Lincoln nursing home cited for alleged preventable death

July 19--BLOOMINGTON -- The Christian Village nursing home in Lincoln has been cited with an AA violation and fined $50,000 by the Illinois Department of Public Health (IDPH) following an alleged preventable death of a resident on Feb. 5.

The long-term care facility's director of nursing referred The Pantagraph to Christian Horizons' corporate office, but calls to that office were not returned Wednesday.

Meanwhile, Accolade Healthcare of Pontiac, Heartland Health Care Center-Normal and Heartland Health Care Center-Decatur each were cited with A violations and fined $25,000 by IDPH after residents' conditions worsened unnecessarily.

The citations and fines were among 35 alleged violations of the state Nursing Home Act by long-term care facilities stateside, announced by IDPH on Wednesday. IDPH releases alleged violations and fines each quarter. Violations announced Wednesday were processed between April and June.

Christian Village nursing home, 1507 7th St., Lincoln, failed to notify a physician of a resident's decline in respiratory status and neglected to follow facility policy on change of resident condition, IDPH said.

The resident, a 64-year-old woman, was admitted to the facility on Jan. 22 for therapy following a motor vehicle accident and planned to return home. She had several diagnoses, but was "cognitively intact," IDPH said.

The resident's plan of care indicated that she was at risk for complications from asthma and encouraged prompt treatment of any respiratory infection. The resident began to experience shortness of breath and complained on Feb. 2 but her physician wasn't notified and she continued to decline. Nursing notes from 8:46 a.m.Feb. 4 through Feb. 5 did not document any assessment of her shortness of breath and only one nebulizer treatment, said IDPH.

The resident was found unresponsive at 7:51 p.m.Feb. 5. She died of staphylococcus aureus bronchopneumonia of the lungs, said the agency.

Accolade Healthcare of Pontiac, 300 W. Lowell St., Pontiac, failed to ensure physician's orders related to diuretic use were implemented for a resident there, IDPH said.

The resident returned to the facility after being hospitalized for acute kidney injury from dehydration with orders to discontinue Lasix, a diuretic medication. But that order was not carried out by the facility, which also failed to ensure fluids were within reach, resulting in the resident receiving 45 doses of Lasix. The resident, in April, developed an ongoing, worsening acute kidney injury because of dehydration, from continued Lasix use and a urinary tract infection, IDPH said.

Accolade Healthcare Owner Moe Freedman said he couldn't comment on the matter. "There is an open appeal and dispute of facts of the case and this is still pending at this time," he said in an email to The Pantagraph.

"Accolate takes all tags and allegations extremely seriously and works to correct and resolve any issues," said Freedman.

Heartland of Normal, 510 Broadway, Normal, was cited for failing to ensure that two staff members were present for re-positioning a patient in bed, resulting in a certified nursing assistant pulling a resident, causing a shoulder dislocation, IDPH said.

Heartland of Decatur, 444 W. Harrison St., was cited for failing to administer medications per physician orders for two residents, resulting in "ongoing untreated extreme pain" for one resident.

Neither Heartland facility returned Pantagraph phone calls.

Contact Paul Swiech at (309) 820-3275. Follow him on Twitter: @pg_swiech

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