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Most Nursing Home Deaths Remain Uninvestigated

In an effort to identify instances of nursing home abuse and neglect, the Illinois Department of Public Health has implemented a death reporting program in ten counties in Illinois.  The pilot program requires nursing homes to immediately report nursing home deaths to the county coroner.  Once reported, it is up to the county coroner to investigate the facts surrounding the death and determine if the death was related to nursing home abuse or neglect.

Most Nursing Home Deaths Remain UninvestigatedFrom July 1, 2007 through June 30, 2008, 8 suspicious deaths were attributed to mistreatment in nursing homes out of a reported 3,669 total nursing home deaths.  The pilot program empowered coroners to investigate deaths by phone, fax, or in person each and assess if abuse or neglect might have contributed to a resident’s death.   The pilot program ran in the Illinois counties of Champaign, Effingham, Kane, Kankakee, Lake, LaSalle, Lee, McLean, McHenry and Morgan.

Of the eight deaths that were attributed to improper nursing care, several fines were imposed against the facilities by state and federal authorities.  In Champaign County, the coroner’s tip-off resulted in federal officials imposing a fine against the Champaign County Nursing Home of $13,600 for the death of a 94-year-old woman who died from a pulmonary embolism shortly after fracturing her leg during a transfer out of bed.  Also in Champaign County, the coroner’s tip-off lead to a $52,500 state fine was imposed against Pleasant Meadows Christian Village Nursing Home for improper treatment of a resident’s bedsore that had advanced to sepsis and ultimate death.

Richard Dees, Chief of Public Health’s Bureau of Long-term Care, says it appears the project failed to show that a state law requiring nursing home death reporting and investigations would have a ‘conclusive’ benefit.  Pointing to the relatively small number of suspicious deaths reported by local coroners.

Arkansas and Missouri are currently the only states that require nursing homes to report all nursing home deaths to local coroners.  In Illinois, it is left to the coroner’s discretion as to investigate the death.  Most coroners and medical examiners only investigate nursing home deaths if the family requests they do so or if criminal activity is suspected.  Sadly, the failure of the state to implement any laws mandating the report of nursing home deaths will result in countless cases of improper nursing home care–especially cases of nursing home neglect– that will forever go undetected.

Read more about this pilot program for Illinois Nursing Homes here.

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  • Char

    My mom was a resident in an Alabama nursing home. She was a viable 81 year young person who liked to read, do crossword puzzles, watch TV among other things although she never wanted to leave her room as she was a nurse at the said facility where she chose to live her remaining years. I was also a nurse in the same facility and had to retire early due to failing health. I talked to my mom on the phone the evening before her early morning demise and she assured me she felt OK or as she always said as good as usual. I was called at approx 4:45 AM and was told my mom had fallen in the bathroom and had expired. My mom wasn’t a DNR but no attempt was made to resusitate her or 911 wasn’t called at the direction of the LPN in charge.
    She had mistakenly checked my mom chart and found a year old DNR which was signed in another facility which my mom was hospitalized in before she became a resident in the facility where she died. The nurse was questioned and fired immediately.
    My mom had a indentation in the right side of her forehead with bruising and places on her right knee which she always complained gave way with her. I took it upon myself to contact the coroner and have her looked at, the deputy coroner was sent and took pictures of her head. He was also called in to give a statement. I talked with him before he went in to make his statement and he said he knew everyone there because he was there several times a day due to the fact he worked for a ambulance transport business for all this particular companies facilities in our area.
    To me that would be a conflict of interest on his part. Anyone who’s ever dealt with this particular situation could you please comment..Thanks.

  • Jonathan Rosenfeld

    Char-
    Sorry to hear of your mother’s situation. Certainly, sitting by and watching a patient die after becoming involving in an accident is not the intention of DNR and the facility was correct to reprimand the nurse involved in this situation.
    I would be interested in learning more about the fall itself and what– if anything caused your mother to fall.
    It would also be interesting to look at your mother’s care plan and see what type of safeguards were to be incorporated into her care and see if they were in fact implemented.
    Again best regards and condolences on your loss.
    Jonathan

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