Pressure Sores

October 9, 2020

Do “No Harm” Citations Adversely Affect Nursing Home Accountability?

by Law Offices of Thomas L. Gallivan, PLLC

A new edition of the Long Term Care Community Coalition Elder Justice Newsletter asks a simple question: does providing a nursing home resident breakfast in their soiled bed constitute harm? How about failing to provide a stop date for a resident’s psychotropic medication?

“No Harm” deficiencies refer to citations of rule violations at nursing homes in which health inspectors determined that the violations caused “no harm” to residents. As the LTCCC notes, data provided by the Centers for Medicare & Medicaid Service, which mandate minimum standards of care for nursing homes participating in their programs, show that more than 95% of nursing home health citations describe “no harm” deficiencies. The LTCCC argues, however, that these no harm citations reflect systemic failures to recognize the suffering of nursing home residents, which in turn results in systemic failures to hold nursing homes accountable through financial penalties. “In the absence of a financial penalty,” the newsletter states, “nursing homes may have little incentive to correct the underlying causes of resident abuse, neglect, and other forms of harm.”

The newsletter proceeds to provide instances of health violations in which regulators determined that no harm was done to the resident in question. For example:

October 6, 2020

Sapphire Nursing and Rehab at Goshen Cited for Pressure Ulcers

by Law Offices of Thomas L. Gallivan, PLLC

Sapphire Nursing and Rehab at Goshen received 49 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 eight surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not properly implement procedures to prevent residents from eloping. Section 483.25 of the Federal Code requires nursing home facilities to provide residents with “adequate supervision and assistance devices to prevent accidents,” including unsafe wandering off the facility’s premises. A June 2019 citation found that Sapphire Nursing and Rehab at Goshen did not ensure one resident was adequately supervised. The citation states that the resident had been assessed at low risk for elopement, but that the facility did not reassess the resident’s supervisory needs after the resident “behavior changes potentially related to increased risk for elopement.” The resident, according to the citation, “exited the building undetected, passing thorough a supervised common room and a supervised lobby, when the assigned staff were distracted by residents that required immediate attention in each of those areas.” The citation goes on to state that the resident was discovered by staff about 20 minutes afterward, then escorted back into the facility. This deficiency, according to the citation, had the “potential to cause more than minimal harm.”

2. The nursing home did not keep maintain sufficiently low medication error rates. Section 483.45 of the Federal Code stipulates that nursing home facilities must keep their medication error rates below five percent. A January 2018 citation found that Sapphire Nursing and Rehab at Goshen a rate below five percent for two residents. An inspector specifically observed administer one resident a multivitamin with minerals even though the physician’s orders “did not include instructions for the multiple minerals ingredient of the medication.” The inspector also observed a Licensed Practical Nurse incorrectly administer another resident’s eyedrops. The citation found that these deficiencies had the “potential to cause more than minimal harm.”

September 30, 2020

Spring Creek Rehabilitation & Nursing Care Center Cited for Pressure Ulcer

by Law Offices of Thomas L. Gallivan, PLLC

Spring Creek Rehabilitation & Nursing Care Center received 33 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 21, 2019. Those citations number one more than the statewide average of 32. 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 nursing home did not implement proper measures to treat, heal, and prevent pressure ulcers and bedsores. Section 483.25(c) of the Federal Code stipulates that nursing home facilities must ensure that residents who enter without pressure sores do not develop them unless their condition renders such unavoidable; and that residents with existing pressure sores receive proper treatment and services. A September 2018 citation found that Spring Creek Rehabilitation and Nursing Care Center failed to comply with this requirement in connection to one resident observed by a state inspector. That resident was specifically observed on numerous instances not wearing the protective heel device ordered by his physician and documented in his comprehensive care plan. The citation notes that the resident had a stage 3 pressure ulcer on his right heel, and as such was required to wear a pressure-relieving device or devices as appropriate. However, the resident was observed on multiple instances without the necessary devices, and the inspector states that “there were no skin checks or dressing changes occurring” at the instances in question. In an interview, a Certified Nursing Assistant said that “sometimes she forgets” to apply the resident’s protective devices and returns later to apply them.

2. The nursing home did not employ adequate measures to prevent and control infection. Under Section 483.80 of the Federal Code, nursing home facilities must “establish and maintain an infection prevention and control program” that creates a “safe, sanitary and comfortable environment.” A September 2018 citation states that the nursing home did not ensure such an environment, specifically by failing to clean or properly maintain “multiple areas in the laundry room.” An inspector observed that the room in question was not “in good repair or condition,” specifically noting that the walls contained chipped paint, that a drain behind a washing machine was dirty, that the drain was “littered with paper,” and that there was a presence of “brown colored” and stagnant water. The inspector also observed a clogged water drain, dust and water built up on the floor beside a washing machine, a sink with a dirty handle, and brown streaks on a washing machine and dryer. In an interview, the facility’s Director of Nursing stated that “she did not know why the laundry room was in such a condition.”

September 17, 2020

Franklin Center for Rehabilitation and Nursing Cited for Pressure Sores

by Law Offices of Thomas L. Gallivan, PLLC

Franklin Center for Rehabilitation and Nursing received 26 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 12, 2019. The Flushing nursing home’s citations resulted from a total of three inspections by state authorities. The deficiencies they describe include the following:

1. The facility did not adequately implement measures to prevent and heal pressure ulcers. Section 483.25 of the Federal Code states that nursing homes must prevent residents with “care, consistent with professional standards of practice, to prevent pressure ulcers.” A November 2017 citation found that Franklin Center for Rehabilitation and Nursing did not ensure the provision of professional standards of care to a resident suffering from a Stage 4 pressure ulcer. The citation states specifically that a nurse applied to the wound “a dressing appliance that was too small,” and employed an “improper technique” to dry the resident’s pressure wound. According to the citation, the nurse applied gauze that only partially covered the wound, leaving its border as well as some “excoriated redness” exposed. The citation states that this deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not adequately protect residents from abuse and neglect. Section 483.12 of the Federal Code ensures nursing home residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A July 2019 found that the nursing home did not protect this right in an instance in which residents sustained an injury during a “resident-to-resident altercation.” According to the citation, the altercation specifically resulted in one resident experienced “a laceration to her right leg that required sutures,” and another “was punched in the head by another resident and suffered a headache and poor vision.” The facility undertook a plan of correction relating to this incident that included the education of licensed nurses on the facility’s Resident to Resident Abuse policy, as well as the adoption of a Behavior Monitoring policy.

September 10, 2020

Oceanview Nursing & Rehabilitation Center Cited over Pressure Sores

by Law Offices of Thomas L. Gallivan, PLLC

Oceanview Nursing & Rehabilitation Center received 30 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The facility was also the subject of a 2009 fine of $2,000 in connection to findings it violated health code provisions regarding accidents. The Far Rockaway nursing home’s citations resulted from a total of four inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not provide necessary care to promote the prevention and healing of pressure ulcers. Under Section 483.25(c) of the Federal Code, nursing homes must offer residents adequate treatment and services to promote the healing of pressure ulcers and bedsores, and to ensure that residents admitted without such do not develop them unless their condition renders it unavoidable. A January 2019 citation found that Oceanview Nursing & Rehabilitation Center did not ensure two residents were provided with necessary treatment and services to prevent the development of pressure ulcers. An inspector observed specifically that a Licensed Practical Nurse did not follow a physician’s order to treat a resident’s wound with dry gauze, instead treating it with a saline-soaked gauze pad. An inspector also observed another resident on two separate instances not wearing heel boots in accordance with a physician’s orders. The citation states that these deficiencies had the “potential to cause more than minimal harm.”

2. The nursing home did not provide residents with necessary treatment and devices to maintain hearing and vision. Section 483.25 of the Federal Code requires that nursing homes must ensure that residents “receive proper treatment and assistive devices to maintain vision and hearing abilities,” including by facilitating scheduling of and transportation to specialist appointments if necessary. A May 2016 citation found that the nursing home failed to ensure it addressed an ophthalmologist’s recommendation for one resident. An inspector specifically found that there was no documented evidence that the resident was seen by a retinologist, per the ophthalmologist’s recommendation. In an interview, the facility’s nurse practitioner stated that she misread the ophthalmologist’s consult, and as such did not know that the ophthalmologist had recommended the resident see a retinologist.

September 1, 2020

Dr. Susan Smith McKinney Nursing and Rehabilitation Center Cited for Abuse

by Law Offices of Thomas L. Gallivan, PLLC

Dr. Susan Smith McKinney Nursing and Rehabilitation Center received 17 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The facility also received a 2019 fine of $4,000 in connection to findings of multiple deficiencies observed in a February 11, 2019 survey. The Brooklyn nursing home’s citations resulted from a total of two surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not ensure residents’ freedom from abuse. Under Section 483.12 of the Federal Code, nursing home residents have the right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A February 2019 citation found that the nursing home did not ensure staff provided residents with services necessary to avoid “physical pain, mental anguish, or emotional distress.” The citation found specifically that one of the facility’s Certified Nursing Assistants tied a resident’s left hand to bed rails using a plastic bag, resulting in psychosocial harm for the resident, “who was totally dependent on staff for all care needs, an unable to call for assistance or help.” The citation also states that another CNA “rough handled” another resident while trying to provide care. A plan of correction undertaken by the facility included the removal of the CNAs in question.

2. The nursing home did not ensure residents’ right to freedom from physical restraints. Sections 483.10 and 483.12 of the Federal Code provides nursing home residents with the right to be “free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms.” A February 2019 citation found that facility staff unnecessarily used physical restraints to inhibit a resident’s freedom of movement. The citation specifically describes a Certified Nursing Assistant tying a resident’s hand to their bed rail with a plastic bag, stating later that “she restrained the resident because he became resistive as she tried to clean feces from his hand.” The citation notes that the resident had no orders to be restrained and that the CNA was allowed by the facility to continue providing the resident with care for two days following the incident. A plan of correction undertaken by the facility states that the CNA as well as a Registered Nurse who “did not report the incident to facility administrative staff” in a timely manner were both removed from the facility. The citation also notes that the incident resulted in “actual harm” to the resident in question.

August 2, 2020

Rockville Skilled Nursing & Rehabilitation Center Cited for Pressure Ulcers

by Law Offices of Thomas L. Gallivan, PLLC

Rockville Skilled Nursing & Rehabilitation Center received 18 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 14, 2020. The Rockville Centre 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 treat and care for residents’ pressure ulcers and bedsores. Section 483.25 of the Federal Code requires nursing homes ensure that residents with pressure ulcers receive “necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A December 2017 citation found that Rockville Skilled Nursing & Rehabilitation Center did not ensure one resident with pressure ulcers received such. The citation states specifically that although a nurse noted the resident’s bilateral heels had “discoloration and were soft and tender,” the Registered Nurse’s full assessment of that resident’s heels “was not relayed to the physician in a timely manner, resulting in a delay in treatment.” In an interview, the Registered Nurse Supervisor stated that she had assessed the resident and documented her findings, but “forgot to write a progress note,” and then passed the findings to a wound nurse. In an interview, that nurse stated that she told the RN supervisor that a note had to be put in the resident’s medical record, and further that told the facility’s Assistant Director of Nursing Services about the resident’s condition, who “wanted to wait for the progress note to be written.”

2. The nursing home did not take adequate measures to prevent residents from being administered unnecessary psychotropic drugs. Section 483.45 of the Federal Code requires nursing homes to ensure that “Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.” A December 2017 citation found that Rockville Skilled Nursing & Rehabilitation Center did not ensure residents taking medication for a redacted condition received gradual dose reductions, “unless clinically contraindicated, in an effort to discontinue these drugs.” The citation specifically describes one resident who was prescribed an antipsychotic medication, Quetiapine, and whose psychiatrist and pharmacy consultant “both recommended a tapering of the medication.” However, according to the citation, “there was no documented evidence that the physician took any action” to implement this recommendation. A plan of correction undertaken by the facility included the implementation of the drug’s dose reduction.

August 1, 2020

Sands Point Center for Health and Rehabilitation Cited for Pressure Sores

by Law Offices of Thomas L. Gallivan, PLLC

Sands Point Center for Health and Rehabilitation received 35 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 15, 2020. The Port Washington 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 provide adequate pressure ulcer care and treatment. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with pressure ulcers “necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A July 2018 citation found that Sands Point Center for Health and Rehabilitation did not ensure such for one resident. The citation states specifically that “there was no documented evidence that a skin condition to the sacrum was assessed or received treatment until five days after the resident was admitted to the facility.” In an interview, the facility’s wound nurse stated that she had not seen the resident until several days after a note was left for her about the wound, and that “the wound should have been treated sooner.” The facility’s Medical Doctor stated further, in an interview, that “the doctor should have been called over the weekend and a treatment initiated.”

2. The nursing home did not take adequate measures to protect residents from the use of unnecessary drugs. Under Section 483.45 of the Federal Code, nursing homes are required to keep “each resident’s drug regimen… free from unnecessary drugs.” A March 2017 citation found that Sands Point Center for Health and Rehabilitation did not ensure such for three residents. The citation goes on to state specifically that one resident was administered an antipsychotic medication despite an absence of any “documented justification or attempts at non-pharmacological intervention”; that another resident was administered an antipsychotic medication without an appropriate diagnosis and that a third resident was administered multiple drugs, including an antipsychotic, without an appropriate psychiatric diagnosis. The citation states that this deficiency had the “potential to cause more than minimal harm” to residents.

July 28, 2020

The Five Towns Premier Rehabilitation & Nursing Center Fined $58,000

by Law Offices of Thomas L. Gallivan, PLLC

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.

July 26, 2020

Our Lady of Consolation Nursing and Rehabilitative Care Center Cited for Abuse

by Law Offices of Thomas L. Gallivan, PLLC

Our Lady of Consolation Nursing and Rehabilitative Care Center received 36 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 9, 2020. The West Islip 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 prevent sexual abuse. Section 483.12 of the Federal Code provide nursing home residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A December 2017 citation found that Our Lady of Consolation Nursing and Rehabilitative Care Center did not ensure that right for one resident. The citation states specifically that a Certified Nursing Assistant witnessed a resident “expose his penis and place” a female resident’s “right hand on his exposed genitalia.” The citation goes on to state that the resident’s records, although they documented past inappropriate behavior, “lacked addressing specific behaviors” for the resident “such as keeping [him] arm’s length away from the female residents.” A plan of correction undertaken by the facility included the resident’s discharge.

2. The nursing home did not adequately treat and care for pressure ulcers. Section 483.25 of the Federal Code stipulates that nursing home facilities “ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A November 2016 citation found that Our Lady of Consolation Nursing and Rehabilitative Care Center did not ensure a resident’s pressure ulcer was assessed after it was identified, nor that a weekly measurement was initiated to monitor its progress. The citation states further that the nursing home did not ensure the review of a physician’s treatment order so as to guarantee the appropriate treatment of the pressure ulcer. In an interview, the facility’s Director of Nursing Services stated that the facility’s Registered Nurse Unit Manager should have initiated the Wound Assessment and Progress Record, and further that the physician who had cared for the resident had “since resigned.”