At the Emerald Park Health Care Center, a Chicago nursing home, the following incidents were noted by IDPH surveyors:
•A resident with a history of alcohol use got drunk, passed out and was carried to his room by an employee. After being put to bed, the resident was not checked by staff. He was found in cardiac arrest by another resident about 11 hours later and was pronounced dead at a local hospital.
• Staff did not monitor other residents who were often intoxicated and their care plans did not note alcohol was a problem.
• An employee pulled off a resident’s wig and threw it on top of a fan. Nursing staff witnessed the incident, but did not intervene. The supervisor said she told the employee to never do it again, but did not report it because she did not feel it was abuse.
• On another occasion, the same resident had a swollen face and was admitted to the hospital with a brain hemorrhage. The administrator did not investigate the injuries or notify the Department as required by state law.
• A resident with a history of wandering was able to leave the facility through a basement door. Staff frequently switched off the door alarm to accept deliveries, but did not provide visual supervision of the exit as required by facility policy.
• Specialized rehabilitative services were not provided to those residents identified with mental illness or substance abuse problems.
• No plans were in place to assist residents with re-integration into the community or to prevent residents from engaging in harmful behaviors.
The Illinois Department of Health produces quarterly reports on nursing home violators. To access the website: http://www.idph.state.il.us/about/nursing_home_violations/quarterlyreports.htm