July 11, 2014

Nursing Home Fined Over $22K after Unsupervised Resident Dies While Eating

The New York State Department of Health (DOH) fined Glengariff Health Care Center, a 262-bed facility located in Glen Cove, New York, $22,879 for numerous deficiencies that contributed to the death of a 65-year-old resident. The affected resident had suffered from a stroke and was also diagnosed with multiple sclerosis and dysphagia, a medical condition in which a person has difficulty swallowing. Because the patient had difficulty with eating and swallowing food, his care plan called for aspiration precautions; such precautions identify patients who are at risk of choking and require that patients be supervised while eating.

On July 21, 2013, a certified nursing assistant (CNA) gave the resident his lunch tray around 12:15 p.m. The CNA then left the patient alone in his room to eat his meal. She stated that she always left the patient alone to eat and told a DOH investigators, "I let him eat alone; I don't remember hearing that it wasn't allowed." However, when the CNA returned a 1:00 p.m. to collect the resident's lunch tray, she found him slumped over in his wheelchair and foaming at the mouth. The CNA then notified a licensed practical nurse (LPN), who found the patient unresponsive and without a pulse. The LPN then summoned another nurse for assistance. The nurse quickly assessed the situation and left the room to announce a "code blue" over the intercom.

defib.jpgIn the meantime, the LPN transferred the resident to his bed with the help of an aide. A nursing supervisor arrived in the patient's room, but she quickly left to get a "crash cart." When the nursing supervisor returned to the room with the car, she then initiated CPR. She did not use an Automated External Defibrulator (AED), a device that administers electrical shocks to help restart a patient's heart. When 911 emergency personnel arrived, they used their AED in an attempt to save the resident, who was then transferred to the hospital. He died a short time later.

During an interview with DOH investigators, the Medical Director of the facility stated that he did not know about the nursing home's policies and procedures regarding CPR. However, the director did state that "any patient on aspiration precautions should always be supervised when eating." A DOH report concluded that staff members failed to provide CPR in a timely fashion and that the "Administration failed to develop and implement policies and procedures for CPR and aspiration precautions; failed to ensure staff were knowledgeable of when to initiate CPR." The facility was also cited for failing to conduct a thorough investigation into the resident's death.

According to the "Nursing Home Compare" website, the facility was rated as being much below average. The facility's health inspection records were also rated as much below average.

July 11, 2014

NYS Officials Warn the Elderly to Beware of Phone Scams that Spike During the Summer Months

According to the National Council on Aging, phone scams targeting elderly victims have become so prevalent that they are now considered the "crime of the 21st Century." The scams are often difficult to trace and are considered a "low risk" crime by fraudsters. Beth Finkel, Director of the AARP in New York, remarked, "It's estimated that fraud cost older Americans $2.9 billion in 2011 alone, and as society ages and people live longer this problem threatens to get worse."

To combat these phone scams, which usually spike during the summer months, Attorney General Eric Schneiderman warned potential elderly victims to beware of five common fraudulent phone calls. The first such scam involves a person who calls an elderly person and claims to be the victim's grandson or granddaughter. In some cases, the scammer will have obtained the grandchild's name from social media sites. In other cases, the scammer will trick the elderly person into giving the grandchild's name by saving, "Hey! It's me. You know who this is?" Once the elderly victim believes that the caller is his or her grandchild, the scammer will then state that he or she is in trouble and needs money immediately. The caller may say that he or she is going to be evicted or needs money to be bailed out of jail.

phone.jpgAnother scam involves a caller who claims to be an officer of the court. The caller will tell the elderly person that there is a warrant out for their arrest for failing to report to jury duty. To avoid arrest, the scammer will tell the elderly victim to send money via services such as Western Union. In one case, investigators were able to trace such a call to a Georgia prison.

Fraudsters may also claim to be with a governmental agency that assists people in claiming lottery winnings. The caller will state that in order to claim the prize, the "winner" must send money to cover taxes and administrative fees. In some instances, the caller will ask the elderly person for personal banking information in order to deposit the "winnings" into his or her account. The scammer will then use this information to make fraudulent purchases or withdrawals.

Scammers will often use electronic devices that will "spoof" their caller-ID information. For instance, their calls may come up on caller-ID as "Internal Revenue Service." In such cases, scammers will claim to be with the IRS. They will tell the elderly victim that he or she owes back taxes and must pay immediately to avoid being arrested. In a similar type of scam, callers will claim to be with a local utility company. The caller will state that the elderly person is behind on his or her utility bill and must send money immediately to avoid a service disruption.

Schneiderman advised senior citizens to hang up the phone immediately if they receive fraudulent calls.

July 11, 2014

N.Y. Health Inspectors: Nursing Home Failed to Provide Appropriate Care to Respiratory Patients Requiring Oxygen

In response to a complaint made in August 2013 against St. Luke's Home, a 202-bed nursing home located in Utica, New York, officials from the New York State Department of Health (DOH) determined that the facility failed to provide appropriate care to residents suffering from respiratory illnesses. One affected resident had suffered from a stroke and was in a vegetative state. The patient had a tracheotomy, was dependent upon a ventilator for breathing, and required constant oxygen. Despite these requirements, health inspectors observed that the resident was not receiving oxygen for most of the day and noted that the patient was wheezing and having difficulty breathing.

oxygen.jpgAnother affected resident was a quadriplegic who was dependent on a ventilator and also required constant oxygen. The patient had a portable ventilator and was able to use an electric wheelchair. During an event for the residents, the patient told a DOH inspector that his oxygen tank had run out. Several minutes later, a staff member assisted the resident and provided him with a new oxygen tank. A supervisor asked about the incident stated that the patient usually notifies a staff member if he runs out of oxygen. She stated that the facility had no formal system in place to perform routine checks of patient's oxygen tanks. DOH officials also observed a similar situation involving a resident suffering from COPD, a chronic lung disease.

During the course of the complaint inspection, health department officials also discovered that the facility made numerous mistakes involving patients' advance care directives. In one instance, a diabetic patient had indicated that she wanted to be resuscitated in the event of a medical emergency. Although the resident should have been wearing a green bracelet to indicate that she required CPR, health inspectors observed that she was wearing a blue bracelet, which indicated that the resident had a DNR in place. In another instance, a patient who had suffered from a stroke had also indicated that he wanted CPR in an emergency. The resident, was not wearing any bracelet, and the name plate outside of his room failed to indicate his advanced directives.

The facility was also cited for failing to provide patients with assistance for their daily living needs. One patient who was paralyzed was frequently incontinent and needed the assistance of two staff members to use her bed pan. While at the nursing home, health inspectors observed that the resident had asked staff members to help her go to the bathroom. However, staff members repeatedly ignored the patient's requests until she was finally helped after waiting for an hour. The DOH inspection report concluded that the delay was caused by lack of adequate staff. The report stated that the "facility did not ensure sufficient nursing staffing levels to maintain the highest practical level of well-being of each resident."

July 11, 2014

Albany Nursing Home Fined $25K for Failing to Treat Patient's Wound that Developed into Gangrene

The New York State Department of Health (DOH) fined the Teresian House Nursing Home, a 302-bed facility located in Albany, New York, $25,350 in November 2013 for failing to treat a patient's open wound that developed into gangrene. The affected resident was originally diagnosed with a thyroid disorder, high blood pressure, osteoporosis and peripheral vascular disease, a medical condition that makes patients susceptible to pressure sores. The resident's care plan stated that staff members needed to assess the patient's skin every shift.

On October 6, 2013, a licensed practical nurse (LPN) noticed that the resident had an open wound between the toes of the left foot. The LPN also noticed that the resident had a large bruise on the same foot. The LPN then notified the nursing supervisor about the patient's open wound. According to the nursing home's policy titled "Pressure Ulcer--Prevention & Care Planning," nursing supervisors are required to assess a patient who is reported as having an open wound. In addition, the nursing supervisor must notify the physician and create a "skin tracker" document to be placed in the patient's medical chart. However, after being told of the patient's wound, the supervisor failed to follow the facility's policy.

On October 18, 2013, twelve days after the resident's wound was discovered, a staff member noticed that the patient's left foot was red and foul smelling. The patient also had a fever. Staff members notified a physician, who ordered that the patient be transferred to the hospital, where the resident was diagnosed and treated for gangrene. An LPN stated that staff members failed to perform daily skin checks as required by the patient's care plan.

DOH investigators looking into the matter concluded that "The facility was unable to provide documentation that the resident's left foot was being monitored, assessed, or treated; or that the physician had been notified of the left foot." The DOH also cited the facility for failing to report the incident to them as a possible case of neglect.

wheelchair entrance.jpgAs a result of the survey, health inspectors also discovered that a dementia patient had eloped from the building. According to a DOH report, the patient was assessed as an elopement risk and was required to wear a Wanderguard, an electronic monitoring device that sounds an alarm if the patient exits the facility. On September 26, 2013, the resident was found by some visitors outside the facility. Although he was brought back into the building, his Wanderguard never went off. Per the nursing home's policy titled "Elopement Management Program," staff members must report cases of elopement within five days of an incident. However, an administrator told a DOH inspector that she did not report the incident because the resident never left the grounds of the nursing home.

July 11, 2014

N.Y. Nursing Home Failed to Provide Adequate Treatment for Suicidal Patient

Investigators from the New York State Department of Health (DOH) recently cited the Indian River Rehabilitation and Nursing Center, a 122-bed facility located in Grandville, New York, for failing to provide adequate treatment to a suicidal patient who died 18 days after being admitted into the center. The DOH report concluded that "the facility did not ensure that a resident who displayed mental or psychological adjustment difficulty received appropriate treatment and services to correct the assessed problem." In addition, health department surveyors concluded that the facility failed to address the nutritional needs of the patient, who lost 17.8 percent of her body weight over a short period of time.

The resident was admitted into the nursing home on February 4, 2014 and was diagnosed with congestive heart failure and memory difficulties. Upon admittance into the facility, the patient told staff members, "I want to kill myself." Staff members checked on the resident every 15 minutes, and a social worker determined that the patient did not have a "plan" to commit suicide. On February 16, 2014, a certified nursing assistant (CNA) was assigned to watch the resident in her room during the night. The CNA stated that the patient was extremely agitated. At one point, the resident stated that she wanted to kill herself and tried to choke herself with her hands. After trying to put her hand down her throat, the resident then began to bang her head against a table. When the CNA told a licensed practical nurse (LPN) about the resident's suicidal remarks and behavior, the LPN notified the nursing supervisor who decideded to give the patient anti-anxiety medication. The LPN told the supervisor that the medication usually had little effect on the patient, but the supervisor ordered it anyway. The supervisor never notified the physician about the resident's suicidal ideations, as is required by the facility's internal policies.

Even after receiving the medication, the patient was still agitated. When the CNA began pushing the resident in her wheelchair towards the bathroom, the patient quickly lunged herself forward and fell onto the floor and hit her head. The CNA immediately notified other staff members, who found the patient to be bleeding from her nose. The patient suffered a facial fracture as the result of the fall. DOH investigators determined that the "RNS [Registered Nurse Supervisor] did not assess resident when medication was not effective in managing behaviors. RNS did not follow facility protocol regarding suicidal ideation."

scale3.jpgIn addition, health inspectors determined that the nursing home failed to address the resident's significant weight loss over a period of 18 days. The resident weighed 165.8 pounds when she was admitted into the facility. On four occasions, staff members weighed the patient and documented that she was losing weight. On February 15, 2014, the resident only weighed 138.7 pounds. A dietitian stated that she was never notified of the patient's condition.

July 7, 2014

Upstate Nursing Home Fined $44K for Multiple Deficiencies Related to Poor Care of Residents

The Washington Center for Rehabilitation and Healthcare, a 122-bed facility located in Argyle, New York, was fined $44,000 in February 2014 for numerous deficiencies related to quality-of-care provided by the nursing home. The fine is the result of Department of Health (DOH) inspections conducted in 2011. Formerly known as Pleasant Valley, the Washington Center was recently taken off the federal government's Special Focus Facility program, a list of nursing homes throughout the country that have a history of providing poor care. While on the list, a facility agrees to implement changes to improve care. If the facility doesn't make the necessary changes, the facility may be shut down by the federal government.

During a DOH certification survey conducted in September 2013, the upstate nursing home was cited for several deficiencies. For example, the facility was cited for failing to "maintain an effective pest control program so that the facility of free of pests and rodents." Numerous residents and staff members complained that the nursing home was infested with flies, which often buzzed around residents' heads as they ate their meals. In addition, the nursing home was also cited for failing to provide care that met "professional standards of quality." For instance, one resident who had undergone a hip replacement sometimes complained of back pain. While her physician prescribed Tramadol, a painkiller, for the patient's back in the past, DOH inspectors discovered that a nurse administered the narcotic on three separate occasions without a doctor's order.

In addition, DOH surveyors discovered that a dementia patient was restrained in her chair for most of the day. According to DOH policies, a "resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience." According to the patient's care plan, the resident was required to sit in a special chair with a locking tray while eating meals. Because the tray locked into place, the resident could not get out of the chair and was effectively restrained. On numerous occasions throughout the day, a DOH surveyor observed that the patient was sitting in the chair with the tray locked into place. The resident was observed to be yelling loudly on these occasions. The Director of Nursing admitted that staff members should apply appropriate behavioral interventions before sitting the resident in the chair.

The nursing home received many more citations than most facilities in New York. On average, most New York nursing homes received 2.2 citations per 100 beds. The Washington Center received 24.5 citations per 100 occupied beds. Most of the citations were related to quality-of-care provided to the residents. Overall, the facility received an overall rating of below average.

July 7, 2014

Health Department: Low Staffing Levels Caused Medication Errors at Nursing Home

After conducting an investigation in April 2012, officials from the New York State Department of Health (DOH) concluded that the Mercy Living Center, a 60-bed facility located in Tupper Lake, New York, failed to employ enough nurses to administer medications to patients in a proper and timely manner. The DOH report stated, "The Administrator failed to have systems in place to ensure sufficient staffing was provided to ensure that the residents' medications and treatment were administered as ordered by the physician." The facility only employed one licensed practical nurse (LPN) per shift to administer medications and treatments to 40 residents. In some cases, patients required multiple visits per shift to receive numerous medications and treatment.

meds1.jpgOne LPN told a DOH investigator that she often failed to provide treatment to a resident who had a Stage II bedsore. In another instance, the DOH discovered that a resident did not receive 14 doses of his Parkinson's disease medication over a period of 20 days. The LPN who was responsible for the missed doses admitted that it "happens a lot." One patient suffering from COPD was prescribed nine medications which he was to receive every morning at 8:00 a.m. However, a DOH inspector observed that his medications were administered two hours late. The LPN who administered the late medication stated that she "gets to them when she can."

Several nurses stated that they complained to supervisors and administrators on numerous occasions that they needed more help to provide adequate care for patients. However, supervisors would often nod and simply say, "I know. I know." One supervisor told employees to "do the best you can." As a result of DOH survey, the facility is now required to have two nurses per shift to administer treatments and medications. If a staff member cannot come to work, the Nurse Manager or the Director of Nursing will be required to work the shift.

DOH inspectors also cited the facility for failing to inform physicians of significant changes to patients' statuses. For instance, one resident was diagnosed with dementia and psychosis. He had a history of making sexually inappropriate remarks towards staff members and residents. His care plan indicated that staff members needed to inform the physician if he exhibited any inappropriate behavior. Over a nine day period, numerous staff members noted that the resident's behavior was sexually inappropriate. In one instance, he kept telling staff member and residents, "I just want to touch and kiss you." In another instance, he was found kissing and groping a female resident. Staff members did not inform the physician of this behavior. Moreover, they did not file a report to begin an investigation into possible cases of sexual abuse.

July 7, 2014

Resident Fractures Hip after Nursing Assistant Fails to Follow Resident's Care Plan

According to investigators from the New York State Department of Health, a resident at the Queens Boulevard Extended Care Facility, a 280-bed nursing home located in Woodside, New York, fractured her hip after a certified nursing assistant (CNA) failed to follow the resident's care plan. In addition, the nursing home did not report the incident until 16 days after it occurred. The DOH investigation concluded that "the facility did not ensure that all alleged violations of abuse, neglect or mistreatment were reported immediately to officials in accordance with State law."

wheelchair5.jpgThe resident's care plan indicated that two staff members were required to transfer the patient from her bed to her wheelchair. In an initial accident report dated March 1, 2010, the CNA stated that she wheeled the patient into the bathroom to use the toilet. As the CNA was helping the resident out of her wheelchair, the CNA stated that the resident complained about severe pain in her right hip. The CNA then eased the patient to the floor. However, in a statement dated March 3, 2010, the CNA admitted that she first transferred the resident from her bed to her wheelchair with the assistance of another staff member. The CNA then wheeled the patient to the bathroom, where the resident complained about hip pain after being helped to her feet. The patient was then transported to the hospital.

After reviewing a hospital X-ray of the patient's fractured hip, a nursing home staff member investigating the incident concluded that the patient sustained her hip injury while "shifting her weight during the transfer." The DOH report concluded that the injury was a result of the CNA's failure to follow the patient's care plan.

When a patient is admitted into a nursing home, a team of doctors, nurses, social workers, therapist and dieticians evaluate the resident's overall health and health care needs. The team of professionals then develops a care plan for the resident. The care plan is usually updated on a regular basis and provides staff members with detailed instructions on how to care for the patient. Failure to follow a patient's care plan can lead to serious and life-threatening injuries.

In addition, any allegations of abuse or neglect of a resident must be reported to the Health Department within 24 hours. The Director of Nursing at the Queens facility stated that she was aware of this requirement. However, she stated that she didn't report the incident involving the CNA until 16 after it occurred because she was waiting to interview the resident after she returned from her hospital stay.

"Nursing Home Compare" rates the facility as much above average. The facility's health inspection record was also considered to be much above average, the highest rating a nursing home can receive.

July 7, 2014

Nursing Home Failed to Respect Residents' Dignity by Not Providing Incontinence Care

The New York State Department of Health (DOH) cited the East Neck Nursing & Rehabilitation Center, a 300-bed facility located in West Babylon, New York, for failing to respect patients' dignity by not providing timely and adequate incontinence care. According to a DOH report issued in April 2013, the nursing home failed to "promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity." In one instance, a resident diagnosed with bipolar disorder repeatedly asked a certified nursing assistant (CNA) to change her incontinence brief. However, the CNA ignored the patient's requests for care, and the patient urinated in her bed. Staff members had to change the resident's soiled clothes and linens as a result of her lack of care.

In another case, a resident's care plan stated that he needed assistance while using the toilet to prevent him from falling. On the night of April 8, 2013, the resident asked a CNA if she could help him to use the bathroom. The CNA stated that she would be back in a few minutes to assist him. After repeatedly asking for help for over an hour, the resident stated that the CNA told him to "just wet the bed." The patient was incontinent in bed due to the CNA's neglect. As a result of the incident, the resident's linens, clothes and wound dressing covering a bedsore were soaked with urine. When staff members finally came to clean him and change his bed, they simply threw the dirty linens in the corner of his room.

syringe1.jpgDuring the same certification survey, the DOH also cited the Long Island nursing home for not preventing "the development and transmission of disease and infection." On April 12, 2013, a DOH inspector observed a licensed practical nurse (LPN) administer a blood glucose test to a diabetic patient. The patient had recently been diagnosed with a contagious infection, and a physician ordered that staff members follow certain contact precautions when entering the patient's room. However, after administer the glucose test, the LPN failed to change her gloves or wash her hands and began touching items on the medication cart. The same LPN also failed to sterilize the top of a vial with an alcohol wipe before she inserted a syringe into it. When questioned about these two incidents, the LPN told a DOH inspector that she "forgot" to follow infection precautions because she was "nervous" about being observed.

According to the "Nursing Home Compare" website, the nursing home received an overall rating that was much below average. The facility's health inspection record and staffing levels were also rated much below average.

July 7, 2014

Two Westchester Nursing Home Employees Arrested for Allegedly Neglecting Dementia Patient

scales.jpgTwo employees of the New York State Veterans Home at Montrose, a 252-bed facility located in Westchester County, were arrested in June 2014 for allegedly neglecting an elderly dementia patient under their care. The employees apparently tried to cover up their neglect by falsifying the patient's medical records. Licensed practical nurse (LPN) Joyce Opoku, 41, was charged with two counts of Falsifying Business Records in the First Degree, a class E felony, and one count of Wilful Violation of Health Laws, a misdemeanor. Certified nurse assistant (CNA) Isabelle Todman, 62, was charged with four counts of Falsifying Business Records in the First Degree and three counts of Wilful Violation of Health Laws. Both employees could face up to four years in prison if convicted of the felony charges. They were both released on their own recognizance after their arraignments.

According to investigators, Opoku and Todman were responsible for taking care of an elderly resident on May 1, 2013. The resident, an 84-year-old Korean War veteran who suffered from dementia and Parkinson's disease, needed to be repositioned in his bed very two hours during the night in order to prevent pressure sores. His care plan stated that two staff members were required to safely reposition him. In addition, the resident, who was identified as being at risk for falls, had an alarm in his mattress that would sound if he got out of bed on his own. Video surveillance footage showed that Todman only repositioned the patient once during the night and didn't have the help of another staff member. However, Todman indicated in the patient's chart that she repositioned him three times with the help of another employee. Opoku indicated that she checked on the patient's bed alarm twice during the night. Video footage showed that she never checked on the resident.

The next morning, the patient was found on the floor next to his bed. He died a short time later. An autopsy report stated that he died of natural causes and that his death was unrelated to his fall or the result of being neglected.

Commenting on the nursing home employees' arrest, New York State Attorney General Eric Schneiderman remarked, "For a health care professional, there is no more important duty than providing care to patients who are fully dependent on them--in this case an ailing veteran of the Korean Conflict. My office will pursue individuals who assume the responsibility of providing care to those in need and then not only fail to provide that care, but falsify records to conceal their failure."

In 2012, the facility was fined $8,000 for having multiple deficiencies. In 2009, the facility was also fined $8,000 for providing substandard care to residents.

June 24, 2014

Inspection Report: Nursing Home Failed to Maintain a Clean and Safe Environment for Residents

According to a June 2013 report issued by the New York State Department of Health (DOH), the Saratoga Hospital Nursing Home, a 36-bed facility located in Saratoga Springs, New York, failed to maintain a safe, clean and homelike environment for its residents. In particular, DOH inspectors stated that the shower room used by many residents was dirty and not properly maintained. For instance, inspectors noted that mold was on the shower tiles and floor. A metal shelf, the shower door, and a grab bar had peeling paint and were rusty; a ceiling tile was also missing. In addition, inspectors noticed that an air vent was covered with plastic wrap and cut tape, preventing the air in the shower room from being properly circulated. The maintenance director and an administrator of the facility stated that they were unaware of the shower room's condition. The nursing home fixed the room in July 2013 as a result of the DOH inspection.

During the same certification survey, the DOH also cited the nursing home for failing to "maintain practices that provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection." For example, while talking to the nurse in charge of the facility's infection control program, a DOH inspector observed a maintenance worker wheeling a large uncovered trash bin filled with garbage through the hallway; the infection control nurse stated that the trash bin should have been covered. When questioned by a DOH inspector, the worker wheeling the bin stated that he usually covers it but that he was "behind" that particular day and was in a rush.

hospital lady.jpgIn another related finding, a DOH surveyor determined that the facility failed to provide staff members and visitors with detailed instructions pertaining to patients who had Contact/Isolation Precautions due to sickness and infections. There were four such residents in the facility. Signs outside the doors of two of these patients instructed visitors to wear a mask, gloves and a gown. Two different residents with such precautions did not have detailed instructions outside of their rooms. The infection control nurse stated that she was not aware of this matter and needed to look into the issue.

DOH investigators also cited the nursing home for failing to provide timely treatment to a dementia patient who lost a significant amount of weight over a short period of time. When the patient was first admitted into the facility, the registered dietician noted that the patient, who was only five feet tall, was at risk of malnutrition and unintended weight loss. The dietitian stated that the resident was to receive daily nutritional supplements. DOH surveyors found no documentation that the resident ever received the supplements. In addition, on February 14, 2014, the resident weighed 109.4 pounds. On March 1, 2013, the resident weighed 106.1 pounds. On April 2, 1013, the resident only weighed 100 pounds--an 8.6 percent weight loss in a two month period. The dietitian stated that the resident should have been weighed more frequently so that the issued could have been addressed and treated sooner.

June 19, 2014

Nursing Aide Faces Four Years in Prison for Allegedly Slapping Elderly Dementia Patient in the Face

Rose Marie Hall, a 53-year-old certified nursing aide (CNA) at the North Shore University Hospital Stern Family Center in Manhasset, New York, was arrested in June 2014 for allegedly slapping a 78-year-old resident in the face. The resident suffers from dementia, stroke-related complications, diabetes, and behavioral issues. She is totally dependent upon staff members for her care. Appearing in First District Court in Hempstead, Hall was charged with two counts of Falsifying Business Records and one count of Endangering the Welfare of an Incompetent or Physically Disabled Person in the First Degree, a class E felony punishable by up to four years in prison. Hall was released on $300 cash bail.

gavel1.jpgPer the criminal complaint, Hall was taking care of the resident on January 26, 2013 when a nurse stated that she saw Hall slap the patient in the face. The nurse stated that the patient's face turned red and that she began crying. One CNA stated that she saw the alleged victim cover up her face with her hand while crying. The nursing facility immediately notified the police after learning about the possible physical abuse allegations. Hall had been a CNA since 2001.

Hall allegedly told some of her colleagues that she slapped the patient after the patient slapped her. However, in a written report about the incident, Hall never mentioned that she hit the resident. In addition, Hall never told her supervisor that the incident involved physical contact. Moreover, in April 2013, Hall allegedly lied to investigators and stated that she had never slapped the resident.

Commenting on Hall's arrest, Attorney General Eric Schneiderman remarked, "Health care workers in New York have a solemn responsibility to care for their patients. Striking an elderly nursing home resident suffering from dementia and other serious conditions and then lying about it are crimes that we will not tolerate." The nursing home did not issue a comment about the arrest.

"Nursing Home Compare" lists North Shore University Hospital Stern Family Center as a facility with 256 certified beds. Overall, the facility received a five star rating, the highest rating a nursing home can receive. In addition, the nursing home's health inspection history is considered to be much above average. Staffing levels at the facility also received a five star rating. The nursing home's quality measures, which are steps a facility takes to ensure that residents receive the best care possible, was rated as much above average. In addition, the facility did not receive any fines within the past three years. The nursing home is part of the North Shore-Long Island Jewish Health System.

Website Resource: Nurse's aide slapped dementia patient, says state AG, NY Newsday, Ellen Yan, June 4, 2014

June 18, 2014

Nursing Home in Troy Received 93 Percent More Citations than Other NY Facilities

According to the New York State Department of Health (DOH) website, the Diamond Hill Nursing & Rehabilitation Center, a 120-bed facility located in Troy, New York, received 93 percent more health citations than other New York nursing care facilities. On average, most New York nursing homes received 2.2 citations per 100 occupied beds; however, Diamond Hill received 30.6 citations per 100 occupied beds. Overall, the facility was issued 35 citations; 21 of these citations--or 60 percent of them--were related to quality-of-care issues. In addition, the facility received 97.1 complaints per 100 occupied beds; the New York State average for most nursing homes is 34.4 complaints per occupied beds. Overall, the facility received a total of 111 complaints and has received $34,755 in fines over the past three years for providing substandard care.

In response to a complaint stemming from a March 2014 incident, the DOH cited Diamond Hill for failing to perform CPR on a patient who died. According to the DOH report, an elderly resident suffering from cirrhosis and heart failure told staff members that she wished to be resuscitated in the event of an emergency. On March 21, 2014, a certified nursing assistant (CNA) found the resident unresponsive in her bed. The CNA immediately went for help, and a "code blue" was called over the intercom. The assistant director of nursing (ADON) and the director of nursing (DON) were the first to arrive in the patient's room. They directed staff members to call 911. The two supervisors determined that the resident lacked any signs of a pulse or respiration. However, both nurses decided that the patient "had expired prior to discovery and resuscitation would be fruitless." In addition, the DON told a DOH investigator that CPR would have been "pointless." A physician stated that he was called by someone from the facility and was told that CPR was not performed because the resident had been dead for at least two hours.

A licensed practical nurse (LPN) who went to provide assistance during the code blue told investigators that she "could not tell how long the resident had been gone" and that "there were no obvious signs to make this determination." A registered nurse (RN) who responded to the code stated that the resident was "not really cold." One CNA told investigators that she was told not to call an ambulance when she asked if she should. The CNA stated that not performing CPR against the patient's wishes "went against everything they have been taught." The facility's CPR policy clearly states that CPR should be administered immediately and that 911 should be called if a patient without a DNR is found without a pulse or respiration.

June 18, 2014

Nursing Home Fined $5K after Unsupervised Alzheimer's Patient Chokes to Death

The New York State Department of Health (DOH) fined the Loretto Health & Rehabilitation Center, a 585-bed facility located in Syracuse, New York, $5,000 after an unsupervised Alzheimer's patient choked to death. According to the DOH report about the incident, the resident was admitted into the facility on July 16, 2012 after she underwent hip-repair surgery. The hospital's discharge notes, which need to be reviewed by the nursing home's admissions department, indicated that the resident should be restricted to a diet of "nectar thick liquids." In addition, the hospital's instructions stated that the patient was at risk of choking and needed "total assistance with oral intake."

hospital food.jpgOn the evening of July 17, 2012, the patient was served kielbasa for dinner and was sitting unattended at a dining table. A licensed practical nurse (LPN) told investigators that she and a family member observed the elderly patient eating her dinner by herself. The LPN stated that the family member was "pleased" that the resident was eating independently. About a half hour later, the LPN saw that the resident was "slumped over in the chair" and told investigators that "she looked like she was already gone." The LPN stated that she didn't think that the patient had choked because the resident didn't have any eating utensils in her hands. After finding the resident unresponsive, the LPN informed her on-duty supervisor. The two nurses then wheeled the woman back to her room and laid her on the bed. The supervisor stated that the resident's airway was clear of any food. In addition, because the resident had a DNR, the nurses did not attempt to perform any life-saving measures. The supervisor pronounced the woman dead at 6:05 p.m.

A forensic autopsy performed on the same day indicated that the patient had choked to death on a piece of kielbasa. The DOH report concluded, "The facility did not have a plan in place to monitor the resident related to aspiration precautions, and did not provide emergency treatment when found unresponsive in the dining room at meal time."

In another deficiency citation, the DOH observed that the facility failed to follow the feeding and diet restrictions of a dementia patient. According to the resident's care plan, the patient had a history of "pocketing" food in the corner of her mouth. The plan stated that the resident was at risk for choking and should be monitored while eating. Moreover, the plan indicated that the resident should eat while sitting at a 90 degree angle. However, a DOH investigator observed that the patient was slouched over while eating alone without the assistance of any staff member. As a result, the facility was cited for failing to follow "the plan of care for aspiration precautions, as identified in the comprehensive care plan."

June 18, 2014

NY Department of Health Cites Nursing Home for Failing to Perform CPR on Resident Found Unresponsive

After investigating a complaint filed against the Crown Center for Nursing & Rehabilitation, a 200-bed facility located in Cortland, New York, the Department of Health (DOH) determined that the facility failed to perform CPR on a resident who was found unresponsive in her room in May 2012. According to the DOH report, although the resident suffered from dementia and terminal lung cancer, she indicated in a signed document that she wished to be resuscitated in an emergency.

On May 6, 2012, the resident was vomiting bile and had a fever. She also complained of stomach pain, and a CNA indicated that the resident's speech was "garbled." The CNA also indicated that the resident's skin was bluish in appearance. Over a period of two hours, the resident rang her bell 27 times and asked staff members to have her taken to the hospital. A nurse who did not assess the patient called a physician who stated that the resident should remain at the nursing home. DOH investigators determined that the nursing facility repeatedly ignored the patient's requests for medical care.

On May 7, 2012, a CNA found the resident unresponsive in her room at 3:50 a.m. The CNA told a nurse that the resident had "passed." The nurse called the supervisor and did not begin CPR immediately. The nurse told a DOH investigator that he decide not to begin CPR because the resident was "too dead" and would have been in a "vegetative state" if she survived. However, when the supervisor arrived in the patient's room, the supervisor directed her staff members to immediately begin CPR. When the supervisor called the patient's daughter, the supervisor told the daughter that her mother had died and asked for permission to stop CPR. When the daughter stated that she wanted staff members to stop performing CPR, the supervisor then called a nurse practitioner and informed him of the daughter's request. The nurse practitioner ordered that staff members stop all life-saving measures. When an ambulance arrived three minutes later, EMT's restarted CPR after learning that the elderly woman had requested that life-saving measures be performed on her in the event of an emergency. The woman was then transferred to the hospital.

wallet.jpgIn another incident that occurred over a year later, a CNA was arrested for stealing from a resident. In July 2013, Jodi Doran, a former CNA at the facility, stole $30 in cash from a resident's wallet. In December 2013, Doran pled guilty to the theft in Cortland City Court. She was given a conditional discharge for the offense, and she was sentenced to 50 hours of community service.