Editorial: Change at River Bluff must start at top

As a whole, Winnebago County Board members must really believe voters are deaf, dumb, blind, stupid, born under a rock yesterday when it comes to River Bluff Nursing Home, Winnebago County’s 304-bed nursing facility on North Main Street between North Towne Mall and Sportscore 1.

What does the County Board really hope to accomplish by commissioning a five-member investigative panel that consists of two members who sat on the original River Bluff Nursing Home Task Force in 1999?

After allegations of abuse, neglect and mismanagement at River Bluff Nursing Home were raised by former River Bluff Admissions Coordinator Diane Bergquist at a July 14 Winnebago County Board meeting, the Board composed an investigative panel consisting of the following five members: Former Winnebago County Deputy Administrator and Board member Judith Barnard; River Bluff volunteer Lorraine Sachs; Rockford Health Council Executive Director Ray Empereur; County Board member Phil Johnson (D-8); and County Board member Ray Graceffa (D-7).

Barnard and Sachs both served on the original task force in 1999. This “new” 2005 investigative panel will probably submit more of the same empty suggestions to River Bluff administrators that the 1999 task force submitted. And, as was done with the 1999 executive summary, many of the suggestions will probably go unheeded by River Bluff administrators.

Unfortunately, the task force’s June 25, 1999, executive summary provided no guidelines for compliance. Therefore, the nursing home was not bound to follow through on any of the task force’s recommendations. Today, the nursing home has failed to make good on a majority of the summary’s suggestions, which included the following: that there be a review of the 1977 court order that forced the nursing home to give preference to those receiving Public Aid, that alternative sources of investment be reviewed, that a foundation and memorial program be established, that the home continue to lobby the state to increase the state Medicaid reimbursement level, that the home consider increasing the nursing home tax rate, and that the home seek support from private nursing homes.

The Winnebago County Board’s commissioning of another investigative panel of River Bluff is unacceptable. It’s time to start making real change at the county nursing home, not just tired suggestions made by the same tired committee members. The alleged neglect, abuse and mismanagement are real. Just listen to what some of the following former and current River Bluff staff members have been quoted as saying in articles published in The Rock River Times and letters sent to the newspaper since 2003:

Karen Martinez, licensed practical nurse (LPN) at River Bluff for 15 years: “There’s always been a clique out there. Between the staff, there’s more socializing as opposed to taking care of the people.”

Husband and wife Doug and Robin Albright (Robin Albright worked at River Bluff for 16 years as a registered nurse (RN) and unit coordinator before being fired for what she alleges was reporting wrongdoing):

“The people that report wrongdoing are the ones that were penalized,” Doug Albright said.

“They single out certain people,” Robin Albright added. “I was there for 16 years…I had every intention of staying.”

Jill Lund, former food service director at River Bluff: “One thing you notice is that Janice [Shelton, a part-time Certified Nursing Assistant (CNA) at River Bluff at the time] does the job she’s supposed to as a union steward, and the others sort of cower down to what the management says. And that’s why she was not hired as an LPN because she would report on the wrongdoing. I wasn’t terminated out there, but I was very much persuaded, and I know that if I hadn’t left when I did, I would have been terminated.”

Diane Bergquist, former admissions coordinator at River Bluff for three years: “The current administration has no integrity, nor does it know the definition of professionalism. Worst of all, they have no compassion and no heart for the nursing home residents. If the resident requires little care, he or she becomes a favorite. If the resident is difficult, he or she is chastised, neglected, threatened, abused, etc.”

Excerpts from a letter sent by an anonymous River Bluff staff member in April 2003: “There is so much wrongdoing in this nursing home and it’s coming from administration. … Staff is underpaid and residents are being mistreated. … In the last five years, there has been a major change in this facility and it’s because of management misusing money by putting private-pay over Medicare, Medicaid. … Speaking of drug abuse, if there was random drug testing, this facility, would be empty. We need random drug testing and criminal background checks. … Old hands have no chance. We’re the ones they love to get rid of and, yes, they do work on you, and if you’re a troublemaker your name is passed around.”

It must be noted that there have been many more conversations with current staff at River Bluff, but many refuse to go on the record because they say they fear retribution by administration. Staff members have also alleged that some staff have been seen smoking cigarettes in patients’ rooms, using drugs or alcohol on the job, and avoiding and mishandling patients. When confronted with many of these allegations, administration claims no knowledge.

As River Bluff Nursing Home Administrator Phyllis Schwebke said in a February 2003 interview: “If those things are happening, obviously they’re not going to do that under my nose. So if someone suspects that or sees that, one way to correct that is to come to me.”

Obviously, staff members would not do such things under the administrator’s nose. But it is the administrator’s job to investigate such situations when they arise, and according to many current and former staff members, that often has not been happening. In fact, many allege that those who do exactly what Schwebke requested and report wrongdoing, are often punished for reporting the wrongdoing. This is unacceptable.

Change is needed at every level of River Bluff Nursing Home, and, as with anything else, the change must start at the top.

Schwebke has served as administrator of River Bluff Nursing Home since 1995. Many residents and staff have described her as a nice person. As Rockton resident Ella Langhoff recently described in a July 27-Aug. 2, 2005, guest column: “Regarding Phyllis Schwebke, I am amazed at how she knows each resident and their family. I don’t know how she does it. If she wasn’t a caring administrator, she would not know each resident and how they are doing.”

Such care was evident in a February 2003 tour The Rock River Times took of River Bluff Nursing Home. Schwebke greeted many residents by first name. One in the special needs room even said to her, “Thanks, thanks, thanks, thanks, thanks.” Others seemed to greet her with warm regards.

Although a nice person, Schwebke is not necessarily an effective administrator. When asked in 2003 how she would deal with a clique atmosphere, her response was: “Remember how it was in high school? I’ve worked in a number of environments in my career. Health care is like my last stop. This is a predominantly female environment. And maybe it’s not that, but women do form their own alliances, and sometimes they’re aligned against another group. And I think that has happened. And I think that it’s not unlike high school. And, as a manager, how do you make that better? I don’t know how you address that exactly.”

How is this effective administration? Schwebke’s inability to dissolve the clique atmosphere continues to foster a poor work environment for the staff at River Bluff. The County needs to put someone in place who knows how to deal with such a situation.

Although some positive programs and initiatives have taken place under Schwebke’s watch, since taking over administration of the nursing home in 1995, the county-run home has struggled with staffing shortages, low staff morale, employee strikes, financial difficulties, alleged stealing of River Bluff
funds by the home’s bookkeeper, lawsuits, poor Centers for Medicare & Medicaid Services (CMS) reviews, and alleged Medicare fraud. All of this is unacceptable, and it is shocking the County Board has not yet held River Bluff’s top administrator accountable for the nursing home’s poor track record.

In November 1998, the nursing home had to pay a $9,555 fine to state and federal agencies for a mistake that led to the death of a resident. Today, River Bluff is again fighting another wrongful death lawsuit, now the second one to be defended on Schwebke’s watch. The lawsuit was filed in 2001 by Lisa A. Johnson on behalf of Rita A. Tinkham, a former River Bluff resident. The 12-point lawsuit alleges Winnebago County and River Bluff failed to properly address issues concerning Tinkham’s fall from a wheelchair on March 22, 2001.

David F. Monteleone of the Rockford law firm Schirger, Monteleone and Hampilos, P.C., alleged that as a result of the fall, Tinkham “developed complications associated with [a] hip fracture, which led to her death on July 4, 2001.”

The latest CMS reviews, conducted between March 11, 2004, and March 28, 2005, show things are getting worse at River Bluff Nursing Home. In an April 25, 2002, CMS review, River Bluff had five deficient areas with a level of harm rate of two on a scale of four. The state average for deficient areas both at that time and today was six, and the national average was seven. The latest CMS reviews reported River Bluff had 11 deficient areas with a level of harm rate of two on a scale of four and one deficient area with a level of harm rate of one. That’s more than twice as bad as it was in 2002.

Specifically, CMS reported River Bluff failed to do the following: “1. Give professional services that meet a professional standard of quality. 2. Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. 3. Provide activities to meet the needs of each resident. 4. Give each resident care and services to get or keep the highest quality of life possible. 5. Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. 6. 1) Develop a complete care plan within 7 days of each resident’s admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident’s family or representative; or 3) check and update the care plan. 7. Develop a complete care plan that meets all of a resident’s needs, with timetables and actions that can be measured. 8. Develop a complete care plan that meets all of a resident’s needs, with timetables and actions that can be measured. 9. Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident’s physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged. 10. Provide services to meet the needs and preferences of each resident. 11. Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in a resident’s physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged. 12. Hire nurse aides who have completed required training and shown that they are skilled.”

When compared with state and national averages, the CMS review revealed the following with regard to River Bluff:

Average number of residents: River Bluff 258; Illinois 105; U.S. 95.3;

RN minutes per resident per day: River Bluff 31; Illinois 36; U.S. 30;

LPN/LVN minutes per resident per day: River Bluff 31; Illinois 30; U.S. 42;

CNA hours per resident per day: River Bluff 2 hours, 1 minute; Illinois 2 hours; U.S. 2 hours, 18 minutes; and

Total number of nursing staff hours: River Bluff 1 hour, 2 minutes; Illinois 1 hour, 6 minutes; U.S. 1 hour, 12 minutes.

The CMS report and information about River Bluff and nursing homes in the county can be found at www.medicare.gov.

In January 2005, a River Bluff bookkeeper was arrested and charged with allegedly stealing more than $172,000 from the nursing home. Her supervisor was forced to resign. River Bluff is also tied to a lawsuit filed by Robin Albright against Winnebago County alleging her Jan. 10, 2003, termination from River Bluff Nursing Home violated The Family and Medical Leave Act of 1993.

The County needs someone who is both a caring person and an effective administrator. Schwebke is about half that. Staffing shortages, low staff morale, financial difficulties, alleged stealing of nursing home funds, lawsuits, poor CMS reviews and alleged Medicare fraud are signs of someone who is not an effective administrator. The County deserves better, and it’s time for the County Board to step up and fight for the voters who put them in office. We can no longer settle for the untrue characterization put forth by Schwebke and others that River Bluff is “among the best of the worst.” As the CMS reviews show, River Bluff is not even close to being among the best of the worst. In fact, River Bluff is actually about twice as bad as the national average. Winnebago County deserves better.

If the Winnebago County Board thinks it can smile its way through another “investigation” of River Bluff as it did in 1999 when the River Bluff Nursing Home Task Force’s executive summary called for changes but provided no guidelines for compliance, it better think again. The time for change is now. Otherwise, those in Winnebago County might as well mark their calendars for the next River Bluff investigation in 2011. Current Winnebago County Board members won’t need to worry about that investigation, however, because voters surely won’t waste their votes on electing the same ineffective batch of County Board members.

From the Aug. 10-16, 2005, issue

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