The Centers for Medicare and Medicaid Services (CMS) and the state of Illinois routinely conduct unscheduled surveys and unannounced investigations to inspect every nursing facility statewide. Their efforts identify serious violations, deficiencies, hazardous conditions and health violations. When surveyors identify serious concerns, the facility has the opportunity to make corrections promptly to maintain the health and well-being of every resident.
In serious cases, the Medicare and Medicaid nursing home regulatory agencies will designate the Home a Special Focus Facility (SFF) and add the Center to the national watch list. This undesirable designation means that the facility must undergo many more inspections and surveys every year to determine that any corrective actions taken to improve the level of care in taking care of the residents is permanent.
In 2017, Wentworth Rehab and Health Care Center was added to the federal watch list and designated a Special Focus Facility. Likely, the nursing home will remain on the list for many more months or years to come. Meanwhile, surveyors will conduct unannounced inspections and investigate filed formal complaints to minimize problems associated with slipping and falling, elopement (wandering away), accident hazards, and substandard care. Some of the major concerns involving the facility are noted below.
This Nursing Home is a “for-profit” Center providing cares and services to the residents of Chicago and Cook County, Illinois. The 300-certified bed Facility is located at:
201 W. 69th St.
Chicago, IL 60621
(773) 487-1200
In addition to providing short-term and long-term skilled nursing care, the facility also offers:
Both the State of Illinois and the Centers for Medicare and Medicaid Services have the authority to issue monetary penalties and fines against nursing facilities identified with serious deficiencies and violations. Over the last three years, Wentworth Rehab and Health Care Center received two fines including a $26,503 fine on September 12, 2016, and a $100,383 fine on February 9, 2017.
Additionally, there were 19 filed formal complaints over the last three years that resulted in citations and 16 facility-reported issues involving citations.
The federal government and the state of Illinois routinely update the national Medicare.gov website with information on data concerning incident inquiries, dangerous hazards, filed complaints, health violations, safety concerns, and opened investigations on every facility statewide. Additionally, the site uses a star rating summary system to help identify nursing facilities that provide superior and substandard care.
Currently, Wentworth Rehabilitation and Health Care Center maintains a much below average one out of five stars compared to every other facility in the US. This ranking includes one out of five stars for health inspections, one out of five stars for staffing, and three out of five stars for quality measures. Some concerns over safety violations and deficiencies are listed below.
Failure to Ensure a Safe Environment Which Ultimately Led to the Resident’s Death
In a summary statement of deficiencies dated February 9, 2017, the state investigator noted that the facility had failed to “provide immediate emergency care for a resident with a change in condition [and] failed to develop a Care Plan for unsafe smoking for a resident.” A separate issue involved the facility’s failure “to report the resident’s elevated blood glucose level and the resident’s refusal of scheduled insulin by the physician [order] and failed to implement Care Plan interventions for the resident’s diabetes.”
In one incident, the deficiency by the nursing staff “resulted in the delayed assessment of care for [the resident] following a facility fire which led to [the resident’s] death.” The resident’s death certificate indicates that the resident’s “cause of death was thermal injury and careless use of smoking materials while on home oxygen therapy.”
On the date of the resident’s death, during the 9:00 AM hour, a Nurse Aide “was standing at the kiosk charting and saw [the resident] sitting between the beds.” The Nurse Aide stated that “the fire alarm sounded and [the resident] wheeled himself into the hallway in his motorized wheelchair [with] his oxygen via and nasal cannula in his nares [nostrils] and was receiving oxygen.” The resident “did not say anything but was observed having a difficult time breathing.” When the Nurse Aide approached the resident, she noticed that “the end of [the resident’s] mattress was on fire.”
After several attempts, the Nurse Aide was finally able to extinguish the fire with an extinguisher after moving the resident “further down the hall.” At that time, a Social Services staff member pushed the resident in their wheelchair to the nursing station to a Licensed Practical Nurse (LPN). The resident was “observed to be slumped over the right side of the wheelchair with no movement observed.” The Licensed Practical Nurse walked over to the resident “and took a quick glance at [the resident] and walked away to stand behind the nursing station.”
A few minutes later, the Licensed Practical Nurse “walked back over to [the resident] and placed the nasal cannula on [the resident, which was] already connected to the oxygen tank on [the resident’s] wheelchair. The LPN “was not observed taking vital signs or performing an assessment on [the resident] between 9:54 AM [when arriving at the nurses’ station] and 9:57 AM [when the resident was moved out of the camera range].”
The facility’s Regional Administrator reviewed a videotape of the event. In the video, the LPN “was not observed providing immediate emergency care to [the resident] after being brought to the nursing station by” the Certified Nursing Assistant and Social Services staff member. The Fire Marshal involved in the incident “stated that the fire involving [the resident] was caused by the ignition of the oxygen tank due to smoking while wearing oxygen.”
A review of the resident’s Social Services Notes for that morning revealed that “Social Services assisted [with] escorting [the resident] to the nursing station.” The Social Services staff member “noticed that [the resident’s] hair, right ear, and face were singed; the police were in the facility and requested that an ambulance be dispatched.” While “waiting for the ambulance, the fire department and nursing were performing cardiopulmonary resuscitation [CPR]; emergency medical technicians (EMT) escorted [the resident] into the ambulance; EMT returned to the facility reported that [the resident] expired in the ambulance.”
Failure to Ensure That the Nursing Home Area is Free from Accident Hazards
In a summary statement of deficiencies dated July 24, 2017, the state surveyor noted the facility’s failure “to update the Fall Prevention Interventions Log [and faiure] to ensure that fall prevention interventions were in place for [a resident].” The occurrence log documented that the resident had fallen at the facility.
The resident’s revised April 15, 2017, Fall Care Plan documents interventions including “floor mats to be placed on each side of the bed when the resident is in bed.” On July 11, 2017, at approximately 2:05 PM, the resident “was lying in bed; there were no floor mats present.” The surveyor interviewed a staff member concerning the resident’s Fall Prevention Interventions. The staff member responded “she really does not fall out of bed. She is not a fall risk. I don’t think she will move out of the bed.”
The surveyor asked the staff member how they would know if the resident was a fall risk. The staff member responded that “they have it on their wrist a yellow bracelet that says fall risk.” The staff member affirmed that the resident “was not wearing a yellow bracelet.” A review of the Fall Event and’s Interventions Log dated July 11, 2017, revealed that the resident “was non-inclusive on the [Fall] list.”
The facility was reminded of their June 2013 Prevention of Falls policy and procedure that reads in part:
“The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate interventions and revise the resident’s Plan of Care… to minimize the risk for fall interventions and injuries to the resident. Assess and monitor resident’s immediate environment to ensure appropriate management of potential hazard.”
Failure to Notify the Resident’s Doctor and Family Member of a Change in the Resident’s Situation or Medical Condition
In a summary statement of deficiencies dated February 9, 2017, the state investigator noted that the facility had failed to “notify the Physician of elevated blood glucose levels and [the] resident’s refusal of insulin.” This deficient practice by the nursing staff affected one resident.
The surveyor reviewed the resident’s October 7, 2013, Hypo/hyperglycemic Reaction Care Plan that had a targeted goal March 7, 2017, with “interventions include report results that are outside ordered parameters to the physician.” The resident’s “refusal to take medication Care Plan dated May 29, 2014, with a goal targeted date of March 7, 2017, interventions [include a] review with [the resident] the consequences of treatment noncompliance.”
On January 19, 2017, at 8:48 AM, the resident’s “weights and vital signs summary indicated” the resident had “blood glucose results of 428 mg/dL.” When reviewing the resident’s Nurse’s Notes, there was “no documentation for physician notification for the elevated blood glucose level or what Care Plan interventions were in place related to blood glucose results greater than 400 mg/dL.”
The resident’s hospital records indicate that “on January 27, 2017, at 4:30 AM [the resident’s] blood glucose level measured greater than 500 mg/dL” where the normal range is “76 – 120 mg/dL.” The resident’s “hospital records indicate that [the resident] was admitted with diabetic ketoacidosis and acute kidney injury related to dehydration.”
The surveyor reminded the facility of their February 2014 Change of Condition policy that indicates:
“Attending physicians or physician on call/nurse practitioner and responsible party will be notified of all changes in condition; follow framework for reporting changes and vital signs or laboratory values based on the American Medical Directors Association guidelines…”
Surveyors documented that the “facility’s Change of Condition American Medical Directors Association guidelines for reporting indicates a blood glucose levels greater than 300 mg/dL or less than 70 mg/dL (diabetic) should be reported immediately.”
Failure to Ensure There is a Pest Control Program That Prevents/Deals with Mice, Insects or Other Pests
In a summary statement of deficiencies dated May 10, 2017, the state investigator noted the facility’s failure “to maintain a pest control program that was effective in the prevention of pests on four of five environmental floors” including the basement, first, third and fourth floors.”
Observations were made at the facility at 11:35 AM on April 24, 2017 “in the basement conference room, brown crawling insects were observed by the surveyors.” During that time, the Administrator was made aware, “observed insects and stated, ‘We have the local exterminator, in today.’”
An additional observation of the facility was made on April 25, 2017, at 10:40 AM with two Maintenance Directors who saw “two black crawling insects …in the second floor’s Janitor Closet.” One Director stated that “we do have problems with roaches every now and then.” The surveyor conducted a group interview at Wentworth Rehab with residents on April 25, 2017, where multiple residents reported that “there is an ongoing problem with pests and stated, ‘We have seen mice, roaches, and anterior at the facility.’”
If you, or your loved one, were abused, mistreated or neglected while residing in Wentworth rehab and Healthcare Center, or any Illinois skilled nursing facility, you can file a claim for financial compensation. With legal representation, you lawyer can ensure that all the necessary paperwork is submitted to the appropriate county courthouse before the Illinois statute of limitations expires.
Personal injury claims, wrongful death lawsuits, and nursing home abuse cases are typically handled through contingency fee agreements. This arrangement allows the lawyer to get to work building your compensation case immediately without the need of making any upfront payment. Your legal fees are paid only if your attorney wins your case through a negotiated out of court settlement or a jury trial award. Contact us today.
For more information on the laws and regulations applicable to Illinois nursing homes, look here.
Attorney Jonathan Rosenfeld
Licensed in Illinois
Chicago Nursing Home Injury Attorney Nursing Home Law Center LLC Home