Evanston Nursing Home Fined $25,000 Over Failures: IDPH

EVANSTON, IL — An Evanston nursing home violated the terms of its license when it failed to assess a resident and notify a doctor of his declining condition, according to health officials. In announcing a $25,000 fine for The Grove last year, the Illinois Department of Public Health said the failure resulted in the resident being sent to a local hospital for emergency treatment. Less than 24 hours later, the resident was dead, according to the department's statement of license violation.

In July, public health officials reviewed records of the facility at 500 Asbury St. for the resident, who died just after midnight on June 25. They found The Grove's assistant director of nursing noted on June 20 there had been a decline in the man's condition "for three consecutive days," their report said. That nursing director later admitted to investigators they did not notify the resident's doctor despite the functional decline, health officials said.

"Record review on facility documentation doesn't indicate any follow up after [the resident's] functional decline on [June 20] until his condition gets worse for hospitalization through 911 on [June 24]," according to the department's statement.

"I should be notified when there is [a] change in condition with [the] patient," the attending physician told investigators."It is part of their protocol." The doctor said they only learned of the resident's change in status after he was found sitting on the floor and lethargic with abnormal vital signs, according to the department. By that point, the doctor said, the patient "was in real shock."

Shilpi Chona, the nursing home's administrator, declined to comment, saying she needed to first consult with corporate headquarters and lawyers. The 124-bed Grove of Evanston L & R is licensed through the entity Evanston Skilled Nursing Facility LLC, a for-profit partnership with an address of 801 Adlai Stevenson Drive in Springfield, state and federal records show.

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In addition to violating the terms of its license, public health officials said the facility violated its own written policies. It assessed a fine of $25,000 for what it classifies as a Type A violation, which "pertains to a condition in which there is a substantial probability that death or serious mental or physical harm will result, or has resulted," according to the department.

According to U.S. Department of Health and Human Services records, The Grove has been issued nine citations in the last three years and one federal fine. Its staffing is rated "below average" on the U.S. Centers for Medicare & Medicaid Services website. Seven health citations were issued in its most recent federal health inspection. They included failing to protect a resident from physical abuse, failure to maintain hearing aids, failure to dispose of expired medications and failure to clean its plastic trays, according to the inspection report.