Pressure Sores

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:

January 5, 2021

Corning Center for Rehabilitation and Healthcare: 28 Covid-19 Deaths

by Law Offices of Thomas L. Gallivan, PLLC

Corning Center for Rehabilitation and Healthcare suffered 28 confirmed COVID-19 deaths as of January 2, 2021, according to state records. The facility has also received 33 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 2, 2020. The Corning nursing home’s citations resulted from a total of six surveys by three inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately protect residents from accident hazards. Under Section 483.25 of the Federal Code, nursing home residents are required to be provided with an environment that is “as free of accident hazards as is possible.” A March 2018 citation found that Corning Center for Rehabilitation and Healthcare failed to ensure such when it served sliced turkey to a resident “who was on a mechanical soft diet with ground meats.” In an interview, one of the facility’s Licensed Practical Nurses stated that “according to the tray ticket, the resident should have received ground turkey, not sliced.” The facility’s Director of Food Services stated in an interview that “someone on the tray line must have made a mistake.” A plan of correction undertaken by the facility included the re-education of dietary staff.

2. The nursing home did not implement 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 designed to… help prevent the development and transmission of communicable diseases and infections.” A March 2018 citation found that Corning Center for Rehabilitation and Healthcare failed to ensure such. The citation states specifically that in connection to one resident, “there was improper incontinence care and lack of glove changing and handwashing,” and that shower stretchers used by the facility for several residents “were not clean.” A plan of correction undertaken by the facility included the cleaning of shower stretchers and the re-education of the Certified Nursing Assistant who failed to provide proper incontinent care.

December 31, 2020

The Riverside: 48 Covid-19 Deaths, Abuse Citation

by Law Offices of Thomas L. Gallivan, PLLC

The Riverside suffered 48 confirmed and 17 presumed COVID-19 deaths as of December 26, 2020, according to state records. The nursing home has also received 53 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on December 26, 2020. The New York 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 protect residents from abuse. Under Section 483.12 of the Federal Code, nursing home residents have a right to freedom from abuse and neglect. A June 2020 citation found that The Riverside failed to ensure such. The citation states specifically that a resident who had “dementia and a history of physical aggression” participated in four altercations with other residents after the facility transferred her to a new unit. According to the citation, the facility did not put interventions in place to address this resident’s behavior and to protect other residents in the unit. It goes on to state that one altercation resulted in a laceration to the crown of another resident’s head; a subsequent altercation resulted in the aggressor’s transfer to the hospital for evaluation. A plan of correction undertaken by the facility included the review and revision of her care plan.

2. The nursing home did not provide adequate treatment for dementia. Section 483.40 of the Federal Code requires that nursing homes provide residents suffering from dementia with “appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.” A June 2020 citation found that The Riverside failed to provide such. The citation states specifically that the facility did not take individualized interventions in response to a resident’s “increasing dementia-related behaviors that occurred after a room change,” specifically, the resident’s instigation of physical altercations with other residents, including hitting one over the head with a footrest. A plan of correction undertaken by the facility included the creation of a person-centered care plan for the resident.

November 24, 2020

Nursing Home Excess Deaths Balloon During Covid-19

by Law Offices of Thomas L. Gallivan, PLLC

A new report by the Associated Press illustrates the devastating toll of the Covid-19 pandemic on nursing home residents across the country. The tragedy is not limited to Covid-19 deaths themselves, but also to deaths from other causes that ballooned as staff dealt with Covid-19 patients. One expert cited in the report estimated that “for every two COVID-19 victims in long-term care, there is another who died prematurely of other causes.” Ultimately, they concluded, there may have been more than 40,000 more “excess deaths” in nursing homes since March, compared to the same period in previous years.

The expert, professor Stephen Kaye at the University of California, San Francisco, attributes the spike in excess deaths to staffing issues at nursing homes. By comparing death rates at nursing homes that experienced outbreaks to nursing homes that didn’t, he found that “the more the virus spread through a home, the greater the number of deaths recorded for other reasons,” which suggests that healthcare workers were “consumed” caring for Covid-19 patients—and/or contracted the illness themselves—and therefore unable to devote adequate care to residents without Covid-19. Kaye suggests this effect was compounded by longstanding staffing issues at nursing homes: “In 20 states where virus cases are now surging,” the report observes, “federal data shows nearly 1 in 4 nursing homes report staff shortages.” Continue reading

November 23, 2020

Baptist Health Nursing and Rehabilitation Center: Pressure Ulcer Citation

by Law Offices of Thomas L. Gallivan, PLLC

Baptist Health Nursing and Rehabilitation Center has received 34 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 28, 2020. The facility has also received two fines totaling $12,000 in connection to findings that it violated health code provisions, among others, regarding quality of care.. The Scotia 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 properly implement infection-control measures. Under Section 483.80 of the Federal Code, nursing homes are required to take steps to prevent and control infection via the maintenance of an infection control program that ensures residents a comfortable and sanitary environment. An August 2017 citation found that Baptist Health Nursing and Rehabilitation Center failed to ensure such. The citation states specifically that staff did not properly wear personal protective equipment when necessary, glucometers were not disinfected after use, and employees “did not observe Contact Precautions during Foley catheter care and when providing housekeeping services to 2 residents.” A plan of correction undertaken by the facility included the education of nurses on glucometer cleaning, the education of a certified nursing assistant on proper foley catheter emptying, the education of a housekeeper and CNA on contact precautions, and the education of nursing staff on wound care techniques.

November 20, 2020

Ellis Residential & Rehabilitation Center: Infection, Pressure Ulcer Citations

by Law Offices of Thomas L. Gallivan, PLLC

Ellis Residential & Rehabilitation Center has received 29 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 28, 2020. The facility has also received a 2016 fine of $20,000 in connection to findings in an earlier inspection that it violated health code provisions regarding accidents, resident assessments, abuse, staff treatment of residents, and administrative practices. The Schenectady 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 infection-control measures. Section 483.80 of the Federal Code requires nursing homes to “establish 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 January 2019 citation found that Ellis Residential & Rehabilitation Center did not ensure such. The citation states specifically that it failed to ensure staff who did not get a flu shot properly wore surgical masks in resident areas, “leaving residents at higher risk for transmission of the flu.” It also states that with respect to a resident on contact precautions, the nursing home “did not ensure that staff donned a gown and gloves prior to entering the resident’s room.” The citation finally states that the nursing home failed to ensure the annual review of its Infection Control policies. A plan of correction undertaken by the facility included the audit of staff required to wear masks, and the re-education of staff regarding face masks.

2. The nursing home took inadequate care of residents’ pressure ulcers. Section 483.35 of the Federal Code states that nursing homes must provide pressure ulcer patients with necessary care to promote healing. A January 2019 citation found that Ellis Residential & Rehabilitation Center failed to ensure such for one resident, and for a second resident “did not initiate interventions to address identified pressure ulcer risk factors to prevent pressure ulcer development with the subsequent development of a pressure ulcer.” The citation goes on to state that the first resident’s records did not contain any documentation reflection the provision of care to the resident’s pressure ulcers. The citation states that these deficiencies had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the education of registered nursing staff.

November 19, 2020

Glendale Home Cited for Infection, Pressure Ulcer Care

by Law Offices of Thomas L. Gallivan, PLLC

Glendale Home has received 23 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 28, 2020. The Scotia 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 adequately prevent infection. Under Section 483.80 of the Federal Code, nursing home facilities must endeavor to prevent and control infection via the establishment and maintenance of a program to provide residents with a sanitary and comfortable environment. A March 2019 citation found that Glendale Home failed to ensure such. The citation states specifically that the nursing home “did not ensure standard precautions were maintained during a dressing change” and that it further failed to maintain standard precautions while a staffer administered a resident’s eyedrops. The citation goes on to state that “a face mask was not properly worn by an employee while on a resident unit.” A plan of correction undertaken by the facility included the assessment of the first resident’s wounds, the assessment of the second resident’s eyes, and the re-education of nursing staff on relevant policies and procedures.

2. Glendale Home received another citation for deficiencies in its infection control practices in June 2017. According to this citation, the nursing home did not maintain proper precautions during dressing changes for two residents. In one instance, staffers were observed leaving equipment on the floor without protective covering, and failing to change gloves after contaminating them. In another, a nurse did not wash her hands or change her gloves during two changes of a resident’s inner knee dressing, and “did not treat the wounds as two separate wounds as she did not complete one dressing change to the inner knee, wash her hands and change gloves and then proceed to the next inner knee dressing change.” The citation states that these deficiencies had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the in-servicing of relevant staff.

November 15, 2020

Groton Community Health Care Center Residential Care Facility: Infection Citation

by Law Offices of Thomas L. Gallivan, PLLC

Groton Community Health Care Center Residential Care Facility has received 96 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received fines totaling $20,000 in connection to findings that it violated health code provisions regarding equipment conditions, pressure sore care, accidents, and administrative practices. The Groton 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 comply with infection control practices and procedures. Section 483.80 of the Federal Code requires nursing homes to “establish 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 January 2019 citation found that Groton Community Health Care Center Residential Care Facility did not ensure such. The citation states specifically that facility staff did not perform hand hygiene while changing a resident’s wound pressure ulcer wound dressing. The citation goes on to describe a Licensed Practical Nurse who, while treating the resident’s wound, “removed her soiled gloves after removing the old dressing, then immediately donned another pair of gloves without performing hand hygiene.” In an interview, the nurse said “she should have performed hand hygiene between glove changes.” In another interview, the facility’s infection control nurse said that “she expected staff to perform hand hygiene after removing and before replacing gloves when completing a dressing change.”

2. The nursing home did not adequately prevent medication errors. Under Section 483.45 of the Federal Code, nursing homes must keep residents “free of any significant medication errors.” A May 2018 citation found that Groton Community Health Care Center Residential Care Facility failed to ensure such for one resident. It goes on to describe specifically a resident who “was not consistently provided with her heart medication as ordered and the facility did not identify the root cause to prevent reoccurrence.” A plan of correction undertaken by the facility included the review and revision of the facility’s medication error policy and the provision of a monthly review of medication error’s to the facility’s QAA committee and Medical Director.

November 13, 2020

Beechtree Center for Rehabilitation and Nursing Cited for Infection

by Law Offices of Thomas L. Gallivan, PLLC

Beechtree Center for Rehabilitation and Nursing has received 65 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received a 2016 fine of $10,000 in connection to findings in a 2012 inspection that it violated health code provisions concerning abuse, accidents, staff treatment of residents, and administrative practices. The Ithaca nursing home’s citations resulted from a total of nine surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not employ adequate measures to prevent infection. Section 483.80 of the Federal Code requires nursing homes to mitigate the risk of infection via the creation and maintenance of an infection control program. An August 2019 citation found that Beechtree Center for Rehabilitation and Nursing did not ensure such for one resident. The citation states specifically that the facility did not maintain infection control standards during a resident’s pressure ulcer dressing change. It goes on to describe the facility’s failure to “provide appropriate personal protective equipment (PPE) or a way to perform hand hygiene in the soiled laundry sorting area; and washers and dryers were not maintained according to the user manual.” The citation describes these deficiencies as having the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the re-dressing of the resident’s pressure ulcer and the placement of PPE in the laundry room.

2. The nursing home did not adequately supervise residents. Section 483.25 of the Federal Code requires nursing homes to provide residents with adequate supervision to prevent accidents. An August 2019 citation found that Beechtree Center for Rehabilitation and Nursing did not ensure such for one resident. The citation states specifically that the facility had no plan in place to address the resident’s smoking. it goes on to state that the resident in question “was observed smoking independently after he had been assessed by the facility to be a safety risk and not eligible for safe-smoking.” The resident, who is described as having “impaired tactile sensation, did not light his own cigarette safely and was likely to drop smoking material.” According to the citation, he flicked ashes onto the ground and threw cigarette butts on the ground but “was not able to put them out.” An assessment found that the resident “was a safety risk and was not eligible for a safe-smoking contract.” A plan of correction undertaken by the facility included the facility’s provision, to the resident, of a smoking alternative.

November 7, 2020

Wayne County Nursing Home: Infection, Pressure Ulcer Citations

by Law Offices of Thomas L. Gallivan, PLLC

Wayne County Nursing Home has received 29 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 14, 2020. The Lyons 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 implement adequate infection control measures. Section 483.80 of the Federal Code requires, among other things, that nursing homes create and maintain a program to prevent and control infection and maintain a sanitary environment for residents. A June 2017 citation found that Wayne County Nursing Home failed to ensure such. The citation states specifically that the nursing home did not have proper data analysis for infections, did not properly implement infection control techniques in connection to one resident’s incontinence care, failed to prevent a transfer sling and oxygen concentrator from becoming soiled, and failed to prevent the soiling of resident’s toilet seat and bathroom wall. The citation states that these deficiencies had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the in-servicing of all staff on infection control, hand hygiene, personal protective equipment policy and equipment cleaning.

2. The nursing home did not adequately care for pressure ulcers. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with necessary services to prevent the development of pressure ulcers and to promote the healing of pressure ulcers. A November 2016 citation found that Wayne County Nursing Home failed to ensure such. The citation specifically describes a “lack of communication regarding skin breakdown, lack of timely assessment, documentation, and treatment of” a resident’s pressure ulcer. A plan of correction undertaken by the facility included the review of all residents’ skin assessments over the prior 30 days to determine whether they received proper treatment.