Nursing Homes Abuse Blog - By Jonathan Rosenfeld

A pattern of disturbing events involving patient care has proved to be enough for officials at the Illinois Department of Health (IDPH) to revoke the license of Hillcrest Nursing and Rehabilitation Center in Joliet, IL.

The Chicago Tribune reported that on April 11th authorities from IDPH sent notice to the corporate offices of Hillcrest that the facilities licence was  to be revoked effective May 11th.  

Hillcrest Nursing Home has been the focus of a series of disturbing events involving patient care during the past several years.  However, inspections conducted at the facility over the past year clearly depict a facility that has little regard for patient safety and well being.  

Two episodes involving suspicious deaths at the Joliet nursing home have proved to be simply too concerning for Illinois officials to overlook.  In particular, a patient died in a January 23rd incident in which the patient apparently strangled herself with a coaxial cable.  An investigation into the incident revealed that staff who were to be supervising did not detect the situation because they did not enter patient rooms.  Equally disturbing were the multiple pieces of drug paraphrenia found in the patient's room.

Another patient death in the past year caught the attention of authorities when a 37-year-old patient at Hillcrest died as a result of "anti-depressant intoxication" from several medications that she was prescribed.  Like the incident above, an investigation into the incident was made essentially impossible as authorities discovered a lack of paperwork documenting the how or when the patient's medication was administered.  Further, authorities learned that staff at the facility destroyed unused narcotic medication in a very unconventional manner-- by dousing the medication with Coca-Cola and pouring it down the toilet.

As a nursing home lawyer who commonly sees patterns of patient injury and death involving certain facilities, I applaud the decisive action taken by IDPH authorities.  While the license revocation will no doubt pose a source of stress and inconvenience for patients, actions such as this are indeed in the best interest of both current patients as well as others whom may have been considering this facility for their skilled nursing needs.

Take a look at recent Hillcrest nursing home surveys via the IPDH site here.

Related Nursing Homes Abuse Blog Entries:

Enough Is Enough. Recently Filed Illinois Nursing Home Lawsuit Highlights The Problems That Accompany 'Difficult' Residents

Morphine Overdose Of Patient Initiates A Lawsuit Against Doctor & Nursing Home

Terms To Better Understand Your Nursing Home

(Photo Caption: A feeding tube error at the Momence Meadows Nursing Home cost a male resident his life.)

During the night of September 19, 2011, a nurse at the Momence Meadows Nursing & Rehab Center in Momence, IL made a fatal mistake. Instead of inserting a feeding tube into a resident’s stomach, the nurse inserted a catheter. The nursing error caused the patient to go into septic shock, and to die in a hospital early the next morning.

While a one-time error might be ultimately pardoned (after, of course, termination and severe reprimanding), the circumstances leading up to “Resident #1’s” death are hardly forgivable. An Illinois Health Department survey conducted on October 18, 2011 noted that “Resident #1’s” feeding tube had come out twice already in two months. And that the nurse who inserted the catheter fell asleep after her mistake.

The night shift nurse inserted a urinary catheter...but reported the wrong resident’s name,” the survey said. The facility discharged the nurse for sleeping on the job and for poor quality of work.

The survey went on to report that the no one bothered to describe why the tube had dislodged on either of the two previous occasions.

All three times when the resident’s tube came out, there was no documentation to indicate what time and why the tube come out or how long it took for its re-insertion, the survey said.

The home’s failure to implement a comprehensive feeding tube policy was one of a multitude of federal violations accrued over the past three years. According to surveys, Momence Meadows also failed to:

• Properly treat residents’ late-stage bed sores
• Keep timely medical records
• Assist residents with basic needs of daily living
• Control infections and enforce hand-washing procedures among staff
• Report suspicious bruises on a 78-year-old resident suffering from Alzheimer’s

Momence Meadows earned just one out of five possible stars on Medicare’s “Nursing Home Compare” Web site. It was particularly lagging in the area of staffing, where it was also given just one star. Momence Meadows logged just 20 minutes of RN time per resident, per day; versus the national and stage averages of 42 minutes.

The smiling seniors on Momence Meadows’ Web site seem bitterly at odds with the daily reality of residents at this troubled home.

Please note: A Nursing Homes Abuse Blog investigation revealed that the owners of Momence Meadows, Michael Blisko and Moishe Gubin, have been linked to several other out-of-compliance nursing homes in the Chicago area. They include:

• Ambassador Nursing & Rehab Center - Chicago, IL
• Belhaven Nursing & Rehab Center - Chicago, IL
• Central Nursing & Rehab Center - Chicago, IL
• Continental Nursing & Rehab Center - Chicago, IL
• Niles Nursing & Rehab Center - Niles, IL
• Northlake Nursing & Rehab Center - Merrillville, IN
• Parkshore Estates Nursing & Rehab Center - Chicago, IL
• Southpoint Nursing & Rehab Center - Chicago, IL
• West Suburban Nursing & Rehab Center - Chicago, IL

If you have a family member at Momence Meadows or any of the other Illinois Nursing homes discussed in this entry and are concerned about their care, we invite you to speak to out nursing home lawyers for a free legal consultation without charge or obligation.

Related Nursing Homes Abuse Blog Entries:

Nursing Home Fined For Poor Care of Patients With Feeding Tubes

Improperly Placed Feeding Tube Results In Systemic Infection of Disabled Nursing Home Patient

Improperly Placed Feeding Tube Results in Death of Nursing Hope Patient

First Quarter 2009 Illinois Nursing Home Violators Released

While nursing homes are indeed medical facilities that have a duty to care for their patients medical needs, I am always dumbfounded by the number of errors that seem to get routinely made--- many of which have nothing to do with specialized medical skills--- just a lack of plain common sense.  

In my minds eye, what frequently puts nursing home errors into a different stratosphere in terms of severity is that many of the errors fail to get detected over an extended period of time and that the victims are people who are already at risk for harm.

Call it poor judgment, carelessness or if you're feeling blunt--- just plain stupidity, an episode of involving a relatively foolish event at an Illinois Nursing Home has once again resulted in tragedy to an elderly patient who suffered from the staff members' failure to perceive the error.

The incident now forms the basis of a nursing home negligence lawsuit in St. Clair County Circuit Court.  As reported in the Madison St. Clair Record, the family of a now deceased nursing home patient has initiated legal proceedings against the facility where she was a patient as well as a medical device manufacturer in relation to an event in which liquid oxygen caused frostbite to the face of an elderly patient.

While the medical device manufacturer may have been negligent in the how the oxygen canister was designed and delivered to the facility, responsibility for the incident has also been assigned to staff at the nursing home who failed to supervise the administration of the oxygen necessary for breathing and take corrective measures when staff acknowledged seeing "a cloud of white vapor" around the patients face.  

In a situation like this, it certainly sounds as though there's more than enough blame to be spread around to the different players, however what continues to astound me is how many nursing home staff members simply go about their task without any questioning if the work that they are doing is actually helping the patient or is even being correctly done. 

More emphasis needs to be placed upon identifying problems as they arise in the nursing home population.  Hopefully, teaching employees to think as opposed to just do, do, do could nip some of these foolish errors quickly before they become a sad situation involving harm or death of others.

Related Nursing Homes Abuse Blog Entries:

Did Nursing Home Patient Commit Suicide With Supplies Left In His Room?

Even The Most Mundane Parts Of A Nursing Home Can Turn Deadly Without Proper Staff Supervision

Nursing Home Workers Charged In Connection To Withholding Oxygen To Resident

Resident Who Smoked & Used Oxygen Suspected Of Causing Fire At Assisted Living Facility

A glaring oversight in current nursing home legislation impacting the State of Illinois may soon be rectified under a proposal under consideration by a legislative panel.  Today, the legislative panel will vote on regulating the minimum amount of daily care each nursing home resident in the state receives from registered nurses (RN's).

Under the present staffing requirements in Illinois, nursing homes are only obligated to provide patients with 2 hours, 42 minutes of care each day.  Further, while the law is specific concerning the staffing requirements for nursing home patients, there is little guidance as to the whom is to provide the care.  The sole parameter in place concerning credentialing of nursing home staff is that each facility must have an RN at the facility for at least eight hours per day.

Likely as a cost-cutting measure, many Illinois nursing homes rarely provided RN staffing beyond what they are obligated to do to comply with the present law.  Significantly, a recent Chicago Tribune article "State panel to vote on new nursing rule at nursing homes" cites a trend among Illinois nursing homes to continually reduce the care that patients receive from registered nurses.  According to staffing data, 17% of Illinois Nursing Homes have reduced the time RN's spend with patients by at least 10% over the last six months.

If passed, the new proposal would gradually increase the amount of direct care registered nurses provide to each patient in Illinois Nursing Homes to at least 46 minutes per day by 2014.

From a quality of care perspective, I'm happy to see that Illinois lawmakers are finally recognizing that for the majority of nursing homes in the state, there is little independent initiative to provide any staffing beyond what is necessary to comply with the law.  Considering that many nursing home quality experts believe that RN staffing levels is the number one factor in determining the quality of care patients' receive at each facility, there is no doubt that the time has indeed come for this important quality measure to be implemented.

Related Nursing Homes Abuse Blog Entries:

Trouble At Chicago Nursing Home Caring For Minorities

Learning About Your Nursing Home: Medicare Ratings- Part 1

Take This Job & Shove It! Disturbing Insights Concerning Working Conditions At Large Nursing Home Chain

Under-Staffing At Nursing Homes: When There's Simply Not Enough Staff To Protect Patients From Harm

While the above information can must be accessed by each facility individually, I would suggest that the webmasters begin to consider making this information accessible on one page (like we did below) to make the comparison of nursing home a bit easier--- as opposed to flip-flopping back and forth.

For explanation purposes, we have collaborated all of the above information on ManorCare facilities in Illinois into the chart below.

For all the volumes of statutes on the books in the State of Illinois, there is a glowing vacancy when it comes to legislation to help protect our elders--- and specifically nursing home patients.  Call it a mere oversight if you wish, but much of the current legislation fails to address problems frequently encountered by individuals and families who have been abused or neglected in the states 1,000+ skilled nursing facilities.

Recognizing the litany of problems nursing home patients face when facilities go under-staffing, Illinois State Rep. Kelly Cassidy (D-Chicago) has introduced a new piece of legislation (HB 5668) to provide more guidance as to how skilled nursing facilities in Illinois need to be staffed.

Building upon existing states laws, Rep. Cassidy's proposed legislation would promote the following issues:

1. Mandatory incident and violation reporting

Resident deaths, abuse, neglect or unusual incidents must be immediately reported to the Illinois Department of Public Health (IDPH), even if a resident does not die at the facility. Death reports must now include disclosure of medication errors or other incidents, and other violations must be reported to a resident’s next of kin or guardian.

Inspection violations must be disclosed to affected residents and their next of kin or guardian.

2. Requirements for treating mentally ill resident

Psychotropic medications can only be administered to objecting residents with a court order. Psychotropic medications may be administered to non-objecting residents incapable of giving informed consent.

IDPH may write rules on assignment of female residents to female-only units, which may be staffed only by female staff.

A psychiatric services rehabilitation coordinator (PSRC) must be available on call whenever there is no PSRC in the facility.

3. Resident advocacy

The Long-Term Care Ombudsman program will represent all long-term care facility residents, not just elderly residents, and increase staffing ratios so there is one ombudsman for every 3,500 licensed or approved beds served by the program by June 1, 2013, and one ombudsman for every 2,000 beds by June 1, 2014.

The state will make information clearly available to the public through electronic access to complete, near-current information on inspections and enforcement; information about facility staffing; and a database of the Consumer Choice Information Reports.

4. Consistent assignment

Staffing requirements will require that the same direct care staff stays assigned to the same residents, to the extent possible. There is an exemption if direct care staff request reassignment.

5. Mandatory liability insurance

All nursing facilities must maintain insurance against risks from neglect of a resident in an amount of at least $1 million per occurrence.

IDPH may deny a license application if the applicant does not have proof of liability insurance, and may suspend, revoke, or refuse to renew a license if the facility fails to maintain its liability insurance.

6. Certificate Of Need requirements

Nursing facility changes of ownership will now require a Certificate Of Need (CON) permit from the Health Facilities and Services Review Board.

A permit for change of ownership of a nursing facility with recent, serious violations will require a plan from the new owner detailing how the facility will remain in compliance. Facilities that do not follow such a plan will be subject to fines.

A nursing facility CON permit may be denied based on additional factors in operator history: insufficient staffing; repeated serious (AA) violations; failure to pay violations fines; termination of Medicare or Medicaid; lack of properly-credentialed administrator; or other “substantial failure” to follow licensing acts in the previous 5 years.

7. State Police training

Requires facility cooperation with State Police to train facility staff on preventing resident abuse and neglect.

8. Home Office Cost ReportsRequires the submission of home office cost reports to the state, by all “chain organization” facilities

Requires the public, online posting of several reports, including “home office cost report,” “facility cost report,” and “Consumer Choice report.”

9. Increased training

Increases training requirements for nursing homes, facilities for developmentally disabled, and Specialized Mental Health Rehabilitation facilities.

Increases minimum age and education requirement for Certified Nurse Assistants (CNAs) from 16 to 18 years, and from an 8th grade to a 10th grade education

As Chicago nursing home lawyers, we are grateful to see a lawmaker going to bat for nursing home patients across the state of Illinois.  Sadly, the provisions of this bill are rarely considered by patients or their families until a nursing home injury or death has occurred.  We will closely monitor Rep. Cassidy's nursing home legislation as the bill proceeds though the revisionary process.

Related Nursing Homes Abuse Blog entries:

Nursing Home Staff: Does Your Facility Love You? If So, They Would Properly Insure You.

Support Mandatory Nursing Home Insurance

Illinois Bill Seeks to Give Families Easier Access to Medical Records

Many Illinois Nursing Homes may soon be stepping upon some new wealth under a recently devised tax-plan that that is intended to provide for an increase in the number of state nursing home surveyors and increased staff at troubled facilities.  By taking advantage of a Federal Government matching-fund program, the program is expected to provide $145 million in new funding for nursing homes in Illinois.

According to a report on the program in The Republic, Illinois officials have allocated $20 million for purposes of hiring 160 new nursing home surveyors and the balance of the funds will be put towards the state's Medicaid program for indigent nursing home patients.

Because much of the funding provided the program is derived from taxes on daily nursing home rates paid by non-Medicare patients, some critics view the program as little more than a tax on the wealthy to distribute funds to facilities that primarily care for the poor. 

As a nursing home lawyer, I can certainly appreciate these the re-allocation-of-funds arguments as directed to the increase in funds allotted to Medicaid facilities.  However, I think that the substantial boost in the number of nursing home surveyors across the state will be beneficial for all nursing home patients in Illinois.  Hopefully, the influx of nursing home surveyors will allow incidents involving patient injury and abuse to be properly investigated in a timely manner so the responsible parties can be properly identified.

Related Nursing Homes Abuse Blog Entries:

Ohio Nursing Homes Forced to Shed 2,800 Jobs; Gov't Budget Cuts to Blame

Will Steep Reimbursement Cuts To Nursing Homes Jeopardize Patient Care?

It's Time To Yank Federal Funding From Dangerous Nursing Homes

Study Demonstrates Nursing Home Workers Earn Less Than Minimum Wage

One of the most frequent claims I hear from nursing homes and hospitals concerning pending litigation is how the lawsuits are simply isolated events and are not really indicative of the type of care that they provide to their patients.  

While such claims may indeed be very true at some facilities, the reality remains that rarely do facilities have their inferior care targeted upon one patient.  Rather, I tend to see patterns of poor care and mistakes scattered amongst multiple patients at a facility.

I recently read an disturbing article concerning the history of dangerous care provided to patients at Heartland of Charleston Nursing Home in West Virginia.  The facility (which happens to be part of nursing home giant ManorCare) has received a good deal of negative publicity in the past few months after the family of a neglected patient received a monumental $90.5 million verdict in compensatory and punitive damages for the dehydration death of their loved one.

While verdicts on the scale of the Heartland case are fairly rare, Zac Taylor of the West Virginia Gazette uncovered a fairly extensive list of problems at the facility that makes it appear as though patients--- past and present-- may be similarly mistreated.  

When analyzing inspection reports from the Heartland facility over the past several years, recurring patient safety problems and sanctions including:

• A resident, labeled as a fall risk, was found face down on the floor six hours after she was admitted. Nurse's aides had placed a fall mat on one side of the woman's bed. She would have struck a tile floor had she rolled off the other side, the report states.
• One resident had an unnecessary catheter for more than two months, while two more residents were not given proper treatment after doctors had declared them incontinent. The inspector found that one of those residents had been sleeping on a bed with a large wet ring stretching across the bottom sheet.
• Some residents were taking medications they did not need. According to the report, nurses continued to give one resident "sliding scale" insulin doses despite a pharmacist's recommendation to stop. The pharmacist noted that the resident's blood sugars were in "excellent control, " and detailed the facility's need to closely monitor the resident's future insulin intake. Staff had not checked the resident's hemoglobin levels in months, according to the report.
• Nurses found one resident on the floor at least five times in two months. In January, the elderly patient fell twice in a span of about 12 hours. Staff labeled some of the falls as "attention-seeking behaviors," according to the inspector's notes.
• Inspectors found that the home's medications were not properly labeled.
• One resident lost seven pounds in three days because staff had failed to provide dietary supplements a doctor had prescribed.
• A resident with a right hand muscle contracture (a permanent shortening of a muscle or joint) was not fitted with a device designed to help minimize the loss of range of motion. The resident's care plan noted a need for the device in February -- four months before the June inspection.
• Nursing staff took 10 to 20 minutes to answer several residents' call lights.
• One nurse's aide was fired after intentionally unplugging a resident's call light. Administrators did not report the incident to Adult Protective Services within the required time frame.
• Since 2006, federal authorities revoked Heartland's medicare funding three different times and imposed $232,375 in fines related to violations

We will likely hear much more about the Heartland verdict in the coming months and years as the case goes though the appeals process.   For the average nursing home patient and their family, this verdict should serve as a reminder that there may be similar stories of inferior care and neglect behind the headline grabbing reports.  As caregivers, it is important to fully investigate such claims....because they just might be true.

Related Nursing Homes Abuse Blog Entries:

Jury Blames Manor Care Nursing Home For Dehydration Death Of Patient

What's In A Name? Are Large Nursing Home Chains Intentionally Attempting To Deceive The Public When It Comes To Corporate Ownership?

Nursing Home Negligence Lawsuit Filed After Man Wandered From West Virginia Facility

Big Verdicts Against Nursing Homes

We’ve had a lot of discussion regarding the sizable nursing home negligence verdict in West Virginia against Heartland of Charleston and the parent company HCR Manor Care.  If you haven’t heard about this landmark nursing home verdict, jurors awarded $91.5 million to the family of a patient at the facility who died shortly after her admission to the facility from complications related to dehydration and pressure sores.

After unsuccessfully arguing that the verdict should be reduced based upon West Virginia’s caps on non-economic damages in medical malpractice cases, lawyers for the nursing home behemoth have now taken a position that a judge should substantially reduce the verdict or order a new trial based upon errors made during the course of the original trial.

In particular, lawyers for Manor Care claim that the company is a far less profitable organization than was alleged at trial by lawyers representing the patient’s family when seeking punitive damages. 

Unlike compensatory damages that are intended to compensate an individual or grieving family for their loss, punitive damages are literally intended to punish the company for its conduct.  In order assure that a reasonable punishment is imposed, most jurisdictions allow the jury to take into account the companies profitability—so theoretically, an commensurately appropriate punishment could be imposed against a mega corporation or small business.

In the Manor Care trial, lawyers claim that the $4 billion that the company was alleged to have pocketed in annual profits was merely its gross revenue and the real income was approximately $75 million.

While the actual amount of the Manor Care’s profits may appear to be an inconsequential mathematical exercise, the issue does highlight the complexity of many nursing home operations and the difficulty in understanding the financial structure behind many facilities.

Nursing home operators routinely have multiple derivative companies that may be responsible for the operation of the facility, the real estate that the facility sits on and staffing at the facility.  While the entities may look to be independent, a closer examination can typically reveal that they are essentially the same with individuals holding positions at the allegedly separate companies.

Albeit on a massive level, the real profitability of Manor Care’s operations should be examined by a forensic accountant to determine the path of funds that the company pulls in and where the money goes.  Given the large discrepancy between the alleged profits in this matter, I suspect that there is a lot more to this situation than is readily apparent.

Related:

Nursing home's earnings misrepresented during trial, lawyers argue, WVgazette.com November 6, 2011

$5 Million In Punitive Damages Awarded To Widow In Bed Sore Case Against Nursing Home & Hospital

New York Jury Punishes Nursing Home Where Man Develops More Than 20 Bed Sores

Nursing Home Injury Laws: West Virginia

Even with a long history of serious patient safety violations, Columbus Manor Residential Care Home on Chicago's West-side, continues to keep its doors open.  Primarily a Medicaid (state) funded facility, Columbus Manor's owners have fought tooth and nail to keep the facility in operation in spite of threats of funding termination for non-compliance with safety measures.

The communities, Austin Talks website, recently discussed how even with a series of uncorrected violations accumulated during inspections from The Illinois Department of Health over the summer months, Columbus Manor manages to remain open--- long after it would appear to be permitted to do so under under the terms of the Medicaid program.  

Nonetheless, Columbus Manor continues to apply for and receive 'waivers' from the state that extend the time allowed to correct various violations.  

In fact, Columbus Manor Res Care Home has accumulated more than their fair share of health deficiencies discovered during various inspections at the facility.  According to Medicare Nursing Home Compare, Columbus Manor has received 47 citations within a 14-month period (5/2010 through 7/2011).  Many of the cited violations are deemed to pose "immediate jeopardy to resident health or safety" or were already acknowledged for causing "actual harm".

Survey findings have acknowledged that Columbus Manor has failed to do the following during one or more surveys:

• Hire only people who have not legal history of abusing, neglecting or mistreating residents
• Report and investigate any acts or reports of reports of abuse, neglect or mistreatment of residents
• Protect each resident from all abuse, physical punishment, and being separated from others
• Protect residents from mistreatment, neglect and/or theft of their personal property
• Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
• Give each resident care and services to get or keep them healthy and prevent dehydration
• Make sure that the nursing home area is free of dangers that cause accidents
• Administer care to each patient in a way that leads to the highest possible level of well being for each resident
• Keeping a group of people to review and ensure quality 

While state and federal agencies evaluate the legal aspects of Columbus Manor's ongoing operation, it is important for families to acknowledge this facilities past problems and remain committed to protecting their loved ones currently at the facility.  Should an incident occur, it is crucial to both obtain medical care and to contact the state's department of health so the incident can be properly investigated. 

In addition, many incidents and injuries may give rise to a civil claim for damages against the facility.  Should you chose to explore your legal options, Rosenfeld Injury Lawyers has experience investigating and litigating nursing home negligence cases.  Our legal consultations remain free and confidential.

Related Nursing Homes Abuse Blog Entries:

Illinois Nursing Homes Continue To Rack Up Fines In 3rd Quarter Of 2010

More Detailed Nursing Home Information Now Available Online

New Government Report Demonstrates Alarming Number Of Criminals Caring For Elderly In Nursing Homes

Ongoing Nursing Home Abuse Results In Closure Of Dangerous Facility

On November 5, 2010, the Illinois Department of Health issued a “Type A” violation and fine of $6,520 against the Chateau Nursing and Rehab center in Willowbrook, IL. The fine was one of several recent warning signs that something at Chateau is seriously amiss.

According to an August, 2010 survey from the Illinois Department of Health, 27 residents had complaints about mistreatment. These included:

A 90-page survey filed in September 2010 by the Illinois Health Department depicts Plaza Nursing & Rehab Center in Midlothian, IL as a chaotic place with little regard for residents’ safety and quality of life [Plaza Nursing and Rehab Center (pdf)] . In particular, Plaza failed to make shower and toilet areas safe for residents, which led to many unsupervised and life-threatening falls.  According to the survey, at least nine residents suffered injurious falls.

In addition to violating patients’ right to a safe and supervised environment, Plaza  staff were also guilty of:

• Keeping water temperatures in bathrooms scalding hot
• Accepting money from patients who asked to do them “favors”
• Closing the patient smoking room without first notifying patients, and without providing an alternative spot
• Failing to clean up dangerous pooling water adjacent to bathtubs
• Serving food in an unsanitary environment, with flies
• Administering injections without first pulling patients’ privacy curtains

Reading through the report, it’s clear that staff at this 91-bed facility are frequently overwhelmed, and don’t have the capacity to treat patients who require specialized care. It’s also clear that a strong undercurrent of abuse is happening at Plaza. According to the survey, “an anonymous note was found on the floor of the administrator, which said that one of the nurses was abusing residents in the facility.”

Reports of suspicious bruises and scratches were common throughout the report, as were complaints of nurses being “rough” with residents. One suspicious incident described a man who tipped out of his wheelchair on facility grounds. The reason for the incident remains murky.

“Nothing addresses how the wheelchair became in disrepair, nor what regular maintenance, including monitoring, the staff will do to prevent it from happening again,” the survey said.

Along with unacceptable behavior from nurses, certain unstable residents who were admitted posed direct threats to other residents. In January of 2010, one resident pushed another resident because “he was frustrated that he could not get the other resident to move out of his way.” The resident who instigated the fight had a history of psychological problems, including bipolar disorder. At least two of the home’s 80 residents had schizophrenia, according to the survey.

Medicare, on its Nursing Home Compare Web site, gave Plaza one star out of a possible five. As a result of the findings in the Health Department survey, Plaza was fined $10,000 in the area of nursing.

If you believe a loved one was mistreated or abused at Plaza Health & Rehab, we would honor the opportunity to speak with you. All of our consultations are free and completely confidential.

Related Nursing Homes Abuse Blog Entries:

First Quarter 2010 Illinois Nursing Home Violations Released

Third Quarter Illinois Nursing Home Violators

53 Illinois Nursing Homes Cited In 2009- 2nd Quarter Violations

For the past several years, I've always highlight some of the Illinois nursing homes represented on the listing of Quarterly violators published by the Illinois Department of Health.  While it may be logistically impossible to investigate every incident involving a nursing home injury, I look at the list of quarterly violations as a snippet of the type of care provided to residents throughout the state of Illinois.

For families and patients seeking information on particular facilities, reviewing the facilities on the quarterly violations is also important as certain facilities tend to appear more frequently than others.  Depending upon the type of violation and if a 'response' is filed by the facility, you may further be able to access a link to the survey with specific information related to the incident or finding.

In particular, when looking at through the recently published findings, there was a fairly steep decline both in the number of facilities cited and the monetary amount of fines imposed.  While we can look at these figures and assume that care is improving at nursing homes throughout Illinois, I think its too early to make that call.  Ever the optimist, we will have to see if indeed this trend can continue when the next quarter's findings are released. 

Related Nursing Homes Abuse Blog Entries:

Illinois Nursing Homes With Second Quarter 2010 Violations

42 Illinois Nursing Homes Cited In 4th Quarter of 2009 For Violations Related To Patient Care

Nursing Home Spotlight: Kenwood Healthcare Center, Chicago, IL

ManorCare Nursing Homes In Chicago: How Does Your Facility Compare?

When it comes to the prevention of decubitus uclers, it very much is a collective responsibility of all parties involved. As opposed to other medical complications that can be traced to the poor care or decision making of one person, situations where a person has developed decubitus ulcers during a nursing home admission are generally reflective of an entire facility poorly doing their job.

After all, when decubitus ulcers develop and progress over time, numerous staff members were (or should be) theoretically in a position to implement changes in the patients care-- or at the very least bring the condition to the attention of other staff.

Recognizing the importance of a team approach to the care and prevention of decubitus ulcer (similarly referred to as: pressure ulcer, pressure sore or bed sore), a recently filed bed sore lawsuit seeks damages from the nursing home itself, the management company and the staff physician.  An Illinois woman's family alleges the following omissions:

Virgil Calvert Nursing and Rehabilitation Center

• Failed to supervise patient
• Failed to provide necessary care and services for patient to maintain body weight and protein levels
• Failed to provide treatment for complications such as a urinary tract infection
• Failed to maintain proper medical records for the patient

SW Management Company

• Failed to properly manage the nursing home
• Failed to provide sufficient levels of sufficient care

Dr. Basga Bernard

• Failed to provide adequate medical treatment
• Failed to send patient to the hospital
• Failed to order proper diagnostic tests to diagnose the underlying medical problems

Particularly, when we are dealing with a situation involving general neglect at a nursing home, I find it particularly important to name all of the potentially responsible parties in order to fully protect my clients.  As this nursing home lawsuit progresses through the litigation process, it certainly will be interesting to see who exactly is to blame for the the death of this patient.

Read more about this pending bed sore lawsuit against an Illinois nursing home here.

Related:

Lawsuit alleges nursing home neglect contributed to patient’s decubitus ulcers

ManorCare Named In Wrongful Death Lawsuit After Patient Developes Pressure Sores During Nursing Home Admission

What are nursing homes required to do to prevent bed sores?

It's no secret that privately operated, "for-profit" nursing homes tend to provide inferior care and have higher rates of deficiencies that their "non-profit" peers, yet a Chicagoland community is set to possibilily turn over the operation of a long-time nursing home to a private company. 

Citing the financial burden of providing quality patient care within the standardized medicare reimbursement rates, Lake County has summoned a panel of experts to an advisory board to help determine if the county should shift operation of the long-standing Winchester House in Libertyville, IL to a private nursing home operator.

Advisory board chairman, Ric Olson seems to have made up his mind:

Based on these modes, combined with the overall volatility and uncertainly presently existing within the senior living environment, the advisory board believes that the most efficient and effective way to continue to provide skilled-nursing services is to solicit bids from the most qualified firms specializing in operating skilled-nursing facilities.

Opening its doors in 1847 Winchester House has the capacity to provide long-term care for up to 360 patients.  Like many nursing homes, Winchester House caters to patients with diverse medical needs.  Winchester provides: twenty-four hour skilled nursing care, intermediate care, a rehabilitation department, occupational and speech therapy and specialized care for patients with Alzheimer’s Disease.

Certianly, I would think that the patients and their families should have a say in how this facility is operated.  Even though things don't appear to be exactly perfect at Winchester House (see Medicare's rating of the facility), I fear that once a this facility becomes privitized as is operated as a profitable entity care levels will diminish even further.

Related:

Illinois Nursing Home Settles Lawsuit Involving Multiple Falls Of Resident

More Care Options for Seniors Leaves Some Nursing Home Operators Crying Poor

Not All Non-Profit Nursing Homes Operate Under With Patients Best Interest In Mind

Given the circumstances, it's not terribly surprising that many nursing home negligence cases involve similar fact patterns and types of injuries.  Perhaps one of the most common fact patterns involves patients who sustain hip fractures after falling at a facility. Particularly in the elderly, falls and hip fractures can be particularly difficult given that many will face a long and painful road to recovery in addition to a loss of independence.

These commonly encountered facts were once again form the grounds of a recently filed nursing home negligence lawsuit filed against an Illinois Nursing Home.  The lawsuit initiated by the patients son, alleges that Walnut Grove Village's failure to supervise his elderly mother resulted her fall and subsequent hip fracture that required surgery.

The nursing home lawsuit further alleges that Walnut Grove Manor Nursing Home compounded the elderly woman's problems when they failed to properly care for her following the surgery which resulted in her developing medical complications and bed sores.

According to news reports of the lawsuit, the facilities failure to provide post-surgical care resulted in the development of a decubitus ulcer on her heel which required hospitalization and surgery.

Sadly, like many nursing home patients who sustain a hip fracture and decubitus ulcers, the ensuing complications claimed the patient's life.

Knowing the real risk of a substantial problems encountered by elderly patients involved in falls, nursing home must remain diligent in terms of prevent falls from initially occurring.  Common fall precautions typically includes:

• Providing adequate assistance during transfers
• Assessing each patients 'fall risk'
• Clearing floors of debris 
• Reducing medication usage
• Encouraging patients to wear shoes instead of socks
• Educating staff on proper methods to assist patients

Related:

Some Medical Conditions Virtually Guarantee Elderly Of Falls In Nursing Homes

Medical Facilities Are Not Doing Enough To Prevent Pressure Ulcers On Patients' Heels

Man files lawsuit against Walnut Grove, Morris Daily Herald April 21, 2011

Study Links Commonly Prescribed Osteoporosis Drugs To An Increase In Hip Fractures

I immediately envisioned scenes from a movie depicting a jail house escape, when I read a disheartening article about a man who recently died while using his bed sheets to escape from a Chicago nursing home.  The Chicago Sun Times is reporting that a 57-year-old patient at Woodbridge Nursing Home recently fell 10-20 feet to his death as he attempted to escape from an upper floor window at the facility.

As Chicago Police investigate this incident, situations such as this are a continuous reminder that many nursing home patients require continual monitoring by staff to evaluate both their physical and psychological well-being.

Though I have no knowledge about this incident, I have worked on a number of cases where patients have caused serious harm to themselves via self-inflicted injuries.  While these cases are indeed sad for all involved, many times I find that the facility itself never took into account any of the verbal and non-verbal cues in the days, weeks and months leading to a serious incident. Certainly, I hope authorities take the necessary time to investigate all aspects of this nursing home tragedy.

Related:

Citation Issued Against Nursing Home That Failed To Intervene In Patient Suicide

Man Falls From Fourth Floor Window To His Death At Alden Nursing Home

Nursing Home Fails To Intervene In Case Involving Dementia Patient With A Known Suicidal Propensity

Chicago Nursing Home Cited For Multiple Violations Following Drowning Death Of Patient

53 Illinois Nursing Homes Cited In 2009- 2nd Quarter Violations

One of the best websites around for accessing valuable information about your particular nursing home is Medicare's Nursing Home Compare site.  Quickly, you can access information about: the overall stared rating of the the facility, number of inspections, number of deficiencies, staffing levels and fire safety violations.  Moreover, you can importantly access information on specific facilities by geographic location.

Below, I've assembled information from the Medicare site regarding Alden Nursing Homes in the Chicagoland area.

Related Nursing Homes Abuse Blog Entries:

Man Falls From Fourth Floor Window To His Death At Alden Nursing Home

Even After Repeated Tragedies, Alden Wentworth Nursing Home Refuses To Hire Additional Staff To Assist Patients

Nursing Home Spotlight: Alden Town Manor

Illinois Nursing Homes Continue To Rack Up Fines In 3rd Quarter Of 2010

Some days my law office gets bombarded with inquires from families wanting to know nothing more than if the facility they are considering placing their loved one in has been sued before.

After all, if a facility has been repeatedly sued, do you really want your family member there?

Though I am familiar with the litigation history at some facilities--- and certainly don't mind sharing my knowledge-- I usually direct the families towards the local courthouse-- or better yet -- the court's website. 

Since most nursing home negligence lawsuits are filed in state court, you first of all may want to look in the court within your county.  Lawsuits are considered public records and most courts freely allow the public to access individual files pertaining to lawsuits.

Better yet, today many state and federal courts have on-line databases where you can review court information from your home. 

Tips:

• Even if you think you know the name of the nursing home, check your state's secretary of state website and / or department of health to confirm the legal entity that owns / operates the facility.  You will not get an accurate court record, if you do not look up the correct entity!
• Input the name of the nursing home where it says 'Defendant'-- this is the party getting sued
• Don't expect to get all the specifics surrounding the lawsuit.  Many jurisdictions do not require all documents to be filed with the court
• Don't expect to find out how much every case was worth.  Many nursing home lawsuits are resolved for 'confidential' amounts prior to trial
• Some cases are settled prior to filing of a lawsuit-- there is no public record for these cases

Below is a sampling of the lawsuits filed against nursing home behemoth ManorCare in Cook County (Chicago), IL.  This list was compiled using the Cook County Court's website, and for accuracy sake, you may wish to pull the actual court file to confirm the accuracy of this compilation.

Lawsuits Filed Against ManorCare In Cook County, IL (as of 1/1/11) Since 1997

• 172 lawsuit filed where ManorCare is a named defendant
• ManorCare Oak Lawn – 2 lawsuits
• ManorCare OakLawn East – 1 lawsuit
• ManorCare OakLawn West – 6 lawsuits
• ManorCare Hinsdale – 7 lawsuits
• ManorCare Skokie – 1 lawsuit
• ManorCare Homewood – 6 lawsuits
• ManorCare Elk Grove Village – 3 lawsuits
• ManorCare Palos Heights – 5 lawsuits
• ManorCare Palos Heights West – 1 lawsuit
• ManorCare South Holland – 8 lawsuits
• ManorCare Naperville – 1 lawsuit
• ManorCare Normal – 1 lawsuit
• ManorCare Wilmette – 2 lawsuits
• ManorCare Northbrook – 2 lawsuits
• ManorCare Arlington Heights – 1 lawsuit
• ManorCare Libertyville – 1 lawsuit

Related Nursing Homes Abuse Blog Entries:

ManorCare Facility Named In Nursing Home Negligence Lawsuit After Patient Fractures Leg

Family Awarded $546,000 In ManorCare Lawsuit

Chicagoland Manor Care Facility Named In Wrongful Death Lawsuit

On July 15, 2010, the Illinois Department of Public Health conducted a survey of Warren Park Health & Living Center in Chicago.  The survey was conducted following a well-publicized drowning death of a psychologically disturbed patient in a bathtub at the facility in the weeks prior.

Rather than an isolated episode, the survey reveals a facility in disarray that frankly appears to be completely incapable of providing necessary care for vulnerable people.  After evaluating patient charts, facility policies, staff interviews and observation of staff, the survey concluded that Warren Park indeed has substantial patient care problems as evidenced by the following findings:

• Leaving tub room unlocked and accessible to residents
• Failing to supervise patients in tub room
• Failing to have any facility-wide procedures for bathing
• Failing to timely complete an incident report following the death of a patient
• Inadequate monitoring and intervention for a patient with clearly articulated suicidal thoughts

Certainly, the above problems played a role in the drowning death of a patient on July 4, 2010.  The evidence revealed that the patient was admitted to Warren Park in March, 2010 with suicidal thoughts.  However, even after repeated verbal suicide threats, staff at the Chicago nursing home failed to take any meaningful interventional measures. 

The most alarming part of the survey is the fact that just weeks before suicide, the patient made a similar attempt to drown herself in a toilet.  Even after the episode was recording in the patient's chart and the Social Services department pledged to 'monitor' the patient, no specific indication of what how exactly the patient was to be monitored or what apparent follow-ups were to be made by staff members.

If the report of the dangerous conditions documented in the survey doesn't get the attention of nursing home administrators, perhaps the type-A violation and the $20,000 fine will? Let's hope it does, as the documented conditions should not exist in any facility.

Related:

Illinois Nursing Homes With Second Quarter 2010 Violations

Third Quarter Illinois Nursing Home Violators

Woman Drowns In Bathtub At Chicago Nursing Home

Warren Park, July 15, 2010 Survey (PDF)

No one at Emeritus of Prospect Heights nursing home, thought much about why William Spears, a resident at the facility, was headed out for a stroll—at 11 p.m.--- on a cold February night— and with his walker.  Why?

That’s what authorities from the Prospect Heights Police Department and the Illinois Department of Public Health are likely asking of the staff at the Chicagoland nursing home.  Shortly after Mr. Spears walked out of the facility for his midnight stroll, he was struck by a SUV as he entered a busy nearby street.

According to a Chicago Tribune report of the incident, Mr. Spears, 78, had been a resident at the Emeritus facility for seven years.

I find situations such as this-- when patients receive horrific injuries--  inexcusable! Too frequently we see patients injured when they leave the safety of their facility and face a world they are incapable of handling on their own. At some point, staff at these facilities needs to step in and use their common sense to help ensure the safety of the residents.  

Related:

Elderly man hit, killed by SUV outside nursing home, Chicago Tribune, February 23, 2011

Nursing Home Patients Involved In Automobile Accidents: Who's To Blame?

Hit & Run Car Accident Costs Ohio Nursing Home Resident Her Life

Lack Of Door Alarms Allows Assisted Living Patient To Wander To Her Death

On August 20, 2010 the Illinois Department of Health issued a 'Type A' violation and $10,000 fine against Ambassador Nursing & Rehab Center located in Chicago, IL.  The sanctions are in response to the conditions documented in July 1, 2010 survey completed at the facility that identified several problems related to patient safety and well-being.

The most troubling aspect of the survey is the fact that the facility failed to properly respond to an abusive staff member at the facility.  An unidentified CNA admitted to physically abusing a paraplegic patient at the facility.  In addition to the admission from the employee, the May 16, 2010 event was also witnessed by another patient and visor where they corroborated the fact that the nurse slapped and choked the patient after complaining about the way she was transferred to her wheelchair.

Yet, even after this troublesome incident was reported to the supervisor at the Chicago Nursing Home, the abusive employee was permitted to remain on the job and have direct and unsupervised contact with other patients and the nursing home failed to report the abusive conduct to the Illinois Department of Health.

The way the facility responded to the event was in violation of the facilities Abuse Prevention Program that stipulates, "[e]mployees of the facility who have been accused of mistreatment will be removed from resident contact until the results of the investigation have been reviewed by the administrator or designee."

Though Ambassador Nursing & Rehab Center has requested a hearing in response to the Health Department's findings, the facility clearly needs to readdress how it handles situations that needlessly jeopardize patient safety.

Rosenfeld Injury Lawyers handles nursing home abuse and neglect matters in Chicago and throughout the country.  If your loved one was abused or otherwise mistreated, we would be honored to speak with you regarding your legal rights.  Our legal consultations are always free and completely confidential. (888) 424-5757

Related Nursing Homes Abuse Blog Entries:

Chicago Nursing Homes Not Making The Grade

Quarterly Review Of Illinois Nursing Homes Reveals Major Problems

Ambassador Nursing & Rehab Center, 7-1-10 Survey (PDF).pdf

With a winter storm quickly approaching, Chicago Police are seeking the help of the public in locating Lidia Constantinesco.  Seventy-nine-year-old Constantinesco was a patient at Alshore Nursing Home, located on Chicago's Northwest-side.  Ms. Constantinesco suffers from diabetes and dementia.

Her whereabouts are unknown as she walked out of the facility with an unknown man, whom she told staff was her brother.  

Soon after she left the Chicago facility, staff learned that Ms. Constantinesco does not in fact have a brother.  A photo of this missing nursing home patient can be seen here.

If you have any information regarding this incident, police are asking that you contact Belmont Special Victims Unit at (312) 744-8200.

Related:

Cops: Woman missing from N. Side nursing home may have dementia Chicago Tribune, January 29, 2011

The above is a question essentially posed to residents of a Gurnee, IL subdivision where Theresa Bicok wishes to operate a home-based assisted living facility out of her 6,000-square-foot home for up to 24 residents.

For the past several years, Ms. Bicok has operated an unlicensed assisted living facility out of her suburban Chicago-land home without much fanfare.  The village wasn't notified of the unlicensed facilities existence until paramedics were called to the home following the death of one of Ms. Bicok's residents.

In order for the home-based assisted living facility to continue to operate, the village board must grant Bicok a zoning variance that Mayor Kristina Kovarik is hesitant to do,

But [with 24 residents] you've literally taken a mini-sunrise assisted living and plopped it into a residential neighborhood

While I certainly appreciate the need for more alternative living arrangements for the elderly, I strongly support regulation of the facilities by state and local governments.  Too often we see residents becoming injured or grossly neglected at facilities out of the government's control.  In this circumstance, it is important for the board to evaluate the impact of this facility not just on the neighborhood itself, but also the safety of the people who may be living there.

Related:

Who Needs To Abide By Regulations? All Troubled Assisted Living Facilities Need To Do Is Re-Organize In Order To Avoid Compliance With Safety Laws

Now That We Rate Nursing Homes, Is It Time To Rate Other Adult-Care Facilities?

Another Iowa Assisted Living Facility Chooses To Abandon Its License

Board agrees to postpone vote on unlicensed assisted living home in Gurnee subdivision Trib Local, by Megan Craig 

A nursing home negligence lawsuit has been filed by an elderly woman who claims she was injured due to improper care by the staff at ManorCare at Elk Grove Village.  As reported on Trib Local Schaumburg, the nursing home lawsuit alleges that the patient fell as staff were transferring her from her bed to a wheelchair.  As a result of the fall, the woman sustained multiple fractures in her leg.

In addition to negligence allegations, the lawsuit further alleges that ManorCare violated Illinois' Nursing Home Care Act when they improperly transferred a frail patient.

Dropped Patients

Many nursing home patients are completely dependent on staff for transfers to and from different equipment throughout the day.  It is important that nursing homes fairly assess all patients and determine the level of assistance required based on the patients level and strength and mobility as well as the patient's physical size.

Further, it is important that staff adhere to the specifications set forth in the patient's care plan be it a one, two or three person assist.  Unfortunately, many staff feel obligated to attempt to do patient transfers without the assistance of their peers due to under-staffing by facilities.

If your family member or friend has sustained an injury during a transfer into or out of a bed, wheelchair, walker, geri-chair or toilet, the incident may give rise to a claim for damages against the facility.  By contacting your state's health department or other agency that regulates nursing homes, soon after the incident, an inspection may be done in a timely manner to determine why the incident occurred.

Related Nursing Homes Abuse Blog Entries:

ManorCare Nursing Homes In Chicago: How Does Your Facility Compare?

65 Illinois Nursing Homes On Second Quarter Violation List

Nursing Home Staff Must Take Precautions While Moving & Transferring Disabled Patients To Minimize Risk Of Dropping

Safe Transfers

Illinois Department of Health: ManorCare Of Elk Grove Village

Illinois Attorney General, Lisa Madigan, is now taking steps to prevent the owners of an unlicensed nursing home in the Chicagoland area from operating a similar facility in the future.  

Earlier we discussed the now shuttered, Bowes Retirement Center, and how despite the fact that is held itself out as a retirement center, it actually was providing services akin to a nursing home. Investigations by the state and local regulatory agencies also revealed filthy living conditions and residents being abused and neglected.

While the physical building that Bowes used to operate may soon be disposed of in a court-supervised liquidation proceeding, Illinois officials want to take further steps to prevent the owners of Bowes to re-open another facility elsewhere in the state.

Consequently, an injunction has been filed against Angel and Bell Corp. of Palos Heights, Ardent Home Health Care Inc. and Benjamin and Angelina Guzman to prevent similar problems in the future.  Madigan's office expects the court to grant the injunction shortly.

Certainly, taking the regulatory steps necessary to prevent unequipped and unlicensed facilities from operating is an important step towards protecting our elderly.  However, I fear that the type of people who operate unlicensed facilities will give little recognition to a court order and may open a similar unlicensed facility when the opportunity arises in the future. 

Related:

State lawsuit vs. Bowes owners near end, Courier News, November 5, 2010 by Katie Anderson

Since 2007, ManorCare has become one of the largest nursing home operators in the world controlled by a private equity company: Carlyle Group.  ManorCare has a formidable presence in Chicago with more than 20 facilities within a 30-mile radius of the Chicagoland area.  

Across the board, ManorCare facilities in Chicago rank well with an average rating of 3 out of 5-stars according to Medicare's Nursing Home Compare site.  

While no ManorCare facilities currently operate within the Chicago confines, there are Manor Care nursing homes scattered amongst the following popular Chicago-land suburbs:

• Hinsdale
• Kankakee
• Palos Heights
• Libertyville
• Highland Park
• Normal 
• Westmont
• Oak Lawn
• Homewood

The overall quality of ManorCare facilities vary considerably by location.  According to the most recent Medicare surveys, Manor Care facilities in the Chicagoland area rate on both the high and low-end of the rating spectrum.

HIGHEST RATING: 5/5 Stars

Heartland Health Care Center – Riverview

500 Centennial Drive

East Peoria, IL 61611

309-694-0022

Heartland Health Care Center – Henry

1650 Old Indian Town Road

PO Box 215

Henry, IL 61537

309-364-3905

LOWEST RATING: 1/5 Stars

ManorCare Health Services – Kankakee

900 West River Place

Kankakee, IL 60901

815-933-1711

Below is a listing of Chicagoland ManorCare facilities with location, telephone and overall Medicare rating.

Related:

Chicago Nursing Homes Not Making The Grade

What's In A Name? Are Large Nursing Home Chains Intentionally Attempting To Deceive The Public When It Comes To Corporate Ownership?

Huge Nursing Home Verdict Tossed Out Because Parent Company Did Not Have Adequate Control Over The Facility

Nursing Home Spotlight: Manorcare of Rolling Meadows

Chicagoland Manor Care Facility Named In Wrongful Death Lawsuit

Continue Reading

A recently completed nursing home survey completed at Kenwood Care Center in Chicago, IL provides a very disturbing glimpse into life at a facility that cares for a group of predominately mentally-ill patients.  One hundred forty-five of the 232 patients at Kenwood had a psychiatric diagnosis and similarly 122 of the facilities patients were receiving rehabilitative services for mental illness and mental retardation.

The extensive survey was completed at the facility over several days in January, 2010 resulted in numerous deficiencies and violations of state and federal law.  In addition to the noted violations, the IDPH issued a type- A violation and a $15,000 fine against the facility

Overall, the survey at Kenwood Care Center paints a picture where mentally-ill patients seem to do as they please in a facility staffed with many inexperienced personnel handling complex patient needs.

In particular, the following themes pervade the most recent survey:

Dangerous Smoking Conditions:

Evidence of residents smoking in their rooms was present on multiple occasions.  Further, many mentally ill patients were permitted to keep their own smoking materials which seemingly allowed them to smoke where and whenever they choose.

In many cases, Kenwood Healthcare failed to assess new patients to see if they smoke.  Consequently, the facility was unable to track smoking patients and provide necessary accommodations for them.

Violence Amongst Patients:

Surveyors consistently heard from patients and staff of violence amongst patients.  In reviewing Kenwood Healthcare Center’s incident reports over the six months prior to the survey, authorities noted that fights continually occurred on the facilities elevator and smoking areas--- yet staff did nothing to reduce these incidents by creating a plan to correct these problems. 

Also, despite the fact that the psychiatrists of the patients were to be notified if the patients were involved in a violent event, most of the time there was no notification.  Similarly, Kenwood protocol calls for 72 hour observation of patients who were involved in physical altercations, yet when questioned by surveyors, Kenwood staff were unaware of what the policy actually contained.

Consistently Eloping Patients:

Several patients were noted to elope, or leave Kenwood, without the knowledge of staff at the facility.  Even after some patients had eloped from the facility several times, the facility failed to implement corrective measures that would prevent future occurrences. 

In some circumstances, patients left the facility and wandered into the community during times during the harsh Chicago winter, putting them at risk for complications due to exposure to the elements--- and even hypothermia.

Patients With Violent Histories That Go Undocumented:

When state surveyors looked into the criminal histories of patients involved in physical or verbal altercations, they discovered many had extensive criminal histories--- and in some cases, active warrants for their arrests.  Yet, for the most part, these criminal histories were notably absent from the patients chart. 

Kenwood's failure to keep track of patients with violent histories restricts that staffs' ability to monitor patients and ensure the safety of particularly vulnerable patients who may be at risk for physical or psychological harm.

Certainly, the above findings are disturbing and are in clear violation of nursing home regulations that stipulate;

The facility mist provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychological well-being of the resident, in accordance with each resident’s comprehensive assessment and plan of care.  Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.

If you have believe a famility member is suffering from mistreatment at Kenwood Healthcare Center, we would honor the opportunity to discuss the situation with you and discuss your legal rights.  As always, our consultations are free of charge and completely confidential. 

Related:

Kenwood Healthcare Center, February 9, 2010 Survey (PDF)

Sexual Assaults In Nursing Homes, Not Exactly A Pleasant Topic-- But Is An Issue That Needs Attention

First Quarter 2010 Illinois Nursing Home Violations Released

Smoking-Related Injury Is A Real Threat To The Safety Of Nursing Home Patients

I really applaud Illinois Attorney General Lisa Madigan's efforts to improve the safety of patients in nursing homes throughout the state.  Her "Operation Guardian" uses multi-disciplinary teams from various state and local agencies to conduct unannounced sweeps at facilities thought to care for people with outstanding arrest warrants.

To date, the operation has conducted 21 unannounced sweeps of Illinois nursing homes that has resulted in the identification of more than 100 nursing home patients with active arrest warrants.  In some situations, the people we not arrested due to the fact that they may have suffered physical or mental impairments that made their arrests unreasonable.

As reported by the Chicago Tribune, the most recent sting operation took place days ago at Central Nursing & Rehabilitation Center on the Northwest side of Chicago.  The crackdown resulted in the arrest of four patients with various criminal pasts.

Yet the fact remains that some potentially dangerous people were arrested from nursing homes where they lived freely amongst especially vulnerable people.

As I have said before, I firmly believe that the more attention that gets heaped on the safety issues facing patients in nursing homes is for the best.  But, my real question is,

Why do skilled nursing facilities continually allow criminals to live freely amongst the most vulnerable people in the first place?

I assume members of Operation Guardian have access to databases where they are able to access information regarding open arrest warrants?  Why not give nursing homes access to these databases and allow them to conduct their own review of patients in their facilities?

Further, until there are severe penalties on the books to encourage facilities to rid themselves of the bad seeds, there is little incentive for facilities to do their own house cleaning.

Related Nursing Homes Abuse Blog Entries:

Sexual Assaults In Nursing Homes, Not Exactly A Pleasant Topic-- But Is An Issue That Needs Attention

Illinois Attorney General Continues To Keep Nursing Homes On Their Tippy Toes With Spot Raids

Attorney General Hunts Down Drug Dealing Nursing Home Patient During Raid

IL Attorney General Nabs Two Patients From An Alden Nursing Home With Criminal Warrants

A recently filed wrongful death lawsuit alleges that ManorCare's Hinsdale, IL facility was negligent in caring for a 74-year-old patient at the facility.  According to the lawsuit, filed in Cook County, the patient died from acute renal failure that was brought about by severe dehydration within 30 days her he admission to the facility due to the fact that the facility failed to monitor the patients fluid intake and output.

Acute Renal Failure

Many people use acute renal failure interchangeably with kidney failure.  Either way, acute renal failure may result after a patient has been denied adequate fluid intake.  In the nursing home setting, I frequently encounter cases where patients suffer various types of injuries simply due to the fact that the facility is not keeping them adequately hydrated.

Particularly in the elderly, it is extremely important for staff to monitor the needs of each patient.  Medications, incontinence, and body composition are all factors that play into how much fluid each patient requires to function optimally.

In some situations, where a patient has a history of dehydration or urinary tract infections (UTI's), a physician may order the staff to keep specific tabs on fluid intake and urine output to assure the patient's health doesn't deteriorate.

However, even without specific physician orders relating to monitoring such specifics, there are many obvious indications that a patient may not be getting sufficient fluids.  Common signs of dehydration include:

• Sunken eyes
• Cracked lips and tongue
• Ashen skin coloring
• Lack of urine and / or very strong smelling urine and darkly colored urine
• Rapid weight loss

Certainly, nursing home staff should be focused on preventing this relatively preventable medical complication and take steps necessary to prevent it.  If you have a situation that you believe is related to dehydration, I would be happy to discuss your legal options.  As always there is never a charge for a consultation.

Related:

Acute renal failure of medical type in an elderly population (PDF) Nephrology Dailysis Transplantation (1998)

Dehydration and the Elderly, Illinois Counsel on Long-Term Care

Hinsdale nursing home sued over resident's death, Mysuburbanlife.com September 2, 2010

On November 24, 2009 nursing home surveyors from the Illinois Department of Health (IDPH) conducted an inspection of Edwardsville Terrace, a nursing home in Edwardsville, IL.  The inspection of the facility found numerous violations of federal and state laws applicable to nursing home care.

In particular, surveyors discovered the following alarming situations at the Southern Illinois facility:

• The facility failed to have written procedures regarding patient care (Section 350.620 Resident Care Policies)
• Edwardsville failed to provide skilled nursing services that are required to maintain each patient's health-- when the facility failed to identify signs of physical and psychological illness that were apparent in one of the patients (Section 350.1210 Health Services)
• Delaying the implementation of medical care that was necessary for patients who need the services of a physician, licensed nurse or professional nurse
• Failed to maintain adequate patient records pursuant to Section 350,1610
• Neglecting a patient in violation of Section 2-107 of Illinois' Nursing Home Care Act

The above violations came to light following an investigation of an extremely sick patient suffering from uncontrolled diabetes and severe mental illness amongst other maladies.

Nursing home surveyors focused on the fact that the patient at issue was admitted to a hospital emergency room after an extended illness Edwardsville Terrace.  The unidentified patient was admitted to the emergency room with the following diagnosis:

1. Septic shock
2. Dehydration
3. Cardiomyopathy
4. E. Coil
5. Sepsis
6. Right nephrolithiasis causing E. Coli sepsis
7. Chronic ear infection
8. Hypertriglycerdemia

The nursing home patients acute illness necessitated extensive medical treatment and extended hospitalization. While reviewing the patient's chart from Edwardsville Terrace, a gross lack of documentation lead the surveyors to believe the facility failed to provide essential medical care.

Certainly, this survey should give patients and their families cause for concern; due to the fact that this facility failed to meet the basic needs of this patient.  Hopefully, the disclosure of poor care (as well as the $20,000 fine imposed against this facility) will cause Edwardsville to improve their documentation and re-commit themselves to providing necessary care for all of their patients.

Nonetheless, I am sure that this incident is not isolated.  If you believe your loved one was mistreated, abused or neglected at Edwardsville Terrace, I would honor the opportunity to speak to you about the situation and your legal options.

Related:

Diabetic Ketoacidosis Is An Under-Appreciated Danger Facing Many Nursing Home Patients

Dehydration & The Development Of Bed Sores In Nursing Home And Hospital Patients

Untreated Urinary Tract Infections In Nursing Home Patients May Result In Urosepsis

Improper Transfer Leads To Broken Arm

First Quarter 2010 Illinois Nursing Home Violations Released

The failure of California Gardens to properly implement a facility-wide smoking policy resulted in a recent fine of $5,000 and a Type A violation issued by the Illinois Department Of Health.  According to a November, 2009 survey report, state officials focused on a 68-year-old patient at the facility who had and extensive history or physical and psychiatric ailments.  

State officials noticed that the man had multiple burns on his chest that were indicative of him smoking in bed--- a clear violation of the facilities smoking policy.  A review of the man's nursing home chart confirmed that he had a history of smoking violations-- including smoking in his bed.

Interviews with nursing home staff at California Gardens paints a picture of a facility with a poorly implemented smoking policy.  On more than ten occasions staff at California Gardens suspected the man of smoking in his room-- yet they failed to take effective action to correct the pattern of dangerous behavior.  

The fact that staff allowed this patient to smoke in his bed obviously poses a threat to the safety of himself and other patients and staff at the nursing home.  According to California Gardens smoking policy:

• No smoking is permitted in any patient bedroom or bathroom
• All residents are expected to abide by the facilities smoking policy
• Cigarettes are to be distributed by the facilities activity department
• Smoking privileges will be withdrawn if they are not properly followed

Certainly, given the obvious safety risks associated with careless smoking facilities need to create and effectively implement a smoking policy for the safety of everyone at the facility.  I have worked on a number of matters where patients have sustained serious burns due to the facilities failure to look after patients who smoke.  Hopefully, this citation will be a wake up call for California Gardens Nursing & Rehab Center to improve their smoking safeguards before a patient is seriously harmed or killed in a smoking-related event.

If you have a family member at California Gardens and are concerned about the care they receive, I would be happy to discuss your legal options with you.  As always, there is no charge to speak to a lawyer and all consultations are confidential.

Related Nursing Homes Abuse Blog Entries:

First Quarter 2010 Illinois Nursing Home Violations Released

Unsupervised Nursing Home Resident Dies From Burns

Nursing Home Patient Sustains Serious Burns After Smoking In His Bed

Smoking-Related Fires Are A Real Threat To Nursing Home Patients. Is It Time To Put Out The Fire?

Illinois Attorney General Lisa Madigan has most recently moved her troops to the Northern Illinois city of Rockford--- Alden Park Strathmoor Nursing Home to be exact-- to search for nursing home patients with criminal warrants. 

Operation Guardian, as the program is known, is a program created by Ms. Madigan in response to the widely publicized articles regarding the presence of violent criminals living in Illinois Nursing Homes.  The program utilizes the combines resources from the Attorney Generals office, as well as representatives from state and local law enforcement agencies for unannounced visits to nursing homes that are suspected to house dangerous patients.

This visit to Alden Park Strathmoor turned up two patients with criminal warrants and two more patients with warrants, but required skilled nursing care at the facility.  The remaining patients with criminal records will be kept under special security.

While I certainly applaud the efforts made by Attorney General Madigan to reduce the number of criminals living amongst the general nursing home population, I feel the only meaningful way to reduce the frequency of criminal living in Illinois nursing homes is to force facilities to do their own criminal background checks.

Until the nursing homes are held accountable for allowing people with known criminal tendencies to freely live amongst our most vulnerable, I firmly believe we are bound for more horrific news headlines chronicling the despicable acts committed on the defenseless.

Read more about this raid on Alden Park Strathmoor Nursing Home here.

Related Nursing Homes Abuse Blog Entries:

Man Falls From Fourth Floor Window To His Death At Alden Nursing Home

Blacks Receive Inferior Care At Most Nursing Homes

Nursing Home Safety Bill Provides Promise Of Improved Care In Illinois

Attorney General Hunts Down Drug Dealing Nursing Home Patient During Raid

A recently filed wrongful death lawsuit claims that clostridium difficile, or commonly known as C. Diff, is to blame for the death of a patient in an Illinois Nursing Home. 

The lawsuit alleges two short-term stays at Helia Healthcare facilities (Helia Healthcare of Energy and Helia Healthcare of Benton) are to responsible for the man's C. Diff infection and development of decubitus ulcers.  It is further alleged that these medical complications contributed to the man's death.

Despite the fact that the man had a prior episode of C. Diff, and was at an increased risk for return of the infection, the nursing homes failed to recognize tell-tale signs of the infection including:

• Poor appetite
• Poor fluid intake
• Diarrhea

It wasn't until the man had long been struggling with signs of the infection did the facility send him to the hospital for treatment. Read more about this wrongful death lawsuit here.

C. Diff and Nursing Homes

C. Diff s a bacterial infection that can cause diarrhea and serious intestinal conditions (such as colitis - inflammation of the colon) and even death.  Though contracting C. Diff may be a relatively common occurrence (there are an estimated 3 million cases reported annually), C. Diff involving nursing home patients is especially problematic due to the fact that many elderly patients have compromised immune systems and are already in a weakened state.

C. Diff bacteria are are contagious and can be passed through the feces of an infected person and can spread to food, surfaces, and objects when infected patients and other nursing home staff do not wash their hands thoroughly.  Proper sanitation techniques such as thorough cleaning and hand washing is crucial in order to prevent the bacteria from getting spread to other patients.  Spores of C. Diff can survive for months unless facilities to a proper job sanitizing patient rooms and common areas such as bathrooms and cafeterias.

Related Nursing Homes Abuse Blog Entries:

Left Untreated, Stomach Aches Can Be Deadly For Elderly Nursing Home Patients

Failure To Monitor Bowel Movements In Nursing Home Patients Can Lead To Impacted Bowels

What is a surviving spouse entitled to in a wrongful death lawsuit against a nursing home?

Spotlight On: Helia Healthcare of Urbana

42 Illinois Nursing Homes Cited In 4th Quarter of 2009 For Violations Related To Patient Care

Barry Community Care Center is a 75-bed nursing home located in Barry, IL. On January 22, 2010, the Illinois Department of Public Health (IDPH) fined Barry Community Care Center $35,000 for violations in the area of policy and procedure. Even with this significant fine, Medicare rated the facility as a three-star or average nursing home facility, with only one health deficiency between February 2009 and April 2010.

This episode demonstrates that even well-regarded skilled nursing facilities can have very serious problems for patients. Barry Community Care Center’s single deficiency involved its failure to provide each resident the care and services required to achieve or maintain the highest quality of life possible, which resulted in immediate jeopardy to resident health or safety. 

This example serves to reinforce how important it is to thoroughly research a potential nursing home because looking at the total number of health deficiencies is not enough. Not all health deficiencies are equal with regard to the level of harm presented to residents. In this case, the facility’s deficiencies and violations were very serious, resulting in the choking death of one resident. (See other Nursing Homes Abuse Blog articles on choking)

A survey conducted by IDPH on November 25, 2009 revealed that Barry Community Care Center failed to provide adequate supervision to a resident during mealtime, which resulted in the resident choking on food. Then, the nursing home did not call 911 for another hour, which led to the resident’s death at the hospital later in the day. 

The resident was known to have impaired cognition and limited range of motion for neck, arm, and hand. The facility’s care plan for the resident required one person to physically assist and supervise with meals. 

On September 26, 2009 at 1:00 pm, the resident was found in her room with a half-full plate of food from lunch in front of her. The resident was having trouble breathing and her face was ashen. A Licensed Practical Nurse (LPN) was called to the resident’s room. The nurse increased the oxygen and encouraged resident to cough. The resident coughed out some food but became too weak to continue. At that point, the nurse began to suction the resident while another nurse called the physician and power of attorney (POA). When the POA arrived, she requested that the resident be sent to the emergency room (ER). 

The ambulance was called at 1:56 pm, almost one hour after the facility found her having trouble breathing and choking on her food. When the ambulance took the resident to the hospital at 2:27, the resident had a rapid pulse and was still having trouble breathing. When the ambulance arrived at the hospital at 2:41 pm, the resident was unresponsive, suffering from major respiratory distress. The resident died at the hospital with a diagnosis of aspiration pneumonia (inflammation of the lungs from breathing foreign matter into your lungs), atrial fibrillation (irregular, rapid heartbeat), hypertension (high blood pressure), Type 2 diabetes, and history of chronic obstructive pulmonary disease (COPD). (See “Elderly Patients Are At Higher Risk for Developing Aspiration Pneumonia When Facilities Fail To Account For Patient Needs”)

The facility never should have left the resident alone with her food tray, especially because the resident’s care plan called for her to have someone assist her with eating and drinking. In addition, the staff knew that the resident had trouble eating her breakfast on the morning of her death. One of the nurses had to physically remove pieces of egg and toast from her mouth before returning the resident to her room. Furthermore, the nurse should have immediately called 911 when she found the resident choking on food and having difficulty breathing. 

The choking death of the resident at Barry Community Care Center is a sad reminder of how quickly a nursing home resident can suffer injury, or in this case, death, when they do not receive proper care and supervision. It took only 30 minutes for the resident to choke on food, when she should have had a staff member helping her eat, which would have prevented her death. 

Thanks to Heather Keil, J.D. for her assistance with this Nursing Homes Abuse Blog entry

Sources:

Illinois Department of Public Health: Nursing Homes in Illinois Quarterly Report

IDPH: Barry Community Care Center

IDPH: Barry Community Care Center - Quarterly Report

Nursing Homes Abuse Blog: Elderly Patients Are At Higher Risk for Developing Aspiration Pneumonia When Facilities Fail To Account For Patient Needs

Nursing Homes Abuse Blog: Choking

Choking Death Just Latest Problem At California Nursing Home

WBBM Newsradio is reporting on a tragedy that occurred this past weekend at a Chicago Nursing Home.  On Sunday evening, a 51-year-old woman who was a patient at Warren Park Nursing Pavilion was taken to Saint Frances Hospital when she was discovered unresponsive in a bathtub at the facility. 

Authorities at Saint Frances pronounced the woman was dead upon her arrival at the hospital.  An autopsy performed by the Cook County Medical Examiner determined that the woman died from drowning.

Chicago police detectives are currently investigating this matter to determine more information about the drowning.

While certainly not a common occurrence in nursing homes and assisted living facilities, many patients-- particularly those suffering from mental and physical disabilities-- are at risk for downing during bathing or recreational activities.  In order to minimize the risk of drowning, staff should identify those who may be at risk an provide supervision to prevent drownings.

Nursing home injuries, such as this downing, deserve to be investigated by the Illinois Department of Health (IDPH).  Many times, investigations completed by IDPH are extremely useful in the prosecution of civil lawsuits against the facilities.  The IDPH has investigated other incidents at Warren Park, you can view some of the findings here.

Related:

Jean Engstrom, 51, Dies in Tub Drowning Incident at Rogers Park Nursing Home, My Fox Chicago, July 5, 2010

 Milestone-Elmwood East is a small, 12-bed nursing home located in Rockford, Illinois. Milestone, Inc. is a private, not-for-profit corporation that provides “residential, developmental, vocational, and social support services for adults and children with mental retardation, autism, epilepsy, and cerebral palsy.” This facility committed serious violations that led to the choking death of one resident. (See Nursing Homes Abuse Blog: Topic – Choking)

This nursing home committed several serious 4^th quarter violations relating to the area of policy and procedure. (See “42 Illinois Nursing Homes Cited in 4^th Quarter of 2009 for Violations Related to Patient Care”) The Illinois Department of Public Health (IDPH) fined the nursing home $25,000 on November 17, 2009. The facility provides services for persons suffering from mental retardation. These residents require more care than average residents because of reduced mental capacities. 

First, the facility failed to conduct quarterly fire drills for the 2^nd shift personnel, which endangered the lives of all residents. In the case of an emergency, including fire emergency, staff members should be trained and prepared. As evidenced by the IDPH report, this did not occur with all personnel. 

The most serious of the violations involve the choking death of a 28-year old nonverbal male resident who was ambulatory (capable of walking), mentally retarded, and also suffered from autism and cerebral palsy. This resident died after choking on food unsupervised. (See “Failure to Follow Orders Results in Death of Patient & Hefty Fine”) The facility’s failures include: 

• Failure to implement policy on neglect
• Failure to ensure that resident’s behavior program was fully documented with certain behaviors of taking food from kitchen
• Failure to ensure that enough staff were available to manage and supervise resident in accordance with his behavior plan which allowed him to eat unsupervised

The violation report completed on September 17, 2009 notes that the facility’s own policy on abuse and neglect defines abuse/neglect as to include “any willful failure to respond to an individual’s obvious needs or to provide the appropriate supervision and care that the individual served should have.” The facility’s failure to provide adequate medical or personal care or maintenance for the resident resulted in physical injury. 

Before his death, the facility’s program charts (completed on May 7, 2009) had the resident on a program to ensure that he ate at a slower pace. To support this goal, a staff member sat next to him at meals to provide verbal cues and physical prompts to slow down. In the weeks before his death, staff members noticed that he was eating even more quickly and was stealing food, which suggested increased agitation. 

AT 7:00 AM, the Director of Nursing found the resident in the living room on his back with chewed up food next to him. The director of nursing called paramedics and performed CPR (cardio pulmonary resuscitation) until they arrived. Despite these measures, the resident died. The cause of death was asphyxiation caused by a sausage found lodged in his throat. It turns out that the resident had stolen a sausage wrap from the food that had been prepared for breakfast. A tray of food covered with foil was left on the kitchen counter. 

One of the direct service providers (DSP) even saw the resident walking out of the kitchen and noticed that the foil on the food had been disturbed. Even though the resident had no documented history of stealing food from the kitchen, he did have a history of stealing food from other residents. However, the facility personnel did not put together his presence near the kitchen, the disturbed food, and the history of stealing food. 

The facility’s assessment for the resident stated that he required 24-hour supervision including assistance with diet, portion control, and eating rate. The DSP who saw the resident coming from the kitchen admitted that it was not unusual to catch residents in the kitchen area. The DSP also stated that the resident had stolen food from the kitchen before but she failed to document this. 

The resident’s Individual Habilitation Plan states that the staff should report all issues of concern to their supervisor and/or the nurse. However, the DSP never reported seeing the resident stealing food from the kitchen. This failure resulted in the resident’s care plan not being updated to include measures to prevent him from stealing food, especially in light of his problems controlling how quickly he consumes food. The DSP also admitted that mornings at the facility were “hectic,” and the facility could benefit from additional staff. In addition, on the morning in question, the kitchen was left unsupervised even though there was food left out on the counter.

The facility’s failure to properly monitor the resident and update his care plan allowed him to steal food from the kitchen unsupervised and ultimately choke to death. Unfortunately, the fines assessed will do nothing to benefit this resident. However, hopefully, it will do something to change the behavior and procedures of the facility in the future in order to protect the other residents. 

Stories like this highlight the fact that there are problems with small nursing homes as well as large nursing homes. Even with fewer residents to care for, oversights and mistakes can occur, and these mistakes can be deadly. In this situation, Milestone-Elmwood East did not properly monitor and care for a young, 28 year-old resident. If you or a loved one have suffered injury at the hands of Milestone, Inc, you may be entitled to compensation. 

Sources:

Illinois Department of Public Health (IDPH); Milestone-Elmwood East

IDPH: Milestone-Elmwood East – 4^th Quarter Violations

IDPH: Nursing Homes in Illinois – Quarterly Report (October-December 2009)

Nursing Homes Abuse Blog: Failure to Follow Orders Results in Death of Patient & Hefty Fine

Nursing Homes Abuse Blog: Topic – Choking

Nursing Homes Abuse Blog: 42 Illinois Nursing Homes Cited in 4th Quarter of 2009 for Violations Related to Patient Care

For the 11th time this year, Illinois Attorney General Lisa Madigan gathered 14 police officers and and state officials to conduct an unannounced sweep of an Illinois Nursing Home.  The sweep was conducted to assure that the facility was complying with state and federal regulations.

This time, the nursing home sweep took place at Golden Moments Senior Care Center in Jacksonville, IL.  During the three hours officials spent at Golden Moments they inspected the facility and review patient files. 

The sweep revealed that most patient files were in proper order and patients were receiving proper care.  However, the sweep did reveal that the the facility failed to conduct 'risk assessments' for three convicted sex offenders housed at the facility.

Though no specific reason was cited by officials in making organizing this raid, Golden Moments has a history of providing questionable patient care including an episode where a 74-year old patient choked to death on food.  The incident resulted in a $50,000 fine against the facility.

According to Cara Smith deputy chief of staff for the Illinois Attorney General, "We've been looking for ways of improving safety for vulnerable adults.  These sweeps are important to send a message to the facilities and the residents that the agencies are working together to ensure safety."

Read more about these Illinois nursing home raids here.

I applaud the Attorney General's decision to step-up random checks on Illinois Nursing Homes.  Certainly, these random inspections will hopefully keep operators on their toes and perhaps provide the added incentive to improve patient care.

While governmental inspections such as this are certainly important, I strongly encourage all families and patients to report episodes of poor care to neglect to officials at the department of health in the state where the nursing home is located. 

In many situations, an inspection triggered by a complaint to a department of health can not only provide answers to how an incident may have occurred, but also trigger an appropriate penalty against the facility should the findings merit such action.

Our sister site, Nursing Home Injury Laws, provides a compilation of contact information for the Department of Health in every state should the improper nursing care be suspected.

Related:

Golden Moments Senior Care Center Continues To Accumulate Fines Related To Providing Poor Care To Its Patients

42 Illinois Nursing Homes Cited In 4th Quarter of 2009 For Violations Related To Patient Care

If you're looking for a great way to get involved in improving the quality of nursing home care, I suggest becoming part of the ombudsman program in your area.  

Ombudsman provide a vital link between nursing home patients and facility staff.  Unlike complaints made to a state's department of health which tend to be serious in their nature, ombudsman are a conduit to resolving many commonly encountered problems that may be addressed relatively easily.

In addition to resolving grievances and answering questions, ombudsman can also help improve patient safety when they notice abusive care or dangerous living conditions at a facility.

In Chicago, The Chicago Department of Family and Support Services (DFSS) announced a new initiative to recruit volunteer ombudsman to fill the important position.  

"It is estimated that nearly 60 percent of residents in Long Term Care facilities never receive a visitor," said Mary Ellen Caron, Ph.D., commissioner of Chicago Department of Family and Supportive Services.  "Becoming a Volunteer Ombudsman allows Chicagoans the opportunity to improve the quality of life for seniors in their community by providing support and friendship to individuals who have limited resources."

Ombudsman can serve patients in the nursing homes within their community or in any area of the city they choose after they complete a training program and become certified by the Illinois Department on Aging.  Coursework will include:

• An overview of the aging process and the people who live in nursing homes
• Federal and state regulations of Long Term Care facilities
• Residents' rights
• An overview of the organizational structure of the long term setting
• Communication and interviewing techniques
• Principals for reporting poor care

If you are interesting in becoming active in this very worthwhile program, call (312) 744-4016 or visit www.cityofchicago.org/fss.

Resources:

The National Long-Term Care Ombudsman Center

How can nursing home ombudsmen help with problems encountered in a long-term care facility?

Are nursing home patients protected under federal law?

Nursing Home Watchdogs: Ombudsmen

On October 28, 2009, the Illinois Department of Public Health (IDPH) fined Fairview Nursing Plaza (a large, 213 bed “skilled and intermediate care facility” located in Rockford, IL) $10,000 for fourth quarter nursing home violations.  These violations included Nursing Home Care Act violations involving improper and inaccurate documentation of diabetes treatment and monitoring, and failure to immediately arrange for ambulance transport for a diabetic resident suffering from diabetic ketoacidosis. 

Also in October 2009, IDPH fined Fairview $10,000 for violating the Nursing Home Care Act (for a Type “A” Violation relating to the area of nursing).  A survey conducted on September 28, 2009 revealed that documentation for insulin dependent diabetics was not always complete and accurate.  This finding was confirmed by the facility’s own Director of Nursing.  The facility failed to properly and accurately document blood glucose levels and scheduled doses of insulin for insulin dependent diabetics residing in the facility. 

Diabetes (Type 1) can be a difficult disease to manage.  It requires careful screening of blood sugar levels, proper nutrition, and insulin shots.  There are many diabetes related complications, and the best way to reduce the risk of complications is to keep blood sugar level close to normal most of the time.  Fairview’s failure to properly document blood sugar levels and treatments put all of its diabetic residents at increased risk of diabetes complications. 

The nursing home failed to immediately arrange ambulance transport services for one diabetic resident with sustained elevated blood glucose levels, resulting in him suffering from diabetic ketoacidosis (too little insulin in your body).  The nurse reported that she checked the resident’s blood glucose levels hourly between 7:45 - 11:30 AM. 

Despite “HI blood glucose results” (> 525 mg/dl), the nurse did not notify a doctor sooner because she thought he was ok, even though the resident was showing signs of confusion, limp limbs, and being unstable sitting in a chair.  (see “Diabetic Ketoacidosis is an Under-Appreciated Danger Facing Many Nursing Home Patients”)  The nursing home’s failures directly endangered the life of this resident, and also call into question whether the nursing staff was properly monitoring other diabetic residents. 

Diabetic ketoacidosis is a very serious complication of diabetes.  Because sugar can no longer enter cells to provide energy, your blood sugar rises, and your body breaks down fat for energy.  This produces ketones, which are toxic, and if left untreated, it can be fatal.  Symptoms include: excessive thirst, frequent urination, nausea and vomiting, abdominal pain, loss of appetite, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion. 

Fairview has a history of higher than average Health Deficiencies.  The Medicare Nursing Home Compare gave Fairview Nursing Plaza an overall rating of one out of five stars, which is much below average rating.  Health Inspections rating was one star (20 Health Deficiencies between 12/1/08 – 2/28/10.  Nursing Home Staffing rating was also only one star.  Quality Measures rating was four stars.  Between 12/1/07 and 11/30/08, the facility received 19 Health Deficiencies. 

The recent health violations at Fairview call into question whether the facility’s residents, especially its diabetic residents, are receiving proper care and treatment.  Diabetes is only one common condition affecting older nursing home residents.  Many common diseases and conditions require close supervision and monitoring to prevent dangerous complications and ensure proper medical care. 

SIR Management Inc.

Fairview Plaza Nursing Center is a facility operated under the control of S.I.R. Management, Inc. S.I.R. Management is a health care consulting company located in Lincolnwood, Illinois, which consults to several Nursing Facilities (Nursing Homes) in the Chicagoland area, including:

• Columbus Park Nursing and Rehabilitation Center
• Elmwood Care
• Maplewood Care
• Neighbors Rehabilitation Center
• Regency
• Albany Care
• Greenwood Care
• Decatur Manor
• Rock Island Nursing & Rehabilitation
• Wilson Care
• Bryn Mawr Care

Sources:

Fairview Plaza Nursing Center

Medicare: Nursing Home Compare – Fairview Nursing Home

Illinois Department of Public Health: Fairview Nursing Home

IDPH: Fairview Nursing Home – 4^th Quarter Violations

Mayo Clinic: Diabetic Ketoacidosis

Nursing Home Abuse Blog: Diabetic Ketoacidosis is an Under-Appreciated Danger Facing Many Nursing Home Patients

Faced a situation where a nursing home was providing inadequate or dangerous care to its patients, officials at the Department of Public Health-- the regulatory agency for Illinois Nursing Homes-- had relatively little in their arsenal when it comes to prodding along facilities.  That is, until now. 

Recently, the Illinois Appellate Court tossed out a Sangamon County judge's ruling that capped fines imposed by the Illinois Department of Public Health at $10,000.  In the case involving Peoria's Rosewood Care Center and The Illinois Department of Health, Judge Leo Zappa ruled in favor of Rosewood in a matter involving a $20,000 fine imposed against the facility for the death of a patient.  Zappa determined that the fine was improper due to the fact that it was illegally inflated and conflicted with state law.

Despite the Appellate Court decision, Illinois officials will continue to use their approach of imposing multiple fines against poorly performing facilities in lieu of more substantial single fines. 

"A fine is one of the few things we can do to make sure a nursing home is compliant with the law," says Illinois Department of Health spokesperson Melanie Arnold.

I agree.  However, until the significance of the fines reaches the point where they pose an actual threat to the livelihood of the nursing home owners and operators, they will not have their intended impact when it comes to motivating facilities to provide quality medical care to patients in need.

Thankfully, our legal system allows nursing home patients who receive poor or negligent care to pursue a claim for damages against the facility under the Nursing Home Care Act.  When pursuing a claim under the act, a patient has no financial limit on the damages they may recover from the facility. 

We have successfully prosecuted nursing home negligence claims in a wide variety of matters including: wrongful death, falls, burns, medication errors, sexual abuse and bed sores.

Read more about this Appellate Court decision involving Illinois Nursing Homes here.

Related Nursing Homes Abuse Blog Entries:

Illinois Nursing Home Task Force Holds Public Meeting Today

31 Allegations Of Abuse At Chicagoland Nursing Home

More Staffing & Stiffer Fines. Welcome To The New Way Of Doing Business For Illinois Nursing Homes?

42 Illinois Nursing Homes Cited In 4th Quarter of 2009 For Violations Related To Patient Care

Perhaps in response to the widely publicized problems involving violence at Illinois Nursing Homes, new legislation would force facilities to increase their staffing levels and improve the care provided to their patients or risk larger fines imposed by the state.

According to legislative sponsor, Senator Jacqueline Collins,

" We are here to say quite boldly and courageously that we're willing to take on the nursing home industry. For too long they've had the influence and power in this state and I want to say that we can mount a strong coalition to state together to fight for policy changes that truly address the disparities in care and the lack of care."

Not surprisingly, the proposed legislation is already being opposed by nursing home industry insiders as unnecessary and too aggressive.

Certainly any legislation that is aimed at improving patient care should be applauded.  For too long nursing home patients in Illinois have be unnecessarily victimized by a system where nursing home operators can legally put their desire for profits ahead of patient needs.  Maybe this legislation could help turn the tables?

Read more about this proposed nursing home legislation here.

Related Nursing Homes Abuse Blog Entries:

Drugs, Criminals & Violence. Welcome To The 'Psychiatric Ghetto' Nursing Home

Illinois Nursing Home Task Force Holds Public Meeting Today

Atleast 50 Convicted Sex-Offenders Living Freely In Illinois Nursing Homes

Sexual Assaults In Nursing Homes, Not Exactly A Pleasant Topic-- But Is An Issue That Needs Attention

In the past year, Westside Rehab & Care Center has had 21 total health deficiencies, which is 13 more than the average number of health deficiencies in Illinois and the United States. This was actually an improvement from the total number of health deficiencies in the previous year, when the facility had a shocking 34 health deficiencies. Not surprisingly, Medicare gave this 96-bed nursing home facility located in Frankfurt, IL an overall rating of one-star, which is a much below average rating.

On August 10, 2009, a female resident suffered a leg fracture (broken bone) after falling during a transfer. The nursing home staff did not update her pain assessment in response to this injury, leaving the resident in unnecessary pain for an extended period of time.

During a complaint investigation, the resident told the investigator, “I am hurting! Can’t you help me?” The investigator reported this to the nurse, who then administered pain medication. This same resident was also noted to have dried blood on her face, neck and right arm and hands, with active bleeding on her right wrist. The resident was feeding herself with her fingers that were soiled with dried blood. The facility failed to prevent unnecessary pain and suffering for this resident, which means that the facility did not ensure that this resident maintained the highest level of physical, mental, and psychosocial well-being.

During the same complaint investigation, the investigator determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents by failing to implement interventions to prevent staff from leaving a total care resident on the toilet alone. This failure resulted in the resident suffering two falls from the toilet.

The first fall occurred in February 2009, when the resident fell from the toilet and had to go the emergency room for evaluation of hip pain. After this fall, the facility should have implemented staff interventions in order to prevent additional falls. However, the facility failed to do so, and the resident fell from the toilet for a second time in June 2009. Falls are particularly dangerous for older adults who have older, weaker bones that are more susceptible to breaks (fractures). Therefore, it is very important that facility’s implement fall precautions in order to prevent resident injury.

Another complaint investigation revealed that the facility staff had knowledge that one resident suffered bruising after being physically restrained for a blood test and another resident was verbally abused. However, the staff did not implement preventative measures or report the potential for abuse to the administration in order to protect these residents and the other 52 residents from actual or potential physical or verbal abuse.

The resident who suffered physical harm was an 85 year old man with diabetes, who displayed behavioral symptoms of resisting care. The nurse woke up the resident in order to perform a blood test. The resident resisted and told the nurse that he didn’t want his blood drawn. The nurse then tried holding down the resident by placing her knee across his abdomen, even after the resident told her to stop. The nurse then called in two certified nurse aides (CNAs) for help in restraining the resident so that she could draw blood.

This incident was viewed by the resident’s roommate, who was awakened by his roommate’s screams. The roommate said that his roommate was shouting, kicking, and screaming for the nurse to stop. As a result, the resident suffered bruising across his abdomen. The nurse was counseled for “inappropriate behavior” and suspended for three days; however, the facility never performed an abuse investigation, as required. Also, the CNAs who were called into the room to help restrain the resident failed to report the mistreatment that they observed firsthand as is required by the internal reporting requirements.

Further investigation revealed that the nurse involved in the above incident was also verbally abusive to another resident. The resident reported that the nurse would yell at her to “move your a—“ and “stop being a baby” when the resident asked for pain medication. The nurse also used the “F” word at the resident. The resident and her roommate told the investigator that they didn’t report the nurse’s behavior because they didn’t want any problems. However, the resident did say that the nurse’s language “hurt her feelings.” Other facility staff members were also aware of the nurse’s verbal abuse and again failed to report the potential for abuse to the administrator in order to prevent abuse and mistreatment.

These incidents of abuse and mistreatment call into question whether Westside Rehab & Care Center can provide adequate and appropriate care for its residents, many of whom rely on the facility’s nurses and staff for activities of daily living. No resident should have to suffer physical mistreatment or verbal abuse such as the incidents reported at the facility. Although the facility has taken steps to improve staff training and intervention, it remains to be seen whether the residents will actually see an improvement in their treatment.

We represent victims of nursing home abuse and neglect.  For a free consultation, contact us (toll free) 888-424-5757.  We are here to help.

Sources:
IDPH: Westside Rehab & Care Center

Medicare: Westside Rehab & Care Center

Chicago Tribune: Compromised Care: West Side nursing home probed after death

Shelbyville Rehab & Health Care Center has 80 certified beds and a one-star (much below average) Medicare rating.  The facility is located in Shelbyville, IL.  Although the facility only had five health deficiencies between 9/1/08 and 11/30/09, a significant abuse incident (see below) occurred in 2009, which led to the facility’s poor rating. 

During an August 26, 2009 annual licensure and certification survey and complaint investigation, it was determined that the facility failed to identify one resident’s willful act of assault of another resident as an act of abuse which resulted in an Immediate Jeopardy situation.  According to the Centers for Medicare/Medicaid Services (CMS), Immediate Jeopardy (Level of Harm – Level 4) is defined as a situation in which immediate corrective action is necessary because the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in the nursing home. 

On August 7, 2009, one male resident assaulted another male resident.  The perpetrator (the resident who attacked the other resident) approached the other resident who was sitting in his wheelchair and placed him in a choke hold and began punching him in the head and yelling at him.  The resident who was attacked was immediately removed from the area and examined.  Thankfully, the resident did not suffer any injuries from the attack. 

This incident was witnessed by a Registered Nurse (RN), who reported the incident to the Administrator.  The perpetrator told the nurse that he attacked the other resident because he made him mad.  The perpetrator received counseling and was removed from the area and was supposed to be placed on 15 minute behavior checks.  Despite orders for increased supervision of the resident perpetrator following the attack, the 15 minute behavior checks never started and the Director of Nursing could not find any documentation of the order, nor could the Director of Nursing explain why the checks were never started.  In the days following the attack, the resident was allowed to move about the facility in his wheelchair without any restrictions or staff observation in order to ensure that he did not have another violent outburst. 

During interviews on August 18th, the resident perpetrator stated that he had been told that the other resident was occupying his dining table spot.  He stated that the other resident refused to move and used a curse word and threatened to “blow [his] head off with a gun.”  The perpetrator said that the grabbed the other resident to see if he had a gun or other weapon before being pulled away by facility staff.  The perpetrator denied hitting the other resident and stated that the other resident had threatened him on previous occasion.  During the incident, both the Registered Nurse (RN) and Licensed Practical Nurse (LPN) witnessed the resident perpetrator hit the other resident in the back and side of the head with a closed fist. 

The facility experienced an Immediate Jeopardy situation, beginning on August 7, following the assault.  The facility failed to identify this assault as abuse and provide necessary resident protections for all residents.  The facility did not identify an Immediate Jeopardy situation until August 18, over a week after the assault.  The facility then took steps to remove the Immediate Jeopardy by placing the resident on visual checks, providing him with a private room, and educating staff about the facility’s abuse prevention policy.  The Immediate Jeopardy was removed on August 20, 2009; however, the facility remained out of compliance because of ongoing intensive monitoring of the resident perpetrator and ongoing re-education of staff. 

The resident who was attacked actually died on August 12, just days following the attack.  However, the resident’s attending physician reported that his death was attributed to a chronic medical condition and could not correlate the death to the recent incident. 

It is alarming that multiple nursing home staff members witnessed one resident attack another resident and no measure were taken to ensure the safety of the rest of the resident population.  The resident who was attacked had the right to be free of abuse and being attacked by another resident with no following investigation or efforts to ensure his safety constitutes abuse.  This abuse investigation also revealed that the facility failed to investigate two of three abuse allegations, and also failed to properly and thoroughly screen two CNAs for criminal backgrounds and eligibility. 

Although Shelbyville Rehab & Health Care Center has a relatively low number of health deficiencies (5), the deficiencies that did occur endangered the entire resident population.  This complaint investigation survey regarding an incident of abuse reveals how even one health deficiency can have dangerous and far-reaching consequences.

Shelbyville is owned and operated by Peterson Health Care.  Peterson Health Care owns and operates Nursing Facilities, Assisted Living Facilities, Independent Living Centers, Supportive Living Facilities and Developmentally Disabled Homes.

Special thanks to Heather Kiel, J.D. for her assistance with this Nursing Homes Abuse Blog entry.

 Resources:

IDPH: Shelbyville Rehab & Healthcare Center

Medicare: Shelbyville Rehab & Healthcare Center

Related:

Feds Yank Funding From Another Chicago Nursing Home With A Troubled Past

Do Former Inmates Deserve To Be Living In Nursing Homes?

Attorney Jonathan Rosenfeld Discusses Nursing Home Violence In AARP Article

Less than a week after federal and state funding was pulled from Somerset Place, officials have moved westward to the Fox River Pavilion in their crackdown of poor nursing home care in the Chicagoland area.  Fox River Pavilion has received much scrutiny lately after reports of violence at the facility.  On December 17th, a patient at the Aurora, IL nursing home was killed in a fight with another patient.

Under-staffing was a primary reason why officials chose to pull funding from this facility.  A patient at Fox River told authorities, "Like today, you see there is really no staff around. There have been days, no staff present."

Furthermore, in the course of conducting its survey of the the facility, the Illinois Department of Public Health, Fox River Pavilion was home to 26 convicted felons.