Half of Illinois' best nursing homes -- those rated four or five stars by the federal government -- have been cited at least once since 2001 for misusing psychotropic drugs, and some violations involved injuries and deaths, the Tribune has found.
The findings underscore the pervasive nature of the problem and the difficulty consumers face when evaluating nursing facilities.
Lake Forest Place is a five-star facility that features lush lawns, flowering gardens and 49 wooded acres in north suburban Lake Forest. Yet it was cited in 2003 for improperly using or monitoring psychotropic drugs given to six residents, state health inspection records show.
One 95-year-old man was given the antipsychotic drug Zyprexa even though he displayed no psychotic behaviors. "He is so sweet," one facility official told inspectors. "He's a gem."
The next year, the state cited the facility for administering psychotropics to three residents without adequate justification or proper consent. An 89-year-old man was on an antipsychotic medication without cause and on a sleeping pill at a dosage over recommended limits, records state.
"His private caretaker was present and was trying to awaken him," inspectors wrote in a report. "He would not wake up."
Lake Forest Place spokesman Robert Werdan said the violations were not characteristic of the quality of care that the facility consistently provides. As a nonprofit run by Presbyterian Homes, "we're not in the nursing business per se and certainly not here to make a profit. It's all about resident care."
At the five-star Hickory Nursing Pavilion in southwest suburban Hickory Hills, a resident had the dosage of her psychotropic drug doubled the same day she complained to staff about people smoking on the bus that was taking her to an outside program.
"The doctor came to see me for one minute, then left," she told inspectors. "Next thing I know he was increasing my medication."
The state cited the home for increasing the dose without reason. Contacted by the Tribune, the facility declined to comment.
Some highly rated homes have been ignorant of the risks of psychotropics, records show. Nurses at a four-star home near Peoria were unaware of a test that can check residents for tics and tremors. At a four-star facility a few miles away, staff was aware of the test but did not know to administer it. Staff wrote on the file of one resident with involuntary movements: "Unable to assess due to inability to comprehend instruction."
Deaths involving psychotropics have occurred at highly ranked homes, including the four-star Wauconda HealthCare and Rehabilitation Centre in Lake County, where in 2000 a woman died after having trouble breathing for three hours, records show. The state cited the home for not promptly calling the doctor and for giving her the anti- anxiety drug Xanax while she was experiencing shortness of breath. The emergency room doctor told inspectors the drug decreases the respiratory rate and worsens air exchange.
In an interview, Wauconda spokeswoman Cheryl Morris acknowledged the home did not properly assess the seriousness of the woman's illness. But she said that because the patient had a history of anxiety attacks, it made sense to give her an anti-anxiety drug -- her normal medication -- when she had trouble breathing. She said regulators were "piling on" when they cited the facility for use of the drug.
At the four-star P.A. Peterson Center for Health in Rockford, a man on multiple psychotropics in 2002 became increasingly lethargic, records show. Without informing the man's doctor, staff withheld the drugs for several days. The man worsened and died.
According to a state inspection report, the doctor said that when he learned the drugs had been withheld, he told a staffer: "You cannot just stop giving medication, even if someone is comatose. They will go into withdrawal." The report indicated the man died of dehydration, kidney failure and low oxygen in the blood.
When the state cited the home, the facility appealed the violation but lost. To prevent future problems, the home agreed to train staff and change policies about contacting physicians.
"That was a very isolated case," said Peggy Holt, the facility's administrator. Nothing like it has happened since, she said.