Inspectors find negligence, abuse in central Illinois nursing homes

You are currently viewing Inspectors find negligence, abuse in central Illinois nursing homesDarrell Hoemann
A review of Illinois Department of Public Health documents found that one of the residents at Champaign Urbana Nursing and Rehab left the facility alone and traveled nearly 40 miles away.

State officials have conducted hundreds of complaint-based nursing home inspections across central Illinois since 2011.

In the seven Medicare-certified nursing homes in Champaign County alone, inspectors from the Illinois Department of Public Health conducted at least 114 complaint-based inspections.

The department of public health sends inspectors to investigate nursing homes after somebody files a complaint, which residents or representatives for residents can do by calling 1-800-252-4343. They can also fill out and submit this form.

Inspectors also investigate nursing homes each year through an annual recertification process.

A review of central Illinois nursing home inspection reports found that typical violations were failing to report health issues, to prevent urinary tract infections, to deliver medication and to care for pressure sores. More serious violations included violence, abuse and sanitary negligence.

While some violations result in fines, others do not.

Below is a list of a eight serious issues that inspectors recorded throughout the past three years. The examples portray the range of problems found in nursing homes.

Eastview Terrace, Sullivan: February 2013

Nursing homes can only use physical restraints for a medical purpose, not for convenience.

A resident noted as “severely cognitively impaired” upon admittance died after she strangled on the seatbelt used to restrain her in her wheelchair.

The resident had dementia and other conditions. The nurses used the seatbelt to keep her from sliding out of her wheelchair.

A nurse contacted the family for initial permission to use the seatbelt, and the family consented. No medical purpose for the restraint was ever documented.

The incident contributed to a $50,000 fine, according to Illinois Department of Public Health records.

“Eastview Terrace always strives to provide the best care possible to all residents,” said Julie Hearst, the facility’s director of census development. “We provide care to seniors who are often not in good health and with multiple illnesses or injuries, and, unfortunately, sometimes unavoidable and unforeseen events occur.”

LeRoy Manor, Le Roy: March 2014

Employees heard yelling from “down the hall” and found a resident on top of another resident in the room. The resident on top’s hands covered the other resident’s mouth and nose, and when a staff member pulled the aggressor off, the victim was slow to respond.

The two residents were roommates and the perpetrator had “a history of intrusive behaviors, which included wandering into people’s rooms constantly drug seeking,” according to a report detailing the incident.

Nursing home officials did not notify the aggressor or victim’s physicians or attorneys until hours after the incident. They also did not report it to the police.

When an inspector interviewed the LeRoy Manor administrator, the administrator did not know the nursing home’s policy on abuse. The administrator also did not know what situations required law enforcement.

The incident was one of the violations that led to a $25,000 fine, according to Illinois Department of Public Health records.

Le Roy Manor declined to comment on the incident.

Heartland of Decatur, Decatur: November 2012

A verbal-abuse allegation was reported when inspectors learned that, for “more than a month or so,” two certified nursing assistants had been saying “mean things” to a resident.

The report on the allegation described that a resident constantly asked where her husband was, and two certified nursing assistants would whisper: “[He] is at home with me. I’m [having sex with] your husband.” The two employees would whisper other things of that nature into the resident’s ear, “making her cry.”

A third certified nursing assistant eventually reported the allegation. She said she waited so long to do so because she was hoping someone else would overhear the nurses.

Illinois Department of Public Health records show the nursing home was fined $1,100 for its November 2012 violations.

Heartland of Decatur did not respond to a request for comment on the incident.

Champaign Urbana Nursing and Rehab, Savoy: August 2014

One night, a resident with dementia who was classified as an “elopement risk,” fled from the nursing home and traveled alone to another city 38 miles away.

An evening certified nursing assistant told another staff member that the resident was “gone.” The other staff member thought the nursing assistant meant he checked out of the nursing home and was with family.

The employees did not know the resident had to wear an electronic monitoring bracelet or that the resident was an elopement risk.

At 4:25 in the morning, a third staff member realized the resident was missing and initiated a search.

Staff members contacted the missing resident’s family. Police later picked the resident up from a family friend’s house that morning. When asked how he got out without triggering the electronic bracelet alarm, the resident said, “The girl at the front desk turned it off and let me go.”

Champaign Urbana Nursing and Rehab’s policy is that residents should be checked on at least every two hours.

As of Dec. 17, Illinois Department of Public Health records show a fine has not yet been posted linked to this incident.

Champaign Urbana Nursing and Rehab declined to comment on the incident.

Champaign County Nursing Home, Urbana: March 2011

Champaign County Nursing Home “neglected to follow the policy for bedpan use” for one resident who eventually developed a severe pressure sore on her buttocks in the shape of a bedpan.

When the pressure sore was first discovered, staff failed to schedule doctor treatment for the resident and failed to monitor the ongoing condition of the sore. As a result, the pressure sore became infected and led to a blood infection that needed hospitalization, surgery and intravenous antibiotics.

Even after the resident was hospitalized, the nursing home failed to notify state officials of the incident.

“She was out of it,” one employee told investigators. “When we took her off the bedpan, we saw the impression of the bedpan. Her bottom was broke down. My impression was somebody left her on the bedpan…”

Illinois Department of Public Health records list a $25,000 fine for April 2011.

Champaign County Nursing Home did not respond to a request for comment on the incident.

Heartland of Champaign, Champaign: August 2013

In December 2012, nurses noted a resident had a blister on his left heel. A month later, nurses noted the blister developed into a heel ulcer. They then made an appointment for the resident at the wound clinic.

An inspection report describing the injury stated that the wound-clinic staff did not know about the heel issue. Instead, the wound-clinic staff reported on previous groin wounds.

A physician at the wound clinic said Heartland staff should have called when the resident was sent back without new medication or instructions. Instead, staff did not make another appointment until they documented the issue a month later.

They then neglected to take the resident to that appointment.

It took five months from the first documentation of the heel ulcer for the resident to see a physician. Treatment required hospitalization at that point.

In an inspection report, an Illinois Department of Public Health inspector noted, “Delaying the Wound Clinic Consult contributed to the development of osteomyelitis,” a bone infection typically caused by bacteria.

As of Dec. 17, Illinois Department of Public Health records show a fine has not yet been posted linked to this incident.

Heartland of Champaign did not respond to a request for comment on the incident.

Helia Healthcare of Champaign, Champaign: February 2014

Helia Healthcare of Champaign failed to document and report problems to a physician when a resident was admitted to the facility with a stage-three pressure sore in October.

There was no documentation of the sore until almost a month later when the nurse wrote that it was a new sore. The resident’s physician did not call to make him an appointment in the wound clinic until a week after that.

Although the wound clinic records said treatment should be done twice daily, staff only took care of the wound once a day and there was no documented treatment for 10 days in December.

A nursing home employee said the wound clinic physician canceled the resident’s appointment in December because he had a meeting and could not reschedule until the end of January.

The sore became worse, and the resident did not see a wound physician until mid-January, when he was admitted to the hospital. At the end of January, the physician said it was clearly an avoidable sore, since it was responding to treatment.

Illinois Department of Public Health records list a $25,000 fine for February 2014, which includes this and other violations.

Helia Healthcare of Champaign declined to comment on the incident.

Illini Heritage Rehab and Healthcare, Champaign: May 2012

Nursing homes are not allowed to use side rails or any other means of physical restraint to punish residents, or because the restraint is convenient for staff. Restraints should only be used for medical purposes.

Upon a recertification inspection, inspectors found Illini Heritage Rehab and Healthcare representatives could not identify a medical reason to use side rails for two residents that day.

A certified nursing assistant said she used full side rails on one woman’s bed to prevent her from getting up and falling. A side rail assessment two months prior to the inspection stated there was no need to use side rails on the resident’s bed.

The U.S. Food and Drug Administration reported that between 1985 and 2009, 480 people died from side-rail related injuries.

The incident contributed to a $6,250 fine, according to Illinois Department of Public Health records.

“We haven’t had a fine since I came in the building, since 2012,” said Chris Collins, the facility’s administrator. “So, I can’t comment on that fine.”

Additional reporting by Robert Holly/

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