In the past year, Westside Rehab & Care Center has had 21 total health deficiencies, which is 13 more than the average number of health deficiencies in Illinois and the United States. This was actually an improvement from the total number of health deficiencies in the previous year, when the facility had a shocking 34 health deficiencies. Not surprisingly, Medicare gave this 96-bed nursing home facility located in Frankfurt, IL an overall rating of one-star, which is a much below average rating.
On August 10, 2009, a female resident suffered a leg fracture (broken bone) after falling during a transfer. The nursing home staff did not update her pain assessment in response to this injury, leaving the resident in unnecessary pain for an extended period of time.
During a complaint investigation, the resident told the investigator, “I am hurting! Can’t you help me?” The investigator reported this to the nurse, who then administered pain medication. This same resident was also noted to have dried blood on her face, neck and right arm and hands, with active bleeding on her right wrist. The resident was feeding herself with her fingers that were soiled with dried blood. The facility failed to prevent unnecessary pain and suffering for this resident, which means that the facility did not ensure that this resident maintained the highest level of physical, mental, and psychosocial well-being.
During the same complaint investigation, the investigator determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents by failing to implement interventions to prevent staff from leaving a total care resident on the toilet alone. This failure resulted in the resident suffering two falls from the toilet.
The first fall occurred in February 2009, when the resident fell from the toilet and had to go the emergency room for evaluation of hip pain. After this fall, the facility should have implemented staff interventions in order to prevent additional falls. However, the facility failed to do so, and the resident fell from the toilet for a second time in June 2009. Falls are particularly dangerous for older adults who have older, weaker bones that are more susceptible to breaks (fractures). Therefore, it is very important that facility’s implement fall precautions in order to prevent resident injury.
Another complaint investigation revealed that the facility staff had knowledge that one resident suffered bruising after being physically restrained for a blood test and another resident was verbally abused. However, the staff did not implement preventative measures or report the potential for abuse to the administration in order to protect these residents and the other 52 residents from actual or potential physical or verbal abuse.
The resident who suffered physical harm was an 85 year old man with diabetes, who displayed behavioral symptoms of resisting care. The nurse woke up the resident in order to perform a blood test. The resident resisted and told the nurse that he didn’t want his blood drawn. The nurse then tried holding down the resident by placing her knee across his abdomen, even after the resident told her to stop. The nurse then called in two certified nurse aides (CNAs) for help in restraining the resident so that she could draw blood.
This incident was viewed by the resident’s roommate, who was awakened by his roommate’s screams. The roommate said that his roommate was shouting, kicking, and screaming for the nurse to stop. As a result, the resident suffered bruising across his abdomen. The nurse was counseled for “inappropriate behavior” and suspended for three days; however, the facility never performed an abuse investigation, as required. Also, the CNAs who were called into the room to help restrain the resident failed to report the mistreatment that they observed firsthand as is required by the internal reporting requirements.
Further investigation revealed that the nurse involved in the above incident was also verbally abusive to another resident. The resident reported that the nurse would yell at her to “move your a—“ and “stop being a baby” when the resident asked for pain medication. The nurse also used the “F” word at the resident. The resident and her roommate told the investigator that they didn’t report the nurse’s behavior because they didn’t want any problems. However, the resident did say that the nurse’s language “hurt her feelings.” Other facility staff members were also aware of the nurse’s verbal abuse and again failed to report the potential for abuse to the administrator in order to prevent abuse and mistreatment.
These incidents of abuse and mistreatment call into question whether Westside Rehab & Care Center can provide adequate and appropriate care for its residents, many of whom rely on the facility’s nurses and staff for activities of daily living. No resident should have to suffer physical mistreatment or verbal abuse such as the incidents reported at the facility. Although the facility has taken steps to improve staff training and intervention, it remains to be seen whether the residents will actually see an improvement in their treatment.
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Medicare: Westside Rehab & Care Center
Chicago Tribune: Compromised Care: West Side nursing home probed after death