Illinois Nursing Home Resident Suffers Injury, Dies Days Later
A female resident at Champaign County Nursing Home suffered an injury that went undetected and died mere days later.
The resident, only known as R7 in a report from the Illinois Department of Public Health, reportedly "slid" out of a lounge chair but was caught by a CNA. According to the report, "CNA slid under (R7) and pulled her onto her lap...(R7) denied pain...did not hit head...did not hit w/c (wheelchair) or w/c pedals. (R7) talking and laughing with staff...able to move arms and legs without a problem or pain...Body check done with no areas of redness noted,". The report, dated January 25, was identified as a "late entry" and it was unclear if the fall occurred that day or prior to that date.
On January 29, bruising was noted on the resident's right leg and hand. Her doctor ordered her to be seen at a hospital where staff noted "right leg has progressively increased in size with diffuse ecchymosis (bruising)...It does appear (R7) struck her head."
The resident was diagnosed with multiple serious problems, which included shock, acute kidney failure, hypovolemia (low circulating blood flow), and acute posthemorrhagic anemia. According to an ER physician, there was an "incredible amount of blood lost in the leg" and 'it "took a lot of fluid and blood to fix (R7's) anemia/shock which resulted in CHF (congestive heart failure)." She died on February 4 from cardiopulmonary arrest, respiratory failure, and hypovolemic shock.
The ensuing investigation by the Illinois Department of Public Health found that the nursing home failed the resident in the following ways:
"failing to implement existing policies on Falls, Lab and Diagnostic Test Results, Laboratory Testing, Orders for Anticoagulants, Anticoagulants and Change in Residdent's Condition or Status";
"failing to notify the physician in a timely manner of high laboratory values, neglected to identify a fall, to notify the Physician/Nursing staff of the fall and implement post fall monitoring";
"failing to assess and monitor significant bruising as a side effect of anticoagulant therapy"; and
neglecting "to notify the Physician of the significant bruising in a timely manner, but continued to administer anticoagulants to R7".
Two other visits to the nursing home by investigators have revealed other problems at the facility.
An April 2, 2010 inspection revealed that the facility failed to follow its own policy in handling an employee allegation. A resident alleged that she had provided money to a staff member for a soft drink but never received it or her money back. She lodged a complaint with another staff member, who failed to report the incident.
The April 29, 2010 inspection found that facility staff did not use proper equipment when transferring three residents. One resident, a 91 year old resident suffering from dementia, broke her hip after standing up from her wheelchair and falling. She was to be wearing a personal safety alarm.
The investigations have resulted in fines of approximately $50,000 against the nursing home. The nursing home is appealing the penalties.
