Hagerstown Nursing Home Abuse & Neglect Attorneys - Part 2

GOLDEN LIVINGCENTER – WESTMINSTER
1234 Washington Boulevard
Westminster, Maryland 21157
(410) 848-0700

A “For-Profit” 170-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 Policies Regarding Mistreatment, Neglect and Abuse of Residents

In a summary statement of deficiencies dated 12/29/2015, a complaint investigation was opened against the facility for its failure to “ensure that [a resident] was free from staff neglect.”

The state surveyor conducting the investigation review the facility investigation report that revealed an allegation that a resident “received a fractured left humerus during care on 09/12/2015 […and that the resident] resides on the facility Alzheimer’s Care Unit

and is totally dependent upon the nursing staff for all aspects of [their] care […and the resident] is cognitively impaired, has limited communication does not have full use of [their] left arm.” In addition, the investigation revealed that the nursing staff used a lift “to perform incontinence care for [the resident] on 09/12/2015 at approximate 2:00 PM.” The handling instructions by the lift indicate that it is mobile, is intended to be used for raising to a standing position or short transfer of residents and that any individual with disabled arms shall be held down in front of the body during the raising by the caregiver or second caregiver to ensure no injury occurs.

The state investigator noted that after two Geriatric Nursing Assistants “perform incontinence care for [the resident] at approximately 2 PM on 09/12/2015, [the resident] was observed with a skin tear injury to the right elbow.” As a result, “the Charge Nurse applied a dressing to the right elbow [that was later observed] swelling and bruising to [the resident’s] left upper arm.” The resident’s “physician was made aware, new orders for an x-ray and pain medication were given.” Later that evening, the Licensed Practical Nurse on duty providing care to the resident “observed a large dark discoloration with swelling to [the resident’s] left upper arm” and that the resident “complained and grimaced when the left upper arm was palpated.”

However, the LPN in charge of providing care indicated that “there were no reports of an injury to [the resident’s] left arm given to the [LPN] and report prior to the beginning of their shift [that evening].” At first, the GNA in charge of providing care to the resident did not provide a detailed description of exactly what happened which is why the LPN in charge was not aware of any injury to the resident’s left arm.

“When questioned, [the GNA] stated that “they] did not tell the truth when interviewed on 09/13/2015 because [they] did not want to get anyone in trouble.” As a part of the investigation, “the surveyor determined that [both GNAs] were aware that [the resident] may have injured [their] left arm and being raised by “the lift on that date] but chose not to inform the Charge Nurse.”

Our Westminster nursing home neglect attorneys recognize that any failure to follow protocols that injures a cognitively impaired resident could cause significant injury or harm to the resident who is unable to communicate pain and discomfort. The deficient practice by the GNAs at Golden Living Center – Westminster might be considered negligence or mistreatment.

BALLENGER CREEK CENTER
347 Ballenger Drive
Frederick, Maryland 21701
(301) 663-5181

A “For-Profit” 143-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Quickly Identify and Effectively Resolve Resident Problems at the Facility

In a summary statement of deficiencies dated 05/07/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “implement an effective Quality Assurance Program that identifies resident problems and effectively resolve the problems.”

State investigators conducted an annual Medicare/Medicaid survey at the facility between 04/29/2015 and 05/07/2015 for a facility failure was identified. The surveyor noted that the facility “failed to accurately call residents on the MDS (Minimum Data Set).” The investigator noted that “this is a repeat deficiency that was cited during the facility’s annual survey conducted on 01/24/2014.”

The surveyor conducted a 05/07/2015 interview with the facility’s Director of Nursing and MDS Coordinator who stated “currently, the information is obtained from the nurses, the GNAs [Geriatric Nursing Assistants] and is used when completing the MDS [and this method] can cause discrepancies because the information is being obtained from various sources.” The Director of Nursing indicated that “moving forward, Corporate will be involved and is planning to revamp the current process due to the discrepancies […and] the plan is to have one person assigned to obtain the information so is complete and accurate.”

Our Frederick nursing home neglect attorneys recognize that failing to quickly identify conflicting information in the resident’s medical records, medication administration reports, physician’s orders, incident reports, weekly and quarterly assessments, TAR (Treatment Administration Record), Brief Interview for Mental Status (BIMS) records and other documents could create a serious situation that leads to injury or harm to the resident. The deficient practice of the nursing staff that Ballenger Creek Center might be considered negligence because the failure to maintain accurate records have been previously cited at the facility by the state surveyors 14 months prior without any corrections or resolutions by the Administrator, MDS Coordinator or Director of Nursing.

GOLDEN LIVING CENTER – FREDERICK
30 North Place
Frederick, Maryland 21701
(301) 695-6618

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 Provide Adequate Care and Assistance to Ensure Residents at Risk for Falling Do Not Fall and Sustain Serious Injury

In a summary statement of deficiencies dated 09/17/2015, a complaint investigation was opened against the facility for its failure to “ensure that residents were free of accident hazards when [a CNA] transferred [a resident] who was a known risk for falls, without assistance of a second staff member, as required in the resident’s care plan.” As a result of this deficient practice “with only one staff assisting during transfer from the toilet, [the resident’s] knees buckled and he/she fell sustaining a fracture.”

The state investigator conducted an interview with the resident and the resident’s daughter at 2:00 PM on 09/10/2015 when the daughter stated “that her mother’s shoulder was broken approximately nine weeks ago as [a GNA (Geriatric Nurse Assistant)] was transferring her mother from the toilet to the wheelchair.” The resident’s daughter revealed that “she was visiting with her mother on Thursday, 07/02/2015, and was present when the incident occurred [stating that the Geriatric Nurse Assistant] assisted her mother into the bathroom […and] that the gait belt which was used by the GNA to assist with transferring of residents, was lying on the dresser in her mother’s bedroom.”

The resident’s daughter revealed “the mother’s knees buckled as the GNA transferred her mother from the toilet to the wheelchair [stating] ‘I attempted to assist the GNA, however, the GNA had already lowered my mother down to the floor’.”

The complaint investigation included a review of the resident’s MDS 06/23/2015 (Minimum Data Set) that reveal “that the resident required extensive assistance from two persons per toileting, during the assessment window of 06/17/2015 through 06/23/2015. The same comprehensive MDS assessment revealed that the resident was at risk for falls, because [the resident] have one fall during the month before the admission.”

The state surveyor reviewed the resident hospice care plan that indicated “that the resident had impaired mobility on admission, due to a right hip fracture. The Care Plan indicated that [the resident] used a wheelchair for locomotion and required extensive assistance from two staff for ADLs (activities of daily living) and required a mechanical lift for all transfers.” The state investigator noted that “toileting is an ADL.”

Investigator conducted a 09/15/2015 2:00 PM interview with the facility’s NHA (Nursing Home Administrator) and the DON (Director of Nursing) when “the NHA gave an account of the incident that occurred on 07/02/2015” that supported the resident’s daughters account of what happened. In addition, the Nursing Home Administrator stated that the Geriatric Nurse Assistant “did not follow the GNA assignment sheet for [that resident] which indicated that the resident was a two person assist with transfers […and] that GNA had the GNA assignment sheet on him and chose not to adhere to it. As a result, [that Geriatric Nurse Assistant] was terminated, because he improperly transferred a resident which contributed to her injury.”

The state surveyor asked the Nursing Home Administrator “if she could provide documentation of education that was done with her staff. The education documentation that was submitted was on fall assessment/prevention and was done on 07/19/2015 through 07/21/2015, with a signature sheet of 13 staff.” However, the state surveyor noted that there were 65 nursing staff members employed at the facility at the time of the survey “including full-time, part-time and PRN, including RNs, LPNs and GNAs.”

The Nursing Home Administrator also provided the surveyor “documentation of a GNA meeting that was held on 08/07/2015, which covered ADL training to include GNA assignment sheets, falls and gait belt use, with a signature sheet of 19 staff […and noted that] Stand-up audits were conducted.” However, the nursing home Administrator “was unable to provide documentation that all staff on all shifts were educated.”

Our Frederick County nursing home neglect lawyers recognize the failing to provide adequate staff and assistance to ensure a resident at risk for falls increases the potential of the resident falling and suffering serious injury to their health and well-being. The deficient practice of the nursing staff at Golden Living Center – Frederick might be considered negligence or mistreatment of the resident who sustained a fracture during the incident.

CITIZENS CARE AND REHABILITATION CENTER OF FREDERICK
1920 Rosemont Avenue
Frederick, Maryland 21702
(240) 772-9200

A “For-Profit”170 -certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Ensure That Residents Are Not Administered Unnecessary Drugs and That Their Medication Is Managed and Monitored to Ensure Their Highest Well-Being

In a summary statement of deficiencies dated 10/23/2015, a complaint investigation against the facility was opened for its failure to “administer a resident the correct medications which in turn lowered the resident’s glucose levels to a critical level which required admission to the hospital.” The state surveyor conducted a complaint investigation noted that the facility’s failure “resulted in a past non-compliance actual harm level citation.”

The complaint investigation was initiated anonymously on 10/23/2015 revealing an allegation that one resident “was given another resident’s medication.” The state investigator conducted a review of the resident’s closed medical record revealing “nursing documentation dated 07/26/2015 at 6:30 PM [indicating the resident] was found unresponsive by the nursing staff with the finger stick blood sugar result of 32 mg/dl [where normal blood levels range between 70-120 mg/dl].”

In response, the documentation indicates that “the nursing staff administered medications to treat [the resident’s condition] that included glucose gel and one milligram of a glucose solution administered to elevate a resident’s blood sugar levels.” Both the resident’s physician and family were notified and the resident “was sent by 911 and closest local hospital.” The state investigator noted by reviewing the resident’s closed medical record physician note that the resident “sent to the local hospital for low blood sugars [… did] not receive any hypoglycemic medication but [the resident’s] roommate does receive oral hypoglycemic medications.”

Documented records from the hospital indicate that after initial assessment and treatment the resident “required being transferred to the hospital ICU (intensive care unit) for further management because [the resident’s] fingers stick glucose levels would drop into the 20’s mg/dl. The hospital record noted [the resident] was not a diabetic.”

The state investigator interviewed the resident on 10/23/2015, more than three months after the negligent medical error. The resident stated they were “given the wrong medication that lowered [their] blood sugar and [they] became unconscious.” The resident indicated that they “did not realize what had happened and that [they] could not recall much during the several days spent in the hospital.” However, member of the hospital staff revealed to the resident that they “receive the wrong medication.”

As a result of the end of the investigation, “the surveyor determine the facility failed to administer [the resident] the correct medication which in turn lowered the resident’s glucose levels to a critical level which required admission to the hospital. This medication error harmed [the resident] by having to go to the hospital and being admitted to the ICU for several days.”

Our Frederick nursing home neglect attorneys recognize that failing to ensure that residents receive the right medication and that all medication administration is managed and monitored effectively could potentially cause significant harm to the resident. The deficient practice by the nursing staff at Citizens Care and Rehabilitation Creek of Frederick might be considered negligence or mistreatment because the failures do not follow the established procedures and protocols adopted by the facility.

WESTERN MARYLAND HOSPITAL CENTER
1500 Pennsylvania Avenu
Hagerstown, Maryland 21742
(301) 745-4200

A “State Government Owned and Operated” 63-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Provide Timely and Appropriate Interventions for Residents Experiencing a Significant Clinical Change in Their Condition

In a summary statement of deficiencies dated 09/01/2015, a complaint investigation was opened against the facility for its failure to “provide timely and appropriate interventions for a resident at risk for [a serious condition] when a significant clinical change in the resident’s condition occurred but the resident was not assessed for one hour and 45 minutes.” The deficient practice by the nursing facility at Western MD Hospital Center placed the resident “in a clinically compromised state with high risk for harm, required emergent treatment in the facility, and required transfer to an acute hospital for stabilization.” In addition, the complaint investigation involved the facility’s failure “to follow physician’s orders.”

The complaint investigation was initiated in part after a review of a Physician’s Monthly 01/27/2015 Progress Note revealing that “the resident had type II diabetes mellitus and that his blood sugars were at times very low and below normal range [where normal is typically 70-100].” The resident’s Plan of Care listed significant “problems of diabetic management needs related to type II IDDM (Insulin-Dependent Diabetes Mellitus) with [a history] of erratic blood sugars.” The nursing staff was required to monitor for signs such as sweating (diaphoresis), pallor (paleness) and decreased responsiveness. The Plan of Care noted that the approach documentation would include monitoring finger stick blood glucose (FSBG – blood sugar levels.

Facility documents indicated that one of the facility’s Geriatric Nursing Assistants (GNAs) providing care to the resident reported to a Licensed Practical Nurse on 02/01/2015 at approximately 10:30 AM. The GNA revealed that “the resident was not acting normal and she had to change his clothes and complete bed linen due to him sweating. However, no assessment of the resident was conducted at the time.”

Four hours later at approximately 2:21 PM, the resident’s Progress Note documented by the Licensed Practical Nurse providing care revealed that “at 12:15 PM [nearly 2 hours after the initial report by the GNA] the resident was by then, unresponsive and diaphoretic, A FSBG test obtained showed a critically low reading of 22 and a repeat reading showed 23. According to the same Progress Note, the LPN then administered 240 cc (cubic centimeters) of orange juice with four packets of sugar.”

The progress notes indicate that the Licensed Practical Nurse then “called the on-call physician and receive an order to administer [additional medications documented in the resident’s MAR (Medication Administration Record)].”] However, the resident “remained unresponsive with a blood pressure of 95/51 and EMS (Emergency Medical System – 911) was activated [after which the resident] was transported to the hospital.”

The state investigator noted that facility documentation revealed that the Licensed Practical Nurse providing care to the resident never assess the resident when the Geriatric Nursing Assistant “reported the change in the resident’s condition. A diabetic resident at risk for [serious complications] was observed with a change in mental status and was sweating but the resident was not assessed until 12:15 PM, one hour 45 minutes later when he was found unresponsive with a FSBG of 22.” The state investigator notes that “a root cause analysis was conducted by the facility following the incident and the deficient practice was identified as past noncompliance.”

Our Hagerstown nursing home neglect attorneys recognizing any failure to follow protocols when providing care and services to a diabetic resident with low blood sugar could place the health and well-being of the resident in Immediate Jeopardy. The deficient practice of the nursing staff at Western MD Hospital Center directly violates federal and state guidelines and regulations and fails to follow the established protocols and procedures adopted by the facility.

A Lack of Quality Care Can Injure or Harm a Resident

The federal government reports that more than 9000 incidences of abuse occurred in nursing homes nationwide within the last two years, resulting in more than one out of every three nursing facilities being cited for serious problems. These reports indicate that a lack of quality care has caused significant harm or injury to the residents in a variety of ways including:

  • Untreated pressure sores
  • Malnutrition and dehydration
  • Substandard medical care
  • Physical, sexual, emotional and mental abuse
  • Inadequate sanitation and poor hygiene
  • Preventable accidents

In many of those cases the nursing home resident suffered actual harm at a level of seriousness that cause them an immediate jeopardy that led to a worsening condition or death.

Hiring a Lawyer

The experienced Hagerstown nursing home abuse attorneys at Nursing Home Law Center LLC are dedicated to serving as advocates and have the necessary resources to hold those responsible for causing a loved one harm legally and financially accountable. Our reputable Maryland elder abuse attorneys have handled cases involving nursing home mistreatment throughout Washington County for years.

We urge you to contact our northern Maryland nursing home neglect law offices at (800) 926-7565 to schedule your free, no obligation full case evaluation. All information you share with our law offices will remain confidential.

For additional information on Maryland laws and information on nursing homeslook 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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