Millview’s key flaws – non-fluent nurses, nurse technicians administering medication, and doctor’s neglecting to treat patients promptly

Mill View Nursing Center had room for 300 patients. It was, by DPH definition, a skilled nursing facility: basically, a long-term home in which some patients require daily care from registered nurses. The second floor, where Donna Sonnenberg lived, reportedly housed patients who needed such care.

Most of Mill View’s nurses and nurses’ aides were from Korea, the Philippines, or Poland. Some worked under temporary permits as registered nurses. Illinois allows an immigrant nurse with a foreign license to work under a permit for six months. If she has not passed the Illinois nursing examination by then, she loses the permit. Except for the director of nursing and her assistant (Patricia Peterson and Arlene Cohen), all of the nurses we’ll be discussing were foreign born and had worked as RNs in their native countries. Two of these seven nurses held Illinois RN licenses. Of the other five, one had failed her exam, two were waiting to hear their exam results (which turned out to be failure), and two had yet to take the exam. This is significant for several reasons.

First, these nurses had difficulty with English, which may have been part of why they failed the nursing exam. Fluency is important in nursing. The Nursing Home Care Reform Act requires even those who have not passed a nursing examination nurses’ aides, technicians, etc.–to speak and understand English. In the Mill View nursing notes are numerous examples of the nurses’ language problem.

At a recent DRE hearing, at which some of these nurses appeared as respondents and witnesses, members of our staff noted that the nurses had a good deal of trouble making themselves understood. It is possible that this affected the nurses’ care of Mill View patients. They would have had a hard time describing to a supervisor or a physician a particular patient’s health problems.

The temporary permit issue is important for a second reason. The nurse who had failed her exam was then re-titled a “nurse technician.” Without a permit or license, a nurse technician is by law not allowed to give medications, take physician’s phone orders, or change sterile dressings. As we will see, this nurse technician and others at Mill View did all of these things.

Walsh interviewed (or tried to interview) the following nurses: Sang Hee Suh, RN (licensed since 1975); she often was regarded unofficially as a supervisor on the 11 pm to 7 am shift (Mill View reportedly had a hard time getting nurses to agree to supervisory duties; there was no extra pay to go with the title); Theresa Choi, RN (licensed since 1971); she worked part-time on the 3 to 11 pm shift, also unofficially regarded as a supervisor; Virginia Cruz, who worked as an RN under a temporary permit in January 1981; she subsequently failed her nursing exam in April; she worked the 7 am to 3 pm shift on the second floor; Elizabeth San Juan, who worked as an RN under a temporary permit in January 1981; she also subsequently failed her exam in April; she worked the 3 to 11 pm shift on the second floor; Zenaida Meriales, who worked as an RN under a temporary permit during January 1981; she was a “floater,” working when and where she was needed; Juliana Tiangha, who worked as an RN under a temporary permit in January 1981, during which time she worked the 11 pm to 7 am shift on the second floor; and Elenita Ciriaco, nurse technician; she also was a floater, usually working the 3 to 11 pm shift on the second floor.

Walsh also interviewed the director of nursing, Patricia Peterson, RN, and tried to interview the assistant director of nursing, Arlene Cohen, RN; Cohen refused to talk to Walsh, as did Sang Hee Suh. The three shifts at Mill View were morning or daytime (7 am to 3 pm), evening (3 to 11 pm), and night (11 pm to 7 am) . Tiangha, Meriales, San Juan, Ciriaco, and Cruz wrote most of the nursing notes, and decubitus report and logbook entries, that we will discuss. A few other nurse technicians also made notations; Walsh didn’t interview them. We have expanded abbreviations. The nursing notes, logbook, and decubitus report tell the following story.

Donna Sonnenberg was admitted October 21, 1980. The first entry in the nursing notes gives her admission diagnosis, also noting her bedsore. She was “alert and coherent,” ate her first meal “with little assistance and good appetite,” could maneuver her wheelchair, and smoked “with care.” The entry records her vital signs blood pressure, pulse and respiration rates, and temperature and notes that Dr. Aren was to see her the next morning. The nurse thought Aren would be there October 22 because that was a Wednesday, and Aren almost always visted on Wednesdays. However, Aren did not give Sonnenberg a physical examination until the following Wednesday, October 29.

DPH requires nursing homes to have new patients examined by an MD within three days after admission. DRE investigator Walsh asked Mill View Director of Nursing Peterson about Aren’s tardiness in examining Donna. Peterson explained that doctors are aware of the requirement but that nurses often have to call the doctors many times to get them to examine new patients. Often the physicians don’t get to the home within 72 hours; but, Peterson said, the nurses couldn’t physically carry the doctors in. Nurse Virginia Cruz observed Aren’s examination of Sonnenberg. She described it as “adequate,” recalling that he had examined Sonnenberg’s bedsore. When Helen Thomas asked him about this examination in late January 1981, Aren could not recall looking at the ulcer. However, when he spoke with Janet Walsh in August, he said he had seen the sore. His orders simply continued Dixon Developmental Center’s: cleanse the wound with Betadine and apply Debrisan powder and a dressing.