Health officials fined an Evanston skilled care facility for failing to notify a physician of a resident’s functional decline, which the state claims likely resulted in the resident’s death, a statement from the Illinois Department of Public Health said.

In a quarterly report posted Oct. 25, the IDPH announced the $25,000 fine on Grove of Evanston Living & Rehabilitation Center for an “A” level violation of its license. The Grove is one of 25 nursing homes in Illinois to receive an “A” violation during the July-September quarter, according to the report.

“An ‘A’ violation pertains to a condition in which there is a substantial probability that death or serious mental or physical harm will result, or has resulted,” IDPH said in its Oct. 25 news release.

Through interviews and record reviews from July, the IDPH found that the 124-bed facility did not notify the attending physician of a resident’s decline between June 20 and the morning of June 24.

That morning, the facility called 911 upon finding the resident “on the floor, lethargic, having abnormal vitals.” Shortly after midnight on June 25, the resident died in the hospital.

“I should be notified when there is change in condition with the patient,” the attending physician told health officials, according to the report. “It is part of their protocol.”

The Grove did not respond to requests for comment.

In an email to the Daily, IDPH public information officer Melaney Arnold wrote that long-term care facilities are required to comply with the Nursing Home Care Act, which is enforced by the skilled nursing and intermediate care facilities code.

“Long-term care facilities are inspected at least annually and upon complaint to ensure compliance,” Arnold said in the email.

A Medicare profile comparing nursing homes ranks the Grove above average overall, but the level of staffing per resident at the Grove is below average. Since March 2016, the Grove has violated the Nursing Home Care Act on four separate occasions, according IDPH quarterly reports. Each instance involved a portion of the code detailing minimum procedural guidelines for general nursing care.

After the report, the Grove submitted a mandatory Plan of Correction to the IDPH. The plan said an audit conducted by the director of nursing on July 22 found all physician notifications regarding change or decline in condition to be complete. The facility also trained staff to comply with physician notification requirements that day, according to the plan.

“Administrator or designee will conduct random (Quality Assurance) audits of five residents once a week for the next two months (starting July 22) to ensure facility’s compliance regarding physician notification,” the Plan of Correction said. “The results of the monitoring will be shared at the QA meeting for review and follow up.”

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