Nursing Home Abuse Lawyer Blog

Fairview Nursing Plaza is a 213 bed nursing home facility located in Rockford, Illinois. This facility is rated as a one-star nursing home according to the new system instituted by The Centers for Medicare and Medicaid, which suggests a below average facility. While the average number of health deficiencies for the State of Illinois is eight, this nursing home has consistently attained a higher deficiency rate. For the 2006 complaint reporting period, this facility had ten deficiencies. For the 2007 complaint reporting period, there were nine deficiencies and for the 2008 complaint reporting period, there were thirteen deficiencies.

All nursing home facilities are required by law to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of its residents and misappropriation of resident property. During this time period, Fairview Nursing Plaza failed its residents in this regard in 2008 and actually placed its residents in immediate jeopardy. The facility did not have a wound management system in place to ensure that nursing staff was knowledgeable in the assessment of pressure ulcers to be able to identify them in the early stages, identify potential deep tissue injury, and the signs and symptoms of wound infection. The facility staff failed to ensure wounds were evaluated for response to treatment, sources of pressure eliminated, and that treatment orders were carried out. No specific care plans were developed for wound prevention and treatment as identified and no evidence was found of nursing oversight and supervision to ensure standards of practice were met. In one instance, a resident’s left heel wound began to emit a foul smelling drainage and the facility continued with the same treatment and failed to re-evaluate the wound. Other residents had pressure sores that were improperly identified and some pressure sores were not measured. In another instance, there was no specific care plan for a resident with multiple pressure sores. Moreover, the facility had no treatment or monitoring system planned for this resident. Another resident with a Stage III pressure sore on his left hip was not given the physician-ordered dressing and the wound showed 90% yellow dead tissue and 10% black tissue. As a result of the state survey, the facility was required to perform a skin check on all residents and obtain treatment orders. Resident Care Plans were updated and the affected residents were evaluated by the Certified Wound Care Specialist, who began approved treatment. Facility staff was in-serviced on wound prevention, wound treatment, and protocols. All nursing home residents need comprehensive assessments periodically to update the resident’s goals and current status. In fact, appropriate Care Plans were not in place for the residents suffering from pressure sores.

It is vitally important that nursing home residents receive the correct medications at the correct time. At least two residents at this facility did not receive their medications because the facility had run out of the medications. Nurse managers and floor nurses audited all medication carts to ensure that medications for all residents were available. Nurses were in-serviced on the appropriate procedure for ordering as well as requesting refills.

While it is important for nursing home residents to receive the correct medications, it is equally important that residents do not take any unnecessary drugs. At this facility, a resident with a known history of substance abuse was abusing Fentanyl patches. Fentanyl patches are used for people experiencing chronic pain. Misuse of the patch can create a dangerous "high" that can also be deadly. The resident had been removing the patch before the scheduled day and claimed to have lost the patch several times. Additionally, one time the resident separated the patch and the gel pain medication had been removed. None of these events were reported to the resident’s physician. The resident was found on the floor, unresponsive, with no pulse or respirations. A post-mortem drug screen found a severe Fentanyl overdose had occurred. The Fentanyl patches were kept in the medication room in a box. After this resident's death, it was determined that at least one of the patches was missing and unaccounted for from the box. An investigation was immediately conducted surrounding the missing Fentanyl patch. It was determined that an agency nurse that had worked at the facility had misappropriated the medication and she was banned from the facility. All licensed nursing staff were in-serviced regarding the monitoring and documentation of residents who are prescribed duragesic patches for pain control and the facility’s requirement of shift-to-shift narcotic counts. An additional in-servicing was conducted concerning residents with known histories of substance abuse to prevent the manipulation of a narcotic analgesic patch and the requirement that a physician be notified if there is a patch missing or tampered with.

Any resident entering a nursing home facility without a catheter is to remain without a catheter unless absolutely necessary. Fairview Nursing Plaza failed to ensure the outflow of urine was not hindered by kinked or twisted urinary catheter tubing and that the collection bag for a resident prone to urinary tract infections was not lying on the floor. The facility provided the resident with a clip so that the bag can be maintained on his bed appropriately. All residents who use catheters were inspected for proper placement of bags and tubing. Nursing staff was in-serviced on proper positioning of foley bags and tubing for residents in wheelchairs and beds and the complications that can occur if not properly maintained.

The nursing home environment should be free of any accident hazards and all residents should receive the appropriate supervision and assistive devices to prevent accidents. The Fairview Nursing Plaza also failed its residents in this regard. One resident did not receive the appropriate supervision to prevent him from removing a hot dog from another resident’s tray. This resulted in the resident choking on the hot dog and CPR had to be initiated after the resident stopped breathing. The resident was revived through CPR and transferred to the Emergency Room. Another resident fell from her wheelchair while trying to put her slipper on. The resident was improperly secured in her wheelchair with a lap belt and her fall resulted in bleeding from her nose and lip and a forehead hematoma. As a result of these failures, residents with an increased risk of choking or aspiration were provided green wristbands to wear to help identify them and were placed at tables in the front of the dining room and monitored by a staff member to ensure safety during meals. Nursing staff were in-serviced on the “Green Band” as well as signs of choking. Nursing staff were also in-serviced on restraint use.

In a separate instance, the facility failed to identify a resident’s risk for head injuries. A resident with difficulty ambulating fell a total of seven times in three months. The final fall resulted in the resident striking his head on a brick wall. He was transferred to the emergency room, where he was found to have a right-sided subdural hematoma that required an emergency craniotomy.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. For more information, call us directly at 1 (888) 317-2525 or visit our website at nursinghomejustice.com.