IDPH has cited and fined Forest City Nursing & Rehab Center in Rockford after a resident there was hit and pushed to the ground by another resident, suffering a fractured hip and broken ribs.
One of the surprising things about nursing homes in Illinois is the number of younger people who reside in them. Some of have long term medical conditions which leave them truly debilitated and in need of ongoing care. Others suffer from forms of mental illness which is significant enough that they need a structured living environment and ongoing supervision and services, but have relatively few true physical disabilities. Where this can present a powder keg is when the younger resident decides to lash out physically toward a geriatric resident who, due to physical and/or mental disabilities or limitations is unable to protect themselves and especially susceptible to sustaining injury.
This is what occurred here. The aggressor was at the time of the incident 31 years old and suffered from a list of mental health conditions, including bipolar disorder, autism, cognitive communication deficits, and insomnia. On the day of the assault, the victim was saving a chair for a friend in the dining room when the aggressor attacked him. As a result, he suffered a fractured hip which required surgical repair and broken ribs.
The fractured hip places him at increased risk for developing bed sores due to loss of mobility and at increased risk of experiencing further nursing home falls. Further, the broken ribs can cause diminished respiratory effort which can set the stage for developing pneumonia. These are significant injuries for a nursing home resident to suffer.
What was at once fascinating and disturbing about the situation is what followed this resident-on-resident assault. Nursing homes are required to run criminal background checks on resident at or before the time of admission. The nursing home ran a check on the aggressor at the time he was admitted to the nursing home (about 6 weeks before the assault), but they entered the wrong date of birth while doing the check, and as a result, the background check came up “clean” – no criminal background. Had the proper date of birth been entered, it would have shown two separate charges of aggravated battery with the victim 60+ in the last year as well as a number of other felony assault charges dating back to 2005. And while the facility could claim to not have known about the criminal history because of the failed background check, one physician progress note before this assault noted that the resident reported that he was going to court later that day for having assaulted someone in the past.
While the failed background check is troubling and an obvious failure on the part of the nursing home, what is even more disturbing is the response to this incident by the nursing home:
- The social services director told the state surveyor, “We do our best, but we can’t have eyes on people 24/7 365 days. All residents are treated the same, behaviors can happen whether it is a person with a history or a little old lady.”
- The Director of Nursing told the state surveyor, “Even if the background check was done correctly, it wouldn’t have changed anything. We would not have done anything different for him [the aggressor] anyway. We don’t base our admissions on background checks.”
One of the basic commitments that nursing homes make is to do the things that are necessary to keep its residents safe. If a nursing home is going to admit a resident to the facility who has a history of assaulting senior citizens, this needs to be addressed in the resident care plan which would include frequent, detailed monitoring of the resident’s behavior for signs of aggressive behavior. Because of the failed background check, when this resident was assessed for aggressive or harmful behaviors, he was scored as a moderate risk, in part because the portion of the assessment which considered his history of criminal behavior was scored as a zero, which was obviously not true. Poor assessments lead to poor care plans which lead to bad outcomes.
The more telling (and disturbing) statement was the one from the Director of Nursing where she said that the nursing home would have admitted him anyway, even knowing of the history of having assaulted two other people over the age of 60. Nursing homes are one of the few explicitly for-profit sectors of the health care industry, and part of their revenue depends on keeping beds filled so that they can be paid their per-day fee from whatever entity is footing the bill. The proper course for a nursing home is to decline the admission of the resident when they are not able to meet the care needs of the resident or when that admission jeopardizes the health and safety of the other residents of the facility.
The fact that this resident would have been admitted even with the pending battery charges against victims who were 60+ tells you that the business considerations, not the safety of residents drives decision-making in this nursing home. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
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