On June 6, 2020, Woodbridge Nursing Pavilion, located in Chicago, IL, released long term care outbreak data reporting of laboratory confirmed COVID-19 outbreak cases. These statics confirm that 219 infections and 32 deaths have occurred at the facility during the COVID-19 outbreak.
A May 6, 2020 article by ABC 7 Chicago noted claims that the facility had withheld information regarding a resident’s test results and the spread of COVID-19 within the facility from a resident’s daughter. The resident’s daughter claims that despite her multiple calls to the facility, they refused to give her any information regarding her father until she was called and told that he had tested positive. At this time, she alleges that the staff member that she spoke with told her that the facility had been lying when they told her that they did not have any information on her father prior, and that her father had actually contracted the virus. Shortly after, the resident died of COVID-19.
Based on the Illinois Department of Public Health’s Quarterly Reports of Nursing Home Violations, Woodbridge Nursing Pavilion was found to be in violation of several procedures.
In Quarter 2 of 2019 (April – June), Woodbridge Nursing Pavilion was fined for Type B violations, including, but not limited to, sections 300.610(a), 300.1210(b), 300.1210(d)(6), and 300. 3240(a). More specifically, in a facility investigation report dated April 25, 2019, the facility psychologist attempted to transfer a resident from bed to their chair, in violation of procedures which mandated that that specific resident needed a mechanical lift for transfer. Further, despite being noted as “not falling” the resident sustained a fractured knee. Following the incident, although the resident was noted as being at risk for falls, no fall risk interventions were observed as being in place to protect the resident from future injuries.
In Quarter 4 of 2018 (October – December), Woodbridge was similarly fined for Type B violations, including, but not limited to, 300.610(a), 300.1210(b), 300.1210(d)(6), 300.3240(a), and 300.3240(f), when a resident wandered into another resident’s room. Given the second resident’s history of aggression, the first resident was scratched and bitten by the other resident. This incident was classified as “resident-to-resident abuse.”
In Quarter 3 of 2018 (October – December), Woodbridge Nursing Pavilion was again cited for Type B violations including 300.1210(b), 300.1210(c), 300.1210(d)(6), and 300.3240(a) when a resident who was at high risk for falls was found lying on the floor with bleeding coming from their face. A facility investigation determined that the fall was a result of the resident not being properly placed in the middle of her mattress, resulting in the weight of her extremities pulling her body to the floor.
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 Woodbridge Nursing Pavilion on April 14, 2016. During the survey, Woodbridge was found to be in violation of several regulations, including, but not limited to, those governing the development of comprehensive care plans when the facility was found to have failed to implement a care plan to address infection control in a resident. In response, the facility submitted a plan of correction. In regard to this specific violation, the facility created and implemented an appropriate care plan for the resident and also held an in-service regarding the creation and implementation of appropriate care plans.
Another recertification survey was completed on May 25, 2017. In this survey, among other things, Woodbridge was specifically cited for violations including those governing the spread of infection and infection control. In response to this specific violation, the facility submitted corrections including hosting an in-service with the appropriate staff members regarding the facility’s infection control program.
Despite these corrections, the facility was again cited for violations regarding infection control and prevention in a March 22, 2018 survey, which found that the facility had failed to implement an infection control and prevention system of surveillance to identify and analyze trends within the facility to prevent infections. Ultimately, this failure resulted in the potential to affect all 212 residents. Ultimately, observations found the facility was not keeping track of infections in any “meaningful” way.
Additionally, this same survey revealed that the facility failed to ensure that the staff followed proper hand hygiene protocols and failed to follow standards of transmission-based precautions by failing to date oxygen tubing, and G-tube feeding bottles and tubing. These shortcomings had the ability to affect three out of three residents reviewed for infection control practices in a sample of 35 residents. In response to these violations, the facility submitted another plan of correction which again included hosting in-services with appropriate staff members.
The facility was cited again for their failure to implement an infection control prevention and control system on April 11, 2019 when a recertification survey noted that tracking documents provided by the facility again failed to keep track of infections in any “meaningful” way. These documents did not provide any analysis of the data, pharmacy data, or lab reports that helped to identify trends in infection rates. A plan of correction was not listed regarding these specific violations.
Founding partner Steven M. Levin described these outbreaks in many Illinois Nursing Homes: “for many years prior to this outbreak, Woodbridge Nursing Pavilion 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.”
Levin & Perconti: Chicago Attorneys at Law
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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.