No One Monitors Nursing Homes

by Pete Gonigam

State Police believe a nurse killed six patients at the Woodstock Residence so her work would be easier. Meanwhile coroner’s numbers show deaths began to skyrocket there before the first killing and stayed high more than a year after she left.

Who’s supposed to be watching for this sort of thing?

Essentially, no one.

Technically the U.S. Department of Health and Human Services monitors nursing homes.

Just not very much.

Regulations require each nursing home to submit weekly reports for each patient including dozens of measures of care.

That includes death.

The numbers go into something called the MDS database but a spokesman said the department has no program to regularly examine it for patterns of unusual deaths.

Some area nursing home administrators send notices of deaths at their facilities to the Illinois Department of Health, but a spokesman there said there is no requirement to do so. A Freedom of Information Act request for IDPH nursing home death records prompted the response that there were none.

HHS regulations also require unannounced inspections at each nursing home “once in a twelve-month” period. In practice in Illinois that works out to an inspection once each year. Surveyors appear unannounced but almost as predictably as clockwork, according to records on the Medicare website.

In Illinois the inspections are carried out by the Illinois Department of Public Health as a subcontractor to HHS.

Otherwise the only time IDPH looks at a nursing home is when someone files a complaint. That’s how the Woodstock Residence came to department attention when a nurse told investigators she couldn’t get management there to look at what was being done to patients.

IDPH’s report on that complaint outlines conditions six months after the annual inspection bordering on the Dickensian.

The report charges blood sugar levels were poorly monitored for at least half the diabetic patients at the home, 10 to 15 percent of all the patients there. Levels too high or too low can lead to complications, coma or death.

Morphine, required to be kept under lock and key, was tossed into a drawer in the desk of the nursing supervisor, according to the report. Police investigators believed morphine left over from the first patient killed was used to kill another patient later.

Inspectors also found filthy toilets, strewn garbage, broken walls, spiderwebs, dustunnies, grime and paint yellowed with cigarette smoke.

Finally, in Illinois, contrary to popular belief, there’s no law requiring nursing home deaths to be reported to the coroner.

A spokesman for the Illinois Coroners and Medical Examiners Association who asked not to be identified said there was a move afoot for that three years ago, but it was shot down by the Cook County Medical Examiner. Cook County, he said, sees several thousand patients die in nursing homes each year and the ME claimed he didn’t have enough time and money to track them.

There remains a state pilot program requiring nursing home deaths reports to the local coroner but only six counties are in it, according to ICMEA.

McHenry County Coroner Marlene Lantz announced recently she will require nursing homes to report all patient deaths. However, that only formalizes the reports she was already receiving “as a courtesy”.

Former Crystal Lake Funeral Director Dave Bachmann said he’d monitor such reports monthly if he were coroner. Indeed, he’s running for the office.

Adam Smith’s “invisible hand” ought to watch over patient care at nursing homes. It’s bad business to kill your customers. Deaths at the Woodstock Residence suggest enlightened self-interest may not always be enough.

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