Based on the Illinois Department of Public Health’s Quarterly Reports of Nursing Home Violations, Peterson Park Health Care Center was found to be in violation of several procedures.
In Quarter 1 of 2017 (January – March), Peterson Park Health Care Center was fined for a Type B violation, including but not limited to, sections 300.121(b), 300.1210(d), and 300.3241(a). Specifically, these violations occurred when a handrail attached to a resident’s bed came loose, causing the resident to fell from their bed. Ultimately, the fall resulted in injuries including a head injury, laceration to the resident’s face, and a fractured clavicle.
The Illinois Department of Public Health conducts annual recertification surveys in which nursing homes are subjected to a review of their regulatory histories, as well as any violations occurring at the facility. When a facility is found to be in violation, the facility is required to submit a plan of correction noting both how it will remedy the violation and how it will prevent similar violations in the future.
A recertification survey was conducted for Peterson Park Health Care Center on November 18, 2016. During the survey, Peterson Park Health Care Center was found to be in violation of several regulation, including those governing infection control and spread prevention, when the facility failed to collect and analyze any information relating to infection control and failed to create a systematic comprehensive plan to prevent infection in the facility. Ultimately, these failures had the potential to affect all 169 residents in the facility. Given their failure to implement infection control policy, more specific violations include a resident’s family members being allowed in an isolation room without any PPE. In response, the facility submitted a plan of correction including changes such as a review of the facility’s policy on infection control, the completion of in-services regarding infection control, and the development of a Quality Assurance Tool to address infection and enhance nursing staff compliance with the facility’s policies.
Despite these corrections, however, the facility was similarly cited for failing to maintain proper infection control practices in an October 12, 2017 recertification survey, which cited Peterson Park for improper hand hygiene and improper disposal of used respiratory suctioning tubes for four residents. More specifically, on several occasions the staff used soiled gloves to perform procedures on residents. Additionally, a previously used deep suctioning catheter was left on a resident’s bedside table rather than being disposed of properly. Another plan of correction was submitted, noting that the facility discarded the deep suctioning catheter and sanitized the bedside table where it was found.
The facility’s most recent violation regarding infection control occurred in a DATE recertification survey. At this time, the facility was cited for failing to follow their Infection Prevention and Control Policy when staff failed to properly use PPE when entering a transmission-based precaution room. Additionally, the facility failed to implement infection control practices by not capping the tip of a resident’s feeding tube and leaving it exposed. These violations effected several residents. Another plan of correction was submitted, which included corrections such as providing in-services regarding proper feeding tube care and auditing the staff at random to ensure proper PPE use.
Founding partner Steven M. Levin described these outbreaks in many Illinois Nursing Homes: “for many years prior to this outbreak, Peterson Park Health Care Center 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.