- While restraints are disfavored in the long term care industry, they can be used when they are necessary and orders for their use are obtained. This resident had an order in place for a seat belt, and this order was obtained in order to prevent falls out of the wheelchair. The seat belt was not on at the time of the accident, and as a result the kind of nursing home fall that the seat belt was intended to prevent occurred.
- The aides moved the resident after the fall without getting cleared by the nursing staff. It is the role of the nurse to check a resident for injury and moving a resident without being cleared poses a grave risk to the safety of the resident. Here, the resident was in the wheelchair when the nurse assessed the resident. It appears from the citation that the nurse did not realize the nature of the fall, contributing the inadequate post-fall assessment.
- The nurse failed to follow up properly on the fall that occurred. It was never documented in the resident chart, the family was not notified that it had occurred, and the doctor was not informed of the fall. These are all steps that must be taken following a fall. Further, at most facilities, after a fall, the resident is placed on a 72-hour fall watch during which the nursing staff should be monitoring for the delayed onset of signs of injury, such as a brain bleed or pain associated with fractures. The failure to start a 72-hour fall watch doubtless contributed to the long delay in obtaining care for the fractures.
- The resident’s pain and injuries went without proper treatment. Subjecting a resident to unnecessary pain for that length of time is simply a form of nursing home abuse.
IDPH has cited and fined Aperion Care Fairfield nursing home after a resident there fell from her wheelchair, suffered a broken leg, and then had the fracture go untreated for two weeks. The resident at issue was wheelchair-bound and suffered from advanced dementia. There was an order in place for the use of a seat belt to prevent her from sliding out of the chair. This is in itself unusual because a seat belt is a form of restraint, and the use of restraints are discouraged in the nursing home industry for a wide variety of reasons. However, a restraints can be used in some very limited circumstances, and then only after a doctor’s order is obtained and informed consent is given by the resident or their surrogate decision-maker. Once the use of a restraint is authorized, the way in which it used must be carefully followed. The intended purpose of the seat belt was to keep the resident from falling out of the chair. To get the order for the use of this restraint, this had to be a recurrent risk to the health and well-being of the resident and its use had to be necessary. When the use of a restraint is authorized by physician order, that order should be followed by the nursing home staff. This nursing home fall occurred when the resident was in the dining room seated in her wheelchair. The seat belt for the seat belt for the wheelchair was not on. The resident fell forward out of the wheelchair, and as she did so, she reached forward and grabbed onto a tablecloth. As she did so, she pulled the table cloth down as well as a television set which was placed on top of the tablecloth. The television set landed on the resident’s leg. The aides in the dining room responded right away and lifted the television set off the resident and helped her to her wheelchair right away rather than summoning a nurse to assess the resident. One of the aides reported the fall to the nurse assigned to the resident, but apparently failed to mention that the television set landed on the resident. When the nurse checked on the resident, she was already in her wheelchair with no obvious signs of injury and given that the nurse was under the impression that this was a “simple fall,” no detailed assessment was done of the resident’s condition nor was the fact of the fall documented in the resident chart or was a 72-hour fall watch started. There was also no physician notification of the fall. Over the next several days, the condition of the resident obviously declined. She remained in bed curled up in a fetal position and was resistive to staff moving her, comforting her, or otherwise trying to care for her. She began to experience vomiting which is something that the doctor was notified about as well as the change in behaviors, but was not told about the occurrence of the fall. Two weeks after the fall, the during the administration morning meeting the topic of the resident’s decline was mentioned. The medical records custodian mentioned that she had heard one of the staff members mention that the resident had a fall. The administrator told the state surveyor that this was the first time that he had heard that there was a fall. He instructed the nursing staff to obtain an order from the doctor for x-rays which showed that the resident had a fractured femur. She was brought to the local emergency room before being transferred to a medical center where she underwent surgery for the fracture. There are a number of shortcomings in the care that this resident was provided:
IDPH has cited and fined South Suburban Rehab nursing home in Homewood after a resident there was shot to death by a fellow resident. One of the basic tasks that families look to nursing homes to do is to keep their family members safe. Sadly, there are incidents each year where residents are victimized by other residents whether by physical or sexual assaults. This is one which turned fatal. The perpetrator of this assault was a 32 year old man who was a paraplegic due to injuries he sustained in a shooting a number of years earlier. He was admitted to the nursing home approximately two weeks before the murder. The nursing home ran a background check on him which showed that he had felony convictions for possession of controlled substances, battery, and unlawful possession of a firearm. The victim was a 77 year old man who suffered from mental illness. He had been involuntarily discharged from the facility earlier in the year due to his aggressive physical and verbal behaviors toward other residents and staff. During the days leading up to the shooting, there had been a number of altercations between the two residents, leading the younger man to make threatening remarks and comments to fellow residents about the victim. He managed to leave the facility, obtain a gun and return. On his return to the facility, he showed the gun to at least one other resident. The resident who saw the gun told the state surveyor that he told a CNA and a nurse about the gun. However, the staff members deny having been told about the gun. On the night of the shooting, the younger man was agitated and moving about the facility in his wheelchair and on at least one occasion tried to leave the facility before being brought back by the staff. At about 3 am, he went into the victim’s room and shot him multiple times. The staff, hearing the gunshots, left the floor and called 911 to advise that shots had been fired and that there was an active shooter on the premises. Police and paramedics arrived shortly thereafter, but the victim was mortally wounded. The murder weapon was recovered from the backpack located on the rear of the wheelchair of the younger resident. Obviously, this is a tragic situation, but one which could have been prevented. As a starting point, the issue of whether the staff was aware of the presence of the firearm on the premises is in dispute. However, there is at least one account which establishes that at least two staff members were aware of the presence of the gun. It is un known whether other residents would say that additional staff members were aware of the presence of the gun. Assuming that were the case, the gun certainly should have been confiscated and the younger resident removed from the facility. Past that, there were other opportunities to prevent this tragedy. Care planning is a mainstay for addressing the potential for resident-on-resident assaults. This is usually done by keeping the residents separated. The victim here had a long and well-known history of aggressive verbal and physical behaviors toward other residents, to the point that he had to be sent out for a psychiatric hospitalization. Closely monitoring the behavior of residents with these types of behavioral patterns and promptly intervening is a mainstay of preventing altercations between residents. However, it does not appear that proper care planning was done to address this potential. Past that, staff told the state surveyor that they were understaffed which would have badly inhibited the ability of the staff to monitor the behaviors and interactions of the residents under their care. Additionally, it appears from the citation that the shooter got the gun out in the community. It also appears from the citation that the resident did not have community pass privileges which would allow him to come and go as he pleased from the facility. Assuming this to be the case, the resident would have had to wander (wandering from a nursing home is also known as elopement) from the facility and return without it being noted in the chart. The defense of this claim in any later nursing home abuse and neglect lawsuit resulting from this incident will doubtless cast blame for the incident on the shooter and claim that the shooting was an unforeseeable criminal act. Shockingly, this can be a viable defense, one which is further complicated by limitations in the ability of the family to obtain police records and witness interviews. This is all the more reason to hire a well-qualified nursing home abuse and neglect attorney for this kind of case. 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: Resident assaulted by roommate at Countryside Nursing & Rehab in Dolton Resident on resident assault at Alden Long Grove Forest City Rehab resident murders roommate Assault by fellow resident results in broken hip at Stephenson Nursing Center Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
IDPH has cited and fined Aperion Care Capitol nursing home in Springfield after the nursing staff there failed to complete the admissions process for a newly-admitted resident suffering from bacterial meningitis, resulting in her not receiving any form of care for the first 42 hours she was in the facility. Nursing homes are businesses, and well-run businesses have processes which are intended to help assure that the basic services that the business is there to provide are in fact delivered in a routine fashion. When those routine processes are not followed, then there is almost inevitably a breakdown in the provision of those services. In the case of a nursing home those are nursing services necessary to assure the health and well-being of the resident, and failing to provide those services is a form of nursing home abuse and can have catastrophic consequences. The starting point of the process by which nursing care is provided starts when the resident is first admitted to the facility. The resident is added to the roster of residents that it is caring for. Usually these days it is an electronic record keeping system. The admission orders for the resident sent over from the hospital are reviewed with the attending doctor and the orders are entered into the system. The care planning process begins with a resident assessment and the development of a preliminary care plan. What happened to this resident is a study of what happens when a resident is brought to the nursing home, but the admissions process is never initiated. The resident at issue was admitted from the hospital suffering from bacterial meningitis and was to be receiving IV vancomycin. She was also a paraplegic and was unable to get out of bed on her own. The resident arrived at 5:50 p.m., but the nurse on duty did not have time to admit the resident, so she passed the resident onto the nurse on the next shift. That nurse never admitted the resident. Due to the failure to even start the process of caring for this resident, the nursing home effectively did not know that the resident was even in the facility. Over the next 42 hours:
- The resident was not fed because there was not an order for her to receive a meal tray;
- The resident did not receive her IV vancomycin, resulting in the resident having critically low levels of vancomycin, meaning that she was not receiving the therapeutic benefit of being on the medication;
- There were not proper supplies for the resident to self-catheterize as was the usual method for her to pass urine;
- She was not turned and repositioned, setting the stage for developing bed sores;
- She did not receive pain medication, even though she complained to the staff of pain levels of 10/10;
- Isolation precautions were not put into place for staff coming in and out of the resident’s room, placing other residents at risk of infection.
IDPH has cited and fined Bria of River Oaks nursing home in Burnham after a resident there suffered a ruptured globe to his left eye after being struck with a broom by a staff member. The resident at issue suffered from mental illness characterized by episodes of delusions which leads to agitation and anxiety. On the day of the incident, the resident was acting out in his room. The aide assigned to the resident got another staff member to help remove chairs from the resident’s room. In response the resident picked up a chair and threw it at the staff. An aide then swung a broom at the resident, hitting him in the eye. He was brought to the emergency room where he was diagnosed as having a ruptured globe in the left eye. The resident was then transferred to a higher level hospital for definitive care. It goes without saying that there is no good reason for a staff member to swing a broom at a resident. When confronted with aggression by a resident, the right response is to de-escalate the situation or to get help from other staff, especially the nursing and social work staff who have more advanced skills for addressing this kind of problem. Having a loved one be the victim of physical aggression by a staff member is one of the common fears that every family member of a nursing home resident has. Because this kind of nursing home abuse was at one time so prevalent, the General Assembly included a provision in the Nursing Home Care Act that makes nursing homes liable for both the intentional and negligent acts of their employees. Oddly, in most kinds of personal injury lawsuits, one of the defenses that an employer can and does make when an employee commits an intentional act against some one else is that the employee was acting outside the scope of his employment – after all, no one hires an employee to deliberately hurt someone else. And surprisingly, this can be a real defense for employers. Not so with nursing homes. However, one thing that a lawyer prosecuting a personal injury suit arising from this incident would have to keep in mind is that insurance coverage is not normally available for intentional acts. However, a smart lawyer would also include a claim that the nursing home was negligent in failing to properly train the aide on de-escalating the situation and generally how to address these kinds of situations which certainly can occur with the kind of mental illness that this resident suffered from. However, failing to properly train employees is one of the hallmarks of how for-profit nursing homes are managed as part of the nursing home business model. 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: Resident sexually assaulted by staff member at Alden Estates Northmoor St. Anthony’s fails to treat resident’s pain during wound care South Suburban Rehab resident murdered by fellow resident Chaplain sexually assaults residents at Good Samaritan in Quincy Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
Recent news reports has shown that IDPH stopped investigating allegations in abuse and neglect during the period between approximately March 15 and June 30. By way of background, the Illinois Department of Public Health is the agency which inspects nursing homes and issues citations for violations of state and federal regulations. When a nursing home has a citation issued to it, they must submit a plan of correction to show what they will do to bring the nursing home back into compliance. This often includes retraining of the staff or repair and inspection of broken equipment. The citations are usually accompanied by a fine which usually tops out at $25,000 for the most serious violations that result in significant injury or death to the resident. Citations may also result in issues with the nursing home’s license or with their Medicare star ratings. The date that IDPH stopped doing the abuse investigations of course correlates with the onset of the coronavirus pandemic. There can be no doubt that the pandemic has hit the nursing home industry particularly hard, especially in terms of resident and staff illnesses and deaths, and has made a hard task even harder. However, the extra demands brought on by the pandemic does not mean that other care needs of the residents could not/should not be met. (Related resource: IDPH Long Term Care Facility Outbreaks COVID-19 – searchable database you can use to find out which facilities have COVID-19 case, how many, and how many deaths) One of the recommendations that we make to families with a loved one in a nursing home is to be a frequent, but unpredictable visitor. In other words, visit often, but not on a set schedule so that the staff always has to be on top of their game with your family member. For example, if the staff know that you always come Tuesday evening, you can be sure that things will look good Tuesday evening … which may be a different story from Friday morning. We also recommend that you be pleasant but assertive regarding your family member’s care. None of this has been possible as of late with restrictions on visitors in nursing homes. Over the last several months, we have heard from a number of families who have been very upset about their limited access to their family members, and justifiably so. Investigations of abuse and neglect in nursing homes are often triggered by mandatory reporting by the nursing home to IDPH after an incident occurring in the nursing home or by a report submitted by a hospital or doctor who was concerned about the condition of a nursing home resident who was sent out for care. While IDPH has been inspecting nursing homes for compliance with infection control measures, the inability of family members to get into the nursing home left IDPH as one of the last lines of defense when it comes to stopping nursing home abuse and neglect. The pandemic has doubtless made many of the basic functions that need to be carried out on a day-to-day basis much more difficult and this has opened the door to many of the types of preventable injuries much more likely to occur. Without even trying to address this in an exhaustive way, these are some of the ways: Bed sores The need to observe proper infection control measures makes going in an out of rooms something that takes longer, which means that the simple act of turning and repositioning bed-bound and chair bound residents is going to be harder to get done. Further, that also feeds in to it taking longer to change a resident after an episode of incontinence. This also makes it more difficult to make sure that residents get adequate amounts of food and liquid. Why is this important? Because immobility, incontinence, and poor nutritional status are three of the main factors which place residents at risk for developing bed sores and addressing these issues are key steps for promoting healing after someone has already developed a bed sore. Nursing Home Falls One of the main stays for fall prevention is to keep residents in a common area where they can be easily monitored by staff. One of the ways of preventing the spread of the coronavirus is to keep residents in their rooms which neutralizes the effectiveness of this tactic. Promptly responding to call lights and assisting residents to the bathroom when they need it are also key fall prevention measures. Just as with turning and repositioning, this is a more difficult task in the current environment. One of our core beliefs is that constant or intermittent confusion is a strong risk factor for nursing home falls because the resident cannot be counted on to make good decisions for their own safety or ask for help. The combination of lots of social isolation and the staff being masked and gowned constantly is something that is likely to lead to further cognitive decline. Past that, residents have a diminished ability to walk and exercise which leads to further decline in range of motion, strength, and balance. Choking Residents are no longer being served meals in dining halls. This means that they are generally eating alone in their rooms which means that residents who are experiencing declines in their ability to swallow are not being noticed and referred for swallow evaluations by speech therapy. Other residents who are already under care plans for choking risk are likely receiving lower levels of assistance and supervision with meals. **** One of IDPH’s roles is to prevent nursing home residents from suffering unnecessary injuries, illnesses, and wrongful deaths, and with families unable to watch out for and advocate for their loved ones, carrying out that responsibility was more important than ever. Supposedly, IDPH has made a dent in the backlog of investigations that piled up while they stopped doing investigations, but the passage of time and the press of business makes it every more likely that those investigations will not be as thorough as they should be. Unfortunately, failure was already baked into the system by which care was being provided in nursing homes in Illinois. For more information on why that is the case, order our FREE report, Built to Fail. If you have a loved one who you believe has suffered unnecessary injuries or been the victim of nursing home neglect or abuse during this time, please contact our experienced Chicago nursing home lawyers. The initial call and meeting are free, and there is no obligation to hire us if you do call. We serve nursing home residents and their families throughout the State of Illinois.
The nursing home industry in Illinois (and really nationwide) has been hard-hit by the coronavirus/Covid-19 pandemic. Here are the things that you need to know. The Illinois Department of Public Health has a link – click here – which provides a searchable database of which nursing homes have had confirmed cases of coronavirus and whether there have been related deaths. This is a page which is being updated on a weekly basis, so you can check back here for additional information as it develops. The fact that a nursing home has coronavirus cases and/or deaths is not necessarily an indicator that they are providing poor care – it has been a struggle to contain the virus everywhere, and once it is in the building, it is that much more difficult. However, under the circumstances now, I certainly would not choose to admit a loved one to a nursing home with confirmed cases, and this is the best resource for identifying which facilities have confirmed cases. What about the legal situation? As I am writing this, there are a lot of open questions which I have not had to consider too deeply, because our office has not as of yet accepted any cases involving coronavirus and am uncertain that we will. Cases involving the coronavirus will likely be inherently difficult. To win a nursing home abuse and neglect case, you need to prove that the nursing home provided substandard care. Proof that this was the case is going to be hard to come by, as much of what could stand as proof will not be in the resident chart, which is a primary source of proof in all nursing home cases. Further, because of the no-visitors rules in place at nursing homes around the state, testimony from family members will be missing as well. Further you need to show that the substandard care caused the negative outcome which is something that will be difficult to show as well. Complicating all of this is the Executive Order issued by Gov. Pritzker declaring Covid-19 a state health emergency. One of the provisions in the executive order provides that persons and entities providing care in response to the outbreak will be immune from liability unless the negligence is either gross negligence or willful misconduct. This is a greatly heightened standard of proof. Obviously, this order is intended to allow health care providers to offer care without having the same concerns about legal liability they ordinarily would have. I have no idea right now whether that governor-created immunity from negligence in the provision of care would withstand constitutional challenge under the Illinois State Constitution, when and if it is challenged. For now, that certainly stands as extra hurdle that nursing home residents and their families might face should something happen which might otherwise warrant legal action. As for other types of cases such as bed sores, nursing home falls, choking accidents, and other forms of nursing home abuse and neglect: our office is still accepting appropriate cases for representation. However, you can be sure that nursing homes will try to use the Executive Order as a defense against even these ordinary, non-coronavirus type of cases, and one of the issues which will have to be resolved at the outset is whether the Executive Order applies to the regular care that is supposed to be provided in nursing homes, in additional the issue of whether it is constitutional or not. You can also be sure that many of these cases will be defended much more aggressively with nursing homes explaining poor care as being a product of the crisis and the additional strains that the crisis brought on. For all of these reasons, it is ever more crucial that in the event that you or your family are considering legal action against a nursing home during this time that you get the help of an experienced Chicago nursing home lawyer to assist you. Contact our office for a free, no-obligation consultation.
IDPH has cited and fined Oregon Living & Rehab Center nursing home after a resident there sustained an unexplained fracture of the humerus. Many nursing home residents, especially females, suffer from osteoporosis, or “brittle bone disease” which leaves them at greater risk for injuries such as hip fractures after nursing home falls. Other common injuries associated with osteoporosis include compression fractures of the lower and mid-back and broken wrists. But there are some fractures which occur which really cannot be explained at all, and that was the case here. The resident at issue suffered from advanced dementia. She also had a history of having two failed hip replacements, so she did not have functioning hip joints. She required the assistance of two for all transfers and activities of daily living. In short, she was dependent on staff for doing any kind of movement at all. The injury was discovered when an aide went to her room to begin to prepare her for bed. He saw that they entire arm was bruised up through the back of her neck and that the there was an indentation pushing out against the skin of her arm. X-rays were obtained which showed that she had a comminuted (broken in at least two places) fracture of the humerus, or upper bone in the arm. Her orthopaedic surgeon told the state surveyor that the fracture was likely traumatic in nature given that the bruising extended all the way to the back of her neck. So how did it happen? The nursing home investigated, and everyone denied doing anything that could have caused the injury, which is of course completely inconsistent with the nature of the injury and the residents own physical limitations. In the words of the nurse assigned to the resident, “I’m furious because somebody knows what happened.” There is actually a doctrine in the law called res ipsa loquitur which can be used in cases like this. In Latina, res ipsa loquitur means “the thing speaks for itself” which requires the injured party to show that there was an injury which would not have occurred in the absence of negligence, and this is the kind of injury that would likely qualify. Clearly bones like the humerus do not simply shatter in the way that happened here which would make that theory of liability applicable under these circumstances. So what was the consequence of this injury? This resident was on hospice, but was actually going to be discharged from hospice because her condition was not declining, but after the fracture, the nurse assigned to her advised the state surveyor that she expected a decline in the resident’s condition, similar to that which you might see after a hip fracture. 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: Broken leg in fall at Generations at Neighbors Fall results in brain bleed and death at Regency Care of Sterling Presence St. Anne resident breaks neck in fall from lift Transport van accident at Generations at Rock Island Resident falls from lift at Oregon Living & Rehab Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
IDPH has cited and fined Carmi Manor & Rehabilitation nursing home in Carmi after multiple residents there were assaulted and generally terrorized by a fellow resident over a period of months. When a resident is being considered for admission to a nursing home, one of the judgments that the admissions staff must make is whether there resident has care needs which would make him unsuitable for the facility or has care needs which cannot be met at the facility. This is an especially critical judgment where a resident has a demonstrated history of psychiatric and behavioral issues which demonstrate a pattern of aggressive or threatening behaviors because a nursing home is often filled with residents who due to physical or mental infirmities may not be able to fend off an aggressor. The nursing home administration here made a horrifically bad decision to admit this resident and then compounded the problem by failing to train or empower the staff as their proper role in protecting residents and then failing to report and/or investigate abuse that this resident perpetrated on his fellow residents. The resident at issue was 62 years old (relatively young for a nursing home setting) and had no major physical limitations, but had a current diagnosis of paranoid schizophrenia and had a history of physically and sexually aggressive behaviors. This included a history of having been found unfit to stand trial on rape charges which had previously been lodged against him. Despite this history, the administrator and social services director decided to accept this resident into the facility. The citation itself is lengthy, and documents at length a disturbing pattern of behavior against his fellow residents. There were seven residents who were victimized by this one resident, both male and female. The male residents were punched and threatened and had their cigarettes stolen from them. Most of the victims were female and they described mainly one of two behaviors. Either they were physically grabbed on the breast by this resident. The other behavior which was directed toward female residents was that he would enter their room proclaim that the female resident was his wife, and act as though he would want to have sex with them. Needless to say this terrified the female residents in the room. The staff would at times simple remove him from the room, but at other times, residents would use their cell phone call 911. The responses to the calls to 911 were especially disappointing. In one instance, law enforcement simply responded by calling the nurse’s station. One nurse related to the surveyor that the local police department refused to make an arrest because they did not want a psychotic person in their jail. So, of course, they left that psychotic person in a nursing home. The victims of this resident’s behavior was not limited to his fellow residents. There were staff members who were manhandled and groped. One CNA found herself alone in a room with him with the door closed and screamed because she was afraid of what he would do to her. This was clearly a situation where the staff was not in control of the nursing home. When a resident is victimized in a resident-on-resident assault, it is incumbent upon the administration to determine whether that resident should remain in their facility. If they cannot keep residents safe, then they need to take steps to discharge the resident. If they believe that the behavior can be managed, then resident abuse prevention care plans need to be modified to take specific and aggressive measures to deter further episodes of abuse. This is another area of failing, as the staff told residents who complained of this resident’s behavior on multiple occasions that they could not do anything about it because they didn’t see this themselves. There really isn’t even a kernel of truth in that. If the staff truly believed that, it represents a massive failure to train. If the staff didn’t actually believe that to be true, it represents a massive failure of leadership because the staff knew that they would not be supported. My guess is that the latter is probably the case because many of the incidents which were described in the citation were never investigated by the administrator who does have an affirmative duty to investigate allegations of abuse. The net effect of these widespread, repeat failures at this nursing home is that these residents were victimized repeatedly by a resident who likely never should have been admitted in the first place, but was then allowed to stay long after it should have been obvious that this was not a proper resident to have in the facility. A nursing home is a “home” for many residents where they live full time. They do not deserve to be terrorized in their own home. They do deserve to be defended from this kind of nursing home abuse, but there were choices made here to not provide the residents with the level of protection they deserved. 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: Multiple residents victimized by fellow resident at Winning Wheels Nurse attacked by resident at Parker Nursing & Rehab Resident sexually assaulted by fellow resident at Dixon Rehab Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
IDPH has cited and fined Alden Estates of Northmoor nursing home in Chicago after a resident there was sexually assaulted by a staff member. The resident at issue was a female, 34 years old and alert and oriented x1. She suffered from incontinence and used an adult diaper. On the night of the occurrence, a nurse was walking down the hallway and saw a male member of the housekeeping staff standing in the resident’s room at bedside with his hand inside her disposable brief. The nurse went into the room and confronted him. He explained that he was picking up a diaper in the trash and left before he could be questioned further. The nurse got another staff member to watch the resident while she alerted the Director of Nursing who called the police. The staff member was placed under arrest. The members of the nursing staff did the right thing. The nurse who saw something being done wrong stopped it, protected the resident, and reported it. The DON called the police and obtained medical care for the resident. This does not mean that the nursing home will escape liability. Illinois has a specific statute called the Nursing Home Care Act which imposes liability on the nursing home for negligent or intentional acts which injure a resident. This kind of nursing home abuse is squarely covered by that provision. You would actually think that a special statutory provision like that would be unnecessary, but when it comes to criminal acts by their employees employers (not limited to nursing homes) usually try to defend the case by claiming that the act by the employee was outside the scope of their employment. Having this provision in places smooths the road for victims and their families to receive compensation. 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: Chaplain sexually assaults residents at Good Samaritan Home in Quincy Resident sexually abused at Countryisde Nursing & Rehab Resident sexually assaulted by fellow resident at Dixon Rehab Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
IDPH has cited and fined Parker Nursing & Rehabilitation Center in Streator after a series of incidents involving a physically aggressive and violent resident which ended with a nurse having to be taken to the hospital. Some readers of this blog may feel that we are unfair to nurses and that they get unfairly blamed for bad things that happen under their watch. And while we don’t want to discount the importance of being responsible for the things that you do or don’t do, we believe that nurses in nursing homes are often dealt a bad hand by the nursing home business model and that they mostly do the best they can given the circumstances and conditions that they work in. In this case, a nurse was the one who was the one who suffered the most due to the business decisions that were made at this nursing home to admit one resident in particular. This gentleman had spent time in prison for aggravated domestic abuse and had diagnoses which included Alzheimer’s, restlessness, and agitation. He had been a resident at another nearby nursing home where he had a demonstrated history of being physically aggressive. According to the staff interviewed by the state surveyor, multiple staff members including the Director of Nursing, asked that the resident not be admitted to the nursing home, but the administrator overruled their requests and allowed him to be admitted to the nursing home. Over the two and a half months that the resident was at the nursing home, there were multiple events where the resident at issue had been physically aggressive and had behaved in an intimidating way with other residents in his locked dementia unit. There were also incidents in which he was aggressive and threatening to staff members. Abuse is a nursing home setting is still abuse even when it is perpetrated by one resident against another. Among the other things that must happen is that it must be reported to the State and steps be taken to prevent the recurrence of abuse. When the issue involves the resident as a perpetrator, it requires adjustment of the care plan and taking steps to discharge the resident from the facility when they cannot keep other residents safe. Part of the issue with resident-on-resident assaults is that the a nursing home is the “home” for the resident who is the victim, and everyone, including and especially nursing home residents, deserve to feel safe in their homes. When the nursing home fails to protect other residents against an aggressor, the other residents have real cause to not feel safe in their own homes. This string of incidents came to an end with a serious assault on a nurse. The resident had been acting aggressively and two aides summoned the nurse from another unit because the nurse who was assigned to work the locked dementia unit was running late. When the nurse arrived, he grabbed her tightly by the wrists. As she tried to calm him, she asked if he needed to use the toilet. He said yes, so she took him to the bathroom. She saw there were feces on the seat so she went to clean it off. As she was cleaning off her hands, he hit her in the face with a plastic soap bottle. He grabbed her by the hair and slammed her face into the door frame repeatedly. He grabbed her stethoscope and began to choke her with it. She lost consciousness and began to exhibit seizure-like activity. 911 was called and the nurse was taken to the hospital and the resident was removed in handcuffs. The nurse here deserves to be treated as the hero of the story because she ended up paying a serious price for trying to keep this resident away from his fellow residents. Any one of them could just have easily been a victim of this kind of attack. What is most striking – and chilling – about this citation are the actions of the administrator. She was the facility’s abuse coordinator, in charge of the investigating episodes of abuse and coordinating the nursing home’s response. She did not treat any of the episodes prior to the attack on the nurse as abuse because she either deemed them “behaviors,” decided that no investigation was required because of the lack of injuries, or simply failed to investigate the incidents. Her response to the attack on this nurse deserves special examination. Someone who is the victim of that kind of attack at work deserves unwavering support, but that was not what happened to this nurse. What the nurse had to say, from the citation:
Am I in trouble? [The administrator] keeps telling me that I am the reason you are here and the facility is going to get in a lot of trouble if I tell you the truth. We have been told so many times to not chart certain things that will get us in trouble by [the administrator]. One time [the administrator] even erased the charting I did in a resident’s chart because [the administrator] said it would be too damaging to the facility. …. [The administrator] even came to the hospital ER [after the incident] and came into my room, even though I told [the administrator] not to. [The administrator] kept telling me all I had was a panic attack. I was physically assaulted. Now [the administrator] is telling me I better not tell you everything or the facility is going to be in trouble. They said you are here because of me.This tells you almost everything you need to know about how this place is run – residents are accepted who never should be, problems being swept under the rug, and doing the right thing coming in a distant second place to what the business needs. This nurse paid the price for the way this nursing home is being run, but it could just as easily have been another resident. There are so many poor choices that were made here for the benefit of the bottom line of the nursing home as a business. 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: Resident-on-resident assault at Alden Long Grove Multiple residents victimized by fellow resident at Winning Wheels Resident sexually assualted by fellow resident at Dixon Rehab Failure to follow feeding tube orders leads to hospice admission for Parker Rehab resident Assault by fellow resident results in broken hip at Stephenson Nursing Center Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
IDPH has cited and fined Countryside Nursing & Rehab in Dolton after a female resident was sexually abused by a male resident from that facility. One of the basic items that families look to nursing homes to do is to protect their families members from being injured, abused, or otherwise taken advantage of while they are at the nursing home. The staff is always a source of concern for families, but the potential for abuse does not begin and end with the staff – residents can be perpetrators of abuse as well …. and that is what the situation was here. The incident which served as the basis for the citation began with a nurse observing a female resident who suffered from advanced dementia walking down the hallway with a sheet wrapped around her lower half, holding two dollars in her hand. When the nurse asked her what happened and where the money came from, the resident was not able to explain exactly what had occurred, but from the discussion, the staff was able to identify a male resident. The male resident was summoned, at which point the female resident said that this was the man who raped her. For his part, the male resident stated that the sex between them was consensual and that he would give her money or provide her with sweets such as a cupcake or pop after having sex. The two men that he shared a room with told staff that he would bring an older lady into the room and could hear them having sex and never heard her say no. The female resident was sent to the hospital for a rape exam. The police investigator sent to the emergency room was unable to interview her due to her mental state. Nursing home residents are adults, and as such, are actually free to engage in romantic relationships of their own choosing. But for this to occur, both of the residents have to be able to consent to enter into that kind of relationship. If one of the residents is not capable of consent due to declines in their mental, intellectual, or psychological condition, then sexual activity involving another resident as here is actually a form of nursing home abuse – even where the staff is not the perpetrator of the abuse. Where there is a potential for a resident to be the victim abuse, this is something that must be addressed in the resident care plan. A care plan would include such items as keeping the resident under direction observation to keep the resident from being victimized. Failing to do that is something that would serve as a basis for a nursing home abuse and neglect lawsuit. 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: Resident assaulted by roommate at Countryside Nursing & Rehab Multiple residents victimized by fellow resident at Winning Wheels Resident sexually assualted by fellow resident at Dixon Rehab Assault by fellow resident results in broken hip at Stephenson Nursing Center Nurse violently attacked by resident at Parker Nursing & Rehab in Streator Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
IDPH has cited and fined the Good Samaritan Home in Quincy after the chaplain of that nursing home sexually assaulted two residents at that facility. He has since pleaded guilty to criminal charges associated with the assaults and has been sentenced to 26 years in jail. Nursing home residents are an inherently vulnerable population. They have physical and/or mental limitations which keep them from being able to live independently or with family. They depend on staff to help them with the basic necessities, to give them the medication and care they need, to provide them with food and drink to sustain themselves, and to allow them to live their lives with some degree of dignity. At a very basic level, families look to nursing homes to keep their loved ones safe and comfortable. One of the basic elements of keeping residents safe is keeping them from people who engage in abuse, physcial, mental, or sexual. And in this case, the nursing home failed seriously at this. The resident whose complaint sparked the investigation which resulted in the arrest, prosecution, and conviction of the chaplain reported to staff that the chaplain entered her room and grabbed her breast for a period of about two minutes before she pushed his arm away. After reporting it, she was tearful and upset and referred for mental health counseling to address her troubles in coping with what had happened to her. The truly shocking part of this nursing home abuse is that this was not the first time that there had been complaints about sexual misconduct regarding the chaplain. Prior to this incident, there were three separate allegations of sexual abuse against him, yet the police and Department of Public Health was never notified. The chaplain was never suspended from working at the nursing home while the allegations against him were never investigated – because they were never truly investigated, and in one case were never even noted in the resident’s chart. Incredibly with three allegations of sexual abuse against him, the administrator told the state surveyor that he could not identify a pattern of allegations against this individual. A nursing home is a “home” for many residents where they can reasonably expect to live for an extended period of time, and they deserve to feel safe in their own homes. When the nursing home employs individuals who abuse residents – mentally, physicall, or sexually – residents can no longer feel safe in their own homes. This is a gross breach of the basic promise that nursing homes make to residents and their families when they agree to have a resident admitted to the nursing home. At this point, what is known is that there were four separate episodes of sexual abuse by the chaplain against residents at this nursing home. However, it is also clear from the investigation conducted by the state that he was a predator with free reign to go about the nursing home with access to all residents within the facility, so even with four known episodes, there may well be more. What of the question of liability? There is a doctrine in the law called respondeat superior which makes employers liable for the negligent acts of their employees. This is why when there is a truck accident, the trucking company is responsible for the injuries for the accident. An exception to this rule generally exists where the employee is guilty of criminal misconduct – after all the company doesn’t hire employees to engage in criminal misconduct. However, the nursing home is subject to a statute called the Nursing Home Care Act which makes the nursing home liable for the intentional and negligent acts of their employees. This means that the nurisng home will not be able to evade liability for the abuse which was inflicted on the nursing home residents by the chaplain. However, this does not mean that there will be insurance coverage. Most insurance policies esclude coverage for intentional or criminal acts, and this kind of abuse would likely fall squarely within that exclusion. However, there are other theories which can be pursued, most specifically the negligence on the part of the administration to investigate the early episodes and remove him from the facility. This is something that would trigger insurance coverage and would provide some avenue of securing commpensation for the victims of this abuse. Generally, there is a 2 year statute of limitations which will apply to this kind of case. However, statutes of limitations will be extended where the resident was under legal disability where they were unable to manage their own affairs, such as when they suffer from advanced dementia or Alzheimer’s. Prosecuting this kind of case reuires the help of an experienced nursing home lawyer. Contact our firm today for a free, no-obligation consultation if you are concerned that your family member may have been a victim of sexual abuse at this nursing home.
IDPH has cited and fined Lutheran Home for the Aged nursing home in Arlington Heights after a resident suffered multiple fractures in a fall which was followed by the staff failing to promptly obtain treatment for the resident’s injuries. This fall has a common theme with many of the nursing home falls and mechanical lift accidents we have described here in this blog: one person doing a two person job and the resident suffering the consequences. For a sampling of incidents which we have addressed see here, here, here, here, and here. The resident at issue had been assessed as having functional limitations in range of motion on one side and needed the assistance of two with transfers for toileting. On the morning of the accident, the resident was getting out of bed and asked to be taken to the bathroom. The aide knew that the resident needed two people to be transferred to the toilet, so she went and asked a fellow aide to help transfer the resident to the bathroom, but that aide said that she could not help right away because she had other residents to attend to. The resident was insistent about using the toilet so the aide attempted to transfer her to the toilet by herself using a sit to stand lift. However, before they were able to reach the toilet, the resident was no longer able to support any of her own weight and the aide was not able to get her onto the toilet so she gently lowered the resident to the ground. “Gently lowering the resident to the ground” is a euphemism for a nursing home fall, and given what was found, how “gently” this resident was lowered to the ground should be a subject of fierce debate. A “fall” has a technical definition in the long-term care industry and generally it is considered to be a failure to maintain an appropriate standing, sitting, or lying position, resulting in an individual’s abrupt, undesired relocation to a lower level. Saying that someone was “gently lowered” are words that are used to mask the fact that a fall has occurred. When an aide is aware that a resident has fallen, it is their job to notify the nurse, who in turn is responsible for assessing the resident, notifying the resident’s doctor, and starting the 72-hour fall watch procedure. The fact that a fall has occurred should be noted on the 24-hour sheets, which are not an official part of the resident’s chart, but which are an important communication tool among the nursing home staff. Here the aide notified the aide notified the nurse, who claims to have assessed the resident and not found any signs of injury. The nurse did not notify the resident’s doctor, did not report the fall to the nurse coming on duty for the following shift, and did not note the fall in the resident chart. Asked why by the state surveyor, she said, “I don’t know why I didn’t report this as a fall at the time; I just had a lot going on.” The failure to report the fall to the doctor denied the resident the opportunity to get prompt treatment for her injuries. The failure to notify the oncoming nurse denied her the chance to be monitored for injuries which come on more slowly, like a brain bleed. During the course of the day, the resident complained of increasing pain which was not relived with pain medication, so the nurse on duty called the resident’s doctor. Because shew as unaware of the fall, when she was asked by the doctor if the resident had fallen, she said that there was no fall, so the doctor believed that the resident was suffering from an inflammatory process and not the effects of injuries. It was not until the nurse who had been on duty at the time of the fall came on duty for her next shift and learned that the resident had been experienced increasing, significant pain through out the day was the doctor told that there was fall. The doctor’s reaction: “I’m absolutely appalled by this situation; I feel the whole situation is neglectful and abusive to the resident.” When the resident was brought to the hospital, x-rays showed that the right leg showed a markedly displaced and overriding impaction fracture of the right distal femoral shaft in respect to the distal femur and condyles. The x-ray of the right arm showed that there was an acute impaction fracture through the right humeral neck. In other words, there were ugly fractures of the right arm and right leg, which raises real questions about just how “gently lowered to the ground” this resident was. Past that, the aide who had been asked to help before the accident came into the room after the accident occurred and told the state surveyor that she saw the resident laying on the floor saying “My shoulder, my shoulder.” These facts tend to show that this was a much more traumatic fall than the description of someone being “gently lowered to the ground” would ever suggest. Moreover, it wasn’t treated as a fall which resulted in the resident being denied treatment for her injuries for an extended period of time and not being monitored for the onset of more severe problems. The real question of course is, why did all this happen? The easy answer is that the aide did a two-person job with only one person, but the deeper answer probably lies with the understaffing of the nursing home. Past the fact that the aide felt rushed to get the transfer done by herself, there is also the nurse on duty saying that she didn’t treat this fall as such because she had “a lot going on.” These are the kinds of things that you hear when the nursing home staff simply does not have the help it needs to get the work done. 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: Resident suffers jaw, facial fractures at Dimensions Living in Prospect Heights Failure to follow recommendations leads to fall and facial fractures at Tower Hill Resident breaks both legs in unsafe transfer at Symphony of Buffalo Grove Resident found with 57 maggots in ear at Lutheran Home for the Aged Glenview Terrace resident suffers multiple fractures when lift topples over during transfer Aperion Care International resident fractures ankle in unsafe transfer Resident suffers broken hip in unsafe transfer at the Pearl of Rolling Meadows Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
IDPH has cited and fined Pekin Manor nursing home after a resident there had to be hospitalized with respiratory failure due to the failure of the staff to order necessary medical equipment. The resident at issue was admitted to the nursing home with orders from his doctor to have his chest tube drained daily until draining the chest tube returned less than 100 cc’s of fluid, at which point the frequency with which the chest tube had to be drained less frequently. On Wednesday, February 27, the nurses treating this resident recognized that they were running low on the bottlesg necessary to drain the chest tube. A request was made internally at the nursing for an order to be placed, but the order was never placed. By Friday, March 1, they were down to the last bottle, so a request was made to have the supplies delivered on a 24-hour basis. However, the medical equipment supplier did not made 24-hour deliveries on weekends, so the resident did not get the chest tube drained over the weekend. The resident was taken to the emergency room Sunday night suffering from respiratory failure. When he was in the emergency room, the doctors there drained 800 cc of fluid from the resident’s chest. The resident was admitted to the hospital. One of the basic tasks that nursing homes are charged with are carrying out physician orders. In this case, that included doing daily drainage of the chest tube. In order to do that, the necessary supplies had to be on hand. Nursing homes are businesses, and well-run businesses have systems in place to deliver the basic services that are supposed to be provided. In the nursing home setting that means having systems in place to ensure that supplies are on hand to deliver the care that the residents need. Here there was a system that simply failed: the supplies that were needed were not ordered. As a resulty, the nursing home failed to provide necessary care. However, once the staff was aware that there were not going to be supplies on hand to provide the resident with the care that the doctor ordered, simply skipping it and hoping for the best was not a real option. This was a situation where physician notification was required, as it was not the nurse’s role to decide whether it would be okay for the resident to go without the care that was needed. 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: Aperion Care Capitol fails to obtain equipment needed to treat bed sore Failure to obtain anti-seizure medication at Lexington of Orland Park California Gardens fails to obtain respiratory equipment Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
IDPH has cited and fined Warren Barr North Shore nursing home in Highland Park after a resident sustained a head injury in a fall that was caused by short-staffing of the nursing home. People who reside in nursing homes need help. That’s why they are there. Federal regulations require the nursing home to have staff on hand necessary to meet the care needs on a 24/7 basis. When nursing homes don’t have enough staff on hand, there are all sorts on negative consequences which ultimately come back on the residents:
- Residents don’t get turned and repositioned or have timely incontinence care provided, which can lead to the development of bed sores;
- Residents who need supervision at meal times may not get it, which can lead to choking accidents;
- Aides may not have time to wait for the help of another aide to use a mechanical lift to transfer a resident which can cause a Hoyer lift accident;
- Residents may not get bathed or showered as they should, which is a form of nursing home abuse — and is one of the things that IDPH cited the nursing home here for. Some residents had gone 10 days without being bathed because there was not enough help to get it done.
IDPH has cited and fined Aperion Care of Mascoutah for repeatedly not answering call lights. The issue raised in the complaint at first blush seems like it may be a trivial one. A resident who needed help getting on a bed pan to go to the bathroom was not getting a response when she sounded the call light for staff to help her. As a result, she had multiple episodes of being incontinent of bowel and was humiliated and embarrassed about it. She reported waiting 30-60 minutes for a response to the call light. When queried about it by the state surveyor, the administrator acknowledged that the DON had reviewed video and seen that call light response times were in need of improvement. One thing that every member of a nursing home staff agrees to is that residents have a right to be treated in a way that assures their dignity. Failing to answer a call light so that residents are left to soil themselves is a form of nursing home abuse. On a surface level, this may not seem to be a big issue, but it is a sign of what is happening at that nursing home. The fact that call lights are not being answered is an indicator that there is understaffing at that nursing home, which has multiple negative impacts on the delivery of care. Past that, failing to answer call lights trains the residents that no one is coming to help, so they are more likely to get up without necessary assistance, setting the stage for nursing home falls. Understaffing leads staff members to try to use a Hoyer lift with only one person instead of two, setting the stage for residents being dropped while being transferred. Failing to answer call lights to help residents go to the bathroom and instead suffer episodes of incontinence sets the stage for residents to develop bed sores. There is a saying that little hinges swing big doors, and little things like not answering call lights sets the stage for much worse things to happen. This citation only called out the loss of dignity, but it could just as easily been a much more serious issue. When call lights are not being answered, avoiding catastrophe is the result of good luck, not good care. Relying on good luck is not a strategy for caring for nursing home residents. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of 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: Failure to recognize infection at Helia of Belleville Brain bleed from fall at Good Samaritan Home in Quincy Failure to answer call light leads to fall at Pekin Manor Broken ankle from fall at Aperion of Mascoutah Resident develops pressure ulcers at Eastside Nursing & Rehab Bed sore caused by leaving resident sitting on bed pan at Mar Ka Nursing Home in Mascoutah Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
IDPH has cited and fined Marigold Rehabilitation & Healthcare Center in Galesburg after a resident suffered a urinary tract injury due to improper insertion of an indwelling urinary catheter. The resident at issue had an indwelling catheter. An indwelling catheter is a tube which goes up the urethra to the bladder. Once the tip reaches the bladder, urine should begin to pass down the catheter tube. The passage of urine through the catheter is the signature that the catheter has reached the bladder. At that point a balloon at the tip of the catheter should be inflated which holds the opening to the bladder open and allow urine to continue to drain through catheter. The male resident at issue had a catheter which needed to be replaced. He apparently suffered from significant dementia and struggled with the staff during catheter changes. This time, he was held down by the staff while a nurse inserted the catheter. She encountered some resistance in passing the catheter, but did not have urine draining from the catheter. Thinking she had reached the bladder, she inflated the balloon and attempted to remove the port for blowing up the balloon. When they did so, the catheter came out of the penis as did large amounts of blood. The resident was sent to the emergency room to get the bleeding under control which was made more difficult due to the fact that he was taking blood thinners (which is part of why nursing home falls are such a serious issue for residents who are on blood thinners – internal bleeding can progress much further than would otherwise be the case). The fundamental issue in this case is an issue of poor nursing technique. The nurse who was responsible for replacing the catheter did not use proper technique in placing the new catheter. Instead of inflating the balloon after the catheter had entered the bladder, she inflated the balloon while the catheter tip was still within the urethra – in other words, she inflated the balloon too early. The signature of a proper placed catheter is a flow of urine from the bladder into the bag. The nurse saw that there was no urine entering the bag but nonetheless inflated the balloon on the catheter. When nurses fail to follow proper technique, this is a form of nursing home abuse and neglect and can be the basis for a civil lawsuit. 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 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 Diabetes care mismanaged at Aperion Care Capitol Urinary catheter injury at Friendship Manor Wheelchair accident at Galesburg Rehab Unsafe transfer at Heartland of Galesburg results in dislocated hip Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
IDPH has cited and fined St. Anthony’s Nursing & Rehabilitation Center in Rock Island for failing to treat a resident for pain during wound care. Click the link in the prior sentence to check out the actual citation issued by IDPH. It is really disturbing reading. The resident at issue was suffering from cellulitis of both lower legs. As a result there were open, weeping blisters on both legs. He was sent to the hospital for treatment and when he was discharged, he received a prescription for Norco, a pain medication. He ripped it up believing that this was the same order that he had before he went to the hospital. When he came back from the hospital, the pain medication was discontinued. Despite the fact that the discharge instructions included continuing pain medication for supportive care, no one from the nursing home called the doctor or the hospital to resolve the discrepancy. As a result he did not receive the pain medication that was ordered for him. The citation graphically describes the results of what happened when he began to receive wound care without the pain medication:
- Before wound care began he described a pain level of 10+ like getting your finger on a hot stove all over his calf and that he had not been able to sleep the night before due to pain;
- When the nurse began unwrapping the dressings, he jumped with each touch, furrowed his brow, and grabbed the arm rests of his wheelchair, and said, “I wish I had a leather belt I could bite on so I don’t scream.”
- When he was offered lunch he declined it saying that he couldn’t eat because he was so nauseous from the pain.
- When they began to work on the other leg, he said, ‘Oh my f***ing God, this hurts.” When asked if he was okay, he replied, “No, I am not okay. This hurts like holy hell.” While the nurse continued to dress the leg, he writhed in pain and moaned.
IDPH has cited and fined Sauk Valley Senior Living in Rock Falls after a resident was admitted to the hospital in respiratory distress due the failure of the nurisng staff provide proper care for a resident with a tracheostomy. The resident at issue was 31 years old who suffered a severe brain injury after choking on food. As a result of this incident she was nonverbal, unable to care for herself of participate in her care, and had a tracheostomy. A tracheostomy is a surgical hole in a person’s throat which helps a person breathe. After the surgical incision is made, there is a tub called a cannula which is placed down the person’s airway. The cannula actually has two components: an inner cannula and an outer cannula. The outer cannula hold open the site of the tracheostomy, while the inner cannula is inserted into the windipipe and can be removed for cleaning. The cannula can become obstructed with fluids or other items. Obstruction of the cannula can result in a loss of oxygen to the patient and ultimately result in the wrongful death of the nursing home resident. One way of resolving an obstruction is by suctioning. The orders for tracheostomy care called for the resident to receive trach care daily and as needed, to be suctioned as needed, and to have the inner cannula changed daily. This was doubtless part of her care plan. On the night of the incident, an aide recognized that the resident was struggling to breathe, so she brought the nurse in. The nurse gave oxygen and listened to the resident’s lungs and recognized that the resident had minimal lung sounds. She admitted to the state surveyor that she did not attempt to suction the resident because she did not have much experience working with tracheostomies. She notified the doctor and obtained an order for the resident to be sent to the hospital. When the paramedics arrived, they recognized that resident was in respiratory distress and was told by the nurse that had been going on for up to an hour. When they arrived at the hospital, the nursing staff found that the tracheostomy cannula was clogged with blood tinged sputum and hair. It was very dirty and it was obvious to the nursing staff that the cannula had not been cleaned or suctioned. They cleaned out the cannula and replaced it and the resident began breathing normally. The obvious issue here is that the resident was not receiving the care that she needed to maintain her airway. When she was brought to the hospital, the inner cannula was clogged with hair and fluids and was very dirty. This indicates that the resident was not receiving the care that she needed and which is actually required under federal regulations. Nursing homes are also required by federal regulations to have sufficient staff with the skills needed to assure resident safety and meet the care needs of residents. The nurse on duty at the time of this incident demonstrated that she did not have necessary skills to care for this resident as she either did not know to suction the resident or did not believe that she had the skills to do so. Either way, the most immediate step to care for the resident was not taken. Violations of federal regulations like this are a form of nursing home abuse and neglect. If the nursing home did not have the staff available to properly care for this resident – and it appears from the description of the cannula in the IDPH citation that this resident was not the only nurse uncomfortable caring for the tracheostomy – then the only proper course for this nursing home would have been to deline the admission. However, this is the kind of medically compromised, complex patient that tends to bring higher levels of revenue for the nursing home, so the profit model says that this resident will be accepted for admission when the wisest course action may have been to decline the admission. One of our core beliefs is that nursing homes are built to fail due to the for-profit business model they follow and that unnecessary accidental injuries and wrongful deaths of residents are the inevitable results. 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: Resident wanders from Good Samaritan Society in Mt. Carroll California Gardens fails to obtain respiratory equipment Urinary catheter injury at Marigold Rehab Resident dies after yanking out own tracheostomy Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
IDPH has cited and fined Friendship Manor nursing home in Nashville, Illinois after a resident suffered injury due to improper insertion of an indwelling catheter. The resident at issue was a 36 year old quadraplegic who had a neurogenic bladder as a result of his injuries, meaning that due to his spinal cord injury, he was unable to control his bladder. Part of his regimen of care for the neurogenic bladder was use of an indwelling catheter which would drain urine from his bladder into a bag. One of the risks associated with the use of an indwelling catheter is an increased chance of developing a urinary tract infection. In the days immediately prior to the injury, the resident was showing signs and symptoms of a urinary tract infection, so his doctor ordered replacement of the indwelling catheter and a urinalysis. An indwelling catheter has a balloon at the end which is inflated once the catheter is inserted into the opening of the bladder. The inflation of the balloon allows the urine to drain from the bladder down the catheter and into a bag. The nurse who was responsible for replacing the catheter did not use proper technique in placing the new catheter. Instead of inflating the balloon after the catheter had entered the bladder, she inflated the balloon while the catheter tip was still within the urethra – in other words, she inflated the balloon too early. Other staff members were not able to resolve the issue, so they contacted the resident’s doctor who ordered the resident sent to the hospital. At the hospital, a CT scan was done which confirmed that the catheter balloon was inflated within the urethra. A determination was made to transfer the resident to another hospital where a urologist would have to perform an open surgical procedure to resolve the problem. The fundamental issue in this case is an issue of poor nursing technique. The signature of a proper placed catheter is a flow of urine from the bladder into the bag. The nurse in this case claimed “maybe a dribble” of urine entered the bag and nurses who attempted to resolve the issue were unable to verify that there was any urine in the bag at all. When nurses fail to follow proper technique, this is a form of nursing home abuse and neglect and can be the basis for a civil lawsuit. 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 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: Urinary catheter injury at Marigold Rehab Diabetes care mismanaged at Aperion Care Capitol Maggots discovered in bed sore at Manor Court of Clinton Fall from toilet at Leroy Manor Click here to file a complaint about a nursing home with the Illinois Department of Public Health.
IDPH has cited and fined California Gardens nursing home in Chicago after it failed to obtain necessary respiratory equipment for a newly admitted resident, resulting in the resident suffering respiratory failure and requiring hospitalization. The resident at issue suffered from respiratory failure due to neuromuscular weakness. His admission to the nursing home was a planned one, and the transfer orders, included the use of a BiPAP machine. This is a piece of respiratory equipment which helps force oxygen into the patient’s lungs. When the resident was admitted to the nursing home, the machine had not yet been ordered from the supplier. The staff called the supplier, but failed to specify that this was a STAT order because they had a resident already in the facility who needed that piece of equipment. The difference: a regular order arrives in 24 hours; a STAT order arrives in 2-4 hours. The order for the machine was placed at 2:30 in the afternoon. By 12:30 a.m., the resident was visibly struggling to breathe and requested the BiPAP. The nurse placed him on supplemental oxygen when she was unable to reach the doctor. There was no documentation of monitoring of the vital signs or blood oxygen levels. By the following morning, the resident was transferred to the hospital where he was shown to be suffering from hypoxemia (low levels of oxygen in the blood) and admitted for treatment of respiratory failure. There are at least three major issues with what occurred here:
- The BiPAP machine that this resident needed was not ordered. There are specific federal regulations relating to the provision of care for residents who need respiratory services, and these regulations place the obligation on the nursing home to provide the care. When that care requires the use of specialized equipment, failing to timely obtain that equipment is unacceptable. This is a form of nursing home neglect.
- Ordering that kind of equipment in advance of the resident showing up at the nursing home is the kind of thing that should be handled as a matter of routine in a nursing home. Nursing homes are businesses, and well-run businesses have systems in place to provide the services that hold themselves out as offering. When a simple matter like this is mishandled, it raises real questions about how many systems are either not in place or not functioning as they should. It is a broader, more worrisome sign of trouble than the one simple error that was made for this one resident.
- When the right equipment was not present and the resident began to experience significant problems, it was the nurse’s job to notify the doctor of the decline in the resident’s condition. Nurses are the eyes and ears of the doctors and the doctor is unable to do anything to help the resident if they don’t know that there is a problem. If they were unable to reach the doctor, then the medical director should have been contacted, and worst case scenario, ongoing monitoring of the resident’s vital signs and blood oxygen saturation levels was mandatory with a call placed to 911 if a doctor could not be reached and the resident’s vital signs continued to deteriorate. Letting the issue go overnight was dangerous and could have easily resulted in the wrongful death of the resident.
Rolling Hills Manor nursing home in Zion was cited by the IDPH after a resident suffered a fractured arm and hip while getting a shower. The resident suffered from advanced dementia. On the day that she was to be showered, she was transferred from bed to a wheelchair to be brought to the shower by two CNA’s. During the transfer, her foot got caught in the sheets, her leg twisted and she said “ouch”. After she was brought to the shower, she became combative, leading one of the CNA’s to pin her arms against her side to give her a shower. When she was returned to bed, one of the aides noticed that her arm looked different. This apparently provoked an eventual transfer to the hospital where it was discovered that she had a broken arm and broken hip. The orthopaedic surgeon was told that this happened in a fall and he believed that the injuries were consistent with that. These are the issues I see with the care that this resident was provided:
- The transfer was done improperly as it resulted in her foot being caught in the sheet, her leg twisting, and her breaking a hip. The resident was known to suffer from osteoporosis, so this is not a surprising outcome. Simply checking to make sure that her feet were clear before beginning the transfer would have avoided the hip fracture.
- Once she arrived in the shower room, she became combative. The likely reason – pain from a freshly fractured hip.
- This was not her first time being combative. In fact, this kind of behavior was addressed in her care plan, which called for the staff to take a break before continuing with care. The staff pressed forward rather than take the break the care plan called for.
- The solution to the combative behavior – pinning her arms to her sides – should never be seen as acceptable and was truly a form of nursing home abuse and likely resulted in the broken arm. Why didn’t the staff follow the care plan and simply take a break from care? The likely reason is that they had more work to get done than they had time to do it – the signature of an understaffed nursing home. This probably also contributed to the underlying problem where her foot became entangled in the sheets.