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COVID inspection finds southwest IL nursing home's residents were in 'immediate jeopardy'

Belleville News-Democrat - 10/16/2020

Oct. 16--Eleven residents at a Granite City nursing home who had COVID-19 ate in the same dining room and, in some cases, shared a bedroom with residents who tested negative for the disease, according to a state investigation.

An Illinois Department of Public Health team conducted onsite observations at Stearns Nursing and Rehabilitation Center and interviewed staff members, residents and families from Aug. 17 to Sept. 4 as part of a federal directive to investigate nursing homes' compliance with regulations to prevent or control the spread of the new coronavirus that causes COVID-19.

At the same time, the state agency also investigated eight complaints filed against Stearns. The Illinois Department of Public Health declined to provide information about who filed the complaints or when the state received them, citing federal confidentiality rules.

During the investigation, employees at Stearns informed the state inspectors that residents with and without COVID-19 diagnoses ate in a dining room together and that seven residents who had tested negative for COVID-19 were roommates with infected residents.

The virus can spread when an infected person coughs, sneezes, sings, talks or even breathes around others, according to experts. Distance and masks are recommended to avoid exposure because there is no vaccine to prevent COVID-19.

The state agency determined on Aug. 26 that Stearns Nursing and Rehabilitation Center's failure to isolate those who were infected put residents in "immediate jeopardy" because it increased their risk for severe illness from COVID-19 and possible death. An "immediate jeopardy" citation is the most serious a nursing home can receive.

Stearns Nursing and Rehabilitation Center said through a lawyer that it disputes some of the findings but that it has worked with the state to make changes since the investigation.

Stearns was the only federally-regulated nursing home in the metro-east to receive an "immediate jeopardy" citation for violating COVID-19 regulations as of Sept. 9, according to a Belleville News-Democrat analysis of publicly available state inspection reports for the seven-county area. Illinois Department of Public Health spokeswoman Melaney Arnold said the serious citation was "not common" statewide; she did not say how many nursing homes had received it during COVID-19 inspections.

The state's investigation found that the "immediate jeopardy" at Stearns started Aug. 9, when 11 residents in the nursing home's memory care center tested positive for COVID-19. Three more memory care residents tested positive between Aug. 15 and Aug. 17, according to the state report.

The "immediate jeopardy" ended on Aug. 27 because the nursing home was separating residents based on their test results or possible exposure to the virus at that point. Stearns also updated staff training as a result of the investigation, according to its plan to correct the deficiencies, which was submitted to state and federal regulatory agencies.

As the state continued investigating Stearns' compliance with rules for nursing homes through August and early September, it found other problems "based on observation, interview and record review," according to the inspection report:

--Three employees worked while they were infected with the coronavirus.

--Two residents did not receive timely medical treatment for COVID-19 symptoms, and they died. One resident's cause of death was respiratory failure and novel coronavirus infection. A cause of death for the other resident was not included in the report. Both had tested positive for COVID-19.

--One resident with Alzheimer's disease wore the same clothes for a week, lost 16 pounds in a month and was hospitalized for dehydration. She no longer resides at Stearns, according to the nursing home's plan to correct deficiencies.

--Residents in the memory care center did not wear face masks or stay at least 6 feet apart, measures that experts believe help prevent the virus from spreading.

--A hallway of rooms for residents with COVID-19 was not cleaned for over a week.

--Five employees either did not wear the required personal protective equipment around residents with COVID-19 or did not remove that equipment before going to other parts of the building.

--Two employees did not administer medications as ordered by a physician to two residents. The residents had no adverse reactions or outcomes from the errors, according to the nursing home.

--Six residents' families were not notified when either there were cases of the virus inside the facility; the resident tested positive for COVID-19; the resident's condition worsened; the resident was transferred to a hospital; or the resident was moved to a different room in the facility. Four of these six residents no longer reside at Stearns, according to the nursing home.

Stearns Nursing and Rehabilitation Center declined through a lawyer to make its staff available for an interview. Taylor Wilson, the nursing home's lawyer, provided a statement from Stearns.

"Stearns Nursing and Rehabilitation Center, LLC worked cooperatively with IDPH throughout the survey process," the nursing home stated. "Although Stearns disputes some of the issues identified during the survey -- and is currently evaluating its options on appeal -- the facility promptly implemented measures to meet any concerns of the state survey agency. The facility continues to do its best to combat Covid-19 and prevent spread to our residents. Through our efforts during and after the survey process, including weekly testing, the facility has no Covid-positive residents or employees. The facility will continue to proactively monitor its residents and staff, and to adhere to all reasonable measures available to it to keep the facility Covid-free.

"Stearns cannot comment on the care provided to any specific resident given state and federal privacy laws."

BEHIND OUR REPORTING

Why we did this story

During a BND investigation of nursing home inspections during the coronavirus pandemic, we found an "immediate jeopardy" citation at Stearns Nursing and Rehabilitation Center. Because it is the most serious citation a nursing home can receive, we decided to post the story about Stearns now as we continue our region-wide investigation.

How we did this story

We learned about the findings of the Illinois Department of Public Health's investigation at Stearns from a Sept. 4, 2020, inspection report that the state published online.

How to learn more

To read the state's inspection reports, go to the website ltc.dph.illinois.gov/webapp/LTCApp/ltc.jsp, search for a nursing home and then click "surveys."

How to share your experience with us

Help the BND report on nursing homes. We're looking for nursing home workers, residents and family members who are willing to share their experiences of the pandemic with us. Contact investigative reporter Lexi Cortes at acortes@bnd.com or 618-239-2528.

Coronavirus pandemic's effect on nursing homes

The Madison County Health Department confirmed that Stearns Nursing and Rehabilitation Center has no active infections through its weekly updates on long-term care centers. Health officials have not reported an increase in Stearns' COVID-19 statistics since September.

According to the health department, a total of 111 cases of the virus have been tied to Stearns since the start of the pandemic.

The total includes 76 residents and 35 staff members from Stearns who tested positive for COVID-19, the inspection report states, citing the health department. Of those, a total of 20 people have died, health officials said.

During the state's investigation in August and September, Stearns did not provide Illinois with documentation showing how it was tracking COVID-19 infections in the 109-bed facility, according to the inspection report.

Madison County Health Department spokeswoman Amy Yeager referred the BND to the Illinois Department of Public Health for comment on Stearns Nursing and Rehabilitation Center.

Yeager did not respond to questions about the health department's role in helping Stearns during its outbreak, including when that help began and whether it advised Stearns to separate residents who tested positive for COVID-19 from residents who tested negative.

Nursing homes have posed unique challenges to health care professionals during the coronavirus pandemic. They care for people who are both the most vulnerable to COVID-19 and who live in the riskiest setting.

Older people and those with existing health conditions have a higher risk of severe illness. The risk of transmission also increases when people are gathered together indoors, especially within 6 feet of each other, according to experts.

Across Madison County, residents and employees at long-term care facilities, including nursing homes, accounted for 12% of the infections countywide and 72% of the deaths as of Oct. 9, the latest date statistics from the facilities were available.

At Stearns Nursing and Rehabilitation Center, the state focused much of its investigation on the facility's memory care center, where residents who have dementia receive specialized treatment, according to the nursing home's website. Employees working in the center talked to state inspectors about the added difficulties they faced with residents who have memory loss.

"The positive residents do wander in rooms of negative residents or vice versa. In and out of each other's room. We try to redirect but with only two CNAs, it can be difficult. They (residents) don't understand and will do it again," a certified nursing assistant told a state inspector, according to the report.

Like many other nursing homes, Stearns was also experiencing staff shortages while battling the coronavirus. Until July, it was reporting shortages to the federal government every week in one staff category or another -- from housekeepers to registered nurses. And those shortages picked up again between mid- and late August, federal data shows.

'I was sick all last week and I worked'

A licensed practical nurse coughed often during her shift at Stearns Nursing and Rehabilitation Center on Aug. 17, according to the state inspector who observed her.

The inspector wrote in the state report that the nurse's eyes were bloodshot, and she was winded. The nurse said she found out she had COVID-19 a day earlier.

She worked again on Aug. 18, a double shift in the memory care center, before quarantining at home, according to a state inspector's notes from their interview. The nurse said she fills in when staffing is low.

"I was sick all last week and I worked," the nurse told a state inspector, according to the report. "(The administrator) knew I was sick with cough, no taste/smell, low grade temp and a headache, too. She told me to come to work even when I had symptoms."

State inspection reports do not include the names of nursing home employees, residents or family members. Stearns' lawyer did not respond to the BND's request for confirmation of the name of the administrator at the time of the survey.

The state reported that it verified the licensed practical nurse's positive test result through the facility's records. It also used the records to verify a positive test result for a registered nurse who told state inspectors she worked while infected with the coronavirus, according to the inspection report. Facility records documented the onset of COVID-19 symptoms for a third employee, a certified nursing assistant who the inspectors saw working five days after her symptoms started; other employees said the CNA tested positive for COVID-19, the report states.

The Illinois Department of Public Health determined that Stearns violated both the facility's own policy and the Centers for Disease Control and Prevention's rules for health care workers, according to the inspection report. Since the state investigation, Stearns does not allow staff members to work while they have symptoms of COVID-19, the nursing home wrote in the plan it submitted to regulators.

During the investigation, state inspectors heard a certified nursing assistant asking coworkers for help because no one showed up for a shift in the memory care center, according to the report. State inspectors listened to staff and resident complaints that housekeeping had not been in to clean the COVID-19 isolation hallway in over a week; the inspection report noted that the floors were "visibly soiled and sticky."

"Honestly, I don't know when the last time it was cleaned," the administrator told a state inspector, according to the report. "Housekeeping called off today. We will call in evening shift to do housekeeping. We should be cleaning high touch surfaces four times a day."

One resident at Stearns complained to her roommate's family visitor "that staff aren't taking care of them," the inspection report states.

"She is in here because of her memory. She has been in those clothes since she came to this room from the other end of the hall, which was two days ago," the resident said of her roommate. "She is not eating."

The state inspector wrote in the report that the resident's roommate was wearing the same outfit on Aug. 25 as she was on Aug. 19: a brown shirt and gray pants with a red stain down one leg from spilled Kool-Aid. That resident repeatedly complained to staff members about stomach pain due to an ulcer and refused to eat, the report states, citing her nurses' notes.

The person designated to make health care decisions for her requested she be sent to the emergency room when she started experiencing nausea and vomiting. A family member told a state inspector they learned she was severely dehydrated. She had dropped to 137 pounds on Aug. 28 from 153 pounds on July 3, according to the state inspector's review of the facility's records.

Another resident's family member expressed concern to a state inspector about her mother's care because of changes in staffing at Stearns. Her mother was one of two residents with COVID-19 who the state determined did not receive timely medical care because employees did not monitor the residents as often as they should or communicate with clinical staff, such as a doctor. Both of the residents died, according to the state's report.

Illinois investigates resident deaths

Nursing home employees are required to monitor residents who have COVID-19 or symptoms of the disease at least three times a day and notify clinical staff if a resident's condition declines.

There was no documentation in one resident's medical records that the staff at Stearns monitored her for three days -- Aug. 15-17, the state's investigation found. Before and after that three-day period, employees documented checking her vital signs once a day, according to the state inspection report.

She tested positive for COVID-19 on Aug. 9, when "immediate jeopardy" began at Stearns. In addition to COVID-19, she had Type 2 diabetes and heart disease, the report states.

A state inspector observed her care on Aug. 19 during the investigation of Stearns. The resident's face was red that morning, and she was taking slow, shallow breaths, according to the report.

"This is not normal for her," a certified nurse's aide told the state inspector. "She has changed."

The aide listed the resident's symptoms -- coughing, sneezing, fever -- and said the resident had not been eating or getting out of bed.

"This has been going on about two weeks," the aide said. "I have reported it to the nurse. I tried to get her temperature, but I was told the thermometer wasn't working and they would get me a new one."

Later on Aug. 19, an employee documented high blood pressure in the resident, administered medication and contacted a nurse practitioner, who said to check the resident's blood pressure again in an hour, inspection report states. The nurse practitioner told a state inspector that the staff did not contact him when the resident's heart rate was elevated, which they documented in her records on Aug. 22. She died the following day, Aug. 23.

"It is possible that she would have been sent to the hospital," the nurse practitioner said. "I will send residents to the hospital unless the family requests them to stay in the facility."

The state reviewed medical records for another resident, who died before the investigation of Stearns began. The resident's cause of death was listed as respiratory failure and novel coronavirus infection, according to the state inspection report, which cited an Aug. 13 certificate of death worksheet.

Two nurses at Stearns documented that the resident had a low level of oxygen in her blood on Aug. 4. Only one called the nurse practitioner, who said to send the resident to the hospital.

The resident's daughter told a state inspector that the hospital confirmed her mother had COVID-19, as well as pneumonia. The resident had a previous diagnosis of dementia, according to the state report.

The nurse practitioner for Stearns "stated he was not sure if a delay in sending (the resident) to the hospital contributed to her death because he did not assess her at that time" in an interview with an inspector.

Sanctions for Granite City nursing home

Because "immediate jeopardy" is the most serious citation for nursing homes, it carries the most serious sanctions, according to the U.S. Centers for Medicare and Medicaid Services, which regulates those facilities along with state agencies.

The Illinois Department of Public Health imposed a "discretionary denial" of payment for new Medicare and Medicaid admissions at Stearns Nursing and Rehabilitation Center on behalf of the federal government, according to the Centers for Medicare and Medicaid Services.

The state also recommended that the federal agency issue ongoing monetary penalties until March 4, 2021, unless "compliance is achieved," Department of Public Health spokeswoman Melaney Arnold wrote in an Oct. 7 email to the BND.

The Centers for Medicare and Medicaid Services had not issued a fine as of early October, but the federal agency said further remedies will be imposed.

The Illinois Department of Public Health was still considering any state-level sanctions in early October, according to Arnold.

Illinois' inspection report for Stearns states that the severity of the nursing home's citation would remain at a level two out of four after "immediate jeopardy" was removed Aug. 27 because "additional time is needed to evaluate the implementation and effectiveness of in-service training."

A level two designation is for situations with the potential for "more than minimal harm," according to the federal definition. Level four is "immediate jeopardy" to resident health or safety.

When asked if the state had completed the evaluation at Stearns, Arnold stated that "follow up is being scheduled."

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