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Assisted-living patient dies because of filing error at facility

An assisted-living home resident was accidentally deprived of life-saving CPR in a shocking case ofnursing home negligence earlier this year.

Why was the man deprived of CPR? The answer: a filing error.

Families in Illinois who place loved ones in nursing homes and other assisted-living facilities might certainly be worried about abuse or incidents of neglect resulting from inadequate staffing. But something as seemingly minor as misplacing a file can have tragic consequences when it comes to nursing home care. Patients suffer from unique disorders and illnesses, requiring unique care and treatment.

The incident, which occurred on March 27, is now being blamed on the facility’s management organization in Minnesota. After investigating the patient’s death, it was determined that the organization was at fault because it kept disorganized records, ultimately contributing to the resident’s wrongful death.

Staffers had confused the man with another patient, according to a report that was released earlier this month. Workers had thought that the man was subject to a do-not-resuscitate (DNR) order, but he was not. The confusion stemmed from the fact that all patients’ DNR orders were held in a single binder. The facility has since changed its practices, putting each patient’s individual documentation in separate binders in order to prevent and avoid mixing up patients’ DNR orders and other important information.

According to reports, the man had been coughing in his room at night, and staffers quickly called 911. Emergency responders said that CPR would be required to revive the patient, but the facility’s employees told rescue crews that the man had a DNR order on file. The man died without ever reaching the ambulance.

He had been in the home since 2010 to receive care for a kidney condition and high blood pressure.

The facility’s management organization has accepted a formal plan to correct the problems that led to the patient’s death. The organization does operate assisted-living facilities in several other states.

Source: Star Tribune, “Report: Filing error brought fatal halt to CPR on group home resident,” Paul Walsh, June 13, 2012


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