Two metro-east nursing homes cited in fatal safety violations

Two metro-east nursing home facilities have been cited by the state for safety violations that led to the death of two patients.

Willowcreek Rehab & Nursing was cited in June for failure to follow an advanced directive regarding cardiopulmonary resuscitation for a resident, resulting in death. Willowcreek, a 122-bed skilled care facility at 40 N. 64th St. in Belleville, was fined $25,000 for a class A violation, according to the Illinois Department of Public Health.

Madison Terrace of Wood River was cited for failure to properly supervise a resident with profound intellectual disability. “As a result, the resident choked on food they had taken and later died,” the citation read.

Madison Terrace is a four-bed intermediate-care facility for the intellectually disabled at 95 N. Main St., Wood River. According to documents from the Illinois Department of Public Health, they were cited with a class A violation and fined $6,250.

Spokesmen from either facility could not be reached for comment.

In the Willowcreek case, on March 30, an unnamed female resident was found unresponsive. While staff initially responded, another staffer told them the woman had a “do not resuscitate” order. The staff then stopped trying to resuscitate her, and she died.

According to the IDPH findings, the staffer misread the chart. The woman’s DNR order was “full code,” meaning that she should have been resuscitated. The facility used a system of red and green dots on the patients’ doors: a green dot permits CPR, a red dot means do not resuscitate. But the unnamed staffer told IDPH that he or she had never been informed of that.

The staffer has been terminated from the facility, according to the report. Subsequent interviews with other staffers indicated some had been verbally informed of the dot system, while others said they had not received any formal training yet.

The day after the woman died, all current staff were given in-service training on code status policy and advance directives, according to the IDPH report.

Willowcreek’s past violations included failing to provide a patient with Alzheimer’s appropriate stimulation in activities according to her care plan; for failing to provide splint assistance to a patient with problems in his upper extremities, and for a care plan for another patient that includes a regular diet when the patient is on a feeding tube, among others.

According to the Madison Terrace inspection report, the unnamed resident was a 47-year-old male who was profoundly disabled with Down’s Syndrome and other disabilities. He was unable to speak, and had a history of swallowing difficulties and aspiration. Thus, all of his food was supposed to be pureed to the consistency of honey.

But when he was repeatedly caught taking food from the kitchen and other residents, procedures were not revised to prevent such actions, , the report read. The resident eventually swiped five pieces of bread, and was found choking on Feb. 21. Staff attempted CPR, during which the resident coughed up bread. He ended up on a ventilator at a hospital but died eight days later.

Schedules later showed that there were nine time periods of two or three hours each in January and February where only one staff member was on duty.

IDPH spokeswoman Melaney Arnold said that Madison Terrace was fined $6,250 while Willowcreek $25,000 because they are different types of facilities; a home licensed for fewer than 17 residents is limited to fines of $6,250 per violation, she said.

Madison Terrace is scheduled for a prehearing on July 20. It is owned by Community Living Options Inc. of Galesburg, Ill.

Willowcreek is owned by Helia Healthcare, which owns nine skilled nursing and rehabilitation facilities in Illinois. It has requested a hearing, but the date has not yet been set, Arnold said.

A third metro-east facility was also cited in June for a nonlethal paperwork violation. Midwest Rehabilitation and Respiratory Center, a 180-bed intermediate and skilled care facility at 727 N. 17th St. in Belleville, was cited with a class A violation and fined $25,000 for failure to have an emergency evacuation plan in place for bariatric patients weighing more than 1,000 pounds. Midwest has requested a hearing, which will be July 20.

In March 2015, an 85-year-old woman was found dead at the bottom of a flight of stairs at Midwest Respiratory and Rehabilitation Center, still strapped into a wheelchair.

Midwest Rehabilitation and Respiratory, formerly the Calvin Johnson Nursing Home, is operated by Senior Healthcare Management in Skokie, Ill., near Chicago. Senior Healthcare Management operates nine nursing homes in the metro-east and Southern Illinois that, like Midwest Rehabilitation, have a one-star rating, the lowest rating given by Medicare.

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This story was originally published July 15, 2016 at 4:51 PM with the headline "Two metro-east nursing homes cited in fatal safety violations."