SPRINGFIELD, IL – The Illinois Department of Public Health has fined Pekin Living & Rehabilitation Center $10,000 (Statement of Violation) for failure to properly follow a resident's transfer orders for administering physician-ordered medications and to conduct laboratory tests. The 202-bed skilled care facility is located at 2220 State St. in Pekin.

Responding to a complaint, Department investigators learned the facility was given physician orders, both written and verbal, regarding treatment and care of a resident prior to his admission. The resident, a kidney transplant recipient, was to receive three immunosuppressant medications, to have regularly scheduled laboratory tests and to routinely visit his kidney specialist.

During his five months at the facility, however, the resident only received one of his three physician-ordered medications, had one laboratory test and never visited the specialist. The resident was hospitalized after he was found unresponsive by a facility nurse.

The resident's specialist stated the resident was experiencing "moderate to critical rejection of his transplanted kidney" and his condition and hospitalization were "due to lack of care and assessment by the facility."

When questioned about the resident's care, facility nurses stated they were only aware of one prescribed medication and, although an appointment had been scheduled during his first month at the facility, had no explanation for why his specialist was never seen or consulted.

After reviewing the resident's file and the original transfer orders sent to the facility, surveyors determined that only one page of his orders had been included in his records. While these records listed the medication he had received at the facility, a statement at the bottom of the page indicated the orders were "CONTINUED NEXT PAGE." Facility staff interviewed about the discrepancy claimed they had not seen the notation and, therefore, were not aware of the missing orders that included his two additional medications.

A Department-ordered plan of correction required the facility to review its policies and procedures to ensure all admission orders and instructions are included in resident care plans; that proper monitoring, evaluation and treatment are provided to its residents; and that physicians are consulted and notified regarding changes in resident conditions.

Pekin Living & Rehabilitation Center has requested hearing on the Department's action. No hearing date has been set.