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.”
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