Deficiency Laden Kentucky Nursing Home Designated “Special Focus Facility Candidate” by Federal Inspectors
Following a complaint report by federal inspectors in February, a large Kentucky nursing home was designated as a “special focus facility candidate.” One of the primary incidents that occurred and caused inspectors to question the quality of care being provided by the facility involved a resident with dementia who slid out of a wheelchair and fell to the floor around 9 a.m. The fall caused the resident to fracture a leg. Although the resident was noted to be in pain after the fall, it was 12 hours before the resident was transported to the hospital. At the hospital, doctors found the resident had a fractured leg and sepsis due to a serious urinary tract infection. The resident had surgery to repair the broken leg but developed complications and died two days after the fall.
Surveyors were at the facility the day before the incident occurred and witnessed that same resident repeatedly calling for help over a period of hours without any response from the facility’s staff members. Inspectors checked into the status of the resident and found he/she had a history of falling from the wheelchair and of developing urinary tract infections. The report noted that nurses were not responsive to the needs of the resident. They did not respond when the resident slid forward in the wheelchair or when he/she asked for assistance to go to the bathroom.
It was also reported that the staff did not ensure that the resident was eating, but instead the surveyors observed employees removing the resident’s food while he/she was still consuming the meal. The resident had lost 65 pounds since being admitted to the facility.
Inspectors also found four violations that placed over a dozen residents in the facility in immediate jeopardy for “death or serious mental or physical harm.” These violations make-up just part of the problems the nursing home is facing as evidenced by four lawsuits filed on behalf of residents by family members alleging abuse and neglect. The lawsuits include three residents who are deceased.
Compliance Perspective
Repeated failures by a facility to provide the level of care needed to prevent placing residents in immediate jeopardy for death and serious mental and/or physical harm from abuse and neglect may result in being designated as a “special focus facility candidate” due to providing substandard quality of care, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures regarding provision of quality care for all residents admitted into the facility and staffing levels needed based on resident acuity.
- Train staff to be aware of and responsive to residents’ conditions, i.e., urinary tract infections, a history of falls, and the potential for abuse and neglect if staff ignore residents’ calls for assistance.
- Review staffing levels frequently to ensure that the number and type of nursing staff required to meet the acuity needs of residents are scheduled. Periodically audit by interviewing residents and family members to determine how quickly staff members respond to calls for assistance from residents. Audit for compliance with the protocol for assessing for injury and transferring residents to the hospital in a timely manner.
