On June 9, 2020, Alden Estates of Naperville, located in Naperville, Illinois, released long term care outbreak data reporting of laboratory confirmed COVID-19 outbreak cases. These statics confirm that 90 infections and 21 deaths have occurred at the facility during the COVID-19 outbreak.
On May 1, 2020, the Chicago Tribune posted an article detailing the issues surrounding Alden Estates of Naperville’s handling of the COVID-19 pandemic. The article begins with the experience of Brenda Petty, who called the facility weeks back to check on her mother who was a resident at Alden Estates of Naperville. The facility explained to Petty that her mother was fine and there were relatively few cases of COVID-19 within the facility. However, just three days after this initial phone call, Petty’s mother was diagnosed with COVID-19 and subsequently died, the article continues that Petty did not learn of the true extent of the outbreak in the nursing home until after her mother had passed away. Following similar issues regarding the lack of communication between the facility and the public, the facility’s new administrator sent a letter to families apologizing for the communication issues and declared such problems unacceptable.
Additionally, the article explains that Alden Estates of Naperville is by far and away the nursing home epicenter of the COVID-19 outbreak in DuPage County, comparing several other facilities in the area and their COVID-19 statistics which are marginal when compared to those of Alden Estates of Naperville. Moreover, according to the article, between April 14 and April 23, paramedics were called to the facility ten different times to treat residents either confirmed or suspected of having COVID-19, including one day in which three residents were treated. The article further brings to light past problems at Alden Estates of Naperville, including the most recent health inspection on August 21, 2019, in which the government found 11 health citations: one for failure to perform hand hygiene after removing gloves during care for residents who are incontinent; another for failure to provide continence care that would prevent potential infection; and failure to assist residents with eating, grooming, and hygiene. Overall, the facility was given a dreadful two stats out of five following this health inspection.
Based on the Illinois Department of Public Health’s Quarterly Reports of Nursing Home Violations, Alden Estate of Naperville was found to be in violation of several policies and procedures prescribed by the Illinois Department of Public Health.
In Quarter 3 of 2018 (July – September) a survey conducted on July 20, 2018, found Alden Estates of Naperville to have committed a Type B Violation, including sections of the Code: 300.610(a), 300.1210(a), 300.1210(b), 300.1210(c), and 300.3240(a). Specifically, the facility failed to conduct a comprehensive assessment to analyze the development and the progression of the facility acquired pressure injuries. The facility also failed to develop a plan of care based on the identified risk factors and co-morbidities of the residents and to consistently implement the plan of care. These failures resulted in one resident developing an Unstageable pressure injury, and another resident whose injury progressed to a Stage 4 pressure injury.
The Illinois Department of Public Health conducts yearly recertification procedures in which nursing homes are subjected to a review of their regulatory history and any violations occurring at the home. Furthermore, during the recertification process, when a nursing home has been found to have committed a regulatory violation, the facility is subsequently required to submit a plan of correction for how it will remedy the violation or prevent similar violations from occurring in the future.
The 2016 recertification survey conducted on September 22, 2016, found Alden Estates of Naperville failed to provide residents assistance with toileting and incontinence care to residents needing assistance from staff to maintain health and sufficient personal hygiene. Specifically, multiple residents were found to have been covered or soaked in urine or stool, and others who had not been adequately cleaned following incontinence care. Another failure documented in the 2016 recertification survey detailed the facility’s failure to clean a resident’s genital area after incontinence care in a manner that would prevent the potential development of infection, and further failed to sufficiently maintain proper hygiene for that resident.
Moreover, the facility was found to have failed to follow manufacturer’s specification of the disinfecting wipes used for disinfecting a blood glucose machine; and further failed to implement its policy for hand hygiene/hand washing and wound dressing change. Failures of this nature are especially alarming within the scope of the current COVID-19 pandemic, as hand washing and hygiene are at the forefront of combating the transmission of the deadly virus, failing to properly wash hands and maintain hand hygiene pursuant to the facility’s own policies and procedures creates a dangerous environment for residents of the facility.
The 2017 recertification survey conducted on August 10, 2017, found Alden Estates of Naperville failed to follow physician’s order to treat a pressure ulcer to prevent further deterioration, and further failed to provide grooming and meal assistance to residents identified as needing extensive assistance with those activities with daily living. Similar to the 2016 recertification survey, the 2017 recertification survey found Alden Estates of Naperville failed once again to adequately administer incontinence care to a resident, who was observed to be soaked with urine accompanied by a strong urine odor. The observation further found staff had not sufficiently cleaned the resident during incontinence care which lead to issues involving the development and deterioration of a pressure ulcer on the sacral area.
Moreover, the 2017 recertification survey explains the facility failed to implement fall prevention interventions and to develop specific interventions to prevent future falls, resulting in one resident who was designated as a high fall risk suffering from a fall and being hospitalized with a laceration. The resident’s care plan before and after the fall did not show any specific interventions to prevent further falls. In addition, Alden Estates of Naperville was found to have failed to follow sanitary practices during dishwashing procedures which the survey notes have the potential to affect all residents that receive oral nutrition from the kitchen. This finding included an instance in which staff handled clean dishes while using used and dirty gloves, re-contaminating the dishes.
Lastly, the facility was documented as failing to sufficiently perform and carry-out its Infection Prevention and Control program. Specifically, the facility policy for handwashing and hand hygiene dated September 2016, which required staff to perform proper hand hygiene when hands have been exposed to fecal material or urine or are visibly dirty and contaminated. Other failures in regard to the Infection Prevention and Control program included a failure to ensure personal items such as wash basins and too brushers were labeled to avoid cross contamination, and staff using the same dirty gloves after administering incontinence care. These repeated failures regarding hand hygiene, incontinence care, and overall infection control and prevention, demonstrates Alden Estates of Naperville’s inability to adequately remedy its past failures and implement its plan of correction. Furthermore, in the scope of the COVID-19 pandemic, these types of failures provide for an environment that is not equipped to combat and prevent the spread of a deadly virus.
The 2018 recertification survey conducted on July 20, 2018, found Alden Estates of Naperville to have committed many of the same failures that were discovered in the previous recertification surveys. Such failures included the failure to conduct a comprehensive assessment to analyze the development and progression of facility-acquired pressure injuries and to consistently implement plans of care that would effectively treat and prevent future injuries. Another similar failure found in previous recertification surveys involved the facility’s failure to implement care plans related to fall interventions and the inability to effectively implement post-fall interventions.
Yet, the repeated failures from past recertification surveys continue to arise in the 2018 recertification survey, as the facility once again is found to have failed to provide both skin protection for incontinent residents and timely incontinence care for those residents. The fact that issues related to incontinence care have now appeared in all three recertification surveys demonstrates the facility’s complete failure to implement and follow plan of corrections that are effective and legitimate solutions to these continuous problems. Upon learning of this continued inability to effectuate real change within the facility, it is no surprise that Alden Estates of Naperville has struggled to appropriately deal with the outbreak of COVID-19.
As previously mentioned in the Chicago Tribune article, the 2019 recertification survey conducted on August 21, 2019, discovered a myriad of regulatory violations and failures on the part of Alden Estates of Naperville. First, the facility failed to assist residents identified as needing assistance with eating, grooming and personal hygiene, including the observation of one resident who had long, uneven, and jagged fingernails covered in black substances. Second, the facility failed to identify, assess, document, and provide treatment to residents with skin breakdown, resulting in one resident suffering from a blister and broken finger. Furthermore, the facility failed to prevent the deterioration of a deep tissue injury for a resident who was identified as a high risk for skin breakdown, resulting in that resident sustaining a Stage 4 pressure ulcer in the sacral area.
The aforementioned recertification surveys provide similar findings and failures on the part of the staff at Alden Estates of Naperville. Continuing with the theme of repeated failures from previous recertification surveys, the 2019 recertification survey found the facility to have failed to provide incontinence care in a manner that would prevent the potential development of infection and to sufficiently maintain personal hygiene. Additionally, the facility was again found to have failed to perform proper hand hygiene after conducting incontinence care, specifically not removing and disposing of contaminated gloves. Just as the case was in the previous recertification surveys, Alden Estates of Naperville was unequivocally failed to implement and follow its plan of corrections, as each recertification survey has documented the same failures in related to incontinence care and hand hygiene. In the current COVID-19 pandemic, these failures are extremely alarming and the facility’s inability to resolve its past failures makes the cause of concern even greater.
Founding partner Steven M. Levin described these outbreaks in many Illinois Nursing Homes: “for many years prior to this outbreak, Alden Estates of Naperville operated with insufficient staff and with a lack of adherence to recognized infection control protocols. It is not surprising that they were ill equipped to handle this outbreak.”
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As COVID-19 continues to spread, it has also magnified systemic breakdowns within Illinois’ long-term care facilities, nursing homes, or assisted living centers. After this latest release of reported data by IDPH, more than half of the COVID-19-related fatalities in Illinois have now occurred at these facilities.