Two families are questioning why their loved ones died at Cahokia Nursing and Rehabilitation Center. The Illinois Department of Public Health and the Illinois State Police are investigating their deaths, and two top officials at the facility — the administrator and director of nursing — have resigned.
Fred Jones of Centreville believes his cousin John Brown Jr., 76, would still be alive if he had received proper care while at the facility.
Jones said Brown developed Alzheimer’s and sometimes would wander down the street, because he loved to walk.
Jones couldn’t keep track of his cousin 24 hours a day, so he placed him at Cahokia Nursing and Rehab Center, located at 2 Annable Court.
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“I thought it was dangerous,” Jones said of Brown’s tendency to wander, “but the nursing home turned out to be more dangerous than the street.
Brown died April 8 at a hospital after he had choked on some oatmeal at the nursing home. Staff members couldn’t immediately perform the Heimlich maneuver on Brown because he was tied to a chair.
Jones said he didn’t see it himself, but was told Brown choked and went limp and was transported to a hospital.
Brown wasn’t the only resident of Cahokia Nursing and Rehab Center to die in April after unusual circumstances.
It’s difficult for Ann Jackson, 65, of Cahokia to talk about the death of her aunt Pauline Purifoy, who was also a resident at Cahokia Nursing and Rehab Center.
“It’s just sad. I know she was 86 years old. It’s just sad the way she left here,” Jackson said.
Jackson said she received a call from the nursing home that her aunt was throwing up bile and was being transported to the hospital. Purifoy died the next day, on April 18.
“If they had been documenting it, they would have known she was constipated,” said Jackson, who used to work in a hospital and knows nurses should document a patient’s bowel movements. “It hurts to think about that.”
Prior to that instance, Jackson said Purifoy was sent to the hospital for having blood in her urine, which was caused by a clogged urine bag.
Illinois State Police agents are investigating Purifoy’s death. Jackson said an ISP agent visited her home to speak to her about her aunt’s death.
A spokesman for the ISP said he couldn’t comment, because it’s an active investigation.
The Illinois Department of Public Health investigated two deaths of residents at the Cahokia Nursing and Rehab Center that occurred in April, according to IDPH spokeswoman Melaney Arnold. Citing privacy rules, she wouldn’t say if the deaths investigated were those of Brown and Purifoy.
“We cited the facility for improper care prior to the two deaths,” Arnold said.
State health investigators were at the facility on May 6. The 52-page report, which details the department’s findings, can be found online.
“At this time there are no fines associated with the May 6, 2015 inspection, but we are requiring the facility to submit a Plan of Correction and we will revisit the facility,” Arnold said.
Robin Suydam, regional director of operations, provided the following statement on behalf of the facility: “Cahokia Nursing and Rehabilitation Center is committed to ensuring that each of its residents receives the appropriate care and services to support their physical, social and psychosocial needs, and is proud of the efforts of its employees in meeting the needs of its population. Recently the facility received complaints alleging a variety of resident care and treatment issues. Unfortunately as a health care provider we cannot provide any specific information or details surrounding the complaints or any individuals that may have been the subject of a complaint out of respect for privacy and confidentiality rights.”
She went on to say the facility takes “all complaints seriously, have ourselves initiated reviews of the allegations set forth in those complaints and have, at all times, cooperated fully with any and all state investigations into those allegations.”
Suydam said Cahokia Nursing and Rehabilitation Center has accepted the resignation of Janice Kalz, administrator, on May 15 and Mary Johnson, director of nursing, on May 20, and “will continue to take all the necessary steps to ensure that our residents receive quality care.”
Both the Jones and Jackson families received anonymous letters in the mail from a then-employee of the nursing home about the care their loved ones received while at the facility.
Health department’s findings
An incident form dated March 29 was filed by a nurse about a resident at the facility who started choking while strapped to a chair, according to the online report dated May 6. Neither the employee nor resident is identified by name in the report.
“I (E32) turned around saw his (R20’s) mouth wide open and tears began to roll down his face. I (E32) immediately pulled resident away from table to lower his chair and turn him on his side. Attempted to do so x2-3 times. Examined R20 to see what was stopping me (E32) from turning R20 on his side. Pulled his shirt up and noted R20 had a gait belt strapping him to his chair with opening behind R20’s chair. Proceeded to remove belt at this time. Assistance arrived. Got R29 out of chair and performed the Heimlich Maneuver. Was able to clear R20 of obstruction which was oatmeal,” the report stated.
According to the report, that use of restraints was a violation of state law.
On April 22, E9, a certified nurse assistant, stated she was the one caring for R20 at the time of the choking incident. “E9 stated she put the gait belt around R20 tying it to the back of R20’s wheelchair to keep him safe while she (E9) passed breakfast trays,” the report stated. “E9 stated she was sent home by E1, (administrator), because they (the facility) would have to do investigation on using the restraint. E9 further stated no one was aware that she had used the gait belt on R20 as a restraint.”
The report recommended giving more instruction to the CNA on unauthorized use of restraints.
The state was never notified of R20’s choking incident on March 29. In an interview April 30 with state investigators, the administrator stated she did not know she was supposed to notify IDPH. “We (facility) are not planning to file a report. We will get the Statement of Deficiency and then see if we need to file a report,” the administrator stated, according to the online report dated May 6.
The state found the facility failed to meet its abuse policy by not reporting an allegation of abuse to the state agency in a timely manner.
The report also found that employees failed to provide care or services for highest well-being.
The facility failed to provide timely assessment and monitor for changes in condition for a resident identified only as R10, according to the report.
“This failure resulted (R10) having a delay in hospitalization and treatment,” the report stated. “R10 was admitted to a local emergency and subsequently to the Intensive Care Unit, with diagnoses of Hypotension, Sepsis, Hyperkalemia, Illeus, Vomiting and Dehydration.”
On April 16, R10 was observed lying crumpled down in her bed and moaning off and on, according to the report, and she had “green pasty material, which appeared to be vomitus, crusted around her mouth, down her chin and neck, and on the front of R10’s gown.”
The pain-management record and the nurse’s notes for the day shift failed to document any information on R10’s moaning, pain or vomiting, the report states.
On April 29, Z3, physician on call, stated on April 16, he was called in reference to R10’s feeding tube orders and was not told R10 had vomited during the day.
“He stated that although she does have a history of periodic vomiting, he feels the staff should have told him, he would want to know,” the report stated. “Z3 stated he does not know if sending R10 to the hospital sooner would have changed her outcome, due to her multiple medical problems but had he known of the nausea and vomiting, he would have admitted R10 to the hospital for fluids and evaluation earlier that day.”
The report also found the facility failed to “provide assistance for timely toileting and hygiene” for 8 of 14 residents, including R10, and failed to follow its policy for timely repositioning of residents for “pressure ulcer prevention” for seven of 10 residents in the sample of 28.
The facility failed to provide timely monitoring and ensure food intake met the required amount ordered by the physician, the report stated, for four residents with feeding tubes in the sample of 28. The report stated this failure resulted in significant weight losses for the four residents, including R10, who was admitted to the hospital in part due to dehydration.
Families hire lawyers
Jones is working with an attorney out of Chicago. “There will be a suit brought against the nursing home,” he said.
Jones remembered his cousin as a “quite person. He never had a hard word for nobody,” Jones said of Brown. “He loved to walk. He’d walk 50 miles if you let him.”
Other than not being able to remember things due to Alzheimer’s, Jones said Brown had rarely ever been sick in his life and never took as much as an aspirin.
“He would eat and do everything he would do,” Jones said.
Brown, who was never married and had no children, entered Cahokia Nursing and Rehab Center in November and died in early April.
Jones said Brown was “way too healthy” to die just six months after his doctor gave him a clean bill of health. Jones thought Brown may out-live him.
“I got my doubts about it,” Jones said of the care his cousin received at the nursing home.
Purifoy had been living at the facility for about seven years, according to her family.
Jackson said she started complaining about her care over the past year.
“When I would visit her, most of the time she would cry when I leave,” Jackson said. “She was just cursing folks out, she would be so mad.”
Typically, she said her aunt was a “joyful person” who loved to laugh and talk.
“She was always a happy person until you messed with her,” Jackson said of Purifoy. “If you did something wrong, she would curse you out.”
Jackson is working with St. Louis-based attorney Richard Dowd.
Dowd provided a statement, which read in part: “Our investigation to date has disclosed that due to a poorly maintained and/or possibly malfunctioning catheter, Ms. Purifoy developed an infection of sufficient severity over time that it resulted in her throwing up bile and being transported to St. Elizabeth’s Hospital of Belleville, Illinois on April 17, 2015. Ms. Purifoy died from gram negative septicemia due to urinary tract infection at 11:03 a.m. at St. Elizabeth’s Hospital on April 18, 2015...Pauline had been taken to the hospital approximately five times due to urinary tract infections while a resident at Cahokia Nursing and Rehabilitation Center.”
On the mend
Bonnie Nichols’ brother Odbie Dibbs, 59, was living at the Cahokia Nursing and Rehab Center until she moved him.
“I moved him, because they weren’t taking care of him,” she said. “He couldn’t walk, and he had two strokes while he was there that affected his speech and his brain.”
Nichols, 68, of Cahokia also said her brother would get bad bed sores. “They didn’t turn him like they should,” she said. “To me, they aren’t taking care of the people like they should.”
Dibbs got dehydrated and kept losing weight, according to Nichols. “To me, they weren’t feeding him enough,” she said. “I didn’t want him going back there.”
Now, Dibbs is living at Willowcreek Nursing and Rehab Center in Belleville. “He’s doing much better,” Nichols said.
Advice for families
Jackson encourages families who have loved ones in nursing homes to visit them and see how they are doing.
“I just want somebody to go in there and check on their loved ones more often, and report anything you see,” she said. “We put them in there to be taken care of. A lot of them don’t know we need to keep checking behind them.”
Jackson regrets not doing that for her aunt.
“I didn’t do that. I didn’t realize she was being misused,” she said. “I wouldn’t expect her to be misused in a nursing home. That’s why you put them in there to be taken care of.”