Bedford Center for Nursing and Rehabilitation Cited for Pressure Ulcers

Bedford Center for Nursing and Rehabilitation received 36 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 22, 2019. It also received a Department of Health fine of $6,000, in September 2011, over alleged violations of sections of the health code relating to the investigation and reporting of allegations, accidents and supervision, and administrative practices. The Brooklyn nursing home’s citations resulted from a total of four inspections by state surveyors. The deficiencies they describe include the following:

1. The facility did not provide an adequate level of treatment and services to prevent and heal pressure ulcers. Section 483.25 of the Federal Code states that nursing homes must provide residents with “care, consistent with professional standards of practice, to prevent pressure ulcers.” A November 2018 citation found that Bedford Center for Nursing and Rehabilitation failed to ensure that a resident received adequate care to prevent pressure ulcers. An inspector specifically observed on multiple instances that the resident was in their bed without wearing heel booties. According to the citation, the resident was at “very high risk” for skin breakdown, and medical orders directed that heel booties be applied while the resident is in bed. In interviews, both a Registered Nurse and a Licensed Practical Nurse stated that they were not certain why the resident was not wearing the necessary assistive devices while in bed.

2. The nursing home did not ensure resident drug regimens were free from unnecessary drugs. Under Section 483.45 of the Federal Code, nursing homes must maintain “each resident’s drug regimen… free from unnecessary drugs,” which includes drugs used in excessive dosage or without adequate indications for their use. A February 2017 citation describes the nursing home’s failure to ensure resident drug regimens were free from unnecessary drugs on two instances. In one, a resident was administered insulin even though their blood glucose level was short of the ordered parameters for insulin administration. In the second, a resident’s antipsychotic medication was reordered even though “there was no documented evidence in the medical record of specific behaviors or rationale to support the reordering.” The citation states that these deficiencies had “potential to cause more than minimal harm.”

3. The nursing home did not employ adequate infection control practices. Section 483.65 of the Federal Code states in part that nursing homes must “establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.” An April 2016 citation describes the nursing home’s failure to ensure the maintenance of infection control practices in two capacities. In one, an inspector observed a Registered Nurse failing to remove gloves, wash her hands, and put on clean gloves after cleaning a resident’s stage 3 pressure ulcer. In the second, an inspector observed a respiratory therapist caring for residents without washing his hands in between.

The attorneys at the Law Offices of Thomas L. Gallivan, PLLC work diligently to protect the rights of nursing home residents.  Please contact us to discuss in the event you have a potential case involving neglect or abuse.

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