Rockford, Illinois Report Card 2008: Alden Alma Nelson Manor
The Alden Alma Nelson Manor nursing home, located in Rockford, Illinois, has repeatedly been cited by the State of Illinois in the past year for deficiencies in quality of care, mistreatment, resident rights, administration, and environment. Early citations do not seem to have created a desire to fix the problem.
In March 2008, Alden Alma was cited for safety when facility staff failed to ensure the side rail of a resident bed was raised before using the rail as an assistive device to turn a resident. The resident, totally dependent on two facility staff for assistance with all activities of daily living, fell from the bed to the floor.
Five days later, the same resident was undergoing routine blood work through an outside laboratory in early afternoon. The lab technician pulled up the resident's shirt sleeve and drew the sample, but failed to release and remove the tourniquet from the resident's arm. Facility staff failed to notice the tourniquet until undressing the resident for bed.
In the past year, this facility also failed to follow its own hiring procedures when hiring new employees. Prior to hire, employees are required to have two completed reference checks to ensure patient safety. The facility failed to complete appropriate reference checks and had to provide training for the person responsible for hiring new staff. Sadly, that training involved orientation to documents required prior to hiring per Alden Alma Nelson Manor's own hiring policy.
Residents of nursing homes deserve professional services at all times and they deserve to be treated with dignity. The State of Illinois has found that this facility failed to provide dignity and professional services to multiple residents. Some residents advised that they were told to "hold" their urine until the next shift if they had to use the restroom after being toileted. Others were put into Depends because facility staff did not toilet them timely. Another resident was told that she had to eat lunch in bed because it was too much of a bother to the staff to get her back up using the required mechanical lift. She reported that she frequently sits in bed wet as a result of staff indifference. Other residents were not treated with dignity. One resident received personal care while her door was open so that facility residents and visitors could see into her room. Facility staff had to be instructed on Alden's Privacy Policy.
Many residents at Alden Alma Nelson Manor stated that they were bored. During an inspection, one resident was found sitting in a wheelchair facing a wall, another was found sitting in front of a television that was turned off, others were not invited to participate in group events in the facility, and it was noted that there were very few one-on-one social visits from facility staff with the residents.
Pressure sores are a known danger for bed-bound residents if the resident does not receive proper treatment (Go here to see pictures of pressure sores). Alden Alma Nelson Manor was cited for failing to provide proper treatment to prevent new pressure sores or heal existing bed sores. One resident suffering from a Stage II sacral pressure sore continued to deteriorate, even though staff purportedly was treating the pressure sore. The resident's ulcer developed into a Stage IV pressure sore and required hospitalization and surgical debridement. At least one resident had a Stage IV sacral pressure sore. After the citation, staff was provided with training for pressure ulcer assessment and prevention and the proper care procedure to be followed for residents at risk for developing pressure sores.
Nursing home resident frequently need assistance with daily hygiene. The Alden Alma Nelson Manor staff often failed to properly hygienically care for a resident. In one instance, a resident needed to have an incontinence pad changed. Facility staff pulled on gloves and wet the end of a towel with water and proceeded to "wipe" the patient. Then, using the same towel, the staff member wiped feces from the resident. The staff member failed to use any soap or periwash and did not dry the resident's skin. Facility staff members did not change their gloves unless they were "really messy" and staff members proceeded to touch other items in the room or scratch their face without removing the unsanitary gloves.
Care Plans are an important part of a resident's care. Each resident should have an up-to-date Care Plan in his or her chart at all times. This facility was cited for failing to give or get special rehabilitation for a resident when it was stated in the resident's Care Plan. The Care Plan for a resident who suffered a neck fracture required a cervical collar to be worn at all times. The resident was found sitting in a wheelchair without the neck brace and no one caring for the resident knew what the Care Plan stated and whether the collar was to be worn or not. Another resident had a catheter in place following a hospitalization. The catheter was removed as a urine culture showed that the resident was suffering from an MRSA infection. The resident's physician ordered a course of antibiotics and re-testing upon completion of the drug course. The resident did not recover after the first drug course and the physician ordered a second treatment and re-testing. The facility failed to obtain a second test as the physician's order was overlooked.
Ensuring a nursing home resident is receiving the appropriate nutrition is vital. At this facility, one resident lost 13.3 pounds in one month. Another resident suffered significant weight loss and the resident's diabetes was out of control. Staff had no idea of the amount of nutrition taken in by another resident because there were no records. The facility was cited for these failures. As a result, the Director of Nursing is now required to review the meal intake sheets, review weights, and review blood glucose reports. The facility staff will be trained on Alden Alma Nelson Manor's Weight Policy, meal monitoring, and intake/output sheet importance. The staff will also be trained on blood glucose sheets and acceptable parameters.
While caring for a resident's physical health is important, it is equally important that a resident's mental health be cared for as well. This facility was cited for failing to meet the needs of residents with mental illness. The residents with mental illness had no special programs in place for their mental health. Instead, mental health patients received the same programs that are provided for all residents of the facility, regardless of its effectiveness. After the citation by the state, Alden Alma Nelson Manor comprehensively assessed residents needing special assistance and were required to initiate appropriate programs to provide mental health rehabilitation services.
Overall, Alden Alma Nelson Manor received nineteen citations in 2008, earning a one-star rating under Medicare's new rating system. A one-star rating is indicative of a facility "much below average", according to Medicare.
The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. For more information, call us directly at 1 (888) 317-2525 or visit our website at www.nursinghomejustice.com.
