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Rockford Nursing Home Cited for Medication Errors & Patient Fall

Medication Errors and Falls in Nursing HomesRockford, Illinois – The quarterly report released by the IDPH (Illinois Department of Public Health) in the fall of 2017 revealed that Forest City Rehab & Nursing Center was cited for multiple violations. The nursing facility is located at 321 Arnold Ave. in Rockford. The report revealed that the facility was fined $29,400 for one Type A violations and two Type B violations. Type A and AA violations are the most serious violations that could or did result in a resident’s death.

The violations were identified in two different state surveys conducted in June and July 2017. In a summary statement of deficiencies dated July 18, 2017, the state investigator noted that the “facility failed to administer medications in a manner to avoid a significant medication [mistake] that resulted in [the resident] receiving [four other residents’] opioid medications.”

A Horrific Medical Administering Mistake

The investigators noted that the facility “failed to provide the necessary care and services by not assessing, documenting vital signs, and monitoring for declining condition for a resident that received multiple opioid medications in error.” This incident involved an unidentified female resident who lived at the facility since 2001. The mistake by the nursing staff occurred when they administered multiple opioid drugs that were supposed to be given to other residents.

State investigators indicate that a nurse at the facility prepped the drugs to give to the other residents but put each pill into a single cup before leaving the room. Another unidentified individual gave the resident the cup containing all the medications. The quarterly report indicates that the female resident became unresponsive and required Narcan, an opiate antidote use for an opioid overdose, to reverse the side effects of prescription pain pills including Vicodin, methadone, oxycodone, codeine, morphine, and others.

Physician intervention was required, and the resident’s doctor left orders for the medical staff to monitor her vital signs each hour. However, the facility failed to follow the doctor’s orders, and the woman died one week later. While the quarterly report does not indicate a direct correlation between the opioid overdose mistake and the woman’s death, the state fined Forest City Rehab & Nursing Center $25,000 as a penalty for the error. The facility received an additional $2200 fine for their failure to inform the resident’s power of attorney of exactly what happened, which is in violation of nursing home regulations.

A Separate Complaint

There was an additional $2200 fine issued to Forest City Rehab and Nursing Center during the same investigative survey. In a summary statement of deficiency dated July 18, 2017, state surveyors investigated a complaint at the facility over their failure “to transfer a resident who needed extensive assist, and history of falls, in a safe manner by not using a gait belt [with] two persons.”

The State surveyor said that the failure to assist contributed to the resident “experiencing a fall following a spontaneous fracture, and sustaining three additional fractures.” It was noted that the resident “fractured both arms and both legs.” The incident involved a resident who was diagnosed with “chronic obstructive pulmonary disease [COPD] with acute exacerbation, muscle weakness, repeated falls, other lack of coordination, difficulty in walking, morbid obesity, hypertension, heart failure, pressure ulcers, Type I diabetes, cellulitis…”

The resident’s June 20, 2017, MDS (Minimum Data Set) indicated that the resident “is cognitively intact, requires [the] extensive assistance of two for transfers, and is not steady moving on and off the toilet….” The resident’s July 4, 2017, Incident Report revealed that the resident “sustained a fall resulting in injury… was in the bathroom, with an aide, transferring from the toilet to the wheelchair with [the] assist of a walker when the resident’s leg popped and buckled at the knee.”

The CNA (certified nursing assistant) providing care lowered the resident to the floor who sustained “lacerations approximately 3 inches received to the upper shin just below the knee and right lower extremity exhibiting a visible outward rotation, not in alignment with the knee.” After an evaluation, the resident “was transported to the hospital emergency per ambulance.”

At the hospital, the resident was interviewed and stated that “he was transferring from the toilet to the wheelchair when his legs gave out and he fell down on both knees.” The resident also stated that “there was just one girl helping me and I told her my legs weren’t working and then down I came. There was no belt around my waist; they usually don’t use one. I don’t recall hitting anything on my way down I was just weak that day. I broke both of my arms and legs.”

The hospital’s records dated July 4, 2017, indicated that the resident “had a spontaneous, open fracture of his right proximal tibia and fibula. He then fell breaking his other three extremities.” An orthopedic physician saw the patient on July 18, 2017, who stated that “based on simple physics if [the resident] was lowered to the ground slowly there would have been less injury. My guess is that [the resident] needs two people to transfer.”

A review of the resident’s June 27, 2017, RISK Review indicated that the resident “is a high fall risk due to a history of falls (bilateral female fractures in October 2016), [the resident] exhibits loss of balance while standing, and has diagnoses of fatigue/weakness.” The state investigator reviewed the resident’s Care Plan that had not been updated since April 29, 2016. The plan showed that the resident “is at risk for falls, has general weakness, moderate to severe range of motion, lost all extremities, bilateral femur fractures, and requires extensive assistance with most activities of daily living.” The report also reveals that the resident is to have a gait belt for all transfers.”

The state investigator interviewed the facility’s Director of Nursing in the early afternoon of July 12, 2017, who stated that “staff is expected to follow the resident’s care plan… She did not know how [the resident] transferring could not explain why current charting shows [that the resident] transfers with [the] extensive assist of two and the staff were using [only] one person for transfers.”

Did Not Follow Facility Policy

The investigators reminded the facility of their February 2017 policy titled: Lifting/Transfer Policy that reveals the staff is “to promote comfort… and decrease the possibility of injury to the resident and/or nursing personnel.” Also, the facility’s February 2017 Gait Belt Policy reveals that the purpose of using a gait belt is “to provide support and safety during ambulation, lifting, or transferring residents.” Because of the nursing staff’s failure to follow procedures and protocols that led to the severe injury of a resident, the facility was fined $2200.

For more information on Illinois nursing home ratings and violations, look here.