Evergreen's subsidiary New Hope Care Center

The Tracy Press out of California had an article about the death of a nursing home resident caused by the neglect and negligence of the nursing home.   New Hope Care Center which is owned by the for profit corporate owner Evergreen Healthcare Companies, LLC failed to properly monitor her medication and failed to check her into an emergency room fast enough when her brain started bleeding.  Caregivers failed to keep a close eye on the condition of the patient after a doctor ordered an increase in medication to prevent blood clots. A possible side effect of the medication is excessive bleeding. Because the nursing home staff didn’t monitor a change in the woman’s condition after the doctor upped her anticoagulant prescription, the state said they missed warning signs that could have saved the woman’s life.  Days after the doctor-ordered increase in her blood-thinning medication, the woman started slurring her words and complaining of a headache.  Even though the woman woke up just a couple hours earlier, she started nodding off, waking up only to vomit.

The facility was fined $100,000 after the nursing home ignored the worsening condition of a patient.  State investigators concluded that New Hope caregivers “failed to ensure that the resident’s medications were monitored and failed to fully assess the resident or promptly notify the physician when there was a change in the resident’s condition, which resulted in the resident’s death,” according to Al Lundeen, a spokesman for the state agency. The fine levied on the nursing home is the maximum penalty the agency can impose for a “AA” citation, the harshest assessment for hospitals and nursing homes in California.

The article mentions several other complaints and investigations into New Hope.

 

 

Death caused by falls lead to lawsuit

The St. Clair Record had an article about the recent lawsuit filed for a resident who died after the nursing home allowed the elderly woman to fall multiple times causing her death.  Dora Haskins-Bond lived at Eldercare Inc., doing business as Calvin Johnson Care Center, from December 2004 until July 31.   During her stay at the center, Haskins-Bond fell on July 7, sustaining fractures to her left femur and right knees.   Because Haskins-Bond had previously fallen several times while staying at Calvin Johnson, the home should have known of her susceptibility to falls and fractures and done something to prevent the falls.

The center and its owners failed to provide adequate resources and monitoring for Haskins-Bond to prevent her from falling.  Because of her fall, Haskins-Bond incurred substantial medical costs, endured substantial pain and suffering in her body and mind and suffered disability, disfigurement and an aggravation to her pre-existing health conditions.

In addition to Calvin Johnson, Eldercare's administrative manager, Steven Wolf, and Prudence Wolf, who had an ownership interest in the company, are included as defendants in the suit.

 

 

Death caused by fall leads to lawsuit

The Northwest Herald had an article about a lawsuit involving the neglect of a resident that led to a fall that caused her death.  The wrongful death lawsuit against a Chicago nursing home, Sacred Heart Home, states that the nursing home failed to prevent the fall that led to the resident’s death.

Kathleen Koch, died after suffering from a broken back, head injuries and paralysis after she fell in a stairwell at the nursing home. The fall happened Dec. 21, and she died eight months later at 61 years old.

The case alleges that staff should have better supervised Koch because they knew she had been diagnosed with bipolar disorder and schizophrenia and was at high risk for wandering and falls.  However, her room was not near a nurse’s station, and Koch was able to go into the stairwell unsupervised.

She was the type of resident that needs to be closely monitored and supervised which clearly was not done.  I am sure the nursing home will blame the resident and claim it was all her fault.

 

Whistleblower sues for wrongful termination

Tulsa World had an article about a nursing home employee who reported neglect and abuse at a nursing home, and was subsequently fired from her job despite her affirmative duty to report such incidents.  This is outrageous.  This employee did exactly what she was supposed to do and the nursing home fired her for it.  She is now suing Cimarron Pointe Care Center and one of its contractors for wrongful termination.  Is it any wonder why many nurses look the other way when residents are abused and neglected?

In the lawsuit, Harris said she worked as a housekeeper at the facility. She was paid by Health Care Services Group, a Tulsa company contracted by the home to provide cleaning services, and supervised by nursing home staff.   During her employment, she observed numerous instances of improper care of the home's residents.

"Mrs. Harris observed a male resident who had been left in his own waste for so many hours that he had feces caked on to his leg from his hip to below his knee, and had wet himself at least one time."   She saw the man sitting in his waste and reported it to her supervisor, the head nurse and two nurse's aides. Her supervisor sprayed deodorant in the man's room to cover the smell. The aides said they would leave him for the next shift.

"Two and a half hours later, he was still sitting in his own waste," Harris said. "He couldn't say nothing. I would always talk to him. He would just light up when I went to clean his room. It's heartbreaking when you see a resident not being taken care of."

Also, an elderly woman paralyzed from the waist down was left in her own waste, Harris said. She rolled out of the bed and into the hallway to get someone to change her soiled garments and the nurses "just laughed at her," Harris said.

"On another occasion, Ms. Harris brought the needs of another female resident to the attention of the nursing staff. The resident's needs were ignored, prompting the resident to write a letter to her family saying goodbye, in anticipation of death from neglect," the petition states.

Another female resident, who was unable to sit up alone, was left on a bench in the shower. She fell and hurt herself, the petition said.

Harris reported each instance of neglect or abuse to the facility's staff.  The home's administrator and a supervisor from Health Care Services Group of Tulsa, the contractor that paid Harris, fired her.   Of course, Cimarron Pointe Care Center denies any improper care of its residents. It also states that Harris was employed by Health Care Services Group, so the nursing home isn't responsible for her termination.   However, Ms. Harris was told that the only basis for her termination was her reporting of the abuse.  Ms. Harris had not done anything else to merit termination, and no other basis for termination were discussed or even suggested."

 

Resident wanders from facility and gets hit by car.

 Fox8.com out of Cleveland had a recent story about a nursing home resident who was left unattended and allowed to leave the facility unsupervised.  The resident ended up walking on the road and getting hit by a car.  She died from injuries sustained in the  "hit and run" accident.  What is amazing about this story is how the article concentrates blame on the driver of the vehicle instead of the nursing home which was responsible for keeping this resident safe and out of harm's way.  The nursing home should have been watching her and not allow her to leave the premises unsupervised.

Citing declining health, her family recently convinced her to check into the nursing home.   She was very unhappy there and wanted to return home.  This is a clear sign of a risk for wandering.  Her family says she was supposed to be staying in a "locked-down area" when she somehow was allowed to escape.

"There was a security door in her room that she was able to disable at 87 years old. They appear to be very short staffed at night. We were told there was a loud alarm going off but no one went looking to see what was going on," says Meldrum.

According to the Avon Police Department, several 911 calls came in Friday evening alerting them of a car versus pedestrian crash in front of the Good Samaritan Skilled Nursing & Rehabilitation Center on Detroit Road. When officers arrived to the scene, they found Warren lying on the side of the road.  Police say the suspect vehicle did not stop after the accident and drove away from the scene.

Is there any investigation as to why and how she was able to leave the nursing home without being noticed?  how long was she missing?  Why didn't anyone hear the alarm or respond to it? Was the nursing home short-staffed?

Neglect and understaffing causes tragic death

The Chicago Tribune has had a series of articles about the tragic death of a nursing home resident who was unsupervised and allowed to wander away from the facility.  The articles are good although many questions remain unanswered.  See articles here, here, here, and here.  Below is a summary of what I believe has been found out thus far.

Sarah Wentworth -- who suffered from dementia -- was found in a snowbank outside The Arbor of Itasca the cold morning of Feb. 5.  She had been exposed to the elements for at least 90 minutes and more likely 5 hours. Wentworth was unable to leave her bed without assistance.   No one is sure how she could have left her room and the building without being noticed by staff.  Staff are required to do a bed check every two hours.  She was known by staff to be a wanderer and wore an ankle bracelet that reminded the staff.

Wentworth was wearing only a hospital gown when police arrived at the nursing home.  She had on an ankle bracelet that should have (and may have) triggered an alarm at the facility's nursing station when she passed through the first of two exit doors.   Inside the nursing station at The Arbor of Itasca is a handwritten note reminding staff that "if this buzzer sounds, staff must go out to the courtyard to check for a resident."

Nursing home staff members told Itasca police they checked the door to the courtyard when the alarm went off, but did not see anyone.   No mention of a polygraph test was noted.

Neglect and obstruction of justice charges may be filed against as many as four employees. Heidi Leon, a 23-year-old staff member on duty the night of the incident, was watching TV in a room adjacent to the nursing station when Wentworth exited a door and triggered the alarm.  She watched three straight episodes of "Dog The Bounty Hunter" and "shrugged off " an alarm that indicated a resident had wandered outside into near-zero conditions.  Instead of checking the courtyard as instructed, the staff member assumed someone "stepped outside to have a cigarette" and turned the alarm off "so it didn't distract her television program."

Tom Hendrix, an attorney for the nursing home, did not respond directly to the allegations but said that "policies and procedures were in place for the supervision and safety of residents, including an alarm system which was in working order." Hendrix did admit that some employees had been suspended.

Mr. Hendrix nor the nursing home employees can explain how she got outside.   She was unable to get out of bed on her own.  Although an alarm sounded at a secure door during the middle of the night when Wentworth left the building, no nursing home employee checked on her.   The outside temperature that morning was about 1 degree.

Heidi Leon was charged Tuesday with criminal neglect of a long-term-care facility resident, criminal neglect of an elderly person and obstruction of justice. If convicted, she faces up to 7 years in prison.

 

 

Wrongful death lawsuit filed for fatal fall

Family sues nursing home after senior falls, dies (09/26/08 Orange County Register) By Rachanee Srisavasdi and Courtney Perkes

Luveda Fern Kessler fell and cut her leg as she got out of bed at her Laguna Hills assisted living apartment.   It was 1:33 a.m. The 83-year-old woman did as she had been told to do: Press a personal emergency response call button.  She waited, bleeding from the two-inch gash. Twenty-four minutes later, at 1:57 a.m., an unidentified staffer at Villa Valencia Health Care Center called 911.  Valencia is owned and operated by Sunrise Senior Living that owns hundreds of for profit nursing homes.

Paramedics arrived at 2:10 a.m. Kessler lay on her stomach, nonresponsive. She was soon pronounced dead at a local hospital. Villa Valencia did not report the incident to the state.  

The Virginia-based company - which runs 445 senior centers internationally - has garnered criticism in two other lawsuits this year over care of residents at Villa Valencia's adjacent nursing home unit.

In one of the cases, a jury in May awarded $2 million to the family of Mary Adams, who died in March 2005 after a brief stay at the center. Lawyers representing the Adams family argued that Villa Valencia was understaffed to give Adams adequate treatment for her pressure ulcers - which lead to her death.

A nurse identified Kessler as being at risk for falls, but she was not given assistance getting out of bed or going to the bathroom.

"My preference would be to have her at my house,'' said Joanne Kessler, who lives in Aliso Viejo. "But I have a condo with a tri-level. There's no way she could handle stairs. I thought, 'It was better than her being alone, back in Seal Beach.' "

Jury compensates family for death of mother.

The Star-Telegram reported a verdict in a tragic nursing home case.  The article asserts that Mable Ann Webb didn’t have to die.   Webb entered CLC Richland Hills nursing home for physical therapy. Within two weeks her skin became flushed and clammy. Her eyes turned red, her tongue swelled and she could not speak.

A month after entering the home, in July 2004, Webb died at a Fort Worth hospital of kidney failure caused by an untreated urinary tract infection and being overmedicated with pain killers.  A  jury awarded Webb’s family $2.1 million from the home and its medical director. The family’s attorney, Geno Borchardt, doubts they’ll collect anything from the nursing home, which did not have insurance. Legal damage caps could also reduce the award, he said.

Gary R. Trebert, who owned the nursing home at the time of Webb’s death, is to be sentenced at 9:30 a.m. Monday for conspiring to evade about $34 million in taxes related to nursing home companies he controlled, including some in Tarrant County.

The jury award included $1.2 million in punitive damages against Dr. Adolphus Ray Lewis of Fort Worth, the medical director at CLC Richland Hills. He was also found 49 percent liable for the $900,000 in actual damages.

Punitive damages against the nursing home are still to be determined, Borchardt said.

The lawsuit alleged that Lewis was responsible for prescribing a painkiller at three times the appropriate dosage.   In August 1998, the Texas Medical Board found that Lewis violated state law by prescribing large quantities of controlled substances, among other deficiencies. Lewis’ medical license was restricted from prescribing certain drugs in an office setting for three years, and he was ordered to complete 50 hours of continuing medical education, state records show. But Lewis was allowed to prescribe medications at nursing homes.

CLC Richland Hills was acquired by a new owner, but Lewis continues as the medical director there.

Among the list of suspected culprits in Webb’s death was the nursing home fax machine. It was broken so nursing home staff did not see an analysis of Webb’s urinary tract infection for about two weeks, Borchardt said.

Trebert, 57, faces up to 10 years in prison and possible fines and restitution.  The tax evasion scheme involved about 70 nursing homes that Trebert and two other North Texas men operated across the country, according to court documents.

 

 

Nursing home appeals fine for allowing resident to fall 14 times

The Almanac News had an article about a nursing home appealing a fine after a resident's death caused by their inattentiveness and lack of supervision.

During her 10-month stay at Atherton Healthcare nursing home in Menlo Park last year, 51-year-old resident Debra Nickel fell 14 times, including a fall where she suffered a traumatic brain injury. She died several days later.  State investigators have determined that the nursing home staff is at fault for Ms. Nickel's death.  The facility was fined $100,000 for the neglect which is the most severe citation possible.

The Department of Public Health concluded that Atherton Healthcare staff was inattentive in caring for Ms. Nickel, who was known to be at risk for falls. The facility was hit with an "AA" citation the most severe citation under state standards.  "The facility failed to identify and continuously assess, evaluate and update the resident's needs and plan of care to prevent further falls and injuries," according to the report.

Nana Cocachvili, executive director of Atherton Healthcare, located at 1275 Crane St., said the nursing home is appealing the decision, and that Ms. Nickel's falls were "unavoidable."

Ms. Nickel died Dec. 1, a week after staff member noticed a "deep lacerated wound" on the patient's head most probably from an "unwitnessed fall," according to the report. The staff member informed a nursing home physician, who stated that Ms. Nickel "does not need to be sent out for stitches because scalp wounds heal easily," the report says.  The staff member notified a second physician, who recommended Ms. Nickel be taken to the emergency room, where she was admitted three hours later with high blood pressure and a heart rate of 128 beats per minute, the report says.

The San Mateo County Coroner's Office confirmed Ms. Nickel died Dec. 1 of swelling of the brain and brain hemorrhages caused by blunt trauma.

The citation linked to Ms. Nickel's death isn't the only Department of Public Health claim Atherton Healthcare is currently fighting.   In April, the state fined the nursing home $20,000 following an investigation into the Oct. 28 death of a 79-year-old man who fell backwards off a wheelchair lift.

The patient, Menlo Park resident Charles Ladeau, suffered major head trauma when he fell while being lifted into a van, and died shortly after the fall.  The incident exposed the fact that Atherton Healthcare was outsourcing the driving of patients to off-site appointments through a private company without a formal contract, and without "written standards how transportation services should be provided," according to the reports.

Ms. Cocachvili said Atherton Healthcare has appealed that decision too, and she argued the blame should lie on the transportation provider whose employee was supervising the patient when he fell, not the nursing home.   however, the nursing home cannot delegate care to a third party.  The nursing home is the health care provider who is ultimately responsible for the care provided to their residents.

In 2005, the facility changed ownership and was known as Canaan Healthcare. The current owners took over in early 2007 and the name switched to Atherton Healthcare.



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