Articles Posted in Neglect

Northern Manhattan Rehabilitation and Nursing Center received 24 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on February 7, 2020. The Manhattan nursing home’s citations resulted from a total of six surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not keep medication error rates adequately low. Section 483.45 of the Federal Code requires nursing home facilities to maintain medication error rates below five percent. A March 2019 citation found that Northern Manhattan Rehabilitation and Nursing Center did not keep medication rates below that threshold. An inspector specifically found that one of the facility’s Licensed Practical Nurses did not administer medication to a resident as ordered, because it “was not in stock at the facility,” resulting in the resident never receiving their ordered daily dosage. The citation states that separately, another Licensed Practical Nurse administered a resident’s injectable medication through an incorrect route. The citation states that these deficiencies had the “potential to cause more than minimal harm.”

2. The nursing home did not implement adequate measures to investigate allegations of misconduct. Under Section 483.12 of the Federal Code, nursing homes are required to investigate, and provide evidence of investigations, any allegations of abuse, neglect, exploitation, or mistreatment. An April 2018 citation found that Northern Manhattan Rehabilitation and Nursing Center did not maintain evidence “that all alleged violations involving resident abuse by facility staff were reported to New York State Department of Health.” The underlying alleged violation was the report by a resident’s family member that a staff member “slapped the resident in her face,” which the citation states the facility failed to report to regulatory authorities in compliance with facility procedure stating that reports “must be made immediately upon having reasonable cause.” A plan of correction undertaken by the facility included the in-servicing of facility staff on relevant policy.

St. Mary’s Center received 26 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on February 7, 2020. The Manhattan 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 failed to prevent residents from taking unnecessary drugs. Section 483.45 of the Federal Code requires that nursing home facilities maintain “each resident’s drug regimen… free from unnecessary drugs.” A March 2017 citation found that St. Mary’s Center did not ensure each of its residents drug regimens were free of unnecessary drugs. An inspector specifically found that one of its residents was administered a certain anti-psychotic medication “without a clear continued indication for use, and without an attempt at gradual dose reduction within the last year.” The citation states that the resident was documented as having intact cognition, “no mood or potential indicators” of a redacted medical condition, “no hallucinations and no delusions,” as well as “no physical or verbal… behaviors noted.” The citation also states that there was no documented evidence that the facility attempted to gradually reduce the resident’s medication dosage, in accordance with federal regulations. A plan of correction undertaken by the facility included the reduction of the medication and continued monitoring of the resident.

2. The nursing home failed to prevent residents from taking unnecessary psychotropic medications. Section 483.45 of the Federal Code also requires that nursing homes ensure residents are not administered unnecessary psychotropic medications, which the code defines as “any drug that affects brain activities associated with mental processes and behavior.” A September 2019 citation found that two residents at Saint Mary’s Home were prescribed psychotropic medications for a redacted condition “with no evidence of behaviors to support the ongoing use of” medication for that condition, and without any attempted gradual dose reductions within the previous two years. A plan of correction undertaken by the facility included the evaluation of both residents by a psychiatrist and attending physician, and the completion for one resident of a gradual dose reduction.

Northern Riverview Health Care Center received 26 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 14, 2020. The Haverstraw 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 keep residents’ drug regimens free from unnecessary psychotropic medications. Section 483.45 of the Federal Code requires nursing homes to keep resident drug regimens free from medications that affect “brain activities associated with mental processes and behavior.” A November 2018 citation found that Northern Riverview Health Care Center did not ensure such. The citation specifically describes a resident for whom the facility did not implement a gradual dose reduction or provide sufficient documentation contra-indicating gradual dose reduction for the use of a medication to treat depression and another redacted disorder. A plan of correction undertaken by the facility included the evaluation of the resident by a psychiatrist and the discontinuation of the medication.

2. The nursing home did not implement proper measures to prevent and control infection. Section 483.80 of the Federal Code requires nursing homes to create and maintain “an infection prevention and control program designed to provide a safe, sanitary and comfortable environment.” A November 2018 citation found that Northern Riverview Health Care Center did not take ensure such a program was maintained. An inspector specifically observed a resident caring for her tracheostomy tube with an improper technique and without using proper hand hygiene measures. In an interview, the resident stated that she had been taught to perform the activity by a doctor in a hospital rather than by facility staff. The citation states further that the resident’s care plan contained no evidence that facility staff trained the resident or attempted to train her to care for her device in a manner that would prevent the potential spread of infection and cross contamination. The citation describes this deficiency as having the “potential to cause more than minimal harm.”

Campbell Hall Rehabilitation Center received 48 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 20, 2020. The facility has also been the subject of a 2016 fine of $12,000 in connection to findings during a 2013 inspection that it violated health code provisions regarding accidents and resident assessments; a 2016 fine of $4,000 in connection to findings during a 2011 inspection that it violated health code provisions regarding accidents and administration; and a 2016 fine of $2,000 in connection to findings during a 2015 inspection that it violated health code provisions regarding the adequate maintenance of hydration. The Campbell Hall nursing home’s citations resulted from a total of five surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately supervise its residents. Section 483.25 of the Federal Code requires nursing homes to provide a resident environment “as free of accident hazards as is possible” as well as “adequate supervision and assistance devices to prevent accidents.” A June 2019 citation found that Campbell Hall Rehabilitation Center did not adequately supervise a resident’s smoking and use of oxygen.  The citation states specifically that a smoking assessment was not completed before the resident was provided cigarettes, and that such an assessment would have identified “smoking safety/hazard risks and strengths,” and would have “initiated care plans with measurable goals and interventions” for the resident. A plan of correction undertaken by the facility included the education of nursing staff and a smoking assessment of the resident.

2. The nursing home did not take adequate measures to ensure the prevention and control of infection. Under Section 483.80 of the Federal Code, nursing homes “must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment.” A June 2019 citation found that Campbell Hall Rehabilitation Center did not establish and/or maintain such. The citation states specifically that the nursing home neglected to “develop a site-specific water management plan for testing for Legionella.” The citation goes on to state that the nursing home had no “sampling plan” established, and “did not obtain required water samples” to test for Legionella. A plan of correction undertaken by the facility included the contacting of its water system operator to take the necessary tests.

Glen Arden received 15 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 20, 2020. The Goshen 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 employ adequate measures to prevent elopement. Section 483.25 of the Federal Code requires nursing homes to provide residents with “adequate supervision and assistance devices to prevent accidents.” An October 2018 citation found that Glen Arden did not adequately supervise one resident “with cognitive impairment” to prevent elopement. The citation states specifically that the nursing home “did not ensure that electronic devices functioned effectively to alert the staff, prevent unsafe wandering and elopement.” As a result, according to the citation, the resident managed to “bypass an alarm device” and exit the premises unbeknownst to staff. The citation states additionally that the facility was not “free from accident hazards,” noting that “multiple areas in both resident units… had poorly maintained flooring.” The citation states that these deficiencies had the “potential to cause more than minimal harm.”

2. The nursing home did not meet food safety standards. Section 483.60 of the Federal Code stipulates that nursing homes must ensure that they “Store, prepare, distribute and serve food in accordance with professional standards for food service safety.” An October 2018 citation found that Glen Arden did not ensure the storage of food in such a manner that food-borne illness was prevented. The citation states specifically that the nursing home did not prevent the storage of uncooked ground beef in a refrigerator beyond its shelf life; the storage of food on the floor of a walk-in refrigerator; and the maintenance of a walk-in freezer’s floor in a clean condition. The citation states that these deficiencies had the “potential to cause more than minimal harm.”

Daleview Care Center received 19 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 27, 2020. The Farmingdale 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 implement adequate measures to protect residents from accidents. Section 483.25 of the Federal Code requires nursing homes to ensure resident environments are maintained “as free of accident hazards as is possible” and to provide residents with “adequate supervision and assistance devices to prevent accidents.” A November 2016 citation found that Daleview Care Center did not ensure such in one of its two facility buildings. An inspector specifically found that one building “no exit alarm system in place for the front and back exit doors for residents who utilized a wanderguard.” Although the building’s back doors had exit alarms, according to the citation, they did not have alarms that were triggered by the devices, and the front doors did not have exit alarms. A plan of correction undertaken by the facility included the transfer of a resident with a wanderguard to a more secure building.

2. The nursing home did not comply with food safety standards. Section 483.60 of the Federal Code stipulates that nursing home facilities must “Store, prepare, distribute and serve food in accordance with professional standards.” A December 2017 citation found that Daleview Care Center did not maintain all equipment in its two kitchens in a clean and sanitary fashion. An inspector specifically observed a “heavily soiled” stainless steel dish machine “with dried-on splashes and in need of thorough cleaning”; a heavily soiled stainless steal box covering part of the kitchen’s Ansel system; and a heavily soiled broiler rack and pan. A plan of correction undertaken by the facility included the cleaning of the relevant equipment. 

The Five Towns Premier Rehabilitation & Nursing Center received 28 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 17, 2020. The facility has also received five fines between 2013 and 2019, totaling $58,000, for findings that it violated health code provisions concerning accidents, administration, quality of care, and more. The Woodmere nursing home’s citations resulted from a total of seven surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate treatment and care for residents with pressure ulcers. Section 483.25 of the Federal Code requires nursing homes to provide residents without pressure ulcers necessary care to prevent pressure ulcers from developing unless unavoidable, and residents with pressure ulcers the necessary care to promote healing, prevent infection, and prevent the development of new ulcers. An October 2018 citation found that The Five Towns Premier Rehabilitation & Nursing Center did not provide such for two residents. The citation states specifically that a resident who was at moderate risk of developing a pressure ulcer developed two ulcers after admission, and that their wounds “were not promptly identified, reported, assessed and monitored, and treatments were not implemented as per the physician’s orders.” As for the other resident, the citation states that they had a stage 4 pressure ulcer, but a physician’s recommendation that they be hospitalized for debridement of the wound was not addressed, resulting in harm to the resident.

2. The nursing home did not ensure residents were protected from significant medication errors. Section 483.45 of the Federal Code requires nursing homes to ensure residents’ are kept “free of any significant medication errors.” An October 2018 citation found that The Five Towns Premier Rehabilitation & Nursing Center did not ensure such for one resident. The citation found specifically that a Licensed Practical Nurse administered an ear medication to the resident’s eye. Later, the resident “complained of mild irritation to the eyes” and “was noted with redness to the eyes.” In an interview, the LPN said that while administering the drug she was “distracted because she was conversing with the [resident’s] family member.” A plan of correction undertaken by the facility included the educational counseling of the LPN.

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.

Presbyterian Home for Central New York suffered 15 fatalities from Covid-19 as of July 12, 2020, per state records. The nursing home also received 37 citations finding it violated public health code between 2016 and 2020, according to health records accessed on July 13, 2020; two such citations found deficiencies in the facility’s infection control practices. The facility has also received fines totaling $14,000 after findings that it violated health code provisions, such as those concerning quality of care and resident rights. The New Hartford 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 implement infection control measures. Section 483.80 of the Federal Code requires nursing homes to establish procedures designed to ensure resident safety and comfort by preventing and controlling infection. A June 2019 citation found that Presbyterian Home for Central New York did not ensure such. The citation sates specifically that resident staff did not perform proper hand hygiene between residents during a medication pass, and that a glucometer “was not sanitized between resident use.” The citation goes on to state that a Licensed Practical Nurse did not perform hand hygiene before or after completing bedside glucose testing for a resident, and did not complete hand hygiene during the preparation and administration of a resident’s insulin. A plan of correction undertaken by the facility included the re-education of the nurse on proper hand-washing technique.

2. A December 2017 citations also found Presbyterian Home for Central New York did not adequately implement infection control procedures. The citation states specifically that the nursing home “did not maintain infection control protocol while providing care” for a resident on contact precautions. It goes on to state that in contravention of facility policy, a Licensed Practical Nurse entered the resident’s room without donning a gown. The citation notes that the resident’s condition “was very infectious and could be spread if not gowning.” In an interview, the facility’s Director of Nursing stated that staff were expected to wear a gown when entering the room of a resident on contact precautions.

A new study in the Journal of the American Geriatrics Society concludes that nursing homes with low staffing levels, low quality scores, and high concentrations of disadvantaged residents also experience “higher rates of confirmed COVID-19 cases and deaths.”

The study’s lead author, Yue Li, a professor at the University of Rochester Medical Center Department of Public Health Sciences, said in a statement: “In nursing homes, quality and staffing are important factors, and there already exists system-wide disparities in which facilities with lower resources and higher concentrations of socio-economically disadvantaged residents have poorer health outcomes… These same institutional disparities are now playing out during the coronavirus pandemic.”

The study notes that long-term care facility residents are demonstrably vulnerable to respiratory diseases like influenza and coronaviruses, and that research suggests COVID-19 “disproportionately impacts older adults and individuals with chronic health conditions.” This makes nursing homes, which have high concentrations of elderly adults with chronic health conditions, especially vulnerable to COVID-19. Since the pandemic reached the United States, roughly 50,000 deaths related to the novel coronavirus “have been linked to nursing homes,” according to the study.

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