Rockford Healthcare & Rehab Center is a 97 bed nursing home facility located in Rockford, Illinois. The facility is rated as a one-star facility according to the new rating system instituted by The Centers for Medicare and Medicaid, which indicates a below-average facility in 2008.
Nursing home facilities are required by law to notify a resident's physician or legal representative of any change in a resident's condition or if an accident or injury has occurred. Rockford Healthcare and Rehab Center failed at least one of its residents in this respect in 2008. A resident had a Stage II pressure sore on the coccyx that was discovered on August 25, 2008. There were no treatment orders in the resident's file for the pressure sore. On September 8, 2008, the resident was observed lying on a soiled incontinence pad with the wound uncovered and no treatment in place. The resident's family had not been notified of the wound. As a result of the state investigation, the facility notified both the resident's physician and family on September 8, 2008. The facilty re-inserviced nurses and counseled nurse who failed to notify the resident's physician on both doctor and family notification procedures. Nurse charting, new orders, and resident changes are to reviewed Monday through Friday for three months.
All residents are entitled to be free from verbal, physical, sexual, or mental abuse, punishment, or involuntary seclusion. Rockford Healthcare and Rehab Center failed to prevent the abuse and injury of an impaired resident by a roommate with a history of physical aggression. The resident with a history of physical aggression broke off a control lever from a recliner and was hitting the resident on the head with the lever repetitively. The resident, who was on blood thinners, complained of head and hip pain and suffered multiple lacerations. As a result of the state investigation, the facility re-inserviced staff on abuse reporting policy and procedure and initiated a new admission acceptance form. The facility will review all available information on resident behavior before admission. Resident Care Plans were reviewed and updated to include abuse or potential to be abused. Resident behaviors must also be reviewed randomly for three months.
Rockford Healthcare and Rehab Center is legally obligated to develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents. The facility failed its residents by not providing nursing care to prevent physical harm and failing to follow facility policies and procedures. For example, a pressure sore was discovered on a resident at the end of August 2008. No treatment orders were in place in August or September 2008 for the pressure sore. Additionally, the same resident did not receive nutritional support to meet his physical needs. Rockford Healthcare and Rehab Center immediately assessed the affected resident and notified the resident's physician. Treatment was initiated immediately. The facility also instituted a policy that within 24 hours of admissions all new admissions will have their skin checked and tube feeders will be assessed. Facility staff were inserviced on skin assessment, physician notification, treatment of skin issues. and tube feed requirements. Quality Assurance will monitor all skin areas weekly and the Clinical Administrator will review all tube-fed residents monthly to ensure adequate nutrition.
Nursing home facilities are legally obligated not to employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law or have a finding entered into the state nurse aide registry concerning abuse, mistreatment, or neglect. Rockford Healthcare & Rehab Center failed its residents when it failed to investigate bruises on a resident's arms and a foot fracture of unknown origin. The facility also failed to fully investigate a resident's allegations of being slapped and a report of staff stepping on her toes. The facility failed to interview the charge nurse and remove the accused staff from resident care until the investigation was completed. After the state intervened, the facility had to re-inservice staff on reporting bruises of unknown origin and abuse allegations to the administrator immediately so investigations could be completed. The facility will investigate thoroughly allegations of abuse.
Rockford Healthcare & Rehab Center residents have a right to receive services in the facility with reasonable accommodations of needs or preferences. The facility failed a new resident in this respect when it it failed to provide the new resident with a wheelchair appropriate for her needs. The resident was found sitting in her wheelchair, crying, and asking to lay down. She was slouched down in the chair and holding on to the arm rests for support. There were no foot rests on the wheelchair and the wheelchair was too small for her body. In fact, it was so small that the resident's thighs were indented by the sides of the wheelchair and the wheelchair armrests were pressing into the resident's waistline. When questioned by the state, the facility immediately removed the resident from the wheelchair and placed her into a new wheelchair that was better suited for her needs. All facility residents were reassessed for wheelchair and appliance appropriateness. Nurses were inserviced so that the problem would not occur again.
Care Plans are vital to a nursing home resident's well-being. Without an accurate Care Plan, the resident will not be able to achieve or maintain the highest practicable physical, mental, and psychosocial well-being. In one instance, an unsupervised resident performed "surgery" using a nail clippers on a foot callus to relieve the pressure on his foot. After this was discovered, the facility Clinical Administrator met with the resident and educated him on the risks and harm that occur from performing "surgery" on his foot. The facility has initiated a new behavior program for the resident.
All care received at Rockford Healthcare & Rehab Center must meet professional standards of quality. An insulin dependent resident was to have his blood sugar checked every morning at 6:00 a.m. The facility had eleven glucose monitoring errors in seventeen days on the same resident where the glucose was checked at the wrong time or was not checked at all. As a result of state involvement, the facility contacted the resident's physician and clarified the order. Facility licensed nurses were inserviced on blood glucose and medication errors.
Pressure sores can be a serious problem for bed-bound nursing home residents if they are unmonitored and not properly treated. If the resident's skin is not properly cared for, infection from the pressure sore can result in serious illness and possibly death. Like all nursing homes, Rockford Healthcare and Rehab Center is required to ensure that a resident entering the facility without pressure sores will not develop pressure sores. A resident with pressure sores is to receive the necessary treatment to promote healing, prevent infection, and prevent new sores from developing. The facility failed several residents when it failed to routinely assess resident skin conditions, identify new open areas, document skin conditions, and obtain treatment orders. Moreover, the facility failed to prevent a resident at low risk for skin breakdown from developing deep tissue injury and further skin breakdown. After the state survey, Rockford Healthcare and Rehab Center counseled nurses who failed to assess and follow up on residents affected with pressure sores. All residents were assessed and pressure relieving devices were provided as needed. The facility also re-inserviced all CNAs and nursing staff on pressure ulcer prevention and protocol.
Rockford Healthcare and Rehab Center is required to ensure that the environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistance to prevent accidents. The facility failed in this respect when staff failed to ensure that a fall-risk resident's chair alarm was turned on and operational. The resident fell forward in his wheelchair and he landed face first on the floor. The facility assessed the resident's chair alarm and found it to be faulty. The alarm was replaced. All other facility alarms were checked for working order and worn out batteries were replaced and/or replaced faulty alarms. After this resident's injury, facility staff were in-serviced on appropriate alarm usage.
Rockford Healthcare and Rehab Center must ensure that residents receive appropriate nutritional support if being tube-fed. The facility failed to ensure that its resident received the appropriate caloric intake through tube feeding. Rockford Healthcare and Rehab Center was forced to rectify this problem through a new care plan and the facility in-serviced its nurses on tube feed requirements.
The Terry Law Firm is experienced in nursing home cases involving abuse and/or neglect. Please contact us at (888) 317-2525 or through our website at www.nursinghomejustice.com.
Linda Shaw
Florence Ko and Maria Tseu