August 31, 2014

Nassau County Nursing Home Cited for 19 Deficiencies

Parkview Care and Rehabilitation Center, a nursing home in Massapequa, Long Island, was cited in an April Department of Health certification survey for nineteen deficiencies. The most serious of these deficiencies resulted in "actual harm" to a resident. A finding of actual harm is the second most serious level of severity that the DOH assesses to a nursing home during a certification survey.

chest.jpgThis most serious incident involved a failure to promptly notify an attending physician of the radiology findings for a resident of Parkview. Because the resident was exhibiting symptoms of pneumonia, a chest x-ray was ordered. The physician was not notified of the results, or lack thereof, of the x-ray until four days after it was taken. Nursing notes for the time between the performance of the x-ray and the and the resident's transfer to the hospital indicate that the nurses did not check the resident's breathing, despite the symptoms of pneumonia that had prompted the physician order for the x-ray. When the physician finally received the x-ray four days after it was performed, he became aware that the patient was suffering from a collapsed left lung. The attending immediately ordered a transfer to the hospital, where the resident was treated for his condition.

In an interview with the DOH, the attending physician indicated that it is incumbent upon the radiology department to notify him immediately of any abnormalities or dangers indicated in the x-ray. Radiology did not adhere to this protocol in this instance.

Although this incident was the most severe of those documented in the certification survey, it was far from the only one in the report. Among the other deficiencies noted by the DOH were a failure to keep the nursing home free of accident hazards, failure to provide proper treatment to prevent and/or treat pressure ulcers, and failure to ensure that residents are free from significant medication errors. There is no word yet as to whether a fine will be assessed against Parkview for these numerous deficiencies.

August 31, 2014

Westchester County Nursing Home Cited for Failure to Prevent Pressure Sores

The Osborn, a Rye, New York nursing home, was cited in a December, 2013 Department of Health deficiency report for failing to properly treat and/or prevent pressure ulcers. According to the report, the facility did not accurately assess the resident's condition, and as such failed to institute a proper plan of care to address her propensity for pressure sores.

The resident was 100 years old upon her admission to the nursing home following a hip fracture. She had a pre-existing Stage I pressure ulcer of the right heel, as stated in the Ulcer Flow Sheet at her admission. Despite the presence of the ulcer, the resident's Minimum Data Set indicated that she had no identifiable pressure sores. The resident had several risk factors for the development of pressure sores, including impaired cognitive skills and requirements for assistance with all activities of daily living. Despite the presence of the sore and these risk factors, no further pressure ulcer assessment was performed.

Less than two weeks into her stay, the resident's right heel ulcer had deteriorated to a Stage II sore. When interviewed, the RN/MDS assessor stated that the inaccuracy of the initial assessment led to a substandard care plan. Because the patient was improperly assessed, the pressure ulcer was allowed to deteriorate rather than heal. It should be noted that when the resident was discharged, the heel ulcer was in the process of healing.

Accurate care planning is essential for elderly nursing home residents. Intake evaluations to determine a patient's risk level for the development of pressure ulcers must be performed diligently and accurately to ensure that residents without pressure sores do not develop them, and residents admitted with pressure sores are properly treated. If untreated, a pressure sore, such as the one exhibited by the Osborn resident, can deteriorate, become infected, and potentially lead to death. Fortunately for this resident the sore was eventually treated and seemed to be healing upon her departure from the facility; had the Osborn conducted a proper intake assessment, the sore may not have ever gotten to Stage II.

August 31, 2014

NYS Health Inspectors: Resident's Blood Clot Caused by Medication Error

After receiving a complaint in October 2013 against the Edna Tina Wilson Living Center, a 120-bed facility located in Rochester, the New York State Department of Health (DOH) fined the facility $4,450 for a medication error that caused a resident to develop a blood clot in her leg. The affected resident was admitted into the nursing home in September 2013. The resident's medical chart indicated that she had received a heart valve replacement, had a pacemaker and was taking Heparin and Coumadin, both of which are blood-thinning medications. A physician ordered that a routine blood test be done on October 14, 2013 to ensure that the blood-thinning medication was working properly. Administration of the Coumadin was to be suspended temporarily under the lab test results came back. However, the blood test was never conducted, and for a period of nine days the resident never received Coumadin.

On October 21, 2013, the resident began complaining about pain in her lower left leg. After conducting an imaging test, a doctor determined that the patient had developed a blood clot in her lower left calf. The physician immediately ordered that the resident be placed back on Coumadin and receive Lovenox, a blood thinner that is injected in the affected area. Moreover, the physician ordered a blood test, which revealed that the patient was at risk of developing more blood clots. Staff members were also instruct to perform tests to ensure that clots did not form on the resident's lungs.

Over the course of the investigation into the matter, DOH officials also discovered that lab tests for five other residents, including those on anticoagulants, were never conducted during the same time period. After working closely with staff members and administrators, DOH surveyors were able to trace the cause of the error to the implementation of a new computer system at the facility. Under the old paper system, nurses were required to manually fill out a lab request form and submit it to the secretary. Under the new computerized system, the nurses were not required to submit a paper lab request. The secretary stated that she was never trained or informed of this new change in policy and procedure. As a result, several lab requests were missed, resulting in actual harm to the resident.

In order to ensure that such an error doesn't occur again in the future, administrators created a written policy pertaining to lab requests. They also provided training to all staff members about the facility's new policy. The DOH report concluded that the appropriate changes were implemented in a timely fashion.

According to the "Nursing Home Compare" website, the facility received an overall rating that was below average.

August 31, 2014

Office Worker Stole Over $45K from Nursing Home Residents

Johnna Scanlon-Howland, a former office worker at the Sunrise Nursing Home, a facility located in Oswego, New York, was convicted in July 2013 of stealing $45,363 from the resident trust account at the nursing home. Investigators from the state's Medicaid Fraud Control Unit (MFCU) stated that Scanlon-Howland falsified business records to make unauthorized withdrawals from residents' accounts. She then spent the stolen money on personal purchases. In a similar incident in June 2013, Jodi Montenaro, a business manager at the Dutch Manor Nursing and Rehabilitation Center, a facility based in Schenectady, was convicted of stealing $4,450 from the resident trust account. Montenaro used some of the stolen funds to pay her personal bills.

When a patient enters a nursing home, he or she can deposit money into a trust account. The patient can then withdraw the money to pay for basic living expenses such as a haircut or personal hygiene products. The accounts accrue interest and are managed by the nursing home, which should issue regular statements much like a bank would. The accounts are insured in the event the funds are stolen or mismanaged. However, a USA Today investigation conducted in 2013 discovered that thousands of residents had their funds stolen by nursing home employees who used the money to pay for personal shopping sprees and gambling outings. In addition, the investigation uncovered that most states do not require routine audits of resident trust accounts, which can allow fraud to occur over a long period of time.

While nursing homes conduct criminal background checks for health care workers, 20 states currently do not require such checks to be extended to office workers, who often handle resident trust accounts. In one case, a nursing home business manager in Alabama stole $115,000 while he was on probation for stealing. The USA Today report also pointed out that some nursing homes fail to carry insurance to cover a potential loss to resident accounts.

In an attempt to address these issues, U.S. Senator Bill Nelson asked the Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees nursing homes, to require that nursing facility inspectors conduct annual audits of resident trust accounts, In a letter to the agency, Nelson wrote, "CMS does not require state agencies to train surveyors on how to identify improper or suspicious withdrawals from these accounts, nor is it clear that the surveyors are required to look for this type of problem. I ask that you require...that surveyors be provided with the training they need to detect improper expenditures from these trust funds, and that these withdrawals be routinely reviewed."

Greg Crist, senior vice president of the American Health Care Association, stated that most nursing homes already conduct routine audits of resident accounts as part of their own internal financial controls system.

August 31, 2014

Study: NY Nursing Homes Failed to Meet Federal Goal to Reduce Use of Antipsychotics

The Long Term Care Community Coalition (LTCCC), an advocacy group that promotes the improvement of nursing home care, released a report in April 2014 about the use of antipsychotic medications in New York nursing facilities. The study, titled "Antipsychotic Drug Use in NY State Nursing Homes: An Assessment of New York's Progress in the National Campaign to Reduce Drugs and Improve Dementia Care," revealed that NY nursing homes failed to meet a federal goal to reduce the use of antipsychotics. In March 2012, the Centers for Medicare and Medicaid Services (CMS) set a goal for all nursing homes to reduce antipsychotic medication use by 15 percent by the end of the year. Despite this goal, in December 2013 the CMS reported that NY nursing homes reduced antipsychotic use by only 14.6 percent, short of the target.

pills8.jpgAntipsychotic medications were developed to treat patients diagnosed with psychosis, such as schizophrenia. However, because such medications have a sedating effect, many nursing homes prescribe such antipsychotics to dementia patients with behavioral issues. In effect, the medication is being used as a chemical restraint to control agitated residents. Moreover, in 2005, the FDA issued a "black box" warning stating that antipsychotics can cause strokes, heart attacks and death in dementia patients.

Discussing the use of antipsychotics in nursing homes, U.S. Inspector General Daniel Levinson remarked, "Too may [nursing homes] fail to comply with federal regulations designed to prevent overmedication, giving nursing home patients antipsychotic drugs in ways that violate federal standards for unnecessary drug use. Government, taxpayers, nursing home residents, as well as their families and caregivers should be outraged--and seek solutions."

Even though only one percent of nursing home residents are diagnosed with psychosis, the LTCCC's report points out that nearly 20 percent of NY nursing home patients are taking an antipsychotic. In general, the study found that nursing homes in the NYC metropolitan area had the highest rate of antipsychotic use, while nursing facilities in the western region of the state had the lowest rate of antipsychotic use. The report concluded that the discrepancy was due to higher enforcement actions in western regions.

To address the problem of antipsychotic medications in nursing homes, the LTCCC has made several recommendations. First, the NYS Department of Health needs to address and enforce the issue when conducting nursing home inspections. The LTCCC study found that higher enforcement leads to more nursing homes complying with antipsychotic use. Second, NYS lawmakers need to pass a bill that will require nursing home residents to give their verbal and written consent before taking antipsychotics. The consent form would list potential side effects of such medications, including the FDA's "black box" warning for dementia patients.

August 31, 2014

Bronx Nursing Home Fails to Maintain Proper Standards for Accident Avoidance

A March 27, 2014 Department of Health certification survey found Bronx nursing home Concourse Rehabilitation and Nursing Center deficient in numerous areas. One such area was related to keeping the facility as free of accident hazards as possible. The incident documented by the DOH concerned improper supervision of a resident while out of the facility.

The resident involved in the nursing home's failure was a 79 year old woman with known risks for wandering and elopement, including dementia and severely impaired cognition. Concourse had a wandering care plan in place for the woman. During a routine trip to the hospital for an appointment, the resident wandered from the waiting room despite the fact that she was accompanied by an escort. The escort and the resident both went to use the bathroom. When the escort came out, the resident had left not only the bathroom but the hospital itself. Staff of the nursing home searched for the resident at both the home and hospital, but were unable to locate her. Not until later that night was the resident found by her granddaughter. The report does not state where she eventually found her grandmother. Additionally, although the report does not specify whether she was fired or left of her own volition, the CNA escort is no longer employed by Concourse.

old man walking.jpgMany elderly nursing home residents are admitted with cognitive impairments that make them risks for wandering and or elopement. Proper care plans can minimize the risk that these events occur, but only if the care plans are followed. When left to fend for themselves, elderly individuals with reduced mental capabilities are at greater risk for dangerous accidents, such as falls and fractures. An accident resulting in a fall can also lead to increased cognitive decline, in addition to the obvious physical injuries that can result.

Fortunately the resident appears to have been unharmed as a result of her wandering from the hospital. This incident is a reminder that while proper care planning is essential to the care of elderly nursing home patients, the execution of the care plan is equally, if not more, important.

August 22, 2014

Federal Report: Medicare Paid $5.1 Billion to Nursing Homes that Failed to Meet Quality-of-Care Standards

report.jpgThe United States Office of Inspector General (OIG) released a report in March 2014 summarizing 25 key findings and recommendations pertaining to health care facilities throughout the nation. The report, titled "Compendium of Priority Recommendations," includes several findings related to long-term nursing home care facilities. For instance, the study pointed out that Medicare paid approximately $5.1 billion to nursing homes that failed to meet minimum quality-of-care standards, which regulate such items such as how nursing homes should provide basic wound care and manage patients' medications and therapies. To address this issue, the OIG recommends that nursing homes improve care planning for residents. Care plans are developed by a team of physicians, nurses, social workers and therapists for each resident to ensure a patient's needs are adequately addressed. Failure to develop such plans, or failure to follow care plans can actually harm residents. The OIG study found that 37 percent of nursing home residents either didn't have a care plan, or had a care plan that was not effectively implemented.

In addition, the OIG determined that many nursing homes failed to provide adequate discharge plans for residents. Approximately one in three residents who left a facility didn't have an appropriate discharge plan in place. Discharge plans often contain detailed and specific instructions for caregivers on how to treat the patient once he or she has left a nursing facility. When caregivers don't have such instructions, they make errors in care, such as improperly administering medication. Such mistakes can lead to costly, yet preventable, hospitalizations.

Another key finding pointed out that one in three residents experienced some type of harm while staying at a nursing home. The finding also determined that 59 percent of harmful or adverse events were caused by poor care and could have been prevented. Such adverse events sometimes lead to hospitalizations. To address this issue, the OIG recommends that health inspectors identify causes of such harmful events and come up with ways to prevent them in the future.

The OIG report also uncovered large scale Medicaid fraud by nursing homes. In 2009, Medicaid made $1 billion in inappropriate payments to nursing facilities. In most cases, Medicaid made payments for services that were never provided. In other instances, Medicaid paid for services that were not medically necessary. In addition, Medicaid overpayments were sometimes the result of "upcoding", a fraudulent billing practice in which a nursing home bills for a higher level of service than what was actually provided. To address this fraud and abuse, the OIG recommends that governmental agencies conduct more extensive audits and reviews of claims submitted by nursing homes to Medicaid.

August 22, 2014

Nursing Home Fined Over $6K for Stocking Expired Medications

As part of a routine certification survey conducted in September 2013, officials with the New York State Department of Health (DOH) fined the Lutheran Retirement Home, a 174-bed facility located in Jamestown, New York, for numerous deficiencies, including keeping expired medications to be given to patients. DOH inspectors discovered that all four units of the nursing home failed to discard expired medications such as vitamins, cough medicine, aspirin and antacids. In two instances, surveyors even observed that several medication carts, used by nurses to dispense medications, contained expired controlled substances used to treat anxiety.

meds2.jpgWhen asked about the expired medications, a licensed practical nurse (LPN) told investigators that the facility did not have a policy in place to check expiration dates on medications. However, a nursing supervisor states that nurses on the night shift are responsible for clearing the shelves in the medication room of any expired items. The pharmacist at the facility stated that nurses often tell him that "they are too busy to do this." Furthermore, the pharmacist stated that nurses should destroy expired controlled substances in accordance with state and federal regulations and guidelines.

DOH surveyors also observed two nurses pass a key to the safe storing narcotics without ever counting the controlled substances in the safe as is standard practice and procedure. An LPN told a DOH investigator that "they are busy and cannot do it that way." After hearing about the incident, the pharmacist stated, "We have to stop that right away." As a result of these findings pertaining to the medications, the DOH concluded that "the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the expiration date...and permit only authorized personnel to have access to the keys."

During the same certification survey, DOH officials also cited the facility for failing to keep an environment that was free of accident hazards. At the time of the inspection, one of the building's units, located on the second floor, was in the process of being renovated. To facilitate the removal of debris from the facility, construction workers removed two windows to create a five foot long by two foot wide opening. Workers used this opening to throw out construction debris rather than carting it throughout the entire building. When the opening was not in use, workers simply covered it with a piece of plywood that was loosely secured by a rope. A DOH inspector touched the plywood and determined that it could easily be pushed out or removed. The surveyor conclude that 28 residents in the unit, including 11 who were cognitively impaired could have leaned against the plywood and fallen two stories to the cement pavement. The DOH report concluded, "These deficiencies and the potential serious impact they represent to the quality of care and the quality of life of facility residents, demonstrate a failure...to ensure effective management and operation of the facility."

August 15, 2014

Study: Nursing Home Ratings May Inaccurately Reflect Care, Satisfaction

A study recently reported in the NY Times found that consumer satisfaction ratings for nursing homes do not always match up with the ratings given to facilities by their residents and their families. The largest disparity occurred with respect to facilities rated at the highest level (five stars) on Medicare's Nursing Home Compare website. Although one would expect that a facility rated five out of five stars would have excellent satisfaction rates, the survey found otherwise. In many cases, residents expressed very low satisfaction rates at these nursing homes that Medicare had rated at the top of the list. Often, these residents' families felt the same.

In the Times' investigation, it was discovered that this discrepancy may be due to differing expectations between Medicare, who ranks the nursing homes, and residents and their families, who deal with everyday life within the facility. While Medicare primarily looks to factors such as infection rate, pressure ulcers/wound care, and medication errors, resident and their families, many of whom are unaffected by these deficiencies, look more to quality of life and dignity within the facility.

Consideration has been given to using feedback from residents and their families into the Medicare rankings, although that has not occurred yet. While it would enable a fuller view of life within nursing homes, the added cost has to be justified to implement such a program. In the meantime, a lesson to be learned for anyone contemplating placing a loved one in a nursing home is to take the Medicare ratings for what they are: accurate measurements based upon the criteria studied, but not necessarily a complete picture of life within a particular nursing home.

The article in the NY Times can be found here.

August 13, 2014

Brooklyn Nursing Home Cited in Deficiency Report

Saints Joachim & Anne Nursing and Rehabilitation Center, a nursing home located in Brooklyn, NY, was cited in an October, 2013 certification survey issued by the Department of Health. Among the several deficiencies noted by the DOH was a failure to establish an infection control program at the facility.

hospital corridor.jpgA nursing home must ensure that it investigates, controls, and prevents infections within the facility. This includes proper disposal of bedclothes and linens of infected individuals when the situation warrants. During this investigation by the DOH, it found an individual who had been admitted to the rehabilitation center with numerous diagnoses, one of which was Possible Scabies. Although one of the most common ways to spread scabies is through used personal items, such as bedding or towels, the facility failed to properly place a "red bin" inside the resident's room in order to properly monitor potentially infectious materials. The nursing home also failed to isolate the resident's supplies from those of other inhabitants of the home.

Individual treatment of the possibly infected resident also deviated from the facility's own procedures and protocols. Per a Registered Nurse at the nursing home, when treating an individual for a possible outbreak of scabies, contact precautions are to be taken, including wearing gloves and a protective gown at all times. Additionally, a sign should be posted outside the resident's room as a warning that the resident is potentially infested. Although it appears from the report that gloves were worn while administering treatment, at least on Certified Nursing Assistant did not wear a gown while in close contact with the individual.

Based upon the DOH report, it does seem that the nursing center took appropriate steps to treat the resident's own potential scabies. Without taking the necessary precautionary measures while doing so, however, could have led to a more major outbreak within the facility, affecting the comfort, health, and well-being of other residents and staff.

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.