Monday, January 12, 2009

LaGrange Rehab Center Fails to Follow Procedures Following Accident

339 S. Ninth Ave. in LaGrange
FINED- April 9, 2001
LaGrange Rehab Center was fined $10,000 for failing
to ensure its staff was properly trained to provide
emergency care services for residents involved in
Responding to an incident report, Department
investigators learned that a resident, who had a
history of pacing and wandering, became entangled in
his gown and a privacy curtain and was found by staff
sitting on the floor next to his bed. The material was
wrapped around his neck, and he was not breathing. The
resident died due to strangulation.
Per record review and staff interviews, surveyors
were unable to determine what, if any, life-sustaining
measures were taken by facility staff.
Staff removed the material from the resident's neck
and checked for a pulse, but made no other assessment
of his condition. Two staff members then moved the
resident into his bed, while a third employee reported
the resident's death to a facility supervisor. One of
the employees indicated no attempt was made to
resuscitate the resident because he had a Do Not
Resuscitate (DNR) order. None of the employees
involved in this incident had cardiopulmonary
resuscitation (CPR) certification.
Facility policies and procedures for accidents and
emergency care instruct employees not to move a
resident, but to assess his condition by checking for
pulse, airway, breathing and circulation and, if the
resident is viable, to begin emergency services.
Policies also address the application of DNR orders
for residents when the incident is an unnatural
Investigators determined the three employees involved
in the incident did not follow applicable policies and
A Department-ordered plan of correction required the
facility to ensure that policies and procedures are in
place for handling medical emergencies and that staff
are properly trained to provide emergency services.

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