South Carolina Nursing Home Blog : South Carolina Nursing Home Lawyer & Attorney : Poliakoff & Associates Law Firm : Elderly Care, Senior Care

The San Jose Mercury News had an article about an $80,000 fine against Homewood Care Center for failing "to provide the necessary services to prevent harm when staff failed to promptly respond to a life-threatening situation involving" a resident.  The facility was given a "AA" citation, the most severe penalty under state law, after a state investigation determined that a nurse's failure to perform the Heimlich maneuver on a patient resulted in his death.

According to the article, the man's medical record indicated that he was admitted to the facility with diagnoses including Alzheimer's and dysphagia, or difficulty swallowing.  The man was assessed as a high risk for aspiration (the entry of secretions into the trachea and lungs) due to difficulty of swallowing.  The facility was clearly on notice that the resident may choke.

At 5:30 p.m. on Aug. 24, 2009, a certified nurse assistant was feeding the man his dinner of puréed food when he began coughing. The man gasped for air and became distressed. Although staff members knew the man was choking on food, no immediate attempt was made to perform abdominal thrusts to clear his airway.

The facility also failed to promptly call 911. Though staff told investigators they called emergency dispatchers at 5:30 p.m., records indicate the call was received at 5:49 p.m., an unreasonable delay of about 19 minutes. The man was already dead when paramedics arrived. He was pronounced dead at 6:09 p.m.

Until January, Homewood Care Center was owned by Jack Easterday, who in 2007 was convicted of 107 felony counts of willful failure to pay employment taxes owed to the government. Easterday withheld more than $9.6 million in payroll taxes from employees' checks from 1998 to 2005.  He was sentenced to 21/2 years in federal prison and $8.71 million in restitution. Easterday was the sole shareholder of Westline Medical Management, which owns Homewood and seven other nursing homes in the state.

 

 

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Florida's State Journal Register ran an article about Golden Moments Senior Care Center in Jacksonville that was fined only $20,000 after one of its nurse's aides terrorized several elderly and sick residents.  The nursing home agreed to pay a reduced fine.  Golden Moments and the Illinois Department of Public Health worked out a deal in which the 113-bed facility will pay a $6,500 fine connected with the nurse's aide's conduct, said department spokeswoman Melaney Arnold.

The complaint said Golden Moments nurse's aide Jessie L. Ross "displayed a pattern of abusive behavior toward residents". That behavior included telling a resident to "go to hell," slapping the resident and depriving the resident of soda and snacks. Ross slapped a different resident, threatened to slit his throat, kicked the resident and held the resident's hands against his chest. Ross also allegedly hid another resident's nail polish and slapped that resident across the face. 

A state inspection report indicated residents had been complaining to staff members about the aide's conduct for weeks, and that several staff members observed, knew about or suspected physical and mental abuse was going on but failed to report the situation to their superiors.  Ross, who told Public Health officials she was training to become a nurse, is fighting the discipline, which hasn't been finalized.

"I find the decision to reduce the fine against Golden Moments for the abuse of residents to be incomprehensible," said Jamie Freschi, regional long-term care ombudsman who works for Springfield's "I CARE" social service agency. "The system has a responsibility to look out for the safety of the residents, not the interests of the facilities."

Officials from the state and federal governments are considering new fines against Golden Moments Senior Care Center after the Oct. 3 death of a 74-year-old resident who choked on food.   A Springfield-based advocate for nursing home residents said she was appalled by the fine reduction and noted that central Illinois nursing homes charge $4,000 to $5,000 a month for the care of one resident.

Golden Moments resident Adam Waelz was pronounced dead Oct. 3 after choking on food provided by the nursing home, Morgan County Coroner Jeff Lair said.   According to a state inspection report, Waelz, who was developmentally disabled, was known to be at risk of choking and often ate or drank too fast and should have been closely supervised while in the dining room.

The day of his death, Waelz, who had no teeth, should have received ham that was ground up, but he instead received ham that had been torn into pieces, according to the report. Lair's death investigation found ham pieces and mashed potatoes from Waelz's mouth lying next to his body. An autopsy revealed a wad of ham pieces the "size of a tangerine" in his windpipe, according to the state report.

Other problems described in the report included failure to keep residents clean, failure to prevent new bed sores from developing on several residents, and failure to provide activities for residents housed in an Alzheimer's unit.

 

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The Orange County Register reported an incident where a nursing home (Tustin Care Center) was fined $50,000 for the choking death of a resident.  has been fined $50,000 by state health officials in the choking death of a nursing home resident.

The unidentified man died in March after choking on his lunch. The report says staff noticed the man had been growing weaker and needed additional supervision while eating.  The facility allowed him to eat regular meals on his own.  On the day of his death,  the man was eating when he began struggling to breathe.  A nurse allegedly started the Heimlich maneuver but could not dislodge the food.  The man died later that day in a hospital. An autopsy found food completely blocking his trachea. The state report concludes that the nursing home failed to assess his ability to eat, which was a direct cause of his death.

 

 

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An Arizona jury awarded a landmark verdict of $11 million to the widow of a 36-year-old man with traumatic brain injury who died after ingesting foreign objects while in the care of Liberty Manor Residency, a Phoenix assisted living facility. The verdict included $2 million for the decedent, $5 million for the wife and $4 million in punitive damages. It was the largest verdict ever awarded against an assisted living facility in the United States.

Earl Scherrer suffered a severe traumatic brain injury as a result of a car accident in 1996.  He lapsed into a coma and was not expected to recover.  Despite doctors' assessment that Mr. Scherrer's condition was permanent, Lydia Scherrer refused to disconnect her husband's life support.  Earl Scherrer remained in a coma for 16 months before he began to slowly emerge.  With his wife's nurturing and support, he slowly started to speak, albeit slowly.  Mrs. Scherrer worked with her husband day after day, using first-and second-grade reading and math textbooks and other elementary learning tools to stimulate his brain function and coax him to reach his full potential.

Lydia Scherrer devoted many hours per week to her husband's recovery, but she also had to work and was forced to turn to assisted living and residential facilities to provide the 24-hour care her husband needed. For years, she visited him faithfully on her days off, every Tuesday and Wednesday, checking him out of the facility and taking him home.

On April 7, 2006, Mrs. Scherrer placed her husband in Liberty Manor Residency, a facility that purported to provide 24-hour supervision of its residents.  One month later - on May 7, 2006 - she received a call saying her husband had been vomiting.  Mrs. Scherrer rushed over to Liberty Manor, brought her husband home and gave him a bath. Within a matter of minutes, he began vomiting black matter and died in her arms.

Autopsy results showed a number of items - including plastic bags, unopened catsup packets, candy wrappers and paper towels - were found in Earl Scherrer's stomach and small intestines. The medical examiner determined these foreign objects were significant contributing factors to his death. The autopsy read in part, "hypertensive heart disease due to mechanical obstruction of the GI [gastrointestinal tract] from the foreign objects."

Lydia Scherrer brought claims against Liberty Manor for abuse and neglect, wrongful death and punitive damages.

At trial, it came to light that Liberty Manor made numerous false entries in its charts with respect to Earl Scherrer's care, including notations of care on days when Mrs. Scherrer had checked him out of the facility.  Liberty Manor was also unable to produce Mr. Scherrer's alleged caregiver, an employee named Raul.

"Lydia Scherrer did not walk away from her husband, in life or in death," said her attorney, Craig Knapp. "Her hope is that this verdict will force the assisted living facility industry to set and meet higher standards of care for their residents, resulting in enhanced protections for the defenseless individuals trusted to the care of others.

 

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The L.A. Times reported another story about a nursing home fined for allowing a resident to choke to death.  This is the third story about choking deaths in nursing homes in the last couple of weeks.  The nursing home was fined $80,000 after a 54-year-old schizophrenic patient choked on a meatball and died.

Raintree Convalescent Hospital had known the patient had problems swallowing.  The spaghetti meatball served to him needed to be chopped or sliced before being given to him.  Both the cook and the nursing assistant who served the meal failed to grind up the meatballs, as required. The cook failed to follow the directions for the patient's meal by not mashing up the meatball. He also said the nursing assistant failed to look at the meal card on the patient's tray -- which would have been a second chance to catch the error -- before serving the lunch. 
 

"I just did not think to chop up his meat that day," the nursing assistant told state investigators.   The facility was probably understaffed which did not allow her time to do her job properly.

The man stumbled out of his room, pale and unable to speak. After a nurse unsuccessfully attempted the Heimlich maneuver, paramedics were able to suction the meatball out of the man's airway, but he was pronounced dead at a hospital emergency room.

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The L.A. Times reported that a nursing home was fined only $75,000 for the wrongful death of a resident.  The nursing home was well aware that the resident had a history of swallowing problems but did nothing to prevent him from choking to death on a snadwich that never should have been given to him.  .  In fact, the nursing home failed to immediately treat the resident when he began choking.

The patient had dementia and a known history of having difficulty with swallowing. The patient's care plan at Anaheim Crest Nursing Center said he should only be given pureed food.  The state investigation documented two incidents Sept. 9 when the patient ate solid food. At dinner, he was fed an incorrect meal and given a spoonful of vegetables and rice. After he started coughing, a nursing assistant performed the Heimlich maneuver and a "tomato-like" material was coughed up.  Later that same evening, the patient got  a sandwich and began to eat it and began choking and turning colors.

According to the state, there was no documented evidence that the patient received emergency treatment for choking.  It is the standard in all nursing homes that if something was not documented then it wasn't done.  Nurses are trained in school on this principle and every nursing home in the country abides by the principle.  Despite this standard, the nursing home is now claiming that the staff did attempt the Heimlich maneuver, administered cardiopulmonary resuscitation and called 911. 

The nursing home tried to claim that the death was a result of a heart attack, and that they had not been informed the patient had a choking incident just before his death.  If that is true, then why did they allegedly try to do the Heimlich maneuver.  They can't keep their lies and cover-up straight!

After the coroner determined that the patient had choked on a piece of food found in his larynx, a subsequent internal investigation uncovered the second, and ultimately fatal, choking incident.

 

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The San Diego Union-Tribune had an article about a nursing home which received the most severe citation and a $90,000 fine after an investigation found that poor treatment and supervision resulted in a resident choking to death last year.   Escondido Care Center, a 180-bed facility, failed to adjust the patient's meal plan to meet his changing dietary needs. The resident suffocated when food became stuck in his windpipe and the right main bronchial stem. He was eating a lunch of beef with barbecue sauce, mashed potatoes, and steamed cabbage and carrots. During lunch, the patient coughed repeatedly until he became unresponsive and slumped over in his wheelchair. The patient died.

The facility was well aware that the resident had swallowing problems and was at risk for choking.  His physician had ordered a strict diet to avoid problems with chewing and swallowing.
On two occasions in November, the facility's dietary supervisor, registered dietitian and a nurse wrote in the patient's file that he was having difficulty chewing and that he was coughing while drinking “thin liquids.”   No records exist to show that any staff member alerted the resident's doctor or tried to alter the man's diet or supervise it more closely.

 

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 The Syracuse Post Standard had an article recently discussing the (small) fine that a nursing home received for neglecting a resident who died as a result of choking.  How could they levy such a small fine for a preventable death? 

The government fined a Minoa nursing home $13,300 for failing to provide prompt emergency care to a choking resident who died.  The Centers for Medicare & Medicaid Services said The Crossings put residents in immediate jeopardy and provided substandard quality of care, the most serious deficiencies.

The Crossings was one of four nursing homes in the region fined for poor care between June 1 and Sept. 19, according to the Long Term Care Community Coalition.   The fine against The Crossings stems from an Oct. 15, 2007, incident involving a resident:  The report said:

The woman was served a dinner of blueberry pancakes and sausage that a nurse aide cut into bite-sized pieces. A short time later, the aide noticed the women's mouth was open, she was not breathing and her lips were blue.  The aide failed to call a "code blue," an announcement that alerts all staff to an emergency situation and summons them to provide assistance. It also activates the 911 system. The aide also failed to start the Heimlich maneuver.  A licensed practical nurse who came to help did not take these steps, either.  The registered nurse supervisor who arrived on the scene did not immediately call a "code blue" or 911.

I wonder what "a short time later" means?  I am surprised the nursing home did not claim that the resident had a DNR so they did not need to intervene!!

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WNBC.com had a story about how a nursing home lied to a resident's family regarding her death at the facility.  This typeof cover up oftens happens in nursing homes. The staff is typically the only ones who really know what happened to a resident.   The staff are worried about their job or are instructed by their corporate masters to mislead or cover up the neglect and abuse.

Olive Chase was 94 when she died at Sunrise at Fleetwood, an expensive assisted-living home in Mount Vernon, in February 2007.  The nursing home told Chase's son that she had died in her sleep. The nursing home created an elaborate story that his mother had breakfast, was left alone at one point, and the aide returned to find she had died peacefully in her sleep.  The staff said Chase was sleeping at 7:30 a.m., but was "unresponsive" four hours later. Days after Chase was cremated, however, her family got a tip from someone with second hand knowledge of her death that the woman did not die peacefully.

Bob Chase, son of the woman who died, spoke with some of the staff and to the source who was the first nurse on the scene after his mother's death.   The nurse saw Olive's head caught between the bars of her hospital bed with her feet hanging off the side. The nurse said it appeared as if she struggled and then died of strangulation.

"Her tongue was protruding. It was purple," the nurse said.

The nurse said one of the maintenance workers then lifted Olive's legs while she held onto one of her shoulders.

"We brought her up, laid her flat on her bed," said the nurse. "I brushed her hair. This nursing coordinator told us, 'Don't say anything.'"

The nurse said the last person to treat Olive for a bedsore raised the bed for the treatment but did not lower it after, despite instructions to do so. Olive was known to wander, the nurse said.

"We had a sign on the top of the bed, readily visible, stating to lower the bed at its lowest level when finishing care," the nurse said.

An anonymous call to the state Department of Health days after Olive's death reported that the woman appeared to have died of asphyxiation after her head was caught in the bars, which triggered an investigation. The department concluded the caller's complaint was valid. The department found that Olive's body had been rearranged after her death, but it was not reported that way in Sunrise's records.

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Attorney for Amel Trezza asked the jury to compensate for his wrongful death at a nursing home  which occurred on May 31, 2001. The total verdict in the case regarding nursing home negligence amounted to $2,522,232.08. The total monetary figure makes the case the largest nursing home negligence case in Connecticut history.

Amel Trezza died on May 13, 2001 after he was administered the wrong food at the Country Manor Healthcare Center in Prospect.  During 2001, there was a widespread strike amongst nursing home employees stemming from a demand for improved wages and conditions of employment.

A replacement worker made the mistake of serving Mr. Trezza, who was blind, food that was supposed to be for a patient on a regular diet. Mr. Trezza was administered a soft diet, which meant that all of his food was put through a food processor, thus making it easier to swallow.

After serving Mr. Trezza the wrong meal and failing to look at the name card, the replacement nurse moved on to other patients in an adjoining room. Meanwhile, Mr. Trezza began to choke after unknowingly beginning to eat the wrong meal. 

Mr. Trezza was found unconscious after he had already lost a great deal of oxygen to his brain, leaving him with severe brain damage. He was subsequently intubated, which was not according to his wishes, and died 10 days later.

The case of wrongful death was tried in Waterbury Superior Court in the recent weeks. Because Connecticut doesn't provide the framework for punitive damages, according to Atty. D'Amico, the case was settled on the basis of non-economical damages. The state of Connecticut enacted such a system as a detriment to lawsuits against nursing homes.

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