October 20, 2000

SPRINGFIELD, IL –The Illinois Department of Public Health has fined Alma Nelson Manor $10,000 (Statement of Violation) for failure to provide proper nursing care and to properly assess a resident's medical condition. The 268-bed skilled care facility is located at 550 S. Mulford Road in Rockford.

Responding to an incident report, Department surveyors learned facility staff administered twice the prescribed amount of an oral anti-diabetic drug to a resident recently diagnosed as a diabetic.

A review of the resident's file found the resident's blood sugar reading was low on three consecutive days and staff noted he was pale, increasingly unresponsive and having trouble breathing. His physician, however, was not notified of his deteriorating condition.

After finding his blood sugar low on the third day, a staff nurse provided no treatment to the resident and left him alone to continue passing medications to other residents. When another staff member came to assist the resident with dinner 75 minutes later, she noticed his breathing was labored and he would not wake up. She summoned other staff for help, but the resident died a short time later.

A Department-ordered plan of correction required facility administration to establish policies and procedures when a resident exhibits symptoms of low blood sugar and to ensure physician's orders for medication are administered accurately.

Alma Nelson Manor has requested a hearing on the Department's action. A hearing date has not been scheduled.