IDPH has cited and fined Parker Nursing & Rehabilitation Center in Streator after a series of incidents involving a physically aggressive and violent resident which ended with a nurse having to be taken to the hospital.
Some readers of this blog may feel that we are unfair to nurses and that they get unfairly blamed for bad things that happen under their watch. And while we don’t want to discount the importance of being responsible for the things that you do or don’t do, we believe that nurses in nursing homes are often dealt a bad hand by the nursing home business model and that they mostly do the best they can given the circumstances and conditions that they work in.
In this case, a nurse was the one who was the one who suffered the most due to the business decisions that were made at this nursing home to admit one resident in particular. This gentleman had spent time in prison for aggravated domestic abuse and had diagnoses which included Alzheimer’s, restlessness, and agitation. He had been a resident at another nearby nursing home where he had a demonstrated history of being physically aggressive.
According to the staff interviewed by the state surveyor, multiple staff members including the Director of Nursing, asked that the resident not be admitted to the nursing home, but the administrator overruled their requests and allowed him to be admitted to the nursing home.
Over the two and a half months that the resident was at the nursing home, there were multiple events where the resident at issue had been physically aggressive and had behaved in an intimidating way with other residents in his locked dementia unit. There were also incidents in which he was aggressive and threatening to staff members.
Abuse is a nursing home setting is still abuse even when it is perpetrated by one resident against another. Among the other things that must happen is that it must be reported to the State and steps be taken to prevent the recurrence of abuse. When the issue involves the resident as a perpetrator, it requires adjustment of the care plan and taking steps to discharge the resident from the facility when they cannot keep other residents safe.
Part of the issue with resident-on-resident assaults is that the a nursing home is the “home” for the resident who is the victim, and everyone, including and especially nursing home residents, deserve to feel safe in their homes. When the nursing home fails to protect other residents against an aggressor, the other residents have real cause to not feel safe in their own homes.
This string of incidents came to an end with a serious assault on a nurse. The resident had been acting aggressively and two aides summoned the nurse from another unit because the nurse who was assigned to work the locked dementia unit was running late. When the nurse arrived, he grabbed her tightly by the wrists. As she tried to calm him, she asked if he needed to use the toilet. He said yes, so she took him to the bathroom. She saw there were feces on the seat so she went to clean it off. As she was cleaning off her hands, he hit her in the face with a plastic soap bottle. He grabbed her by the hair and slammed her face into the door frame repeatedly. He grabbed her stethoscope and began to choke her with it. She lost consciousness and began to exhibit seizure-like activity. 911 was called and the nurse was taken to the hospital and the resident was removed in handcuffs.
The nurse here deserves to be treated as the hero of the story because she ended up paying a serious price for trying to keep this resident away from his fellow residents. Any one of them could just have easily been a victim of this kind of attack.
What is most striking – and chilling – about this citation are the actions of the administrator. She was the facility’s abuse coordinator, in charge of the investigating episodes of abuse and coordinating the nursing home’s response. She did not treat any of the episodes prior to the attack on the nurse as abuse because she either deemed them “behaviors,” decided that no investigation was required because of the lack of injuries, or simply failed to investigate the incidents.
Her response to the attack on this nurse deserves special examination. Someone who is the victim of that kind of attack at work deserves unwavering support, but that was not what happened to this nurse. What the nurse had to say, from the citation:
Am I in trouble? [The administrator] keeps telling me that I am the reason you are here and the facility is going to get in a lot of trouble if I tell you the truth. We have been told so many times to not chart certain things that will get us in trouble by [the administrator]. One time [the administrator] even erased the charting I did in a resident’s chart because [the administrator] said it would be too damaging to the facility. …. [The administrator] even came to the hospital ER [after the incident] and came into my room, even though I told [the administrator] not to. [The administrator] kept telling me all I had was a panic attack. I was physically assaulted. Now [the administrator] is telling me I better not tell you everything or the facility is going to be in trouble. They said you are here because of me.
This tells you almost everything you need to know about how this place is run – residents are accepted who never should be, problems being swept under the rug, and doing the right thing coming in a distant second place to what the business needs. This nurse paid the price for the way this nursing home is being run, but it could just as easily have been another resident.
There are so many poor choices that were made here for the benefit of the bottom line of the nursing home as a business. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. 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.
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