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Nursing home fined $75,000 for death of resident, escape of another

Nursing home fined $75,000 for death of resident, escape of another

Aperion Care in East Moline

Aperion Care in East Moline being fined by the Illinois Department of Public Health. Thursday, Jan. 25, 2018.

EAST MOLINE — The strangulation death of a resident and the escape of another has resulted in Aperion Care Moline being assessed $75,000 in fines by the Illinois Department of Public Health.

The nursing facility, 430 S. 30th Ave., East Moline, was notified by IDPH in November. 

According to the department's fourth-quarter report, Aperion Care Moline was fined $50,000 for the accidental strangulation death of a resident in August and $25,000 in October when a resident escaped and was found wandering on a roadway. Both incidences resulted in 12 code violations — six for each occurrence. 

On Aug. 11, a male resident was discovered unresponsive and not breathing on the floor at the foot of his bed at 8:27 p.m., hanging by the ties of his nightgown, which were wrapped around the post of his foot board. The report states CPR was not administered until ambulance crew members were called and arrived 20 minutes later. 

The resident's roommate was interviewed by IDPH officials Aug. 24 and said he pushed the call light for help when the resident got out of bed to retrieve his coat from the closet. The roommate was already in bed for the evening. 

"I pressed my call light to get (him) help," the roommate said. "The next thing I know, (resident) was on the floor. It took 15 to 20 minutes before anyone came to help. I heard (resident) at first, the next thing (resident) wasn't breathing. I always leave the light on above my bed so we can see."

IDPH officials interviewed two nurse's aides on duty that night, who stated they returned from their break together at 8:27 p.m. One of the aides responded to the call light from the resident's room and discovered him on the floor. The nurse's aide said the man's face and fingers were dark blue. After the aide untied the nightgown strings from the bed post, the man began vomiting, so the aide turned him on his side. No CPR was given to resuscitate him. 

The report states the aide ran out of the room to get the other nurse's aide. They returned to the room, and one aide stayed with the resident while the other aide went to search for a nurse, going to two different nurse's stations in the facility. A licensed practical nurse (LPN) arrived in the resident's room and said there might be a DNR (do not resuscitate) order on the resident. The LPN said CPR could not be administered anyway since the man was vomiting. 

During questioning by IDPH officials, the LPN said a DNR order was brought to the resident's room, but realized the order was for another resident. A code crash cart was brought into the room for the purpose of resuscitation, but EMS had arrived and began suctioning the resident and administering CPR. At that time, the resident's correct paperwork was located, which stated the resident was "full code" and to be resuscitated. 

The EMS run sheet reports the 911 call was received at 8:47 p.m., 20 minutes after the resident was discovered hanging by the ties of his nightgown. EMS crew reported, "Patient unresponsive, not breathing, skin cold to touch, pupils fixed and dilated. No CPR initiated prior to arrival."

It was later discovered that the code crash cart lacked the required medical equipment necessary for suctioning a patient and administering IV fluid. 

The report further states that three out of the 16 CNA (certified nursing aide) staff for night shifts are trained in CPR, and just three out of 23 CNAs on the day shift are certified. 

Aperion Care Moline Administrator Tara Wassell declined to comment, referring questions to the facility's attorney. 

Frederick Frankel, general counsel for Aperion Care, said the issues are being addressed.  

"This was a fluke accident that occurred," Mr. Frankel said about the strangulation. "Steps are taken to make sure nothing like this would happen at this facility again."

He said staff at the facility have been working in different ways to decrease the response time to call lights. 

When asked about the lack of CPR certification for nurses, Mr. Frankel said, "CPR training at the facility is fine. Steps have been taken to make sure this incident will not occur again. Whoever is required to be certified, is (certified.) I don't believe CNAs are required.

"We're still dealing with the state. Education is first and foremost, and we are developing new procedures to make the process easier and have less room for error. All (incidences) are taken very seriously. We try to hire good staff and get them trained."

Aperion Care's policy for CPR training states all nursing and hostess staff are to be certified within 90 days of employment and recertified in CPR yearly. 

Resident escapes

An incident in October resulted in a $25,000 fine when a male resident escaped from the facility and was found wandering on a roadway partially clothed in 38-degree weather. 

A wander guard alarm had been placed on the resident, who was determined to be at high risk of escape, when he was admitted Oct. 25. The report describes the patient as agitated and "confused on why he was in the facility."

According to surveillance footage, the resident left through an unlocked rear door at 5:35 a.m. Oct. 26. The IDPH report states the door had two alarms, but neither was functioning at the time. The wander guard only works if the resident exits through the main entrance. 

Nursing staff called a "Code Pink" (missing resident) at 6:30 a.m. At that time, all staff began looking for the resident. According to police records, Aperion Care Moline reported a missing person at 7:27 a.m.

A motorist picked up the resident, who asked the motorist to take him home. After trying to locate the resident's house, the resident became nervous and asked to be let out of the vehicle. At that time, the motorist called police, who then arrived to take care of the resident. Police reported the resident was only wearing gym shorts, a T-shirt, and socks with no shoes. The resident's catheter was disconnected, and he was covered in urine. 

The police officer said, "It was 38 degrees that morning. (Resident) was so cold, I put him in my police car and drove him to the fire department. They took him to the hospital. (Resident) was confused the whole time."

The brother of the resident picked him up from the hospital. He told IDPH officials, "He doesn't have his mind; He is not able to make his own decisions. The facility knew they needed to watch him."

In addition to the fines, Aperion Care Moline must submit a plan of correction related to the incidences. The facility also was issued a conditional license until June 7, 2018. If the fine is not paid by that time, the facility will lose its license. 

Mr. Frankel said he is not aware of any pending litigation related to either matter. 


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