Thursday, September 17, 2009

McAllister Nursing Home of Tinley Park Fined for Inadequate Prevention of Bed Sores

Tinley Park

McAllister Nursing Home
18300 S Lavergne Ave, Tinley Park
Fined- August 21, 2008
McAllister Nursing Home was fined $30,000 for failure to follow through on facility policy regarding prevention of and treatment for pressure sores. The facility also demonstrated a failure to implement prevention policy for residents identified as high risk for falls.
Upon investigation, surveyors found that staff did not provide appropriate treatment for pressure sores- as surveyors asked to see documented wounds, they observed that wounds were bare and often exposed to fouled diapers. Few skin care charts could be located, and those that were located were out of date.
In addition, the facility failed to prevent falls among high risk residents. Two residents suffered falls so severe they required hospitalization; two others experienced falls which was not reflected in an updated care of plan laid out by the facility.

McAllister Nursing Home Cited for Failing to Protect Residents from Abuse

Tinley Park

McAllister Nursing Home
18300 S Lavergne Ave, Tinley Park
Fined- February 19, 2008
McAllister Nursing Home was fined $10,000 for failure to protect residents and ensure they are free from abuse.
Acting against policy, the facility failed to ensure that allegations of abuse and injuries of unknown origin are investigated. Administrators also failed to remove employees accused of abuse from resident contact pending the outcome of an abuse investigation.
In one incident, a resident identified as having no memory recall difficulties stated that a nursing assistant had kicked him in the knee. According to the resident, three nursing assistants as well as the Director of Admissions for the facility were present at the time. Despite the resident’s requests for help, staff directed him to report his complaint to the Nursing Supervisor. The accused nursing assistants remained at the facility in the interim, as well as after an investigation was launched.
In another incident, a resident’s leg became caught between the footboard and the mattress. Despite the resident’s screams for help, nurses did not come to the resident’s aid until a surveyor at the facility prompted them. Upon examination, the resident’s knee appeared swollen. No documentation was made of the incident, and staff later confirmed that no abuse investigation had been initiated.

Rest Haven of South Holland Fined for Failing to Supervise Patient at Risk for Falling

South Holland

Rest Haven South Nursing Home
16300 Wausau Street, South Holland
Fined- April 2, 2008
Rest Haven South Nursing Home was fined $20,000 for failure to provide supervision for residents identified as high risk for falls.
Two residents at the facility sustained falls that resulted in treatment for fractures. Both residents had been identified as high risk for falls (one of them already had a history of multiple falls). In one case, a staff member did not consult the resident’s chart before allowing her to walk; in the other case, facility staff did not adapt the resident’s care plan after each fall to prevent additional falls.

Monday, August 31, 2009

Rolling Meadows Nursing Home Fined for Late Detection of Spinal Fracture

Rolling Meadows

Clearbrook Center
3201 West Campbell Street, Rolling Meadows
Fined- June 13, 2008
Clearbrook Center was fined $10,000 for failure to document and assess a resident’s condition change.
In an incident between two residents, one resident pushed the other one to the floor. At the time, the nurse on duty noted that there appeared to be no injuries. In the following days, the resident who was pushed started to display reluctance to stand and agitation at being moved. Eleven days after the incident, the resident was sent for X-rays, which determined that the resident suffered from a fractured femur and a compression fracture of his spine.

Clearbrook Center Assumes Patient is Dead and Fails to Initiate CPR

Rolling Meadows

Clearbrook Center
3201 West Campbell Street, Rolling Meadows
Fined- January 11, 2008
Clearbrook Center was fined $10,000 for failure to provide a resident with appropriate nursing care.
Based on interview and record review, surveyors found that facility staff did not initiate CPR on a resident who was found unresponsive but warm to the touch. Two nurses assessed the resident shortly after he was found. Neither one performed CPR because both assumed he was already dead. He was pronounced dead forty-five minutes later.

Poor Nursing Care at Glenshire Nursing and Rehab Results in Cardiac Arrest

Richton Park

Glenshire Nursing and Rehab Centre
22660 South Cicero Avenue, Richton Park
Fined- August 6, 2008
Glenshire Nursing and Rehab Centre was fined $20,000 for failure to provide a resident with appropriate nursing care.
Based on closed record review and staff interview, investigators determined that the facility failed to provide the necessary care and medical services that resulted in a resident’s blood pressure going high without medical attention for five hours. The failure to seek timely medical intervention for this potentially critical condition placed the resident at serious risk. He suffered a full cardiac arrest and died five days later after being removed from life support.

Wednesday, August 26, 2009

Separate and Unequal - Black Seniors are Not Getting the Care they Deserve

If there is one group of people that understands the effects of discrimination, it is African American seniors. After all, they’ve lived through a lot. According to a recent article in the Chicago Reporter, however, they may face one final insult when they go into a nursing home. According to the report, nursing homes where a majority of the residents are black are receiving significantly worse treatment than patients in homes with mostly white residents.

The data used by the Chicago Reporter was gathered from Medicare’s Nursing Home Compare Website. The website rates nursing homes based upon health inspections, staffing levels and other specific criteria. The researcher determined that the worst rating (a one on a five point scale) was given to 57 percent of black nursing homes and only 11 percent of white nursing homes. On the other end of the spectrum, the highest rating was given to no black nursing homes and 29 percent of homes with majority white residents. In addition, the black nursing homes had higher rates of malpractice and personal injury lawsuits.

A part of the disparity may be explained by staffing levels. Nearly 85 percent of black nursing homes received the lowest possible rating for “nursing staff hours” whereas only 21 percent of the white homes got that same rating. Similarly, the quality of the nursing home staff was rated much better in the white nursing homes.

Perhaps the most disturbing finding was that poverty did not change the results. The reporter concluded that “people in white homes got better care than those in black homes, even if both were poor.”

Most families do not have the opportunity to compare the quality of care provided at other nursing homes. As a result, the disparity between black and white nursing homes may be surprising. Many families, however, are not surprised to hear that residents are receiving inadequate care. On the contrary – they see examples of this every day.

There is much to be done to change public policy and improve care. The state needs to mandate higher staffing levels. The regulatory agencies may need to decertify more “repeat offender” nursing homes. Injured residents and their families may need to pursue their legal remedies more often. On an individual level, however, the best thing you can do is to seek out the best possible care. For some pointers on how to do that – you may wish to read our articles entitled Ten Tips for Choosing a Good Nursing Home and Recognizing and Responding to Nursing Home Neglect. (Links Below)

http://library.stotis-baird.com/index.php?option=com_content&task=view&id=37&Itemid=47
http://library.stotis-baird.com/index.php?option=com_content&task=view&id=30&Itemid=47

Thursday, July 23, 2009

Patient Asphyxiated by Bed Rails at Rest Haven Palos Heights

Rest Haven Central
13259 South Central Road, Palos Heights
Fined- August 15, 2008
Rest Haven Central was fined $20,000 for failure to supervise, assess, and monitor a resident who had been identified as high risk for falls.
The resident had demonstrated extreme agitation, particularly after nightfall. Facility staff failed to re-assess the continued need for side rails after implementation of a low bed, bed alarm, and mattress pad on the resident’s floor. As a result, the resident got her head trapped in the side rail and was asphyxiated.

Oak Park Healthcare Fails to Monitor Wandering Resident

Oak Park Healthcare Center
625 North Harlem, Oak Park
Fined- June 4, 2008
Oak Park Healthcare Center was fined $10,000 for failure to monitor a resident who was identified as a wanderer and had a history of falls.
In February of 2008, the resident managed to elope from the facility undetected. Conditions outside were cold and icy; the resident fell and was injured badly enough to require hospital emergency room admission.

Lexington of Oak Park fined for Failure to Provide Adequate Oxygen

Lexington of Orland Park
14601 South John Humphrey Drive, Orland Park
Fined- September 11, 2008
Lexington of Orland Park was fined $20,000 for failure to ensure that a resident who required continuous oxygen received it.
Despite a physician’s order that a resident receive continuous oxygen, facility staff sent the resident to a clinic appointment without oxygen. When the transport reached the clinic, the resident was found slumped over in his wheelchair and unresponsive. He was rushed to the emergency room where he coded and was subsequently revived. He died the following day.

Wednesday, July 8, 2009

The Importance of Teaching Doctors About Geriatrics

As they do every July, hospitals across America are welcoming new interns, fresh from medical school graduation. Given how much these trainees have yet to learn, common wisdom holds that it’s not a good time of year to get sick. This may be particularly true for older patients, because American medical schools require no training in geriatric medicine. [1]

This was the conclusion of a doctor and professor at Mount Sinai School of Medicine in a recent editorial in the New York Times.

Dr. Rosanne Liepzig had the courage to speak out about this serious problem. She was part of a group of doctors that recently published a report in the Journal of Academic Medicine setting forth some minimal abilities that they believe medical students should demonstrate before caring for elderly patients. The group jokingly nicknamed the report the “don’t kill granny list.”

According to Liepzig, even experienced doctors often do not appreciate the differences between a 50 year old patient and an 80 year old patient. Diseases such as pneumonia may have entirely different symptoms in a younger patient than in an elderly patient. Medication dosages for a senior may need to be 50% lower than for a patient in her 50s. The effects of lost functional mobility may also be underestimated by physicians with no training in geriatric medicine.

This gap in medical training is especially surprising given the number of geriatric patients. According to Liepzig, geriatric patients make up 48% of all inpatient hospital days and 32% of the average doctor’s workload in surgical care.

All medical students are required to have clinical experiences in pediatrics and obstetrics, even though after they graduate most will never treat a child or deliver a baby. Yet there is no requirement for any clinical training in geriatrics….” [2]

Liepzig also points out that Medicare contributes more than $8 billion dollars a year to support residency training, yet it does not require that part of that training focus on geriatrics. [3]

The Institute of Medicine reached similar conclusions in their 2008 report titled “Retooling for an Aging America.” That report concluded that all licensed health care professionals should be required to demonstrate competence in the care of older adults.

There is no question that our population is aging. The only question is when the medical establishment will start training doctors to care for them.

You can read the full text of Dr. Leipzig’s article at http://www.nytimes.com/2009/07/02/opinion/02leipzig.html


[1] The Patients Doctors Don’t Know. OpEd by Dr. Rosanne Leipzig. July 1, 2009. New York Times.
[2] The Patients Doctors Don’t Know. OpEd by Dr. Rosanne Leipzig. July 1, 2009. New York Times.
[3] The Patients Doctors Don’t Know. OpEd by Dr. Rosanne Leipzig. July 1, 2009. New York Times.

Wednesday, July 1, 2009

Regal Health Center Fined for Failing to Correct Problems with Pressure Sores

Fined- September 2, 2008
Regal Health and Rehab Center was fined $100,000 for failure to address the Plan of Correction after the March 2008 violation.
As before, surveyors determined that the facility failed to accurately assess and document all pressure sores, failed to consult with a physician regarding sores, and failed to treat observed pressure sores.
As a result, one resident was hospitalized with uncontrollable bleeding from a pressure sore wound, and another resident developed 10 pressure sores during his time in the facility and was hospitalized with a diagnosis of sepsis. A third resident died from a pressure sore that led to sepsis. A fourth resident was admitted to the facility with no wounds. Within three months, she acquired four pressure sores that became worse until she was hospitalized with dehydration and failure to thrive.

Regal Health Center Fined for Improper Treatment of Bed Sores

Regal Health and Rehab Center
9525 South Mayfield, Oak Lawn
Fined- March 24, 2008
Regal Health and Rehab Center was fined $30,000 for failure to follow through on facility policy regarding prevention of and treatment for pressure sores.
The failure was broad enough to be considered systemic. Based on observation, record review and staff interview, surveyors determined that the facility failed to identify new and recurrent pressure sores, failed to treat existing sores with current treatment orders, failed to provide preventative measures, failed to accurately asses and plan care for residents identified with or at risk for pressure sores, and failed to notify the physician of positive wound culture results.

Friday, June 19, 2009

Hampton Plaza Fined for Allowing Fire to Occur

Hampton Plaza Nursing and Rehab Center
9777 Greenwood, Niles
Fined- August 15, 2008
Hampton Plaza Nursing and Rehab Center was fined $150,000 for failure to effectively implement and follow their policy and procedure regarding smoking and failure to properly train all staff in emergency preparedness.
On May14, 2008, a fire broke out in the facility. The fire was attributed to the unsupervised smoking habits of a resident who was identified as a risk while smoking. The fire began in that resident’s room and resulted in the deaths of the resident and his roommate.
Staff was not immediately alerted to the fire, as the facility did not have properly installed battery-operated smoke detectors and had not maintained the existing smoke detectors. The facility had not conducted fire drills as required, and so once aware, staff did not follow appropriate procedure for securing the safety of residents.

Thursday, June 4, 2009

Plaza Terrace Cited for Failure to Monitor Patient

Plaza Terrace
3249 West 147th Street, Midlothian
Fined- February 28, 2008
Plaza Terrace was fined $5,000 for failure to supervise a resident who was identified as an elopement risk.
Staff failed to adequately monitor the resident, who left the facility on foot in November of 2007 without the staff’s knowledge. She walked three to four miles into Hazel Crest and was picked up by Hazel Crest police. She was found knocking on homeowners’ doors, unable to identify the facility where she resides.

Imperial of Hazel Crest Violates State Standards for Treatment of Bed Sores

Imperial of Hazel Crest
3300 West 176th Street, Hazel Crest
Fined- March 28, 2008
Imperial of Hazel Crest was fined $30,000 for failure to follow through on facility policy regarding prevention of and treatment for pressure sores.
Three residents at the facility displayed symptoms of neglect upon investigation. Surveyors determined that the facility failed to identify and assess each pressure sore that developed on these residents, and did not obtain a physician’s order for treatment of newly developed pressure sores. Staff also neglected to provide treatments and notify a physician when a resident’s pressure sore did not improve or respond to treatment within two weeks.
One of the residents developed a stage two pressure sore that was treated by facility staff without an order from the physician. The other two residents both required immediate hospitalization for treatment of pressure sores so developed that there was possible bone involvement.

Elmwood Care Fails to Provide Timely Psychiatric Consult

Elmwood Park

Elmwood Care
7733 West Grand Avenue, Elmwood Park
Fined- September 2, 2008
Elmwood Care was fined $25,000 for failure to monitor a resident with suicidal tendencies.
Based on record review and interview, investigators determined that the facility failed to follow-up on a psychiatric consultation for a resident who had talked about feeling hopeless and suicidal. The consultation was ordered but not done. The day following the scheduled consultation, the resident was found to have broken the dialysis catheter located in his jugular vein. By the time he was found, he had already bled to death.

Wednesday, May 27, 2009

Sacred Heart Home Fined for Failure to Monitor Patient on Suicide Watch

Sacred Heart Home
1550 South Albany, Chicago
Fined- December 9, 2008
Sacred Heart Home was fined $20,000 for failure to supervise a resident on suicide watch to ensure that she did not harm herself.
By December of 2007, the resident had an extensively documented history of trying to kill herself in a variety of different ways. Despite this, facility staff did not place her under consistent monitoring and in interview said they could not imagine how she could try to kill herself. In the afternoon of December 21, 2007, she was found to have thrown herself down a concrete stairwell located right next to her room.
She sustained lacerations to her head and knee as well as fractures of several vertebrae and the complete rupture of one vertebra. As a result, she was paralyzed from the waist down and placed on a ventilator.

Chicago's All Faith Pavilion Fined for Poor Management of Bed Sores

All Faith Pavilion
3500 South Giles Avenue, Chicago
Fined- October 15, 2008
All Faith Pavilion was fined $25,000 for failure to follow through on facility policy regarding prevention of and treatment for pressure sores.
Staff at the facility failed to identify, assess, and treat pressure sores on three residents. As a result, one resident experienced pressure sores that went untreated and undocumented, while a second resident had a pressure sore that was treated incorrectly. A third resident suffered from a pressure sore that remained untreated for several weeks, and was only noticed when the resident was sent to the hospital for another procedure. The sore had gone untreated for so long that it developed an E-coli infection and required emergency surgery.

Wednesday, April 29, 2009

Visit Stotis & Baird Personal Injury Blog

In addition to this Elder Law blog, Stotis & Baird Chartered maintains a Personal Injury blog at http://chicagopi.blogspot.com/. The blog contains information about topics ranging from car accidents to medical malpractice. In addition, you can find articles on a wide variety of legal topics at our main website, located at www.stotis-baird.com.

Ridgeland Nursing in Palos Heights Fined for Failing to Address Fall Risks

Ridgeland Nursing and Rehab Center
12550 South Ridgeland Avenue, Palos Heights
Fined- April 15, 2008
Ridgeland Nursing and Rehab Center was fined $20,000 for failure to provide appropriate supervision for residents who had been identified with a fall risk.
Facility staff failed to evaluate the effectiveness of interventions for fall and injury prevention, consistently track falls, or thoroughly investigate each fall incident. These failures resulted in the following injuries sustained by residents: two ankle fractures, a finger fracture, a spinal fracture, a clavicle fracture, and numerous head lacerations.

Rest Haven Resident Asphyxiated In Bed Rails Incident

Palos Heights
Rest Haven Central
13259 South Central Road, Paols Heights
Fined- August 15, 2008
Rest Haven Central was fined $20,000 for failure to supervise, assess, and monitor a resident who had been identified as high risk for falls.
The resident had demonstrated extreme agitation, particularly after nightfall. Facility staff failed to re-assess the continued need for side rails after implementation of a low bed, bed alarm, and mattress pad on the resident’s floor. As a result, the resident got her head trapped in the side rail and was asphyxiated.
.

Oak Park Healthcare Center Fined for Failure to Monitor Wandering Resident

Oak Park Healthcare Center
625 North Harlem, Oak Park
Fined- June 4, 2008
Oak Park Healthcare Center was fined $10,000 for failure to monitor a resident who was identified as a wanderer and had a history of falls.
In February of 2008, the resident managed to elope from the facility undetected. Conditions outside were cold and icy; the resident fell and was injured badly enough to require hospital emergency room admission.

Monday, April 27, 2009

Lexington of Orland Park Fined for Failing to Provide Oxygen to Resident

Orland Park

Lexington of Orland Park
14601 South John Humphrey Drive, Orland Park
Fined- September 11, 2008
Lexington of Orland Park was fined $20,000 for failure to ensure that a resident who required continuous oxygen received it.
Despite a physician’s order that a resident receive continuous oxygen, facility staff sent the resident to a clinic appointment without oxygen. When the transport reached the clinic, the resident was found slumped over in his wheelchair and unresponsive. He was rushed to the emergency room where he coded and was subsequently revived. He died the following day.

Regal Health of Oak Lawn Fined for Bed Sores Resulting in Injury and Death

Regal Health and Rehab Center
9525 South Mayfield, Oak Lawn
Fined- March 24, 2008
Regal Health and Rehab Center was fined $30,000 for failure to follow through on facility policy regarding prevention of and treatment for pressure sores.
The failure was broad enough to be considered systemic. Based on observation, record review and staff interview, surveyors determined that the facility failed to identify new and recurrent pressure sores, failed to treat existing sores with current treatment orders, failed to provide preventative measures, failed to accurately asses and plan care for residents identified with or at risk for pressure sores, and failed to notify the physician of positive wound culture results.
Fined- September 2, 2008
Regal Health and Rehab Center was fined $100,000 for failure to address the Plan of Correction after the March 2008 violation.
As before, surveyors determined that the facility failed to accurately assess and document all pressure sores, failed to consult with a physician regarding sores, and failed to treat observed pressure sores.
As a result, one resident was hospitalized with uncontrollable bleeding from a pressure sore wound, and another resident developed 10 pressure sores during his time in the facility and was hospitalized with a diagnosis of sepsis. A third resident died from a pressure sore that led to sepsis. A fourth resident was admitted to the facility with no wounds. Within three months, she acquired four pressure sores that became worse until she was hospitalized with dehydration and failure to thrive.

Monday, April 20, 2009

Hampton Plaza Cited for Inadequate Smoke Detectors

Hampton Plaza Nursing and Rehab Center
9777 Greenwood, Niles
Fined- August 15, 2008
Hampton Plaza Nursing and Rehab Center was fined $150,000 for failure to effectively implement and follow their policy and procedure regarding smoking and failure to properly train all staff in emergency preparedness.
On May14, 2008, a fire broke out in the facility. The fire was attributed to the unsupervised smoking habits of a resident who was identified as a risk while smoking. The fire began in that resident’s room and resulted in the deaths of the resident and his roommate.
Staff was not immediately alerted to the fire, as the facility did not have properly installed battery-operated smoke detectors and had not maintained the existing smoke detectors. The facility had not conducted fire drills as required, and so once aware, staff did not follow appropriate procedure for securing the safety of residents.

Plaza Terrace in Midlothian Fails to Supervise Resident

Plaza Terrace
3249 West 147th Street, Midlothian
Fined- February 28, 2008
Plaza Terrace was fined $5,000 for failure to supervise a resident who was identified as an elopement risk.
Staff failed to adequately monitor the resident, who left the facility on foot in November of 2007 without the staff’s knowledge. She walked three to four miles into Hazel Crest and was picked up by Hazel Crest police. She was found knocking on homeowners’ doors, unable to identify the facility where she resides.

Friday, April 10, 2009

Imperial of Hazel Crest Fails to Provide Adequate Treatment of Bed Sores

Imperial of Hazel Crest
3300 West 176th Street, Hazel Crest
Fined- March 28, 2008
Imperial of Hazel Crest was fined $30,000 for failure to follow through on facility policy regarding prevention of and treatment for pressure sores.
Three residents at the facility displayed symptoms of neglect upon investigation. Surveyors determined that the facility failed to identify and assess each pressure sore that developed on these residents, and did not obtain a physician’s order for treatment of newly developed pressure sores. Staff also neglected to provide treatments and notify a physician when a resident’s pressure sore did not improve or respond to treatment within two weeks.
One of the residents developed a stage two pressure sore that was treated by facility staff without an order from the physician. The other two residents both required immediate hospitalization for treatment of pressure sores so developed that there was possible bone involvement.

Elmwood Care Nursing Home Cited for Failure to Monitor Suicidal Patient

Elmwood Park

Elmwood Care
7733 West Grand Avenue, Elmwood Park
Fined- September 2, 2008
Elmwood Care was fined $25,000 for failure to monitor a resident with suicidal tendencies.
Based on record review and interview, investigators determined that the facility failed to follow-up on a psychiatric consultation for a resident who had talked about feeling hopeless and suicidal. The consultation was ordered but not done. The day following the scheduled consultation, the resident was found to have broken the dialysis catheter located in his jugular vein. By the time he was found, he had already bled to death.

Lexington of Chicago Ridge Fined for Poor Treatment

Lexington of Chicago Ridge
10300 Southwest Highway, Chicago Ridge
Fined- May 15, 2008
Lexington of Chicago Ridge was fined $30,000 for failure to provide adequate nursing care.
In one incident, a resident with a diagnosis of chronic constipation was not properly monitored. Staff failed to notice changes in the resident’s condition or to report those changes to a physician- as a result, the resident was sent to the hospital with abdominal distension and fecal impaction.
In another incident, staff failed to provide appropriate preventive measures for pressure ulcers and then failed to notice when a resident developed pressure ulcers. The ulcers continued to decline, but staff failed to asses the resident’s pain and did not obtain or administer medications to the resident.

Friday, April 3, 2009

Woodbridge Nursing Fined for Failure to Provide Emergency Power to Patients Including Those on Oxygen

Woodbridge Nursing Pavilion
2242 North Kedzie, Chicago
Fined- July 24, 2008
Woodbridge Nursing Pavilion was fined $5,000 for failure to supply emergency electrical power when the general supply was off in the area.
This failure resulted in a forty minute delay in obtaining emergency electrical power to the facility, thus placing all residents in the facility at risk for harm due to the lack of emergency power. The emergency generator did not start, and the facility was observed without any lighting, including exit signs, emergency outlets, and stairwell lighting. Flash lights were found in the basement and provided the only light during the blackout. Three residents needing, respectively, oxygen concentrators, tube feedings, and suction machines required emergency services and hospitalization.

Warren Park Nursing Fined for Sending Wrong Patient for Bone Marrow Biopsy

Warren Park Nursing Pavilion
6700 North Damen Ave, Chicago
Fined- August 15, 2008
Warren Park Nursing Pavilion was fined $15,000 for failure to follow policy for sending a resident out of the facility for a medical procedure.
Surveyors determined that facility staff did not pay sufficient attention while responding to a physician’s orders, and sent the wrong resident out for a Bone Marrow Biopsy. The resident did not understand why he was being tested, and despite asking repeatedly, no one would answer his requests to understand what the test was and why he would be getting it. The mistake was not discovered until after the procedure had been performed. The resident returned to the facility in considerable pain. His confusion remained until surveyors in the facility were approached by the resident, who asked them to investigate.

St. Agnnes Healtchare Fined for Failure to Give Oxygen and Antibiotics in a Timely Manner

St. Agnes Healthcare and Rehab Center
1725 South Wabash, Chicago
Fined- June 13, 2008
St. Agnes Healthcare and Rehab Center was fined $20,000 for failure to apply appropriate and timely medical care to residents.
Upon investigation, surveyors determined that on a number of occasions, residents did not receive proper medical care. On several occasions, residents in respiratory distress were not given oxygen in a timely manner. Seven other residents who were diagnosed with resistant infections did not receive consistent treatment and nurses did not maintain clinical tracking records for the treatment residents did receive. Of those residents, three were transferred to acute hospital care and another one died from delay and inconsistency with antibiotic treatments.
In addition, surveyors noted that crash carts were not properly supplied and that nurses who were not trained or qualified to do so were changing levels of respiratory ventilators. The facility also failed to provide licensed nursing staff with annual in-service training about policy for dealing with emergency situations.

Wednesday, March 25, 2009

Somerset Place Resident Murdered After Being Allowed to Leave Facility Unsupervised

Somerset Place
5009 North Sheridan, Chicago
Fined-August 15, 2008
Somerset Place was fined $55,000 for failure to ensure that a resident with pass restriction was prevented from leaving the facility.
The resident in question was diagnosed with Schizophrenia, Seizure and Bipolar Disorder, and was on parole for drug use while living in the facility. She had a known history of using drugs, soliciting for sex, and being physically assaulted when out of the facility.
Despite the fact that she was not permitted to leave the facility unsupervised, the resident left the grounds one evening in May of 2008. Neither the local police, nor her parole officer were made aware of her disappearance. She was found murdered in a nearby hotel room (about 4 blocks from the facility) about a week and a half later.

Rainbow Beach Care Center Fails to Report Instances of Abuse and Monitor Patients

Rainbow Beach Care Center
7325 South Exchange, Chicago
Fined-August 15, 2008
Rainbow Beach Care Center was fined $10,000 for failure to report incidents or to initiate abuse investigations despite allegations of staff-to-resident physical abuse, resident-to-resident physical abuse and resident-to-resident sexual abuse.
In one incident, a resident reported that she had been raped by another resident. He had been accused of raping the woman previously, and policy forbade him from being on her floor. Facility staff were made aware of the incident, but there was no follow-up.
Another physical altercation between a staff member and a resident was not investigated at the time- later surveyors conducted interviews and found that each participant and every witness had a different recollection of what happened.
Other incidents lacked documentation, including one in which a resident claimed to have been raped, and several where different residents were found after having been assaulted by other residents.
Fined- September 30, 2008
Rainbow Beach Care Center was fined $10,000 for failure to ensure that a resident identified with poor community survival skills received adequate monitoring and supervision to prevent the resident from wandering away from the facility.
The resident had been identified as unfit to leave the facility on his own, but ran out of the building one day in March 2008. He did not return to the facility for 7 hours, and the facility could not provide any documentation that staff had made any attempts to locate him.
Staff did not reassess the resident’s elopement risk and a month later, the resident managed to elope from the facility again. Although documentation indicated that the resident’s family was told immediately, an outside agency tracking the resident’s treatment discovered that the family was not told for three days.
The resident was found weak and disoriented a month later and could not account for his time.

Lakeview Nursing and Rehab Fined 60K for Failing to Prevent Falls

Lakeview Nursing and Rehab Center
735 West Diversy, Chicago
Fined- July 24, 2008
Lakeview Nursing and Rehab Center was fined $60,000 for failure to appropriately monitor residents who required supervision, note changes in condition which could have led to faster treatment, or implement courses of action to prevent further damage.
Between 4 am and 7:20 am, a resident at the facility suffered six falls, developed slurred speech, and was found with several medication vials, some without caps on them. No vital signs or assessments were documented for any of the incidents, and the resident was found at 7:20 am with no vital signs. Paramedics were called and the resident was declared dead twelve minutes later.
Two other residents were involved in incidents where care was delayed – one resident suffering from respiratory distress waited two hours to be sent to the hospital, and the other resident suffered a fractured leg that was not treated for two days.
In addition, the facility failed to address a rapid rise in falls among residents, resulting in multiple injuries. During the first five months of 2008, the facility reported between 19 and 27 falls per month. Despite being about to identify at-risk residents, the number of falls continued to escalate and a prevention plan was not implemented.

Wednesday, March 4, 2009

International Village Fined for Use of Dialysis Machines Without Adequate Training

International Village
4815 South Western Ave, Chicago
Fined- September 26, 2008
International Village was fined $25,000 for failing to ensure that appropriate care and services were provided by not competently assessing the access to the facility’s dialysis machine.
Staff and nurses who had not been fully trained on the facility’s dialysis machine were allowed to operate it, which led to an incident where a resident was found lying in a pool of blood from a disabled part of the dialysis machine. He was sent to the emergency room and admitted with a collapsed lung.

Hammond House Fined for Battery of Resident

Hammond House
6701 South Morgan, Chicago
Fined- June 13, 2008
Hammond House was fined $10,000 for failure to implement their policy on resident abuse.
Based on record review and interviews, investigators learned about an incident where one facility staff member came upon a resident lying on the floor, whereupon the staff member called her names and kicked her in the stomach, yelling for her to get up. Another staff member witnessed the incident and did not report it. The incident was only reported after a third staff member overheard the other two discussing the fact that they were not going to report the situation, and that they believed that was how you handled such behavior from residents.

Davis House Cited for Failure to Respond to Sexual Abuse

Davis House
4237 South Indiana Avenue, Chicago
Fined- May 22, 2008
Davis House was fined $25,000 for failure to ensure implementation of their policy prohibiting sexual abuse.
Surveyors determined that several incidents of sexual abuse took place at the facility. In February of 2008, a staff member coerced a resident to have sex with him several times. The incident was not fully investigated by the facility once the incident came to light. Subsequently, the same resident was sexually aggressive with another resident on a bus trip. The facility failed to notify the Illinois Department of Public Health and the administrator of the incident.

Friday, February 27, 2009

Dementia Patient Sets Himself on Fire While Unsupervised in Smoking Area

Ambassador Nursing Center
4900 North Bernard, Chicago
Fined-March 24, 2008
Ambassador Nursing Center was fined $25,000 for failing to monitor a resident who was identified as needing supervision.
The resident, who suffered from dementia, was recognized as requiring supervision to smoke. He wandered onto an unsupervised facility smoking patio, procured a cigarette and lighter from an unknown source and, while attempting to light it, set himself on fire. Two other residents on the patio tried to extinguish the fire but failed as flames engulfed the resident. A staff member heard the commotion, ran out to the patio, and used a fire extinguisher to put out the resident, The resident was taken to the hospital in critical condition, and shortly thereafter died.

Alshore House in Chicago Fined for Failing to Take Steps to Prevent Falls

Alshore House
2840 West Foster Ave, Chicago
Fined- February 5, 2008
Alshore House was fined $20,000 for failure to prevent and address falls among residents.
Based on observation, interviews and record review, facility staff failed to provide consistent supervision for residents who were identified as high risk for falls, neglected to complete re-assessments following each resident fall incident, and did not create updated care plans following each fall incident with specific interventions and approaches for staff to implement to prevent further falls.
Between April and December of 2007, two residents had multiple falls, resulting in numerous fractures and head injuries. Both residents required multiple trips to the emergency room to address the injuries sustained during the falls. Another resident suffered a fall as the result of continued self-transfer from bed to wheelchair despite increasing frailty. After the fall, staff neglected to alter the resident’s care plan to anticipate and prevent self-transfer.

All Faith Pavilion Fails to Prevent Beating at Chicago Nursing Home

All Faith Pavilion
3500 South Giles Avenue, Chicago
Fined- July 24, 2008
All Faith Pavilion was fined $50,000 for failure to protect one resident from his roommate, a resident with violent tendencies.
In May of 2008, a resident was found in his bed, beaten so badly in the face and head by a clock radio that he suffered several strokes and has been in a coma ever since. Evidence clearly pointed to the resident’s roommate as the perpetrator of the attack, even though he did not remember having carried it out (he suffers from dementia).
From interviews and reports, investigators determined that facility nurses and staff had observed the resident’s roommate behaving violently for several weeks. Despite numerous occasions of the resident yelling and screaming at other residents while kicking doors and walls, staff only intervened once, by walking the resident outside and calming him down.

Thursday, February 19, 2009

Alden Wentworth Fined for Failure to Treat Bedsores

Alden Wentworth Rehab and Healthcare Center
201 West 69th Street, Chicago
Fined- September 12, 2008
Alden Wentworth Rehab and Healthcare Center was fined $10,000 for failure to follow the facility’s Policy and Procedure for the Treatment and Prevention of Skin Breakdown.
Based on observation, staff interviews and clinical record, it was determined that staff failed to asses a resident for the development of bedsores, neglected to report a significant change for the worse in condition of the bedsores, and then implemented a plan of treatment without the consultation of the treating physician. An order signed by the physician turned out to have been forged by a nurse at the facility. The resident’s feet were eventually so badly damaged that she was sent to the hospital for treatment.

Alden Village North Cited for Fracturing Patient's Leg During Poorly Executed Lift

Alden Village North
7464 North Sheridan Road, Chicago
Fined- July 17, 2008
Alden Village North was fined $20,000 from a number of incidents that stemmed from a consistent problem with being short-staffed.
In one incident, a resident’s leg was fractured during a poorly executed lift, where staff did not follow guidelines for proper lifting techniques. The staff member lifted the resident alone instead of lifting with another person as required.
During the ensuing investigation period, surveyors observed nine residents with considerable bed sores, the result of staff neither following procedures for regular turning, nor consistently filling out skin care reports.
In addition, emergency carts appeared inoperable. Checklists indicated that they had not been checked in months and they were not adequately stocked for emergency use.

Bridgeview Health Care Center Fined for Neglecting Bed Sore

Bridgeview Health Care Center
8100 South Harlem Avenue, Bridgeview
Fined- June 30, 2008
Bridgeview Health Care Center was fined $20,000 for failure to provide basic nursing care.
A resident at the facility developed a pressure ulcer in January of 2008, and it remained untreated through April of the same year. Surveyors determined that the ulcer was made worse by repeated and sustained exposure to fecal matter as facility staff were slow to change the resident’s diaper. The resident eventually required hospitalization for the ulcer.

Monday, February 16, 2009

Pershing Convalescent Fined for Excessive Patient Falls

Pershing Convalescent Home
3900 South Oak Park Avenue, Berwyn
Fined- February 25, 2008
Pershing Convalescent Home was fined $20,000 for failure to prevent and address falls among residents.
Three residents experienced numerous falls at the facility during the 2007 calendar year. In one three-month period alone, one resident had four unwitnessed falls resulting in injury. Her injuries included lacerations on her head and arm, bruises on her head, and a fractured nose.
Surveyors visiting the facility learned that in addition to not supervising residents who are prone to falls, the facility failed to have in place an effective fall program. Facility administrators lacked a list that identified residents at risk for falls, as well as updated assessments, care plans, interventions, and documentation of interventions tried.

Patient Dies After Being Caught in Bed Rails at Berwyn Rehab

Berwyn Rehabilitation Center
3601 South Harlem Avenue, Berwyn
Fined- August 25, 2008
Berwyn Rehabilitation Center was fined $50,000 for an incident where established precautions were not taken to prevent a resident from becoming wedged between his bed rails and mattress, resulting in his death.
On investigation, surveyors learned that despite the fact that the resident demonstrated unsafe behaviors, including banging on the side rails and trying to get out of bed while the side rails were up, the nursing staff neglected to communicate observations of the resident’s behaviors amongst themselves or observe policies designed to keep him safe.
In particular, a vendor was allowed to replace the approved bed rails with rails that had been prohibited for this resident. Shortly afterwards, the resident was found unresponsive, having gotten caught between the prohibited bed rail and the mattress.

Blue Island Nursing Home Fined for Numerous Patient Care Issues

Blue Island Nursing Home
2427 West 127th Street, Blue Island
Fined- May 13, 2008
Blue Island Nursing Home was fined $10,000 for failure to meet a number of criteria for nursing homes set forth by the state.
In one incident, the guardian for a resident with dementia was prevented from accessing the resident’s personal funds, which were to be used for the resident’s healthcare.
In another incident, a resident with diabetes and a recent history of renal failure was not provided with the appropriate follow-up medical procedures; when procedures eventually were done, facility administrators did not report abnormal findings to the physician. The resident subsequently suffered from renal failure. In response to this episode, the facility was placed under Immediate Jeopardy. The ruling was lifted after the facility presented new policies to address communications between the physician’s office and the facility lab.
On investigation, surveyors also determined that the facility had no designated Abuse Prohibition Coordinator, and that two incidents of abuse (resident-resident and resident-staff) had never been investigated.
Surveyors also observed that established programming for the facility was not carried out- that despite posted times for activities, residents were left in their rooms or alone in common areas.
The facility was also penalized for: failure to maintain the cleanliness of the rooms, including floors, walls, ceilings, closets, and portable commodes; failure to follow physicians’ orders regarding appropriate dosage of medication, failure to monitor severe weight loss in residents, resident bedrooms that were too small, and failure to check on the competency requirements for 8 employees.

Monday, February 9, 2009

Woodbine Nursing Home Fined by Failing to Investigate Abuse Allegation

WOODBINE NURSING HOME
6909 W. North Ave. in Oak Park
FINED- November 4, 2003
Woodbine Nursing Home was fined $10,000 for failure
to report and investigate allegations of abuse by
staff members.
During an annual inspection, Department surveyors
learned the facility had information regarding abuse
of five residents by staff, but did not report this to
the Department or the residents' families and
physicians. In addition, the facility did not
thoroughly investigate the allegations and there was
no evidence corrective actions were taken.
One incident involved nursing staff forcing a
resident into the shower room. The resident, who was
terrified of shower rooms because of having been in
concentration camps during World War II, was
screaming, crying and trying to brace herself in the
doorway as she was pushed into the room.
Another incident occurred after a resident asked an
employee to change her gloves after providing personal
care to another resident. The employee removed the
gloves and then rubbed them on the resident's face.
In other instances, a resident complained a nurse
cursed at her and called her names and two residents
claimed to have sustained bruises after being
mishandled by staff.
The facility also failed to remove the employees
suspected of abuse from resident care as required by
state and federal regulations.
The Department-ordered plan of correction required the
facility to review its policy to ensure it reports all
allegations of abuse to the administrator and the
Department, and to fully investigate all reports of
abuse.

Oak Park Healthcare Center Fined for Failing to Provide Emergency Care to Seizure Patient

Oak Park Healthcare Center
Facility I.D. Number 044602
625 North Harlem
Oak Park, Il 60302
Date of Survey: 01/17/02
Complaint Investigation
"A" VIOLATION(S):
The advisory physician or medical advisory committee
shall develop policies and procedures to be followed
during the various medical emergencies that occur from
time to time in long-term care facilities. These
medical emergencies include, but are not limited to,
such things as: Other medical emergencies (for
example, convulsions and shock).
There shall be at least one staff person on duty at
all times who has been properly trained to handle the
medical emergencies listed in subsection (a) of this
Section. This staff person may also be counted in
fulfilling the requirement of subsection (d) of the
Section, if the staff person meets the specified
certification requirements. The facility must provide
the necessary care and services to attain or maintain
the highest practicable physical, mental, and
psychosocial 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. Objective observations of changes in a
resident’s condition, including mental and emotional
changes, as a means for analyzing and determining care
required and the need for further medical evaluation
and treatment shall be made by nursing staff and
recorded in the resident’s medical record. AN OWNER,
LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A
FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
Based on Interviews with Z1, Z2, Z3, E2, E5 and record
review of nursing home and hospital records, as well
as paramedic transport records, the facility failed to
provide timely assessment and emergency care to one
resident suffering with grand mal seizures from
3:55a.m. until abated by paramedics at 5:10a.m. on
1/11/02. Resident was not transported to a hospital
until 5:40a.m. for care and evaluation.
Facility failed to recognize that emergency services
were needed in a timely manner when seizure
300.1030a)5)activity did not stop and respond to 02.
Seizures did not stop until paramedics administered
Versed IM at 5:10a.m--1 hour and 15 minutes after
symptoms started.
Findings include:
R2 with known history of seizure activity had
previously low Dilantin levels, on 12/10/01 the level
was 0.4mcg/ml and on 12/20/01 the level was 1.3
mcg/ml. Normal levels are 10-20 mcg/ml
(micgrogram/milileter). Per interview with Z3, the
facility had made Z3 aware of the levels and he had
ordered Neurontin and observation to check if R2 was
med compliant. R2 has care plans to monitor for
seizures; medication administration; to monitor labs
and to notify MD (medical doctor) of abnormal levels;
to establish airway and loosen clothing, observe and
record progression of a convulsion and to monitor the
time, intensity and duration of a convulsion. There
was no documentation or interview indicating that any
of this was done.
Computerized medical records from the facility dated
01/11/02 at 7:17a.m, after R2 had already been
transferred to the hospital, stated that R2 had
episode of seizures at 4:00a.m. and M.D. ordered
transfer to hospital, but was refused and R2 was
diverted to another hospital. Surveyor interviewed Z1,
Z2, and E2, who denied that R2 was diverted from one
hospital to another. There was no evidence that R2 was
observed or positioned to maintain the airway as per
care plan. And there was evidence that the facility
failed to differentiate petit mal seizure activity
from grand mal seizure activity that was identified by
the emergency medical team upon arrival to the nursing
home.
Per interview, Z1 stated that on 01/11/02 at
approximately 4:30a.m. at the hospital, he received a
call from E5 stating that R2 has been having seizures
since 3:55a.m. (35 minutes earlier)." I asked the
nurse at the facility what had they done to stop the
seizures. The nurse stated "nothing - we are still
waiting on Superior ambulance. Z1 continued " I then
asked the nurse if this resident was still seizing and
he stated, yes. I told the nurse to call 911 since
they are faster and they can stop the seizing". Per
ambulance records, it was not until after E5 spoke
with Z1 that E5 placed a call to the ambulance service
--even though R2 was having continuous seizure
activity since 3:55a.m.
Per interview with Z2, the facility had placed 02 at 2
liters on R2 and taken minimum vital signs and nothing
else had been done. When Z2 arrived in the room at
4:50a.m., R2 was having grand mal seizures and was
left unattended. Z2 told Surveyor that E5 told Z2 that
R2 was having petit mals but upon observation, R2 was
having tonic/clonic movements indicating severe grand
mal seizures. Z2 also felt that R2 was febrile because
R2 felt extremely hot. Facility had not obtained any
temperature readings from R2 during this time. Z2
responded to the emergency by giving Versed IM,
increasing 02 to 4 liters, and applying ice packs to
both axillas. Z2 left the facility at 5:40a.m. after
stopping the seizures around 5:10a.m. The run time
record indicates that the resident arrived at the
hospital at 5:45 a.m.
Surveyor interviewed E5 on 1/16/02 at approximately
2:40p.m. E5 denied he had waited until 4:41a.m to call
the ambulance and stated that he called 5 minutes
after seizures started for R2 at 4:00a.m. E5 stated
that he administered 02 and never left the room. This
conflicts with the interviews with Z1 and Z2 and the
run sheet for the ambulance company which clearly
states that ambulance was called at 4:41a.m. not
4:00a.m. E5 admitted to talking to Z1 but at 4:00a.m.
instead of 4:30a.m. This is also contradicted in
hospital record review which lists the time of call
clearly at 4:30 to 4:40a.m.
Surveyor requested all nursing notes related to
incident - all notes that were available were received
and read. The nursing notes received concerning the
incident is the 01/11/02 at 7:17a.m entry.
Interview with E7 on 01/17/02 at the facility on
speaker phone with E1 present , E7 stated that R2 was
found unresponsive and with white of eyes showing at
3:55a.m. on 01/11/02. E7 continued "I called E5, who
came in and checked her and gave her oxygen." E7
continued, "I continued to make my rounds on the
floor, but I kept going back to check on her. I went
back at 4:00a.m., and noticed her jerking, her whole
body was jerking, and she was foaming at the mouth. I
got E5 again and he checked on her, took her vital
signs and then left the room to call her doctor. I
left the room to see where E5 was. We both left the
room!"

Wednesday, February 4, 2009

What is Probate and When is it Necessary

When a person dies, it may or may not be necessary to open a probate estate to transfer the assets of the person’s estate to his or her beneficiaries. Probate is the process by which a court oversees the collection of assets, the payment of creditors, and then the final distribution of assets to the beneficiaries of the estate. If the deceased had “individually owned” assets totaling less than $100,000, then a probate proceeding is unnecessary to transfer the assets. Retirement accounts and/or life insurance that have a designated beneficiary, and assets owned jointly with another person, are not individually owned assets and are not counted towards this threshold amount. Assuming the deceased’s individually owned assets total less than $100,000, then an interested person (who is usually a relative) may sign a small estate affidavit, which is a sworn statement that the value of the assets does not exceed $100,000, that the creditors of the estate have been paid, and that the assets will be distributed to the proper persons. Using this document, the family members may obtain the decedent’s assets from third parties, such as a bank. The Small Estate Affidavit is not effective to recover real estate or when the decedent’s individually owned assets exceed $100,000.

The “small estate affidavit” procedure allows people to avoid probate for modest sized estates. It also helps people who established trusts but failed to re-title all of their assets, so that they are “trust assets” and not individually owned assets. One common goal of an estate plan is to limit “individually owned” assets to under $100,000, through the use of trusts and other techniques. For example, any real estate could be re-titled into the name of the trust, and therefore, avoid probate. When done correctly, even a large estate can pass quickly to the beneficiaries rather than being delayed in probate.

In some cases it makes sense to open a probate proceeding regardless of the amount of the deceased’s “individually owned” assets. For instance, creditors have 2 years from the date of death to file a claim against a decedent’s estate that is not probated. If the decedent’s estate is probated, this period may be reduced considerably, to approximately 6 months after the date of death. For a decedent with potential creditor problems, it may make sense to open a probate proceeding to shorten the creditor claims period.

Through proper planning with an experienced attorney, a person can ensure his assets will be transferred in accordance with his wishes and in a manner that will avoid the necessity of opening a probate proceeding. Stotis & Baird has attorneys with experience that can answer any questions you have about estate planning or estate administration.

In a future article, we will discuss the Illinois Intestacy Statute and how it determines who receives the individually owned assets of a person that dies without signing a will or trust. It might not be what you would expect.

Concord Extended Care of Oak Lawn Receives Second Fine for Allowing Patient to Wander

CONCORD EXTENDED CARE
9401 S. Ridgeland Ave. in Oak Lawn.
FINED- January 29, 2004
The Illinois Department of Public Health has moved to
revoke the operating license of Concord Extended Care
and fined the facility $15,000 for failure to prevent
a resident from leaving the facility unsupervised.
The Department gave notice it intends to revoke
Concord's license as a result of the facility's
failure to implement an imposed plan of correction
ordered last year to ensure staff thoroughly search
all areas inside and outside the building when a
resident is missing.
Responding to a complaint, Department surveyors
learned a resident, who was wearing an electronic
monitoring device, was able to cross a busy street and
intersection before he was noticed by members of the
local fire department. Local police returned him to
the facility unharmed.
Although the resident had made repeated attempts to
leave the facility, staff did not revise his care plan
to address the behavior.
An employee heard an exit door alarm sound and
checked the area where the alarm was triggered, but
did not find anyone. The staff member then started a
headcount by checking a roster of residents instead of
first determining the location of residents equipped
with electronic monitoring devices who are prone to
wandering. While taking the headcount, the facility
received a call from the fire department notifying
them of the missing resident.
The administrator said that facility policy called
for the search outside the facility and the headcount
to be conducted at the same time.
Concord Extended Care had been fined $5,000 in
February 2003 for failing to prevent a resident from
leaving the facility unsupervised. The resident, who
had a history of wandering and wore an electronic
monitor, left the facility undetected and was found
uninjured about a half mile from the facility.
Following the incident, the facility was ordered to
ensure staff were aware that in order to locate a
missing resident all areas inside and outside the
building must be thoroughly searched.

Manor Care Oak Lawn Resident Freezes to Death After Nursing Home Fails to Monitor Resident

MANOR CARE AT OAK LAWN
6300 W. 95th St. in Oak Lawn.
FINED- June 2, 2004
Manor Care at Oak Lawn/95th was fined $10,000 for
failure to prevent a resident from leaving the
facility unsupervised.
As part of an incident report investigation,
Department surveyors learned a resident with a history
of wandering died from cold weather exposure after
leaving the facility unnoticed. The wind chill index
during the nearly two and one half hours the resident
was missing ranged from minus 12 degrees to 3 degrees
above zero.
On the day of the incident, several employees took
their dinner break at about the same time, leaving
only a nurse and two nurse aides on the unit. When a
nurse aide realized the resident was missing, she
began a search, but did not notify a supervisor or
other staff for 40 minutes. It was another hour before
police were called.
A police officer and a bystander found the resident
lying face down on a street. He was admitted to a
local hospital and died the following day of bronchial
pneumonia and hypothermia.
The resident was outfitted with an electronic
monitoring device, but staff did not recall hearing an
alarm sound. The alarm system was not checked after
the incident to see if it was working.
A Department-ordered plan of correction required the
facility to provide adequate supervision; to review
and revise, as necessary, policies for resident
wandering; and to train staff on appropriate actions
and interventions to prevent a resident from leaving
the facility unsupervised.

Monday, February 2, 2009

Resident victim of Sexual Abuse at Regal Health and Rehab

REGAL HEALTH AND REHABILITATION CENTER
9525 S. Mayfield Ave. in Oak Lawn
FINED- April 21, 2004
Regal Health and Rehabilitation Center was fined
$10,000 for failure to immediately and thoroughly
investigate an alleged sexual assault.
Responding to complaints, Department surveyors
learned an employee witnessed another employee
sexually assault a resident. Although the incident was
reported to the facility's administration, it was two
days before an investigation was launched. The
facility also waited two days before notifying the
resident's physician and representative, the local
police and the Department.
The resident was not taken to a hospital for an
examination and the facility did not save the
resident's clothing and bed linens for evidence. Most
of the staff was unaware of the facility's abuse
policy or what should be done after an allegation of
sexual abuse.
The alleged attacker was fired after he cornered the
witness in a room following her report of the
incident. He has been charged with aggravated criminal
sexual assault and unlawful restraint.
A Department-ordered plan of correction required the
facility to conduct immediate and thorough
investigations; to review and revise, if necessary,
its policies on abuse; and to train staff on
appropriate actions and interventions to prevent
resident abuse and on the reporting process when there
is an allegation of abuse.

Concord Extended Care of Oak Lawn Cited for Allowing Patient to Wander

CONCORD EXTENDED CARE
9401 S. Ridgeland Ave. in Oak Lawn
FINED- 2003
Concord Extended Care was fined $5,000 for failure to
prevent a resident from leaving the facility.
As part of an incident investigation, Department
surveyors learned a resident, who had a history of
wandering and wore an electronic monitor, left the
facility undetected. The resident was found unharmed
about a half mile from the facility by an employee of
a neighboring long-term care facility.
The resident had made four previous attempts to leave
the facility, the last one occurring two days prior to
the elopement. Nursing staff told surveyors that the
resident, who was confused and anxious, had to be
watched frequently and monitored every two hours.
There was no evidence this was done.
Staff did not hear the resident's alarm sound when he
slipped out of the facility. Following the incident,
staff determined the resident left through one of two
back doors. One door had an audible alarm and the
other was equipped with a sensor to detect electronic
monitors. Maintenance was called to check the alarm
on one of the back doors, but failed to ensure that
all facility doors were functioning properly. During
the investigation, a surveyor observed the testing of
another facility door with an electronic sensor.
The alarm was only audible when standing near the
door. The Department-ordered plan of correction
required the facility to provide residents with
adequate supervision and to ensure all
resident-accessible exterior doors are equipped with
functional alarms or are monitored by constant visual
supervision.

Monday, January 19, 2009

Glen Bridge Nursing and Rehab Fails to Seek Timely Emergency Care for Resident

Niles
GLEN BRIDGE NURSING AND REHABILITATION CENTRE
8333 W. Golf Road in Niles
FINED- November 14, 2001
Glen Bridge Nursing and Rehabilitation Centre WAS
fined $10,500 for failure to seek timely emergency
care for a resident with a head injury.
Responding to complaints, surveyors learned it took
nearly 2 hours from the time a resident was found with
a head injury until she arrived at the hospital for
treatment.
After the resident emerged from a room with blood
dripping from the back of her head, an ambulance was
called. When informed the ambulance could not arrive
quickly, staff suggested it come within 30 minutes.
The ambulance, however, did not arrive for about an
hour. The resident’s condition worsened, but staff did
not arrange for immediate medical assistance.
A facility nurse left a message for the resident’s
physician, but the physician did not get the message
in a timely manner. The physician indicated 9-1-1
should have been called and he should have been paged.
Interviews with staff revealed the resident complained
of a headache, her eyes started to droop and she
became increasingly sleepy and lethargic.
When the resident was admitted to the hospital, she
was comatose and placed on life support. The family
withdrew life support the following day and the
resident died. According to the coroner’s report, the
resident died of a subdural hematoma due to blunt head
trauma.
A Department-ordered plan of correction required the
facility to notify a resident’s physician in a timely
manner of any accident, injury or significant change
in condition; to have written policies and procedures
for medical emergencies and to ensure staff follows
them; and to record changes in a resident’s condition
in the resident’s medical record.
.

Resident of Manor at Lincolnwood Place Dies After Facility Fails to Monitor

MANOR AT LINCOLNWOOD PLACE
7000 N. McCormick Blvd. in Lincolnwood.
FINED- June 7, 2001
Manor at Lincolnwood Place was fined $10,000 for
failure to adequately supervise a resident with a
history of wandering.
Responding to an incident report, Department
investigators learned a resident left the facility
unnoticed about 2 a.m. and was found the next morning
face down in the snow between two vehicles in an
automobile dealership parking lot which is about 1,000
feet from the facility. The woman was transported to a
local hospital emergency department where she was
pronounced dead from hypothermia.
The resident, who had been missing for about six
hours, was dressed only in a housecoat and was not
wearing shoes. The overnight temperature was between 8
degrees and 10 degrees.
Per staff interviews, surveyors found the resident
had been wandering around the facility much of the
previous evening and had to be redirected to her room
several times. While conducting rounds, a nurse -- who
had previously guided the resident back to her room --
noticed the resident was not in her room and a search
of the facility failed to locate her.
It is assumed the resident left through an east exit
door that is also used as an entrance for the
facility's assisted living section. This door requires
a key card to enter the facility, but there is no
alarm on the door or key card required for exit.
A Department-ordered plan of correction required the
facility to ensure that supervision precautions are in
place for residents diagnosed with wandering behaviors
and that all resident-accessible exterior doors are
equipped with an alarm or are visually monitored.

Wednesday, January 14, 2009

Problems with Long Term Care Insurance

According to the U.S. Department of Health and Human Services, 70 percent of people over age 65 will require long term care services at some point during their lives. Contrary to popular belief, most of these services are not covered by Medicare. And the cost of this care is high. The average cost of a private room in a nursing home is $209/day. And in many areas, the cost is higher. It is not surprising, then, that people are interested in purchasing long term care insurance.

Unfortunately, purchasing long term care insurance may not be the answer. After reviewing 47 long term care insurance policies, Consumer Reports recently concluded that long term care insurance is too risky and too expensive for most people. A combination of fine print exclusions and unfair practices is denying benefits to thousands of seniors.

Inherent Problems

All insurance policies offer to pay for some “losses” and not others. This is not necessarily unfair, as long as the limitations of the policy are properly explained. Here are some common limitations of current long term care insurance policies:

Your premiums can increase

…and they probably will. Most LTC policies do not contain a restriction on premium increases. This is a problem because, you must keep your long term care insurance in force continuously in order to collect the benefits. Many seniors pay the premiums for many years, but eventually have to drop the coverage because the premiums become too high. If you stop the coverage, you have simply lost that money.

Your benefits may not increase

…but the cost of medical care will. Policies that do not provide increased coverage based upon the rate of inflation can leave you without adequate coverage. A policy which guarantees to pay $200 a day may be sufficient now, but it won’t be in 2020.

They won’t start paying immediately.

Many policies have an elimination period of 30, 60 or 90 days before they will pay any benefits. Most policies will only pay if you can prove a certain level of disability. Some even have provisions that they will only pay if you are transferred to a nursing home after a hospital stay. This can be important because, according to the government, 57% of people go to a nursing home without a prior hospitalization.

They won’t pay forever

Most LTC policies do not pay for nursing care indefinitely. Many policies limit coverage to 4 years. There are also policies that cover less. It is important to know how long they will pay.
They won’t pay for everything

In addition to limiting total payments, there are many services that are not covered. Some plans will not cover home care, even though they would cover the same treatment in a nursing home. Some will only cover “skilled care” and exclude many necessary routine functions that a nursing home would ordinarily provide.

What would cause me to forfeit the policy

Do you forfeit the policy if you miss one payment? Are you required to make payments even when you are collecting benefits? Does the insurance company have to notify somebody else of a potential forfeiture if I develop dementia? These are all important questions to ask.

Is the policy renewable?

This has become less of a problem in recent years. In some early policies, however, the insurance company could simply decide not to renew the coverage. If they fail to renew the policy when you are ill or over 70, (for example), it may not be possible to get other coverage.

All of problems described above are considered “fair” practices for insurance companies. The difficulty is that many consumers don’t know these limitations when they buy the policy. Inquiring about these potential limitations can help you to ensure that you are getting what you paid for.


Unfair Tactics

Unfortunately, there are also some unfair tactics that insurance companies use to deny coverage. If you are a victim of one of these tactics, you should contact the state insurance commissioner. If you cannot resolve the dispute, you may even need to contact a lawyer. Here are a few common tactics:

Agent Overselling

Long term care insurance agents make a substantial commission on each sale. Unethical agents will paint a rosy picture of all of the benefits the policy offers, and downplay any limitations. Remember that the written insurance policy and NOT the agents promises will govern your coverage. It is almost impossible to prove that the agent lied to you about what you would receive. You should assume that if it is not in writing, it doesn’t exist. Given the length of time you will pay for the policy, you should get a copy of the policy and review it before you buy it.

They say I don’t need nursing home care

Insurance companies have a long history of denying medical treatments that they believe are unnecessary. It is not uncommon for them to require a policyholder to visit a doctor chosen by the insurance company for an exam. These doctors are likely to be more concerned about pleasing the insurance company than the patient.

They rescinded my policy for “misrepresentations” on my insurance application

A common practice by unethical insurance companies is to rescind coverage long after the policy was issued. Here’s how it works. The policy application asks you to list any medical conditions that you have. The insurance agent encourages you to only list the “important” conditions. You write down the major stuff, but forget a minor back injury that has mostly resolved. The policy is issued and you pay the premiums for a year or so. A problem arises and you need the coverage. You submit a claim. Instead of paying, the insurance company orders all of your medical records, going back ten years. They discover the back injury and claim that you “misrepresented” your health condition. As a result, they rescind the policy, return your premiums and deny the claim. To get the coverage, you have to fight them in court. This can be difficult when you are near the end of life and in a nursing home.

One way to avoid this problem is to disclose everything on your insurance application. Do not trust an agent who suggests that you don’t have to list everything.


Deliberate bureaucratic hassles

Several long term care insurance companies have become notorious for making it so difficult to make a claim that their policy holders simply give up. The New York Times recently reported that “some long-term-care insurers have developed procedures that make it difficult – if not impossible – for policyholders to get paid.”[1] For example, in 2003, a subsidiary of Conseco insurance sent an 85 year old woman suffering from dementia the wrong form to fill out, according to a lawsuit, then denied her claim because of improper paperwork. In California alone, nearly one in every four long-term-care claims was denied in 2005.

If you, or a family member, are a victim of one of these practices, you may need to fight for your rights. If you are unsuccessful on your own, you may consider calling the Illinois Department of Insurance to make a complaint. The Illinois Attorney General is another option. If none of these are successful, it may be necessary to consult a lawyer.

[1] “Aged, Frail and Denied Care by Their Insurers” New York Times, March 26, 2007

Monday, January 12, 2009

LaGrange Rehab Center Fails to Follow Procedures Following Accident

LaGrange
LAGRANGE REHAB CENTER
339 S. Ninth Ave. in LaGrange
FINED- April 9, 2001
LaGrange Rehab Center was fined $10,000 for failing
to ensure its staff was properly trained to provide
emergency care services for residents involved in
accidents.
Responding to an incident report, Department
investigators learned that a resident, who had a
history of pacing and wandering, became entangled in
his gown and a privacy curtain and was found by staff
sitting on the floor next to his bed. The material was
wrapped around his neck, and he was not breathing. The
resident died due to strangulation.
Per record review and staff interviews, surveyors
were unable to determine what, if any, life-sustaining
measures were taken by facility staff.
Staff removed the material from the resident's neck
and checked for a pulse, but made no other assessment
of his condition. Two staff members then moved the
resident into his bed, while a third employee reported
the resident's death to a facility supervisor. One of
the employees indicated no attempt was made to
resuscitate the resident because he had a Do Not
Resuscitate (DNR) order. None of the employees
involved in this incident had cardiopulmonary
resuscitation (CPR) certification.
Facility policies and procedures for accidents and
emergency care instruct employees not to move a
resident, but to assess his condition by checking for
pulse, airway, breathing and circulation and, if the
resident is viable, to begin emergency services.
Policies also address the application of DNR orders
for residents when the incident is an unnatural
accident.
Investigators determined the three employees involved
in the incident did not follow applicable policies and
procedures.
A Department-ordered plan of correction required the
facility to ensure that policies and procedures are in
place for handling medical emergencies and that staff
are properly trained to provide emergency services.

Mercy Nursing in Homewood Fails to Perform CPR

Homewood

MERCY NURSING HEALTHCARE AND REHABILITATION CENTER
19000 Halsted St. in Homewood
FINED- 2002
Mercy Nursing Healthcare and Rehabilitation Center
was fined $10,000 for failure to provide adequate and
emergency nursing care to prevent a resident death.
Responding to a complaint, Department investigators
learned facility staff did not immediately notify a
resident's physician of her deteriorating condition
and, when the woman became unresponsive, did not
perform cardiopulmonary resuscitation (CPR),
incorrectly believing the woman had a "Do Not
Resuscitate" order. The resident expired.
A review of the resident's record found family
members noticed she was not eating and had become
increasingly lethargic. The family requested a
physician evaluate her condition and she was to be
seen the next time a doctor was at the facility.
Records indicate facility staff did not notify the
resident's physician of her declining condition for
more than 17 hours and did not send her to the
hospital after her doctor did not immediately respond
to a page.
The facility failed to follow its policy to contact
the resident's physician or the facility's medical
director or to send the resident to the hospital when
a significant change in a resident's condition occurs.
A Department ordered plan of correction required the
facility to train its staff on proper resident
monitoring and procedures to immediately notify a
physician when there is a significant change in a
resident's condition.

Friday, January 9, 2009

Hickory Nursing Pavilion cited for Failure to Supervise Confused Patient

Hickory Hills
HICKORY NURSING PAVILION
9246 S. Roberts Road
FINED- 2006
Hickory Nursing Pavilion was fined $15,000 for
failure to provide adequate supervision to a confused
resident identified as at risk for leaving the
facility. The resident left the facility without staff
knowledge and was found walking in traffic by police.

Imperial of Hazel Crest Fined for Failing to Supervise Resident

Hazel Crest
IMPERIAL OF HAZEL CREST
3300 W. 175th St. in Hazel Crest

FINED- 2006
Imperial of Hazel Crest was fined $20,000 for
neglecting a resident by failing to provide specific
supervision, monitoring, treatment and care. The staff
had not checked on the resident for approximately
14-hours due to the resident's aggressive behavior
toward staff. The resident was found behind a
barricaded room door, dead on the floor.
Hickory Hills

Tuesday, January 6, 2009

Alden Heather Fails to Prevent Patient from Wandering

FINED- 2003
Alden Heather Rehab and Health Care Center was fined
$50,000 for failure to take necessary precautions to
prevent a resident from leaving the facility
unsupervised.
Responding to a complaint, Department surveyors
learned a resident, who had a history of wandering,
left the facility unnoticed and froze to death before
staff found her in an alley behind the nursing home.
When staff realized the resident was missing, the
building and grounds were searched and the resident
was found in the snow, wearing only a T-shirt, sweat
pants and slippers. Her body temperature was 84
degrees.
A review of the nurse's notes revealed that the
resident would wander during the night and had
previously attempted to leave the facility. Because of
this behavior, her whereabouts were to be monitored
every two hours. However, there was no evidence that
this was done.
During the Department's investigation, surveyors
observed that the facility's front doors did not have
an alarm. The administrator told surveyors that the
doors were monitored between 8 a.m. and 8 p.m. There
was no supervision of the doors during the time the
resident left the facility.
The Department-ordered plan of correction required
the facility to provide residents with adequate
supervision and to ensure all resident-accessible exit
doors are equipped with functional alarms or are
constantly monitored.

Alden Harvey Fined for Failing to Investigate and Report Sexual Assault of Resident

Harvey

ALDEN HEATHER REHABILITATION AND HEALTH CARE CENTER
15600 S. Honore St. in Harvey
FINED- May 21, 2002
Alden Heather Rehabilitation and Health Care Center
was fined $10,000 for failure to properly investigate
or to report the sexual assault of a resident by
another resident.
Responding to a complaint, Department surveyors
learned the facility administrator, after being
informed a resident had sexually assaulted another
resident, instructed staff not to notify the
resident's physician or call police, as required by
the facility's abuse policy. The administrator also
told staff to write an incident report, but not to
include it in the residents' files.
According to staff interviews, the man led a
confused, non-verbal woman resident into his room and
barricaded the door with a night stand while he
assaulted her. Fifteen minutes prior to this incident,
an aide stopped the man from taking the same resident
into his room, redirected the woman back to her room,
which was about 50 feet away, and left her alone.
Family members contacted police about 18 hours after
the attack and asked facility staff to send the
resident to the hospital to be examined by a
physician. The resident's doctor told surveyors he was
notified when the woman was taken to the hospital, but
only told a male resident had been found in her room.
Following the assault, facility staff did not
re-evaluate the man's care plan or take steps to
protect other residents. The man was arrested for
rape, but his physician was not notified until about
12 hours after he was taken into custody.
A Department-ordered plan of correction required
facility administration to initiate a complete and
thorough investigation into allegations of abuse, to
notify the appropriate authorities of suspected abuse,
to conduct an immediate evaluation of the alleged
perpetrator and to protect its residents from harm.

Clearbrook-Wright Nursing Home Fined for Failure to Detect and Treat Bed Sore

Gurnee
CLEARBROOK-WRIGHT HOME
34377 N. Almond Road in Gurnee.
FINED- September 5, 2003
Clearbrook was fined $10,000 after a resident
developed a pressure sore behind his left knee that
went unnoticed and untreated for about a month. By the
time the sore was discovered, the resident’s tendon
was exposed. The pressure sore may have been caused by
a protective device that was left on the resident’s
knee for an extended period of time. Staff did not
notice the pressure sore because they did not
completely remove the device or look at the back of
the resident’s knee while giving him a bath.