Recently, the Illinois Department of Public Health issued it’s “Quarterly Violator’s Report.” This report–viewed here–includes a list of various facilities across the state which have been cited for different violations over the past few months. Helpfully, the website includes access to the full reports from each of these incidents. In that way, intersted readers are able to delve more deeply into the details of the situation to understand what happened and learn about what incidents actually occur in facilities across the state each day. Of course, the citations issued here represent only a fraction of the actual problematic incidents that occur in Chicago assisted living facilities and similar homes throughout Illinois.
This particular incident occured last spring at the Alden Wentworth Rehabilitation and Healthcare Center based in Chicago. It involved several “Type A” Violations and a conditional $20,000 fine. One of the underlying problems, according to the report, was a lack of communication by the facility between doctors at the nursing home and hosptial where a resident was discharged from. Attorneys working on neglect cases often see this type of negligence–those providing care do not share all pertinent information, and resident suffers as a result of bungled treatment.
In this situation, instructions from the hosptial to the nursing home were explicit. They noted that the resident was not to receive narcotics upon moving to the long-term care facility. However, those instructions were not passed on to or heeded by the attending physician at the long-term care facility. As a result, contrary to explicit medical orders, the resident received narcotics. This lasted for three weeks before the resident died. The resident’s death certificate listed narcotic intoxication as a cause.
The doctor and the hosptial explained that he recalled the exact order, noting that the patient could receive pain medication, just not narcotics–he had a history of drug abuse. Common narcotic pain medications include fentanyl (often in patch form) and Vicodin. However, a nurse at the nursing home admitted that she did not explain those instructions to the nursing home doctor. As a result of the communication error, the resident was given a Fentanly patch which also contributed to his death.
This incident, and the many like it, is a reminder of the fact that serious injury and even death often result from simple oversights and mistakes by caregivers. When discussing the poor conditions in so many homes there may be a tendency to assume that critiques are all related to gross recklessness or intentional abuse. But those incidents are more the exception. On the other hand, basic neglect, like communicaton errors that lead to medication mistakes, are quite common. Considering the fragility of many seniors at these facilities, even simple mistakes threaten lives. It is for that reason that we must keep pressure on facilities to improve. Allowing basic neglect without real pressure to change means that lives will be lost unnecessarily in the future.
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