Columbia Missouri Nursing Home Abuse Attorney - Part 2

1525 West Monroe
Mexico, Missouri 65265
(573) 581-7261
A “For-Profit” 124-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Follow Procedures and Protocols in Reporting and Investigating Any Act or Alleged Act of Abuse, Neglect or Mistreatment of Residents

In a summary statement of deficiencies dated 09/11/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility's failure to “immediately report an alleged violation of misappropriation of [a resident’s] narcotic pain medication to the facility Administrator and to the State Survey Agency.” In addition, the state investigator noted the facility’s failure “to report the results of the investigation of the allegation to the State Agency within five working days of the incident.”

The deficient practice was noted by a state investigator after a 6:00 AM 09/10/2015 interview with the Registered Nurse at the facility who revealed that “on August 24, 2015  at 10:00 PM, the change of shift narcotic count was incorrect.” One of the resident’s cards was missing. As a result, the Registered Nurse “call the Director of Nursing and left a message [and] call the Assistant Director of Nursing and was instructed to make a new count sheet and place count sheet without a corresponding card of medication with a statement under [their] door.

During an interview that occurred at 3:20 PM on 09/09/2015, the Assistant Director of Nursing revealed that on August 24, 2015, the Registered Nurse called them “to report the change of shift narcotic count revealed a missing card.” At that time, the Assistant Director of Nursing instructed the Registered Nurse “to write a signed statement of the incident, instruct all staff involved to write a signed statement, make copies of the narcotic count sheet and place all information under [the Assistant's] door.”

However, the Assistant Director of Nursing “did not notify anyone else about the incident until the next morning [and] informed the Administrator and Director of Nursing the next day.” However, the Assistant noted that they “did not know the facility’s misappropriation of property policy.”

The state investigator conducted a 09/09/2015 interview with the facility's Director of Nursing who said that the resident’s cards involved in managing controlled pain medication were “missing from the narcotic drawer in the medication cart on South 1 Hall, [and that] the first incident occurred on 08/25/2015.” In addition, the “second incident occurred on 09/02/2015.” At the time that the prescription was sent to the pharmacy for a refill, the pharmacy indicated “that the medication was ineligible for a refill. The resident should not have taken all the medication delivered on 08/24/2015.” When the Administrator was interviewed at 10:30 AM on 09/09/2014, it was revealed that they were “aware of the two cards missing from the narcotic drawer in the medication cart [and] the first incident had occurred on 08/25/2015 and [that they had] been notified when [they] arrived to work on 08/26/2015.”

The Administrator also indicated that they would expect the staff to notify them “immediately, not the next day, of any allegation of abuse, neglect or misappropriation of property.” The Administrator also said that they had not “notify the state survey and certification agency regarding the alleged incident on 08/25/2015 [and] was unsure why the State had not been notified of the incident.” The Administrator also verified that “the second incident occurred on 09/02/2015 [and] did not notify the state agency on 09/03/2015.” The Administrator “decided to call the State agency after two similar incidences occurred, [in that the facility] had a larger problem than [they] originally considered.” The Administrator also said that “the investigation was not completed [and that the Director of Nursing] was writing the report with the investigation findings.

The facility’s “investigation did not determine the perpetrator of the medication. The narcotic drawer keys were accessible to multiple staff members and lay on the cart unattended for a period of time.”

Our Mexico Missouri nursing home neglect attorneys recognize that failing to follow procedures and protocols to report and investigate any allegation or act of mistreatment, neglect or misappropriation of property violates both state and federal regulations. The deficient practice by the nursing staff and Administrator at Golden Living Center – Pin Oaks might be considered an act of negligence because their actions failed to follow the facility’s 01/15/2015 policy titled: Reporting Alleged Abuse Violation that reads in part:

“It is the responsibility of all employees to immediately report any alleged violation of abuse, neglect, injuries of unknown source and misappropriation of resident property.”

“It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect or misappropriation of resident property.”

“Such violations are also reported to state agencies in accordance with existing state law. The center investigates each such alleged violation thoroughly and reports the results of all investigations to the Executive Director or his/her designee, as well as to state agencies as required by state and federal law.”

1024 Adams Street
Jefferson City, Missouri 65101
(573) 635-1320
A “For-Profit” 120-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Ensure That Every Resident Is Provided an Environment Free of Accident Hazards and Provide Adequate Supervision to Prevent an Avoidable Accident That Led to Actual Harm

In a summary statement of deficiencies dated 04/03/2015, a complaint investigation against the facility was opened for its failure to “utilize foot rest on wheelchairs when wheeling residents.”

The complaint investigation involved gathered information showing that “staff wheel residents seated in wheelchairs without foot rests, causing residents to let their feet off the floor and maintain them raised while staff wheeled them.” In addition, two residents “were unable to maintain their legs lifted off the floor.] As a result, one resident [sustained a fractured leg while staff wheeled the resident without foot rests on [their] wheelchair.”

In one incident, the state investigator reviewed a resident’s 02/25/2015 MDS (Minimum Data Set) that revealed the resident has adequate hearing and vision, able to understand and make themselves understood, uses a walker and/or wheelchair and requires extensive assistance for locomotion. In addition, the documentation also indicates that the resident suffers from shortness of breath with exertion, and is on oxygen and anticoagulant medication.

The investigator also reviewed the resident’s 02/24/2015 Care Plan that indicates the resident is at “high risk for falls related to fatigue. Interventions staff planned to address this issue do not address the resident use of a walker/wheelchair for locomotion.”

The resident’s documents were faxed to the surveyor at 10:30 AM on 03/24/2015 revealing that “on 03/23/2015, the resident’s right knee was bent back when [they were] being propelled in the resident’s wheelchair. The resident’s right knee has had past history of surgery and has pins place. After the leg was bent, an open area was noted under the right knee. The area was bleeding profusely. Pressure dressing was applied, swelling noted in the right knee and bruising noted.”

The documentation shows that the resident’s family “were at the bedside and requested an x-ray.” The x-ray was performed and showed no fracture or break and that the resident experience no pain on that day. However, by 03/24/2015, the resident started experiencing pain and was only given Tylenol 325 milligrams in two tablets every four hours to handle their pain. However, after taking the Tylenol two times that day the resident experienced “no relief in pain” and asked if “can we have something stronger please?” The notation also states that the resident’s knee was still profusely bleeding.

The facility conducted an internal investigation on 03/23/2015 with documentation from the staff that indicates that on that day “the resident had propelled [themselves] part of the way down the hallway.” As a part of their therapy, the resident “was it is supposed to be propelling [themselves] or ambulating with one assist.” At that point, “the resident asked the aide if [they] could take [the resident] the rest of the way as [they were] tired, short of breath.”

At the point where the nursing staff was “pushing the resident, the resident’s right leg went back under the wheelchair. The Aide stopped and reposition the resident’s leg and continue to [their] room.”

“The staff documented under the headings Steps Taken by Facility Prevent Further Incidents” documents that the staff has been educated “to remind resident to hold/elevate legs when being pushed in the wheelchair.”

The state investigator conducted an 8:54 AM 04/07/2015 telephone interview with the Certified Nursing Assistant who said that they were “in the hall of the resident was self-propelling [themselves and their] wheelchair. The resident asked [to be pushed back to the room because they were “shorter breath. The resident held up [their legs] must have gotten tired because [they drop their legs] and one leg went under the wheelchair.”

The investigator interviewed the resident’s physician at 12:00 PM on 04/06/2015 who said: “if the resident had not had the accident, they] would not have ended up in the hospital.”

Our Jefferson City nursing home neglect attorneys recognize that failing to provide a level of care to ensure the health and well-being of every resident could place the resident’s life in jeopardy and cause actual harm. The deficient practice of the nursing staff at Adam Street –A Stonebridge Community might be considered negligence or mistreatment because their actions directly caused the actual harm to the resident causing pain and profuse bleeding.

MOBERLY NURSING and rehabilitation Center
700 East Urbandale Drive
Moberly, Missouri 65270
(660) 263-9060
A “For-Profit” 101-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Develop, Implement and Enforce a Program That Investigates, Keeps or Controls Infection from Spreading throughout the Facility

In a summary statement of deficiencies dated 07/09/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility's failure to “properly clean and disinfect the shower room floor after being contaminated with feces.” The deficient practice of the nursing staff at Moberly Nursing and Rehabilitation Center directly affected one resident at the facility.

The deficient practice was noted by a state investigator after a review of a resident’s 05/07/2015 Quarterly MDS (Minimum Data Set) that revealed the resident has “severely impaired cognition, incontinent of bowel and [requires] extensive assist of one staff for dressing, toileting, personal hygiene and bathing.”

An observation was made at the facility at 9:00 AM on 07/07/2007 that showed a Certified Nursing Assistant “assisted the resident to the shower room and [the resident’s wheelchair while placing it in front of the toilet.” While the Certified Nursing Assistant (CNA) transferred the resident from the wheelchair to the shower chair “the resident had a loose bowel movement on the floor.” At that point, the Certified Nursing Assistant “push the shower chair [with the resident seated on it] to the shower bay [and] assisted [the resident] with their shower and drying (tossing soiled linens on the shower bay floor).

The Certified Nursing Assistant then pushed the shower chair back to the toilet area [using a towel to wipe the feces out of the way] where the smears of feces remained on the floor in front of the resident.” At that point, the Certified Nursing Assistant through soiled towels and wash cloths on the floor.

Next, the Certified Nursing Assistant now “in front of the resident, who remained in the shower chair, with [their] shoes coming in contact with the fecal soiled area and apply the resident’s incontinence brief, pants, socks and shoes. The resident shoes also came in contact with the area.”

At this stage, the Certified Nursing Assistant “wheels the resident’s chair to the grab bar, tracking through the soiled area, and had the resident stand and hold onto the grab bar.” The Certified Nursing Assistant “then grabbed a soiled towel from the pile on the floor and began to dry the resident’s backside. The towel was soiled with feces, the surveyor advised [the Certified Nursing Assistant of this while the CNA] assist the resident into [their] wheelchair.” At this stage, the wheels of the wheelchair also came in contact with the feces that was smeared on the floor.

The surveyor conducted an interview 20 minutes later with the Certified Nursing Assistant who verified that they “should not have thrown linens on the floor [and] should have cleaned the feces from the floor using the sanitized wipes (disposable, disinfectant cloths) that were nearby [and] clean all equipment and clothing items that came in contact with the smeared feces should be clean with sanitized wipes and [that they] would do so.”

The state investigator interviewed the facility’s Administrator at 10:40 AM on July 9, 2015 who said that “she would expect feces to be cleaned up off the floor with disinfectant before staff walk or roll over the area in their wheelchairs.”

Our Moberly nursing home neglect attorneys recognize that failing to develop, implement and enforce programs that minimize the spread of infection and maximizes sanitation at the facility could place the health and well-being of all residents in jeopardy. The deficient practice by the nursing staff at Moberly Nursing and Rehabilitation Center might be considered mistreatment or negligence because their actions fail to follow the facility’s June 2006 policy title: Body Substance Precautions System that reads in part:

“Proper environmental cleaning is an essential component of the entire spectrum for preventing and controlling infections.”

“Always clean grossly soiled areas (feces, urine, vomitus, sputum, and drainage) with an organic cleaner/detergent before using the disinfectant.”

1600 East Rollins
Moberly, Missouri 65270
(660) 263-6887
A “For-Profit” 96-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Provide Proper Care and Treatment to Residents to Prevent the Development of a New Bedsore or Allow an Existing Bedsore to Heal

In a summary statement of deficiencies dated 03/12/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility's failure to “turn or reposition to residents [at the facility] who were incontinent and who the facility staff assessed as being at risk for pressure ulcers.”

The deficient practice was noted by state investigator after a review of a resident’s 01/08/2015 Braden Scale revealing a result of 11 that indicates that the resident is at high risk for development of pressure ulcers. In addition, the investigator also reviewed the resident’s 01/13/2015 Quarterly MDS (Minimum Data Set) that revealed that the resident had difficulty in making daily decisions due to being severely impaired.” The document also revealed that the resident is “always incontinent of bowel and bladder and requires total assist of two staff and physical assist for bed mobility, transfers, toilet use, personal hygiene and bathing.” The document also shows that the resident is “at risk for pressure ulcers.”

The state investigator also reviewed the resident’s 01/14/2015 Care Plan that also indicates the resident “requires assistance with all cares, transferred with mechanical lift with two staff assist and checked for incontinence every two hours and as needed.” The document also directs the nursing staff to “monitor/document/report to my physician any skin breakdown, turn and reposition at least every two hours and as needed.”

A continuous observation of the resident was made on 03/10/2015 with 13 notations made between 5:45 AM and 10:10 AM. Each documented observation noted that the resident was lying on their right side in their bed. The state surveyor notes that “the resident remained in [their] bed on [their] left side from 5:45 AM to 10:10 AM for a total of four hours and 25 minutes without being repositioned. The staff did not reposition, toilet or check on the resident for incontinence.”

At 10:10 AM on the same morning, the state surveyor observed two Certified Nursing Assistants assisting “the resident to turn or reposition in bed. The resident’s brief, draw sheet and bottom sheet were saturated with urine.” At that point, a Certified Nursing Assistant provided the resident perineal care where the perineal area and coccyx on the resident were reddened.

Our Moberly nursing home neglect lawyers recognize the failing to provide all the necessary care and treatment to ensure a resident does not develop a new pressure sore could place their health and well-being in immediate jeopardy. The deficient practice of the nursing staff and failing to follow the resident’s Care Plan to reposition and checked for incontinence violates the facility’s December 2012 policy titled: Turning and Repositioning that reads in part:

“All residents identified at risk for skin breakdown, or with the presence of wounds, will be placed on a turning/repositioning program”

“the program includes a consistent plan for changing the resident’s position and realigning the body”

The turning/repositioning program should be organized, planned, documented, monitored and evaluated based on an assessment of the resident’s needs”

“Completion of turning/repositioning should be documented, at a minimum, on every shift by the Certified Nursing Assistant or licensed nurse.”

The Ways in Which the Nursing Home Abuse and Neglect Occurs

Because many nursing facilities are motivated by the generating profits, the owners, managers and administrators will often employ a nursing staff that is poorly trained, unqualified to provide care or hire individuals before conducting necessary background checks. Without proper vetting, nurses and other employees with histories of aggressive behavior, abuse and neglect can work for days, weeks or years at the facility, placing the health and well-being of every resident in immediate jeopardy.

The Missouri nursing home abuse attorneys at Nursing Home Law Center LLC have provided legal services to victims who have reported kinds of abuse and neglect. Most of our cases involve:

  • Pressure Sores and Infections – Bedsores (pressure sores; pressure ulcers; decubitus ulcers) occur when elderly residents cannot turn or reposition their body periodically to relieve pressure and allow blood flow and oxygen to reach the skin and underlying tissue. Every bedsore in a nursing facility is preventable. Without proper treatment, a small unassuming pressure sore can easily develop into a life-threatening infection of the bone (osteomyelitis) or blood (sepsis).
  • Malnutrition and Dehydration – When the nursing home resident is debilitated or bedridden, they lack access to food and water without assistance. Often times, the most vulnerable residents are not properly nourished or hydrated because of a lack of quality care by caregivers who failed to assist the resident in drinking and eating throughout every day.
  • Slipping and Falling – Every slip and fall occurring in a nursing facility is preventable with adequate supervision and the development and enforcement of an effective Plan of Care. Most slip and fall accidents occur when staff members are not available to assist the resident in toileting or fail to answer a call light in a timely manner.
  • Unnecessary Restraints – Many nursing home staff members will use unnecessary and unauthorized restraints including a physical restraint involving a belt, or chemical restraint by overmedicating the resident with sedatives.
  • Physical, Mental and Sexual Abuse – Uncaring, malicious, lazy or cruel staff members will use physical or mental abuse to subdue the resident into submission or as a way for staff to avoid doing their job. Other residents become the victim of sexual abuse when assaulted by a nursing home employee or another resident at the facility.
  • Lack of Proper Medical Care – Any deviation from acceptable standards of medical and nursing care is considered abuse, mistreatment or neglect. This can come in the form of denying the resident medications, medical tests or examinations or failing to properly diagnose and treat the resident when a change in their condition occurs.
Hiring an Attorney

Only a reputable personal injury attorney with years of experience in handling nursing home abuse cases should handle a claim for compensation. This is because Missouri tort law requires experience and a comprehensive understanding of the rules of procedure and filing a case for recompense.

The Columbia nursing home abuse attorneys at Nursing Home Law Center LLC have helped many victims of nursing home neglect pursue a claim for compensation. Our team of Missouri elder abuse lawyers has fought to protect the rights of the loved one to ensure they receive the level of recompense they deserve. We encourage you to contact our law offices today at (800) 926-7565 to schedule a free, no-obligation full case evaluation to discuss the merits of the claim. We accept all nursing home abuse cases, wrongful death lawsuits, and personal injury claims through contingency fee arrangements, so no upfront fees or retainers are required.

For additional information on Missouri laws and information on nursing homes look here.

Nursing Home Abuse & Neglect Resources

If you are looking for information on a specific facility or an attorney, please see links below to respective locality pages.

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