State regulators have cited a troubled Chicago facility for disabled children in yet another death, this one involving a 14-month-old girl.
Authorities concluded that staff at Alden Village North waited two days to contact the girl's doctor when test results in July showed signs of a serious infection. After the doctor was reached, the girl was sent to a hospital, where she died within hours.
Regulators also cited Alden for 21 additional violations, including failing to investigate allegations of neglect and not taking children on outings for months at a time — problems that have plagued the facility in the past.
Alden has been under fire since October, when a Tribune investigation revealed a high number of deaths at the home and the worst safety record in Illinois for facilities of its kind. The girl's death brings to 14 the number of children and young adults who have died at the home since 2000 in cases that resulted in state citations.
The Illinois Department of Public Health finished investigating the girl's death last week, an agency spokeswoman said. About 90 people live at the North Side facility, most of them children and young adults with severe or profound cognitive impairment.
"We care for a very fragile patient population who suffer from very serious medical conditions," Alden Management Services, which oversees the facility, said in a statement Monday. "Our residents are like family to us and we grieve whenever one of them passes. We continually evaluate the care that we provide to all of our patients to see if there are areas for improvement."
State inspection records show that the 14-month-old girl, whose identity was not disclosed, suffered from heart ailments and a seizure disorder. On the morning of July 3, test results showed she had "heavy growth" of
, or methicillin-resistant Staphylococcus aureus, a kind of staph bacterium that is resistant to some antibiotics. Yet her doctor was not notified until the evening of July 5.
The girl arrived at a hospital with a temperature of 105.4 degrees and a pulse of 180. She died the next day of septic shock, a drop in blood pressure brought on by infection.
While investigating the girl's death, state inspectors learned that another Alden Village North resident, a 14-year-old boy with profound mental disabilities, was also sent to the hospital in July after a lengthy delay.
Records show that after the boy began breathing rapidly, Alden staff paged his doctor six times over 19 hours before the physician responded. In citing the facility, regulators concluded that the home should have contacted its medical director instead of waiting for the doctor to respond.
The teenager died two months later, but records do not state whether the delayed trip to the hospital was a factor.
Though inspection records do not name the boy, his stepfather, David Noe, contacted the Tribune and identified him as Stephen Pruitt. Both the stepfather and the boy's mother, Shirley Noe, told the newspaper they think a lack of care at Alden hastened Stephen's death.
"The bottom line is I think they were inattentive to him," David Noe said.
Shirley Noe, of downstate Wood River, said she was planning to visit her son the weekend he died. "He had the prettiest smile," she said. "If he could laugh out loud, he would."
Last month, Floyd Schlossberg, president of Alden Management Services and operator of the Alden nursing home chain, said in an interview that Alden Village North had improved since he acquired it in 2008.
But eight of the 14 deaths resulting in citations have occurred since he took over.
And the 21 violations found in the public health department's most recent annual inspection of the facility are double the number typically found before Schlossberg became its operator. From 2005 to 2007, nine violations were found on average during annual checks. Since Schlossberg took over, the average has been 25.
Alden Management Services said in its statement that the most recent annual inspection "showed that we continue to improve the care that we provide at Alden Village North. … We will evaluate each finding and look for ways to improve."
The latest annual review took place in December, though some violations involved incidents that occurred months earlier. Inspectors frequently spot older violations when reviewing patient records.
One citation was for not thoroughly investigating two allegations of abuse and two allegations of neglect.
The guardian of a 14-year-old blind girl alleged in November that the child had such poor hygiene that she had to be bathed at school. Yet the facility did not follow up, the inspection report states.
In another case, a 19-year-old resident who breathed with the aid of a ventilator complained to staffers in February that "he was dropped on the floor on his back." Again, the allegation wasn't fully investigated, inspectors wrote.
The teen died the following month, though inspection records do not state the cause.
Inspectors also checked the files of 10 residents and found that the facility rarely took any of them on outings. One 11-year-old boy with profound mental disabilities had been to a park once in June and once in July but nowhere else for the next five months.
The facility now has been cited six times in the last three years for not providing enough activities or outings.
Bob Molitor, chief operating officer of the Alden chain, said in an interview in December that the facility had recently stepped up activities, including trips to the
Asked to explain the most recent violation, Alden did not respond.
Other violations in the latest inspection included nurses making or about to make mistakes while administering medicine to several children, the facility not fixing two residents' wheelchairs and staffers allowing two residents to develop bedsores, a painful condition that can occur when immobile patients are not frequently repositioned.
Meanwhile, in a separate regulatory action, state monitors have been visiting the facility several times a week since October, when
ordered the additional scrutiny in response to the Tribune articles.
The two monitors — a registered nurse and a licensed social worker contracted by the state — spend much of their time observing interactions between residents and staff. According to their reports, copies of which were obtained by the Tribune, the monitors have not observed any serious problems.
But they have noted an unusual number of Alden corporate officials at the facility, with one monitor writing: "I wonder how the facility operates when staff from corporate are not present."
In fact, on the day monitoring began, Molitor greeted the monitor at the facility. According to the monitor's report, Molitor said there was no "legal reason" for monitoring because the home was in compliance with the rules. Nonetheless, he said, the facility would cooperate. "He also mentioned," the monitor wrote, "that he 'knows the governor.'"
In an interview with the Tribune, Molitor said he recalled greeting the monitor but not making those comments. He said he did not know the governor.