St. Anthony’s Nursing and Rehabilitation Center has been cited by the Illinois Department of Public Health because of abuse and neglect of two residents, incurring five license violations and a fine of $2,200.
According to the IDPH's 2020 first-quarter report on nursing-home violations, St. Anthony's, 767 30th Ave., Rock Island, "failed to follow its policy and wash hands in between glove changes, avoid touching clean items with soiled gloves and avoid direct contact with a wound for one resident; and failed to identify and assess a pressure ulcer wound for (another) resident."
Following an investigation by IDPH on Oct. 25, 2019, the report states the director of nursing entered the room of the first resident Oct. 22 to change a dressing for a bedsore on the resident's tailbone.
The director of nursing (DON) removed the resident's soiled wound dressing, removed the contaminated gloves and put on clean gloves without washing hands. The DON then "cleansed the coccyx wound with gauze pads and normal saline. DON then removed the soiled gloves and placed on clean gloves with no hand washing occurring (again)."
The report states the director of nursing then applied collagen powder directly to the resident's wound with a gloved hand. The DON then reached into a pocket with the soiled gloved hand to retrieve a pen and proceeded to mark the date on the bandage on the wound. The DON changed gloves for a third time, again without washing hands in between glove use. After disposing of the resident's biohazard waste bag, the DON washed hands in a nearby sink.
"I should have washed my hands in between glove changes," the DON stated in the report. "I shouldn't have reached into my pocket with soiled gloves on. I hadn't used that powder; I used my fingers and probably shouldn't have. That makes more sense."
The report states the second incident occurred with a resident who was admitted to the facility on Aug. 7, 2019, with a brain tumor, debility and severe muscle deconditioning. By October, the resident had developed a bedsore on the tailbone. As a result of nursing staff's failure to follow the attending physician's order to treat the wound, it worsened from "dermatitis to an unstageable ulcerated wound."
Furthermore, the open wound on the tailbone was not recorded in a weekly pressure ulcer — or bed sore — log kept of the resident's wounds.
The IDPH report states, "None of the resident's detailed wound notes were presented by the facility or found as part of the resident's medical record. No weekly wound notes were presented documenting assessments of the resident's coccyx wound."
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