Ballard Nursing Center is yet another large nursing home facility located in Des Plaines, Illinois. Ballard can accomedate 231 Medicare / Medicaid patients. Ballard scored three out of five stars according to the Medicare Nursing Home Compare website, which is an average rating. Ballard had only five health deficiencies in the past year, which is three less than the average in Illinois and in the United States.
Despite the relatively low number of health deficiencies, some residents failed to receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.
During a recertification survey on August 14, 2009, inspectors found that one resident was in severe pain for over twenty hours because the facility failed to reassess and relieve her pain within a reasonable timeframe. The resident was a 70 year-old female who had recently had surgery on her left thigh and was admitted to the facility with a non-healing surgical wound. She complained to nurses that she was experiencing severe knee pain and was given Tylenol and a Lidocaine patch. However, the severe pain persisted with no relief from the prescribed treatment. The facility did not order any additional pain medications until the surveyor intervened on her behalf. As a result, this resident suffered excruciating knee pain for over twenty hours.
Another resident, a 48 year-old female who is in a vegetative state and cannot communicate because of a traumatic brain injury, was observed in her room moaning and crying out. A review of her clinical chart revealed that she had no current pain assessment. When the surveyor asked staff why the resident was crying out, they responded that they didn’t know and that she cried out on occasion. In addition, because the resident cannot communicate, the staff must anticipate potential for pain. The facility failed to do so when removing hand splints, which may have caused the resident pain.
The facility also failed to ensure that food was stored and distributed under sanitary conditions, which exposed all residents in the facility to potential harm. Older adults are particularly susceptible to food poisoning because of weakened immune systems, and many older adults already have weakened immune systems because of age, illness, or disease and their bodies cannot handle the added onslaught of food poisoning illness. The surveyor found cups of juice and milk in the refrigerator without labels indicating the date they were opened. Also, food debris was observed on dishes after being “washed” in the dishwasher.
During a complaint investigation concerning the death of a 61 year-old male resident, it was found that the facility failed to ensure that the resident was free from neglect and also failed to thoroughly investigate the improperly placed tracheostomy tube. The facility’s failures resulted in the hospitalization and eventual death of the male resident because he did not receive enough oxygen during a respiratory arrest which led to respiratory failure.
Although the facility was supposed to check on the resident every four hours because he had a tracheostomy, documentation revealed that the Respiratory Therapist failed to check on the resident every four hours. A Certified Nurse Aide (CAN) found the resident with his trach tube out and reinserted it. The CNA called the Respiratory Therapist when the resident was unresponsive. While attempting to revive the resident, the resident passed out and coded. At this point, the facility called an ambulance, and the resident was rushed to the Emergency Room in “Full Arrest with Cardiac Pulmonary Resuscitate (CPR) in progress by the paramedics. In the ER, doctors removed the tracheostomy and inserted a new tube into the trachea to ventilate. However, by that time, the resident had gone at least half an hour without ventilation. The resident died as a result of fatal respiratory arrest.
The facility then failed to thoroughly investigate this occurrence that led to the resident’s death. In addition, the facility did not notify the state reporting agency of the occurrence. The facility fired the Respiratory Therapist for “unsatisfactory work performance” nine days after the incident. However, no evidence of an investigation was found even though the Respiratory Therapist’s actions led to the resident’s death. In response to these serious deficiencies, the facility checked all 37 residents with trach tubes and reviewed the policy on trach and vent checks with respiratory staff. Hopefully the facility response will prevent any future preventable deaths.
Although Ballard Nursing Center received an average rating from Medicare, the facility has suffered from problems, which even led to the death of one male resident. In a large nursing home such as this, sometimes not all residents receive adequate and appropriate care which can lead to serious health complications.
Furthermore, this recent survey demonstrates that seemingly quality nursing homes, such as Ballard, still have episodes where poor care result in patient injury or death. Families of patients at all nursing homes– regardless of their reputation– should visit regularly and speak up if dangerous conditions are seen. Your observations may prevent unfortunate situations from occurring.
Thank you to Heather Keil, J.D. for her assistance with this Nursing Homes Abuse Blog Entry
IDPH: Ballard Nursing Center
Medicare: Ballard Nursing Center