August 16, 2001
JACKSONVILLE NURSING HOME FINED IN RESIDENT DEATH
SPRINGFIELD, IL The Illinois Department of Public Health has fined Skyview Terrace $10,000 (statement of violation) for failure to provide physician-ordered medications and nursing services in accordance with a resident's needs. The 113-bed skilled care facility is located at 1021 N. Church St. in Jacksonville.
Responding to a complaint, Department investigators learned facility staff failed to continuously monitor a resident, did not notify her doctor immediately when her condition deteriorated and did not administer her physician-ordered medications.
Nurse's notes reveal that staff assisted the resident with a meal in her room and when they returned an hour later she was slumped over in her wheelchair. The resident's physician and a friend, who was the woman's health care power of attorney, were notified. Later the same day, staff noted swelling in the woman's right arm that appeared to be from an old puncture wound. The woman's friend visited consulted another doctor and the resident was transferred to a local hospital where she was treated for cellulitis, a skin tissue infection.
A doctor ordered antibiotics administered four times a day and continuous monitoring for any change in her condition. The medication administration sheets, however, indicated the resident did not receive the antibiotics. Staff told Department surveyors the resident was unresponsive and could not be given the oral medication.
The resident's physician was not notified until three doses had been missed. Upon notification, the physician issued a new order for medication, but the resident received only the first injection. When asked why the next dose was missed, a staffer told surveyors she "did not have time." Less than three hours later the resident died.
A Department-ordered plan of correction requires the facility to record significant changes in a resident's condition and notify the person's physician so a plan of care and treatment may be determined. In addition, the facility was ordered to properly administer physician-ordered medications; to adequately monitor, re-evaluate and treat its residents; and to ensure a resident's guardian is notified when changes appear in resident conditions.
of Public Health
535 West Jefferson Street
Springfield, Illinois 62761
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