Sapphire Nursing and Rehab at Goshen Cited for Pressure Ulcers

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.”

3. The nursing home did not provide residents with adequate pressure ulcer care. Under Section 483.25 of the Federal Code, nursing home facilities are required to provide residents with care and services to promote the healing of pressure ulcers. A January 2018 citation found that Sapphire Nursing and Rehab at Goshen did not ensure one resident received adequate care to promote the healing of a pressure ulcer. An inspector specifically found that “the use of a new topical treatment recommended by the Nurse Practitioner… was not ordered or implemented to promote healing for a non-healing pressure ulcer” on the resident’s right heel. The citation states that the resident’s Treatment Administration Record continued no evidence that this recommendation was carried out, and instead documented that the resident continued to receive treatments “that had been discontinued.” According to the citation, this deficiency had the “potential to cause more than minimal harm.”

The attorneys at the Law Offices of Thomas L. Gallivan, PLLC work diligently to protect the rights of nursing home residents.  Please contact us to discuss in the event you have a potential case involving neglect or abuse.

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