New York Nursing Home Attorney Report: Peekskill Nursing Home Found Substandard in DOH Report

In a detailed deficiency survey dated January 31, 2012, the Department of Health cited West Ledge Rehabilitation and Nursing Home in Peekskill, NY for several areas of substandard care. Two such areas involved the development and implementation of care plans.

A facility must develop a comprehensive care of plan for each individual under its supervision. The care plan must be unique to the individual, including measurable objectives to meet the resident’s needs. One resident, although diagnosed with a history of urinary tract infections, was not given a care plan to address potentially recurring UTI’s. Due to the patient’s history, this should have been included in the care plan. The resident had shown a propensity for developing these infections. The facility did not provide an explanation for why this was not addressed in the care plan.

The services provided by the facility must be administered by qualified persons in accordance with each resident’s care plan. The DOH report illustrates how West Ledge failed in this regard. One resident, diagnosed with cellulitis and osteoarthritis, had a physician’s order that required a chair alarm be in place when the resident was out of bed. This may have been to prevent a potentially dangerous fall. She was observed out of bed without a chair alarm, however. The Nurse Manager revealed that the chair alarm had been discontinued by a staff member, but not a physician (a physician initially put the order in place). The physician reportedly felt that this was a necessary intervention, yet it appears from the DOH report that someone else independently changed the order. This, according to federal regulations, is unacceptable.

Care plans are created to provide nursing home residents with a path toward rehabilitation and recovery. They include safety measures to ensure that a resident is monitored and unable to inadvertently harm him or herself. When a care plan is inaccurate, or is not followed, the possibility of harm is increased.

For a full report of the DOH findings, click here.

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