The incident rate of neglect and abuse in nursing facilities has become an all too common occurrence in America. Many senior citizens, the rehabilitating, ill and disabled become victims of mistreatment at the hands of caregivers, visitors, employees, and other residents.
If your loved one was mistreated, abused or neglected, the Illinois Nursing Home Law Center lawyers can provide immediate legal intervention. Our team of attorneys has successfully resolved cases just like yours. Contact us now so we can begin working on your case today. Let us work on your behalf to ensure your family receives adequate financial compensation that you deserve and those responsible for causing your harm are held legally accountable.
This Medicare/Medicaid-participating long-term care (LTC) center is a 95-certified bed "for profit" home providing services to residents of Carlinville and Macoupin County, Illinois. The facility is located at:
1200 University Avenue
Carlinville, Illinois, 62626
(217) 854-4433
In addition to providing long-term and short-term skilled nursing care, Heritage Health – Carlinville provides other services that include:
Illinois and federal nursing home regulatory agencies have the legal authority to impose monetary fines and deny payment for Medicare services for any nursing facility cited for serious violations of regulations and rules. Within the last three years, Heritage Health - Carlinville self-reported two serious issues that resulted in citations. Additional information about fines and penalties can be found on the Illinois Department of Public Health Nursing Home Reporting Website concerning this nursing facility.
To ensure families are fully informed of the services and care that every long-term care facility offers in their community, the state of Illinois routinely updates their database system. This information contains a comprehensive list of safety concerns, incident inquiries, opened investigations, filed complaints, dangerous hazards, and health violations of homes statewide posted on the Medicare.gov website. This data can be used to make an informed decision before placing a loved one in a private or government-run facility.
According to Medicare, this facility maintains an overall rating of one out of five stars, including one out of five stars concerning health inspections, two out of five stars for staffing issues and two out of five stars for quality measures. The Macoupin County neglect attorneys at Nursing Home Law Center have found serious deficiencies and safety concerns at Heritage Health - Carlinville that include:
In a summary statement of deficiencies dated June 29, 2018, the state surveyors noted that the facility had failed to “assess and re-evaluate the use of bolstered mattress and side rails as a restraint with a risk for entrapment.”
The investigators reviewed the resident’s MDS (Minimum Data Set) Assessment and Brief Interview for Mental Status that shows the resident is “moderately impaired with cognition and decision-making.” The MDS also reveals that the resident “has no bed rails or restraint.” A review of the resident’s Electronic Health Record shows the resident has “cerebral infarction with right side weakness.
Observations were made of the resident on the morning of June 27, 2018. The patient “had a mattress with four built-in bolsters of the head and foot of the bed.” The resident “had partially padded half side rails in the middle of the bed [and] was up in a wheelchair, with right side weakness.” The resident “had difficulty expressing self, due to their [medical condition].”
The patient was observed the following morning at 9:23 AM while asleep in bed on their right side. “The side rails remained in the middle of the bed with the bolstered mattress. Fall mats were on each side of the bed.” The resident “woke up and used [their] left arm and hand to grab the side rail and move [themselves] about in the bed. The risks documented in the consent [include] Incontinence/increase incontinence and reduced range of motion. There is no assessment or consent in [the resident’s electronic health record] for the use of the four-bolstered mattress.”
The state investigators interviewed the facility Resident Care Coordinator on June 28, 2018, and asked, “about the side rails and the mattress for [the resident].” The Coordinator said that the resident “was on another hall. I am wondering if they brought [the resident’s] bed from the other hall, Rosemont.”
The Restorative Nurse stated at that time, “I will have to assess that. [The resident] has no falls from bed [and] does not use the side rails and help to turn [themselves] over.” The Nurse said that the resident “has a right-side weakness from a CVS.” The nurse said, “I never considered [the patient’s] mattress or side rail as a restraint, more as enablers.” The nurse said they do “not assess the four-bolstered mattresses as a potential restraint.”
The investigators reviewed the facility’s policy and procedure title Restraint Program revised on November 10, 2015, that reads in part:
“It is the policy of this facility to provide appropriate care for residents in relation to restraint utilization. Prior to the use of any restraint, unless restraint is used in an emergency situation), each resident is assessed for potential alternatives by using the restraint pre-restraining and quarterly evaluation.”
The investigators observed the resident “sitting in her wheelchair in her room wearing a positioning vest” on the afternoon of May 15, 2017. “The front part of [the resident’s] positioning vest was up near the neck area and [the resident] was leaning toward the right. The positioning vest was attached to [the resident’s] wheelchair from the top near the handles with a plastic clip fastener and at the bottom of the seat.”
The following morning at 8:35 AM, the resident was observed “sitting in her wheelchair in her room wearing the positioning vest. The front part of [the] positioning vest was in her neck/throat area and [the resident] was leaning toward the right. At this time, [the resident] was interviewed and stated she has been in the facility for a long time and she wears the best because she does not walk good.”
The surveyors asked the resident “if she was able to take off the vest?” The resident replied, “she has never tried to take the vest off [stating that] the vest scratches and hurts her neck.” The resident “grabbed the front/top of the vest and pulled it outward away from her neck as she spoke.”
On May 16, 2017, a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) transferred the resident “to her wheelchair. [The resident’s] positioning vest was attached to her wheelchair from the top near the handles with a plastic clip fastener and at the bottom of the seat.” At that time, both nurses put the resident’s “bilateral arms through the shoulder harness [and] proceeded to reposition [the patient] in her wheelchair with [her] arm still in the harness.” The RN “then zipped up the vest.”
In a summary statement of deficiencies dated May 22, 2017, the state investigators documented that the facility had failed to “supervise a steam table to prevent potential thermal hazards/burns. This [failure] has the potential to effect four residents at the facility.”
The investigative team documented that “this failure resulted in an Immediate Jeopardy which was identified to have begun on May 15, 2017, when the facility failed to supervise a steam table having a surface temperature of 160°F to protect residents from the potential injury from steam table’s surface temperatures and the hot water in the steam table.”
The surveyors removed the Immediate Jeopardy on May 17, 2017. However, the facility “remains at Severity Level 2 as the facility continues to in-service staff and update its policies and procedures as needed.”
The investigators reviewed a cognitively impaired resident’s MDS (Minimum Data Set) assessment that shows the resident requires “extensive assist of one staff for transfers and ambulation in room and hallway. The MDS documents [the patient’s] balance for all transfers is unsteady and [the resident] is only able to accomplish them with staff assist only and a walker.”
The resident’s Care Plan documents that the patient “has a poor safety awareness and will attempt to sit on the furniture before looking at where he is. The goal is to minimize fall risk with interventions being: Assist with transfers and ambulation using a walker, encourage two uses walker and leave it on the floor, encourage restoratives. Pressure alarm to be under the resident when sitting or lying in bed, remind the resident to use the walker when seen ambulating without it.”
The investigators noted that the “Care Plan does not identify any falls that have occurred.” However, a review of the facility Falls Log documents that the patient “has had five falls in the past six months. The most recent fall was on March 16, 2016, at 6:40 PM when he attempted to sit on a chair and slid off. The fall was witnessed by [a Certified Nursing Assistant (CNA)], and the fall conclusion documents [the resident] was ambulating with a walker up and down the hallway and around the living room.”
The resident “was then observed to sit down in a chair but sat on the armrests of the chair and slid off the armrests to the floor before the staff could intervene to prevent a fall. There was no indication staff assist was being provided during this time as documented in the Care Plan and identified in the MDS (Minimum Data Set). The intervention at that time was for an alarm to be added but failed to identify whether or not [the resident] was ambulating about the hallway unassisted.”
In a summary statement of deficiencies dated May 22, 2017, a state investigator noted the nursing home's failure to “maintain proper hand hygiene practices for residents and blood changes to prevent the spread of infection for three residents.”
The state survey team observed a Certified Nursing Assistant (CNA) just after noon on May 16, 2017, while assisting two residents “with feeding. With the same hand, [the CNA] was touching cups, spoons and other items on [both resident’s] trays.” One patient “was observed touching her cup during the meal.” The CNA “did not sanitize their hands between residents.”
The investigators interviewed the Director of Nursing who said “as long as the staff is touching the resident’s bib, spoons or cup, and there is no skin-to-skin contact. I have no issues with it.” However, the investigators reviewed the facility’s policy titled: Hand Hygiene Technique dated March 1, 2010, that reads in part:
“To prevent the spread of infection. To decrease the risk of transmission of infection from person-to-person or from an object-to-person. Indications for decontamination using alcohol-based rub: If hands are not visibly soiled.”
“After contact with the resident’s intact skin. After contact with bodily fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled.”
The surveyors observed a resident on May 17, 2017, receiving “indwelling urinary catheter care. One CNA “reached in the basin containing multiple washcloths soap and water and peri-wash, removed the washcloth and cleansed [the resident’s] penile head, around his catheter.” The CNA “discarded that washcloth.”
Using the same gloved hands, the CNA “reached back into the clean water to get another washcloth to wash the same area again.” The CNA “repeated this process of reaching into contaminated water without changing gloves or perform hand hygiene while cleansing the penis, scrotum and inner thighs. With new gloves, [the CNA] removed another washcloth from the same basin, cleansed [the resident’s] rectum, with bowel movement noted on the cloth after the wipe. Without changing gloves, [the CNA] continue to go back to the same basin, removing washcloths two more times to cleanse the bowel movement from the rectum and again to cleanse the right and then the left buttock.”
The investigators reviewed the facility’s policy titled: Perineal Care Policy and Procedure dated November 2016 that reads in part:
“Following evidence-based practice, blood changes and the performance of hand hygiene during perineal care may be limited to, before initiating perineal care, anytime gloves are visibly soiled and at the completion of care.”
Do you suspect your loved one was victimized by visitors, caregivers, employees or other residents while living at Heritage Health - Carlinville? If so, call the Illinois nursing home abuse and neglect attorneys at Nursing Home Law Center at (800) 926-7565 now. Our network of attorneys fights aggressively on behalf of Macoupin County victims of mistreatment living in long-term facilities including nursing homes in Carlinville. Contact us now to schedule a free case review to discuss how to obtain justice and resolve a financial compensation claim.
Our knowledgeable attorneys offer legal representation to patients with cases that involve abuse and neglect happening in public and private nursing facilities. We accept every case involving nursing home neglect, wrongful death, or personal injury through a contingency fee agreement. This arrangement postpones the need to pay for our legal services until after our legal team has resolved your claim for compensation through a jury trial award or negotiated settlement out of court.
We provide every client a “No Win/No Fee” Guarantee, meaning if we are unsuccessful at resolving your compensation claim, you owe us nothing. We can provide legal representation starting today to ensure your family is adequately compensated for your damages. All information you share with our law offices will remain confidential.
Attorney Jonathan Rosenfeld
Licensed in Illinois
Chicago Nursing Home Injury Lawyer Nursing Home Law Center LLC Home