Nursing Home Spotlight: Warren Barr Pavilion, Chicago, Illinois

Warren Barr Pavilion is a large 221 bed nursing home facility located in the near north side of Chicago.  According to the government’s Medicare website , the facility received only two out of five stars, which is a below average rating.  This is in large part to the facility’s high number of health deficiencies.  In the past year, the facility had eleven health deficiencies, which is higher than both the average health deficiencies for both nursing homes in Illinois and across the United States.  The facility’s most significant health deficiencies were improper care and services and risk of falls/accidents.

The nursing home has an obligation to provide a safe and secure facility for its residents and to provide proper care and supervision to maintain the health of its residents.  According to the survey reports, the facility received multiple violations for:

• Failing to investigate injuries
• Allowing residents to develop pressure sores
• Discrepancies in prescribed feeding for a feeding tube
• Improper resident supervision
• Expired medication
• Falling to correct fall hazards
• Resident elopement
• faulty alarms for residents with wandering tendencies
• Dirt and debris in the facility

The numerous deficiencies reported in these surveys calls into question the ability of this facility to properly care for its residents.  The elderly are particularly vulnerable to improper care, which can lead to serious injury and even death.

Pressure sores are a very serious medical condition, especially for residents requiring prolonged bed rest, or with limited mobility and weakness.  Nursing home staff must regularly turn this bedridden group in order to ensure proper blood circulation. Federal regulations require nursing homes to provide residents proper treatment to prevent new pressures sores or heal existing pressure sores.

According to a recent survey at Warren Barr, one resident was admitted to the nursing home with Dementia with Depression and was dependent on staff for all activities of daily living.  The patient developed a Stage 1 pressure sore on the right buttock and had been placed in a chair without a pressure relieving device because the nurse did not notice the pressure sore.

Federal laws also require nursing homes to give each resident care and services to maintain the highest quality of life possible.  In the case of Warren Barr, the facility failed to meet this requirement when one patient had to wait nine days for treatment of a toe infection.  The facility waited until the podiatrist’s next scheduled facility visit, rather than calling the podiatrist’s office for immediate treatment.   The podiatrist stated that the facility should have called his office for an immediate visit to avoid/prevent complications, especially because the patient suffered from diabetes.

Survey results also demonstrate Warren Barr failed to follow its own abuse policy regarding investigation for an injury of unknown origin.  This investigation requirement is in place to prevent nursing home injury and abuse. Staff members failed to investigate an injury (skin tear on the leg) suffered by a resident with Dementia.  When questioned, the certified nurse aid was unable to provide more information about the skin tear.   Yet, no inquiry was made concerning this injury.

The elderly are particularly vulnerable to injuries resulting from falls.  As such, the nursing home must ensure that the nursing home area is free of accident/fall hazards.  During one site visit to Warren Barr, the facility failed to provide adequate supervision to a resident who required extensive assistance and had a doctor’s order for fall precautions.  On this occasion, the resident was left sitting nude on a toilet while a certified nursing assistant was getting the resident dressed.  The staff member accidentally locked the resident in the bathroom without any supervision, and the resident was left alone in the bathroom for three whole minutes while a key was located.  In other residents’ rooms, the inspector noticed old newspapers on top of the heater, expired drops of nasal drops, and a radio cord that created a potential tripping hazard.

Nursing homes are required to minimize the risk of resident elopement.  Warren Barr Pavilion failed to adequately monitor and supervise one resident suffering from Alzheimer’s and Dementia, who had been identified by the facility as an elopement risk because of a prior elopement incident.  As a result, the resident left the facility without being noticed by the staff despite wearing an electronic monitoring device.  The electronic monitoring device failed to activate/alarm when the resident passed through the sensor at the entrance of the building because of system malfunction.  Thankfully, the police were able to locate the resident only three blocks away from the facility.  Nonetheless, elopement is an extremely serious danger that puts the residents in immediate jeopardy.

The nursing home has an obligation to give proper treatment to residents with feeding tubes to prevent problems.  During one site survey, the nursing home failed to ensure that two of seven residents in the sample who were on feeding tubes received the correct type of formula and the correct amount of feeding as prescribed by the physician.   During the period of observation, two patients received significantly less formula than prescribed; each discrepancy was equivalent to over an hour of feeding time missed. This seemingly minor oversight, puts these residents at risk for malnutrition and dehydration.

Nursing homes have an obligation to prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.  On several occasions, the staff at Warren Barr Pavilion served food to patients that was not maintained at proper temperatures (hot foods are maintained at 135 degrees F).  During a residents interview, residents complained that food was often cold upon delivery.  A review of the resident council minutes showed that residents had been complaining about cold food for the past six months.  In addition, several family members had complained about the cold food.

This two-star rated facility has many deficiencies which might be a troubling sign that nursing home residents might not be receiving the proper care and attention they need and deserve.

For laws related to Illinois nursing homes, look here.