Thursday, July 23, 2009

Patient Asphyxiated by Bed Rails at Rest Haven Palos Heights

Rest Haven Central
13259 South Central Road, Palos Heights
Fined- August 15, 2008
Rest Haven Central was fined $20,000 for failure to supervise, assess, and monitor a resident who had been identified as high risk for falls.
The resident had demonstrated extreme agitation, particularly after nightfall. Facility staff failed to re-assess the continued need for side rails after implementation of a low bed, bed alarm, and mattress pad on the resident’s floor. As a result, the resident got her head trapped in the side rail and was asphyxiated.

Oak Park Healthcare Fails to Monitor Wandering Resident

Oak Park Healthcare Center
625 North Harlem, Oak Park
Fined- June 4, 2008
Oak Park Healthcare Center was fined $10,000 for failure to monitor a resident who was identified as a wanderer and had a history of falls.
In February of 2008, the resident managed to elope from the facility undetected. Conditions outside were cold and icy; the resident fell and was injured badly enough to require hospital emergency room admission.

Lexington of Oak Park fined for Failure to Provide Adequate Oxygen

Lexington of Orland Park
14601 South John Humphrey Drive, Orland Park
Fined- September 11, 2008
Lexington of Orland Park was fined $20,000 for failure to ensure that a resident who required continuous oxygen received it.
Despite a physician’s order that a resident receive continuous oxygen, facility staff sent the resident to a clinic appointment without oxygen. When the transport reached the clinic, the resident was found slumped over in his wheelchair and unresponsive. He was rushed to the emergency room where he coded and was subsequently revived. He died the following day.

Wednesday, July 8, 2009

The Importance of Teaching Doctors About Geriatrics

As they do every July, hospitals across America are welcoming new interns, fresh from medical school graduation. Given how much these trainees have yet to learn, common wisdom holds that it’s not a good time of year to get sick. This may be particularly true for older patients, because American medical schools require no training in geriatric medicine. [1]

This was the conclusion of a doctor and professor at Mount Sinai School of Medicine in a recent editorial in the New York Times.

Dr. Rosanne Liepzig had the courage to speak out about this serious problem. She was part of a group of doctors that recently published a report in the Journal of Academic Medicine setting forth some minimal abilities that they believe medical students should demonstrate before caring for elderly patients. The group jokingly nicknamed the report the “don’t kill granny list.”

According to Liepzig, even experienced doctors often do not appreciate the differences between a 50 year old patient and an 80 year old patient. Diseases such as pneumonia may have entirely different symptoms in a younger patient than in an elderly patient. Medication dosages for a senior may need to be 50% lower than for a patient in her 50s. The effects of lost functional mobility may also be underestimated by physicians with no training in geriatric medicine.

This gap in medical training is especially surprising given the number of geriatric patients. According to Liepzig, geriatric patients make up 48% of all inpatient hospital days and 32% of the average doctor’s workload in surgical care.

All medical students are required to have clinical experiences in pediatrics and obstetrics, even though after they graduate most will never treat a child or deliver a baby. Yet there is no requirement for any clinical training in geriatrics….” [2]

Liepzig also points out that Medicare contributes more than $8 billion dollars a year to support residency training, yet it does not require that part of that training focus on geriatrics. [3]

The Institute of Medicine reached similar conclusions in their 2008 report titled “Retooling for an Aging America.” That report concluded that all licensed health care professionals should be required to demonstrate competence in the care of older adults.

There is no question that our population is aging. The only question is when the medical establishment will start training doctors to care for them.

You can read the full text of Dr. Leipzig’s article at

[1] The Patients Doctors Don’t Know. OpEd by Dr. Rosanne Leipzig. July 1, 2009. New York Times.
[2] The Patients Doctors Don’t Know. OpEd by Dr. Rosanne Leipzig. July 1, 2009. New York Times.
[3] The Patients Doctors Don’t Know. OpEd by Dr. Rosanne Leipzig. July 1, 2009. New York Times.

Wednesday, July 1, 2009

Regal Health Center Fined for Failing to Correct Problems with Pressure Sores

Fined- September 2, 2008
Regal Health and Rehab Center was fined $100,000 for failure to address the Plan of Correction after the March 2008 violation.
As before, surveyors determined that the facility failed to accurately assess and document all pressure sores, failed to consult with a physician regarding sores, and failed to treat observed pressure sores.
As a result, one resident was hospitalized with uncontrollable bleeding from a pressure sore wound, and another resident developed 10 pressure sores during his time in the facility and was hospitalized with a diagnosis of sepsis. A third resident died from a pressure sore that led to sepsis. A fourth resident was admitted to the facility with no wounds. Within three months, she acquired four pressure sores that became worse until she was hospitalized with dehydration and failure to thrive.

Regal Health Center Fined for Improper Treatment of Bed Sores

Regal Health and Rehab Center
9525 South Mayfield, Oak Lawn
Fined- March 24, 2008
Regal Health and Rehab Center was fined $30,000 for failure to follow through on facility policy regarding prevention of and treatment for pressure sores.
The failure was broad enough to be considered systemic. Based on observation, record review and staff interview, surveyors determined that the facility failed to identify new and recurrent pressure sores, failed to treat existing sores with current treatment orders, failed to provide preventative measures, failed to accurately asses and plan care for residents identified with or at risk for pressure sores, and failed to notify the physician of positive wound culture results.