State recommends fine for nursing home after 90-year-old's suicide

State recommends fine for nursing home after 90-year-old's suicide

URBANA — The Illinois Department of Public Health is recommending a fine against the Champaign County Nursing Home after a 90-year-old resident of the facility took his life there in February.

According to a department investigation of the facility earlier this month, staff members at the facility "failed to assess, supervise, formulate interventions and/or obtain a psychiatric consultation" for the resident who had "a known history of self-harm."

The man, who had been admitted to the nursing home on Feb. 3, was found unresponsive in his bed on Feb. 16 with an orange elastic band around his neck. He was taken to an unidentified hospital emergency room, where he was pronounced dead.

The cause of death, according to the IDPH investigation, was documented as elastic-band strangulation. The cause of injury, said IDPH, "is documented as 'strangled self with elastic resistance band.'"

The state agency is recommending to the federal Centers for Medicare and Medicaid Services a civil money penalty of $20,000 per day starting on June 2 (the date that IDPH identified an "immediate jeopardy" at the facility) and lowered to $200 per day on June 5 (the date that the "immediate jeopardy" designation was removed) until the facility comes into compliance, said Melaney Arnold, a IDPH spokeswoman.

She said the federal agency would make a final determination of a fine, and the nursing home would have the ability to contest the finding and any fine.

Although the IDPH was looking into at least one other recent death at the nursing home, Arnold said she didn't believe any other actions are pending against the facility.

The investigation and recommendation come at a particularly inopportune time for the nursing home, which is in the process of undergoing a change in management and may soon be for sale.

Both nursing home Administrator Karen Noffke and the home's private manager, Management Performance Associates of Chesterfield, Mo., are leaving the facility within the next two weeks.

A new management firm hasn't been hired yet, but the county board is expected to vote Thursday on contracting with SAK Management Services of Northfield, a firm that specializes in operating "distressed" health care facilities, to take over the home on July 1.

Separately, the board will consider a contract with another firm to market the nursing home for a possible sale. Voters gave the county board authorization to do so in April.

A relative of the resident who took his life — and is not identified by name in the investigative report — allegedly told a nursing home staff member at the time of admission that the man had tried to kill himself with an elastic cord the week before he was admitted to the nursing home and that he had stated that he wanted to die.

Physician not notified

Over the next several days, according to the investigation, there were numerous troubling incidents involving the resident:

— On Feb. 6, a social service assistant said the man "has a psychiatric history, exhibits depression, anxiety and fear."

— On Feb. 9, he expressed fears "that Orientals were taking" him and tying him up.

— Four days later, another employee said the resident stated he was being held captive in a basement.

— The next day, the resident allegedly became agitated in the dining room and struck another resident in the back of the head and referred to war and how he "wanted to kill more of them."

— In the early morning hours on the day that the resident is said to have taken his life, a nurse reported that the man was yelling, banging on the wall and saying that he wanted to die.

"There is no documentation of physician notification," said the investigative report.

IDPH demands plan

Other nurses and employees told the IDPH investigator that it was "common knowledge that (the man) was unhappy and wanted to die" and also that he had talked of killing himself.

The resident's primary care physician told the investigator in May "the expectation of the facility would be when a resident such as the (deceased) is making comments of wanting to die or do self-harm, the facility would either send (him) out to the emergency room or get a psychiatric consult." The primary care physician was never notified of the patient's "behaviors or suicidal ideations," said the report.

Arnold said the nursing home "failed to notify the physician of the resident's change in condition, and they neglected to assess and seek further direction from the physician because the resident had known suicidal behaviors, and they also failed to prevent self-harm for a resident who had known suicidal ideations."

She said the home must write a plan of correction and implement it. After that, she said, the department will perform another inspection of the nursing home "and make sure that it is an acceptable plan of correction and that they are indeed implementing it."

County Administrator Rick Snider said Friday that the county would consult with the current management company, MPA, and its attorneys before determining what sort of action to take in the aftermath of the investigative findings.

Sections (2):News, Local

Comments

News-Gazette.com embraces discussion of both community and world issues. We welcome you to contribute your ideas, opinions and comments, but we ask that you avoid personal attacks, vulgarity and hate speech. We reserve the right to remove any comment at our discretion, and we will block repeat offenders' accounts. To post comments, you must first be a registered user, and your username will appear with any comment you post. Happy posting.

Login or register to post comments

787 wrote on June 17, 2017 at 9:06 am

Maybe if the Nursing Home had union employees, things would be better.   Union members are supposed to be better at their jobs than anyone else.

Maybe I should ask County Board member and Nursing Home Board member Josh Hartke about that.

That Nursing Home building was built with union labor and by union contracting firms.  It was simply one mistake after another, along with shoddy materials, and the mistakes are still being corrected (new boilers was one of the last ones).   Millions of dollars in repairs on a 10 year old building.  

The nursing home is staffed with union labor, and it is still one mistake after another. 

 

rsp wrote on June 17, 2017 at 9:06 am

A relative of the resident who took his life — and is not identified by name in the investigative report — allegedly told a nursing home staff member at the time of admission that the man had tried to kill himself with an elastic cord the week before he was admitted to the nursing home and that he had stated that he wanted to die.

 

If your family member or a friend talks about suicide, call for help. Call your doctor. Not only are there medical interventions but there are some medications that can cause suicidal thoughts in some people. If they make an attempt call 911. There are treatments that can help.

billbtri5 wrote on June 17, 2017 at 2:06 pm

 one government agency fining another government unit.  Taxpayers lose,  no matter what.....

what's the point?...