To ensure the public remains fully aware of the level of care every nursing home provides, the state of Tennessee and Centers for Medicare and Medicaid Services (CMS) conduct routine surveys and investigations at every facility statewide. Their efforts help to identify health hazards, serious violations, and deficiencies that harm or could harm residents. When problems are detected, the facility must make immediate improvements to the level of care they provide and changes to their policies and procedures.
For nursing homes that have ongoing violations and serious underlying issues, the regulators may designate the Home as a Special Focus Facility (SFF). This undesirable designation identifies the Center as problematic in the level of care they provide residents. These homes are added to the Medicare deficiency watch list and must undergo additional investigations, inspections, and surveys every year.
In 2017, nursing home regulators designated Creekside Health and Rehabilitation Center as a Special Focus Facility. Since the Home was added to the watch list, the staff has made some improvements and changes to their policies and procedures. Likely, Creekside (SFF) will remain on the list for many years until regulators are assured that the corrections made by the Home remain permanent. Some of the serious issues, violations, and deficiencies involving this facility are detailed below.
This Nursing Center is a ‘for profit’ facility providing services and cares to residents of Madison and Davidson County, Tennessee. The 139-certified bed Long-Term Care Nursing Home is located at:
306 W Due West Ave
Madison, TN
(615) 612-4499
In addition to providing around the clock skilled nursing care, the facility also offers:
Both the federal government and the state of Tennessee have the legal authority to levy monetary penalties against any nursing facility identify with serious deficiencies and violations. These fines are meant to alert the public and place the facility on notice that the continuation of substandard care will no longer be tolerated.
Over the last three years, regulators have imposed two monetary penalties against Creekside Health and Rehabilitation Center. These penalties include a $45,808 fine on April 1, 2016, and a $766,774 fine on June 6, 2016. Additionally, Medicare refused a request for payment on June 6, 2016, due to substandard care. During the same time, regulators received nine formally filed complaints that following the completion of investigations all resulted in citations.
The state of Tennessee routinely updates their long-term care home database system to reflect all filed complaints, safety concerns, opened investigations, health violations, incident inquiries, and dangerous hazards. This information can be found on numerous sites including Medicare.gov.
Currently, Creekside Health and Rehabilitation Center (SFF) maintains an overall two out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, four out of five stars for staffing issues, and four out of five stars for quality measures. Some serious concerns, violations, hazards, and deficiencies at this facility include:
In a summary statement of deficiencies dated April 1, 2016, a state investigator noted the facility failed to “report to the State Agency and thoroughly investigate an unwitnessed fracture as an injury of unknown origin for one resident…” The surveyor reviewed a resident’s medical record documented by the night shift Licensed Practical Nurse on January 15, 2016, that revealed: “received a report from resident’s caregiver [a Certified Nursing Assistant] of a complaint of pain.” The resident “was guarding her left leg and foot.”
A review of the resident’s x-ray medical records dated January 15, 2016, revealed SIGNIFICANT FINDINGS – Acute spiral mildly displaced fractures of the distal diaphyses and meta-diaphyseal junctions of the tibia and fibula.” The resident was sent to the emergency room for an orthopedic evaluation. A review of the resident’s emergency room H & P (History and Physical) dated January 15, 2016, revealed that the resident was a “severely demented female who has contractures of her left knee and left hip.”
There is documentation that the resident suffered injuries while at the “nursing home with the left tibia and fibula fracture.” However, there was “no real documentation when she suffered her fault. Per daughter, she is non-ambulatory and in a wheelchair.”
The documentation further revealed that the resident “suffered an unfortunate event that was not witnessed, resulting in the left minimally displaced comminuted spiral pattern mid-shaft tibia fracture which extends inarticulately with a posterior malleolus (ankle) fracture…” The resident’s Medical Record with Discharge/Aftercare Instructions dated January 15, 2016, revealed that the resident’s tibia and fibula bone fracture “injury often happens when the ankle is twisted strongly. This [movement] tears ankle ligaments. It also causes a break in the bones [that] the ligaments hold together.”
The facility’s undated Fall Scene Investigation Report revealed that the nursing staff checked on the resident at 11:00 PM. The Certified Nursing Assistant stated that “she was dry, so there was no need to change her, so on the next round at 1:00 AM, she was wet, and ‘I go to change her [and] she complains of pain in her left leg screaming it hurts.’ I finished changing her and immediately got the nurse to examine her.”
The investigator interviewed the Director of Nursing on March 30, 2016, who stated that they had “investigated the incident” but “denied the fracture being an injury of unknown origin.” The Director stated that “she did not know why the Medical Director had documented that the fracture occurred with the fall.” However, the investigator noted that the Director “had not completed a root cause analysis in the effort to determine the cause of the incident that led to the spiral [fracture] and fibula bones of the lower left leg.”
In a summary statement of deficiencies dated April 1, 2016, a state investigator noted the facility failed “to provide supervision for safe transfers for [a resident] and… failed to maintain a bed alarm intervention to address falls for [one resident].” The deficiency by the nursing staff to “provide supervision resulted in harm for [a resident].”
This deficiency involved a resident injury noted above associated with an injury caused by an unknown origin. The surveyor interviewed the facility’s Administrator and conducted a “review of the resident’s Electronic Medical Record on March 31, 2016.” The Administrator confirmed that “there was no intervention care planned to address the resident’s assessed need for extensive two total dependents for transfer with the physical assistance of two persons.”
An interview conducted with a Registered Nurse Unit Coordinator on January 31, 2016, confirmed that the resident “resided on our unit during the seven months of the resident state and revealed [that the Registered Nurse] was not able to recall that the resident required one or two persons for physical assistance for transfer.”
In a separate summary statement of deficiencies dated August 11, 2016, a state investigator noted the facility failed “to supervise the resident to prevent a fall.” The surveyor reviewed a Certified Nursing Aide’s Care Card dated October 23, 2015, that was still in use on July 5, 2016. The card revealed that two staff members were “needed for bed mobility. The resident is difficult to turn and is unable to assist with turning. The resident has a rigid body position related to Parkinson’s disease.”
A review of the facility Investigation Report dated July 5, 2016, revealed that “during bath time, the resident lost seated balance upward and required staff to physically assist to the floor to prevent a fall.” There was a “skin tear to the right small tow [and a] small bruise on the upper left arm. Bruises [were noted] bilaterally to the inner thighs.”
A Post-Incident Action Report dated July 5, 2016, revealed that according to a Certified Nursing Aide the “resident was being placed on the bed and began to lose his balance leaning over to his left side and needed to be assisted to the floor to prevent him from falling from the bed.” However, further review of the physician’s diagnosis revealed that the resident had “a superficial bruising of the lower leg; contusion of the right lower leg; [and a] contusion of the left lower leg.”
In a summary statement of deficiencies dated June 16, 2016, a state investigator noted the facility failed “to notify the physician of a pressure ulcer for [a resident] reviewed for pressure ulcers.” The deficiency by the nursing staff involved a “failure to notify the physician of a pressure ulcer that resulted in actual harm to [the resident].”
A review of the resident’s Wound Assessment Report documented by a Licensed Practical Nurse on April 19, 2016, revealed that a resident “had an abrasion to the coccyx that was identified on April 19, 2016.” However, the surveyor conducted a telephone interview with the facility’s Medical Director on May 19, 2016, who revealed that they were “unaware of any …wound for [that resident].”
The surveyor asked the doctor if the “Wound Nurse had contacted him on 4/19, 4/27, 5/4, and 5/9 regarding a wound to the coccyx with an increase in size and drainage for [the resident].” The doctor replied, “No, I definitely was not called four times. I was not aware of any problems until the Director of Nursing called me yesterday to ask if I knew anything about a shearing problem for [the resident].” The doctor stated that they had not heard of it.
The surveyor interviewed the facility’s Nurse Practitioner on May 19, 2016, who revealed that the Nurse Practitioner “was present in the facility five days a week.” The Nurse Practitioner claimed that “I never knew of any wound to [the resident] and I worked very closely with [the Medical Director].” The Nurse Practitioner stated, “I can attest that he never knew anything either.”
In a separate summary statement of deficiencies dated October 24, 2016, a state investigator noted the facility failed “to notify the physician of residents with blood glucose [levels] greater than 400.” This deficiency involved four residents reviewed for diabetes mellitus. The deficiency by the nursing staff “placed all diabetic residents in Immediate Jeopardy.”
The facility was reminded of their policy titled: Change in Resident’s Condition or Status that reads in part “the physician should be notified when the blood sugar falls above his/her specified blood sugar range … above 400 mg/dL (milligrams per deciliter).” A review of a resident’s Medication Administration Record (MAR) revealed numerous readings higher than 400 mg/dL including:
However, the state surveyor noted that upon review of the resident’s medical records there was “known notification to the Medical Doctor or Nurse Practitioner regarding elevated blood sugars.”
In a summary statement of deficiencies dated June 16, 2016, a state investigator noted the facility failed “to assess the presence of a pressure ulcer on the Minimum Data Set [(MDS) for a resident].” A review of the resident’s Nursing Risk Assessment revealed: “a visual body map documenting [the resident] had an abrasion on the left gluteal coccyx area (low buttock/back area).” There was also a report in the Departmental Notes documented by the Licensed Practical Nurse that also noted “an open area on the coccyx.”
During an interview with the facility’s Director of Nursing on October 19, 2016, the Director confirmed that the “facility policy was to notify the physician if their blood sugar was less than sixty or greater than 400. The continued interview with the Director of Nursing confirmed that the facility failed to follow the policy to notify the physician of elevated blood sugars for [the resident].”
In a summary statement of deficiencies dated October 24, 2016, a state investigator noted that the facility failed to “prevent a resident’s neglect when it failed to complete blood glucose monitoring at specific times.” Also, the facility “failed to administer insulin at scheduled times, and failed to administer cardiac, blood pressure, and other medications within the scheduled time frame.”
The investigator noted that the facility had also failed “to follow physician’s orders to recheck [the residents’] blood glucose after an abnormal value was found and failed to document interventions for [twelve residents] reviewed for medications.” These deficient practices “placed all diabetic residents in Immediate Jeopardy.”
In a summary statement of deficiencies dated June 16, 2016, a state investigator noted that the facility failed to “timely identify, provide treatment and prevent deterioration of a pressure ulcer for [a resident] reviewed for pressure ulcers. The deficiency of the nursing staff led to a “failure to timely identify, provide treatment and prevent deterioration of a pressure ulcer that resulted in actual harm to [the resident].”
If your loved one was harmed by caregivers while residing as a patient at Creekside Health And Rehabilitation Center (SFF), or any nursing facility, contacting a personal injury attorney could help. Lawyers working on behalf of the victim can ensure your family receives the financial compensation they deserve to recover damages. The law firm will file all the necessary paperwork, investigate the claim, build the case, and resolve the lawsuit through a negotiated out of court settlement or a jury trial award in the county courthouse.
Nursing home and medical malpractice claims for compensation are typically accepted through contingency fee arrangements. These agreements mean all legal fees are paid only after the plaintiff’s attorneys have resolved the case for financial compensation. These law firms offer a “No Win/No Fee” Guarantee, so the plaintiffs are never out of pocket with expenses. Contact us today!
Sources:
Attorney Cameron Jehl
Licensed in Tennessee
Chicago Nursing Home Injury Lawyer Nursing Home Law Center LLC Home