New York Nursing Home Abuse Lawyer Blog

Northern Riverview Health Care Center, Inc. in Rockland County, NY was fined $24,000 as a result of a Department of Health Certification Survey dated April 8, 2010. The survey noted no less than 14 deficiencies that contributed to the substantial fine.

Among the shortcomings noted by the surveyors were failures with respect to comprehensive care plans (a repeat deficiency for Northern Riverview), the failure to keep the facility free of accidents hazards, and failure to take proper measures to treat and prevent/heal pressure sores.

A facility must develop, review, and revise a comprehensive care plan for each resident. With respect to two patients, Northern Riverview failed to do this according to the DOH. In one case, the patient did not have a care plan in place for dehydration treatment, despite the fact that the patient was being monitored for dehdration. In the second instance, a patient had no care plan for limited functionality in her left hand, although it was observed that the resident was unable to unclench that hand.

A facility must also ensure that the resident environment remains as free from accident hazards as possible. On March 22 of last year, a resident eloped from Northern Riverview. The resident had been diagnosed previously with both Alzheimer's Disease and Depressive Disorder. Needless to say, the potential dangers of an elderly resident leaving a facility unattended are amplified when additional diagnoses such as Alzheimer's and depression are added to the situation. Fortunately, in this instance the resident was returned to Northern Riverview unharmed. However, without diligent checks on residents with the potential to wander, occurrences such as this could lead to much more serious consequences in the future.

As this blog has discussed frequently, a facility is required to ensure that a resident who enters a facility without pressure sores does not develop them unless the sores are clinically unavoidable, and a resident with pressure sores receives the necessary treatment to promote healing, prevent infection, and prevent new sores from developing. In the DOH report, it is noted that a resident, although noted to be at moderate risk for the development of pressure sores, still developed several pressure ulcers between Stages II and IV. Although the patient's care plan called for turning and positioning every two hours, it is not noted in the nursing notes that this was performed consistently. Additionally, the survey details departure from protocal while cleaning and dressing the wounds, such as a failures by LPN's to wash hands during the process and placing an undressed wound directly on bed linens. In limited instances, skin breakdown in an elderly person is an unavoidable side effect of underlying disease processes. Failing to take all necessary steps to avoid this breakdown is certainly avoidable, however, as is failing to properly clean and dress wounds.

Documentation of Northern Riverview's fine can be found here. The full DOH survey results are linked below.

Website Resource: Northern Riverview Health Care Center, Inc.

Three nurse's aides at Beth Abraham Health Services in the Bronx were arrested after failing to notice the elopement of a 64 year old schizophrenic patient in a wheelchair, and then attempting to cover-up the incident. Although police found the man approximately six hours later at a friend's home, the aides at Beth Abraham allegedly documented that they had checked on him and given him his medication during the period that he was missing.

Title 10 Section 415.12(h) of the New York Code of Rules and Regulations states that "[T]he facility shall ensure that: (1) the resident environment remains as free of accident hazards as is possible; and (2) each resident receives adequate supervision and assistive devices to prevent accidents." Clearly, allowing a schizophrenic patient to elope from the facility violates the regulation above. It was the duty of the nurse and her aides to report the missing patient as soon as they were aware of his elopement. That said, what makes the incident much worse is the attempt to cover-up the mistake by falsifying documentation.

Maintaining a safe environment for nursing home residents is a duty and should be a priority for the administration and staff at long-term-care facilities. This is not always the case, however. Diligence must be maintained to be certain that nursing home residents, particularly residents with special mental needs, are cared for in the manner mandated by both state and federal law. Thankfully, in this instance, the NYS Attorney General's Office investigated and plans to hold those responsible accountable.

Website Resource:
Three nursing home aides lied about missing schizophrenic patient in wheelchair: AG, New York Daily News, Kathleen Lucadamo, February 24, 2011

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

A Department of Health (DOH) study regarding the 2008 elopement of a 59 year old woman at Fieldston Lodge Care Center in Riverdale, NY found the facility's measures to prevent such wanderings lacking. The patient, identified in the report as "Resident # 1," entered the facility in November, 2007 with diagnoses ranging from Hypertension to paranoid Schizophrenia. Upon admission, the facility recognized that Resident # 1 was an elopement risk, both through its elopement risk assessment tool and the Comprehensive Care Plan. She was fitted with a wanderguard, among other standard interventions for elopement

Fieldston documented that Resident # 1 grew increasingly anxious about leaving the facility and returning home. Her score on the elopement assessment tool increased as well. Despite these warning signs, Fieldston implemented no additional interventions or monitoring. On August 16, 2008, Resident # 1 left the facility of her own volition. Not until August 19 did three staff members finally find the resident in her apartment building. Luckily, she was not seriously injured.

The Code of Federal Regulations and the NY Public Health Laws have very specific requirements to ensure the safety of residents and the prevention of neglect on the part of the facility. The Department of Health cited two relevant sections in its write-up of Fieldston. Title 42 Section 483.13(c) of the Code of Federal Regulations states that "[t]he facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property." Additionally, Title 42 Section 483.25(h) sets forth that: : "The facility must ensure that (1) The resident environment remains as free of accident hazards as possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents." The DOH cited each of these sections in its deficiency report for Fieldston. In a situation fraught with risk as in the case of Resident # 1, the Department of Health demands that a certain standard of care be maintained by the facility with respect to the patient. In this case, the department obviously felt that this standard was not met.

Website Resource: Department of Health

Elant at Brandywine, a Westchester County nursing home in Briarcliff, New York was recently fined $38,150 by the U.S. Federal Government based on findings of substandard care made by surveyors during a September 2, 2009 investigation. According to the inspection report, surveyors cited the facility for failing have systems in place to adequately monitor and prevent residents with cognitive impairment and/or unsafe wandering or elopement behaviors from exiting the facility undetected.

The surveyors uncovered that a cognitively impaired resident who had eloped from the facility 2 days prior, eloped again during the night, and was found approximately 3 ½ hours later more than 3 miles from the facility by a staff member on her way to work. The staff had not placed a Wanderguard, a monitoring device, on the resident as would have been appropriate given her medical history. Elant at Brandywine received an immediate jeopardy citation, the most serious classification, as a result of this incident.

Elopement occurs when a nursing home resident, usually a resident with Alzheimer's or dementia, is allowed to exit the facility without supervision. Elopement of cognitively impaired nursing home residents can result in falls, fractures, brain injuries, hypothermia or heat stroke.

Website Resources:

New York State Dept. of Health, Elant at Brandywine, September 2, 2009 Survey.
Long-Term-Care Community Coalition, 9/09-12/09 NY Enforcement Action Report.