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.
On April 20, 1981, when the department received DPH’s April 16 letter asking for an investigation of Marvin Aren, DRE had already assigned investigator Janet Walsh (now Janet Peters). The department had been reviewing the case before DPH wrote.
Two weeks earlier, on March 30, Mrs. Sonnenberg had called DRE to lodge a complaint against Donna’s physician, Marvin Aren. DRE employee Peggy Gorman summarized Mrs. Sonnenberg’s concerns:
Complainant alleges neglect of respondent [Aren] in care of her daughter which resulted in hospitalization for a severely infected decubiti, followed by death. Department of Public Health investigated the matter and made recommendations for improvement in the nursing regimen. However, complainant wishes to pursue the allegation of negligence against the respondent which resulted in the death of her daughter, as evidenced by the initial investigation by the Evanston North Shore Health Department.
On April 15, the Complaint Committee met to evaluate the case, taking into consideration medical records and other documents the Sonnenbergs had dropped off the night before. The committee recommended that DRE obtain Dixon records, attempt to interview Mill View nurses about their communications with Aren, obtain the regulations for a doctor seeing a nursing home patient, and get Aren’s billing records from the Department of Public Aid. The next day, the day DPH Director William Kempiners mailed his letter to DRE, investigator Walsh was assigned. The Medical Investigation Walsh began by reviewing Donna Sonnenberg’s medical records from Mill View. She then spoke with Helen Thomas, the nurse-investigator from Evanston-North Shore Health Department who first investigated the Sonnenbergs’ complaint. Walsh went on to interview the nurses who worked on Donna Sonnenberg’s floor, who might have spoken with Aren about the patient’s bedsore; she also interviewed Aren himself. Walsh basically reconstructed the story we outlined in the previous chapter, the story Helen Thomas and the DPH investigators learned.
Interviewing the nurses, Walsh filled in many details; we will give the complete story below. Her investigation did not, though, lead to the Medical Disciplinary Board taking any action against Aren. More than a year after Donna died, the board found that there wasn’t enough evidence of neglect to discipline Aren. We take our account of Sonnenberg’s stay at Mill View from the nursing notes and decubitus report, which Walsh studied, and from Walsh’s interviews. The decubitus report is a special report describing a patient’s bedsore problems and treatment. In the nursing notes, also part of the individual patient’s record, the nurses write observations about the patient’s overall condition, including any bedsore problems. Another nursing home document that Walsh tried to get was the nurses’ logbook. Each floor at Mill View had a logbook; in it different shifts communicated with each other about any problems on the floor. Mill View administrators couldn’t find the logbook for Walsh. Long after her investigation was over, the logbook turned up. Though we have supplemented what follows with the logbook’s entries, our account doesn’t differ from Walsh’s.
The Complaint Committee consists of the medical coordinator, the chief of medical investigations, and two board members; it meets at least twice a month. Examining each complaint, the committee decides if the case involves possible violations of the Medical Practice Act, then recommends that the case be either opened or not opened.
When opening a case, the committee may specify what it wants done in the investigation. Here the chief of medical investigations takes over. He oversees investigations in DRE’s two offices, in Springfield and Chicago. The appropriate unit’s supervisor assigns the case to an investigator and together they draw up an outline of the investigation. The investigator then gathers and examines records and other documents, interviews respondents and witnesses, and does whatever else is needed. If, during his investigation, the investigator has a medical question, he asks the medical coordinator.
At the end of his study, the investigator summarizes the material he has gathered for the medical coordinator. The medical coordinator in turn reviews the file summary and writes his recommendations to the Complaint Committee. Any of several things can happen to the case at this point.
The Complaint Committee may close the case for insufficient evidence (the full Medical Disciplinary Board must concur); ask for futher investigation; give the case to the chief regulatory officer (the department’s prosecuting attorney) for possible disciplinary or legal action; refer the case to an outside professional agency, such as the Chicago Medical Society; ask the Attorney General’s Office to prosecute; or decide with the prosecutor to call the doctor in for an informal conference.
At the informal conference, the doctor and his attorney meet with DRE’s attorney and one board member who is also on the Complaint Committee. DRE reviews the doctor’s compliance with department directives, gathers additional information, and discusses the issues with the doctor, who can submit documents and make an oral statement. The conference can result in any of four recommendations to the board: close the case, investigate further, enter into a consent order with the doctor, or refer the matter for a formal hearing or for prosecution. Formal hearings are held before the full Medical Disciplinary Board; a department-appointed hearing officer presides. Both the accused person and the complainant can present evidence. If the director of DRE feels the doctor’s continued practice might endanger others, he can temporarily suspend the doctor’s license, pending the hearing results.
The board writes to the doctor with its findings and conclusions. He can ask for a rehearing within 20 days. If he doesn’t, the DRE director can act on the board’s recommendations. The director cannot take any disciplinary action unless the board directs him to. If he is dissatisfied with the board’s decision for example, if he thinks the doctor’s license should be suspended to protect the public when the board has recommended no suspension the director can order a rehearing by the board or other examiners (II 4449) . This is a basic outline of how DRE handles complaints against physicians; it is basically how the department handled the Sonnenberg case.
The Department of Public Health (DPH) investigated the actions of the nursing home as a whole; that is where its jurisdiction lies. Another department has jurisdiction over the professionals who work in nursing homes: the Department of Registration and Education (DRE). DRE licenses a wide array of professionals in the state, including doctors, nurses, and nursing home administrators. When DPH officials thought the professionals involved in Donna Sonnenberg’s care should be investigated, they asked the appropriate department to investigate: DRE. DRE’s general mandate is to protect the public health, safety, and welfare through licensing the appropriate professional and occupational groups; 32 such groups in all, with 81 licensing categories (according to a 1981 auditor general’s report).
The department, along with its boards and committees, sets standards, tests, licenses, investigates, inspects, and disciplines these groups. About 455,000 people and agencies hold DRE licenses, including architects, private detectives, funeral directors, physicians, real estate brokers, embalmers, public accountants, barbers, collection agencies, horseshoers, psychologists, and dentists. The department’s duties vary from profession to profession. Statutes governing some occupations detail the qualifications for getting a professional license but stop there, without saying what acts by the licensed professionals DRE is to monitor. At theother extreme, some statutes set up virtually no minimum qualifications for licensure but focus on specific actions that DRE must regulate. Most professions fall between these poles, with detailed licensing qualifications and some (though not much) attention to actions by licensees.
The auditor general’s report (1981) criticized this lack of uniformity, pointing out that itmakes DRE’s job all the harder. The auditor general’s report also criticized the variability and poor definition of the responsibilities of the department’s boards and committees. In 28 of the 32 professional areas DRE handles, a board or committee develops standards for licensure and acts as a hearing board in *DRE’s enabling statute is Ill. Rev. Stat. ch. 127, IT IT 60-62. Chapter Ill contains most of the relevant statutes concerning professionals.
The director of DRE appoints the members of all but two boards; the governor appoints the members of the Medical Disciplinary Board and the Board for Opinions on Professional Nursing, with senate approval. Most boards are made up of professionals in the appropriate area; the Medical Disciplinary Board and the Nursing Home Administrators Licensing Board are two of the only three boards with members from outside the profession. Most boards have considerable authority in DRE matters. For example, in medical investigations the director of DRE may not take disciplinary measures “except upon the action and report in writing of the Board” (Ill. Rev. Stat. ch. 111, ft 4449).
In some of DRE’s other licensing areas, the department can exercise none of its duties or functions without board approval. The auditor general’s report criticized the general lack of clear separation of powers and responsibilities. The statutes governing the professions, the boards and committees, and the Department, as now written, cannot be efficiently administered nor consistently complied with. A system of checks and balances between the boards and committees and the Department has not been achieved. Most enforcement control authority is vested in boards and committees; most responsibility is placed with the Department. The Department cannot act without board/committee approval, and the boards/committees cannot unilaterally enforce the acts. A more reasonable division of authority and responsibility needs to be achieved, and statutory conflicts and inconsistencies need to be addressed. We merely report this criticism here.
The reader might bear it in mind in discussions of the Medical Disciplinary Board’s involvement in the Sonnenberg case. Medical Investigations The Medical Disciplinary Board, which handles complaints against physicians, is made up of five physicians, one chiropractor, one doctor of osteopathy, and two members who have nothing to do with medicine. The non-medical members, added to the board a year and a half ago (by Public Act 82-1036), have no vote in the board’s decisions. Acting as the chief enforcement officer for the board is the medical coordinator, a doctor. He reviews all complaints that come into the office and decides if there’s enough information to bring the complaint before the Complaint Committee. If he needs moreinformation, he may ask for a preliminary investigation.
Litwiller wrote that Donna Sonnenberg’s care at Mill View was unfortunately not too unusual, in this case pointing to Aren’s absence from the home until the bedsore had gotten very bad:
“While this is not an acceptable standard of care, it is typical of physician involvement in most nursing homes.”
He concludes his memo: It was a good experience for me to have had a conversation with Mr. and Mrs. Sonnenberg at their home. Through someone’s fault their daughter is dead. At this point I would believe that Mill View is a principal contributor. With this perspective, we should consider a Class “A” violation against the nursing home. I would recommend that Mr. Uhlig and our legal section review all of the available documentation in considering their final determination. Two weeks later, on April 16, DPH officials did four things.
First, DPH Director William Kempiners ordered Irvine to review the department’s findings to see if it would be possible to cite Mill View with a type A violation.
Second, Kempiners ordered that DPH scrutinize Weiss Hospital’s involvement. Third, he asked the Department of Registration and Education (DRE) to examine Aren’s treatment of Donna. And finally, DPH Legal Advisor William Radkey sent the Sonnenbergs a summary of DPH’s position in the case.
He wrote that DPH had notified Mill View of B and C violations on February 23; that the facility had submitted a plan of correction for the violations; that DPH “is currently reviewing its initial findings to determine whether any other violation” had been committed; that the department had asked DRE to evaluate Aren’s conduct; and that the Sonnenbergs had the right to a hearing “to review or contest the department’s determinations regarding the complaint investigation.” A week after that, on April 24, DPH nurse investigator Carole Hinich reviewed Sonnenberg’s medical records; she was unaware of the first investigation, so her bosses could use this impartial review to assess the initial report’s adequacy. Also on that date, Fred Uhlig ordered William Irvine to investigate the department’s handling of the entire case. Irvine assigned Judy T. Weber and Frank Moore of the central and southern offices.
They reported on May 13, basically outlining what we have described in the last few paragraphs. They also reported that the regional administration had in their opinion failed to comply with the Nursing Home Care Reform Act of 1979 and had “failed to respond to the immediate needs of the Evanston-North Shore Health Department; the resident, Donna Sonnenberg and her family; and the Department of Public Health.”
The complaint had not been reduced to writing or logged in with time and date; a notice of violation had not been given to the facility; and Elaine Washington’s report of January 28 hadn’t been transferred to the appropriate DPH form, so that no plan of correction was received from Mill View (this was her first investigation; her supervisor hadn’t told her to fill in the right forms). Also, in cases of alleged type A violations (as Evanston-North Shore had recommended), supervisors (i.e., Helen Byrd) are to determine the immediate course of action. She didn’t. Though both internal investigations cast a bad light on Byrd’s handling of the case, neither apparently showed any fault with Kristopaitis’s and Schaffer’s investigation. In their summary, Moore and Weber mention visiting the Sonnenbergs.
“During our visit . . . it became apparent that they had spoken with many commentators and many of the explanations were contradictory. The conflicting statements left them with the opinion that they were getting the ‘run-around,’ or that the Department was concealing some activity. Taking into consideration the emotional state of the parents, there does seem to be some validity to their statements, and most of this deals with the classification of the deficiency as Type ‘A’ or Type ‘B’.” This sets the tone for the Sonnenbergs’ subsequent dealings with DRE and explains their feeling that state agencies are at best incompetent, at worst crooked. Whatever the internal problems in its investigation, the Department of Public Health corrected its initial error relatively quickly and decisively. Its communications with the Sonnenbergs were informative and honest. As we will see, the Sonnenbergs had a different experience with DRE.
Mill View’s neglect of Sonnenberg was deemed a type A violation after all. For this DPH fined Mill View $1,598.40 The department also pursued the other type B and C violations that Kristopaitis had cited in her February 23 report, for the same activities but against other residents–unlicensed nurse technicians administering medications, taking physicians phone orders, giving treatment. The DPH system of notification, plan of correction, and inspection then followed. On March 4, Mill View submitted a plan of correction to be adhered to no later than March 15. On April 30, DPH workers found that the promised changes had not occurred, found an additional type B violation, and notified Mill View.
The home again promised to eliminate the violations by May 6 and June 15; again, DPH found that the home hadn’t, in inspections on May 7 and July 1. An inspection on August 20 also showed that Mill View continued its practices. For these violations, DPH fined Mill View $39,704 on July 1, 1981. The fines were for violations beginning February 23 (plus the B violation found April 30) and continued to increase each day after July 1, so long as the violations went uncorrected. The department also revoked Mill View’s license on June 15. Mill View, under DPH rules, could contest the fines and the license revocation, and did so, asking for a hearing. DPH scheduled a hearing ultimately for September 21. The Criminal Case Failure to correct type A or B violations (not type C) is a class A misdemeanor, and DPH may ask the state’s attorney to prosecute. Because Mill View repeatedly failed to correct the type B violations that Kristopaitis originally found on February 23, Cook County Assistant State’s Attorney Stuart Sikes, of the Nursing Home Division, representing DPH, filed criminal charges on August 11.
Mill View, having the option, chose to defend against the criminal charges first, receiving a judicial stay against all administrative proceedings until the criminal case was resolved. (Meanwhile Mill View Associates, owners of the home, sold it; the new home was called Spring Meadows and began operating under a temporary license September 30, 1981.) Against the criminal charges, Mill View mounted a constitutional defense; the home alleged that the Illinois Nursing Home Care Reform Act of 1979 the basis for the misdemeanor complaints?as well as DPH regulations were unconstitutional. Mill View said that the act denied the equal protection clause to the Fourteenth Amendment of the U.S. Constitution by exempting state-run homes from DPH scrutiny; the nursing home also said that DPH rules and regulations were unconstitutionally vague in that the same rules could be the basis for both civil and criminal actions. Associate Judge Kenneth J. Cohen of the Circuit Court of Cook County found for Mill View, holding that the Nursing Home Care Reform Act was unconstitutional, on April 23, 1982.
Subsequently, the Illinois Supreme Court on September 29, 1983 reversed the lower court and upheld the act and *Sikes said he considered bringing a charge of manslaughter but didn't for lack of evidence.
DPH rules in People v. Gurell, 98 111. 2d 194 (1984). The court rejected the defendants’ argument that the act jeopardized their right to carry on their business: “No case has been called to our attention in which the right to economic gain . . . has been held to be a fundamental right guaranteed by the Constitution.” Also, the court found a rational basis for exempting state facilities from the act and found no violation of the equal protection clause. “In our case the legislature chose to deal with the problems it perceived in the nursing-home industry one step at a time by regulating private facilities. . . . State-operated facilities are under the direct control of the State and . . . most of these facilities are regulated by statutes other than the one in question.”
The court also rejected the defendants’ notion that the civil-criminal possibilities in DPH rules were vague. Only civil penalties may be imposed for initial violations; after that, the violator has a right to a hearing. No criminal penalties may be imposed unless the defendant intentionally fails to correct type A or B violations within the time specified in the notice or the plan of correction. All of this took place over two years, during which the activities described in the rest of this report took place. In the end, Myron Gurell pleaded guilty to the criminal charges on May 4, 1984 in Cook County Circuit Court. The state dropped its charges against the other Mill View owners. Gurell was sentenced to one year’s criminal probation. For five years he is barred from serving as administrator or licensee of any Illinois nursing home.
Our discussion to this point has centered on DPH involvement in the Sonnenberg case: after some unfortunate lapses, a responsive and timely involvement. The focus of our report the role of the Department of Registration and Education follows. We have already mentioned that DPH asked DRE to investigate Donna’s physician at Mill View. In one of its many letters to the Sonnenbergs, DPH wrote: “You will be interested to know that in response to Director Kempiners’ request the Illinois Department of Registration and Education has assigned a medical investigator named Ms. Janet Walsh to investigate the conduct of Dr. Aren on this matter.” In the next chapter we will examine Walsh’s investigation including DRE’s findings about Donna Sonnenberg’s care at Mill View and the department’s dealings with the Sonnenbergs.
A month later, after Donna had died, Mrs. Sonnenberg called Alan Litwiller, asking what DPH had learned. This was the first Litwiller had heard of the matter. He asked Helen Byrd where her report was; she said there had been no investigation but would not explain why. When Litwiller assigned a doctor-nurse team – Bernard J. Schaffer and Regina Kristopaitis – to conduct the neglected investigation, Byrd gave him a hand-written preliminary report of surveyor Washington’s January 28 visit.
This investigation had been Washington’s first, done apparently without supervision. She had looked at Donna’s nursing home records and spoken with Dolores Lindenbaum and with a nursing supervisor; she reported that there was inconclusive evidence of neglect. It remains unclear why Byrd suppressed or ignored Washington report.*
Kristopaitis and Schaffer toured Mill View and reviewed Sonnenberg’s chart on February 23. Kristopaitis generally noted Donna’s deterioration. She remarked on the paucity of nursing observations and lack of vital signs in the chart as well as the “lack of professional staff involvement in resident evaluations.” Kristopaitis also pointed out that unlicensed, unauthorized workers – nurse technicians – had apparently taken Aren’s phone orders for medication changes, that the doctor hadn’t countersigned these orders within 72 hours as required by DPH regulations, and that the doctor hadn’t physically examined Sonnenberg within five days of her admission, again in violation of DPH regulations. She told the Mill View administration of these deficiencies and gave notice of type B and C violations. These violations resulted from deficiencies not only in Sonnenberg’s chart but in other patients’ charts as well; the type B and C violations were for Mill View’s practices concerning all patients, not just Donna Sonnenberg.
About two and a half years later, when we spoke with Kristopaitis about her investigation, she recalled the poor condition of the records. She especially recalled how blase Mill View officials were when she questioned them about unlicensed nurse technicians giving medications and taking physicians’ phone orders. She found their unconcern unbelievable . Schaffer also outlined Donna’s decline during January. He wrote of the patient chart’s lack of evaluations, vital signs, and laboratory work, and the fact that unlicensed *Byrd was later fired for her alleged misconduct in this and other situations. Allegedly she diverted investigations of homes in return for financial and other favors. She appealed her dismissal; as of this writing, the matter is pending.
Nurse technicians had taken Aren’s phone orders and changed Donna’s dressing. Touring Mill View, he observed the home’s need of maintenance and housekeeping. He found almost every room, including the central medical supply room, ill kept. In his summary, Schaffer made six recommendations:
1. Review, evaluation and implementation of home’s resident care policies to assure necessary followup and awareness of resident status with involvement of all disciplines of house’s personnel. (Administrator, Medical Director and Director of Nursing).
2. Upgraded documentation to be more meaningful and inclusive of all phases of resident care. (Examinations, vital signs).
3. Timely resident visits and greater awareness of the more critically ill in the home. (Daily critical resident list).
4. Care, treatment and documentation by licensed personnel.
5. Review of resident care by utilization review.
6. Upgraded surveillance and monitoring of residents.
Schaffer and Kristopaitis gave Alan Litwiller their report on February 26, telling him the home had committed type B and C violations against several patients, and that the home’s treatment of Donna Sonnenberg also constituted type B and C violations, not type A. Litwiller told Mrs. Sonnenberg the results of the investigation. She was dissatisfied. She told Litwiller that she thought the violations against Donna should be type A; she also said she wanted to sue both the physician and the nursing home. We should pause here to explain the DPH procedure on receiving a complaint. The department is supposed to investigate alleged type A violations within 24 hours, B and C violations within 30 days. The violator has to correct a type A violation immediately, or, if the department agrees, within 15 days. With type B and C violations, the violator submits a plan of correction within ten days. If the department accepts it, the facility has up to 90 days to correct patient-related deficiencies. If subsequent inspections show that the violations continue, DPH may accept a new plan of correction or impose fines, which are figured in a very orderly, comprehensive way. DPH may fine a violator immediately for a type A violation, but in type B and C violations only after finding an accepted plan of correction unmet. The department may also suspend or revoke a facility’s license for such violations.
In any case, the facility may ask for a hearing to contest the penalties. Because of Mrs. Sonnenberg’s dissatisfaction, and because of Helen Byrd’s questionable handling of the initial complaint, the department paid continuing attention to the case, including two internal investigations about how the complaint had been handled. About a month after Litwiller told them the investigation’s results, the Sonnenbergs called Fred Uhlig, DPH deputy director. Apparently they convinced him that the B and C violations might be inadequate; he told Litwiller that he wasn’t satisfied with the classifications and would like a review and new determination. Litwiller visited the Sonnenbergs on the first of April to get their permission to review Weiss Hospital’s files. In his memorandum to his supervisor William Irvine, Litwiller expressed his reservations about the case and about the initial type B and C determinations:
“It appears as if the facility [Mill View], the physician and the hospital share the blame, if in fact blame could or should be assessed.”
He points out the possible inadequacies on the part of each: There should have been more professional nursing involvement with the ramifications of better treatment of the ulcer, better nursing observations, better documentation on the medical records, and consequently a more aggressive approach to the attending physician. The attending physician appears to have not been as responsive or aggressive in the medical supervision of this resident as he should have been. . . . The records do not indicate if the facility Medical Director was informed of the resident’s condition and apparent lack of appropriate attending physician involvement. The Medical Director should have been informed and could have superceded in this resident’s care. The hospital medical records indicate that there were as many as six physicians involved with the resident’s plan of care in the hospital. … It is entirely possible that the resident could have contracted an infection during the decubitus debridement or the insertion of the pulmonary artery catheter. . . . I realize that there is a fine line between minimal care, inappropriate care, and neglect. I believe this holds true equally with the nursing home, the attending physician, the Medical Director, and the hospital.
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.
This archive was such a good read I decided to publish it here.
Chapter 1 INTRODUCTION AND BACKGROUND
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.