Monday, November 1, 2010

South Holland Nursing Home Fined for Failing to Attend to Bedsore

Phoenix Court
17312 Clyde Avenue, South Holland, IL 60473
Fined- January 6, 2009
Phoenix Court was fined $20,000 for not properly attending to a resident’s sore. Over the course of three weeks, the resident developed a bedsore that eventually turned black and reached all the way to the resident’s hip bone. Although staff noticed the sore getting worse, they did not implement policy to make sure the man lay on his other side sometimes. In addition, he was not given medicine for the bedsore each time his diaper was changed.
The resident was eventually admitted to the hospital.

Meadows Nursing of Rolling Meadows Fined for Failing to Report Neglect

3250 South Plum Grove Road, Rolling Meadows, IL 60008
Fined- March 2, 2009
Meadows was fined $10,000 for failure to report and follow up on an incident of neglect. A resident who was found to have put a foreign object into his rectum was prescribed 24 hour surveillance. Within two days, the resident was left alone and proceeded to insert another foreign object into his rectum. The first time, the resident required surgery and a colostomy; the second time, the object was removed at the hospital without surgery.

Clearbrook East of Rolling Meadows Fined for Failing to Prevent Falls

Clearbrook East
3802 South Old Wilke Road, Rolling Meadows, 60008
Fined- January 8, 2009
Clearbrook East was fined $15,000 for failure to implement preventative falling measures for a resident who was ambulatory and prone to seizures. In a five-month period, staff documented that the resident fell thirteen times, the last of which caused her to sustain two fractured ribs.

Cicero Nursing Home Fined For Failure to Monitor Bedsores

Westshire Nursing and Rehab Center
5825 West Cermak Road, Cicero, IL 60804
Fined- February 18, 2009
Westshire Nursing and Rehab Center was fined $35,000 and its license was placed in Immediate Jeopardy for failure to monitor residents at risk for pressure sores. Of the eight residents examined at the facility, all of whom were considered at risk, five had pressure sores.
The sores ranged from mild to severe, and included pressure ulcers that were infected with fecal matter and had eaten away to the bone.
In addition to not providing preventive measures, nurses at the facility did not know how to treat the sores (either topically or with antibiotics), and did not notify the physician of the ulcers. Regular assessments for residents were incomplete, preventing investigators from getting a full picture of each resident’s health.

Southview Manor Chicago Fined for Smoke Detector Violations

Southview Manor
3311 S. Michigan Ave, Chicago, IL 60616
Fined-January 8, 2009
Southview Manor was fined $5,000 for failure to enforce smoking policies.
Of 94 rooms, 76 did not have smoke detectors in them. None of the smoke detectors in the rooms either worked or had batteries. On the day of the investigation, a resident started a fire in a room- firefighters were called and the building evacuated. Immediately upon reentering the building, two residents were found smoking in a stairwell.
Fined- February 18, 2009
Southview Manor was fined $15,000 for failure to assess, individualize treatment plans, and implement those plans so that residents with histories of drug abuse and addiction were encouraged to be drug-free and healthy.
The facility has no reliable method for preventing residents from bringing drugs and drug paraphernalia into the facility with them- this failure resulted in an incident where a resident was found unresponsive on the bathroom floor after injecting himself with drugs in the stomach and behind the ear.
Surveyors also determined that there were no individualized treatment plans at the facility. Residents were not given specific progressive intervention, and upon investigation, several residents said that they had asked for services (to be part of a particular group, to get help moving to a less structured living situation) were disregarded.

South Shore Fined for Failing to Examine Abdomen

South Shore
2649 East 75th St, Chicago IL 60649
Fined- January 6, 2009
South Shore was fined $25,000 for the neglect of a resident with a serious medical condition.
The 86-year old resident, who was described as alert and oriented, complained of stomach pain. Her daughter alerted staff to the complaint, and told them that her mother’s abdomen was swollen and hard. Staff assured her that an ultrasound would be done; when the daughter called the next day, she found that her mother had not been examined and the physician had not been told.
At that point, the resident was sent to the hospital with a suspected Ruptured Abdominal Aneurysm which required emergency surgery.

Somerset Place Fined by State for Violations

Somerset Place
5009 North Sheridan, Chicago IL 60640
Fined- February 9, 2009
Somerset Place was fined a total of $25,000 for several different types of violations.
The facility failed to have a plan of action or intervention for resident to resident abuse- as a result the number of incidents in the facility was found to be high, and several documented incidents of resolving conflict were fairly violent. In September of 2008, there were a total of 44 documented altercations between residents.
One resident with suicidal thoughts was not monitored, and was found (alive and unharmed) with a shoelace tied to the bathtub faucet and around his neck.
Residents have the right to be fully informed about changes in their treatment- however, in a sampling of 30 residents, 5 were shown to have been given psychotropic medications without giving consent themselves or having had a guardian give consent. For some residents, this included up to three medicines at a time.
In addition, the facility disregarded regulations prescribing residents’ right to timely mail delivery, access to personal financial information, and access to the facility’s latest evaluation. Residents’ rooms were entered without permission and they were found to be wearing torn clothing. The facility appeared to not be kept up- for example, many of the rooms were dirty and cluttered; the bathrooms were moldy, dirty, and smelled of urine; clean, adequate clothing storage was not provided to every resident; garbage was uncollected and filled to the brim in several rooms.

Alden Village Chicago Fails to Monitor Resident

Alden Village North
7464 North Sheridan Rd, Chicago, IL 60626
Fined- January 26, 2009
Alden Village North was fined $35,000 for the death of a 12-year old non-ambulatory and non-verbal resident.
Nurses assigned to the resident left early and arrived late, allowing for a period of time during which he was unmonitored. Though the actual cause of his death was unclear, examination revealed a lapse in a number of policies, including: disregard for a physician’s order to monitor the resident overnight; failure to notice that a unauthorized staff member stopped, disconnected, reconnected and restarted the resident’s feeding tube; failure to fill out a report on the resident’s status before the shift change during which he became unresponsive and subsequently died.