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More on the Problems at Sauk Valley

We recently posted about the disappointing record attributed to nursing home facilities in Sauk Valley by a nursing home watchdog and advocacy group. In Dixon County, for example, a nursing home was cited after failing to properly observe a patient who required CPR, and no CPR was administered because of a disorganized and inaccurate file maintained on the patient that led aides to believe he should not be resuscitated. It was also found that the facility and others did not maintain up-to-date web pages as required by law.

The watchdog group, Families for Better Care, conducted a lengthy and in-depth investigation that yielded even more information than what we briefly touched on in a prior post. The majority of homes in the area were hit with at least one severe deficiency citation in approximately the last two years. Yet in multiple instances the homes’ fines were reduced in spite of the need for sanctions that could actually foment change in how they operate. The overall failures are disturbing in light of the fact that the nursing home industry is heavily regulated in the state of Illinois through both the Nursing Home Care Act as well as federal regulations tied to Medicare, Medicaid and any other federal programs. As reported, last year the state health agency employed 228 surveyors to investigate 4,575 complaints within Illinois.

In addition to Dixon County, the Polo Rehab and Health care Center in Illinois also experienced an incident worthy of sanctions. A resident there reported that they were feeling anxious, and the nurse on duty duly made note of that. A quarter hour later, the resident experienced bluish-colored skin and a severely diminished level of oxygen in their body. After a head nurse took out the patient’s tracheostomy tube and was unable to put it back in, the resident stopped breathing and staff tried to revive the patient with chest compressions as the patient’s oxygen level continued to decrease while an ambulance was on its way. However, nursing staff did not do as they should have because the tracheostomy tube should not be removed in full, but only in part so manual resuscitation can be performed. There was only an oxygen mask used in this case after the tube was completely removed, and the patient’s heart rate dropped more while she lacked oxygen for approximately ten minutes. After this horrible experience in which she also went into multiple seizures, the patient died less than a week later.

The nursing home was subsequently sent an enforcement letter by the Centers for Medicare and Medicaid (the federal sub-agency that regulated homes accepting federal funds through those programs) that listed the violations and CMS also fined them over $30,000. The Illinois Department of Public Health (IDPH) informed the facility it must get its tracheostomy tube and respiration procedures and protocols in compliance by a certain date, and also fined the facility $25,000 separate from the federal sanctions. As is part of the protocol, the facility can also respond with a proposed “plan of correction” to address and remedy the sanctioned deficiencies. Polo Rehab did so in this case, including plans to properly train staff in these areas and to require some CPR-certified aides on staff at all times.

The Sauk Valley study examined 20 different nursing homes across Lee County, Whiteside County, Ogle County, and Carroll County, as well as one facility in Bureau County. Potential residents and their loved ones should examine these facilities’ records closely, and ensure that they are up to speed with regulations and that they are in compliance. These homes appear to contribute to Illinois’ overall ‘F’ rating by the Families for Better Care group.

See Other Blog Posts:

Sobering Statistics on the Elderly Population and Abuse

Negligent Caregiving at Hospital Results in $6 Million Levin & Perconti Settlement