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.