If you suspect poor care in a nursing home, one of the most important things to do is to document the mistreatment. Obviously, this can be a difficult—if not impossible– for an individual who may not be familiar with the system. Perhaps the easiest way to document poor care is to file a complaint with the state health department. The complaint will trigger an investigation (or survey as they are commonly known) by the state’s department of public health into the alleged poor care. These investigations tend to be thorough and usually entail chart reviews, employee interviews, resident interviews and examination of any relevant physical evidence.
The findings are prepared in a report format that is standardized by the Department of Health and Human Services Centers For Medicare & Medicaid Services. Copies of the complete report along with interview summaries and incident forms may be obtained via individual state’s Freedom of Information Act (FOIA).
In addition to learning more about a specific incident or pattern of care, once a complaint initiated survey is completed, the survey or report becomes part of the facilities file with the department of health and is available for inspection by perspective residents and their families.
Lastly, surveys reveal if the facility violated any federal regulations with respect to resident care. The Federal Health Regulations for Long Term Care Facilities are identified according to ‘F Tags’. F Tags correlate to specific rights granted to nursing home residents under federal law in the Code of Federal Regulations (CFR).
Palos Hills Extended Care LLC
Palos Hills Extended Care is a 203-bed facility in Palos Hills, IL that caters to individuals who require skilled nursing care and intermediate nursing care. In April, 2008 an investigation was completed and revealed the following problems:
Pressure Sores (F 314, CFR 483.25(c)): Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individuals clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
A review of five residents charts revealed one resident developed pressure sores during their admission to Palos and three others had pressure sores that ‘became significantly worse’ during their stay. The investigators’ review of the residents’ charts also revealed that the facility failed to conduct mandatory skin assessments of residents as required by Federal Law.
In one case, the facility failed to apply “DuoDerm” as directed by a physician to a resident who was admitted to the facility with a stage I pressure sore on her buttock. Within one month of her admission to Palos, the pressure sore had advanced to stage III measuring 15.5 cm x 16.5cm. In addition to failing to tend to the woman’s pressure sore, Palos also failed to provide proper nutrition—the woman lost 27 lbs. during the course of her admission.
Accidents and Supervision (F 323, CFR 483.25 (h)): The facility failed to ensure that the resident environment remains free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
In a sampling of five Palos Hills Extended Care residents, the facility failed to protect take safeguards necessary to prevent accidents. In particular, the survey identifies a resident who suffered multiple falls where she sustained a fractured clavicle in one fall, a head injury requiring 12 sutures on another and a fractured femur during another fall. The falls and resulting injuries occurred despite the fact that Palos identified the woman as a ‘high fall risk’ and the staff noting the resident’s propensity to fall on multiple occasions, the staff failed to supervise the resident to prevent future falls and implement fall prevention measures.
If you suspect mistreatment of nursing home resident, please contact the Department of Health in your state or your local ombudsman. Reporting poor care today can lead to improved care for others down the road.