CASEY NURSING HOME DISCIPLINED IN RESIDENT DEATH

SPRINGFIELD, IL – The Illinois Department of Public Health has fined Heartland Manor Nursing Center $10,000 (statement of violation) for failure to ensure proper treatment of a resident following an accident. The 99-bed skilled care facility is located at 410 N.W. Third St. in Casey.

As part of an incident investigation, Department surveyors learned a resident being transferred to her wheelchair was dropped when a mechanical lift malfunctioned. The resident sustained a deep laceration to her head and died 20 minutes later.

A licensed professional nurse (LPN), who responded to the incident, told surveyors she placed the resident in bed and provided oxygen, but did not initiate cardiopulmonary resuscitation when the resident stopped breathing because she had a “Do Not Resuscitate” (DNR) order.

A review of the facility’s policies found there was no directive on whether a DNR order should be followed in the event of an accident. Surveyors also noted staff failed to follow the facility’s “medical emergency” procedures for moving an individual with a head injury.

A Department-ordered plan of correction required facility administration to review its policies and procedures regarding the implementation of DNR orders in the event of an accident; to ensure staff are properly trained to provide emergency services; to conduct staff training on the proper use of mechanical lifts; and to routinely inspect mechanical lifts for safe operating conditions.

Heartland Manor Nursing Center requested a hearing on the Department’s action.

By Final Order dated May 4, 2005, Violation Amended, Fine Assessment Amended, and Notice of Conditional License Withdrawn.