Choking/Aspiration

January 11, 2021

The Commons at St. Anthony: Covid-19 Outbreak Infects 137, Kills 24

by Law Offices of Thomas L. Gallivan, PLLC

An outbreak of the novel coronavirus has infected 137 residents and killed 24 at The Commons at St. Anthony, a nursing home in Auburn, New York. According to a report on syracuse.com, the outbreak began on December 21, 2020, “as a wave of post-Thanksgiving Covid-19 cases began hitting the county,” per an official overseeing the home’s operations. The outbreak has affected 47 employees. Of the residents who died, 21 died at the nursing home, while three died at the hospital. Prior to the first three deaths that were reported at the nursing home on December 29, 2020, “There had been no nursing home Covid-19 deaths in Cayuga County.” As of the report’s publication on January 9, there have been 2,650 confirmed cases in Cayuga county.

According to the report, the nursing home responded to the pandemic by requiring employees to wear “gowns, gloves and face shields at all times when working with residents,” and isolated positive cases on their own floors. Employees are tested weekly, while residents are tested “on a schedule established by the state Health Department.” An infection by state health authorities found no issues with the nursing home’s infection control policies and procedures.

Records maintained by the Health Department show that as of January 8, 2021, The Commons at St. Anthony had received 27 citations for violations of public health code between 2016 and 2020. The citations resulted from a total of six inspections by state surveyors. They include the following:

October 18, 2020

Elderwood at Waverly: 19 Coronavirus Fatalities

by Law Offices of Thomas L. Gallivan, PLLC

Elderwood at Waverly suffered 19 fatalities from Covid-19 as of July 18, 2020, per state records. The nursing home also received 17 citations finding it violated public health code between 2016 and 2020, according to health records accessed on July 20, 2020. It was additionally the recipient of a 2019 fine in connection to findings in a 2018 survey that it violated unspecified health code provisions. The Waverly nursing home’s citations resulted from a total of six surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not properly supervise residents to prevent accidents. Section 483.25 of the Federal Code requires nursing homes to ensure resident environments are kept as free as possible of accident hazards, and that residents received “adequate supervision and assistance devices to prevent accidents.” A January 2019 citation found that Elderwood at Waverly failed to ensure residents received an adequate level of supervision with the use of assistance devices. The citation specifically describes a resident with “moderate cognitive impairment” who required the assistance for transfers and walking. “The resident utilized a wheelchair and walker, was not steady when moving fro a seated to standing position and for surface to surface transfers,” according to the citation, which goes on to describe an instance in which the resident was observed “self-propelling from the dining room to her room using doorways and handrails to assist” and with her feet under her wheelchair’s leg rest foot plates; it also describes another instance in which she stood from her wheelchair to move to the other side of a table in the dining room, and another in which she self-propelled with her feet under her wheelchair’s leg rests. In an interview, the facility’s Director of Therapy stated that “any resident who self-propelled in a wheelchair with their legs and feet should not have leg rests on the chair due to the risk to fall and impeding mobility.” A plan of correction undertaken by the facility included a revision of the resident’s care plan concerning the use of leg rests.

2. The nursing home did not protect residents from abuse. Section 483.12 of the Federal Code requires nursing homes to protect each resident’s right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” An October 2018 citation found that Elderwood at Waverly failed to ensure such. The citation specifically describes a resident who “was observed on video being hit by facility staff.” According to the citation, a Registered Nurse “bent to kiss the resident on her forehead” after administering medication, at which point the resident struck theRN in the face, and the RN “responded by grabbing and slapping the resident’s left arm.” A plan of correction undertaken by the facility included the termination of the RN.

October 16, 2020

Long Island State Veterans Home: 66 Covid Fatalities, Citations

by Law Offices of Thomas L. Gallivan, PLLC

Long Island State Veterans Home suffered 66 fatalities from Covid-19 as of July 18, 2020, per state records. The nursing home also received 10 citations finding it violated public health code between 2016 and 2020, according to health records accessed on July 20, 2020. The Stonybrook nursing home’s citations resulted from a total of two surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not take adequate steps to prevent accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure resident environments remain as free from accident hazards as is possible, and that residents receive adequate supervision to prevent accidents. An August 2016 citation found that Long Island State Veterans Home failed to ensure such for one resident. The citation specifically describes a resident who “was observed during a meal being fed by a family member using unsafe techniques.” It goes on to state that the resident was “seated with his head slightly extended,” while the family member was standing over the resident “Forcing his hands down on the table with her left hand while feeding the resident with a spoon.” In an interview, the facility’s Charge Nurse Registered Nurse told a surveyor that the family member “does feed the resident for lunch and dinner three times a week.” In a separate interview, the family member said “she holds his hands down as a distraction so he will eat the food off the spoon.” A plan of correction undertaken by the facility included the education of the family member regarding safe feeding practices.

2. The nursing home did not ensure the reporting of medication irregularities. Section 483.45 of the Federal Code provides for the regular review of resident drug regimens by a licensed pharmacist, and requires the pharmacist to report any irregularities to the resident’s attending physician. A March 2019 citation found that Long Island State Veterans Home did not ensure such. The citation states specifically that a resident received 2.5 milligrams of a redacted medication every eight hours when necessary for 14 days, “without supporting documentation for the use.” The citation additionally states that there was “no documented evidence the Pharmacy Consultant” reported the irregularity to the resident’s physician. The citation states that this deficiency had the “potential to cause more than minimal harm.”

July 18, 2020

Hill Haven Nursing Home: 16 Covid-19 Deaths

by Law Offices of Thomas L. Gallivan, PLLC

Hill Haven Nursing Home suffered 16 fatalities from Covid-19 as of July 12, 2020, state records report. The nursing home also received 29 citations over violations of public health code between 2016 and 2020, according to health records accessed on July 13, 2020. The Webster nursing home’s citations resulted from a total of seven surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not adequately protect residents from neglect. Section 483.12 of the Federal Code stipulates that nursing homes must ensure residents are kept free from abuse and neglect. A November 2019 citation found that Hill Haven Nursing Home did not ensure such for one resident. The citation states specifically that the resident “did not receive incontinence care, positioning, or bedtime care for two consecutive shifts resulting in skin issues.” After a Certified Nursing Assistant reported to a Licensed Practical Nurse that it appeared the resident had not received care—that the resident “was still sitting in the chair, wearing the same clothes as the previous day, and was soaked with urine and feces through the incontinence brief and the pants”—the Registered Nurse Manager initiated an investigation and found that the resident had not received care over two shifts and “remained in the chair all nigh.” A plan of correction undertaken by the facility included the re-education and disciplining of relevant staff.

2. The nursing home did not adequately protect residents from accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure resident environments are kept as free as possible of accident hazards, and that residents are provided with adequate supervision to prevent accidents. A July 2019 citation found that Hill Haven Nursing Home did not ensure such. The citation specifically describes a resident who “rolled out of bed and was found with his legs resting on the baseboard heater that was next to his bed” and sustained a redacted injury to hi slower extremities. A plan of correction undertaken by the facility included the relocation of the resident to another room with a bed that was further from the baseboard heater.

April 10, 2020

Medford Multicare Center for Living Cited for Choking Incident, Pressure Ulcer Care

by Law Offices of Thomas L. Gallivan, PLLC

Medford Multicare Center for Living received 63 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 4, 2020. The Medford nursing home’s citations resulted from a total of 19 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately protect residents from neglect. Section 483.12 of the Federal Code requires nursing homes to ensure each resident’s “right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A May 2018 citation found that Medford Multicare Center for Living did not ensure such for one resident. The citation states specifically that a Certified Nursing Assistant gave the resident food “that was intended for another resident,” and that the resident subsequently consumed the food from their tray and choked. A plan of correction undertaken by the facility included the termination of the CNA and the revision of the resident’s care instructions to include a “nothing by mouth” instruction.

March 9, 2020

Hempstead Park Nursing Home Cited, Fined $18,000

by Law Offices of Thomas L. Gallivan, PLLC

Hempstead Park Nursing Home received 30 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 5, 2020. The facility has also been the subject of a 2012 fine of $10,000 in connection to findings during a 2009 inspection that it violated unspecified health code provisions; and a 2011 fine of $8,000 in connection to findings in a 2010 inspection that it violated health code provisions regarding mistreatment and neglect, the investigation and reporting of alleged violations, social services, and administrative practices and procedures. The Hempstead nursing home’s citations resulted from a total of four surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately supervise residents. Under Section 483.25 of the Federal Code, nursing homes must ensure residents receive “adequate supervision and assistance devices to prevent accidents.” A May 2019 citation found that Hempstead Park Nursing Home did not ensure such for one resident. The citation states specifically that the resident had been “identified as at risk for aspiration,” yet was observed eating in their bed without supervision. In an interview, a Certified Nursing Assistant told an inspector that “she was not aware the resident was supposed to eat in the dining room while supervised by staff.”

January 19, 2020

Bezalel Rehabilitation and Nursing Center Cited for Accident Hazards

by Law Offices of Thomas L. Gallivan, PLLC

Bezalel Rehabilitation and Nursing Center received 25 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 9, 2020. The Far Rockaway nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not ensure residents’ drug regimens were free from unnecessary psychotropic medications. Section 483.45 of the Federal Code requires that nursing homes keep residents’ drug regimens free from the unnecessary use of any drugs that affect “brain activities associated with mental processes and behavior. A June 2019 citation found that Bezalel Rehabilitation and Nursing Center did not ensure a resident properly received gradual dose reductions to discontinue the use of a psychotropic medication. The citation states specifically that the resident was admitted to the nursing home already receiving the medication, but the facility did not attempt a gradual dose reduction, and “there was no evidence that the resident displayed any mood or behavioral symptoms that warranted continued use of the medication without a GDR attempt.” The citation states further that the nursing home did not attempt, before the resident was admitted, to confirm their psychiatric history.

2. The nursing home did not maintain an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing homes are required to provide residents with an environment as free as possible from accident hazards, and with adequate supervision to ensure that residents do not experience accidents. A June 2016 citation found that the nursing home did not take adequate accident prevention measures with respect to one resident who had planned monitoring for swallowing difficulty and aspiration precautions. According to these citations, the precautions included “being observed while eating, sitting upright while eating and for at least 30 minutes after eating, never eat in bed and if resident experiences coughing or secretions, during or without meal hold the feed till totally clear.”