Independence Missouri Nursing Home Abuse Lawyer
Moving a loved one into a nursing facility is never an easy choice when families are no longer able to provide their loved one the care they require. The families trust that they made the right decision in placing their spouse, parent, grandparent in a safe environment in a facility provides a safe environment with loving and compassionate care. However, the Independence nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC have handled many nursing home neglect and abuse cases involving society’s most vulnerable citizens.
Many nursing homes cut corners to stay in business by operating with minimal staff, improperly trained nurses or hiring employees who are not qualified to provide acceptable standards of care. In many incidences, the residents who are being treated poorly are too afraid to speak up in fear retaliation or are incapable of communicating at all due to their health challenges.
The number of cases involving abuse and neglect in nursing facilities is on the rise in Jackson County. Of the more than 685,000 residents in the county, approximately 92,000 are senior citizens. This number has risen significantly in the last five years. However, the number of nursing homes throughout the community has remained stable. This places an increased demand on a limited number of beds available for senior citizens who require the highest level of care. Overcrowded conditions usually result in poor standards of care, cases of neglect and abuse that lead to preventable injuries and death.Independence Nursing Home Resident Health Concerns
Our Missouri elder abuse attorneys work aggressively to ensure that elderly parents, grandparents and spouses receive the highest level of care available. We serve as advocates for every nursing home resident throughout the state who require legal assistance in stopping the abuse and holding those responsible for the harm legally and financially accountable.
In addition, we continuously update our findings of filed complaints, safety hazards, opened investigations and health concerns occurring in nursing facilities all throughout Missouri. We gather this information from various public available resources including Medicare.gov. Many families use this information as a valuable tool before placing a loved one in a nursing facility who requires the best health care, medical treatment and hygiene assistance.Comparing Independence Area Nursing Facilities
The list below was compiled by our Jackson County nursing home attorneys outlining Independence area nursing facilities that currently maintain substandard ratings compared with other nursing homes throughout the United States. In addition, we have published our primary concerns that details specific cases where residents in nursing facilities throughout the Independence community have suffered harm, injury or death through negligence, mistreatment or abuse.
ROSEWOOD HEALTH AND REHABILITATION CENTER
1415 West White Oak
Independence, Missouri 64050
A “For-Profit” 300-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Develop, Implement and Enforce Policies to Prevent Abuse, Neglect or Mistreatment of Residents
In a summary statement of deficiencies dated 08/07/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “complete an incident report and conduct an investigation regarding a resident to resident altercation for [a resident] at the facility.”
The deficient practice was noted by state investigator after reviewing a resident’s Facility Face Sheet that showed that the resident was admitted to the facility with dementia with behavioral disturbance (loss of thinking, remembering and reasoning so severe that it interferes with the individual daily function and may cause changes in personality, mood and behaviors).”
In addition, the Face Sheet revealed that the resident suffers from anxiety and “an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks.”
The investigator also reviewed the resident’s 04/12/2015 Quarterly MDS (Minimum Data Set) that reveals of the resident “was sometimes able to make [themselves] understood and sometimes was able to understand others; had severe cognitive impairment with short-term and long-term memory problems; had disorganized thinking and impairment when making daily decisions; and wandered around the unit.”
The resident’s 02/26/2015 Care Plan indicated that “the resident wandered into unsafe/inappropriate areas; the intervention was for the staff to redirect the resident to a safe location, using a calm approach; no documentation of any updates developed after a resident to resident altercation [occurred] on 07/12/2015 at 8:30 PM.”
A review of the resident’s 8:45 PM 07/12/2015 Nurses Progress Notes revealed that a Certified Nursing Assistant “notify the nursing staff that the resident had been wandering the unit and went into another resident’s room.” At that time, [the other resident was upset that [the wandering resident was in their room].” As a result, staff members redirected the resident “to come out of the other resident’s room.” That is when the other resident hit the wandering resident’s “left hand on the thumb side of [their] cane.”
As a result of the altercation, the wandering resident was seen with a “furrowing of the brow (facial sign of pain or discomfort) when [their] left hand was touched by a staff member.” When the nursing staff assessed the resident’s left hand, the resident winced “during passive and active range of motion of [their] hand.” To provide treatment, the nursing staff applied ice to the hand and notify the House Supervisor, the resident’s doctor and their spouse.”
However, the state investigator noted that the “resident’s medical record found no further documentation related to the resident to resident altercation and no documentation to determine the root cause of the incident.”
The investigator conducted a 12:15 PM 08/06/2015 interview with the facility’s Licensed Practical Nurse who verified that “an incident report should be completed with any [any incident involving a] resident fall, bruising or skin tears and resident to resident altercation.” The Licensed Practical Nurse also indicated that “incident reports are completed by the Licensed Practical Nurse or Supervisor and then report is sent to the Assistant Director of Nursing for review and then passed on to the Director of Nursing, and [that] the resident incidents are reviewed and discussed during the facility morning meetings in which starts the investigation process.”
30 minutes later 12:45 PM, the investigator conducted an interview and record review with the facility’s Director of Nursing who verified that they “were unable to locate any witness statements, incident reports or investigation dated for 07/12/2015, related to the resident’s altercation with another resident.” The Director of Nursing also verified that the nursing staff is responsible for completing and documenting an incident report and that the Director would expect staff members to complete the incident report of any resident to resident altercation.”
Our Independence nursing home neglect attorneys recognize that failing to develop, implement and enforce policies that prevent abuse, neglect or mistreatment of residents could place the health and well-being of every resident in Immediate Jeopardy. The deficient practice by the administration and nursing staff at Rosewood Health and Rehabilitation Center might be considered negligence or mistreatment because their actions fail to follow the facility’s updated October 2012 policy title: Abuse and Neglect Policy and Procedure that reads in part:
“All accidents are incidences where there is an injury or potential to result in injury, unexplained bruise or abrasion, allegations of theft, abuse, neglect or misappropriation of funds will be reported to the accident/incident report and/or the resident protection report.
These reports are initiated immediately by the Charge Nurse, House Supervisor, Nursing Administrator or Administrator and are then reviewed by the Administrator, Nursing Administration and Social Services by the next working day to monitor for multiple occurrences, patterns and/or trends that may constitute abuse and determine the direction of the investigation.”
INDEPENDENCE MANOR CARE CENTER
1600 South Kings Highway
Independence, Missouri 64055
A “For-Profit” 99-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Follow Acceptable Procedures When Transferring Residents Between Beds and Wheelchairs to Minimize the Potential of an Avoidable Accident or Injury
In a summary statement of deficiencies dated 10/26/2015, a complaint investigation was opened against the facility for its failure to “use the appropriate transfer method to ensure the resident was transferred safely.” The deficient practice by the nursing staff at Independence Manor Care Center affected three residents at the facility.
The complaint investigation involved a review of a resident’s Face Sheet that show the resident was admitted to the facility with osteoporosis and hypertension. A review of the resident’s 06/01/2015 Care Plan revealed that the “resident required assistance of one staff person with a gait belt to transfer; staff were to remind the residents to ask for assistance for all transfer; staff were to monitor for a change of condition that may warrant increased staff supervision and assistance and notify the resident’s physician as needed.”
The investigator also reviewed the resident’s 06/14/2015 Admission MDS (Minimum Data Set) that shows that the resident “was moderately cognitively impaired; required extensive staff assistance for transfers, dressing, toileting and personal hygiene […and] required limited staff assistance for locomotion.”
The investigator made a 10:30 AM 10/21/2015 observation of the resident who was “sitting in [their] wheelchair in [their] room.” At the time of the observation, “the resident was in contact isolation precautions” which are guidelines used to reduce the potential risk of spreading infection throughout the facility.
During the observation, two Certified Nursing Assistants placed themselves on either side of the resident while facing the resident. At that point, each Certified Nursing Assistant “hooked one arm under the resident’s arm and with their other hand, grabbed the resident’s pants waistband […and] then lifted the resident from the wheelchair to pivot the resident to the bedside.”
At that time, the resident did not bear any weight on their lower extremities nor did they place their feet completely on the floor during the transfer process. However, the observer noted that both Certified Nursing Assistants “did not use a gait belt (a canvas belt use to assist for transfers] for this transfer” as directed by the resident’s Care Plan.
The state investigator conducted a 10:35 AM 10/21/2015 with both Certified Nursing Assistants who informed the surveyor that “the resident did not bear weight and they did all the lifting during the transfer […and] the resident had not been bearing weight during the transfer since [the resident] got sick a few weeks ago.” The Certified Nursing Assistants also admitted that “they did not notify the nurse or Physical Therapy of the change in the resident’s transferability [of no longer being able to bear] weight during the transfer.”
The Certified Nursing Assistants performing the transfer indicated that they “did not use a gait belt because of the resident was on isolation precautions and they did not want to contaminate their personal gate belts […and] the resident did not have a dedicated gait belt to use for [their] transfers.”
A few minutes later at 10:50 AM, the Physical Therapist was interviewed by the state surveyor and revealed that they were “not notified that the resident was not bearing weight during the transfers.” The Physical Therapist also indicated that the staff “should always use a gait belt to transfer the resident who can bear weight […and] should never use a resident’s clothing to assist with transfer.” The Physical Therapist also verified that the “staff should not pull up on the resident’s arms/shoulders to assist with the transfer […and] if the resident no longer bears weight, the staff to notify the nurse and the nurse will notify the Physical Therapist so the resident could be evaluated for proper transfer technique.”
Our Independence nursing home neglect lawyers recognize that failing to use appropriate methods and techniques when transferring residents between the bed and wheelchair could cause additional harm or injury. The deficient practice by the nursing staff at independence Manor Care Center that might be considered negligence or mistreatment because their actions fail to follow the facility’s October 2009 policy title: Safe Lifting and Movement of Residents Policy that reads in part:
“The nursing staff, in conjunction with the rehabilitation staff, should assess the individual resident’s needs for transfers on an ongoing basis […and] staff will document the resident’s transferring and lifting needs in the Care Plan.”
The REHABILITATION CENTER OF INDEPENDENCE
1800 S Swope Drive
Independence, Missouri 64057
A “For-Profit” 130-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Provide Every Resident the Necessary Services and Care to Maintain Their Highest Well-Being
In a summary statement of deficiencies dated 05/26/2015, a complaint investigation against the facility was opened for its failure to “provide an intervention for pain to administer pain medication in a timely manner for one supplemental resident, and respond to a resident’s needs to maintain their highest practical well-being.”
The complaint investigation involved a review of a resident’s medical records that revealed that the resident was receiving narcotic medications used to relieve moderate to severe pain. The physician’s orders indicated that one tablet was to be administered every six hours as needed (PRN) for moderate/severe pain.
An observation of the resident occurring between 4:28 AM and 5:00 AM on 05/20/2015 revealed that at 4:28 AM, “the resident’s call light was on. The laboratory technician who was coming from the resident’s room told the Certified Nursing Assistant the resident requested pain medication.” At that time, the Certified Nursing Assistant “enter the resident’s room, the resident told [the Certified Nursing Assistant that they] needed pain medication.” In response, the Certified Nursing Assistant “turned the call light off.”
One minute later at 4:29 AM, the Certified Nursing Assistant “walked to the nurse’s station but did not see the nurse and went back to the hall without telling the nurse that the resident requested pain medication.” Nine minutes later at 4:38 AM, “the resident walked to the nurse’s station and asked [the Licensed Practical Nurse] for pain medication. The nurse did not offer any type of non-pharmacological intervention.” The LPN then asked the resident for their name and check the MAR (Medication Administration Record). Over the next few minutes, Licensed Practical Nurse attempted to find the keys to the Certified Medication Technician’s medication cart.
At 4:40 PM, the Licensed Practical Nurse told the resident that they “could not find the keys to the medication cart and that [they] would bring the medication to the resident.” Even though the Licensed Practical Nurse located the keys to the medication cart with the assistance of the Corporate Nurse they instead answered a resident distress call from another hall. By 4:52 AM, the resident turned their call light on again and asked the CNA that responded: “if the nurse found the keys to the medication cart.” In response, the Certified Nursing Assistant said that they had not seen the nurse.
“As a 5:00 PM, the resident had not received [their] pain medication and continued to wait in [their] room for response to the request for the medication to relieve [their] pain.”
The state investigator interviewed the resident 11:55 AM two days later on 05/22/2015 where the resident revealed that they had finally gotten their pain medication “but it took a long time to get it.”
Interviewed the facility’s Director of Nursing at 9:50 AM the following morning on 05/23/2015 along with the facility’s Administrator who said: “were going to begin to in-service right away and on responding to call lights, not just turning the call lights off without the needs being met.” In a separate interview with the Director of Nursing at 2:45 PM on 05/26/2015, the Director revealed that they “would expect what has to be performed if at all possible when the call light is turned off […and] if the staff member had to have someone else assist the resident, [they] would expect the staff member to tell the resident […and that they] would expect the resident to have [their] needs met within no more than 10 to 15 minutes.”
The VILLAGES OF JACKSON CREEK
3980 South Jackson Drive
Independence, Missouri 64057
A “For-Profit” 120-certified bed Medicaid/Medicare-participating facility
Overall Rating – 3 out of 5 possible stars
Primary Concerns –
Failure to Provide Residents Services and Care to Ensure Their Highest Well-Being Is Maintained
In a summary statement of deficiencies dated 12/14/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “offer, provide and/or document non-pharmacological interventions prior to the administration of pain medication for one resident and to assess and monitor pain after a fall for another resident. The deficient practice of the nursing staff at The Villages of Jackson Creek affected two residents at the facility.
The deficient practice was noted by state investigator after a review of a resident’s 11/14/2015 Quarterly MDS (Minimum Data Set) that revealed the resident “was cognitively intact, had no difficulty hearing, [their] speech was clear, was able to make [themselves] understood and was able to understand others.” In addition, the documentation revealed that the resident “required limited physical assistance from one staff member for transfers, dressing, toileting and personal hygiene and had received scheduled pain medicine in the last five days.”
The investigator also reviewed the resident’s 11/30/2015 Care Plan that revealed that the resident “had problems with pain […and] would exhibit relief of pain after administration of ordered medications and alternative comfort measures.” In an effort to help, the “staff was instructed to position [the resident] frequently as needed to promote comfort […and] to administer medications as ordered to monitor for side effects and effectiveness […and] to use supported devices to promote and sustain a comfortable position.” In addition, the staff was also instructed to encourage mobility and physical activity as tolerated […and] to assess and treat pain and discomfort as ordered by the resident’s physician and to notify the physician of pain unrelieved by the order interventions.”
The investigator reviewed the resident’s 12:25 AM 12/04/2015 Post Falls Nursing Assessment Form that revealed that a falling “incident occurred on 12/04/2015 at 12:25 AM […and] the resident complained of some back pain [… with a] pain intensity of two [on a pain scale between 1 and 10].”
“The Post Falls Nursing Assessment Form did not show up the staff had offered any non-pharmacological or medication related to the resident’s complaints of pain.”
A review of the resident’s medical records revealed that the last pain evaluation had been completed in December 2015. In addition, the resident’s 11/15/2015 through 12/14/2015 Physician Order Sheets revealed that the physician had ordered a narcotic pain medication patch to be applied every 72 hours. In addition, the resident was to receive two tablets of the pain medication by mouth three times every day PRN (as needed for pain) and additional pain medication was to be given by mouth every six hours as needed for temperature or pain.
However, the state investigator noted that the resident’s MAR (Medication Administration Record) documenting pain administration between 11/15/2015 and 12/14/2015 did not show that any medications for pain were administered after the resident’s fall occurred on 12/04/2015.
The state investigator conducted at 2:45 PM 12/07/2015 interview with the resident who informed the surveyor that they had fallen “about two weeks ago and [that their] back pain had been worse since then […and] had pain in [their] back every day.” In a follow-up interview at 12:15 PM the following day on 12/08/2015 the resident told the surveyor “my back hurts really bad. It’s really bad.”
An interview was conducted at 9:50 AM on 12/14/2015 with the facility’s Registered Nurse who “said when a resident falls, nurses note should be completed every shift for 72 hours after the resident falls to monitor [their] condition after the fall.” The nurse also said that “pain should be assessed after the fall […and] the staff should always ask the resident if [they are] in pain. The resident had not told the nurse that [they were] in pain after [their] fall.”
The investigator interviewed the Director of Nursing later that afternoon at 12:05 PM who “said staff should have assessed the resident’s pain after [their] fall on 12/04/2015 […and] a resident’s pain should be addressed with either non-pharmacological interventions or as needed medications if needed.”
Our Independence nursing home abuse law firm recognizes that failing to provide residents necessary medications and care to minimize their pain could place their health and well-being in jeopardy. The deficient practice by the nursing staff at The Villages of Jackson Creek might be considered negligence or mistreatment because their actions failed to follow physician’s orders that resulted in unnecessary pain experienced by the resident under their care.