A Galesburg nursing home was fined $50,000 by the Illinois Department of Public Health for the most serious classification of licensure violation -- one that causes a resident’s death.
The former Heartland of Galesburg, 280 E. Losey St., is among five facilities statewide cited for “AA” violations of the Nursing Home Care Act in the first quarter of 2022.
That level of violation is cited when a condition or occurrence at the facility proximately causes a resident’s death.
In this case, a 74-year-old woman fell at home and fractured her hip on Oct. 7, 2021.
According to the IDPH investigation, the woman lived independently in her own home prior to that day.
She was taken to a Galesburg hospital emergency room. Medical staff determined she did not need surgery, but a catheter was inserted so she would not have to get up to use the bathroom that night.
The following day, she was admitted to Heartland of Galesburg, which is now ProMedica Skilled Nursing and Rehabilitation, and the catheter stayed in.
The facility changed its name on Feb. 10, 2022, according to the Illinois Health Facilities and Services Review Board.
The stay at Heartland was meant to be short-term as the woman recuperated from the injury.
But just over two weeks after the woman was admitted to Heartland, she would die from multiple organ failure due to sepsis.
IDPH determined the facility failed to identify and assess the medical justification for continued catheter use.
They also failed to identify and monitor signs of a urinary tract infection and to implement appropriate medical interventions.
Those failures resulted in the resident developing sepsis from the urinary tract infection, and ultimately her death, according to IDPH.
Medical records note on the day of the resident’s admission to Heartland that the catheter was present and draining “adequate amounts of yellow urine.”
According to IDPH, medical records from Oct. 8 to Oct. 21 do not include a physician’s orders or justification for continued use of the catheter.
The catheter is not mentioned in medical records again for eight days.
On Oct. 16 and 17, records note the catheter was still present, but was “draining cloudy yellow urine.”
According to the investigation, there was no further assessment of the catheter or urine until Oct. 21, when the resident was transferred to the hospital around 1:45 p.m. and admitted with severe septic shock.
She died twelve hours later.
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