A DRE Investigation – Infected Bedsore causes weightloss, fever and eventual death in Illinois Nursing Home
In January 1981, Donna grew sick. Her bedsore became infected, as it had many times at Dixon, but this time the infection got out of control. On January 16, early in the evening, an admitting clerk from Louis Weiss Memorial Hospital called Donna’s parents, Donald and Marylyn, to ask for Donna’s social security number, saying Donna might be admitted the next day. Mrs. Sonnenberg told us that she then called Mill View to find out what was wrong with her daughter, but the switchboard operator could get no answer from Donna’s floor, the second. The next morning, Saturday January 17, Mrs. Sonnenberg called Mill View again; again the operator could get no answer anywhere in the building. She then called Weiss and was told there was no bed available so Donna wouldn’t be admitted yet. She pleaded for them to admit Donna, though Mrs. Sonnenberg didn’t know what was wrong with her daughter. At about 11 am she called Mill View once more but again got no answer from the second floor. Some time later, a Weiss admissions worker told Mrs. Sonnenberg that Donna would be admitted at 3 pm. At 4 that afternoon she got through to Donna’s room at Weiss. Donna answered the phone but could hardly speak. Mrs. Sonnenberg then telephoned the nursing station and asked the nurses to go to Donna’s room as something was wrong. They responded, “But we were just in there. Everything’s okay.” She told them something must be wrong: Donna couldn’t talk. They told her that Donna didn’t know how to talk; apparently a Mill View worker had told them so. Weiss staff had also been told that Donna had no family.
Mrs. Sonnenberg, in spite of her flu and fever, decided to go to Weiss. Donna seemed to Mrs. Sonnenberg to have lost as much as 25 pounds, quite a bit in someone so small. Her eyes bulged and she was very pale. She grunted when trying to speak to her mother. Mrs. Sonnenberg and her husband stayed at Weiss all night. The next morning, Sunday, the Sonnenbergs met Donna’s doctor, Marvin Aren, for the first time. Mrs. Sonnenberg asked him how he could have let their daughter deteriorate so far. Aren assured the Sonnenbergs that Donna would be all right. Over the next two weeks, Aren called in several specialists to care for Donna – an infectious diseases expert, a plastic surgeon, an orthopedic surgeon. She was given large doses of antibiotics in a combination designed to cover the bacteria probably involved. The plastic surgeon, Harry Springer, debrided the wound, cutting away dead and dying tissue. Though she did show occasional improvement, Donna’s course was downhill. On the 22nd of January, the Sonnenbergs persuaded Aren to transfer Donna to the intensive care unit, where she continued to receive massive doses of antibiotics and where Springer once again debrided her wound. On the 30th the Sonnenbergs fired Aren. He was replaced by Jerome J. Frankel. Donna died February 1, 1981 of congestive heart failure secondary to septicemia, which resulted from her infected bedsore. Bacteria had invaded her entire body, including her bloodstream, overtaxing her immune system and finally her heart. The DPH Investigation While Donna was still alive, before she was tranferred to the intensive care unit, Mrs. Sonnenberg asked Weiss social worker Jan Shah how to file a complaint about Donna’s care at Mill View. Shah told her to call the Chicago Board of Health, which in turn said to call the board of health in Niles. A municipality may license nursing homes already licensed by the state; Niles did, and contracted with Evanston-North Shore Health Department to inspect Niles’ six homes. On January 21, Mrs. Sonnenberg called Evanston-North Shore, which assigned the case to nurse investigator Helen Thomas. Thomas went to Weiss Memorial Hospital on January 22 and interviewed the nursing supervisor and charge nurse Gloria David. They told her that Donna was in septic shock, about to be transferred to the intensive care unit. Thomas reviewed Donna’s chart and spoke with David Anderson Balling, the infectious diseases consultant. She also spoke with Donna’s father.
Thomas then had Aren paged and spoke with him by telephone. She asked if he’d seen Donna’s bedsore when she was admitted to Mill View. He answered that he hadn’t. Had he given her a physical examination? He said he had, but that when a patient is in a wheelchair, he doesn’t expect the assisting nurse to get the patient undressed and into bed for the exam. He explained that his initial orders for Betadine and Debrisan powder simply continued Dixon’s orders. Though he hadn’t said as much, Thomas suspected that Aren had first seen Donna’s bedsore on January 16, when he decided to transfer her to Weiss. That afternoon Thomas went to Mill View, where she examined Donna’s records and spoke with Arlene Cohen, the assistant director of nursing. (We will detail Donna’s records in the next chapter.) Thomas did not tour Donna’s floor or speak with any of the nurses who had treated Donna; on leaving the facility she interviewed Assistant Administrator Dolores Lindenbaum. Thomas’s supervisor at Evanston-North Shore, Helen Hilken, told her to phone her findings to DPH. Thomas told regional Administrative Coordinator Helen Byrd at DPH that she considered this to be a type A violation?under the DPH statute, one “which creates a condition or occurrence relating to the operation and maintenance of a facility presenting a substantial probability that death or serious mental or physical harm to a resident will result therefrom.” Type B and C violations directly or indirectly (respectively) threaten a resident’s “health, safety, or welfare” (Ill. Rev. Stat. ch. 111 1/2, 4151-129 to 4151-131). An alleged type A violation is to be investigated within 24 hours. The day after Thomas’ investigation, Hilken wrote to Mrs. Sonnenberg: “We have forwarded a copy of [our] report to the Illinois Department of Public Health and requested that the Department take formal action regarding the care which your daughter received. If you wish to discuss this with the Illinois Department of Public Health, who has legal jurisdiction over this matter, may I suggest that you contact Mr. Alan Litwiller, Assistant Chief, Division of Long-Term Care.” Hilken also called Helen Byrd at DPH to tell her what investigator Thomas had found and to say that she was sending Thomas’s report. When Byrd received the report four days later, on January 27, she assigned the case to nurse surveyor Elaine Washington, who visited Mill View the next day.