Nursing Homes With Histories Of Infection-Related Problems Lacked Transparency As COVID-19 Outbreaks Spread
By Dave Savini and Christopher Hacker
CHICAGO (CBS) — Certified nursing assistant Tainika Somerville has seen a lot during her 20-year career, but she said nothing compares to what happened during this pandemic.
As her patients at the Bridgeview Health Center nursing home began to fall ill, she said the home's management failed to respond quickly enough to the growing outbreak.
"We had a lot of residents who were laying in bed with 103, 102 degree temperatures and they were just treating them as if they had pneumonia and that was it," Somerville told CBS 2. "Nobody was tested."
At least 46 residents and staff there have now tested positive for COVID-19, and 16 residents have died. But Somerville said she and her colleagues didn't find out about the deaths from the nursing home's management. Instead, she said, they heard it on the news. And in March and April as the pandemic was growing, Somerville said workers weren't given proper personal protective equipment (PPE).
Things eventually got so bad in early April that she felt she had to do something.
"Call me a whistle blower, I don't care," Somerville said in a video posted to Facebook. "But the state needs to know whats going on in these nursing homes."
Two nursing homes with the same owners — Bridgeview Health Center, where Somerville worked, and Woodbridge Nursing Pavillion in Chicago — have a combined 258 COVID-19 cases and 44 deaths. Now both are facing allegations by families of loved ones that they weren't transparent as the outbreaks spread — and nursing home staff like Somerville are speaking out.
Somerville said she and her coworkers were "panicking" because of what was happening to residents who fell ill with the virus. Many patients were kept at the nursing homes until they were so sick they had to be transferred to area hospitals, according to Sommerville. It was at those hospitals that residents were finally tested for COVID-19 — and where some eventually died.
One of those residents was James Zbonski.
In March, Bridgeview Health Center was on lockdown, closed to visitors to prevent them from bringing the virus into the home. But the virus was already there, and it had infected Zbonski.
Zbonski's step-daughter, Tina Meskill, said she had no idea. Despite having power of attorney over Zbonski, she said she wasn't told until late March that he had a soaring fever and wasn't eating or drinking for days. Meskill said the home waited until Zbonski was unresponsive before sending him to the hospital, where he ultimately tested positive and died.
"They had one job and one job only: to make sure their residents are safe and taken care of," Meskill said. "And I feel like they did not do that. They did not follow proper protocol."
Somerville agreed. In early April, she and other nursing home staff decided they'd had enough, and marched into the nursing home's main office, demanding transparency about the outbreak. They asked for more staff, better safety measures and sick pay for staffers who fell ill with symptoms of COVID-19.
"What about us?" Somerville said in a Facebook Live video. "While you sitting on your yachts, we're here in Bridgeview."
Courtesy of Tainika Somerville
Two days later, management responded. They fired Somerville.
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Meanwhile, another facility, Woodbridge Nursing Pavillion in Chicago — which is under the same owners as the Bridgeview Health Center — was experiencing an outbreak of its own.
Madelyn Feliciano said she and her sister wanted to make sure their parents, both of whom lived at Woodbridge Nursing Pavilion, were safe there when the nursing home went on lockdown in March because of the pandemic.
Feliciano said she asked "repeatedly" whether there were any cases at the nursing home, but staff denied there were.
Woodbridge is now reporting 28 COVID-19 deaths and 212 positive cases.
Both of Feliciano's parents contracted the virus in late April; her mother, Genoveva Feliciano, died five days after getting sick. She was never taken to the hospital.
"She meant the world to me," Feliciano said. "Of course. She's our mom."
Feliciano said she and her sister were devastated by how their mom was treated. She said her mother, who was recovering from a stroke, seemed otherwise healthy before contracting COVID-19. She also said the facility should've taken her to a hospital for more advanced care.
"I lost my mom," Feliciano said. "We lost our mom. She could've lived longer."
The CBS 2 Investigators found the Woodbridge Nursing Pavilion has a history of problems with care of residents. CBS 2 searched Medicare records and found 50 deficiencies for not meeting medicare health standards at the home during the past three and a half years. In fact, out of 700 nursing homes, Woodbridge is in the top 15 percent for homes with the most deficiencies statewide.
Medicare, which oversees nursing homes, uses the term "deficiency" when inspectors determine a facility failed to meet its standards.
Nursing Homes With Infection-Related Deficiencies
Infectious disease-related deficiencies at Illinois nursing homes are surprisingly common. Use this map to explore homes in the state that have been cited at least once.
In one inspection report from April 2019, inspectors said Woodbridge Nursing Pavilion "failed to implement an infection prevention and control system of surveillance to identify and analyze trends within the facility and prevent infections," adding that the deficiency "has the potential to affect all 212 residents residing in the facility."
Click here to view a list of all nursing homes with infection-related deficiencies.
At the Bridgeview Health Center, CBS 2 found a similar history. The nursing home was cited for five infectious disease-related deficiencies in the last three and a half years — among the top 5 nursing homes in the Chicago area with the most deficiencies for failing to meet medicare disease control standards.
At least one of Bridgeview Health Center's previous infection-related deficiencies was related to an outbreak of scabies — an itchy rash caused by a parasitic mite that lays eggs below the skin's surface.
Now, both Meskill and Feliciano have hired legal representation. Meskill is now being represented by Chicago law firm Levin & Perconti; Feliciano has hired Hart McLaughlin & Eldridge, another Chicago firm.
In a statement emailed to CBS 2, a spokesperson defended the actions of both homes.
"As soon as Bridgeview receives confirmation that a COVID test is positive, the facility notifies the resident and their family member," the spokesperson said, referring to Bridgeview Health Center. "If a resident's condition declines, the resident's family is notified of the change in the resident's medical condition. If the resident passes away, the residents loved ones are notified immediately."
Read their full responses to our questions:
Bridgeview – Attributable to Martha Peck, Administrator for Bridgeview
Regarding Family Claims
We are unable to comment further due to any pending legal action taken by the family.
Regarding Former Employee
While we do not get into specifics about terminated personnel, we require each of our staffers to commit to behavior that prioritizes the safety, welfare and comfort of our residents and employees. We have also not disciplined anyone for raising concerns about their safety. Indeed, we provide a number of avenues for employees to voice their concerns; this individual took none of them.
As a general matter, we take strides in protecting our vulnerable resident population and workforce – oftentimes at great expense. Further, our on-duty staff are regularly kept abreast of any changes in COVID at the facility and it is probable that this individual was unaware of these updates due to her being on leave for the last half the month of March.
Regarding Surveys & Inspections
Infectious disease specialists have developed a comprehensive Infection Prevention program under the guidance of the facilities. Our Infection Prevention team includes a physician and a nurse practitioner who specialize in infectious disease. A year ago, the facility had some residents exhibit suspicious rashes; 3 of these residents were confirmed to have scabies. Under the guidance of the facility infectious disease specialist the residents were treated, and the situation was resolved. No further such rashes have occurred. Bridgeview continues to work closely with our infectious disease nurse practitioner and physician to maintain a very through infection prevention program.
Regarding Recent Numbers
We have had 37 positive resident cases, 7 of which were asymptomatic. To date, 8 have fully recovered. We grieve for the 16 residents who have succumbed to this terrible disease.
With respect to employees, 9 have tested positive, of which 3 have fully recovered. We have had no employee deaths.
Regarding Communications on Positive Cases
At the end of March, the only way we were able to get testing is if residents had symptoms that required a higher level of care. The residents then were transferred to local hospitals, where they received testing if medical personal at the hospital thought they met criteria. As of April 21st, we were able to submit a request to IDPH for testing. We have since been able to require & administer tests at the facility if needed. We were notifying families under the recommended IDPH guidelines. However, in late March, the difficulties we were having initially were that we sometimes were finding out from families that their loved one tested positive while at the hospital. We were not receiving notification from the hospitals to confirm positive test results to us on our residents. Those early communication issues led to significant confusion and made notification of families & staff of positive cases impossible.
We now we have better access to testing & improved communication with hospitals regarding positive COVID-19 cases. Bridgeview Health Care Center rolled out a new text-based notification program for next of kin to enroll in. Our goal is to provide loved ones the information they need regarding positive COVID-19 cases at our facility and increase the overall communication they are receiving. We implemented this program at the end of April and received positive feedback from our resident's loved ones.
Regarding Communication with Families
Bridgeview communicates with residents and their families throughout the week. This communication takes many different forms, including bringing the resident to the lobby to visit with their family members through the glass doors. Staff will also answer questions at that time. Families are notified via phone, email, text, push notifications, to mention a few. Family members are free to contact the facility at any time to discuss their loved ones. Also, a weekly letter is sent to all families, which includes an update and review of COVID status in the facility and the facility's measures, including if there is a change in the facility's normal routine or development of a new program.
As soon as Bridgeview receives confirmation that a COVID test is positive, the facility notifies the resident and their family member. If a resident's condition declines, the resident's family is notified of the change in the resident's medical condition. If the resident passes away, the residents loved ones are notified immediately.
Woodbridge – Attributable to Patricia Correa, Administrator for Woodbridge
Regarding Family Claims
Woodbridge Nursing Pavilion had been in contact with the family for Mr. and Ms. Feliciano regarding their care at the facility. The family was notified of Mrs. Feliciano's positive COVID case on 4/27/2020. Woodbridge staff provided additional updates to the daughter and also conducted a FaceTime call with parents on 4/29/2020. The Woodbridge staff consulted with the daughter regarding her mother's further decline through the Woodbridge staff and the Nurse Practitioner during her stay at the facility. We are unable to comment further due to any pending legal action taken by the family.
Regarding Deficiencies
Concerning the 50 deficiencies cited from 2017 to the present, only 20 were related to resident quality of life and care. Of those 20; 2 citations were scored at few residents involved for actual harm, and 18 citations were scored for minimal or potential for actual harm. In 2020 to date, there has only been 1 citation for potential harm. The facility has corrected all deficiencies at the time of its occurrence.
Regarding Recent Numbers
Woodbridge Nursing Pavilion can confirm we have had 146 residents test positive for COVID-19, 5 of those were admitted COVID positive. We are happy to report that 22 of those 146 residents have already recovered. We are anticipating another 15 additional resident recoveries this week. And of those residents who remain ill with COVID, 46 are asymptomatic.
We also are happy to report that due to our aggressive mitigation approach, we have had no new resident COVID cases for the past two weeks.
It is with a heavy heart that we can report we had a total of 28 resident deaths due to COVID-19. To date, we have had 66 employees test positive for COIVD, of which 52 have recovered.
We have had no employees pass away due to COVID. With respect to the IDHP website, the high number of positives cases combines both residents and employees.
Regarding Communications on Positive Cases
We requested through the city of Chicago the ability to test our entire resident and staff population. We expected these numbers to be high by mid-April, and at the time we were seeing our first positive cases at Woodbridge we were learning more about the spread of asymptomatic carriers.
Still, even before our first positive case, we put any residents that had respiratory symptoms in droplet precautions. The whole facility went into droplet precautions by April 22nd, 2020, the same day we received the state-issued tests. Our aggressive approach allowed us to determine who was asymptomatic-positive and allowed us to treat and isolate residents better. Many facilities in Chicago have not yet taken this step, but we saw this as path to better managing a COVID outbreak. As you can see from the sheer numbers of our asymptomatic positive cases, the numbers speak for themselves and show that this virus unlike anything we have ever seen. Testing your entire staff & resident population is the best way to manage any COVID cases at a facility level.
Regarding Communication with Families
Woodbridge communicates with residents and their families throughout the week. This communication takes many different forms, including bringing the resident to the lobby to visit with their family members through the glass doors. Staff will also answer questions at that time. Families are notified via phone, email, text, push notifications, to mention a few. Family members are free to contact the facility at any time to discuss their loved ones. Also, a weekly letter is sent to all families, which includes an update and review of COVID status in the facility and the facility's measures, including if there is a change in the facility's normal routine or development of a new program.
As soon as Woodbridge receives confirmation that a COVID test is positive, the facility notifies the resident and their family member. If a resident's condition declines, the resident's family is notified of the change in the resident's medical condition. If the resident passes away, the residents loved ones are notified immediately.
