Accountability in health care: two sides of a DRE investigation

This archive was such a good read I decided to publish it here.



Donna Sonnenberg was a 31-year-old paraplegic nursing home patient. While she was at Mill View Nursing Center in January 1981, her chronic bedsore became infected. Though her doctor ordered standard care for an ordinary infected bedsore, the infection turned out not to be routine; she deteriorated to the point that she needed to be hospitalized. At Weiss Memorial Hospital in Chicago, Sonnenberg received extensive care. After five days on a regular medical ward she was transferred to the intensive care unit. In spite of massive antibiotic and other therapy, she died February 1, 1981. Her parents complained about the nursing home to the local public health agency, Evanston-North Shore Health Department. Its investigation led to the Illinois Department of Public Health (DPH) also scrutinizing the nursing home and eventually fining the home for thousands of dollars. Because Mill View failed to correct the problems DPH had found, the state’s attorney filed criminal charges against the home’s administrator and owners. The Sonnenbergs also asked the Department of Registration and Education (DRE), which licenses doctors, nurses, and nursing home administrators, to investigate whether these professionals were responsible for their daughter’s death. This report describes DRE’s investigation of the physician, nursing home administrator, and nurses; it also discusses DRE’s treatment of the Sonnenbergs. As the resolution mandating our investigation implies, the DRE investigation was delayed and the Sonnenbergs were put off. Unlike most citizens running up against bureaucratic inertia, the Sonnenbergs persisted in trying to find out what DRE was doing. This was difficult; in the end they had to muster the help of their state senator, the governor, the director of DPH, and our commission before they were treated in a respectful and responsive way. In this first chapter we give the background to the case, briefly describing Donna Sonnenberg’s death and the involvement of the first agencies to look into the nursing home. In the next chapter we discuss DRE’s investigation of the doctor; chapter 3 describes DRE’s failure to investigate the nursing home administrator and the nurses. Finally, we will discuss how the department treated the Sonnenbergs.



Donna Sonnenberg spent 29 of her 31 years in institutions for the developmentally disabled mentally and physically handicapped people. From the age of two until about a month before her 31st birthday, Sonnenberg lived at Dixon Developmental Center, a state institution. She then moved to a private nursing home under the state’s program of “deinstitutionalization.” Throughout the 1970s, Illinois discharged from state institutions thousands of mentally ill and developmentally disabled persons, placing them in the community if they didn’t need the state institutional environment and if placement would help them lead more normal lives. Under this program, Sonnenberg at the age of 30 moved to Mill View Nursing Center in Niles to be closer to her family on Chicago’s northwest side. She had lived at Dixon for nearly 29 years; she would live at Mill View for slightly less than three months, then spend her last two weeks at Louis A. Weiss Memorial Hospital. Donna was born November 30, 1949. She had spina bifida with a meningomyelocele–her lower spinal cord had developed outside the protective vertebrae, part of it protruding from her body, leaving her paralyzed below the waist. She also had a clubbed left foot. When she was five months old she developed hydrocephalus, which gradually subsided but never completely abated. In stature a dwarf, she reached the mental age of seven years. Though paralyzed below the waist, Donna could transfer herself from wheelchair to bed. She enjoyed crafts and was friendly with Dixon staff and other residents. She could talk normally though with occasional grammatical mistakes. Because she was confined to her bed and wheelchair, in 1975 she developed an ailment common to such patients: a bedsore, or pressure sore, or decubitus ulcer, on her left buttock toward the hip, about 1 1/2 inches across. Dixon staff treated this bedsore with Betadine irrigation and Debrisan powder.* From time to time it became infected and had to be more closely watched and aggressively treated. By early 1979 the wound was bad enough that it had to be surgically closed. However, because Donna was bed- and chair-ridden–so that the area was constantly irritated the sore opened again. Her doctor concluded she would *Betadine (povidone-iodine) is a topical antimicrobial agent effective against a wide spectrum of organisms. Debrisan powder (dextranomer) helps draw away from a moist wound the foreign and dead material. It absorbs secretions and prevents a crust from forming.


Dixon nurses controlled the bedsore as they had before the surgery, cleansing it with Betadine then applying Debrisan powder and a sterile dressing twice a day. To reduce irritation, Donna used a foam pad in her wheelchair, and nurses tried to keep her off her left buttock as much as possible. These treatment orders were sent with her medical records to Mill View when she transferred there on October 21 , 1 980. At Mill View, Donna continued her interest in crafts. As at Dixon, she was friendly and talkative with Mill View staff and residents. Her brother took her home for the Thanksgiving weekend, during which she celebrated her 31st birthday. She went home again for Christmas.