Articles Posted in Nursing Home Violations

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A new report by New York Attorney General Letitia James’s office found that some nursing home facilities in the state had inadequate personal protective equipment at the outset of the Covid-19 pandemic, putting their residents at increased risk of harm.

The report, released last week, notes that both state and federal laws mandate that nursing homes provide adequate infection control supplies to their staff and residents in order to protect them from the risk of contracting or spreading diseases like Covid-19. The Attorney General’s office found that some nursing homes failed to comply with these requirements, and that if these failures had not taken place, New York’s nursing homes may have experienced “better health outcomes” for their residents. Continue reading

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New York Attorney General Letitia James has called for state lawmakers to lift the partial immunity from civil lawsuits it gave to nursing home facilities early in the Covid-19 pandemic, according to a report by NBC New York. The immunity shield, granted in the spring of 2020, gave nursing homes as well as hospitals and other healthcare providers protection from civil suits as well as criminal prosecution.

Lobbyists behind the legislation described it as a means of protecting overextended healthcare providers, like nursing homes, from lawsuits that might cripple them for trying their best to care for patients during the pandemic. Over the summer, state legislators lifted some of the immunity provisions, specifically those regarding patients who didn’t have Covid-19. According to NBC News, “It has never applied to instances of gross negligence, intentional criminal or reckless misconduct.” Still, nursing home and other healthcare providers remained shielded from lawsuits or prosecutions over their Covid-19. Continue reading

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A new report by New York Attorney General Letitia James found that the state may have undercounted nursing home Covid-19 fatalities by as much as 50%, and that nursing homes may be responsible for “nearly one in every three coronavirus fatalities in the state.” The report, released last week, found a litany of failures by nursing homes to implement infection prevention and control procedures, from failing to isolate nursing home residents infected with Covid-19 to failing to test staffers for the novel coronavirus.

According to the New York Post, Attorney General James said in a statement that “As the pandemic and our investigations continue, it is imperative that we understand why the residents of nursing homes in New York unnecessarily suffered at such an alarming rate… While we cannot bring back the individuals we lost to this crisis, this report seeks to offer transparency that the public deserves and to spur increased action to protect our most vulnerable residents.”

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Elderwood at Williamsville suffered three confirmed COVID-19 deaths as of January 23, 2021, according to state records. The facility has also received 19 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 23, 2020. The Williamsville 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 adequately protect residents from accidents. Section 483.25 of the Federal Code requires nursing homes to ensure each resident environment is ‘as free of accident hazards as is possible.” A February 2019 citation found that Elderwood at Williamsville failed to ensure such. The citation states specifically that three resident units “had issues involving electric heating units in resident rooms with metal surfaces that were very hot to touch and were not shielded from resident access.” In an interview, the facility’s Director of Maintenance said that the nursing home “does not monitor the metal surface temperatures of wall-mounted electric heaters.” A plan of correction undertaken by the facility included the movement of resident beds away from the heaters.

2. The nursing home did not protect residents from the unnecessary use of psychotropic medication. Section 483.25 of the Federal Code stipulates that nursing homes must ensure that residents do not receive psychotropic medications unless they are clinically necessary, and that residents who use them receive gradual dose reductions in an effort to discontinue their use. A February 2019 citation found that Elderwood at Williamsville failed to ensure such. The citation states specifically that one resident receiving an anti-psychotic medication did not receive gradual dose reduction attempts and that there was no documented evidence of behaviors that supported the continued use of the medication. A plan of correction undertaken by the facility included the implementation of a gradual dose reduction.

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A new report by the Long Term Community Care Coalition found that nursing homes are understaffed even as their resident populations shrink. The LTCCC published new data regarding staffing levels at every nursing home in the United States on January 22, 2021, with the goal of helping “the public, news media, and policymakers identify and assess the extent to which nursing homes in their communities provided sufficient staffing to meet basic clinical and quality of life needs.” The data is sourced from the Centers for Medicare & Medicaid Services, which collects information from nursing homes around the country. Continue reading

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Elderwood at Cheektowaga suffered 18 confirmed COVID-19 deaths as of January 23, 2021, according to state records. The facility has also received 27 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 23, 2020. The Cheektowaga 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 adequately prevent and control infection. Under Section 483.80 of the Federal Code, nursing homes are required to create and maintain an infection control program “designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” A November 2019 citation found that Elderwood at Cheektowaga failed to ensure such. The citation states specifically that in one resident unit, dirty bed linens “were placed directly on the floor without a protective barrier,” and that in another unit, oxygen tubing “was observed directly on the floor during multiple observations,” all in contravention of facility policy. A plan of correction undertaken by the facility included the discarding of the tubing and the re-education of the staff member who placed dirty linens on the floor.

2. The nursing home did not sufficiently prevent medication errors. Under Section 483.25 of the Federal Code, nursing homes must keep their residents “free of any significant medication errors.” A January 2019 citation found that Elderwood at Cheektowaga failed to ensure such. The citation states specifically that one resident’s medications “were not ordered in accordance with discharge medications specified on the hospital discharge summary.” The resident according received incorrect dosages of certain medications, and didn’t receive other medications at all. A plan of correction undertaken by the facility included an audit and reconciliation of the medical records.

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Elderwood at Hamburg suffered 26 confirmed COVID-19 deaths as of January 17, 2021, according to state records. The facility has also received 36 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 17, 2020. The Hamburg 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 employ adequate measures to prevent and control infection. Section 483.80 of the Federal Code stipulates that nursing homes must create and maintain an infection prevention and control program “designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” A September 2020 citation found that Elderwood at Hamburg failed to ensure such. The citation states specifically  that the facility failed to maintain a program “to ensure the health and safety of residents to help prevent the transmission of COVID-19.” It goes on to state that the nursing home failed to maintain social distancing on two resident care units. A surveyor observed residents “sitting side by side in wheelchairs less than 6 feet apart across from the Unit 2 Nurses Station,” with face masks hanging on the back of their wheelchairs. When a Registered Nurse walked past the residents, the citation states, she “made no attempt to socially distance the residents six feet apart.” A plan of correction undertaken by the facility included Covid-19 testing for the residents in question, who were found to be negative.

2. The nursing home did not protect residents from accidents. Section 483.25 of the Federal Code requires nursing homes to provide residents with adequate supervision to prevent accidents. An October 2019 citation found that Elderwood at Hamburg failed to ensure such. The citation states specifically that the facility “did not provide fluid in the consistency ordered by the Physician” for two residents. It goes on to state that they were served soup at an incorrect consistency. A plan of correction undertaken by the facility included the placement of one of the residents on aspiration precautions and the re-education of relevant staff.

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The New York State Health Department has told the Empire Center for Public Policy, a watchdog group, that it requires three more months to respond to a records request for an accounting of Covid-19 deaths in nursing homes, “because the records potentially responsive to your request are currently being reviewed for applicable exemptions, legal privileges and responsiveness.”

According to a report in the New York Post, the Empire Center submitted a Freedom Of Information Law request in early August, asking for “the total number of COVID-19 nursing home fatalities,” including those who died in nursing homes and those who died after being sent to hospitals. As things stand, the Health Department’s accounting only includes residents “physically died in nursing homes.” Continue reading

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Newfane Rehab & Health Care Center suffered 21 confirmed and 7 suspected COVID-19 deaths as of January 17, 2021, according to state records. The facility has also received 36 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 17, 2020. The Newfane 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 protect residents from accidents. Under Section 483.25 of the Federal Code, nursing homes must provide every resident with “adequate supervision and assistance devices to prevent accidents.” A September 2019 citation found that Newfane Rehab & Health Care Center failed to ensure such. The citation states specifically that a resident who was care-planned to receive check-ups every 15 minutes and one-to-one supervision when off-unit was “observed wandering off the unit with no 1:1 staff or 15-minute check.” A plan of correction undertaken by the facility included the updating of the resident’s care plan and a monthly review of weekly wander-guard system summaries.

2. An August 2018 citation also found that Newfane Rehab & Health Care Center failed to adequately comply with accident hazard protocols. The citation states specifically that three resident care units “had issues with water temperatures exceeding 120 degrees Fahrenheit… in resident rooms and care areas.” The citation goes on to state that a resident who smokes had not received a smoking assessment, and that fall prevention interventions were not executed as plans for another resident. A plan of correction undertaken by the facility included the adjustment of a water mixing valve.

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Our Lady of Peace Nursing Care Residence suffered 22 confirmed COVID-19 deaths as of January 17, 2021, according to state records. The facility has also received 13 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 17, 2020. The Lewiston 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 adequately protect residents from accidents. Section 483.25 of the Federal Code requires nursing homes to provide residents with sufficient supervision and assistive devices to prevent them from sustaining accidents. A January 2020 citation found that Our Lady of Peace Nursing Care Residence failed to ensure such for one resident. The citation states specifically that the resident was on aspiration precautions and that their care plan provided for “small bites and sips, alternate solids with liquids, encourage to eat slow, supervision assistance with eating.” However, the citation states, the resident was not adequately supervised during a mealtime and “was observed to cough several times.” A plan of correction undertaken by the facility included a review of aspiration precaution procedures and the re-education of nurses involved with the resident’s feeding assistance.

2. The nursing home did not take adequate steps to promote the healing of pressure ulcers. Under Section 483.25 of the Federal Code, nursing home residents have a right to a level of care that promotes the healing of pressure ulcers. The citation states specifically that the resident’s “pressure ulcer treatment was not completed as planned.” The citation states specifically that Santyl was applied to the resident’s sacral area when it was supposed to be applied to the right gluteal ulcer. In an interview, the Registered Nurse involved in the treatment said she had never completed the resident’s treatment before, and that “Normally, she would check the computer to review the order prior to completing the treatment, but today she did not.” A plan of correction undertaken by the facility included the re-education of relevant staff.

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