Articles Posted in Quarterly Violator List

Our examination continues of the latest report of Illinois nursing homes that have violated basic resident health, care, and safety laws. Rainbow Beach Car e Center, a nursing home just north of the city in Evanston, recently received several Type “A Violations from the Illinois Department of Public Health and fined $10,000. The violations resulted from the facility’s failure to ensure the proper monitoring of residents with specific mental illnesses and at risk of elopement.

Many residents at the facility have specific care needs and pose specific risks to themselves and others. One group of residents with special mental problems are deemed “elopement risks”-they exhibit behavior that make it more likely that they could attempt to leave the facility unmonitored. These residents are under unique care plans that include special monitoring and check-ins to ensure their safety.

When those policies are not followed severe consequences often result. For example, one mentally ill resident at Rainbow Beach ended up leaving the facility unbeknownst to the caregivers. The resident was gone for over 10 days and traveled over 25 miles. The resident wandered across railroad tracks and burst intersections without supervision. Afterwards the resident was very confused and may have suffered set-backs in his mental health development.

Wandering remains a serious problem at many nursing homes. It is only a matter of luck that the resident did not suffer severe physical harm in this case-others are not that fortunate.
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Today we continue our examination of the latest report of Illinois nursing homes that have been found to have violated basic laws concerning resident health, care, and safety. Searles Group Home, a nursing home in Rockford, recently received several Type “A Violations from the Illinois Department of Public Health and fined $10,000. The violations resulted from the facility’s failure to take proper steps after the allegation of physical abuse of a resident by one of its employees.

Earlier this year a resident at the facility with severe mental retardation was discovered with a strange bruise on her wrist. The employee who discovered it found it suspicious and asked her co-workers about it. At first it was assumed that the resident must have bumped into something. However, upon more investigation two employees admitted that the resident told her another direct service worker had hit her, causing the bruise.

As with most facilities, the nursing home has clear policies related to the appropriate contact and force that any employee should use on a resident. It also has plans that need to be followed after abuse is discovered so that other residents are not harmed by the dangerous employee.

Unfortunately, none of those procedures were followed in this case. The staff member involved was not suspended or disciplined in any way. The allegation of abuse went nowhere. The employee remained in her regular duties without any steps taken to protect other residents or punish the abuser.
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Our look at the latest report of Illinois nursing homes that have been found to have violated basic laws concerning resident health, care, and safety continues today. A Chicago-area nursing home, Pine Terrace, located in Waukegan recently received several Type “A Violations from the Illinois Department of Public Health and fined $40,000. The violations resulted in part from the facility’s poor treatment of several residents suffering from pneumonia.

Specifically, investigators of the facility reported that there was inadequate care given to residents with pneumonia in the small sample of residents examined, placing over a dozen at risk for severe illness or death.

Overall, the Illinois nursing home failed to ensure that nurses completed an on-going assessment of the sick individuals after the diagnosis, including basic lapses like no monitoring of vital signs, temperature, and lung sounds. The facility did not abide by general hospital guidelines regarding the activity of residents with the illness including ensuring proper rest and drinking milk.

The staff involved in treating the residents were not trained in recognizing any signs or symptoms of pneumonia. That inadequate training likely affected the poor care given to the residents suffering from the potentially life threatening complication. The immune systems of many residents are particularly vulnerable. It is therefore unconscionable that staff members and medical personnel at a nursing home would be untrained and ill-equipment to provide even the most basic pneumonia-related care to help save these residents’ lives.
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The Illinois Department of Public Health recently released the latest list of nursing homes found to have violated basic laws concerning resident health, care, and safety. One of those negligent nursing homes, The Monroe Pavilion and Health Treatment Center, recently received several Type “A” Violations from the Illinois Department and fined $15,000. The sanctions resulted from, among other events, the failure to prevents and appropriately respond the physical assault of one resident on another.

One of the violations included failure to prevent a violent physical altercation between two residents. Apparently an aggressive resident became agitated following being asked a question by a second resident. The aggressor picked up a patio chair nearby and swung it at the side of the other resident’s head, cutting the side of the man’s face and his right arm. The victim fell onto the ground following the attack, at which point the aggressor began kicking the downed resident. The victim had to be transported to the hospital with multiple facial injuries and a arm laceration.

Subsequently, nursing home investigators discovered that the facility provided inefficient oversight of the potentially violent resident-creating an environment where the attack was more likely to happen. Additionally, the facility had inadequate procedures in place to respond to the event and ensure the safety of all residents.
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Another of the many Illinois nursing homes that was cited for care violations by the Illinois Department of Public Health was the Evergreen Health Care Center on South Kedzie in Evergreen Park. The nursing home was charged with several Type “A” Violations from the Illinois department and was fined $30,000. The large fine was caused by several different act of negligent care at the facility that put many residents in extreme danger, leading to the death of one victim.

For example, a resident was admitted to the facility after suffering from abdominal pain, leg swelling, and many other medical problems. She was prescribed an intravenous drug, to be administered 12 hours a day. The resident’s medical condition deteriorated over the next month, however. After one apparent problematic rise in her condition a private ambulance was called. Paramedics noticed that the woman’s blood pressure was much worse than the nurse had indicated. They also observed that the intravenous drug had been removed. The emergency medical crews were unable to start a new intravenous program and the resident went into cardiac arrest. She died at the hospital shortly after.

Later, officials conceded that there was problematic care provided to the resident. Her change in condition was not properly noted by employees and 911 should have been called instead of a regular ambulance.
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One of the many Chicago nursing homes that was recently cited for care violations by the Illinois Department of Public Health was the Columbus Manor Residential Care Home, located on the 5100 block West Jackson Boulevard. The nursing home was charged with several Type “A” Violations from the Illinois department and was fined $15,000. The violations resulted from the facility’s failure to properly protect and report on abuse of several residents by others.

One nursing home resident was found sad and tearful at the facility one evening. Upon further investigation, officials realized that the resident had an injury on her arm. It appeared to be a significant sore. When asked further, the resident admitted that another individual at the facility had burned a cigarette out on her arm. Apparently, the victimized resident had told the aggressor that she was not allowed to smoke in that location and asked her to extinguish the cigarette. That led the smoker to get angry and put the cigarette out on the victim’s arm.

The report of the incident prepared by nursing home employees makes no mention of the alleged aggressor or concerns about retaliation by other residents. Also, the employees failed to confiscate the cigarettes and take any steps to ensure that similar actions were not taken in the future.

In one of several other acts of negligence, staff members failed to stop one resident from physically and sexually assaulting another. The 67-year old victim was in her bed one night when a male resident entered. The intruding resident inappropriately grabbed the victim in bed and made sexual demands. When the victim refused the abuser punched her in the face and started choking her. The attack only ended when other residents heard the commotion and rushed into the room.

These represent only two of several horrific acts of negligent care documented in this latest report.
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We continue our look at Chicago nursing homes that were recently cited for violations by the Illinois Department of Public Health. Earlier this year Alden Wentworth Rehab Center, a facility located on West 69th Street, recently received several Type “A” Violations from the Illinois Department of Public Health and was fined $20,000. The violations were given as a result of various acts of negligence, including failure to investigate allegations of residents abusing one another and the facility’s failure to follow even basic nutrition guidelines in feeding residents.

When inspectors visited the facility, they noticed that the meal being served for lunch appeared to be quite small. A hamburger was served that weighed only 2.2 ounces. It was also documented that many residents were not fed lunch until late. Other basic nutritional procedures were not followed by the staff members of the facility.

In addition, the Chicago nursing home breached its own policy protocol after one female resident accused a male resident of sexually assaulting her-no investigation or action of any kind was taken by the nursing home. The victim reported being approached by the aggressor while she was in bed. He tried to kiss her but she rebuffed him. The man then became forceful, eventually touching her inappropriately.

Even after the incident, the aggressive resident had free reign of all the floors and locations in the facility. At the time of the nursing home inspection, little to nothing had been done following the alleged abuse.
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Unfortunately, many Chicago nursing homes are found on the Quarterly Violator List of negligent facilities by the Illinois Department of Public Health. For example, Warren Park Health and Living Center located at the 6700 block of North Damen recently received several Type “A” Violations from the Illinois Department of Public Health and was fined $20,000. The violations were given as a result of negligent care that led to the death of a suicidal resident while taking a bath.

The victim was admitted to the facility earlier this year with several ailments, including bi-polar disorder, chronic obstructive pulmonary disease, and noted suicidal ideation. A few months ago, the resident was found unresponsive in a tub room on the first floor. The woman was laying face up in the tub with the water pouring full blast straight into her mouth. The resident died at a local hospital shortly after.

An investigation into the event revealed the resident had told other employees several times before of her desire to commit suicide. Specifically, she had previously tried to drown herself-only a month before this incident. She was placed on monitoring over those concerns, but that monitoring lapsed.

Overall, the facility did not have any policies and procedures in place to ensure that residents did not have unfettered access to the unsupervised tub room. They did not fill out an appropriate incident report following this accident, nor did they pass along the information to the Regional Health Department as required.
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