URBANA – A recent state investigation of the Champaign County Nursing Home was precipitated by an incident in which a female patient at the facility fell, suffered an injury that went undetected and died several days later.

The incident has led to a chain reaction of investigations, reports and findings that have resulted in $50,000 in fines against the nursing home, the loss of some Medicare and Medicaid funding and the potential loss of all Medicare and Medicaid funding.

The nursing home administration is contesting the findings and appealing the penalties.

Officials at the nursing home say the elderly woman's health was poor when she arrived at the facility, and note that the Illinois Department of Public Health, which conducted the investigation, did not blame the nursing home for her death.

But a public health spokeswoman said the department never assesses blame in nursing home deaths.

"That is something the agency cannot say. We do not determine the cause of death," said public health spokeswoman Melaney Arnold.

"Did one of the things they did lead to the death? We don't know. We would never say a facility caused a death."

Meanwhile, two other visits to the nursing home by public health inspectors – one on April 2 and another on April 29 – found more problems at the facility.

In the April 2 inspection, it was determined that the nursing home did not follow its own policy in handling an allegation lodged against an employee. A resident alleged that she had given money to a staff member for a soft drink but never got it or her money back. She complained to another staff member, who did not report the incident.

All complaints are supposed to be investigated immediately.

Also that day, the inspector determined that the nursing home staff "failed to provide appropriate treatment and services to maintain or improve abilities in toileting and transfers" for four residents.

The April 29 inspection found that nursing home staff failed to use proper equipment when transferring three patients. In the most serious case a 91-year-old patient suffering from dementia broke her hip after she stood up from her wheelchair and fell. The woman was supposed to have had a personal safety alarm on her wheelchair.

The series of accidents and investigations is worrisome to the nursing home's board of directors, said board chair Mary Ellen O'Shaughnessey of Urbana.

"Is the board concerned? We are absolutely concerned. The health and welfare of the residents are paramount to what our mission is.

"Of course it's troubling."

In the incident which set off the series of investigations, a patient identified only as R7 slipped out of a chair while in a lounge area, but apparently was caught by a certified nurse aide.

"CNA slid under (R7) and pulled her onto her lap ... (R7) denied pain .. did not hit head ... did not hit w/c (wheelchair) or w/c pedals. (R7) talking and laughing with staff ... able to move arms and legs without a problem or pain ... Body check done with no areas of redness noted," said a report identified as a "late entry," and dated Jan. 25. It is not clear whether the incident occurred that day or earlier.

There was no other documentation of the fall before Jan. 25.

By Jan. 29, however, nurses noticed bruising on the woman's right leg and right hand. A physician ordered the woman be taken to an unidentified hospital. There, an emergency department attendant said the woman's "right leg has progressively increased in size with diffuse ecchymosis (bruising) ... It does appear (R7) struck her head."

She was diagnosed with a number of serious conditions, including shock, acute kidney failure, hypovolemia (low circulating blood flow), and acute posthemorrhagic anemia.

There was an "incredible amount of blood lost in the leg," an emergency department physician said. It "took a lot of fluid and blood to fix (R7's) anemia/shock which resulted in CHF (congestive heart failure)."

The woman died on Feb. 4. Her death certificate says the cause was "cardiopulmonary arrest, respiratory failure and hypovolemic shock."

The Public Health investigation of the incident, dated Feb. 25, found the nursing home neglected to properly care for the patient in at least four ways:

– "By failing to implement existing policies on Falls, Lab and Diagnostic Test Results, Laboratory Testing, Orders for Anticoagulants, Anticoagulants and Change in Resident's Condition or Status;"

– "By failing to notify the physician in a timely manner of high laboratory values, neglected to identify a fall, to notify the Physician/Nursing staff of the fall and implement post fall monitoring;"

– "By failing to assess and monitor significant bruising as a side effect of anticoagulant therapy and a fall;" and

– Neglecting "to notify the Physician of the significant bruising in a timely manner, but continued to administer anticoagulants to R7."

But Matthew Murer, a Chicago attorney who is representing the county and the nursing home in their appeal to public health, cautioned that the process is an adversarial one.

"Generally when they cite a violation they cite it in a very one-sided fashion," said Murer, an attorney with the Chicago firm Polsinelli Shughart. "I do not think it's their objective to present a balanced report. It's their objective to provide a basis for what they think is a violation, which of course we disagree with, which is why we filed an appeal and why we're fighting it."

That's unfortunate, he said, "because the statement is put out there and people presume that's the whole story when that is not the case."

"I don't think people should jump to any conclusions because that's just one side of the story and we strongly believe that there's no basis for the violation and that's why we're appealing it and why we're fighting it."

In the meantime, the nursing home has instituted changes in response to the public health findings. For example, training will include special attention to reporting falls. "An episode where a resident lost his or her balance and would have fallen were it not for staff intervention, is a fall. In other words, an intercepted fall is still a fall," said a memo.

And when employees are accused of mistreatment of residents, a memo says they "will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible mistreatment shall not complete the shift."

O'Shaughnessey, the chair of the nursing home board of directors, said it's best to look at the investigations and reports as a "learning opportunity."

"Every time we've been cited I think the staff has risen to the challenge and has found a way to provide a system where that mistake will not happen again. That's what is important," she said.