Independence Missouri Nursing Home Abuse Lawyer - Part 2

MONTEREY PARK REHABILITATION and HEALTH CARE CENTER
4600 Little Blue Parkway
Independence, Missouri 64057
(816) 795-7888

A “For-Profit” 122-certified bed Medicaid/Medicare-participating facility

Overall Rating – 3 out of 5 possible stars

3 stars 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 from Occurring

In a summary statement of deficiencies dated 01/29/2016, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “transfer a resident in a safe manner using a gait belt (a campus belt use to help staff transfer a weight-bearing resident).” The deficient practice by the nursing staff at Monterey Park Rehabilitation and Health Care Center affected one resident at the facility.

The deficient practice was noted by state surveyor after a review of a resident’s Face Sheet that showed the resident suffered from, Cerebrovascular Disease [where the disease affects the flow circulation to the brain], osteoarthritis [aid degenerative disease that affects the joints and bones], pain, COPD [Chronic Obstructive Pulmonary Disease that increases the lungs ability to perform ventilation], edema [swelling caused by the buildup of abnormally large fluid volume in the body’s circulatory system or between tissue cells], falls, difficulty in walking, urinary tract infection, dementia, glaucoma, asthma, fatigue and hypertension [high blood pressure].”

The investigator also reviewed the resident’s 01/25/2016 Order Summary Report that revealed that the resident was “full weight-bearing” as of 01/14/2016. In addition, the resident’s 11/18/2015 Quarterly MDS (Minimum Data Set) revealed that the resident “had mild impairment in cognition […and] required extensive assistance with a staff member of one for transfer, bed mobility, dressing, toileting and bathing; did not walk; and required supervision with a staff member of one for locomotion on and off the unit.”

The incident in question was documented at 5:30 AM on 11/07/2015 in the resident’s Occurrence Report revealing that the resident “had a witnessed fall in [their room while being] transferred to the toilet by staff using a gait belt when the resident’s feet began to buckle causing the staff to lower the resident to the floor.” The documentation showed that the resident was wearing fitted shoes and “had preventative measures in place at the time of the fall.”

The resident’s Occurrence Report on the following day at 8:15 AM on 11/08/2015 revealed that the resident had another “witnessed fall in [their room while being] transferred to the toilet, and when [the resident] stood up from the toilet [their] legs gave out. The Certified Nursing Assistant lowered the resident to the floor.”

An additional record review of the resident’s Occurrence Report documented a 9:00 AM 12/26/2015 “unwitnessed fall in [the resident’s] room.” At this time, the resident was found lying on their right side and “was sent to the emergency room due to a complaint of right hip pain.” The notations indicate that the resident “had fallen asleep in [their] wheelchair and woke up [while] sliding and then falling out [of the wheelchair.” Notations also show that the resident was wearing TED hoses and slipper socks and had “nighttime toileting needs.” Upon return from the hospital, it was “recommended that [the resident’s] wheelchair be evaluated for safety and [a nonslip mat] place into the seat of the wheelchair.”

An observation of the resident was made at 5:40 AM on 01/26/2016 during a transfer. The observation revealed that the Certified Nursing Assistant (CNA) “had the resident place [their] arms around the CNA, [while the Certified Nursing Assistant Pl. their] arms under the resident’s arms and saying ‘one, two, three’ led to the resident under [their] arms and then transferred [the resident to the] wheelchair without using a gait belt.”

The state surveyor conducted an interview with the Certified Nursing Assistant 10 minutes later at 5:50 AM when the CNA revealed that “the resident usually used a grab bar and was standby assist […and] since the resident’s illness [date] had become a pivot transfer […and] the resident did not need a gait belt as a resident place more weight on [the CNA].”

A subsequent interview was conducted two days later at 8:30 AM on 01/20/2015 with both the Occupational Therapist and Assistant Occupational Therapist. During the interview, it was revealed that “a resident who is extensive assist require 1 to 2 person staff assistance for changes of the environment […and] staff should use a gait belt for all hands on assistance.” In addition, the therapists said that “a gait belt is used for residents who are a fall risk to provide a handle for staff to assist and should the resident lose balance to ensure safety.” The therapist also indicated that “a gait belt should be used even when a resident required only supervision for optimal safety. The therapist noted that this resident “is maximum assist with an assistance of one person using a gait belt.”

Our Independence nursing home neglect attorneys recognize that every resident requiring assistance during transfer should be provided an environment free of accident hazards and provide adequate supervision and equipment to ensure avoidable accidents are prevented. The deficient practice by the nursing staff at Monterey Park Rehabilitation and Health Care Center might be considered negligence or mistreatment because their actions fail to follow the resident’s Care Plan that had been revised after numerous falls had occurred.

AUTUMN TERRACE HEALTH and rehabilitation Center
6124 Raytown Road
Raytown, Missouri 64133
(816) 358-8222

A “For-Profit” 154-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Follow Procedures and Protocols to Maintain a Rate of Medication Errors to Less Than 5% to Avoid Administering the Wrong Dose, Wrong Drug or at the Wrong Time

In a summary statement of deficiencies dated 10/07/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure their medication pass error rate was less than five percent. There were 10 medication errors out of 41 opportunities for a 21.9% medication error rate, affecting four residents at the facility.”

The deficient practice was noted by state investigator after a review of a resident’s Admission Records showing that the resident was admitted to the facility with Cardiovascular Disease (a thickening of arterial walls), swelling, COPD, a disease that decreases the lungs ability to perform ventilation and hypertension (high blood pressure).

The state investigator also reviewed the resident’s October 2015 physician’s order sheet and MAR (Medication Administration Record) that revealed that the resident was administered six out of their seven medications at the time frame greater than one hour before the scheduled administration time.

The investigator interviewed the facility’s Certified Medication Technician at 9:04 AM on 10/02/2015 who verified that “medication should be administered according to the resident’s physician’s instructions and [that] medication should be administered no earlier than one hour before and no later than one hour after the scheduled administration time.”

During a subsequent interview at 10:55 AM on 10/07/2015 with the facility Director of Nursing, the Director also verified that the medications according to physician’s orders “should not be administered with any other medications, especially not a proton pump inhibitor [taken by the resident, and that the] staff have one hour before and one hour after a scheduled medication administration time to administer [the resident’s] medications.”

Our Raytown nursing home neglect attorneys recognize that failing to follow procedures and protocols to minimize medication errors has the potential of jeopardizing the health and well-being of all residents receiving medication. The deficient practice by the nursing staff at Autumn Terrace Health and Rehabilitation Center might be considered mistreatment or negligence because their actions fail to follow physician’s orders, and failed to follow the facility’s 2015 policy title: Medication Management Program Policy that reads in part:

“Medications are administered no more than one hour before or one hour after the designated medication pass time.”

HIDDEN LAKE CARE CENTER
11400 Hidden Lake Drive
Raytown, Missouri 64133
(816) 737-1010

A “For-Profit” 112-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 from Occurring

In a summary statement of deficiencies dated 11/06/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure they completed a comprehensive fall investigation and updated the resident’s Care Plan to show current fall interventions for [2 residents at the facility].”

The deficient practice was noted by state investigator after a review of a resident’s Admission Face Sheet that revealed that the resident was admitted to the facility with “osteoarthritis involving multiple sites; difficulty walking; and generalized muscle weakness.” In addition, the resident’s 07/09/2015 Admission MDS (Minimum Data Set) reveal that the resident was “severely cognitively impaired […and] required extensive assistance by one staff member for bed mobility, toileting, dressing and personal hygiene.”

The Admission MDS (Minimum Data Set) also revealed that the resident “required extensive assistance by two staff members for transfers, required a wheelchair for mobility […and] was frequently incontinent of bowel and bladder […and] in the areas of falls, had no documentation [that the resident had fallen] on 08/05/2015, 08/07/2015 […and] two falls on 10/05/2015 and a fall on 10/14/2015.”

The state investigator reviewed the resident’s 07/16/2015 Care Plan that showed that the resident “was at risk for falls related to impaired mobility/balance issues and decrease safety awareness, and [their] interventions included: wear properly fitted nonskid shoes; verbal reminders not to ambulate or transfer without assistance; […and] notified the physician of changes in the resident’s condition.” The staff was instructed to “place frequently used items within reach; [use the] assistance of two staff members with the use of a gait belt for transfers.” An addition was made in the resident’s Care Plan involving falls on 08/05/2015 when a non-skid mat to the wheel chair cushion was added as an intervention.

Documentation in the resident’s 08/17/2015 INVESTIGATION revealed that “the resident was found lying on the dining room floor curled into a fetal position. Contributing factors were behavior, neuropathy, antipsychotics and prior fall in the last 30 days.” The documentation also reveals that “the resident was alert with confusion prior to [their] fall.” At the time of the incident “there was no environmental, or footwear/equipment documented as contributing factors.”

The state surveyor notes that the investigation handled by the facility “did not show what the root cause of the resident’s fall was, what interventions staff were going to implement to prevent the resident from sliding out of [their] wheelchair, or monitoring to help prevent the resident from getting up and putting [themselves] onto the floor.”

The investigator also noted that there “were no recommendations documented to prevent further falls (nothing was documented under the section recommendations to prevent further falls), and interventions initiated immediately after the fall including nonskid to [their] wheelchair.” In addition, the facility’s 08/18/2015 Nurse’s Notes “did not address the resident’s fall on 08/17/2015″ nor were there any updates in the resident’s Care Plan “that showed any changes in fall interventions after the resident’s fall on 08/17/2015.”

However, the resident’s 1:00 AM 10/05/2015 Nurse’s Notes revealed that the resident “was yelling out for help [when the] staff found the resident sitting up on the floor mat beside the bed.” At that time, “the resident was unable to explain what happened [however] the resident’s roommate said the resident was sitting up on the side of the bed when [they] went into the bathroom.” However, these notes did not document “the root cause of the fall […and there was] no documentation of any new interventions.”

Our Raytown nursing home neglect law offices recognize that failing to provide adequate supervision and take all necessary precautions to prevent an accidental fall from occurring could place the health and well-being of the resident in Immediate Jeopardy. The deficient practice of the nursing staff at Hidden Lake Care Center might be considered negligence or mistreatment because their actions fail to follow established procedures and protocols enforced by federal and state nursing home regulatory agencies.

EDGEWOOD MANOR NURSING HOME
11900 Jessica Lane
Raytown, Missouri 64138
(816) 358-7858

A “For-Profit” 66-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 with Reduced Range of Motion Receives the Proper Care and Services to Increase Their Range of Motion

In a summary statement of deficiencies dated 10/23/2015, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “ensure restorative services were provided a scheduled to [one resident at the facility] in order to maintain [their] current level of mobility in range of motion.”

The deficient practice was noted by state surveyor reviewed a resident’s October 2015 Physician’s Order Sheet that revealed “physician’s orders to transfer the resident using a sit-to-stand lift (a hydraulic lift used to assist in moving persons with limited mobility from one location to another), for the resident to be out of the bed in [their] wheelchair daily, and to provide assistance bars for transfers and bed mobility. There were no physician’s orders for therapy or rehabilitative services.”

The surveyor also reviewed the resident’s 07/21/2015 Quarterly MDS (Minimum Data Set) that revealed that the resident “was cognitively intact without any behavioral symptoms […and] needed extensive assistance with transfers and transferred with a mechanical lift and used a wheelchair for mobility.”

A review of the resident’s 07/30/2015 Physical Therapy Discharge Summary revealed that “the resident should get out of [their] bed 75% of the time with the use of the mechanical lift, with assistance to increase the resident’s health and skin integrity.” The discharge summary statement also recommended, “the resident to be up in [their] wheelchair no longer than three hours at a time.”

The state surveyor reviewed the resident’s 08/04/2015 Nursing Notes that revealed that “the resident had been discharged from physical therapy on 07/30/2015 and was to continue on the restorative program twice weekly for 90 days.”

The surveyor observed the resident and 8:54 AM on 10/20/2015 and noted that the resident “was alert and oriented and was sitting up in [their] bed watching television.” At that time, the resident said that they “had entered the facility after having back surgery and was there for rehabilitation […and] was initially receiving physical therapy and occupational therapy three times weekly but it had stopped.” The resident told the surveyor that they “did not remember how long it had been since [they had] received therapy services, but it had been a while since anyone was working with [them].”

During the interview the resident also said that they were supposed to continue exercising, lose 30 pounds as a condition to be placed on a liver transplant list […and that they] “usually try to get up in the afternoon and since [they started their] pain regimen, the pain had been controlled very well.”

The investigator then conducted a 12:42 PM interview with the facility’s Physical Therapy Assistant on the same day of 10/20/2015. At the time, the Physical Therapy Assistant said that “the resident had been receiving therapy services since 07/30/2015 and [they] were supposed to start [their] restorative program [four days later] for transfers, to put on and take off [their] back brace and [for] range of motion/strengthening.”

During the interview, the Assistant also said that “the restorative program was to be from 08/03/2015 to 11/01/2015 […and] about three weeks ago, the Restorative Aide had quit and they were in the process of hiring another one […and] no one had been receiving restorative services for the last three weeks.” Upon review of the resident’s Restored Care Documents, the assistant said that “the Restorative Aide had not documented anything showing [they] provide restorative services to the resident or that the resident declined services [because every document sheet was blank].” The Assistant verified that “the resident should have been receiving restorative services since 08/03/2015 and it seemed that the resident had not been receiving it.”

The physician’s order showing physical therapy for the resident including evaluation and treatment three times every week for four weeks was verified by the state investigator by a physician’s telephone orders documentation dated 10/21/2015.

The state investigator then conducted a 12:42 PM 10/23/2015 interview with the facility’s Director of Nursing who verified that “restorative services had been inconsistent since the Restorative Aide was no longer working in the facility […and] residents were not receiving restorative services as they should and they were in the process of hiring a Restorative Aide”.

Our Raytown nursing home neglect law firm recognizes that failing to follow physician’s orders when providing restorative care to a resident at the facility for rehabilitation could place their health and well-being in jeopardy. The deficient practice by the nursing staff to provide much-needed care to the resident was a failure to follow established procedures and protocols enforced by federal and state nursing home regulatory agencies.

WILSHIRE AT LAKEWOOD
600 N E Meadowview Drive
Lees Summit, Missouri 64064
(816) 554-9866

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

Overall Rating – 3 out of 5 possible stars

3 stars rating

Primary Concerns –

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

In a summary statement of deficiencies dated 04/06/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “follow their facility policy and procedure to determine if an allegation of abuse had occurred for [one resident the facility].”

The deficient practice was noted by a state investigator after reviewing a resident’s Face Sheet showing the resident was admitted to the facility with a fracture of [their] lower leg. The Face Sheet also showed the resident was susceptible to falls and suffered from “spinal stenosis, urinary incontinence, urinary tract infection, mononeuritis (a disorder of the nervous system that affects two areas and can result in severe pain, loss of motor ability in a loss of sensation into random areas of the body), and muscle weakness.”

The state investigator also reviewed the resident’s Annual MDS (Minimum Data Set) that revealed that the resident “had no cognitive deficits” but “required one person assist with dressing, toileting bathing […and] was independent with personal hygiene.”

The state investigator reviewed a facility 04/02/2015 CNA Employee Disciplinary Form showing an infraction date of 08/02/2015. The form revealed an infraction description noting “threatening, coercing, intimidating or interfering with employee or resident.”

The infraction involved a report by the resident that the Certified Nursing Assistant “was rough with [them] during cares and cause pain.” It also shows the Certified Nursing Assistant had let the resident’s “leg drop roughly after transferring [them to their] chair instead of gently putting them down as requested.”

The report also indicated that the resident stated the Certified Nursing Assistant told the resident, “you don’t have to yell at me like an animal” when the resident asked the Certified Nursing Assistant “to get [their] cell phone from the counter.”

The report also indicated that on 08/02/2015, the Certified Nursing Assistant “had forced the resident to change into [their] pajamas at 4:00 PM as [the Certified Nursing Assistant] did not want to change the resident at a later time. The resident was fearful of [the CNA] and told Social Services that [they] did not want [the CNA] to answer [their] light when it was on.” The document also notes that the disciplinary action led to the termination of the Certified Nursing Assistant.

The facility’s 04/03/2015 Investigation Report documented that “there was no injury to the resident […and] the Administrator was notified on 04/02/2015 at 2:00 PM.” However, the incident had occurred on 04/01/2015. The documentation in the report also shows “the nature/location of the incident was not likely to have been accidental or self-inflicted […and] the initial facility staff [member] to become aware of the incident was the social worker on 04/02/2015.”

There was ample evidence to show that “the resident was capable of reporting abuse and problems with care.” Documentation also shows that “the resident was interviewed by the Social Worker on 08/02/2015.” The Director of Nursing at the facility interviewed the Licensed Practical Nurse involved in the incident on 4/2/2015 and that the Certified Nursing Assistant “was sent home on our 04/02/2015″ and interview by telephone the following day. The documentation also noted that “the investigation found no abuse or neglect to have occurred.”

The investigator interviewed the facility’s Administrator 1:25 PM on 04/03/2015 who revealed that “the investigation with the resident had been completed […and that the Certified Nursing Assistant] was terminated.” In a subsequent interview at 1:14 AM on 04/06/2015, the Administrator verified that “the resident was interviewed by the Director of Nursing […and that the Certified Nursing Assistant] was interviewed by telephone.” However, the state investigator notes that no additional residents were interviewed “as part of the investigation.”

Our Lees Summit nursing home abuse attorneys recognize that failing to follow procedures and protocols when investigating and reporting any act or allegation of abuse could place the health and well-being of the resident in Immediate Jeopardy. The deficient practice of the nursing staff and Administrator at Wilshire at Lakewood might be considered negligence or mistreatment because their actions failed to follow procedures and protocols to protect the resident, investigate the incident by interviewing other residents and reporting the incident to state agencies as required by law.

The Warning Signs of Nursing Home Neglect and Abuse

Many families are unaware of the obvious and not so obvious warning signs of abuse and neglect occurring in nursing facilities. Unfortunately, many residents suffer undue pain, insufficient care, abandonment, intimidation or premature death.

When family members understand the warning signs, it’s possible to save the life of their loved one from harm, serious pain or preventable injury. The signs include:

  • Restraint – Nursing home residents can become victims of two specific types of restraints – physical or chemical. Many residents are restrained without authorization by physical straps or other equipment in an effort to provide a level of convenience for the nursing staff in charge of providing them care. Other times, the nursing home will use chemical restraints or the victim is over medicated in an effort to control their behavior or diminish the amount of care the staff must provide to meet the resident’s needs.
  • Staff Inattention – Failing to respond to a resident’s needs in a timely manner is a serious problem in many nursing homes throughout Missouri. This is especially true for residents who require special care. Any lack of attention in providing health care, medical treatment or hygiene assistance can diminish the quality and comfort of the resident’s life and place their health and well-being in jeopardy.
  • Falls – Many falling accidents occurred in nursing facilities are the result of a lack of supervision. Falling is a serious issue because many individuals in later years suffer from a variety of medical conditions including poor vision and muscular degeneration. It is the duty and responsibility of nursing facilities to develop, implement and enforce a Plan of Care that eliminates the possibility that a resident can fall and suffer serious, life-threatening injuries.
  • Pressure Sores – Every facility-acquired pressure sore (bedsores; pressure ulcers; decubitus ulcer) is preventable. Without early detection or necessary treatment, an early stage bedsore can easily degrade to a life-threatening condition where the wound becomes open to expose the bone, muscle and tendons below. Within days, the wound can become infected leading to osteomyelitis (bone infection) and/or sepsis (blood infection), which can easily claim the life of the resident.
  • Bruises – Family members should never ignore a bruise on the skin of their loved one residing in a nursing facility. Any bruise, cut, laceration or skin injury that requires medical attention should be always evaluated to ensure that the root cause has been determined. In some cases, bruising is a first indicator of neglect or abuse.
  • Weight Loss – Any unexplained weight loss is usually an alarming warning sign of abuse or mistreatment. In many cases, the contributing factors to weight loss involve poor quality food, illness, dehydration or lack of care.

The warning signs listed above are not in any special order. Each type of neglect, mistreatment, and abuse can be equally harmful. It is imperative that family members take immediate action at the first sign or suspicion that their loved one is being mistreated.

What to Do

It only takes a single voice to make a change when a nursing facility is providing substandard care to a resident. The legal actions taken by the Independence nursing home abuse attorneys at Nursing Home Law Center LLC have brought to light many of the horrors of unsanitary conditions, poor quality of care and abuse occurring in nursing homes throughout Missouri. Our Jackson County elder abuse attorneys fight aggressively to protect our clients’ rights and seek legal avenues to obtain the financial compensation they deserve for their injuries, damages and losses.

If you suspect your loved one has been victimized by the nursing home, nursing staff, employees, visitors or other residents, we encourage you to contact our law offices at (800) 926-7565 today. By scheduling a free, no-obligation consultation, we can discuss the merits of your case and provide a variety of legal options on how best to proceed. No upfront fee is required because we accept all nursing home cases through contingency fee arrangements.

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.

Client Reviews
★★★★★
Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
★★★★★
After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric