Jonathan Rosenfeld's Nursing Homes Abuse Blog : Jonathan Rosenfeld's Nursing Homes Abuse Blog | Lawyer & Attorney : Strellis & Field Law Firm | Bed Sores, Senior Neglect, Elder Abuse, Sexual Abuse: Chicago, Illinois

Even at nursing home facilities with relatively high Medicare ratings and low average number of health deficiencies, serious problems can still occur. Despite a three-star (average Medicare rating), Addolorata Villa (a nursing home located in Wheeling, Illinois with 91 certified beds) failed to provide proper care and services to an elderly female resident after a fall, which then required an ER visit for serious injuries. 

Addolorata received two stars for its health inspections for five health deficiencies over the past year. This is three less health deficiencies than the average number of health deficiencies for Illinois nursing homes and also three less than the average number of health deficiencies for United States nursing homes. Despite the average rating, this facility still suffers from serious health deficiencies, which resulted in serious injuries. 

In March 2009, Addolorata Villa failed to properly monitor a resident after a fall and also failed to properly notify the attending physician of a change in condition. The resident ended up in the ER with a brain bleed and fracture because of these failures. Elderly residents are particularly susceptible to falls because of weakness, illness, and balance problems. 

On March 24, 2009, an 83 year old female resident suffering from Dementia fell from her chair directly across from the nurse’s station. The resident suffered facial lacerations, swelling, and bruising. The nurse assessed the resident, returned her to the chair, and administered first aid. 

Facility staff continued to monitor the resident who denied pain despite restlessness, agitation, grimacing (which is a symptom of pain) and continued swelling and bruising of her left eye, which progressed to the extent that the staff was unable to open her eye to check the eye and pupil response. However, on the morning of March 26, the resident was noted to be more lethargic and was sent to the emergency room (ER) for evaluation. The resident was then admitted to the hospital with a brain bleed and cervical fracture. 

The facility failed to provide timely, frequent and comprehensive neurological assessments, and also failed to notify the physician in a timely manner of the change in neurological status and change in the condition of the left eye. These failures resulted in a 33 hour delay in medical treatment for the elderly resident. The facility’s failures and neglect resulted in this resident suffering from prolonged pain and further injury, ending in an ER visit. 

Each and every nursing home resident has the right to receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This requirement was not met when the facility failed to provide proper treatment to this resident after her fall. During the following May 7, 2009 complaint investigation, the surveyor found that the facility’s significant failures placed this resident’s health and safety in immediate jeopardy.

When choosing a nursing home facility for a family member, there are many factors that should influence your decision, including the number of residents, number of staff, location, past health deficiencies, Medicare rating. You must be aware that even relatively good facilities with an average Medicare rating can have serious health deficiencies, which can result in serious injuries. 

Sources:

IDPH: Addolorata Villa

Medicare: Addolorata Villa

Chicago Business: Illinois Ranks High on Bad Nursing Home Report  

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Like many families, Kenneth Gall sought a sense of closure with respect the circumstances surrounding his mother's death after she sustained an injury during her admission to Presbyterian Homes of Arden Hills.  Unfortunately, more than a year after his mother's death, questions still remain as to the facilities role in the matter-- and how a disabled, primarily bed-bound-woman managed to fracture her neck while admitted to a nursing home.

Was it due to a fall?  Was the fracture related to violence?  Did Mrs. Gall get entangled in a bed rail?

What is known is that 91-year-old Gladys Gall died about two weeks following an incident in which she sustained a unusual type of fracture in her neck called a hangman's fracture and died from complications shortly thereafter.  

The circumstances surrounding Mrs. Gall's death were investigated by the Minnesota Office of Health Facility Complaints (OHFC) and a determination was made by the agency that the incident was due to mistreatment.  The state even consulted with a neurosurgeon who opined that the nature of Mrs. Gall's injury could only be caused from severe trauma.

Now however, after the nursing home appealed the states findings and presented evidence from their own investigation, the state has changed its findings relating to improper care from 'substantiated' to 'inconclusive'.

The role of state investigations into injury or death in a nursing home

Most states have agencies (usually associated with their health department) to investigate suspected mistreatment of patients in a nursing home.  Investigators can quickly access the patient's chart and interview employees and other patients who may have knowledge of the incident.  While certainly not always perfect, the investigations typically provide much sought after information to families asking 'how' and 'why' an incident occurred.

In most jurisdictions, the state investigative findings and the reports generated are not admissible in court proceedings related to a nursing home negligence lawsuit.  Nonetheless, the information contained within the investigative report can be invaluable in the course of litigation.

In the case of Mrs. Galls death, I humbly suggest to her family to seek out an experienced lawyer to prosecute this matter and give them more information relating to the circumstances of their loved ones death.

Read more about this suspicious death in a Minnesota nursing home here.

Related:

Nursing Home Cited For Mistreatment Of Resident Following Investigation Of Resident's Fractured Neck

Falls Amongst The Elderly Can't Be Ignored

Nursing Home Watchdogs: Ombudsmen

Nursing Home Inspectors Miss Major Problems

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A man admitted to Azalea Court Nursing and Rehabilitation Center for rehab for a broken leg, soon realized he was getting more than rehab at the facility he chose to help him- maggots.  The maggots were seen in an open wound during a dressing change.  Azalea Court's complaint and inspection reports from the past several years did not reveal any glaring problems. Investigators from the State Attorney’s Office visited Tuesday.  Read more about the maggots here.

This is a prime example of neglect nursing homes.  Nursing homes are required to provide the best care possible for their residents.  The failure to clean and open wound is a clear case of patient neglect.

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Despite long standing warnings from the FDA, bed rail entrapment continues to be a real threat to the safety of people in nursing homes, hospitals, and long-term care facilities.  After FDA warnings were issued on rail safety, many manufacturers began production of safer designs.  Although the warnings have been issued, the FDA has not imposed any bed rail recalls on beds known to commonly be the source of injury and death.  The lack of formal action by the FDA will likely result in future incidents involving: injury, fractured bones, strangulation, asphyxiation and death.

The safer rail designs have yet to make there way to the places they are needed.  At many facilities there is little incentive to discard a usable bed, despite the fact that the design may be antiquated and unsafe.  Further, many beds are rented from medical supply companies that have a substantial inventory of beds with older designs. 

Rental beds are typically the least safe beds in use today.  Many rental companies pay little attention to the combination of parts used when distributing beds for home and facility use.  It is common to see a mattress designed for one bed used with the frame from a different manufacturer.  The combination of mattresses and bed frames results in unintended 'gaps' in which a person can easily get caught.

In 1985 the FDA issued a Safety Alert on the dangers of entrapment in bed rails, and other parts of hospital and nursing home beds.  The alert was directed to home healthcare agencies, hospices, and nursing homes.  The FDA based the alert on its published reports documenting deaths and injuries associated with beds and bed rails.

By 1999, bed safety had become such an important issue, the Hospital Bed Safety Workgroup (HBSW) was assembled by the FDA, the medical bed industry, national healthcare organizations, patient advocacy groups and other federal agencies. After years of debate, the HBSW produced a brochure, which provides guidance for selecting a bed and instructions on how to measure for dangerous gaps between the mattress and bed rails.

Lightweight patients are generally at the greatest risk for bed rail entrapment.   Smaller people are more likely to fall into gaps between the mattress and the bed frame.  Other factors in determining a persons susceptibility of bed rail injury are: their mobility, agitation and temporary or chronic reduced mental capacity.  Patients with the above conditions require ongoing monitoring from the staff in order to reduce their risk of harm.

In order to minimize the risk of bed rail injury you should examine the bed and mattress to make sure the mattress 'fits' with the frame.  If you see gaps between the frame and the mattress, you should point out the situation to the facility.  Lastly, ask questions.  Do not be afraid to ask the nursing home or long-term care facility about the type of beds they use and if they have had any problems with the bed before.

For additional information on bed rail safety, review Professor William Hyman's article appearing on McKnight's website here.

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According to the FDA, there are more than 2.5 million hospital and nursing home beds in use in the United States.  Between 1985 and 2008, there were 772 incidents of where nursing home residents were caught, trapped, entangled, or strangled by bedrails.  Of the above incidents, there were 460 deaths.  Most of the injured individuals were elderly in weakened physical and emotional conditions.

Currently, I am are representing a 77 year old woman who became entangled in a bedrail while attempting to locate the 'call button' in her room.  The woman sustained a fractured ulna and radius to her arm which necessitated open reduction / external fixation.

For the FDA Guide To Bed Safety Bed Rails In Hospitals Nursing Home and Health Care: The Facts, click here.

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Nursing homes, hospitals, and long-term care facilities should have 'call lights' for residents to get the attention of the staff.  Most call lights are connected to patient beds.  The call lights should be located within easy reach of the residents and the calls should be responded to promptly by staff.  Most call light systems are connected only to a central nursing desk.  As a result, some 'call light' pages may go unanswered or responses to the call lights may be delayed if the staff is not in close to the desk.

A newer call light system, utilizing pager technology would help staff respond quicker to residents requests.  Yet other call light systems allow residents to carry pagers which prompt nursing home staff to respond to a page regardless of where the residents it.  A mobile pager would be especially helpful for dealing with nursing home falls.

Look at the full Salt Lake City Tribune article here.

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