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Southwest IL nursing home's 'systemic failures' resulted in 8 COVID deaths, state says
Belleville News-Democrat - 3/6/2021
Mar. 6—More from the series
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COVID in nursing homes
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Nursing home's 'systemic failures' with COVID resulted in 8 resident deaths, IL says
What penalties have IL nursing homes faced for serious citations in COVID inspections?
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Eight people died in December as a result of a Washington County nursing home's "systemic failures" to prevent or contain an outbreak of the coronavirus, according to a state inspection report.
They were among 72 residents infected with the virus in a span of about three weeks at Friendship Manor Health Care in Nashville, the report states.
The Illinois Department of Public Health issued Friendship Manor the most serious citation available to regulatory agencies on Dec. 18; it said residents' health and safety was in "immediate jeopardy" based on what it saw.
Friendship Manor Administrator Heather Stich said in response to questions submitted by the BND that the nursing home's leaders "vehemently disagree" with the state's findings because they believe the circumstances were misrepresented.
The state denied Friendship Manor's first attempt at an appeal through a third-party reviewer, CertiServ, but the nursing home plans to try again, according to Stich. She said they requested a hearing before a federal administrative law judge, another option for nursing homes seeking to appeal citations.
Stich said staff shortages have been a challenge for Friendship Manor, like other nursing homes across the country, and that it received little assistance when it sought help. But she says Friendship Manor has closely followed regulations "from the onset of COVID-19," the disease caused by the coronavirus.
The state argues problems started at the nursing home when the first resident was diagnosed with COVID-19 on Nov. 24 and Friendship Manor "failed to complete effective facility disinfection practices" to kill the virus, according to the inspection report.
By Dec. 9, when the state inspector arrived at Friendship Manor, the first three residents had died.
Joyce White, 60, was one of them, according to details from the inspection report verified by her family.
White endured years of health problems before the coronavirus pandemic, so her death just a week after testing positive for COVID-19 came as a surprise to the family, her daughter Elyse Coil said.
"I just couldn't understand how she could go from 'A little bit of a cough, but I'm feeling fine' to gone," Coil said.
The coronavirus can have devastating effects on older people and adults with existing health conditions, according to experts. They have a higher risk of severe illness or death from COVID-19, the Centers for Disease Control and Prevention says.
In Washington County, 70% of the 27 COVID-19 deaths were from long-term care facilities as of the end of February, according to the most recent state statistics.
White's official cause of death was congestive heart failure and diabetes, but a physician told the state he would consider COVID-19 to be a contributing factor. The other seven Friendship Manor residents died from pneumonia and COVID-19, according to the state's inspection report.
Nursing homes are risky settings for transmission. The CDC says the virus spreads most easily when people are gathered together indoors, especially within 6 feet of each other, and an infected person coughs, sneezes, talks, sings or even breathes.
The federal agency recommends that nursing homes clean often. But it acknowledges that getting COVID-19 from touching surfaces is less common.
Inspections like the one at Friendship Manor are new, prompted by a federal directive for state agencies to assess nursing homes' preparedness to control the spread of infectious disease during the pandemic in order to protect residents from COVID-19.
The Illinois Department of Public Health inspector who traveled to Nashville in December was also investigating four complaints that had been filed against Friendship Manor, the report shows.
The state inspector read Friendship Manor's records, talked to its employees and watched them work over four days.
The inspector found the following five violations, according to the state report:
—The nursing home did not keep two residents with COVID-19 away from residents without it.
—An employee did not assess or quarantine a resident with a cough, one of the symptoms of COVID-19.
—Two employees did not follow the Environmental Protection Agency's or the facility's directions for cleaning.
—Three employees did not wear required personal protective equipment to shield their eyes.
—The nursing home did not stock supplies or hang a sign near a quarantined resident's room, indications for employees who might enter to take precautions.
The Illinois Department of Public Health said the "immediate jeopardy" to residents ended on Dec. 22 — one month after it started — because Stich developed a deep cleaning regimen for the nursing home and updated staff training in the areas covered in the inspection.
Only three federally-regulated nursing homes in the metro-east had gotten an "immediate jeopardy" citation for violating COVID-19 regulations as of Feb. 11: Friendship Manor in December, Integrity Healthcare of Smithton in September and Granite City'sStearns Nursing and Rehabilitation Center in August, according to a BND analysis of publicly available inspection reports for the seven-county area. Feb. 11 was the most recent date of the reports available on the state's website this week.
Melaney Arnold, a spokeswoman for the Illinois Department of Public Health, said just 50 of the more than 700 nursing homes in the state received the serious citation in the new inspections in 2020.
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 Friendship Manor in Nashville. Because it is the most serious citation a nursing home can receive, we decided to post the story about Friendship Manor 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 Friendship Manor from a Dec. 22, 2020, inspection report that the state published online.
State reports do not include residents' names, so the BND used details from the report on Friendship Manor, including when and where residents died, to find families through obituaries with the same details.
The BND believes Joyce White is one of the residents mentioned in Friendship Manor's report because the family verified additional unique details that were included in the state document: the date she tested positive for COVID-19 and her cause of death.
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 story with us
Help the BND report on nursing homes. We're looking for nursing home owners, managers, workers, residents and family members who are willing to share their experiences from the pandemic with us. Contact investigative reporter Lexi Cortes at acortes@bnd.com or 618-239-2528.
What Illinois says Friendship Manor did wrong
No. 1: Nursing home did not isolate residents with COVID-19
Friendship Manor did not move two residents with Alzheimer's from the specialized memory care unit to an isolated area of the nursing home with rooms specifically for residents with COVID-19 when it learned they tested positive.
Stich, the nursing home administrator, told the state inspector that the COVID-19 isolation unit had three unlocked doors leading outside, and they were afraid the infected residents with Alzheimer's would leave the building.
The inspector observed and interviewed four staff members over two days and reported that they did not ask a resident with COVID-19 who was walking the halls in the memory care unit to go back to her room or to put on a face mask and stay at least 6 feet away from others who had not yet been diagnosed with the disease. Experts believe masking and distancing help prevent the coronavirus from spreading.
"We can't stop them, and we can't move them to the COVID-19 unit, and we can't keep them contained," a licensed practical nurse told the state inspector.
Within about two weeks, 15 out of 18 residents in the memory care unit were infected, and two of those residents died, according to the inspection report.
In response to the BND's questions, Stich said that Friendship Manor decided the risks associated with moving the infected residents "far outweighed" the risks of keeping them in the memory care unit.
"Our decision to keep them in our dedicated, secure memory care unit was consistent with CDC guidelines," Stich added. "Moreover, we contacted our local health department, per IDPH guidelines, and the administrator agreed with our decision."
When asked if she agreed with the decision, Washington County Health Department Administrator Elizabeth Lehde said in a statement to the BND that her department's role is "to provide guidance, not be the definitive decision maker for any facility."
"Local health departments are not well versed in the regulations that nursing homes must meet for licensing purposes," Lehde said.
CDC regulations recognize the challenge of keeping dementia patients in their rooms and the risk that creates for other residents who may become exposed to COVID-19. But they also encourage nursing homes to consider safety concerns for dementia patients before moving them to a COVID-19 isolation unit.
"Facilities may determine that it is safer to maintain care of residents with COVID-19 on the memory unit with dedicated personnel," the CDC states.
Friendship Manor had put up a plastic barrier to separate the infected residents' rooms from the other 16 residents' rooms in the memory care unit, according to the state report. But the residents did not stay behind the barrier, and Friendship Manor did not have enough staffing for a 1-to-1 employee to resident ratio to provide constant supervision, Stich told the inspector.
Residents also tried to pull the plastic barrier down, and managers worried they would get tangled in it and hurt themselves, so they removed it and began operating as if all the dementia patients were infected, the inspection report states.
"Memory care residents exposed to COVID-19 were isolated per CDC guidelines by December 18, 2020," Friendship Manor states in its plan to correct the problems cited in the report, which it submitted to Illinois.
No. 2: Employee did not assess, quarantine resident with cough
The state says a licensed practical nurse did not evaluate or quarantine a resident when an aide reported to her one morning that the resident had a new cough, one of the symptoms of COVID-19.
The licensed practical nurse contended that the aide did not tell her about the resident's cough and that she had not heard the resident coughing when she distributed medication that morning, according to the state inspector's account of their interview.
The nursing home performed a rapid test and learned the same day that the resident had COVID-19, the inspection report states.
No. 3: Employees did not clean effectively
Two housekeepers who the inspector observed and interviewed over two days did not leave a disinfectant on surfaces for 10 minutes like the EPA directs to kill the coronavirus.
One of the housekeepers used the same rag, which she periodically dipped in a bucket of disinfectant, to clean a bathroom shared by residents and two residents' rooms. The two residents whose rooms the housekeeper cleaned tested positive for COVID-19 about a week after the observation, according to the report.
The other housekeeper did not wipe down some frequently-touched surfaces — door knobs and light switches — in the room of a resident who was diagnosed with COVID-19 later that day. The housekeeper also told the inspector that she does not get to wipe down another frequently-touched surface — hallway handrails — twice per shift like nursing home managers directed.
Stich, the administrator, said in a statement to the BND that all housekeepers had received and continue to receive training on cleaning to kill the virus.
No. 4: Employees did not wear protective equipment
During an interview with three staff members in Friendship Manor's COVID-19 isolation unit, a certified nursing assistant told the state inspector that she did not think she needed to wear eye protection since she tested positive for COVID-19; a licensed practical nurse referred to glasses as eye protection; and another CNA said she was new and that she was not aware she was supposed to be wearing eye protection.
Stich said the new CNA had received eye protection to wear and was just intimidated by talking to the state inspector, according to the inspection report. The administrator added that eye protection is for protecting staff members from infection, and two of the three employees interviewed had already tested positive for COVID-19.
No. 5: Nursing home did not stock supplies by quarantine room
At one quarantined resident's room door one day during the inspection, there was no sign alerting staff members that he was quarantined, no personal protective equipment for staff members to wear before they went inside the room and no bin for staff members to discard used PPE on their way out.
The director of nursing told the state inspector that they had put signs on the resident's door "but (he) must have taken them down." Employees were putting on their PPE in a neighboring room and discarding it in a room a few doors down from the resident's room, managers told the inspector.
The nursing home received the resident's positive COVID-19 test result the same day as the observation, the inspection report states.
Nursing home inspected amid first COVID outbreak
The state was investigating Friendship Manor during its first outbreak of the coronavirus, nine months into the pandemic.
The outbreak grew to a total of 118 infections — 76 residents and 42 staff members tested positive for COVID-19, according to Stich. The county health department said Friendship Manor has not reported a new COVID-19 diagnosis since Dec. 28.
A total of 18 people from Friendship Manor have died from COVID-19, according to the Illinois Department of Public Health, which reported the most recent death on Feb. 19 in statewide long-term care statistics that are updated weekly.
The initial inspection report on Friendship Manor said "systemic failures" during the outbreak had resulted in 10 resident deaths. The state later determined two of the residents died because of major health issues that did not involve COVID-19, according to Arnold, spokeswoman for the state health department.
'Virtually no staffing assistance' provided despite pleas
Friendship Manor was experiencing shortages of nurses, aides and other employees throughout December while it responded to the coronavirus outbreak, according to information it submitted to the federal government.
Elyse Coil said she tried to be understanding of that challenge when her mother Joyce White told her she could be left waiting for Friendship Manor workers to answer a call light at times.
"I work in a hospital so I get that everybody's busy, everybody's understaffed...I get it," said Coil, a hospital pharmacy technician. "But that's my mom. They're supposed to be there advocating for me because I can't be (there)."
Stich, the administrator, said the 120-bed facility tried accessing local and state resources to bolster its staff, but it received little assistance and sometimes no response at all.
Friendship Manor reported to the Illinois Department of Public Health that it was at "crisis staffing levels," advertised its open positions, requested help from staffing agencies and registered with Illinois Helps, a state system to find volunteer health care professionals during the pandemic, according to Stich.
"Despite numerous pleas to multiple local and state resources that can help long-term care facilities like ours, virtually no staffing assistance has been provided to date," she wrote in a statement. "In many cases, we did not even get responses.
"Of those staffing agencies who did return our calls, most eligible staff identified to help refused to work in a COVID positive setting."
In a letter to nursing homes, the Illinois Department of Public Health and Department of Healthcare and Family Services said state agencies had relaxed licensing requirements and started Illinois Helps to make more professionals available. But it included a reminder: ensuring adequate staffing levels "is first and foremost the (long-term care) facilities' responsibility." The letter is undated, but it was included in the May 4 memo to Illinois Municipal League members.
Arnold, from the state health department, reiterated nursing homes' responsibility in a recent statement to the BND.
"Long-term care facilities are reimbursed by residents, private insurance or Medicare/Medicaid to provide appropriate care in all situations, including infection prevention," Arnold stated in an email. "Facilities are required to have emergency preparedness plans and adequate staffing for all situations pursuant to state regulations. This can include working with a staffing agency or other facility operators, but it is incumbent upon the facility to provide the services for which they are paid."
Arnold added that Illinois agencies took the steps detailed in the letter to nursing homes because some facilities were not prepared with acceptable emergency staffing plans at the beginning of the pandemic.
The human toll of COVID-19
Elyse Coil saw her mom as unselfish, willing to help other people even through her own personal struggles.
Joyce White raised two children, took care of her in-laws and was active in her community before her longtime health problems worsened and she needed nursing home care, according to Coil.
"She was always the caretaker even though she's had health issues all her life," Coil said.
Friends saw her the same way Coil did. She was caring, kind, sweet, they repeated in their condolences to the family after White died at Friendship Manor on Dec. 9.
Their lengthy separation during the pandemic is only adding to Coil's disbelief following White's death. Nursing homes have been largely locked down since March — with some exceptions — in an effort to help prevent the virus from spreading to residents.
White got a smartphone during the pandemic, and Coil said her mom called and texted often. They had hoped to use the new phone to make a video call and see each other while they were apart. But Coil said her mom died before they could.
"She's known pain all her life," Coil said of her mom's illnesses. "... That's the only comfort I do have is that she's not in pain."
Sanctions nursing homes face for 'immediate jeopardy'
Because "immediate jeopardy" is the most serious citation for nursing homes, it carries the most serious sanctions, according to the Centers for Medicare and Medicaid Services, the federal regulatory agency for the industry.
As of last month, state and federal agencies said they had not yet made a decision about any penalties Friendship Manor, a for-profit nursing home, will face.
They levied over $200,000 in fines against the first two metro-east nursing homes to receive "immediate jeopardy" citations, according to the Illinois Department of Public Health.
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Stearns Nursing and Rehabilitation Center: $242,000 fine ($189,800 from federal and $52,200 from state)
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Integrity Healthcare of Smithton: $232,571 fine ($207,571 from federal and $25,000 from state)
A lawyer for Stearns did not immediately respond to an email or phone call requesting comment about whether the nursing home is appealing the sanctions. Integrity of Smithton Administrator Sara Hoover-Shaw declined to comment.
Illinois' inspection report on Friendship Manor stated that the severity of the nursing home's citation would remain at a level two out of four after "immediate jeopardy" ended because "additional time is needed to evaluate the implementation and effectiveness of the 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.
The Illinois Department of Public Health will follow up with another inspection at Friendship Manor, according to Arnold, the state spokeswoman.
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