IDPH has cited and fined Alden Estates of Barrington nursing home after a resident there died from respiratory distress and an elevated potassium level after staff failed to inform the resident’s physician of pertinent information regarding the resident’s condition.
The resident at issue suffered from kidney disease and hypothyroidism (low thyroid), among other problems. This placed him at risk for developing edema and/or an electrolyte imbalance. There was a care plan which was specifically put into place to address this potential which included notifying the doctor of any acute changes and monitoring for fluid excess through monitoring for weight gain or the development of edema. Of course, notifying the doctor or changes in the resident’s condition is one of the basic tasks in a nursing home setting, including significant weight gains which is generally defined in the nursing home industry (and was defined in this facility’s policies and procedures) as more than 5% in one month, 7.5% in three months, or 10% in six months.
In the care of this resident, there were multiple failures on the part of the staff to notify the resident’s doctor of important changes and information regarding the resident’s condition:
- Over a period of 10 days, the resident’s chart showed that his weight weight increased from 208 lbs to 242 lbs. There was an order in place for daily weights because of concern regarding fluid retention. Several days went without any weights being taken at all because the facility’s scale was broken. The resident’s doctor and nurse practitioner were not aware of the extent of the weight gain, and told the state surveyor that they would have sent the resident to the hospital to have fluid taken off.
- The resident had labs taken which showed an elevated potassium level. Elevated potassium levels can cause irregularities in the heart. To address this, there was an order in place for a medication which was intended to drive down the potassium levels. However, the resident refused the medication. The staff failed to notify the doctor of the resident’s refusal. Had the doctor been informed of the resident’s refusal, he would have ordered the resident sent to the hospital to have the elevated potassium levels treated.
- The resident had a chest x-ray performed which showed changes consistent with pulmonary venous congestion. The nurse practitioner explained to the surveyor that this meant fluid overload impending hypoxia due to fluids in the lungs. The nurse on duty at the time paged the doctor with the results. However, he did not return the page and endorsed the results over the nurse coming on to the next shift to pass the results on to the doctor. The nurse coming on at the next shift denies receiving a report about this at the change of shift report. The net result was that the results were never communicated to the doctor.
What was the net result all this? On the morning of the 10th day, the resident sounded the call light and asked to be repositioned promptly. Staff reported that he was anxious and was urging them to reposition him more quickly. After getting him into an upright position, he slumped forward. A code blue was called. The rescue squad could not resuscitate the resident, and he died. Cause of death per the death certificate included severe hyperkalemia or elevated potassium levels.
There were multiple opportunities to prevent this tragic outcome. This resident essentially suffocated on excess fluids. The potential for this was something that was supposed to be addressed in his care plan, by physician orders, facility policies and procedures, and basic standards of nursing practice. One way that care in a nursing home is different from a hospital is that there is not a doctor on site on a 24/7 basis, so nurses need to serve as the eyes and ears of the doctor to notify them about the kinds of changes that were occurring in this resident. This outcome is a sad lesson in what happens when this isn’t done properly.
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