Ludeman Developmental Center releases COVID-19 statistics showing 313 COVID infections and 10 deaths. Levin & Perconti, Illinois nursing home lawyers launch investigation into gross negligence in preventing the spread of COVID-19
On May 29, 2020, Ludeman Developmental Center, located in Park Forest, Illinois, released long term care outbreak data reporting of laboratory confirmed COVID-19 outbreak cases. These statics confirm that 313 infections and 10 deaths have occurred at the facility during the COVID-19 outbreak.
On May 8, 2020, CBS Chicago detailed the COVID-19 outbreaks occurring at Ludeman Developmental Center, providing that the number of infections at the facility had doubled in just the last three weeks. At the time the article was written, of the 1,200 residents and staff on campus, 266 had tested positive for COVID-19, more than double the number of infections on April 20. Additionally, more than 56% of the resident had at one point tested positive along with 7% of the staff. The article further mentions the outbreak was so severe at the facility that at one point the National Guard was called in to give temperature checks and administer questionnaires to visitors. On May 10, 2020, the Chicago Tribune featured an article detailing the COVID-19 outbreak at Ludeman Developmental Center, providing much of the same facts and data as the CBS article along with issues regarding staff at the facility not having the proper protective equipment at times during the pandemic.
The Illinois Department of Public Health conducts yearly recertification procedures in which nursing homes are subjected to a review of their regulatory history and any violations occurring at the home. Furthermore, during the recertification process, when a nursing home has been found to have committed a regulatory violation, the facility is subsequently required to submit a plan of correction for how it will remedy the violation or prevent similar violations from occurring in the future.
For Ludeman Developmental Center, a survey in regard to a complaint investigation conducted on January 24, 2020 found the facility failed to ensure there was immediate notification of the Administrator on Duty regarding an allegation of abuse impacting a resident. Moreover, another survey conducted on the same day found the facility’s governing body failed to exercise operating direction over the facility adversely affecting residents and their overall health and wellbeing. Yet another survey was conducted on January 17, 2020, in which the governing body failed to ensure that the switchboard operator has a back up to receive emergency calls, and further failed to ensure a resident who is non-responsive with a DNR status in place ensures their DNR policy addresses who to call when such a situation arises. Specifically, the investigation detailed the occurrence of a resident being found non-responsive and due to his DNR status paramedics did not attempt to resuscitate and the resident was pronounced deceased. After staff found the resident unresponsive, they attempted to call emergency services but because of the aforementioned issues with the switchboard, emergency personnel were not reached until it was too late.
The 2016 recertification survey conducted on August 30, 2016 found the facility’s governing body failed to provide general operating over the facility and further failed to maintain appropriate and sanitary living environments affecting dozens of residents. Specifically, bathrooms in the facility were not equipped with the necessary materials and one bathroom in particular was found to have feces smeared on the base of a toilet. Furthermore, the same survey found instances in which the facility failed to ensure medications were given in accordance with physician’s orders, and to ensure a resident was checked every thirty minutes while using an abdominal binder.
The 2017 recertification survey conducted on August 31, 2017, found the facility’s governing body failed to develop and implement a system which, in a timely manner, identified and resolved maintenance issues. Specifically, the failure to implement this system resulted in the facility not being cleaned or well-maintained which was evidenced by broken countertops in living spaces with glass panes missing. Additionally, the bathrooms had appliances that were not functioning properly and were also found to be missing basic amenities such as soap and paper towels. Moreover, this same survey found that the facility’s plan of correction from May 17, 2017 was not being followed as the same issues that plan was supposed to resolve were still occurring in the facility, namely the failure to ensure medication carts were secured and properly labeled. This failure to abide by their plan of correction demonstrates the facility’s unwillingness to implement appropriate and adequate policies and procedures to maintain the well-being of its residents.
For 2018, two recertification surveys were conducted for Ludeman Developmental Center on June 21, 2018 and November 11, 2018. The June survey details several issues with bathrooms at the facility, similar to those expressed in the 2017 recertification survey with missing or deficient appliances and materials. Moreover, the facility was found to have failed to ensure residents privacy during personal hygiene (toileting and showering), and further failed to ensure a thorough investigation into an altercation occurring in the facility. Lastly, this survey found the facility failed to ensure staff demonstrated techniques needed to provide ongoing monitoring of residents.
The November survey coincided with a follow-up visit regarding a significant event report from September involving a missing resident and the facility’s failure to appropriately and adequately monitor the resident. Once more, the facility was found to have failed to ensure both health measures were maintained, and that medications were administered in accordance with physician’s orders. Another clear indication that the facility was not adequately implementing its plan of corrections as the same failures had been noted in previous recertification surveys.
As for 2019, the recertification survey conducted on August 30, 2019 found the facility failed to ensure confidential personal information was concealed from public access or viewing. Additionally, the facility was again found to have failed to immediately report and investigate an allegation of abuse affecting multiple residents, and this resulted in a subsequent failure to prevent further potential abuse after the allegation occurred. Moreover, the facility failed to ensure dignity was maintained for multiple residents as the facility specifically failed to ensure clothing was placed on them correctly, failed to ensure shoelaces were tied and secured, and failed to change clothing that was saturated with food debris. Lastly, the facility was found to have failed to ensure appropriate and preventative health and hygiene measures were implemented for several residents including neither sanitizing of dining room tables nor washing and sanitizing residents’ hands before eating.
The 2020 recertification survey conducted on January 24, 2020 repeated several of the previous survey findings including the facility’s failure to ensure there was immediate notification of the Administrator on Duty regarding an allegation of abuse and failure to ensure all medications were locked and secured and out of public view or access. As has been previously mentioned, these findings of repeated neglect by the staff at this facility and the subsequent failure to implement and follow its plans of correction demonstrate an overall failure by this facility to maintain an adequate environment for its residents.
Founding partner Steven M. Levin described these outbreaks in many Illinois Nursing Homes: “for many years prior to this outbreak, Ludeman Developmental Center operated with insufficient staff and with a lack of adherence to recognized infection control protocols. It is not surprising that they were ill equipped to handle this outbreak.”
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As COVID-19 continues to spread, it has also magnified systemic breakdowns within Illinois’ long-term care facilities, nursing homes, or assisted living centers. After this latest release of reported data by IDPH, more than half of the COVID-19-related fatalities in Illinois have now occurred at these facilities.