The Complaint Committee Evaluates the case against Mill View Nursing Home

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.