DOH Inspectors: Nursing Home Failed to Treat Patients with Dignity and Did Not Adhere to Policies to Prevent Infections

According to a February 2014 New York State Department of Health Inspection report, the Katherine Luther Residential Health Care & Rehabilitation center, a 280-bed nursing home located in Clinton, New York, failed to respect the dignity of patients and did not follow proper procedures to prevent infections. In one instance, a resident suffering from dementia, osteoporosis and COPD was observed eating oatmeal with her bare hands. The resident, who needed help with her personal hygiene, wiped the oatmeal in her hair and on her clothes. After sitting for three hours with dried food in her hair, the resident finally got the attention of a CNA who simply brushed the oatmeal from the patient’s clothes and hair. When asked about the incident, a supervising nurse stated that the CNA should have immediately washed the patient’s hair and changed her clothes.

gauze.jpgIn another instance, a resident who suffered from dementia, anxiety and depression was observed sitting in the hallway with dried blood between his nose and lip. The patient’s care plan mandated that staff members monitor the resident because he was at risk of bleeding due to his anticoagulation medication. However, while the elderly resident sat in the hallway with dried blood on his face, staff members ignored him; one CNA said “hi” to the patient and kept on walking. When asked about the incident, a supervising nurse stated that the CNA should have stopped to clean the man’s face. In addition, the CNA should have asked a nurse to assess the man’s condition to ensure that the bleeding had stopped.

The facility was also cited for incidents in which staff members failed to follow policies to prevent infections. For instance, one resident had developed a stage II pressure sore. While eating in the dining room, inspectors for the DOH observed that the resident’s wound dressing had fallen off. A nurse stated that she would replace the dressing as soon as the patient was done eating. The nurse did not change the dressing until two hours later. When she finally did change the dressing, the nurse touched a floor mat in order to move it. She then touched the sterile gauze that was going to be used to clean the wound with the hand she used to touch the dirty floor mat. The inspector told her to change her gloves and find a new piece of gauze. The nurse later stated that she should have changed the dressing sooner, and that she should have changed her gloves and the gauze after touching the floor mat.

In another instance, an Alzheimer’s patient who suffered from urinary incontinence was observed sitting in the dining room with his catheter bag on the floor. A CNA saw the bag on the floor but did nothing about it. When the same patient went to the bathroom, the catheter bag was still filled with some urine and was draped over a metal bar. The bag was also uncapped. A registered nurse stated that the bag should have been emptied, rinsed, capped and then sealed in a plastic bag for safe storage in order to prevent an infection.

According to the “Nursing Home Compare” website, Katherine Luther nursing home received an overall rating of below average. Its health inspection results were considered much below average.

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