On July 15, 2010, the Illinois Department of Public Health conducted a survey of Warren Park Health & Living Center in Chicago. The survey was conducted following a well-publicized drowning death of a psychologically disturbed patient in a bathtub at the facility in the weeks prior.
Rather than an isolated episode, the survey reveals a facility in disarray that frankly appears to be completely incapable of providing necessary care for vulnerable people. After evaluating patient charts, facility policies, staff interviews and observation of staff, the survey concluded that Warren Park indeed has substantial patient care problems as evidenced by the following findings:
- Leaving tub room unlocked and accessible to residents
- Failing to supervise patients in tub room
- Failing to have any facility-wide procedures for bathing
- Failing to timely complete an incident report following the death of a patient
- Inadequate monitoring and intervention for a patient with clearly articulated suicidal thoughts
Certainly, the above problems played a role in the drowning death of a patient on July 4, 2010. The evidence revealed that the patient was admitted to Warren Park in March, 2010 with suicidal thoughts. However, even after repeated verbal suicide threats, staff at the Chicago nursing home failed to take any meaningful interventional measures.
The most alarming part of the survey is the fact that just weeks before suicide, the patient made a similar attempt to drown herself in a toilet. Even after the episode was recording in the patient’s chart and the Social Services department pledged to ‘monitor’ the patient, no specific indication of what how exactly the patient was to be monitored or what apparent follow-ups were to be made by staff members.
If the report of the dangerous conditions documented in the survey doesn’t get the attention of nursing home administrators, perhaps the type-A violation and the $20,000 fine will? Let’s hope it does, as the documented conditions should not exist in any facility.