Brooklyn nursing home Keser Nursing and Rehabilitation Center received deficient ratings in ten standard health inspection categories during a March, 2014 inspection conducted by the New York State Department of Health. Among the deficiencies reported by the DOH were failure to establish an infection control program, failure to inform of accidents and/or significant changes in resident status, and failure to ensure that a resident’s nutritional status remains unchanged unless unavoidable.
A nursing home must establish and maintain an infection control program to minimize and help prevent the spread of infection. During its inspection of Keser, the DOH encountered several situations for which it cited the facility. First, a resident’s nasal tubing was not properly secured behind his ears, but rather allowed to hang in such a way that it was touching the floor. Inspectors also noted several instances in which garbage pails and trash bins were left uncovered in common eating areas, subjecting eating residents to a potential spread of infection from the refuse.
The remaining two deficiencies referenced above involve a single resident, a sixty year old male with multiple underlying conditions including diabetes, hypertension, and epilepsy. Per the report, the resident also displayed “severely impaired cognitive skills for daily decision making.” During routine weight checks, it was noted that the man had lost eighteen pounds, nearly eleven percent of his total body weight, in the several months prior to late October, 2013. The dietary note for this resident also documented conflicting information, at one time stating that the patient’s appetite was “fair to good,” yet at another stating that he was eating less than 75% of his meals. Despite this weight loss and the differing information in the notes, no new interventions were ordered for the resident. The physician’s notes from the relevant time period list the resident’s weight as steady at 170 pounds, again in conflict with the weight records. During an interview with the Department of Health regarding this patient, the current physician informed investigators that the doctor who had written the notes for August, September, and October 2013 was no longer employed by the nursing home.