State rips nursing home - Violations at East Peoria facility lead to a $100,000 fine

The hell of a mental health facility combined with a nursing home. An investigative report by the Chicago Tribune

A troubled East Peoria nursing home and state health officials are gearing for battle after authorities fined the home $100,000 -- one of the largest such fines ever -- for neglect and faulty care of mentally ill and elderly patients.

In a report obtained by the Tribune, state health officials detailed violations at East Peoria Gardens Healthcare Center that are unusual in scope and severity, according to state officials and watchdog groups.

After a police raid in April, the state report provides additional evidence to support claims that mentally ill patients were sometimes out of control and tormented elderly residents, a pattern that developed after the facility began accelerating the admission of younger, more volatile psychiatric patients in August.

In the 1990s, the state relaxed rules on nursing homes, allowing psychiatric and geriatric patients to live side by side. After a disturbing series of incidents involving abuse of the older patients, including dozens of injuries and deaths reported to the state, new rules were created in 2000 governing the way those two patient populations are monitored.

But among nearly 4,500 detailed investigation reports compiled each year, officials say the situation at East Peoria this spring was one of the worst they have seen.

The Illinois Department of Public Health cited the facility for poor or no staff training, ignoring numerous falls of patients, failing to check patients for criminal backgrounds and providing no appropriate service to mentally ill residents, according to the report dated June 26, which was made in response to two dozen separate complaints.

"The facility failed to provide services necessary to avoid physical harm, mental anguish or mental illness," the report reads.

A police dragnet at the home in April led to the arrests of three patients and two employees on outstanding criminal warrants.

East Peoria Gardens plans to contest the fines and charges at a state hearing, a date for which has yet to be determined.

"Not only are we now operating in compliance, we categorically deny each and every charge -- including the fine -- presented by the state," said Meyer Magence, attorney for the home. "We are going to fight every one of them."

Authorities say the facility, which has about 100 residents, has improved procedures and conditions since the April raid.

The 50-page report paints a picture of a period in which communication was poor, mental patients did not receive proper medical and psychiatric care, and elderly patients were left to deteriorate.

"The breadth of the violations is extraordinary," said Wendy Meltzer, executive director of the watchdog monitor Illinois Citizens for Better Care. "It's really unusual to see this many violations affecting so many people. It's not something you see, fortunately, often."

Among the allegations in the report:

• Staff failed to try to revive a heart patient who fell and injured his head because they believed he was a hospice patient. He died soon after.
  
  
• Staff failed to properly diagnosis and monitor a 54-year-old patient who developed gangrene in his left toe.
  
  
• A 72-year-old mentally ill resident choked and died after eating a doughnut. A speech therapist had warned against giving the man difficult to swallow food but staff said they knew of no such order.
  
  
• An 81-year-old woman at the facility fell 10 times without staff putting in place precautions and a prevention plan. She died of complications from a fall.
  
  
• The facility did not have any treatment programs in place for 11 of 51 residents identified as "seriously mentally ill." With limited proper supervision in place, the safety of elderly residents was threatened when some psychiatric patients became agitated.
  
  
• The facility added more than 40 mentally ill patients from August 2006 to January and had no effective administration or adequately trained staff in place for the change.
  
  
• Seven patients were admitted with criminal records. The facility was unable to produce records showing it had notified the state as required.
  
  
• The facility failed to do background checks on 15 of the 19 residents with criminal records.

Magence declined to respond to the charges individually but called them "inaccurate."

State officials are not the only ones threatening the nursing home.

Medicaid and Medicare withheld five days of reimbursements for 66 eligible patients who were at the home in April, according to federal and state officials. Magence said he plans to contest that action.

A relative of Betty Saal, the 81-year-old woman who died after falling, is suing the facility.

The Tazewell County coroner also said he plans to soon convene an inquest into Saal's death to decide whether to file homicide charges.

"We don't know if she was pushed or fell down," said Coroner Dennis Conover. "We do know this was a nursing home gone wrong and that neglect led to her death."

The state also cites neglect in the case of 72-year-old Donald Utech, who died in April after eating breakfast. According to a preliminary autopsy, Utech died of choking. A Peoria County coroner's inquest concluded last week that the death was accidental.

But there is still conflicting testimony in Utech's case; home staffers say no food was in the man's mouth, while paramedics said food was trapped in his airway. The coroner's finding does not address the issue of neglect, according to Peoria County Coroner Johnna Ingersoll, who has jurisdiction because Utech was taken to a hospital in her county.

Officials from the Department of Public Health have called three other deaths in the last two years suspicious, but Magence said the facility bears no responsibility in any deaths.

"Absolutely none," he said.

Last month's $100,000 citation and report mark the second time the facility has faced stiff fines and sanctions.

In 2005, the facility was fined $20,000 by the state and faced weekly monitoring after two residents died following choking incidents.

The facility is again being monitored, this time twice a week, state officials said.

"The question is why was this allowed to go on for months unchecked?" asked Steven Levin, a Chicago personal injury attorney representing Saal's relative in a civil suit.