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Grove of Elmhurst resident dies due to delay in physician notification

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

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

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

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

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

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

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

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

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

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

One of our basic beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

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

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

Feeding tube error at Aperion of Westchester

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

Untreated infection leads to resident death at Elevate Care South Holland

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

 

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

 

Marshall Rehab resident fractures back in van accident

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IDPH has cited and fined Marshall Rehabilitation after a resident there suffered a fracture to her lumbar spine in an accident while a passenger on board a van from the nursing home.

Many nursing homes operate passenger vans which are used to transport residents to and from doctor appointments or community events.  When the nursing home uses a van that way, it is responsible for three things: (1) that the van is operated in a safe manner, (2) that the residents who are passengers in the van are handled and secured properly within the van, and (3) that the staff is properly trained on both of the other points.  This citation was about what happens when neither is true.

The resident was in a wheelchair in the facility van returning from a doctor appointment in Champaign.  There was road construction on the way back.  While passing through the road construction zone, the driver hit a large bump in the road.  The impact with the bump caused the resident to be jolted up and down in her wheelchair.  When she came down, she felt a pop in her lower back and began to have significant ongoing pain in the low back which persisted even with the use of strong pain killers.  Her doctor eventually ordered an MRI which showed an acute compression fracture in the lumbar spine.  the doctor ordered that she be placed in a LSO brace (turtle shell brace) for six weeks.

The investigation into this incident showed that even though the van was equipped with a restraint system, it was not in use because the aide who was driving the can had not been trained in how to use it.

This was a highly preventable injury has the nursing home and its staff adhered to the three basic principles outlined above.  First, safer driving in the form of reduced speed and keeping a safer lookout in a construction zone would have likely reduced the violence of the impact with the bump.  Second, the resident was not in the restraint system which would have kept her from being thrown up out of her seat.  Finally, the aide admitted that she had not been trained in the use of the restraint system.

Of the three failures, the last is the one which is most predictable given the basic nursing home business model, which includes failing to invest in the training of staff.  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:

Transportation van accident at Generations of Rock Island

Resident falls from van at Casey Healthcare

Hilltop Skilled resident breaks leg in fall from bed

 

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

Loft Rehab of Rock Springs resident suffers fractured hip in fall

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IDPH has cited and fined Loft Rehab of Rock Springs nursing home in Decatur after a resident there suffered a fractured hip due to tripping over decorative landscaping in the facility smoking area.

Some are surprised to learn that residents in nursing homes are permitted to smoke – it is a health care facility after all!  However, nursing homes are the home for the residents there and as adults, residents have the right to smoke.  However, unlike in a private residence, residents in a nursing home are not permitted to smoke wherever they please.  Nursing homes have a designated area – usually a patio – where residents are permitted to smoke.

However, like all areas within a nursing home, the smoking area must be safe for residents.  Federal regulations relating to nursing home falls require that the facility be as free of accident hazards as possible.  Further, one of the standard fall prevention measures in every fall prevention care plan is to keep areas free of clutter and tripping or slipping hazards.

The resident at issue was someone who was at risk for falls.  He required the assistance of a wheelchair or walker for mobility and had difficulty when rising from a seated position.

On the day of this nursing home fall, the resident went to the smoking area accompanied by a member of the housekeeping staff.  As he got up from his chair to return indoors, the wheel to his walker got caught on a decorative railroad tie.  The resident fell to the ground with obvious pain to the left hip.  He was brought to the emergency room where he was diagnosed with a hip fracture.

The post-fall investigation concluded that the decorative railroad tie was the cause of the fall and an unnecessary tripping hazard.

This fall demonstrates how the tension between the business objectives of nursing home management clashes with the care needs of residents.  Management wants to have an attractive facility – families that tour the facility want to see their loved ones in a place that at least looks nice.  Things like decorative railroad ties on a patio are stylish and visually appealing even as they create additional hazards for residents.  Having the decorative railroad tie there was a choice that management made which sacrificed the safety of residents.  Unfortunately that is a common thread in the decisions that get made about how nursing home are managed.

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 St. Elmo resident breaks hip in fall

Fall with broken hip at Heritage Health in Mt. Zion

Resident at Hickory Christian Village in Forsyth suffers multiple fractures in fall

Auburn Rehab resident suffers hip fracture in fall

 

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

 

River Crossing of East Peoria resident suffers brain bleed due to unsafe use of lift

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IDPH has cited and fined River Crossing of East Peoria nursing home after a resident there suffered a brain bleed when her wheelchair tipped while being transferred from her bed to her wheelchair by an aide who was attempting the transfer by herself.

Used properly, mechanical lifts are a useful tool in nursing homes.  They allow residents who need that level of assistance to be transferred to and from their bed, chair, wheelchair, toilet, and so forth.  It reduces the risk of injury to residents and staff alike from attempting to transfer residents manually who truly require a higher level of assistance.

The key to this is of course that the lift be used properly.  Proper operation of the lift requires the assistance of two staff members – one to operate the controls of the lift itself; the other to handle the resident in the sling of the lift.  One common theme in many of the citations we have written about is that the injury to the resident resulted from one person doing a two-person job (see here, here, here, here, and here for examples).

On the morning of this nursing home fall, the resident was being transferred from bed to her wheelchair to be brought to breakfast.  The resident required the assistance of two staff with most activities of daily living because she was not able to use one arm or her legs.  She also required the assistance of two staff and a mechanical lift for transfers.  There were two staff members present when the resident was getting her morning care but had left the room when it was time for her to be transferred from her bed to her wheelchair.

Rather than get another staff member to come help, the aide attempted to transfer the resident from her bed to her wheelchair on her own.  The required being able to control the left, the remote control for the lift, and the resident all on her own – a task which is simply impossible to do safely.

As the resident was being lowered into her wheelchair, she was not positioned properly in the wheelchair so that her weight was high and to the rear.  This resulted in the wheelchair tipping over and the resident falling backwards to the floor, hitting the back of her head on the floor.  She was brought to hospital where she was diagnosed with a brain bleed.

The aide, who was agency staff, had been trained that two staff were required for mechanical lift transfers was told to leave the facility and would not be allowed to return – essentially, she was fired.  She admitted to the state inspector that she knew that two people were required for mechanical lift transfers, but did not wait for help because it was so busy.

When staff takes shortcuts in the care of residents – such as attempting a two-person job on their own – it raises the issue of whether the nursing home was understaffed.  Federal regulations require that the nursing home have enough staff on hand to meet the care needs of the residents on a 24/7 basis.  Unfortunately, nursing home often fail to meet that standard because understaffing is a key component 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:

Mason City Area Nursing Home resident suffers fatal brain bleed in fall

Christian Nursing Home resident suffers severe leg injury in fall

Cornerstone Rehab resident falls from lift during transfer, breaks leg

University Rehab Northmoor resident falls from bed, breaks hip

Farmington Manor resident suffers broken leg due to failure to follow care plan

Pekin Manor resident suffers brain bleed in fall

 

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

Landmark of Richton Park resident dropped from lift, breaks both legs

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IDPH has cited and fined Landmark of Richton Park nursing home after a resident there broke both legs after being dropped to the ground when the sling on a lift broke.

Used properly, a mechanical lift is a very beneficial piece of equipment for use in a nursing home.  It allows residents who have significant strength and mobility issues to be transferred from bed to wheelchair, wheelchair to chair, and so forth safely while at the same time reducing the risk of injury to residents and staff.

The key part of that statement is of course, the “used properly” part.  Proper use of a mechanical lift includes making sure that there are two staff members involved in all transfers because having on person do a two-person job is a formula for disaster (see here, here, here, here, and here for examples).  The other part of “proper use” is that the lift itself and all of the associated equipment is in condition for safe use and is used properly in accordance with manufacturer specifications.  When the equipment is not in good condition or is not used properly, that is a formula for disaster.

The resident at issue was dependent on the use of a mechanical lift for all transfers.  The resident care plan called for among other things, use of a mechanical lift with two staff for all transfers, following all safety procedures for transfers, and checking the sling for signs of fraying or loose threads.

On the day of this nursing home fall, the resident was being transferred to bed using a mechanical lift.  As required, there were two staff assisting with the transfer.  At the time of the transfer, they were using a sling with a hole in the center of it.  It was a special sling which was intended for transferring residents to the toilet, not a general use sling.

While the resident was being transferred to bed, the resident got off balance in the sling, in part because of the kind of sling that was being used.  As the lift got out of balance, the lift started to tip over, with a portion of the lift hitting the resident’s bed.  The strap to the sling broke, and the resident fell to the floor. The resident was brought to the hospital where scans showed that there were fractures of both femurs.

The investigation into this incident revealed two things.  First the sling that was used was not appropriate for the task at hand.  It was designed for and intended to be used in connection with toileting.  Second, the sling itself was in a state of disrepair and should not have been used.  As an initial matter, the staff assisting the resident should have inspected the sling before putting it to use.  However, the investigation also revealed that the laundry staff was not following the required steps to help maintain fabric integrity.  This led to the dismissal of laundry staff.

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:

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

AHVA Care of Stickney resident breaks hip in fall

Grosse Pointe Manor resident fall and breaks hip after being left unattended

Glenview Terrace resident suffers multiple fractures when lift topples over

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

 

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

One of our basic beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

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

Dehydration leads to hospital admission for resident at Mattoon Rehab

Aperion Care of Wilmington resident suffers ruptured colon from fecal inpaction

Failure to notify doctor of abnormal labs at Momence Meadows

 

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

Sheridan Village resident suffers hip fracture in fall

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IDPH has cited and fined Sheridan Village Nursing & Rehabilitation nursing home in Chicago after a resident there suffered a fractured hip in a fall caused by him tripping over a bedside table which was left in the hallway.

One of the basic fall prevention strategies in nursing homes is to keep areas used by residents free and clear of clutter and tripping hazards.  Areas such as hallways are used by a wide range of residents, some of whom may be at increased risk for falls as a general proposition.  Others who may not be at high risk for falls still may be at risk for significant injuries such as brain bleeds associated with use of blood thinners or anticoagulant medications or hip fractures associated with osteoporosis or brittle bone disease.  Keeping common areas free and clear of clutter and tripping hazards is a simple, low-cost measure to prevent serious injuries to nursing home residents.

Due to the pandemic and the need to maintain social distancing, the staff would at times bring residents bedside tables out to the hallway so that residents could eat dinner.  This would allow them to maintain social distancing while at the same time have some ability to see and converse with one another.

Prior to this nursing home fall, the resident involved walked independently.  At approximately 1 am, he was walking back to his room after watching television in the common room.  There was a bedside table that had been left in the hallway from dinner hour.  The resident stumbled over the bedside table, causing him to lose his balance and fall to the ground.

He was sent to the emergency room where he was diagnosed with a fractured hip and underwent surgery.  At the time that the survey was conducted by IDPH, he was still rehabilitating the fractured hip but now was requiring assistance with walking and standing and many activities of daily living.

This was a highly preventable injury for this resident.  While the goal of allowing residents to enjoy mealtimes together while maintaining social distancing is laudable, there was no need for the bedside table to be left in the hallway so long after the mealtime had passed.  Leaving the bedside table in the hallway simply created an unnecessary tripping hazard, one which would have been alleviated by simply getting the table out of the way.

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:

AHVA Care of Stickney resident breaks hip in fall

Grosse Pointe Manor resident fall and breaks hip after being left unattended

Glenview Terrace resident suffers multiple fractures when lift topples over

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

One of our basic beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

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

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

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

 

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

 

 

Grove of St. Charles resident suffers fractured hip after being rolled out of bed by staff

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IDPH has cited and fined the Grove of St. Charles nursing home after a resident there suffered a fractured hip due to being rolled out of bed while receiving incontinence care.

The resident involved suffered from incontinence of bowel and bladder.  Her Minimum Data Set (MDS) showed that she required the assistance of two staff members with bed mobility (turning from side to side and changing and holding positions in bed) and her care plan called for the assistance of two staff members with incontinence care.

One the day of this nursing home fall, the resident was in bed on a low air loss mattress.  She was receiving peri care after an episode of incontinence.  There was a single aide who was providing the incontinence care.  As the resident’s leg was moved over across her body, the leg went over the edge of the bed and the resident followed, landing on her knees.

She was brought to the hospital where a hip fracture was diagnosed.  However, even though the nature of the fracture likely warranted it, the decision was made to not proceed with surgery because of her pre-injury lack of mobility, her risk factors, and other medical issues.  She now has to be transferred using a lift.  In the meantime, she has unstable hip which is subject to movement during transfers with the lift, while being turned and repositioned to prevent bed sores, and while receiving incontinence care.

This a tale that we have told many times about the results you get when you have one person doing a two-person job (see here, here, and here  for examples).  When two people are required to assist with bed mobility, the purpose of the second staff member (the one not providing the incontinence care) is to provide safety and help prevent the resident from falling out of bed.  This is especially necessary where the resident is on a low air loss mattress because they tend to provide less friction and resistance and make it easier for the resident to slide out of bed.

This is a simple case of a staff member violating the resident care plan and taking a short-cut in providing care to the resident.  The deeper question of course is why did she feel compelled to provide care to the resident on her own when two were required?  The answer likely lies in short-staffing of the nursing home.  Unfortunately, understaffing is a feature and not a bug in 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:

Michaelsen Health Center resident rolled from bed, suffers brain bleed

Warren Barr North Shore resident rolled from bed, suffers fractured ankle

Bella Terra Streamwood resident suffers multiple fractures in fall from bed

Grove of Skokie resident breaks leg due to violation of care plan

 

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

AHVA Care of Stickney resident suffers fractured hip in fall

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IDPH has cited and fined AHVA Care of Stickney nursing home after a resident there suffered a fractured hip in a fall.

One of the focuses of care in the long-term care industry is fall prevention.  Many residents in nursing homes are at risk for significant injuries due to falls, and many studies have confirmed that fall injuries have significant negative impacts on the quality of life for nursing home residents.  Additionally, some types of injuries, in particular fractured hips, are strongly associated with increased mortality.

Because of all of this, one of the regular assessments that is done is of a resident’s fall risk.  Nursing homes use a variety of standardized tools to assess fall risk, but two of the main factors in just about every fall risk assessment are: (1) some form of musculoskeletal weakness or gait or balance dysfunction and (2) some type of mental or cognitive issue – intermittent or constant confusion, dementia, poor safety awareness, or impulsive behaviors.  The reason that the mental/cognitive aspect feeds into a resident’s fall risk is that when one or more f these issues is present, the resident cannot be counted on to follow instructions or make good decisions regarding his/her own safety.

When a resident is considered to be a fall risk, a fall prevention care plan must be created.  This is a series of steps which must be taken on a day-to-day, shift-to-shift basis which are intended to reduce the resident’s risk of falls.  Two of the main stays of fall prevention are keeping the resident under observation by the staff, frequent rounding, and keeping the resident’s environment free and clear or tripping or slipping hazards.

The resident at issue was one who was considered at risk for falls.  She was known to have intermittent confusion with impulsiveness and poor safety awareness.  Further her Minimum Data Set (MDS) indicated the resident was not steady and could only stabilize with staff assistance while walking and rising from a seated position.

On the day of this nursing home fall, an aide entered the resident’s room and found the resident sitting on the other bed her room.  When the resident was asked what she was doing there, she reported that she had gotten up to throw something in the garbage can and had tripped over the cord to her roommate’s oxygen concentrator machine.

The resident’s physician was notified of the fall and a portable x-ray was ordered of the pelvis.  However, the results of the x-ray were inconclusive for fracture of the left hip.  Rather than report the inconclusive results back to the doctor to see what needed to be done, no one contacted the doctor for three days during which the resident complained of hip pain.  The resident was eventually sent to the hospital where a CT scan showed a comminuted (broken in more than two pieces) fracture of the femur, extending into the femoral neck (the bridge of bone extending from the thigh bone into the hip).

There were a number of shortcomings in the care that this resident received.  Inadequate supervision and failing to round on the resident led to her getting up without the assistance she required and her falling over an obvious tripping hazard (the cord to the medical equipment).  Past that the resident was subjected to additional unnecessary pain as her fractured hip went untreated for three days due to the failure of the staff to report the inconclusive results of the x-ray back to the doctor.

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 at Chateau Nursing Home in Willowbrook suffers spinal fractures in wheelchair accident

Manorcare of Palos Heights East suffers hip fracture in fall

Grosse Pointe Manor resident fall and breaks hip after being left unattended

 

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

 

Rushville Nursing & Rehab resident suffers untreated surgical wound infection

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Heartland of Galesburg resident dies due to untreated urinary tract infection

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

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

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

 

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

 

Piatt County Nursing Home resident breaks neck in fall from power recliner

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IDPH cited and fined Piatt County Nursing Home in Monticello after a resident there fell from a power recliner chair and suffered fractures to her neck, leading to placement in hospice.

Any piece of equipment used in the care of nursing home residents must be safe for use with that particular resident, and it is upon the staff to make assessments as to whether that piece of equipment is safe for use.  If the equipment is not safe or could not be made safe through adjustments to the equipment, education of the resident, or close supervision of the resident, then the equipment should not be put into use.

That of course assumes that the assessment of the safety and appropriateness of the equipment is made.  This incident is about what happens when a proper assessment is not made.

The equipment at issue is a chair known as a power recliner.  It is a chair which tilts backward like a regular recliner, but is useful for people who have a hard time getting up from a seat because it tilts forward and boosts the back upwards to make it easier for the user to get up from a standing position.  The chair moves from a reclined (tilted back) to a tilted forward position with a power control which can be operated by the user.

The power recliner had been in use at the nursing home for a long time – to the point that they no longer had the owner’s/operations manual.  During the investigation into this incident, the IDPH representative contacted the manufacturer who advised that they had stopped manufacture of this particular chair in 2007.  However, the manufacturer had advised that in order to use the chair safely the resident had to have the ability to bear weight independently and be alert enough with the cognitive ability to safely use the chair.

The resident involved in this incident had a history of stroke with residual left-sided weakness.  Those impairments were significant enough that she required the use of a mechanical lift for transfers.  She had been assessed as having moderate cognitive impairments.

On the night of this nursing home fall, the resident had been dangling her foot over the edge of her bed and telling the staff that she needed to leave to go somewhere.  The staff transferred her with a lift to the recliner.  At some point during the night, the resident used the remote to lower the chair and then bring it forward so that she was in a position where she was tilted forward.

As she reached that position, she fell forward, hitting her face on the floor.  There was immediate obvious bleeding, so she was sent to the hospital.  There she was diagnosed as having fractures of the C1 and C2 vertebra.  After a brief hospital admission, she was returned to the nursing home under the care of hospice.  The

This was a case where the proper assessments were not made for the resident to use this equipment.  She had demonstrated, known cognitive impairments, known musculoskeletal deficits, and was not able to bear weight  well enough to participate in regular transfers.  She did not meet any of the standards for use given the manufacturer’s recommendations for the use of this equipment.  Past that, the resident had been verbalizing a desire to go elsewhere.  As with residents who elope from the nursing home, her expressed desire to go elsewhere was a sign that she was likely to try to get up unassisted, and the use of this chair made that all the more hazardous.  Very simply, this was a resident for whom use of this equipment was not suitable as a general proposition, but especially that night.  The net result – catastrophic yet preventable injuries for this resident.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Pleasant Meadows Senior Living resident breaks hip and wrist in fall

Failure to follow care plan leads to fall, fractured hip at Piatt County Nursing Home

Arcadia Care Bloomington resident breaks hip and back in from from wheelchair

Piatt County Nursing Home resident fractures hip in fall

Sling breaks during transfer at University Rehab in Edwardsville

Gardenview Manor resident suffers broken hip during unsafe transfer

Westminster Village resident suffers multiple fractures in fall

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

 

Pleasant View Rehab resident fractures hip in fall

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IDPH has cited and fined Pleasant View Rehabilitation & Health Care Center in Morrison after a resident there suffered a fractured hip in a fall.

The resident at issue was admitted to the nursig home three and a half months before the fall at issue.  Four days after admission, the resident was discovered lying flat on his back on the floor of his room.  When a nursing home resident is discovered on the floor like this, it should be presumed to have been the result of a fall.  It is well-recognized in the nursing home industry that falls tend to beget additional falls, so the resident’s fall prevention care plan was updated to include the use of a bed alarm.

Beyond the resident’s history of falls, the resident was considered a fall risk due to dementia and poor safety awareness.  When a nursing home resident demonstrates either intermittent or constant confusion, this is considered a contributor to fall risk because the resident cannot be counted on to make good decisions for their own safety.  This is why a measure like a bed alarm is considered an appropriate fall prevention tool – because the sounding of the alarm serves to alert the staff that the resident is up and to remind the resident that they should wait for help.

Two and half weeks before the fall, the resident’s care plan was updated to reflect that the resident had a known behavior of getting up out of bed unattended.  A floor mat was added to the fall prevention care plan.

On the day of the resident’s nursing home fall, the CNA and nurse was at the nurse’s station when they heard the noise of the fall coming from the resident’s room.  They went to the room immediately and found the resident lying on the floor with bleeding coming from the head,complaining of pain to the leg.  The alarm had not sounded and the floor mat was away from the bed on the other side of the room.

The resident was brought to the hospital where a fractured hip was diagnosed. Surgery was performed, and the resident was returned to the nursing home.  Unfortunately, the resident developed a post-operative wound infection and was receiving antibitoics for the infection at the time that the citation was issued.

The nursing home properly recognized that this resident was a fall risk.  The hospital records described the resident as being nonambulatory, and the resident had a history of falls, confusion with poor safety awareness, and a known behavior of getting out of bed unattended.  The steps care planned were a reasonable start to attempting to prevent further injury to this resident by calling for the use a bed alarm and floor mats.  However, the bed alarm did not sound when the resident got out of bed and the floor mats were found on the other side of the room when the staff responded to the noise from the fall.  A care plan not actually implemented is useless.

Past that, there were likely additional measures that could have been taken to help prevent this fall.  Given that the resident had a known behavior of getting out of bed unattended, increased rounding was called for.   The fall occurred at 6:20 a.m., an hour when the resident may have been waking up with an urge to use the bathroom.  A toileting schedule would have likely been an effective fall prevention measure because it would have helped the staff better anticipate known behaviors of the resident which presented increased fall risk.  Truly effectivecare plans actually tailored to the needs of the resident – and in fact, this is what federal regulations require.

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:

Rochelle Rehab resident breaks leg due to unsafe use of wheelchair

Waverly Place of Stockton resident breaks hip in unsafe transfer

Aperion of Spring Valley resident suffers fatal brain bleed in fall

 

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

 

Hilltop Skilled resident breaks leg in fall from bed

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IDPH has cited and fined Hilltop Skilled Nursing & Rehabilitation Center nursing home in Charleston after a resident there suffered a broken leg in a fall from bed.

The resident at issue had a complex medical history which included paraplegia, a right arm contracture, and a Stage 4 pressure ulcer to the buttock and another bed sore to the sacrum.  After a nursing home resident develops a bed sore, federal regulations require the nursing home to provide care, treatment, and services to promote healing, prevent infection, and prevent the development of new pressure ulcers.  Here, as part of the wound care strategy, there was an order in place for the use of a low-air loss mattress.

One of the main risk factors for the development of bed sores is pressure (part of why they are called pressure ulcers).  Pressure is also an impediment to wound healing.  A low-air loss mattress helps to prevent bed sores and aid in the healing of existing ones by reducing pressure.  One of the downsides of the use of a low-air loss mattress is that it is harder to maintain a safe position in bed because of the way that the mattress supports the body.  This is especially true with resident who have impaired mobility, as was the case with this resident who suffered from paraplegia and had an upper extremity contracture.  These mobility impairments were recognized in advance of this nursing home fall as the resident’s Minimum Data Set showed that the resident required the assist of two staff with bed mobility and transfers.

Further, even before the fall occurred, the staff was aware that the resident had difficulty maintaining her position in bed as the staff would find that she had slid down to the bottom of the bed or at other times found that she had her feet hanging over the edge of the bed.

This situation – the use of an air mattress with a resident who had known impairments to bed mobility and who had demonstrated recurrent problems with safe positioning in bed – presented a picture where the resident was at risk of falls, specifically sliding out of bed and being injured.  When there is a risk of a resident experiencing a fall, then a fall prevention care plan must be put into place.   Unfortunately, despite the need for a care plan to address this risk of injury to the resident, nothing was done.  During IDPH’s investigation, the administrator admitted that the care plan should have been updated to include monitoring the resident’s position in bed and that the resident’s injury was their fault.

On the morning of this nursing home fall, the resident was discovered on the floor at about 6 am by the staff.  She told the staff that she slid out of bed.  The resident was complaining of pain, but the staff failed to notify the resident’s physician, but instead called to have a portable x-ray service come in.  The x-rays were no performed until the early evening. The results from the radiologist who read the films did not come in until nearly 9 pm.  The x-rays showed a fracture of the lower part of the femur.  At this point, the resident’s physician was notified and he ordered the resident sent to the hospital.

Besides the resident experiencing an unnecessary fall, this resident was also subjected to experiencing prolonged unnecessary pain by the failure of the staff to timely notify the doctor.  The doctor told the state surveyor that had he been made aware of the situation, he would have sent the resident to the emergency room earlier.  Most nursing staff will agree when asked that subjecting a resident to unnecessary pain is a form of nursing home abuse.

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:

Pleasant Meadows Senior Living resident breaks hip and wrist in fall

Unlocked furniture results in fall and fracture at Mount Vernon Countryside Manor

Charleston Rehab resident suffers brain bleed and fractured hip in fall from bed

Grove of St. Charles resident suffers fractured hip after being rolled from bed

Tuscola Health Care Center resident dropped from lift, breaks ankle

Aperion Care Fairfield resident falls from wheelchair, fractured leg goes untreated

Casey Healthcare resident breaks hip in fall due to failure to follow care plan

 

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

 

Feeding tube error puts Burgess Square resident into heart failure

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IDPH has cited and fined Burgess Square Health Center nursing home in Westmont after a resident there was given tube feedings well in excess of that ordered by the physician, causing her to experience acute congestive heart failure and requiring hospitalization.

One of the basic functions of nurses in a nursing home setting is to provide care in accordance with physician orders.  Each resident will have a diet order.  Some residents have an order for a general diet, other residents have a modified diet such as a mechanical soft diet which is intended to reduce the risk of nursing home choking accidents.  Still other residents receive their nutrition through tube feedings, and this is something which requires the help of the nursing staff.

When a resident receives nutrition through a feeding tube, the order will usually include what kind of formula should be given and how much.  Failing to give the right kind of formula can cause medical problems for the resident, while failing to give as much as ordered can lead to malnutrition and other illnesses for the resident.  Here, we have a situation where the resident was given far more than ordered.

The order that was in place called for the resident to receive a 275 ml of formula three times a day.  Typically, that amount would be given over two to three hour period.  Instead of providing the tube feeding as ordered, the nurse gave the resident 275 ml of formula per hour for five hours.  This means that the resident received a far greater amount than was ordered, far faster than was ordered.

The net result of this was that the resident experienced fluid overload which led to acute congestive heart failure.  The resident experienced severe abdominal pain from overfeeding.  She also experienced significantly elevated blood sugars.  All of this led to an unnecessary hospitalization for her.

The root cause of this feeding tube accident was that the order was not followed.  The order was for a 275 ml bolus (single dose), rather than 275 ml per hour continuously.  In much the same way that medication errors in nursing homes can be prevented by making the proper checks, this incident could have been easily avoided by checking the physician order before administering the tube feedings.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result.  Order our FREE report, Built to Fail, to learn more about why.  Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are.  Contact us to get the help you need.

Other blog posts of interest:

Feeding tube error at Aperion of Westchester

Grove of Elmhurst resident dies due to delay in physician notification

Aperion Care Wilmington resident suffers ruptured colon due to fecal impaction

Burbank Rehab resident hospitalized due to missed dialysis sessions

Failure to obtain treatment for congestive heart failure at Avantara Long Grove

 

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

 

Resident at Chateau nursing home in Willowbrook suffers spinal fractures in wheelchair accident

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IDPH has cited and fined Chateau Nursing & Rehabilitation Center nursing home in Willowbrook after a resident there suffered spinal fractures due to falling from her wheelchair after being pushed forward by the staff when there were no leg rests on her wheelchair.

Wheelchairs are a common sight in nursing homes, and as long as they are used properly, they are generally safe, helpful equipment for the care of nursing home residents who need that level of assistance.  The key of course is that they are used properly, and proper use of a wheelchair requires that the leg rests to the wheelchair be applied when the wheelchair is being pushed by staff.

The reason that leg rests are required to be used when the resident is being pushed forward in the wheelchair is that without the leg rests in use, there is a chance that the resident’s feet will drop to the floor while the wheelchair is being pushed forward.  When this happens, one of two things are likely to occur: (1) that the resident’s legs will get pulled underneath the chair, resulting in a twisting mechanism which can produce fractures or tears to ligaments and cartilage or (2) that the resident can be thrown forward out of the chair, resulting in the kinds of injuries you might see if a resident falls forward while walking – except that this fall will happen at a higher speed.

The resident at issue was wheelchair bound.  She suffered from Parkinson’s which left one arm contracted against her body.  However, she was able to self-propel in her wheelchair using her feet, meaning that she was able to move throughout the nursing home in her wheelchair by walking her feet forward.  For many wheelchair-bound residents, this is an important part of maintaining some degree of independence.

This resident experienced not one, but two nursing home falls due to staff pushing her in her wheelchair with no leg rests applied.  The first occurred two months before the fall at issue.  In that fall, she was being pushed forward by staff with no leg rests on the wheelchair.  She dropped her feet to the floor and was thrown forward out of the wheelchair.  Fortunately, there were no injuries from this fall.

After the fall, there was a care planning meeting held with the family.  The family agreed to obtain leg rests for the wheelchair and a bag for them to be kept on the back of the wheelchair.  The resident’s care plan was updated to include using leg rests while pushing the resident in her wheelchair and the staff was given in-service training on the use of leg rests while pushing the resident in her wheelchair.  The change in the care plan was noted on the care card which advises staff of the contents of the care plan.

On the day of the fall, the resident was being pushed forward into the dining room by an activity aide.  There were no foot rests applied to the wheelchair even though they were in the bag that was hanging on the back of the chair.  Even though she attended the in-service training, the aide explained to the state surveyor that she did not know that the leg rests needed to be applied according to the care plan and that she could not see the bag because the resident was seated on top of a mechanical lift sling and the bag with the leg rests was was hidden by the sling.

While the resident was being pushed into the dining room, the resident’s feet dropped to the floor and the resident was thrown forward out of the wheelchair, and hit her head on the floor.  This is of course a near-replay of the fall two months earlier.  It is also one of the truly predictable mechanisms of injury when a nursing home resident is pushed in a wheelchair that has not foot rests.

Sadly, in this fall the resident did not escape injury.  She was brought to the hospital where it was determined that she suffered a fracture of the C1 vertebra, the bone at the top of the spinal column.  She had a previous compression fracture of the T4 vertebra, located in the upper portion of the mid-back.  It was decided that she was not a good surgical candidate, so she was placed in a hard cervical collar.  Because she actively tried to remove it while in the hospital, restraints were used.  Once she was discharged to the nursing home, she received supervision from a 1:1 sitter whose job was to keep her from removing the hard collar and causing further injury to herself.

The obvious and basic cause of this fall is the failure to place the foot rests on the wheelchair while pushing her forward.  It resulted in a very predictable injury to the resident.  Even though the staff and this aide specifically were in-serviced to use the foot rests, this should be a basic part of the training that staff receives in caring for every resident in the facility.  This resident was not the only one put at risk from being pushed in a wheelchair with no footrests.

Past that, the aide explained to the state surveyor that the care card which indicated that foot rests were required was in the resident’s room, and as an activity aide, she did not go into resident rooms.  However, part of the care planning process is communicating the contents of the care plan to the staff charged with carrying it out.  The care plan is supposed to guide the actual provided, and if the staff delivering the care does not know what is required, the plan is nothing more than paperwork.

These breakdowns, especially the failure to train staff, are sadly common in the long-term care industry.  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:

Good Samaritan of Pontiac nursing home resident suffers multiple fractures in wheelchair accident

Wheelchair accident at Avanti Wellness

Assisi at Clare Oaks resident suffers broken neck in fall from wheelchair

 

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

Warren Park Health & Living Center resident suffers brain bleed in fall down stairwell

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IDPH has cited and fined Warren Park Health & Living Center nursing home in Chicago after a resident there accessed the stairwell and suffered a fall in which she suffered a brain bleed.

Federal regulations regarding nursing home falls provide that the nursing home environment should be as free of accident hazards as possible.  For nursing home residents, stairwells pose a serious risk of falls and injury.  This is because many nursing home residents have strength and/or balance problems which make the use of stairs especially hazardous.

Compounding the risk associated with the use of stairs is the fact that stairs are usually out of the line of sight for staff members, so they will not be in a position to offer help to residents who need help and attempt to go up and down the stairs.  Additionally, if a fall occurs, the fall and any injury that occurs may not be timely discovered which can result in delaying the receipt of care.  This can have fatal consequences where a resident suffers an injury such as a brain bleed.

To alleviate the risk of stairwell falls in a nursing home setting, access to the stairwells by residents should be restricted.  The most common means by which this is accomplished is either: (1) locking the stairwells so you can only get in the stairwell with a key or (2) more commonly, they are secured with a key pad access system which limits access to the stairwell or sounds an alarm when someone uses the stairwell without the proper code.  However, as we have seen in situations where the resident has eloped or wandered from the nursing home, the alarm system is ineffective where the key pad is disabled or the access code is commonly known among the residents (see here, here, here, and here for examples of this).

The resident at issue lived on the second floor of this nursing home and had a friend who she liked to visit who lived on the third floor of the nursing home.  She would frequently use the stairwell to get from the second to the third floor.  She was a fall risk, as she had a history of falls, and we know that having one nursing home fall tends to beget additional falls.

On the day of this nursing home fall, she was in the stairwell when she either lost her balance or tripped and fell.  She hit her head and was knocked unconscious.  She suffered a laceration to the head which required surgery, but more significantly, suffered a brain bleed when she fell.  This is an injury which can progress, and if left untreated can have catastrophic consequences.

The investigation into this incident showed that the key pad access system for the stairwell had been disarmed, so residents were able to freely access the stairwell, and thereby be exposed to the hazards of going up and down the stairs.  Exposing residents to risk of harm this way is a violation of federal regulations.

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 fractures leg in unsafe transfer at Ascension Nazarethville in Des Plaines

Grosse Pointe Manor resident falls and breaks hip after being left unattended

Sheridan Village resident suffers hip fracture in fall

Generations Oakton Pavilion resident falls and fractures hip

 

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

Tuscola Health Care Center resident dropped from lift, breaks ankle

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IDPH has cited and fined Tuscola Health Care Center after a resident there suffered a fractured ankle after she was dropped from a lift during transfer.

Used properly, a mechanical lift is a wonderful tool for use in a nursing home.  It saves from wear-and-tear on the staff and keeps them from getting hurt.  It allows safe transfers of residents who need that level of assistance.

The phrase in the sentence above is “used properly.”  Proper use of a mechanical lift requires the assistance of two staff members during transfers (see here, here, and here for examples of what happens when one person does a two-person job), the lift and its accessories must be properly maintained (see here and here for examples of that not occurring), the right accessories must used.

The nursing home fall that is the subject of this citation is what occurs when proper accessories are not used.

The resident issue had a history of stroke with residual weakness on one side.  Transfers from bed to wheelchair, wheelchair to chair and so forth were done by lift.

On the day of the fall, the resident was being transferred by two staff from bed to wheelchair using a lift.  The sling for the lift was not the right size.  Because of this, the straps that pass underneath that resident could not be criss-crossed as normal.  Because the transfer was a short distance, the staff decided to attempt it.

As they did so the resident slipped out of the sling, landing on the floor on top of her ankle.  X-rays were taken and she was sent to the hospital where she was diagnosed with a fractured ankle.  The treating orthopaedic surgeon attributed the fracture to the fall and stated that the resident would have some chronic discomfort in the ankle despite her limited weight bearing status.

This was a highly preventable injury.  The right number of people for the transfer were there, but the right accessories to the lift were not.  This led directly to the resident’s fall and injury.  Had the proper sling been used, this resident likely would not have been injured at all.

The fact that the staff decided to go ahead with the transfer raises questions about whether this is an understaffed nursing home.  Whenever there are shortcuts taken in the care of residents, it is an indicator that they do not have time and space to deliver care the way that it needs to be.  Sadly, short-staffing is a 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:

Marshall Rehab resident fractures back in van accident

Resident at Hickory Point Christian in Forsyth suffers multiple fractures in fall

Failure to follow care plan result in fall with broken arm for resident at Heritage of Hoopeston

Casey Healthcare resident breaks hip in fall due to violation of care plan

Taylorville Skilled resident sustains fractured hip after multiple falls

 

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

Sunset Rehab resident chokes to death

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IDPH has cited and fined Sunset Rehabilitation & Health Care nursing home in Canton after a resident there choked to death while eating lunch.

The resident at issue here had a history of having had a traumatic brain injury.  One way in which this manifested itself was in behavior disturbances which manifested itself by eating very rapidly, not chewing, and walking around while eating.  These behaviors placed the resident at risk for choking.

When a resident is at risk for harm, it is incumbent on the nursing staff to develop a care plan outlines a series of steps which are to be taken on a day-to-day, shift-to-shift basis to prevent the harm from occurring.  It also recommended that he be given “finger foods” to eat. In this case, the steps incorporated into the resident care plan was to provide one person assistance with eating – a level of care which was also documented on the resident’s Minimum Data Set (MDS).

On the day of this nursing home choking accident, the resident was given a slice of ham, sweet potatoes, and a vegetable to eat.  He got up from the table while still eating and began to choke, collapsing in a nearby hallway.  The staff attempted to clear the airway and perform CPR, but the resident died before he could be brought to the hospital.  Cause of death was brain hypoxia, or loss of oxygen to the brain.

IDPH’s investigation of the incident uncovered a number of troubling findings:

  • Even though the use of finger foods was a part of the resident’s care to address his risk of choking, there was no diet order to that effect.  In fact on the day that he died, he was served ham and sweet potatoes – things that can hardly be characterized as finger foods.  Further the ham was not cut into smaller pieces to mitigate the risk of choking.  The facility cook stated that he was not aware of the resident’s care plan and never looked at resident care plans.
  • The resident’s care plan called for one person assistance with eating while he was only receiving supervision that day.  The difference between the two is getting some physical help versus cues and reminders to slow down while eating.  The net difference here was that there was no one to cut his food into smaller pieces which very easily could have been the difference between having a fatal choking accident and surviving this event.
  • Many of the staff had expired CRP certifications, including several of the staff members who responded to the emergency.  Beyond having expired certifications, the ambu-bag (a device which uses a bag to force air into the lungs during CPR) was never employed until the paramedics arrived, the staff did not know how to determine the resident’s code status, or whether CPR should be attempted on a resident who is DNR (it should).

This is a classic example of a situation where the nursing has failed the resident for a long period of time, but avoided catastrophe only by sheer luck.  Good luck is not a substitute for good care.  The resident had a care plan which did not correlate with the diet orders, the process by which that care plan would be implemented (having the kitchen prepare meals which complied with the car plan) didn’t work because the kitchen staff didn’t review care plans, and the staff was ill-trained and without required certifications.  This is an accident which could have occurred to any number of residents on any number of days.

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 of Spring Valley resident chokes to death

Resident at Aspen Rehab in Silvis chokes to death due to failure to follow care plan

Fatal choking accident at Spring Creek in Joliet

 

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

 

Westminster Village resident suffers multiple fractures in fall

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IDPH has cited and fined Westminster Village nursing home in Bloomington after a resident there sustained multiple fractures in a fall.

The resident involved was admitted for rehabilitation following a urinary tract infection and for age-related debility.  However, less than 2 weeks after being admitted to the nursing home, the resident was discharged from physical therapy.  The therapy discharge summary stated that the resident required stand by assist for all functional mobility due to decreased awareness of limitations.  It also stated that the resident had limited potential for further gains and that resident would likely not achieve independent levels of function.

The resident was assessed as being at risk for falls and a fall prevention care plan was put into place.  This called for assistance with activities of daily living and  supervision with toileting and transfers.  However, her Minimum Data Set showed a more extensive level of assistance being required: supervision with toileting, transfers, personal hygiene, and walking in her room.

On the night of this nursing home fall, the aide assigned to care for the resident set things up for the resident to get ready for bed including brushing her teeth.  He left to attend to other residents because he believed that she was independent with those activities.  He was unable to return for a while because other resident’s call lights were sounding.

After the resident got done brushing her teeth, she pushed the door to leave the bathroom and lost her balance, falling forward and hitting her face on the floor.  She was complaining of chest pain, so she was sent to the hospital where she was diagnosed as having rib fractures, a fractured sternum, and multiple fractures of the jaw.  The jaw fractures were significant enough that she required transfer to another hospital for a higher level of care.

There was a disconnect between what the resident needed and what the resident required in the way of care.  The discharge summary from physical therapy called for the resident to get stand-by assist with all functional mobility, while the CNA assigned to the resident believed that she was independent.  The care plan only called for supervision with activities of daily living.  Clearly there was a breakdown in what was needed and was being provided.  This resident needed someone in the room helping at the time of the accident, but did not get that help, and as a result sustained serious injuries in this fall.

The injuries that this resident sustained are significant above and beyond the pain which she experienced from the broken bones.  Rib fractures and a fractured sternum make it difficult to inhale and exhale normally which can set the stage for developing pneumonia.  The jaw fractures will result in decreased oral intake, which can set the stage for the resident to develop bed sores.

The fact that the aide was not able to return to the room in a timely fashion because of the needs of other residents raises a question of whether this is an understaffed nursing home.  Unfortunately, not having enough staff on hand to meet the care needs of the residents is a common feature in the long-term care industry.  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 at Westminster Village suffers broken leg in fall from toilet

Resident breaks hip in fall at McLean County Nursing Home

Fall results in fractured kneecap at Country Health in Gifford

Failure to assist resident to bathroom leads to fall at Heritage Health in Peru

 

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

Alden Estates of Huntley fails to follow orders to give antibiotic

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IDPH has cited and fined Alden Estates Courts of Huntley nursing home after a resident there had to undergo surgery to replace an artificial knee after developing an infection brought on by the failure of the nursing home to obtain and give antibiotics that had been ordered for the resident.

The resident at issue had a history of chronic discitis bacteremia, which mean that her low back was colonized with infectious organisms  In this case it was staph bacteria.   To combat this and prevent the bacteria from spreading to other parts of her body, the resident had been permanently placed on an antibiotic called doxycycline prophylactically, meaning that she was to receive the mediation on an ongoing basis to keep her from getting critically ill with sepsis.  Once the body is colonized with infection-causing bacteria, they can cause infection in other parts of the body.  Implants such as artificial joints, stents, and pacemakers are often places where infection results.

When the resident was admitted to the nursing home from the hospital with orders on the discharge papers to receive an antibiotic doxycycline, 100 mg twice per day.  However, when the resident was admitted to the nursing home, the order was never transcribed onto the physician order sheet, and as a result, the medication was never ordered from the pharmacy.  With the orders never transcribed onto the order sheet and the medication never obtained, the resident did not receive any of the antibiotic that was ordered for her for the first  13 days of her admission to the nursing home.

After missing the first 13 doses, the resident suffered an episode of chest pain and was admitted to the hospital for a total of 13 days.  When she was discharged from the hospital, she again had orders for doxycycline, 100 mg twice per day.  Once again, the order was never entered into the physician order sheet and the medication was never ordered.

The net effect of this nursing home medication error is that the resident did not receive a total of 52 doses of the medication that was ordered to suppress the bacteria and prevent her from suffering a serious infection.

Due to not receiving the medication that had been ordered for her, the resident developed an infection and was sent to the hospital in a critically ill condition.  She was suffering from septic shock and had an infection of her artificial knee.  Due to the infection of the knee prosthesis, she had undergo surgery to remove the prosthesis and have a new one implanted.  The orthopaedic surgeon attributed the infection to the bacteria which were intended to be controlled by the antibiotic which the resident did not receive.

Assuring continuity of care is a critical part of helping nursing home residents maintain their health and well-being.  Nursing home resident are almost always admitted suffering from some condition of ill-being whether it is acute, as may the case with patients admitted for short-term rehabilitation, or may suffer from long-term chronic medical conditions, as was the case here.  The common thread between them is that these conditions are being managed by a physician who is relying upon the nursing home home staff to implement the care that they have ordered.  When they do not, catastrophe can result.

Nursing homes are businesses, and well-run businesses have systems in place to carry out their basic functions.  Admitting residents to the nursing home and assuring continuity of care is one of those basic functions.  Here there was clearly a problem with the system that the nursing home was operating under, as the antibiotic ordered for this resident was not given after two separate admissions.  The fact that this was a common thread between the two admissions speaks to a larger problem than a simple breakdown of the system due to human error.  Once could be a mistake, twice could be a larger issue.

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:

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

Accolade of Paxton fails to give resident post-operative antibiotics

Medication error leads to hospital admission at Arista Healthcare

 

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

Aperion Care Wilmington resident suffers ruptured colon from fecal impaction

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IDPH has cited and fined Aperion Care Wilmington nursing home after a resident there developed fecal impaction which led to a ruptured colon which required multiple surgeries.

The resident at issue suffered from mental illness and was receiving several psychotropic medications.  One of the risks associated with the use of these kinds of medications is that the resident will suffer from constipation.   When a resident is receiving psychotropic medications, one of the steps typically included in the resident care plan is to monitor the resident for signs and symptoms of constipation as well as tracking their bowel movements.

Prolonged periods of constipation increases the risk that the resident will experience fecal impaction.  When someone suffers from fecal impaction, there a hard balls of feces in their digest tract which are hard to push through to the end of the digestive tract.  The presence of a fecal impaction can cause abdominal pain and other digestive issues, and in advanced cases can cause perforation of the structures of the digestive tract.

Perforation or rupture of structures in the digestive tract results in the contents of the digestive tract leaking out into the abdominal cavity.  The causes a type of infection known as peritonitis.  Peritonitis is very painful and can be a life-threatening condition.  It is also a very difficult condition to treat and often requires a prolonged course of IV antibiotics and may require multiple surgeries to remove portions of the digestive tract.

The resident was discovered in bed with blood coming from his rectum the day that he was taken to the hospital.  Additional blood was found in the toilet.  At the hospital, the resident underwent a CT scan which showed the presence of free air in the abdominal cavity.  This is a sign of rupture of one of the structures in the digestive tract.

The resident was brought to surgery where it was discovered that the resident’s colon had ruptured, that there were digestive contents throughout the abdominal cavity, and that there was extensive evidence of infection throughout.  Several large balls of feces were found within the digestive tract.  There was also evidence of necrosis (tissue death) of the colon.  All of this indicated that this was a condition which was present for several days.

Ultimately, the resident underwent several surgeries, including removal of his colon and placement of an ileostomy, which is similar to a colostomy except that it removes waste matter from the end of the small intestine rather than the colon.  Besides being an issue of dignity, this has significant negative impacts on the nutrition of the resident.

When IDPH went to investigate this incident, they questioned the staff about the tracking of the resident’s bowel movements in the chart.  The answers made it apparent to the surveyor that there was no meaningful tracking of the resident’s bowel movements.  As a result this led to the resident suffering prolonged periods of constipation.

Had the resident’s bowel movements truly been tracked in a regular, systematic way, the resident’s constipation could have been addressed in a number of fairly simple ways, ranging from diet changes, use of a laxative  or stool softener, or digital removal.  This was not done, leading to a catastrophic outcome for this resident.

Additionally, the resident was suffering from necrosis of the colon and from a significant infection at the time he was brought to the hospital and this had likely been present for a long time before this.  This is a strong indicator that the staff was not monitoring the condition of the resident and did not notify the resident’s physician of changes in the resident’s condition.

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:

Failure to monitor anticoagulant levels at Greentree of Bradley

Hillside Rehab resident suffers brain bleed due to failure to obtain lab work

Failure to follow orders at Generations at Applewood

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

 

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

Glenview Terrace resident suffers multiple fractures when lift topples over during transfer

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IDPH has cited and fined Glenview Terrace nursing home after resident sustained multiple fractures to her back and sacrum when a mechanical lift toppled over during a transfer.

Used properly, a mechanical lift is a useful tool for caring for residents in a nursing home setting.  It allows residents to be transferred safely from one place to the other with minimal risk of injury.  It also reduces the risk of injury to staff members by eliminating the lifting that has to be done by staff in manual transfers.  However, the key to this is that the lift must be used properly, and proper use of a mechanical lift requires two staff members to assist in transferring a resident from one place to the other.  Having on person do a two-person job when it comes to transfers is a formula for disaster, as we have written about many times on this blog (see here, here, here, here, and here for examples).

The resident at issue was wheelchair bound and had a medical history which included a stroke with residual weakness on one side.  Her care plan called for transfers to be done with a mechanical lift with the assistance of two staff members.  Two staff members are needed for transfers with a lift because one staff member is needed to operate the lift while the other staff member keeps the resident steady in the sling.

On the day of this nursing home fall, the resident was being transferred from wheelchair to bed by a single aide using the mechanical lift.  After the resident was placed in the sling to the lift and was lifted up from the chair, the resident began to sway in the sling.  This resulted in the center of gravity shifting and the lift itself toppling over.  The resident landed on the floor on her back.  She was brought to the hospital where she was diagnosed with multiple fractures to the vertebrae in her lower back as well as to her sacrum.

The obvious cause of this mechanical lift accident was the aide failing to follow the terms of the care plan and failing to follow generally recognized safe practices regarding the use of the lift.  The deeper question is, why did he not get assistance before attempting the transfer.  The answer to this likely relates to the understaffing of the nursing home – he was too rushed to get the extra help needed to accomplish a safe transfer of this resident.  Alternatively, it could simply be poor training of the aide.

Either option – understaffing or poor training of the staff – implicates the choices made regarding the management of this nursing home.  Sadly, failing to invest in the staff so as to help assure that residents receive the care they need and deserve is 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:

Violation of care plan at Generations Oakton Pavillion leads to fall and fracture

Avantara Lake Zurich resident suffers lower leg wound during unsafe transfer

Grove at the Lake resident suffers multiple injuries in mechanical lift accident

Resident suffers jaw, facial fractures at Dimensions Living in Prospect Heights

Niles Nursing & Rehab resident suffers fatal brain bleed in fall

Failure to provide needed assistance leads to fall at Generations of Elmwood Park

Resident suffers broken hip in unsafe transfer at Pearl of Rolling Meadows

Grove of Skokie resident breaks leg due to violation of care plan

 

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

 

Victorian Village resident develops pressure ulcer from orthotic boot

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IDPH has cited and fined Victorian Village Health & Wellness nursing home in Homer Glen after a resident there developed a pressure ulcer on her heel from her orthotic boot.

“Pressure ulcers” are commonly referred to as bed sores because they frequently develop on persons who are unable to get out of bed and are caused by pressure from the weight of the body against the bony prominences.  This is why some of the most common parts of the body for bed sores to develop are the buttocks, hips, sacrum, and heels.

However, pressure from the weight of the body is not the only way that pressure ulcers can develop.  One common way for bed sores to develop is pressure against the body from medical devices and equipment such as casts, catheters, immobilizers.  The risk associated with the use of these devices is well-known in long-term care industry and should be addressed in the care planning process.  The risk from these devices can be mitigated by frequent skin inspections; checking the device for fit, condition, and positioning; and obtaining doctor orders permitting removal when appropriate.

The resident at issue was admitted to the nursing home for rehabilitation after suffering a fall at home.  One of the complications that she had as a result of the surgery was that she had a drop foot on one side for which she was given an orthotic boot to wear.  On admission to the nursing home, she underwent a full skin inspection and there were no pressure ulcers.

After being admitted to the nursing home, she would periodically complain of a burning sensation in the heel.  However, no one would take the boot off to inspect the underlying skin or the condition of the boot; they would simply loosen  the boot for a period of time.  Further, no one notified the doctor that the resident was complaining of a burning sensation in the heel.

The pressure ulcer was not discovered until the resident had been admitted to the nursing home for about 10 days, at which point a staff member removed it to clean the foot.  At this point, the wound was considered an unstageable pressure ulcer which is by definition at least a Stage 3 or possibly a Stage 4 pressure ulcer.  According to the citation, the wound had extended up to the Achilles tendon of the resident.

Why did the resident develop the pressure ulcer?  Inspection of the boot revealed that even though it was lined, a portion of the lining had worn away so that the heel of the resident was laying directly on the frame of the boot.  This is exactly the kind of thing that causes pressure ulcers to develop with the use of medical devices and equipment – prolonged pressure from an inadequately padded device.

What should the nursing home have done?  For starters, the regular inspections of the skin and the device were not done.  Had the boot been removed and the condition of the skin and the boot been observed, the relationship between the resident’s complaints about a burning sensation in her heel would have been readily apparent.  Beyond that, the frequent appearance of a burning sensation in the heel also should have resulted in physician notification.  This was not 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:

Moweaqua Rehab resident develops pressure ulcer from fracture brace

Resident at Christian Nursing Home in Lincoln develops pressure ulcer from brace

Oak Brook Care Center resident develops pressure ulcer from immobilizer

Pressure ulcer from surgical boot at Amberwood Care Center

 

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

Resident at Hickory Point Christian Village in Forsyth suffers multiple fractures in fall

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IDPH has cited and fined Hickory Point Christian Village in Forsyth after a resident there suffered a fractured arm and fractured hip in a fall.

The resident at issue had a history of repeated falls, including two falls within a 24 hour period, the last of which resulted in a fractured right hip which brought about the admission to the nursing home.  On admission the resident was noted to have strength and mobility deficits and suffered from dementia and confusion.  Having a history of falls is a significant fall risk factor, as are strength and mobility deficits and dementia/confusion.

On the day of this nursing home fall, the resident was brought to the bathroom by an aide.  The aide did not consult the Kardex for the resident and was unaware of the resident’s history of falls and fall risk status. He requested some privacy so she closed the door to leave him in the bathroom.  When he was done, she realized that she did not have supplies for cleaning him up, so she left him unattended in the bathroom while she went to get them.  While she was gone, the resident got up from the toilet and fell, suffering fractures to the left arm and left hip.

This was a fall that likely would have been avoided had the aide checked the Kardex for the resident’s fall risk status and/or had the aide brought the necessary supplies to clean up after the resident.  Neither of these things occurred, and as a result, a very preventable fall occurred.

Given that this resident had a fracture to the right hip from which he was recovering, an additional fracture to the left hip will make recovery from the two injuries much more difficult.  These fractures were compounded by the fact that the resident suffered a fracture of the left arm as well, which would complicate any effort to have the resident engage in any form weight bearing using a walker or in the parallel bars in physical therapy.  If the resident does not regain his ability to walk, this has serious negative consequences for his quality of life as well as his risk of developing additional complications such as bed sores.

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:

Charleston Rehab resident suffers brain bleed and fractured hip in fall from bed

Cumberland Rehab resident suffers brain bleed due to fall from toilet

Hilltop Skilled resident breaks leg in fall from bed

Piatt County Nursing Home resident fractures hip in fall

Heritage Health Pana staff violates care plan leading to fall and fractured hip

 

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

 

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