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Pinecrest one of two nursing homes fined for violations

By Kathleen Schultz

The Illinois Department of Public Health fined two area nursing homes $25,000 each in the last quarter of 2017 for A-level violations, those that created “a substantial probability that death or serious mental or physical harm will result, or has resulted.”

According to the IDHP reports released Jan. 24, Pinecrest Manor, 414 S. Wesley Ave., Mt. Morris, was fined for failure to perform CPR on a woman found unresponsive and presumed dead because they mistakenly thought her status was do not resuscitate.

Franklin Grove Living and Rehabilitation Center, 502 N. State St., Franklin Grove, was fined for failing to properly monitor a new resident known to be at risk of falling out of bed. The resident fell and fractured a recently repaired hip, necessitating another surgery.

The Pinecrest resident, recovering from pneumonia, was admitted to the nursing home on Sept. 11, with orders not to intubate, but to perform CPR should it become necessary.

The woman was found unresponsive around 2:45 a.m. Sept. 22 by a certified nursing assistant, who notified a male registered nurse.

He checked the resident’s vitals and determined she was dead.

He did not open the resident’s chart, but checked its binder for a heart sticker that would have indicated her orders called for life-sustaining efforts. 

Absent the sticker on the outside of the chart and on the nameplate on her room door, the nurse thought she was DNR.

The coroner was called, and he requested an ambulance crew verify the death. 

The nurse told paramedics the resident was DNR, then opened her chart and discovered that in fact, she was not. 

By that time, CPR was not an option and the resident was pronounced dead.

Staff did not know why stickers indicating the resident’s code status were not affixed according to Pinecrest policy.

The director of nursing told investigators that who placed the stickers varied, and that she now realized the sticker system “gave a false sense of security” regarding code status. 

In an intense situation such as finding a resident without vital signs, she would have looked for the stickers and also would not have opened the chart, she said.

Pinecrest officials and staff members were recognized last August for earning a perfect score in a federal inspection conducted earlier in the year.

A team of surveyors from the Center for Medicare and Medicaid Services regional office in Chicago spent four days in March at Pinecrest to conduct a comparative survey. 

The team observed resident care, conducted interviews with residents, family members and staff, and reviewed policies and procedures to ensure compliance with all federal standards of care for nursing homes.  

The Franklin Grove Rehab resident, who showed signs of confusion, was admitted July 31 after she fell in her apartment and broke her left hip. 

The next day, she fell twice, at 6:25 a.m. and 11:30 p.m., trying to get out of her recliner.

After the second fall, she was given a chair alarm, and policy called for staff to look in on her once every 30 minutes. There was no documentation that they did.

At the request of her daughter, the woman was X-rayed on Aug. 2, revealing the second fracture, at her hip implant, which her orthopedic surgeon said was a direct result of her fall from the recliner.

In both cases, the nursing homes were required to update, tighten and clarify their procedures.

A year earlier, Franklin Grove Rehab was fined $50,000 for a mechanical lift failure and other violations that may have contributed to a resident’s death, but reached an agreement with the state, reducing that fine to $12,500.

Inspectors determined that the facility’s mechanical lift equipment wasn’t being properly maintained or used, and that incidents involving sling failures weren’t being properly recorded.

The most serious violation occurred June 6, 2016, when a resident who was being transferred from a wheelchair to a bed suffered broken legs when a loop on the sling broke, and she fell to the floor.

The broken bones caused her condition to deteriorate and contributed to her death four days later, her physician said.

Other sling malfunctions involving other residents also were noted in that report, as was staff failure to regularly inspect the slings or report such incidents.

The nursing home disagreed with some of the report’s findings, appealed the citation, and a consent agreement was reached in April, reducing the severity of the violations, and the fine.