Calling it the “most serious licensure violation levied by the state,” the Illinois Department of Public Health (IDPH) charged 17 facilities across the state, including the Pavillion of Forest Park, with type “A” violations of the Nursing Home Care Act.

The charges came with hefty fines ranging from a $5,000 to $50,000, depending on the number of counts and the seriousness of the alleged violations.

Pavillion received one of the highest fines, $20,000, for two alleged violations. Of the list only two other facilities received a higher fine: Provena St. Anne Center, with $50,000, and West Chicago Terrace, with $25,000.

According to a press release from IDPH, Pavillion has been fined for a “failure to assess and treat a resident’s left knee pain and swelling for five days” and for having “failed to protect a cognitively impaired resident from another resident who had a history of sexually inappropriate behavior with her.”

Pavillion is disputing the civil monetary penalty and, to her knowledge, this is the first time the facility has been fined for this kind of infraction, said Linda Flaherty, director of Risk Management for Care Centers, the management company for Pavillion.

“It is alleged misconduct,” she said. “We cleared all of the tags that they had cited during the survey. I can’t speak to the specific issues”I am not at liberty to do that”[but] we are currently appealing the fine at this time.”

The first alleged violation occurred on Feb. 9, 2005 according to the statement of violations filed by the IDPH.

In the statement, the department alleges that Pavillion failed to protect the female resident, even though the facility’s staff first identified the alleged offender’s sexual misconduct on May 19, 2004.

On Feb. 9 at 3 p.m., the statement said, staff at Pavillion reported finding a male resident with the female, who allegedly said, “No, no,” as the male encouraged her to put her head on his exposed lap.

The alleged victim, the statement reveals, is a cognitively impaired women “who does not have the ability to make a consensual choice, and at least on one occasion, on Feb. 9, 2005, was visibly upset by [the alleged perpetrator’s] forceful demands.”

According to the report, the male patient was moved to the third floor of the facility, which “houses ventilator-dependent residents who would be non-mobile and at risk,” following the Feb. 9 incident. However, a family member requested the facility move him back to the second floor”the same floor as the female”on Feb. 14.

He was moved back on Feb. 16 and the facility took no further steps to protect the female, the report alleges.

Flaherty said the male was moved back because “in general, the patients have rights, and oftentimes the family makes decisions for them. Families have the right to make their wishes known, because that is part of the patient’s right.”

The female in this case suffers from dementia and depression, among other ailments, and was classified by Pavillion as having a cognitive ability of “2,” the report states. The male, on the other hand, was classified as a level “1” and suffers from diabetes, arthritis and anemia.

“[A level] 1 can make most of their own decisions, a level 2 isn’t able to make decisions and needs direction from someone,” explained Tammy Leonard, a spokeswoman for the IDPH.

In addition, an employee of the facility allegedly confirmed to IDPH inspectors that this was not the first time this had happened between the residents in the last two years.

In fact, the statement reports, the inspectors found medical records dated from May 19, 2004 regarding inappropriate sexual behavior between these two patients.

Slow to diagnose broken bone

In the second case, the resident, a female, suffers from Alzheimer’s disease and arthritis, and is “very confused and cannot communicate her needs and discomfort consistently,” the report states.

According to the IDPH, the facility’s failure to investigate her knee swelling resulted in “periods of prolonged pain and finally being diagnosed with a fractured femur.”

The fracture was diagnosed on Feb. 16, 2005. However, the report reveals the patient began to complain about the pain on Feb. 11 and was given Ibuprofen.

By Feb. 13, the report states that witnesses told a staff member the patient was “grimacing” and the “left knee and thigh were very swollen and discolored.”

Pavillion staff allegedly only started looking at the condition on Feb. 14, when a nurse noticed the swelling and bruising, but it wasn’t until Feb. 15 that the X-rays were checked and the fracture identified.

On Feb. 16, as a result of the alleged neglect, the IDPH states that the patient was hospitalized and needed surgery for open reduction and internal fixation of the femur.

Flaherty said the fines should not diminish people’s confidence in the institution, adding that the facility learns from its mistakes and is always striving to protect its residents.

“We are a facility that practices continuous quality improvement,” she said. “We always work for the safety of our patients, we always try to keep our patients safe, we don’t put the patients in a situation where they would be in danger.”

In addition, Leonard said the IDPH will also continue annual inspections of all facilities.

“Our goal isn’t to put places out of business; our goal is to ensure that they are meeting the health and safety needs of their residents,” she said. “We will go back out and make sure they are in compliance, and we annually inspect all of our long term facilities in our state. [We] are in every facility at least once annually.”

Also fined were Alden Heather Rehab and Health Care Center, Harvey; Aspire Eastern, Bellwood; the Glen Bridge Nursing and Rehabilitation Center, Niles; Glenshire Nursing and Rehabilitation Center, Richton Park; Good Samaritan Nursing Home, Knoxville; Hampton Plaza Nursing and Rehabilitation Center, Niles; Lakeview Living Center, Chicago; Lebanon Terrace, Lebanon; Palos Hills Extended Care, Palos Hills; Ponds of Wealshire, Lincolnshire; Provena Cor Marine Center, Rockford; Shawnee Christian Nursing Center, Herrin; and Vermilion Manor Nursing Home, Danville.