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Nursing Home Fined $75,000 for Death of Resident, Escape of Another

The Dispatch

By Sarah Hayden

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.