Found and fined: Violations that matter

December 4, 2011

Here's a look at some of the problems the state found and issued fines for in nursing homes across Central Illinois, based on a review of the state's quarterly reports of nursing home violators.

Illini Heritage Rehab & Health Care, Champaign - March 2011

This nursing home was fined $5,000 after it failed to clear snow and ice from three of four emergency exits.

The ice and snow had been on the sidewalks for eight

Though the main exit was free of snow and ice, one emergency exit door could only be opened 12 inches, and snow and ice had accumulated five to six inches along sidewalk. At another exit near the resident room corridor, the door was able to open but had two inches of encrusted snow and ice along the sidewalk.

Additionally, 38 of the 39 residents were in wheelchairs.

The failure to keep the sidewalks clear prevented “a clear pathway for egress for residents in the event of a fire or need for evacuation. This failure placed all 49 residents at risk.”

(Full report

North Logan Healthcare Center, Danville - February 2011

The facility did not do a criminal background check for three new residents between November 2010 and January 2011 as required by law. 

Residents must be screened for criminal offenses and sex offenses within 24 hours of admittance. It was a repeat violation.

The facility was fined $500.

(Full report

Heritage Manor, Bloomington - May 2010

A woman brought her husband to the facility to move him in on Saturday. The couple had paid a $5,000 deposit the day before.

The man needed assistance into the nursing home. Instead of waiting for a wheelchair, a nurse's aide put the new resident in the flip-down seat of the wheeled walker he brought with him and tried to push him in that walker.

Employees later told inspectors that they wanted to get the man into the facility rather than wait for a wheelchair as is policy because “it was chilly and raining at the time.”

During the move,  the walker’s arms “folded together” and the man fell backwards and hit his head.

He was taken to the hospital, where he had surgery for swelling and bleeding in the brain; however, he never regained consciousness and later died.

In an interview with inspectors, the administrator stated the man “was not admitted to the facility when the occurrence happened. We (facility) considered (the resident) as a guest and treated and delivered care as a good Samaritan."

The facility was fined $20,000 in August 2010.

(Full report

Paris Health Care Center, Paris - April 2010

A 62-year old woman was admitted to the facility for rehabilitation following a hospital stay in March 2010. She was “eager to get better and go home.” After a second hospital stay, she was readmitted to the facility in late May.

At 9 a.m. one morning three days after her readmission, the resident was given her medication as usual. Half an hour later the woman was given a bed bath and a nurses’s report indicated that the resident had shortness of breath.

The resident asked a nurse’s aide to check her oxygen level.

The nurse’s aide passed along the request to an employee who gathered up an oxygen monitor went into the resident’s room.

The employee found the resident with blue lips and nails and not responsive. The employee went to the nurse’s station to check the resident’s code staus and then went to find the director of nursing, who was outside in the smoking area near her office.

The employee told the director to “come quick.” They both returned to the resident’s room to call a code and start CPR.

A note indicated that the resident was found unresponsive at 10:10 a.m. and CPR was initiated.

Emergency crews took the woman to the hospital at 10:47 a.m. where she died about 10 minutes later.

The facility was fined $20,000  for the incident.

(Full report

Danville Care Center, Danville - June 2010

The facility failed to prevent the spread of infections and failed to isolate residents with infectious illnesses.

In one instance, the staff allowed a resident who had an uninfected surgical wound to stay in the same room with a resident who had a case of MRSA. The uninfected resident developed MRSA as a result.

Staff did not wear protective gowns during the care of the residents and did not dispose of the gowns in a dedicated container. Staff also failed to disinfect equipment used to care for the infected residents.

The facility was fined $10,000

(Full report

Hawthorn Inn of Danville, Danville  - March 2010

A resident suffered bleeding from her stomach, bruising to her chest and cuts to her right foot after the facility failed to follow her doctor’s orders regarding medication.

She was hospitalized twice within two weeks. The resident was on Coumadin, which acts as a blood thinner.

Her doctor reported: “I was not told of the Coumadin medication error. I would have ordered another PT/INR (test for blood clotting). Was the facility aware? The only medication errors the facility has called me about are antibiotics which is unacceptable. Coumadin is more serious. I don't trust monthly PT/INR's. My personal policy is every two weeks for someone on Coumadin. I depend on the facility to follow my orders. It is a check and balance system. They get the labs as ordered and it reminds me to order the next one. If they don't follow my orders and someone gets hurt they are negligent."

The facility was fined $10,000.

(Full report

Heartland of Normal, Normal - March 2010

An incapacitated resident told nurses that “a man touched me,” and “I was woke up and his hand was where it shouldn’t be,” and explained that his hand was on her vaginal area.

The suspect, an employee at the facility, was suspended from work but allowed to return before the investigation was completed. The incident was not reported to police until the next day.

The facility was fined $10,000 for failing to completely investigate the allegation of sexual abuse, for failing to report it to police immediately and for allowing the alleged suspects to continue to work.

(Full report

Lincoln Manor, Decatur - October 2009

A resident who had a history of falls tipped his wheelchair over and hit the exposed metal rail that was suppose to house the foot board of his bed.

According to reports, there are seven beds in the facility without foot rails and each of them have a metal bracket that extends out from the foot of the bed in an L shape.

When the resident tipped his wheelchair over, his neck hit the metal foot frame and caused a cut eight to 10 centimeters long along the lower left jaw, through the back of the neck and then through the bottom of his mouth. He also received cuts to his lip and left ear.

The resident was taken to the emergency room.

The accident prevented the resident from swallowing, and the family opted for no feeding tubes. He died eight days later.

A nurse’s report noted that the resident’s “medical condition was pretty stable up to the point of the accident. I would certainly think that this accident contributed significantly to (resident’s) death. The resulting trauma inhibited (the resident’s) ability to swallow.”

The facility was fined $30,000.

(Full report)

Asta Care Center of Bloomington,  Bloomington - August 2009

An incapacitated female resident was in the facility’s dining room and talking with a male resident who is a known sex offender.

A staff member saw them holding hands as the female resident “always grabs for someone’s hand to hold.”

The employee told the male resident to go and watch a movie on TV, which was a few feet away. He told her he didn’t like the movie.

The employee left them alone to find someone to help, and as they were coming back into the dining room, she saw that the male resident was touching the female resident’s breast.

“I did not realize he could offend that fast,” the employee said. “I have not had any training in dealing with sexual predators.”

The male resident was new with a strong history of “fondling unalert/non-oriented females.”

He was transferred to a new facility.

In an interview with inspectors, the male resident said, “I was able to walk around the building as I wanted to. I walked myself to my meals ... The staff never watched where I was at, I went where I wanted to go ... No, I never touched any of the ladies. Women are nothing to me. Women are nothing for me."

The facility was fined $10,000.

(Full report)

Imboden Creek Living Center,  Decatur - November 2009

Five residents fell a collective 62 times between October 2008 and August 2009.

One resident fell 30 times and sustained a hip fracture.

Another resident, who fell 10 times in nearly seven months, lost two teeth and sustained a left hip fracture.

Still another resident fell and fractured an arm.

It is noted in one case that the facility did not assess how some of the falls occurred and what interventions were used to prevent falls.

The facility was fined $35,000.

(Full report

Source: Illinois Department of Public Health