IDPH has cited and fined Warren Barr North Shore nursing home in Lincolnshire after a resident bled to death after she manipulated her dialysis port.
The resident at issue was a long-term resident of the nursing home and received dialysis three times a week. In addition to the medical issues which required dialysis, she was on blood thinners and suffered from advanced dementia. She had a fistula for dialysis in her left upper arm. The fistula would allow the blood to drawn out of the body, have the waste filtered out, and the blood returned to the body.
Before the incident that resulted in the wrongful death of this nursing home resident, there were two other incidents where the resident experienced bleeding related to her dialysis site. The first of these took place approximately three months earlier, when an aide found the resident in bed with the resident’s sheets soaked with brown, hardened, coagulated blood. The fistula site was identified as the source of the bleeding. Approximately a month and a half later, a wound was found on the resident’s arm next to the fistula and the staff documenetd that the resident was known to scratch at the area.
During the survey process conducted by IDPH, other staff members and health care professionals acknowledged that the resident frequently scratched at the dialysis site. There was speculation that tape that held the port into place was an irritant.
At 11 pm the day before the resident died, the nurse took her hand away from the fistula site. She was checked on twice that night before being found the next morning around 4 am. The citation describes a horrific scene – the resident covered head to toe in blood, blood saturating the sheets and blankets, blood on the floor and wall. The resident was already deceased. Cause of death per the death certificate was exsanguination, meaning that she had bled to death.
This case demonstrates a breakdown in the care planning process and delivery of care is impacted by the nursing home business model. The underlying premise of the care planning process is that the risks to the health and well-being of the resident are identified and steps are taken to address the risks.
The staff here knew of a behavior which represented a threat to the health and well-being of the resident – her behavior of scratching at the fistula site. In fact, they got a preview of how serious an incident that could be in April when she had a significant bleeding incident caused by scratching at the fistula site. Further the staff had at least a notion of the underlying cause of the resident scratching at the fistula site: irritation of the skin from the tape.
There were at least a couple of simple solutions available to address this risk. One would be to use a different type of adhesive which did not cause the irritation. Without the irritation, there would be no scratching at the fistula site and this incident would not have occurred. The other option would have been to protect the fistula site with a dressing which would have kept the resident from dislodging it. Neither of these options appear to have been pursued and there is no indication in the citation that the risk of this kind of bleed-out was ever addressed in the care planning process.
The likely reason that this was never addressed in the care planning process is that it is not one of the specific areas that is part of the standard care planning process like the risks of nursing home falls, developing bed sores, or elopement (or wandering). One of our beliefs is that the nursing home business model stretches staff so far that little critical thought is given to the health and well-being of residents. This was a situation that called for a little extra critical, outside-the-box thought and consideration which never happened.
Order our FREE report, Built to Fail, to learn more about how the nursing home business model ends up causing unncessary injuries and deaths to nursing home residents. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
Other blog posts of interest: