IDPH has cited and fined Forest City Rehab nursing home in Rockford after a resident there murdered his roommate.
Sadly, this is not the first time that we have written about resident on resident assaults at this facility. In one recent post, we described an incident where a resident was pushed to the the ground by a fellow resident, suffering ae fractured hip.
This kind of injury is disturbing in and of itself, but the attitudes which were on full display for the state surveyor made the situation even more disturbing and really set the stage for this incident. Part of the problem in the earlier incident was that when the nursing home ran the required background check on the aggressor resident, it entered the wrong date of birth and therefore missed the fact that the aggressor had multiple arrests, including two arrests in the last year for assaults on persons over 60 years of age. When this information came out, this was the reaction that the state surveyor recorded:
- The social services director told the state surveyor, “We do our best, but we can’t have eyes on people 24/7 365 days. All residents are treated the same, behaviors can happen whether it is a person with a history or a little old lady.”
- The Director of Nursing told the state surveyor, “Even if the background check was done correctly, it wouldn’t have changed anything. We would not have done anything different for him [the aggressor] anyway. We don’t base our admissions on background checks.”
That is a proverbial shrug of the shoulders – “wouldn’t have made any difference any way.”
With that incident in the rear view mirror and a citation and hefty fine from the State, you would think and hope that the nursing home would clean up its act and be more proactive about assuring the safety of its residents from one another.
You would be disappointed.
The aggressor and victim were roommates. When you see the backgrounds of these gentlemen (below), you will wonder why they were ever put in a room together to start with. Past that, they asked for a change, were told that they would get one when a room was available. There were rooms open – but the social services director did not think that it was necessary, leaving a volatile situation brewing until things went completely wrong.
The victim had been in another nursing home before this one. There, he had complaints about his roommate, specifically that the roommate smelled bad. This led to a physical altercation between the roommate where our victim was the aggressor. These issues were described in records from the earlier nursing home which were supplied to this nursing home. However, that information was never considered in care planning or in making placement decisions.
The aggressor had diagnoses related to mental illness. He had an extensive criminal history and problems at a number of different living situations including with families, hotels, and other health care facilities. He had a reported history of impulse control. The Identified Offenders Report indicated that he needed closer observation and more frequent monitoring than most residents.
The staff on the floor told the state surveyor that they were not aware of the histories of the two residents or that they required additional monitoring, so it was not being done. Their room was located near the end of the hall, second furthest from the nurse’s station.
On the night of the incident, the aggressor came to the nurse’s station at approximately 11:30 pm, asking to use the phone. The nurse commented that it was late to be calling family, and in response the aggressor stated that he thought that he killed his roommate. The bed was pushed to one side. There was a broken window and a hole in the wall which was not present earlier.
The nurse ran down to the room and found the victim on the floor motionless and pulseless. 911 was called and he was brought to the hospital where it was shown that the victim was not going to recover and he died several days later.
The aggressor told police that they were arguing over whether the light should be off or or. The aggressor wanted the light on, so he got up to turn it on. The victim punched him, so he put the victim in a headlock, keeping him there until he was no longer moving.
There are so many problems with the care that these residents were provided that the list is hard to make. It begins with the fact that the nursing home apparently did not learn anything from the earlier incident regarding the admission and/or monitoring of residents with a criminal history. These are men who were likely never suitable admissions to any nursing home, let alone being placed in the same room. They clearly recognized it and asked for a change which the nursing home could have made but failed to do so.
Past that, the need for close monitoring was never recognized in the care planning process or communicated to the staff who would have been charged with carrying it out.
Further, this resident-on-resident assault was one which was allowed to take place over a span of several minutes at a minimum. They had been arguing over the light for some period of time before the final assault. One the physical altercation started, it was violent enough that the bed in the room was moved, a hole was punched through the wall, and a window was broken. Despite all of the noise that was undoubtedly generated from this, the first time the staff went into the room was after the aggressor reported to them that he thought that he killed his roommate.
This is a story of failures that started well before these residents actually entered the nursing home and continued up through the moments that one was choking the life out of the other.
The real question is why would a nursing home accept this kind of situation and the easy answer is that they are paid by the state each day a bed is kept full. If their motivation was delivering quality care to those who need it, this situation would not be allowed to persist at this facility. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
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