|April 9, 2001
LAGRANGE NURSING HOME FINED
SPRINGFIELD, IL The Illinois Department of Public Health has fined LaGrange Rehab Center (Statement of Violation) $10,000 for failing to ensure its staff was properly trained to provide emergency care services for residents involved in accidents. The 203-bed skilled and intermediate care facility is located at 339 S. Ninth Ave. in LaGrange.
Responding to an incident report, Department investigators learned that a resident, who had a history of pacing and wandering, became entangled in his gown and a privacy curtain and was found by staff sitting on the floor next to his bed. The material was wrapped around his neck, and he was not breathing. The resident died due to strangulation.
Per record review and staff interviews, surveyors were unable to determine what, if any, life-sustaining measures were taken by facility staff.
Staff removed the material from the resident's neck and checked for a pulse, but made no other assessment of his condition. Two staff members then moved the resident into his bed, while a third employee reported the resident's death to a facility supervisor. One of the employees indicated no attempt was made to resuscitate the resident because he had a Do Not Resuscitate (DNR) order. None of the employees involved in this incident had cardiopulmonary resuscitation (CPR) certification.
Facility policies and procedures for accidents and emergency care instruct employees not to move a resident, but to assess his condition by checking for pulse, airway, breathing and circulation and, if the resident is viable, to begin emergency services. Policies also address the application of DNR orders for residents when the incident is an unnatural accident.
Investigators determined the three employees involved in the incident did not follow applicable policies and procedures.
A Department-ordered plan of correction required the facility to ensure that policies and procedures are in place for handling medical emergencies and that staff are properly trained to provide emergency services.
LaGrange Rehab Healthcare Center has requested hearing on the Department's action. No hearing date has been set.
of Public Health
535 West Jefferson Street
Springfield, Illinois 62761
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