JACKSONVILLE - State officials have fined Golden Moments Senior Care Center $50,000 for poor care connected with the Oct. 3 death of a 74-year-old resident who choked on food.
Adam Waeltz was developmentally disabled and known to be at risk of choking on food, but wasn't fed a proper diet, according to an inspection report from the Illinois Department of Public Health.
Waeltz often ate or drank too fast and should have been closely supervised while in the dining room. He had no teeth and should have received ham that was ground up. But on Oct. 3, he was given ham that had been torn into pieces, the report said. He collapsed and died.
The Morgan County coroner, who pronounced Waeltz dead at the nursing home, found ham pieces and mashed potatoes from Waeltz's mouth lying next to his body.
An autopsy found a wad of ham pieces the "size of a tangerine" in Waeltz's windpipe.
Coroner Jeff Lair filed a complaint with Public Health that triggered the state's investigation.
The nursing home is fighting the fine and has requested a hearing, Public Health spokeswoman Melaney Arnold said. Golden Moments administrator Christopher Robb didn't return a phone call Tuesday.
The nursing home, at 1021 N. Church St., recently agreed to pay a $6,500 fine to settle a different case.
The facility originally faced $20,000 in state fines connected with allegations that a nurse's aide displayed "a pattern of abusive behavior toward residents" in April and May. The fine was reduced as part of an agreement between the state and Golden Moments.
The aide, Jessie L. Ross, has since been fired, but she is fighting the state's attempt to have her declared an abuser on the Illinois Health Care Worker Registry. If the state is successful, Ross would be permanently banned from working in the long-term care industry in Illinois.
$10,000 cap bypassed
A ruling almost a year ago by Sangamon County Circuit Judge Leo Zappa limited the flat fine that could be issued by the state for each major violation to $10,000. But the Illinois Department of Public Health has begun to issue multiple violations - each carrying a $10,000 fine - instead of one fine to get around the $10,000 limitation in some cases.
That's what happened with the fines against Golden Moments, a 113-bed nursing home. Multiple "Type A" violations, each carrying a $10,000 fine, were cited in the choking death case and the case involving the nurse's aide.
Some nursing homes have complained when multiple $10,000 fines have been issued in connection with a single Public Health inspection, Arnold said. Those facilities have claimed the department lacked statutory authority to issue total fines exceeding $10,000.
That argument hasn't succeeded when nursing homes fought the fines through administrative channels at the department, Arnold said. Those cases haven't been taken to court.
Public Health is asking the Illinois Appellate Court to overturn the $10,000 cap. Even though the department occasionally has issued multiple fines to get around the cap, Arnold said Zappa's ruling has had a ripple effect and led to a decrease in total state fines last year.
The department issued $1.95 million in fines in 2009, compared with $2.6 million in fines in 2008.
Too focused on fines?
The nursing home industry welcomed the $10,000 cap. The state has focused too much of its efforts on fines in the past, according to Terry Sullivan, regulatory coordinator for the Health Care Council of Illinois, the public-policy arm of the state's nursing home industry.
Sullivan said he's uncertain whether the $10,000 cap or the change of administrations played a role in the declining amount of fines. Gov. Pat Quinn replaced Gov. Rod Blagojevich in January 2009.
Sullivan added that he disagrees with Public Health's practice of issuing multiple $10,000 fines connected with a single inspection.
"We are on the opposite sides of a legislative and public policy discussion," he said. "I don't think more and more fines improve care."
Dean Olsen can be reached at 788-1543.
*The charge: A developmentally disabled nursing home resident choked to death after being given a meal that included chunks of ham instead of ground ham, according to Morgan County Coroner Jeff Lair.
*The penalty: Illinois Department of Public Health found Golden Moments Senior Care Center of Jacksonville guilty of Five "Type A" violations. The home was fined $10,000 for each violation.
*The legal debate: A judge has ruled that IDPH can fine violators no more than $10,000 per incident. IDPH, however, has begun to issue multiple violations in some cases.
