Both the State of Tennessee and the Centers for Medicare and Medicaid Services (CMS) conduct routine surveys and unannounced inspections at every nursing facility statewide. Their efforts help to identify serious violations and hazardous deficiencies that harm or could harm residents. When the problem is identified, the state provides the nursing home the opportunity to make improvements in the level of care they provide and corrections to their written policies and procedures.
In the most egregious cases, the surveyors will classify the nursing center as a Special Focus Facility (SFF) and add the Home to the Medicare deficiency watch list. This designation alerts the public that the facility is under scrutiny for providing substandard care. If the underlying problems are not corrected promptly, the facility may face monetary penalties or lose their contract to provide care to Medicaid and Medicare-funded patients.
In 2017, Brookhaven Manor was added to the deficiency watch list and designated a Special Focus Facility. This action came just months after the Tennessee Health Commissioner suspended admissions of new residents to the nursing home in December 2016. Likely, the facility will maintain its undesirable designation for many months or years to come. Some serious hazards, dangerous deficiencies and nursing home violations involving this facility are detailed below.
This Nursing Center is a ‘for profit’ facility providing services and care to residents of Kingsport, and Sullivan and Hawkins counties, Tennessee. The 180-certified bed Long-Term Care Nursing Home is located at:
2035 Stonebrook Place
Kingsport, TN 37660
(423) 246-8934
Both the State of Tennessee and the federal government have the legal authority to impose monetary penalties when the facility is identified with serious failures over an extended period. Other additional penalties include a denial of payment for services rendered.
On December 7, 2016, nursing home regulators levied a $428,837 fine against Brookhaven Manor. On the same date, Medicare denied a request for payment due to providing residents substandard care. Over the last three years, nursing home regulators have followed up on four formally filed complaints and six facility-reported issues that after investigations all resulted in citations.
On December 19, 2016, the Tennessee Health Commissioner suspended new resident admissions at Brookhaven Manor after a complaint investigation, and an annual survey were completed from November 1, 2016, until December 7, 2016. The report lists the serious violations including those that involved substandard performance in physician services, administration, nursing services, infection control, and resident’s rights. The released report indicated that:
“The Commissioner of Health may suspend admissions to a nursing home when conditions are determined to be or are likely to be, detrimental to the health, safety or welfare of the residents. The order to suspend admissions remains effective until conditions have been and continue to remain corrected.…”
Families can review publically available data on every long-term and intermediate care facility in Tennessee by visiting numerous state and federal government databases including the Medicare.com website. This data is a valuable tool to use when choosing the best location to place a loved one who needs the highest level of services and care in a safe environment. The website details incident inquiries, dangerous hazards, opened investigations, health violations, filed complaints, and safety concerns at every nursing home in the US.
Currently, Brookhaven Manor maintains an overall one out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, one out of five stars for staffing issues, and three out of five stars for quality measures. Some serious violations, deficiencies and health hazards concerning this facility include:
In a summary statement of deficiencies dated December 7, 2016, a state investigator noted the facility failed to “properly notify the physician of the presence of a pressure ulcer for [two residents] reviewed for pressure ulcers.” The deficiency by the nursing staff placed two residents in “Immediate Jeopardy (a situation which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death).”
The state surveyor reviewed a resident’s medical records and Wound Assessment Report dated August 5, 2016, that revealed a pressure ulcer located on the sacrum. However, after interviewing the Treatment Nurse on November 8, 2016, it was confirmed that “the physician was not notified of a Stage I or Stage II pressure ulcers upon admission and there were no orders obtained for wound care.”
The surveyor interviewed the facility’s Director of Nursing who revealed that “with Stage I pressure ulcers, we basically reposition [the patient] and notify the doctor or nurse practitioner when they visit to do their assessment.” If the bedsore has progressed to a stage II or higher degradation, the Director stated that the nurses “would call the doctor for an order.”
An interview with the Nurse Practitioner on November 9, 2016, confirmed that they were “not notified of the [resident’s skin] shearing.” The nurse practitioner stated that the nurses “should have been treating [the bedsores] was something.” The Director of Nursing confirmed that “the facility had failed to notify the resident’s physician to obtain an order for [treating the bedsore]. Because of the failure of the nursing staff, the resident’s “wound declined after it had been identified and treatment was not implemented.”
In a summary statement of deficiencies dated October 20, 2015, the State surveyor noted during an annual licensure and certification survey that the facility failed to “maintain contact isolation precautions for [a resident] reviewed for infection control.” The surveyor’s findings included observation of a resident’s room on October 20, 2015 “from the hallway outside” that revealed “a sign affixed to the door which read ‘Report to Nursing Station before Entering Room.’”
Continuing observation “reveal the clear plastic storage container with isolation gowns, gloves, masks and shoe covers inside the doors.” However, on October 20, 2015, at 12:37 PM, the surveyor observed a Certified Nursing Assistant responding to an activated call light.” The Assistant entered “the room without donning gloves or other personal protective equipment and deactivated the call light by pushing the button on the wall above the resident’s bed, spoke with the resident and exited the room without washing their hands at 12:39 PM.”
One minute later, the facility Medical Director “entered the resident’s room without donning gloves or personal protective equipment, approached the resident, [and] placed the resident’s chart on the bedside table.” The Medical Director then touched “the resident, used a stethoscope to listen to the resident’s heart and lung sounds, spoke to the resident while making contact with the bed, exited the room with the chart and did not wash their hands.” The Medical Director then “walked to the Nursing Station and place the chart on top of the desk at the Nursing Station at 12:49 PM.”
The surveyor interviewed the Director of Nursing who confirmed that the resident “was placed on contact isolation due to VRE infection in a surgical wound and all staff were expected to wash hands, put on gloves, gowns, and masks [before] entering the room.” The Director also stated that upon leaving the room, all staff members must “remove the protective equipment inside the room, and perform hand hygiene [before] exiting the room. The continued interview confirmed the facility failed to maintain contact isolation precautions for [the resident].”
In a summary statement of deficiencies dated December 7, 2016, a state investigator noted the facility failed to “prevent mental, physical, and verbal abuse for nine residents.” The nursing staff’s “systematic failure to immediately remove the accused, failure to report allegations to administration, and failure to investigate allegations of abuse, placed [six residents] in Immediate Jeopardy.”
The state inspectors reviewed a facility’s investigation dated February 6, 2016, that revealed that a resident “reported to the Registered Nurse that a Certified Nursing Assistant had told the resident she was wet and nasty and [the CNA] was going to change her.” The CNA then grabbed the resident’s legs “and made her move over [before telling the resident] ‘I would not have to do this if your filthy lazy ass would get up and go to the bathroom instead of pissing on yourself.’”
The Registered Nurse stated that she heard the resident “screaming and crying because she had never heard the resident do that before, she immediately went to the resident’s room.” Upon entering the room while the CNA was exiting, the Registered Nurse “assessed the resident for injuries and administered [medication] to help settle the resident down.” The Registered Nurse told the CNA “not to go back to the resident’s room.” However, the CNA “was allowed to finish his shift unsupervised.”
The state investigator reviewed the CNA’s personnel file that revealed the CNA “was suspended on February 6, 2016, through February 10, 2016, [but only] after finishing his shift on February 6, 2016, pending investigation of the abuse allegation.” The investigator also interviewed the Registered Nurse who confirmed that the resident “was so upset” that they had to administer medication to calm the resident down. However, the Registered Nurse “did not suspend the CNA [as required by law and,] he was allowed to finish his shift.”
The surveyor interviewed the resident who stated that “I feel like I was abused because of what he said and because he said no one would believe me (if she reported to the facility’s Administrator or staff).”
As a part of the investigation of alleged abuse, another resident reported to a different Certified Nursing Assistant that “she did not want [the allegedly abusive CNA] back in her room. The continued review revealed [the allegedly abusive CNA] entered the room to provide incontinent care, grabbed the resident by her left arm and pulled her over. The resident told him not to do that because it hurt.” The allegedly aggressive CNA told the resident he “could hurt her if he wanted to because it was his job to change her.”
In a summary statement of deficiencies dated December 7, 2016, the State surveyor noted during an annual licensure and certification survey that the facility failed to “provide services to prevent neglect for three residents.” The deficiency by the nursing staff involved a failure “to provide services to prevent neglect is likely to place all residents requiring assistance with incontinent care in Immediate Jeopardy.”
The state investigator reviewed the facility’s Investigation Report that stated February 7, 2016, that revealed a resident “reported to a Registered Nurse that she told a Certified Nursing Assistant “she was soaking wet and requested incontinent care. The continued review revealed [the allegedly abusive CNA] told the resident he was two hours behind and he could not get to her.” The Registered Nurse “reported the incident to the Director of Nursing on February 8, 2016.” The Director interviewed the resident who “reported the same incident” to the Director. During an interview with the Director of Nursing on December 5, 2016, it was confirmed that “she expected residents to be checked and changed every two hours and as needed.”
In a summary statement of deficiencies dated December 7, 2016, a state investigator noted the facility failed to “immediately report allegations of abuse and complete a thorough investigation for an allegation of abuse [involving seven residents].” The failure of the nursing staff placed seven residents in Immediate Jeopardy.”
Due to the actions of the allegedly abusive Certified Nursing Assistant, the investigator noted that the facility had failed to follow their undated Abuse Policy that reads in part:
“The facility [shall] report and investigate all alleged incidents of resident abuse, mistreatment, neglect, and misappropriation of property.”
“The facility will complete a thorough investigation of an alleged incident by the appropriate staff.”
“The Charge Nurse notifies the Shift Supervisor of the allegation. The Supervisor initiates notification to the Social Services Department and begins an investigation immediately.”
“Immediately notify the Director of Nursing and the Administrator by phone, if necessary.”
“Investigate the alleged incident during the shift on which the allegation of abuse occurred.”
“Interview the resident or other witnesses. The interview is to be dated, documented and signed by the Supervisor.”
“Interview the Staff implicated. Have the employee document, in writing if able, their knowledge/version of the incident. Ensure that employee’s written narrative is signed and dated. Interview any staff witnesses or other available witnesses. Have the witnesses document their knowledge/version of the incident.”
When a staff member is implicated in the potential resident abuse situation, the employee is to be removed from all patient care areas and sent home after the narrative is obtained from the employee.”
“The employee is instructed to contact the Director of Nursing Services or the Administrator the next day.”
“Reporting and documentation requirements investigation continues as needed over the next 24 to 48 hours.”
If you believe that your loved one suffered abuse, mistreatment or neglect while a patient at Brookhaven Manor, or any other nursing facility, call a personal injury attorney now. A lawyer working on your behalf can ensure all the necessary documentation is filed in the appropriate County Courthouse before the Tennessee statute of limitations expires. Your attorney will investigate your claim, build your case, and negotiate a settlement or present the evidence in front of a judge and jury at a lawsuit trial.
Contact us today. No upfront payments are required because personal injury attorneys accept every wrongful death lawsuit, nursing home abuse or negligence case and medical malpractice for compensation on contingency agreements. This arrangement means all legal fees are paid only after the law firm has won your case at trial or negotiated an out of court settlement on your behalf.
Sources:
Attorney Cameron Jehl
Licensed in Tennessee
Chicago Nursing Home Injury Attorney Nursing Home Law Center LLC Home