New York Nursing Home Abuse Lawyer Blog

In its June 14, 2010 inspection report, the Department of Health cited Marcus Garvey Nursing Home in Brooklyn for violation of regulations applicable to New York nursing homes. The violation details substandard quality of care with respect to wandering and elopement of patients within the facility.

Title 10 Section 415.12(h)(2) of the Code states: "The facility shall ensure that each resident receives adequate supervision and assistive devices to prevent accidents." The deficiency report details a resident, referred to as Resident #1, with documented and frequent elopement attempts. Although the facility labeled Resident #1 as an elopement risk, his picture was not in the elopement risk photo book at the security desk, nor was he on the elopement risk list. Resident #1 successfully eloped on 5/29/2010. Resident #1 was missing for appriximately seven and a half hours before his family informed the facility that they had located him in the Bronx.

Among its residents, Marcus Garvey Nursing Home had identified nineteen residents as potential elopement risks. Despite this number, the Director of Nursing was unaware of the facility's use of wander guards to prevent elopement, stating that she "did not really read the policy." The facility Administrator was unaware of the Residents at Risk for Elopement book, stating that photos of such residents are posted by the security desk. At the time of inspection, two pictures were posted on the security desk wall.

Wandering and elopement pose a serious threat to elderly nursing home residents. Unmonitored wandering can lead to falls and fractures, among other consequences. Merely identifying residents who pose such a threat to themselves is not enough. Facilities must ensure that these residents are not allowed to wander and create additional risk for themselves. An individualized comprehensive care plan is a necessary first step. Following through on these care plans is equally, if not more, important.

Website Resource: New York State Department of Health

In a certification survey dated December 17, 2009 on the New York State Department of Health (DOH) website, Bishop Charles Waldo Maclean Nursing Home in the Far Rockaway section of Queens received numerous deficiences, ranging from pressure sore treatment to substandard overall safety measures.

The surveyors found that the facility did not ensure that a resident with pressure ulcers received the necessary dietary assessment, treatment and re-evaluation to prevent the development of new pressure ulcers (bedsores, decubitis ulcers) and failed to promote healing of the existing ulcers. The Nursing Readmission Assessment dated 6/19/09 documented ". . .skin dry and intact" and listed the GT site as the only skin problem.

The comprehensive care plan for Pressure Ulcers dated 6/24/09 documented a 13 Braden Score (scale used to predict pressure sore risk). The Braden Risk Assessment documented that a score of 13 placed the resident "at moderate risk" for pressure ulcer development. The pressure ulcer care plan documented interventions to prevent pressure ulcer development and maintain skin integrity.

A pressure ulcer Flow Sheet dated 6/24/09 identified a Sacral Stage II Pressure Ulcer measuring 1 centimeter (cm) x 1 cm . The physician's interim order dated 6/24/09 documented a treatment to cleanse the sacral ulcer with normal saline, apply Dermafix Spray and a dry sterile dressing every shift. There was no documented physician's progress note addressing the Stage II pressure ulcer until one week later when it was identified as a Stage IV on 6/30/09.

The pressure ulcer Flow sheet for the Sacral Pressure Ulcer dated 6/30/09 documented that the ulcer had deteriorated increasing in size to 7 cm x 4 cm. A Physician Progress Note dated 6/30/09 documented that the Sacral Ulcer was a Stage IV measuring 7 cm x 4 cm with 10% bloody drainage. There was no reference to any nutritional recommendations. There was no documented evidence of a Dietary Reassessment addressing the resident's nutritional needs related the the deterioration of the pressure ulcer to a Stage IV on 6/30/09.

The following ulcers developed and deteriorated during the resident's stay at the Queens facility:
Stage II Sacrum 1 cm x 1 cm-onset 6/24/09. 9/1/09-Stage IV 10.0 cm x 12.0 cm x 3.0 cm.
Right Heel closed Blister-onset 7/1/09. 9/1/09-Eschar Stage IV 8 cm x 5 cm.
Left Heel-Blackened discoloration 4 cm x 7 cm-onset 7/9/09. 9/1/09-5 cm x 4 cm.
Stage II Right Hip 0.5 cm x 0.5 cm-onset 7/20/09. 9/1/09-Stage IV 14 cm x 10 cm x 4 cm
Stage II Left Hip 0.3 cm x 0.3 cm-onset 7/28/09. 9/1/09-Stage IV 7 cm x 6 cm x 1.5 cm.

The facility violated at least twenty-six sections of Title 42 (Public Health) of the Code of Federal Regulations. Prior entries in this blog have detailed several of the Code sections violated in this particular instance (bedsores, overrall care, etc.). Below please find a sampling of additional regulations Charles Waldo Maclean failed to comply with according to the survey:

• 483.70(h)(4): The facility must...maintain an effective pest control program so that the facility is free of pests and rodents (both live and dead roaches were observed on several occasions in several different areas of the facility)

• 483.35(d)(3): Food. Each resident receives and the facility provides food prepared in a form designed to meet individual needs

• 483.20(k)(3)(ii): The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.

Again, these are just several sections of the Code that this facility violated according to the DOH survey. The full list, which is too extensive to replicate here, can be found on the DOH website. The scope of Public Health Law violations that this facility has amassed is disturbing. Changes are certainly in order. Perhaps the DOH survey will serve as the impetus for the facility to reevaluate its standards and increase quality of care for its residents.

The New York State Department of Health (DOH) has cited Elant at Newburgh in Orange County, NY of numerous violations of the state's Public Health Laws. Graphic at times, the report chronicles the deficient care that several residents received throughout their stay at Elant.

As this blog has noted several times in the past, Public Health Laws regarding the prevention and treatment of pressure ulcers articulate very specific standards of care that facilities must maintain with respect to their patients. The extensive document that the DOH recently released to the public details a number of incidents at Elant during which these standards of care were neglected, unknown, or seemingly ignored. In certain cases, the development of pressure ulcers in elderly residents of nursing homes is an unfortunate, yet unavoidable, occurrence. The facility's duty is to ensure that safeguards are in place to prevent avoidable sores. The practices at Elant depicted in the DOH report not only seem to disregard this duty, but also to quicken the development of pressure ulcers in already debilitated patients.

Residents suffering from incontinence are particularly susceptible to pressure ulcers. Title 10 Section 415.12(d) of the New York Administrative Code states that: "Based on the resident's comprehensive assessment, the facility shall ensure that: (1) a resident who is incontinent of bladder receives the appropriate treatment and services to...restore as much normal bladder function as possible." Yet, at Elant, a tour of the facility revealed that, among other deviations from standard care, 8 of 8 Certified Nursing Assistants (CNA's) interviewed were unaware of the facility's toileting program, and 7 of 8 CNA's demonstrated poor infection control techniques during perineal care. Section 415.12(c) of the Code mandates that the facility ensure that "(2) a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing." Again, the CNA's at Elant failed in this charge, with 5 of 8 interviewed stating that they would not report open skin areas to the charge nurse. On one occasion the Director of Nursing was intervewed following a comment by a Licensed Practical Nurse who posited that a pressure ulcer with a scab was "healed." The Director's response: "No, by no means. I'm so embarassed."

The work of Nursing Home facilities is difficult and intense. This does not excuse a lack of proper care and knowledge by the staffs of such facilities. Based upon the DOH report, it seems that Elant has significant work to do to ensure that it brings its staff members up to date on current acceptable practices for elder care.

Website Resource: New York State DOH