Do nursing homes ignore abuse?

Michael Owens of the Bristol Herald Courier wrote an article about National HealthCare-Bristol ignoring the obvious warning signs of abuse including those acts done by James Wright who was recently convicted of sexual assaults.

The article talks about one resident who rolls into a fetal position and reaches with both hands between her legs and around her back and shifting hands from side to side along her inner thighs have left her flesh tissue thin, red and raw as if to block sexual advances. The actions are the psychological remnants of a sexual assault by former employee and convicted serial molester James Wright.

The traumatized woman is among the dozen patients that state detectives say were sexually assaulted at NHC between February 2000 and August 2007.  State detectives have linked him to seven attacks. State medical licensing documents also tie Wright to a later rape at another assisted-living facility, where he took a job immediately after leaving NHC.

Somehow, the abuse continued for seven years even though there were red flags.

The first showed up in February 2000. A resident accused Wright of touching her inappropriately, and then warned him to stay out of her room.  In the following years, accusations by three other patients sent officers from multiple law enforcement agencies looking for an unknown assailant.

NHC contends the attacks could have been stopped had only the abuse been reported up the chain of command to the home administrator.  Employee records and witness accounts suggest that NHC-Bristol management also might have harbored concerns about Wright.   Five female patients complained of being attacked in the months leading up to Wright’s departure. Three times, co-workers blamed Wright almost immediately.

However, instead of firing him or reporting him to the authorities, NHC allowed him to resign with favorable recommendations amid a crescendo of sexual assault complaints. Wright jumped to a similar job at nearby Grand Court Assisted Living immediately leaving NHC.  A solid recommendation by then-NHC Director of Nursing Elizabeth Anne Franklin helped him land the job, internal Grand Court documents show. The reference-check report, penned by Grand Court recruiter Sue Huff, does not mention any warning that Wright had been the prime suspect in a sexual assault case just days before he applied for the job.

These assaults, and the manner in which the complaints were handled, illustrates the skepticism that surrounded abuse claims, and the problem of nursing homes failing to investigate or worse, covering the abuse up.

 

Resident Suffers Severe Burns

BakersfieldNow had an article about the neglect suffered by Anita Ramirez after spending less than two weeks at LifeHouse Parkview nursing home.  The family discovered that Ramirez ended up with serious burns during her brief stay. Ramirez was sent to the nursing home to resolve a bedsore from a recent hospitalization

"She needed to be turned every two hours," Dias (daughter) said. "And she was on an I.V. antibiotic, and they felt this was the best course of action."

The family soon had concerns about Ramirez' care.  Another daughter, Amanda Ayala, was very worried and she called police to help get Ramirez transferred to the hospital.  "The same nurse that saw her two weeks or three weeks prior, saw her -- and said, What happened to you?" Dias said. "One of the nurses that bathed her cried, and said nobody deserves this."

The doctors then ordered Ramirez to be transferred to the burn center at San Joaquin Hospital. 

"Once they did an evaluation, they came to realize that these were severe burns all over her body," Dias said. The family has photos showing badly damaged and darkened skin. "She literally has no skin left on parts of her body," Dias said.

The article states that Eyewitness News contacted the California Department of Public Health, and spokesman Ralph Montano said the agency "can confirm an on-going investigation regarding Parkview Health Center." He could not say if that relates to the complaints regarding Ramirez.

Checking the state Health Department website, two complaints are currently on file regarding the LifeHouse Parkview facility on Real Road, but one is from mid-March and the other was started in mid-January.


 

Cover up of sexual abuse

WQAD had a story about the cover up of sexual abuse at Windmill Manor nursing home. State and federal authorities have levied more than $92,000 in fines where staff are accused of covering up the sexual abuse of an elderly resident.  State records say a male resident of Windmill Manor was found in bed with a female resident in November, and both were undressed. And then, on Christmas Day, staff saw the two having sex. Staff did nothing to prevent the two from engaging in sexual activity.

In addition to the fines against Windmill Manor nursing home, criminal charges were filed recently against its former director of nursing, Karen Etter.  Regulators also allege that Etter warned staff members not to tell anyone of the incident if they wanted to keep their jobs. Regulators say the woman, who has Alzheimer's disease, could not have given informed consent to sex.


 

Failure to Investigate Abuse

Dallas News had another article about the lack of supervision, enforcement, and investigation of nursing home complaints of neglect and abuse in Texas.  Regulators have repeatedly found problems and cited violations at Veterans Land Board, which the General Land Office is the parent agency of the veterans board.   But the criminal investigation into Bryson Vanderbilt, 25, and Connie Mae Johnson, 52, charged with "striking, pushing, grabbing and forcefully handling" two residents in separate incidents languished for over two years because of confusion over who should investigate, cumbersome bureaucracy and conflicts among local police, state officials and home administrators,

The witnessed allegation of abuse includes a CNA grabbing a 97-year-old from his wheelchair and slam him into his bed. Another employee at the home was accused of punching and trying to choke Albert Teague, 84, a Marine who fought at Iwo Jima. Felony charges were finally filed against the ex-employees last month.   The allegations that resulted in the recent criminal charges were first checked by Big Spring police in late 2007. But interviews and records obtained by The News through state open-records laws indicate that a criminal investigation was delayed partly because the police yielded to the state agency that inspects nursing homes.

Senior Dimensions, the Austin-based firm that manages the home under a state contract, said it contacted the police and began an internal investigation. The police report, dated Nov. 9, 2007, said Cpl. Adam Stovall spoke with a unit manager who said a certified nurse aide had seen a male co-worker abusing one of the residents.

But, Stovall wrote, the home's administrator, Bob Kerr, would not give police copies of the employee statements about the incidents.

Stovall said he saw one statement, from resident Wilson Sikes, who said he had slammed Vanderbilt's hand in his nightstand because the man was going through his belongings. Vanderbilt then "lifted his wheelchair and dumped Sikes in his bed, then sat on him and slapped him across the face with gloves," the police report said.

Sikes recounted the same abuse to Stovall, who said he saw no "obvious injuries" to Sikes.

Kerr, a Senior Dimensions employee, told The News that he couldn't recall whether he declined to turn over witness statements. But if so, he said, it was "because we were in the process of doing an internal investigation and we felt those were part of our internal investigation."

Senior Dimensions said last week that it wouldn't release a copy of its internal investigation.

 

Over the past three years, inspectors from the state's Department of Aging and Disability Services have documented several problems at Amarillo veterans home.

The Veterans Land Board, the division of the land office that runs the homes, says the price is cheaper than most privately owned nursing homes because of extra funding from the Department of Veterans Affairs.

Inspections by the state's Department of Aging and Disability Services, reviewed by The News, show a series of problems at the Amarillo home, which is run by San Antonio-based Touchstone Communities. Among them:

• A woman was hospitalized with gastrointestinal bleeding after a lab test, including blood work, was not done and a staff member misread her doctor's orders. As a result, she received too much of a blood-thinning drug, resulting in an "abnormal bruise" from her lower back to her right leg from a fall.

• An elderly woman with Alzheimer's was found on the floor with the neck of her nightgown caught in her bed's rails. The inspection found that she had redness around her neck. A previous assessment of the woman said a staff member needed to get her in and out of bed, but it didn't call for the use of safety devices or restraints, which are used to prevent falls.

• From September 2008 to April 2009, four residents suffered first- and second-degree burns from spilled hot coffee. After three residents were hurt, an employee put a sign on the coffee machine for her colleagues: "You will bring coffee down to 140 degrees by adding ice. No exceptions. You will go to the Administrator's office to explain why you burnt someone!!!"

 

\The Big Spring home, which opened in 2001, is a sprawling complex that state regulators cited the home for several violations, including:

• A resident, unattended in his wheelchair, left the veterans home building. The resident was found in the cold darkness, lying on the cement about 80 feet from the front door, with swelling to his left eye and cheekbone. He spent two days in the hospital.

• A man choking to death on a radish, although his physician earlier had ordered a soft diet for him. The man had Alzheimer's disease, schizophrenia and dementia.

• A resident with Parkinson's disease who was not offered timely counseling or psychiatric help last year after he talked three times about death and suicide, and then wrapped his feeding tube around his neck twice in one day.

• Lack of a system for ensuring that beds were in locked positions after a man fell when his bed rolled. The home also did not properly supervise another resident who had been found on the floor at least four times in less than two months.

In one case, a man who was known to be at risk of falling tumbled out of bed and then fell twice in the bathroom, hurting himself each time. An inspector asked an employee why she didn't investigate the last incident.

"I guess I missed that one," the employee replied, according to the inspection report.

 

 

Administrator covered up sexual assaults

Bristol Herald Courier had an article about the Virginia Medical Licensing Board's conclusion that reports of sexually abused nursing-home patients were both ignored and discouraged by supervisors at the National Health Care-Bristol facility.  The accusations against two current NHC-Bristol staff members and a former nursing director detail a series of assaults already attributed in court documents to ex-nursing aide James Wright.

NHC-Bristol Administrator Charlotte Wilson is accused of failing to investigate reports of sexual assault on 12 patients from 2000 until 2008. She also is accused of neglecting to pass the reports on to the patients’ doctors, or to Adult Protective Services. Wilson also is accused of setting up a chain of command that led to a dead end for reports of abuse, while also circumventing state law.

“Until 2007, you enforced a policy that employees could report allegations of abuse only to their next superior, rather than to the administrator and any state or local official as required by law,” states the complaint against Wilson.

 

Failure to investigate, notify, or recognize fractures

The Daytona Beach News-Journal had a tragic story about a 76-year-old resident at a DeLand nursing home who went for 12 hours without treatment after she broke her shoulder and both her legs in a preventable fall.  The incident under investigation started when a patient fell out of bed at 5 a.m. Friday as her bedding was being changed.  The patient, whose identity was withheld by police, was put back into bed after the fall. But it wasn't until after the next shift came on -- at 4:42 p.m. -- that emergency workers were summoned to attend to her injuries. She was taken to Halifax Health Medical Center in Daytona Beach where she was admitted.

The incident is under review by the Agency for Health Care Administration, which is charged with overseeing 31 nursing homes. Records with the state agency show that at its last inspection in October, nine deficiencies were cited at the facility that is owned by Graystone Healthcare Management, which operates 28 nursing homes in Florida, Indiana and Ohio. Among the citations: accident hazards and food storage.

 

Criminal indictment for Neglect

Lexington Herald-Leader had an article about Kentucky indicting nursing home employees for neglecting a resident and trying to cover it up.  A nurse and two nursing assistants have been indicted in connection with a case of neglect at Creekwood Place Nursing Home in Logan County.

One of the nursing assistants, Melissa L. Lyon, was trying to transfer a patient into bed on her own, even though the patient's care plan called for two people to lift the person.   As a result, the patient suffered a fractured leg.   After the incident, Lyon and the other nursing assistant, Destiny W. Duncan, "concealed the true facts of the incident," the news release says.

The nurse, Barbara A. Moore of Beechmont, "did not call a physician or family member or check on the victim, all of which caused the victim prolonged suffering and pain," the release states.  Each of the women was indicted on a single count of knowing abuse or neglect of an adult, a Class C felony. 

 

Resident's penis rots because of failure to provide wound care

There have been several articles about the lawsuit filed against Everett Rehabilitation and Care Center that neglected a resident's penis until it rotted off.  See articles here, here, and here.

A lawsuit has been filed against a Washington state nursing home accused of neglecting Charles Bradley's penile infection.   The lawsuit states that Bradley was taken to an emergency room, where doctors discovered his penis had decayed, leaving only a gaping wound. He died 18 days later, in March 2008.   The lawsuit cites an investigation by the state Department of Social and Health Services, which shows the nurse told a manager in November 2007 that the man had a wound on his penis. Staff noticed that Bradley's skin was breaking down while changing his diaper in November 2007.  The records say the manager forgot about the report and neglected to properly care for the wound.  Though staff notified a care manager, that manager failed to notify Bradley's doctor. Instead, the manager went on a three-week vacation and when she returned she forgot about the nurse's report.

Bradley's family claim staff at the nursing home left a wound on the elderly man untreated for months. Nursing home records allege that staff changed the man's diaper daily and provided him weekly baths between November 2007 and March 13, 2008.  During the four months that followed the initial notice of the wound, Bradley's genitals essentially broke apart bit by bit while the elderly man steadily lost weight.   By allowing Bradley's injury to fester and worsen for months, the nursing home and parent company SunBridge Healthcare Corp. violated a promise to care for him. "They trusted that the nursing home would provide the care they said they would provide," family spokesman said Wednesday. "We're not talking about extraordinary care. We're talking about basic daily needs."

An investigation conducted by the center's director of nursing "did not find any impropriety" by staff. State regulators, though, issued the center a citation for failing to meet quality of care requirements set by federal law.  The state determined that the home failed to meet a federal standard for care. The man didn't receive timely medical attention and the facility failed to notify his family or his doctor of changes in his health, the state determined. 

"There was no evidence the facility had contacted the resident's physician … to allow for timely medical intervention," the state investigators said in an investigatory report provided by DSHS. "There was no evidence the facility had contracted their social services department or the resident's family."  A financial penalty was not assessed.

“They definitely should have seen it. There was no documentation that his penis was beginning to fall off,” Gooding said. “We believe they chose not to put it in the records.”  Sounds like a cover up but no monetary fine was issued!

 

 

NHC's DON threw complaints about abuse into trash can

Michael Owens has a follow up article to his recent articles about how NHC cover uped and protected a sexual predator and allowed him to continue working in the health care field despite being required by law to report abuse.  This is a fascinating story that needs to be told.  It is a perfect example of how corporate greed conflicts with quality care of nursing home residents.  Obviously, Mr. Wright will go to jail but so should the Administrator and Director of Nursing who let this predator roam the halls of nursing homes.  It will be interesting to see if law enforcement and regulatory agencies do anything about this tragic case.

The article explains that the DON Anne Franklin not only ignored four National Healthcare Bristol nursing home employees who filed written accusations that Wright was sexually assaulting patients but actually  threw at least two of those complaints into a trash can.   Was this a cover up or just the corporate policy so there wouldn't be a paper trail?

 Luckily, CNA Cynthia Aldrich, lashed out in a fit of frustration at the nursing home’s on-call doctor, urging him to do something.  More than a month later, James W. Wright would leave the nursing home, but not before one more nurse complained to supervisors that she twice caught him sexually abusing a blind woman patient.



 

$75,000 fine for choking death

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.

 

Poliakoff & Associates, P.A., is one of South Carolina’s most respected and distinguished law firms. The Poliakoff firm began nearly 60 years ago by three attorney brothers: Matthew, J. Manning, and Bernard. With a history of believing the justice system...More...