|December 3, 2002
GODFREY FACILITY FINED FOLLOWING RESIDENTS' DEATHS
SPRINGFIELD, IL Beverly Farm Foundation has been fined $20,000 (Statement of Violation), by the Illinois Department of Public Health for failure to provide adequate and emergency nursing care to prevent resident deaths. The 300-bed intermediate care facility for the developmentally disabled is located at 6301 Humbert Road in Godfrey.
As part of a complaint and incident report investigation, Department surveyors learned four residents died after emergency medical equipment could not be located or when emergency services were not obtained in a timely manner. All four deaths occurred in a one-month period.
A check of the facility's 10 cottages for emergency equipment found all were missing critical supplies and what was available was not located in the same place in each building or kept locked in an office. On three occasions, emergency equipment could not be found in the building where the resident lived and staff had to locate equipment in another building. An employee said that one reason staff could not find a piece of equipment was because they did not know what it looked like.
The facility also neglected to adequately assess and monitor residents' conditions and to obtain emergency care when needed.
A resident with a diagnosis of a possible blood clot in the lung was readmitted to the facility after a week in the hospital, but she was not closely monitored and emergency services were not immediately sought when her condition deteriorated. Although the resident was suffering respiratory distress and gasping for air, her physician was not contacted and paramedics were not summoned. The on-call nursing supervisor was on break and she told staff she would respond when her break was over.
About 75 minutes after she began having trouble breathing, the resident stopped breathing and was transported to the hospital where she died.
In another instance, an employee gave medication to a resident to help lower his fever and to ease congestion and labored breathing. However, the employee did not check for three hours to see if the medication was helping the resident, who had a history of pneumonia. She also did not take all vital signs or listen to his lungs. When another employee evaluated the resident several hours later, he was transported to a local hospital, where he died of pneumonia.
The Department-ordered plan of correction required the facility to notify physicians of any significant changes in residents' conditions; to revise policies concerning the monitoring and care of residents during a medical emergency; to develop a check list to ensure that the necessary equipment is readily available; and to ensure staff are informed of the location of emergency equipment and appropriate actions to be taken during an emergency.
Beverly Farm Foundation has requested a 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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