behavior. One CNA stated, “the changes in [the resident] started [several days earlier] and this is when he started notifying the nurses and the Director of Nursing.” Staff consistently reported that these changes were markedly different from the resident’s usual behaviors.

On the morning of the incident, a speech therapist visited the resident around 9:00 AM and found them unresponsive in bed, lying flat with food nearby. The therapist stated, “she called out to [the resident] and no response” and “she performed a sternal rub and [the resident] did not respond.” When the therapist notified a nurse, she “was informed that this was a behavior and not to worry about it.” The therapist provided education to staff about not feeding the resident while lying flat.

The morning nurse recognized the seriousness of the situation and contacted the Nurse Practitioner between 10:30 AM and 12:00 PM, receiving orders to send the resident to the emergency room. However, rather than calling 911 for an immediate emergency response, the nurse called for a regular ambulance transport. When told there would be an hour wait for an ambulance, the nurse informed the oncoming shift nurse and left at the end of his shift.

When staff finally responded to the emergency around 4:30 PM, they found the resident with “respiratory depression. Pulse present, weak and thready… Resident diaphoretic, bilateral pupil dilation, increased oral/nasal secretions. White in color with thick frothy consistency. Resident unresponsive to verbal stimuli, tactile stimuli notes no response.”
During ambulance transport, the resident went into cardiac arrest, requiring CPR. At the hospital, the resident was diagnosed with “Cardiac Arrest and Severe Septic Shock” and required intubation and ventilator support.

In a Root Cause Analysis conducted by the facility, they admitted: “Facility failed to Assess, monitor, and provide timely treatment. Nurse failed to follow up, assess resident and call MD. Nurse thought this was resident behavior. Poor assessment skills by nurse.”

Both the Nurse Practitioner and the resident’s physician stated they were not properly informed of the resident’s deteriorating condition. The physician stated that “if he was notified that [the resident] was unresponsive to a sternal rub and attempts to arouse [the resident] had failed he would consider that an emergency and would have sent [the resident] to the hospital with lights and sirens.”

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 Alden Lincoln Park Rehab when a resident with Alzheimer’s disease suffered bilateral subdural hemorrhages (bleeding in the brain) after a fall. The incident reveals several failures in following proper care protocols and responding to changes in the resident’s condition.

The situation began when the resident returned from a weekend visit with family, showing an unusual level of anxiety and odd behavior. Early the next morning staff noted that the resident was “walking very fast from room to room” and appeared to be looking for an exit.

The resident’s behavior was notably different from their baseline, including “howling while pacing” and leaning forward while walking.

This would be considered a material change in condition in a nursing home. What’s particularly concerning in this case is how the staff handled this change in condition.

When the night nurse noticed these changes in the resident, she attempted to contact medical staff but failed to fully communicate the severity of the situation. As one staff member noted: “We were worried that she was going to fall, that’s why we were trying to get her to sit down and lay down. Leaning forward was something new for this resident.”

The Nurse Practitioner later stated that had they been properly informed of these changes, they would have taken immediate action: “If her gait is somewhat acute I would have sent her out, ordered a wheelchair, close monitoring… Even without the leaning forward, I feel that anyone that is confused and leaning forward will eventually fall.”

A resident’s gait can be described as “acute” if they experience a sudden, noticeable change in their walking pattern, often due to a recent injury, illness, or neurological event that has caused a new or significantly altered gait abnormality.

The situation culminated in the resident coming out of their room bent forward and falling face first in the hallway, hitting their head. CT scans later revealed “Mixed density right subdural hemorrhage… Another small isodense subdural collection along left frontoparietal convexity… Left frontal scalp hematoma.”

In this case the facility failed to follow their own policies, particularly their “Change of Condition” policy which requires that “Attending physicians or physicians on call /NP and responsible party will be notified of all changes in condition.” Additionally, they failed to complete proper fall risk assessments, as evidenced by incomplete documentation.

This case highlights systemic issues in the facility’s care protocols, particularly in recognizing and responding to changes in a resident’s condition, maintaining proper documentation, and ensuring adequate communication between staff members about resident safety concerns. The resident’s subdural hematomas were a direct result of these failures in care and oversight.

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 Bria of River Oaks when two separate residents both experienced critical changes in their conditions that were not appropriately addressed by staff and ultimately contributed to their deaths.

The first resident in question was a male with a history of cerebral infarction, type II diabetes, and dementia.

He was found vomiting in his room one afternoon. The nurse on duty assessed the resident and found abnormal vital signs, including high blood pressure (177/94) and low oxygen saturation (87%). The Nurse documented that the resident “had four episodes of vomiting within the hour, looked pale and was confused.” Despite these concerning symptoms, emergency services were not called until two hours after the initial assessment.

When paramedics arrived, they found the resident alert but “complaining of shortness of breath with no relief from O2 (oxygen) via nursing home.” They increased his oxygen support, which improved his saturation. At the emergency room, the resident was diagnosed with a “large subdural hematoma (blood in brain) with midline shift,” a critical condition requiring “emergent neurosurgical consultation.” The resident was airlifted to another hospital for advanced care but unfortunately passed away.

The resident’s physician emphasized the seriousness of the situation, stating, “If a patient is experiencing an increase of blood pressure such as the 170’s or higher, it is important to assess mental status. If the mental status has decreased from baseline, it is an emergency and the patient should be rushed to the emergency room via 911 to rule out a stroke, brain bleed or hypertensive encephalopathy.” The delay in seeking emergency care for the resident potentially contributed to the severity of his condition and subsequent death.

The second case involved a resident with type II diabetes, chronic kidney disease, and hypertension.

On the day of this second incident, at around 9:15 PM, the resident was assessed by a Nurse with symptoms of low blood sugar, including “sweating and slow with speech.” His blood sugar was measured at 73. Despite attempts to raise his blood sugar with sugar packets and orange soda, a subsequent check at 9:40 PM showed it had dropped to 62. The Nurse administered an emergency glucagon injection, and at 10:00 PM, the resident’s blood sugar had risen to 107.

However, the situation took a dramatic turn less than an hour later. At 10:56 PM, the Nurse observed the resident “slow to respond” in bed. By 11:00 PM, the resident was found “unresponsive, not breathing and without a pulse.” CPR was initiated, and 911 was called at 11:02 PM. When paramedics arrived at 11:11 PM, they found the resident in cardiac arrest with a critically low blood sugar of 45.

The resident was revived and taken to the hospital, where he was treated for “hypoglycemia (low blood sugar), respiratory distress, and cardiac arrest.” He was later discharged to home hospice and passed away shortly thereafter, with the cause of death listed as “Hypoxic Brain Injury.”

The second resident’s physician highlighted the critical nature of managing low blood sugar, stating, “the resident should have quickly gone out to the emergency room after the nurse determined the blood sugar was critically low and a glucagon injection was needed in order to prevent further lowering of the blood sugar. If the blood sugar gets too low, as in the case of this resident and the patient can stop breathing, the brain loses oxygen and can lead to fatality.”

These cases illustrate significant failures in recognizing and responding to medical emergencies in a timely manner. The delays in seeking emergency care for both of these residents likely contributed to the severity of their outcomes, underscoring the critical importance of prompt assessment, intervention, and escalation of care in nursing facilities.

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 Aperion Care Marseilles when staff members were embroiled in confusion, refusing to follow a physician’s order for a resident in seriously declining health. This failure resulted in a delay of treatment, leading to continued decline and eventual admission to the local hospital’s intensive care unit with multiple comorbidities, including Sepsis and Pneumonia.

On the day of the incident the Dialysis RN documented that the resident in question had been ill for a few days and was getting worse. The RN further noted that the resident had “rales in upper lobes per auscultation,” was unresponsive, had a temperature of 100.4°F, cloudy and brown urine with a strong odor, and oxygen saturation of 81% on room air.

Despite these concerning symptoms, the floor nurse believed it was due to “fluid overload” and that the resident “just needs dialysis.”

When the Dialysis Nurse received push back from the facility RN, she contacted the resident’s Nephrologist, who agreed that the resident should be evaluated in the emergency room.
The Dialysis Nurse wrote an order at 4:15 pm stating, “Please have nursing home send patient to emergency room for evaluation of elevated temperature, decreased O2 (oxygen) saturation, MS (mental status) changes, rales upper lobes.”

However, this order was scanned into the miscellaneous tab of the resident’s electronic health record and was not processed into the Physician Order tab.

Despite the fact that the order was scanned into the incorrect tab on the electronic health record, the Dialysis Nurse did give the order to the floor nurse at the facility. The facility RN then began to argue with the Dialysis Nurse and “basically refused to send the resident out.”

The Dialysis Nurse then spoke with the Director of Nursing (DON). The DON responded that “my staff got different vitals than you did and that the resident seems ok.”

The situation is a complex one, as the resident was also suffering from a UTI, and there was some belief on the facility’s part that if the resident received an antibiotic, she would be better in 24 hours.

The facility then went ahead and proceeded with dialysis treatment despite the resident’s condition.

After the dialysis treatment, the resident’s condition remained poor. The Dialysis Communication Report noted that the resident was “Moaning, confused, labored respirations” with a temperature of 99.5°F.

Despite the continued poor condition of the resident, she was not sent to the hospital until the next day.

The resident was admitted to the hospital ICU “with sepsis and very high troponin level.” The hospital discharge paperwork revealed multiple serious conditions, including “Sepsis related to MRSA infection, Pneumonia, ESBL UTI, MRSA bacteremia leading to acute endocarditis suspected related to catheter associated infection, Acute on chronic systolic heart failure with pulmonary edema,” and several other complications.

Multiple staff members, including a LPN, a RN, and a second RN, confirmed that there was confusion and disagreement about sending the resident to the hospital. When questioned, the DON even said that “If there was an order for her to be sent to the hospital (I) would not have, not sent her.”
It was later explained by the Dialysis Nurse that the facility staff members did not fully comprehend the risk involved with sending the resident out to dialysis. If there had been infection in the resident’s blood stream the infection could have been spread throughout the body during dialysis, making it worse for the resident. This is why the dialysis team was concerned about moving forward with the treatment and why the Physician felt the resident should be sent to the ER to be examined.

This incident highlights significant issues in the facility’s communication processes, order management, and decision-making regarding resident care, particularly in emergent situations. The delay in following the physician’s order resulted in a potentially preventable decline in the resident’s condition and subsequent intensive care hospitalization.

Nursing homes are businesses, and well-run businesses have systems in place to carry out their basic functions. Assuring that patients are not neglected and that they receive timely medical care and attention is one of those basic functions. Here there was clearly a problem with the system that the nursing home was operating under, as the facility’s failure to implement timely emergency care during the resident’s obvious medical crisis subjected her to a negligent delay in 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 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 Aliya On 87th when the facility failed on multiple levels, including failing to keep the resident elevated at mealtime, failing to follow code blue policy, failing to notify the physician in a timely manner, and failing to relay STAT lab results to the physician. These failures resulted in the resident remaining at the facility in place of being rushed to the ER, ultimately leading to the resident’s death.

The resident in question was admitted with multiple medical conditions, including dysphagia, cerebral infarction, and a history of aspiration pneumonia, amongst others.

According to the resident’s care plan and physician orders, staff were to keep the resident’s head elevated 45 degrees during and 30 minutes after tube feeding, provide one-to-one feeding assistance, and monitor for signs of aspiration, reporting any issues to the physician.

However, a certified nurse assistant (CNA) stated ”I made rounds and the resident was resting in bed. Dinner trays came up and I passed out the food trays, and I gave the resident a dinner tray as well. I did not reposition the resident or raise the head of bed up. Approximately around 5:30 PM, I was walking down the hallway picking up the dinner trays. I went into the resident’s room and saw half of his food missing from the food tray and he was making gurgling gasping sounds with vomiting coming from his nose and mouth. The vomit looked like it was his dinner, with food particles. The resident was lying down in bed and leaning on his side, shaking like he was having a seizure, and his eyes was rolled back into his head.”

The CNA further stated “I ran out and got the nurse. The Nurse went into the resident’s room and yelled out for help. The LPN said the resident is aspirating and get the crash cart. A Registered Nurse came running into the room to help with the crash cart. The Registered Nurse called over the speaker system code blue, and other nurses came to help. I passed the resident his dinner tray, I did not know the resident needed one to one feeding assistance. I thought he could feed his self. After the code, the Registered Nurse asked me if I gave the resident a food tray and did the resident feed himself alone. I told the RN I did give the resident his food tray, but I did not know the resident was a one-to-one feed assist. The RN told me that the resident was lying down too far and aspirated on his dinner while eating alone. The RN told me that the resident should have sitting up 90 degrees due to his aspiration precautions, and I needed to feed the resident.”

Even worse, when a Licensed Practical Nurse (LPN) and Registered Nurse responded to the incident, they failed to call 911, despite the resident’s unresponsiveness and difficulty breathing. The Registered Nurse stated, “I did not call 911 when the resident was unresponsive because the resident was left lying down in bed and aspirated, that situation could be managed by nursing interventions.”

Approximately three hours later that evening a Nurse Supervisor called the physician on call service, Third Eye Physician, and failed to provide a complete and accurate report of the resident’s condition. The Third Eye Physician stated, “I was not made aware that code blue was called in the facility for the resident at 5PM, three hours prior to calling me. I was not made aware that the resident was found lying flat in bed, unresponsive, oxygen level in the 70’s percentile, threw up food particles out of his nose and mouth, having difficulty breathing, needed to be suction, started oxygen, and needed continuous oxygen to sustain a blood oxygen of 92%. If the LPN gave me a completely accurate report of the resident’s condition, I would have given an order to send the resident to the hospital.”

Furthermore, the resident’s critical laboratory and diagnostic test results were never relayed to a physician. The Third Eye Physician stated, “I did not know the resident’s labs came back, and his white blood count was 15, and chest Xray showed early infiltrates in the right lung base. No one from the facility notified me or my staff at the Third Eye of the test results. Those results indicated the resident aspirated, and now developing pneumonia. If I would have received the test results, I would have sent the resident to the emergency room.”

The following morning after the incident the resident was found unresponsive in his bed.

While all of these failures are startling, a close read of the investigation report paints a hectic, borderline chaotic situation at the nursing home. The LPN assigned to the resident claims that she was busy with multiple code blues on the same day at the same time. The LPN states “I did not chart on the resident, the RN and Nurse Supervisor help me chart that day because there were a couple of code blues on the same day and same time. I did not call the resident’s physician; we must use Third Eye Physician on call service on the weekends. I did not call the Third Eye Physician, the Nurse Supervisor called third eye and spoke with the physician. I do not know what time the Nurse Supervisor called the physician.

The Nurse Supervisor that did speak with the on-call physician admitted that she had only peaked into the resident’s room and did not assist with the code blue. The Nurse Supervisor stated “I see the documented progress noted dated with my name, but I cannot remember. To access a call with a Third Eye physician, each nurses have their own individual log in and passwords to access the video call. No one could document or call the Third Eye Physician under my name; I must have called the Third Eye Physician. I am so confused, and I do not recall the code for this resident.”

This would explain why the Nurse Supervisor did not communicate all of the resident’s details in a complete and accurate manner to the physician. The three hour delay in calling the physician can also be explained by what appears to be an overworked staff, as there were multiple code blues occurring at the same time.

Another staff member, this time an Agency RN, paints a hectic picture the day of the incident. She states “I was so busy with the other residents and suctioning the resident (with the code blue) that I did not have time to ask another nurse (for help). I did not chart on the resident because I was too busy taking care of the other residents. I took one set of vital signs, but I did not place the vital signs in the resident’s electronic chart, I just ran out of time and forgot to put them into the system.”

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 such as the one detailed here 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 Center Home Hispanic Elderly when the facility failed to provide emergency treatment and care to a resident, resulting in a nearly six hour delay in the administration of oxygen. A staff member mistakenly believed that “if a person has a DNR there are no interventions that should be provided.”

The resident in question was found at approximately 3:20am with hands that were cool to the touch and their oxygen saturation at 84%. Instead of immediately administering oxygen, the Licensed Practical Nurse (LPN) simply noted “resident DNR will continue to monitor” in the progress notes. At 6:00am, the resident’s SPo2 had dropped even further to 82%, yet the LPN still did not administer oxygen.

This failure to act was based on the LPN’s misinterpretation of the resident’s Do Not Resuscitate (DNR) status. In an interview the LPN stated, “if a person has a DNR there are no interventions that should be provided and with a DNR you should keep the the resident cleaned and comfortable.” This statement suggests a lack of understanding regarding the appropriate care for a resident with a DNR order.

The resident’s Physician Orders for Life-Sustaining Treatment (POLST) specified that while no CPR should be attempted, comfort-focused treatment should include the use of oxygen. The Director of Nursing (DON) reinforced this in an interview, stating, “DNR does not mean that a nurse does not provide care and care still needs to be provided.”

The LPN’s decision not to administer oxygen, despite the clear indication to do so based on the resident’s low SPo2 levels and the POLST, resulted in a significant delay in the resident receiving necessary care. It was not until 6:57am, when another nurse assessed the resident, that oxygen was finally administered. By this time, the resident’s condition had deteriorated to the point of requiring emergency hospitalization. Unfortunately the resident died the next day at the hospital.

This incident highlights the importance of ensuring that all nursing staff, including LPNs, fully understand the implications of a DNR order and the appropriate interventions that should still be provided to ensure patient comfort and well-being. The failure to administer oxygen in a timely manner, as a result of misinterpreting the DNR order, led to severe consequences for the 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. 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 Alden of Waterford when the facility failed to recognize the severity of a critically low potassium level. In place of calling 911, a RN called the local ambulance service, which took nearly two hours to arrive, only to find the resident in cardiac arrest, requiring CPR, and subsequently passing away at the hospital.

The resident’s progress notes written by an RN state that the lab called the nursing home facility and spoke with the RN about the low potassium level (of 2.4mmol (millimoles)/L (liter)). The RN paged the resident’s Primary Physician and spoke with a Nurse Practitioner. The NP advised that the RN send the resident to the ER. The notes further mention that the local private ambulance was called around 5:15 PM, and they stated an estimated pickup time of 1-2 hours later. Upon the ambulance’s arrival at approximately 7:13 PM (nearly 2 hours later), the resident was found unresponsive, and compressions were started. 911 was called at 7:15 PM, and paramedics arrived at the scene at 7:22 PM, transporting the resident to the ER at 7:34 PM. Later that evening the ER nurse informed the facility that the resident had expired in the ER.

The critical error in this case was the failure to immediately call 911 when the RN was informed that it would take 1-2 hours for the local ambulance service to arrive on site. The RN claimed that the resident’s vital signs were stable, and that when the lab called regarding the low potassium level “it did not seem urgent.” The RN mentioned that “the resident had a poor appetite but that even his oxygen level was ok.” Further, “If the potassium was low then it would cause heart issues. I would think there would be a change in his vital signs. There was no change since the AM. I had him all day.”

The Nurse Practitioner at the Primary Physician’s office stated “they were to send him to the ER. They should have called 911. With a potassium that low that would have been urgent. They never called me back to say that it was going to be 1-2 hours.”

The Director of Nursing, also expressed that waiting 1-2 hours for an ambulance was unacceptable and that with a critically low potassium level, they should have called 911.

The facility’s failure to follow their change of condition policy, assess the resident properly, and call 911 (in place of the local ambulance service) resulted in a delay in receiving a higher level of care and ultimately 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. 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 Continental Nursing & Rehab Center when a resident died after it took over four hours for the resident to be transported to an emergency room.

The resident in question had multiple medical diagnoses including asthma, cerebral infarction, type 2 diabetes, dysphagia, and dementia. The resident experienced an acute change in condition at the care facility. A registered nurse observed that the resident was lethargic, had continuous hiccups, and had oxygen saturation levels ranging from 82% to 90% on room air. The nurse administered oxygen at 4 liters per nasal cannula, which increased the resident’s oxygen saturation to 96%. However, the resident’s skin color was not good and slightly moist.

The nurse contacted the resident’s physician, who gave a telephone order to send the resident to the hospital for an emergency room evaluation. The nurse completed the necessary paperwork and called the facility’s contracted ambulance company around 9:20 PM, requesting transport to the emergency room. The ambulance company informed the nurse that there would be a two-to-three-hour estimated time of arrival. The nurse did not notify the physician or the Director of Nursing about the delay in transport.

According to the ambulance company’s “Patient Care Report,” the facility staff nurse called dispatch at 10:26 PM, not 9:20 PM. The ambulance arrived at the facility at 12:25 AM and made direct contact with the resident at 12:30 AM. The ambulance left the facility at 1:02 AM, and the resident arrived at the hospital emergency room at 1:38 AM, approximately 4 hours after the initial physician’s order to send the resident to the hospital.

Upon arrival at the facility, the ambulance crew, consisting of two Basic Emergency Medical Technicians, assessed the resident and found him to be lethargic, incoherent, unable to speak clearly, with an increased heart rate and wheezing in bilateral lungs. The nurse informed the crew that this was the resident’s baseline orientation and vital signs, with the exception of the newly administered oxygen. The nurse did not disclose to the crew that the resident’s oxygen saturation had earlier dropped to 82%. The EMT stated, “If I would have received that information in report, I would have called our advanced life support, if they were too far out the I would have called 911 and stayed with the resident until 911 arrived.”

At the hospital, the resident was diagnosed with acute respiratory failure with hypoxemia, altered mental status, hiccups, systemic inflammatory response syndrome, and elevated lactic acid. Despite receiving treatment, the resident passed away.

The resident’s family member expressed concerns about the delay in transport and the facility’s decision to send the resident to a hospital 19 miles away, bypassing several closer hospitals. The family member stated, “If the resident was stable, then why did the physician give the order to send a stable resident to the hospital emergency department. From the nursing home facility which is located on the north side of Chicago and transported the resident to a south side of Chicago hospital which was 19 miles away from each other, bypassing several closer hospitals that was terrible. The resident arrived at the hospital over 4 hours later in respiratory failure. The Administrator and the Director of Nursing seem not to understand, a delay in transport means a delay in receiving medical treatment, just maybe the resident would still be alive, all the nurse had to do was call 911.”

The facility’s Change in Resident’s Condition or Status policy states that during medical emergencies such as unstable vital signs or respiratory distress, 911 will be notified for transport to the hospital. However, the facility failed to follow this policy and did not immediately call 911 when the resident’s condition worsened.

The Director of Nursing, however, stated, “I understand the policy, however, once the resident was receiving 4 liters of oxygen he became stable, and the nurse should not have phoned 911. The change of condition policy was not followed in terms of calling 911, that was because the resident became stable, there was no reason to call 911.”

The resident’s physician, when informed of the details in the nurses’s progress note, stated, “Oh my goodness, the nurse absolutely did not tell me that the resident was lethargic, continues hiccups, elevated heart rate, oxygen saturation in the 80’s, skin color was not good, and skin was moist. I would have called 911 myself. I would have told the nurse to call 911 for immediate care, treatment, and transport. The nurse did not notify me that the ambulance service was going to be two-to-three hours getting to the facility. The nurse should have called 911 for this resident, he was not stable. I am so sorry that the resident expired. The nurse did not tell me all the information stated in her progress note, the nurse should have called 911.”

The facility’s failure to follow their change of condition policy, assess the resident properly, and call 911 when his condition worsened resulted in a delay in receiving a higher level of care and ultimately contributed to the resident’s death. The facility has since implemented corrective actions, including staff education and audits, to ensure compliance with the change of condition policy and prevent similar incidents from occurring in the future.

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 such as this one 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.

IDPH has cited and fined Belleville Healthcare Center after the staff failed to order an antibiotic to treat a leg infection for over a week . . . and neglected to inform the resident’s doctor of the delay.  The resident subsequently died of sepsis shock and bacteremia.  

The resident in question suffered from multiple medical conditions including anemia, vitamin deficiency, and skin changes putting him at risk for complications. 

When the resident developed swelling in his left leg, doctors ordered tests and an antibiotic, cefixime, to treat early signs of infection.

Critically, the nurse at the nursing home could not enter the prescription due to a possible drug allergy alert. 

The nurse notified the wound care nurse of the issue but did not notify the doctor that the antibiotics were not started. Over the next week, the resident missed 10 doses of antibiotics. His leg continued deteriorating yet the doctor was not updated about the missed medication doses or worsening wound.

Approximately one week later the doctor had to reorder the same antibiotic prescription. 

Approximately another six days passed until a wound doctor first evaluated the resident and found a severe infection requiring debridement surgery, stating “By the time I was notified of the resident’s wound it was already really bad. I am not sure why they even waited so long for me to see him. The size of this wound was not something that would just appear overnight.  His whole left leg was a big bag of pus. I had never seen anything like it . . . The facility should have been monitoring the resident more closely.” 

Approximately two weeks after the appointment with the wound doctor the resident was admitted to the hospital for sepsis and shock. He tragically passed away from widespread infection four days later.  

Timely intervention with antibiotics and proper communication with doctors may have prevented such a tragic 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.

IDPH has cited and fined Aperion Care Bradley nursing home after the staff failed to adequately track and report a resident’s symptoms that lead to a delay in treating his stroke.  

The resident at issue, a 53-year old man with a mild cognitive issue, kept asking staff to take him to the hospital because of numbness and a “pin and needles” feeling in his right arm, which are common stroke warning signs.  He recounted clearly saying “Listen, I know my own body.  I knew something was very wrong. I was really scared from the numbness and tingling.  I pleaded with my nurse to please send me to the hospital right away but she said No.”

That morning, when the resident first told his nurse of his arm issue around 9 or 10 AM, she only focused on his high blood pressure of 177/102.  The nurse admitted “Maybe I didn’t mention his arm tingling to the Nurse Practitioner because I was overly worried about the blood pressure.”  So she failed to pass on this stroke indicator.  The Nurse Practitioner agreed “They should have informed me if the resident was still having numbness after getting blood pressure medicine.”

The nurse was also supposed to check the resident’s vitals that night because of new medications but the agency nurse never did the required checks. The agency nurse admitted ”I’m not supposed to take vitals unless the nurse tells me to.”

The next morning, a nurse found the resident inexplicably lying on the floor, slurring words, with a droopy face and weakness on one side.

Tragically, a scan at the hospital showed that the resident had already suffered an untreatable stroke with permanent damage. The director of the nursing home acknowledged they neglected handling the resident’s ongoing numbness complaint.

Their lack of monitoring and reporting of his symptoms led to his disability after a preventable stroke.

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.

IDPH has cited and fined Fireside House Of Centralia due to a failure of the staff to correctly obtain timely emergency care for worsening signs of a large gastrointestinal bleed, leading to the death of the nursing home resident en route to the Emergency Room.

One of the basic roles that a nurse in a nursing home setting plays is to serve as the eyes and ears of the resident’s doctor.  When a resident shows signs of a change in condition, has a nursing home fall, or is demonstrating some other condition of ill-being, it is the nurse’s job to notify the doctor.  The doctor then can issue orders over the phone for treatment to be delivered at the nursing home, go into the nursing home to see the resident himself, or order the resident sent to the hospital for examination and treatment there.  Occasionally a situation arises where the nurse does not have time to contact the doctor, and must make a decision as to whether or not to call an ambulance service or 911 when the resident’s condition warrants.  That was the case in this troubling nursing home death. 

The resident at issue was exhibiting altered mental status, with symptoms including sluggish dilated pupils, difficulty speaking, and abnormally slow responses. Although the LPN (Licensed Practical Nurse) initially stated “she was going to send the resident out to the hospital”, she inexplicably changed course and directed staff to get the resident prepared for her scheduled medical appointment that morning. However, when the resident was found to have a temperature of just 95.7 degrees, the LPN then ordered her back to bed and called the ambulance company at 6:55AM. Crucially though, upon being told no ambulances were currently available, the LPN explicitly stated she would continue to wait rather than contact 911 for emergency assistance.

Over the critical next hour, the facility staff stood by while the resident yelled out in pain, unable to verbally communicate, and even screamed “everywhere!” when asked where she was hurting – clear signs of emergent distress. A CNA reported she kept checking on the resident, who was trying to talk but couldn’t, while the patient continued to deteriorate now that the LPN had decided to delay ambulance transport. Later, another nurse would state “Honestly, if it came down to it, I would push them to the hospital. It is right next door,” indicating the staff were aware they had a duty to act.

Finally at 7:35AM the ambulance arrived, but by then the resident was documented as unresponsive. She went into cardiac arrest en route to the hospital ER, and was pronounced dead shortly thereafter due to complications of a massive gastrointestinal bleed.

Nursing homes are businesses, and well-run businesses have systems in place to carry out their basic functions.  Assuring that patients are not neglected and that they receive timely medical care and attention is one of those basic functions.  Here there was clearly a problem with the system that the nursing home was operating under, as the facility’s failure to implement timely emergency care during the resident’s obvious medical crisis subjected her to a negligent, hour-long delay in treatment and ultimately resulted in her 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.