Articles Posted in Pressure Sores

Van Duyn Center for Rehabilitation and Nursing suffered 13 coronavirus deaths as of May 17, 2020, per state records. The nursing home also received 78 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on May 18, 2020. The facility has additionally received seven enforcement actions, including: a 2019 fine of $2,000 in connection to findings in a 2015 inspection that it violated unspecified health code provisions; a 2018 fine of $10,000 in connection to findings in a 2015 inspection that it violated unspecified health code provisions; and a 2016 fine of $40,000 in connection to findings that it violated health code provisions regarding transfer and discharge requirements, discharge, quality of care, and staff treatment of residents. The Syracuse nursing home’s citations resulted from a total of 14 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not take adequate measures to prevent infection. Section 483.80 of the Federal Code requires nursing homes to maintain an infection control program that ensures residents a sanitary environment. A January 2017 citation found that Van Duyn Center for Rehabilitation and Nursing did not ensure such. The citation states specifically that two employees “did not receive the flu vaccine, did not sign a declination of influenza vaccination, and were observed wearing their flu masks incorrectly.” The citation goes on to state that eight other employees wore their flu masks incorrectly, “potentially exposing residents and staff to influenza.” The citation states that this deficiency had the “potential to cause more than minimal harm.”

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The Hamlet Rehabilitation and Healthcare Center at Nesconset received 37 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 19, 2020. The Nesconset 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. Section 483.12 of the Federal Code requires nursing homes to “Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.” A September 2018 citation found that The Hamlet Rehabilitation and Healthcare Center at Nesconset did not ensure such for one resident. The citation states specifically that the resident in question “reported allegations of sexual and verbal abuse to facility staff,” and these allegations were not “promptly reported” to administrative authorities and investigated until the following day. in an interview, the facility’s social worker said that although she usually interviews residents making such allegations as soon as possible, “she was not made aware of any of the resident’s allegations of abuse” on the day they were made, instead learning of them at a staff meeting the following morning. A plan of correction undertaken by the facility included the in-servicing of relevant staff.

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A new report by the Long Term Community Care Coalition asks the question: “Can animals in a zoo or kennel expect better treatment and conditions than that which many human nursing home residents actually receive?” Noting that its goal is not to trivialize the experiences of nursing home residents or animals, the report seeks to demonstrate how nursing homes are subject to systemic accountability failures, resulting in rampant abuse and neglect that “not only fall below the federal nursing home standards of care, but also below accepted standards for the humane treatment of animals.”

The report compares conditions in eleven key areas of interest: freedom from abuse and neglect; general care and treatment; sufficient staffing with appropriate skills and competencies; nutrition and hydration; safe food handling; medical supervision; simulating and safe environment; freedom from restraints; treatment of injuries; appropriate medications; and infection control and prevention. Below is what the LTCCC found in each of those categories.

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The Hamptons Center for Rehabilitation and Nursing received 18 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 24, 2020. The Southampton 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 prevent medication errors. Section 483.45 of the Federal Code requires nursing homes to ensure residents “are free of any significant medication errors.” A June 2017 citation found that The Hamptons Center for Rehabilitation and Nursing did not ensure such for one resident. The citation states specifically that the resident received was administered the wrong dose of an anti-arrhythmic agent for ten days In an inspection, a Licensed Practical Nurse was observed preparing to administer the resident a pill from a blister packet labeled 400 milligrams. When informed by a surveyor that the physician’s orders were for the resident to receive a different dosage, and asked why there was a 400 milligram blister pack on the medication cart along with a 200 milligram blister pack, the LPN stated that the larger packet “was discontinued and should not have been on the cart.” A plan of correction undertaken by the facility included the removal of the 400 milligram blister pack and the education and disciplinary counseling of involved nursing staff.

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Suffolk Center for Rehabilitation and Nursing received 51 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 15, 2020. The facility has also received two fines: one 2017 fine of $10,000 in connection to findings in a 2016 inspection that it violated health code provisions regarding quality of care; and one 2016 fine of $10,000 in connection to findings in a 2013 inspection that it violated health code provisions regarding quality of care. The Patchogue 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 maintain low enough medication error rates. Section 483.45 of the Federal Code requires nursing home facilities to ensure medication error rates below five percent. A December 2018 citation found that Suffolk Center for Rehabilitation and Nursing did not ensure a low enough rate. The citation states specifically that an inspector observed two errors out of 27 opportunities in a medication pass, leading to an error rate of 7.4 percent. The citation goes on to state that a Licensed Practical Nurse crushed a resident’s medication tablets whose blister packets stated “Do Not Crush.” In an interview, the LPN stated that she had not read the instructions. The facility’s consultant pharmacist stated in an interview that when crushed, one of the medications causes a bitter taste and may cause diarrhea, while the other would be more difficult to swallow. A plan of correction undertaken by the facility included the in-servicing of the facility’s medication nurses.

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St. Johnland Nursing Center received 37 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 11, 2020. The facility has also received a 2019 fine of $2,000 in connection to findings in a 2019 inspection that it violated unspecified health code provisions. The Kings Park 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 abuse. Section 483.12 of the Federal Code gives nursing home residents “the right to be free from abuse.” A January 2019 citation found that St. Johnland Nursing Center did not ensure such for one resident. The citation states specifically that one resident demonstrated a “history” of chasing after another, female resident “with a show in his hand.” The citation describes an incident in which the male resident “aggressively grabbed” the female resident’s wheelchair, “causing her to fall to the floor” in an “altercation” which lasted for more than 13 minutes and which staff did not witness, according to the citation. A plan of correction undertaken by the facility included the counseling of staff responsible for monitoring the aggressor resident, who was “placed on 1:1 supervision” for a period of two weeks.

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Yonkers Gardens Center for Nursing and Rehabilitation received 43 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 24, 2020. The Yonkers 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 take adequate measures to prevent accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure resident environments that are as free as possible from accident hazards, and that they provide every resident with adequate supervision and assistance to prevent accidents. A May 2019 citation found that Yonkers Gardens Center for Nursing and Rehabilitation did not ensure such. The citation specifically describes a resident who was cognitively impaired and depended on the help of one staffer for toileting, hygiene, and dressing. It goes on to describe an interview in which the resident said that due to a broken commode frame in his bathroom, he had been using a public restroom in the hall near his room, and “had fallen several times in his room and once in the lavatory.” A plan of correction undertaken by the facility included the placement of the left side of the commode frame in the resident’s bathroom, and the evaluation of the resident by a physical therapist.

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Pinnacle Multicare Nursing and Rehabilitation Center received 29 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 24, 2020. The facility has also received a 2012 fine of $18,000 in connection to findings in a 2011 inspection that it violated health code provisions regarding abuse, accidents, nutrition, and nurse aid competency; and a 2011 fine of $4,000 in connection to findings in a 2009 inspection that it violated health code provisions regarding quality of care and nutrition. The Rye nursing home’s citations resulted from a total of five inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not protect residents from the administration of unnecessary drugs. Section 483.25 of the Federal Code requires nursing homes to keep “each resident’s drug regimen… free from unnecessary drugs.” An April 2016 citation found that Pinnacle Multicare Nursing and Rehabilitation Center did not ensure such for one resident. The citation states specifically that the resident continued to receive sliding scale insulin coverage even after this treatment was discontinued. In an interview, the resident’s physician stated that the resident’s monitoring order “should have been changed when the order for the sliding scale insulin was discontinued.” The citation states that this deficiency had the “potential to cause more than minimal harm.”

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Luxor Nursing and Rehabilitation at Sayville received 34 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 3, 2020. The facility has also received two fines: one 2011 fine of $10,000 in connection to findings in a 2010 inspection that it violated health code provisions regarding pressure ulcers, and one 2010 fine of $10,000 in connection to findings in a 2009 inspection that it violated health code provisions regarding quality of care. The Sayville 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 implement measures to treat and care for residents with bedsores / pressure ulcers. Under Section 483.25 of the Federal Code, nursing homes must ensure residents with pressure ulcers are provided “necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.” A November 2018 citation found that Luxor Nursing and Rehabilitation at Sayville did not ensure such for one resident. The citation states specifically that there was “no documented evidence that the resident’s heels were being offloaded and no documented evidence of timely follow-up after the resident complained about right heel pain,” and that the resident developed a Stage II pressure ulcer on their right heel. A plan of correction undertaken by the facility included the in-servicing of a staff nurse regarding how to communicate a patient’s wound development to the wound care nurse.

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Maria Regina Residence received 18 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 4, 2020. The Brentwood 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 care for bedsores / pressure ulcers. Section 483.25 of the Federal Code requires nursing homes to ensure that residents with pressure ulcers receive necessary treatment and care. A May 2019 citation found that Maria Regina Residence did not ensure such for one resident. The citation states specifically that the resident developed a Stage II pressure ulcer on their right heel, but that there was “no documented evidence of monitoring of the pressure ulcer” for a several week-long period after its development. In an interview, the facility’s Director of Nursing Services stated that she “could not commented why the wound care team had not been following the resident’s heel ulcer.” A plan of correction undertaken by the facility included the in-servicing of all licensed nurses and the addition of the resident’s pressure ulcer to the wound management section of their medical record.

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