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

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

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
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,
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
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

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

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

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

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

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