Kansas City Missouri Nursing Home Abuse & Neglect Attorneys - Part 2

2323 Swope Parkway
Kansas City, Missouri 64130
(816) 924-1122

A “For-Profit” 97-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 When Administering Wound Care Treatment That Cause the Resident Extensive Pain during the Procedure

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 “assess the resident’s pain level and administer pain medication prior to performing wound care when the resident told the staff it really hurts when [their] dressing was changed to [their] foot, and to stop the wound care procedure when the resident showed signs of pain such as grimacing, tensing up, squirming and making faces.”

The state surveyor making the notations also noted that “the resident saying to the staff that it was hurting and staff proceeded to hold the resident’s leg held down during wound care for a worsening Stage III pressure ulcer.”

The deficient practice was noted by the state surveyor after a review of a resident’s 06/03/2015 Annual MDS (Minimum Data Set) that revealed the resident “was cognitively intact for making daily decisions, required the total assistance of one person with dressing and hygiene; needed limited assistance with one person for bed mobility; require total assistance of two or more people for transferring […and] had impaired range of motion of [their] upper and lower extremities on one side.”

The state investigator also noted that the resident “was frequently incontinent of bowel and always incontinent of urine.” Notations were made that the resident “had one worsening Stage III pressure ulcer” that involves full thickness tissue loss. A Stage III pressure ulcer might have subcutaneous fat that has become visible inside the open wound however at this point, muscles, tendons and bones are not yet exposed. However, there is often tunneling and undermining.

A complete review of the resident’s August 20 15,015 Care Plan revealed that the resident was “at risk for a wound infection, was being treated for multiple conditions, and should receive weekly wound consultations.” The documentation also revealed the resident “should be monitored for wound redness, odor and pain; and should be assessed for pain every shift.”

The investigator noted that there was a 09/16/2015 Physician’s order for the staff to “cleanse the wound on the resident’s left heel with wound cleanser, apply powder to the wound bed, cover with silver alginate and foam dressing and wrap with Kling. The order was to change the dressing daily and as needed until healed.”

The state investigator made an observation at 12:55 PM on 11/03/2015 noting that the “resident was in bed, resting on [their] low air loss mattress [when a Registered Nurse] enter the resident’s room to administer wound care/treatment on the resident’s left heel.” A few minutes later “the resident said it really hurts when the dressing is changed.” At that point, the Registered Nurse “asked the resident about [their] pain and the resident confirmed [that they] had pain.” The Registered Nurse then asked the Certified Medication Technician “if the resident had received any pain medication.”

The Certified Medication Technician responded that they “had not given the resident anything for [their] pain, because the resident had not told [them] about [their] pain. At this point, the Registered Nurse continued performing wound care on the resident including removing the old dressing and wrap.

During this part of the procedure when the Registered Nurse “began removing the resident’s old dressing, the resident grimaced, became tense and said the wound was hurting.” The resident’s wound bed was covered with necrotic (dead) tissue, slough and the edges were calloused. The resident continued “squirming in making faces while the wound was being cleansed and the treatment applied.”

The Certified Medical Technician “held the resident’s leg in place [while] the resident was pulling and moving [their] legs. At this time, both the Registered Nurse and the Certified Medical Technician “tried to encourage the resident to keep still so that the treatment could be completed. The resident kept stating it was hurting.”

The state investigator conducted 11:25 AM 11/06/2015 interview with the Registered Nurse who said “the resident usually complains because [they do] not want the wound treatment done and [they] should have stopped, assessed and treated the resident’s pain before continuing the wound treatment and dressing change.”

Later that afternoon at 5:15 PM, the state investigator conducted an interview with the facility’s Director of Nursing who said that they “would have expected the treatment to be stopped and pain medication to be administered.”

The investigator also conducted a 10:32 AM 11/19/2015 interview with the facility physician who said “usually a pain medication has been ordered that can be administered prior to the treatment that the resident is in pain; the resident is verbal and can make it known if pain is present and pain medication should have been given to the resident when [they said they] had pain, prior to dressing change and treatment being continued.”

Our Kansas City nursing home neglect lawyers recognize that failing to follow procedures and protocols when administering wound care treatment that causes pain could be harmful to the health and well-being of the resident. The deficient practice by the nursing staff at Parkway Health and Rehabilitation Center might be considered negligence or mistreatment because their actions fail to follow the facility’s revised March 2015 policy titled: Wound and Skin Care Policy and Protocol that reads in part:

“Resident should be assessed for pain, related to pressure ulcer or its treatment per policy. Manage pain by eliminating or controlling the source when possible wound covering, support services, repositioning. Try to prevent or relieve pain associated with or made worse during dressing changes and debridement.”

621 Carondelet Drive
Kansas City, Missouri 64114
(816) 941-1300

A “Not for Profit” 162-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Ensure That Medication Administration Procedures Met Professional Standards of Quality in Accordance with State and Federal Regulations

In a summary statement of deficiencies dated 02/01/2016, a complaint investigation against the facility was opened for its failure to “ensure staff follows the acceptable standard of practice for providing care to [one resident at the facility].” In addition, the state investigator also noted the facility’s failure “to ensure the medication was reordered in a timely manner, [and a failure] to notify the physician when the staff did not give the ordered medications […and a failure] to assure the medication administration record reflected that.”

The complaint investigation included a review of a resident’s medical documents including their 12/23/2015 Care Plan that showed that the “resident will be free of skin breakdown. Staff should inspect resident skin for signs and symptoms of breakdown.” In addition, it was noted that the “resident was at risk for complications related to the use of antidepressant medications. Monitor for depressive behavior and document interventions.” A review of the resident’s 12/30/2015 Admission MDS (Minimum Data Set) noted that the resident “was cognitively intact.”

The state investigator reviewed the resident’s MAR (Medication Administration Record) which noted that the resident did not receive their physician ordered cream on three occasions including 01/09/2016, 01/10/2016 and 01/11/2016.

In addition, the investigator noted that the interdisciplinary notes between 01/09/2016 of 01/11/2016 “did not show that the staff notified the resident’s physician when the resident ran out of [their medication] cream.”

The state investigator interviewed the facility’s Registered Nurse at 3:15 PM on 01/25/2016 who said that they had ordered the resident’s medication cream on 01/11/2016 after noticing that [the resident ran out of these medications. The resident complained of itching and seemed more withdrawn than usual. The staff should reorder medications by placing the reorder sticker on a fax and fax the request to the pharmacy to assure the medication is delivered before the resident runs out of the medication.”

The Registered Nurse also noted that “if a medication runs out the nurse is to notify the physician, get a dose from the emergency kit if it is available or call the pharmacy and request a STAT order and delivery. The resident should not have to go without their medication.” The Registered Nurse had said that they had “been off work for two days prior to noticing the resident ran out of the medication […and] reorder the medications when [they] return to work.”

The state investigator interviewed the resident a few minutes later 3:15 PM who said that they “it’s so bad when [they] did not receive [their medication] cream and felt like [they were] scratching their arms off.” The resident indicated that they felt sad and hopeless and cried because of the miss medication doses and did not know why they did not receive their medication for three days. The resident indicated that family members had brought in another cream because it was not being supplied by the facility. However, that cream did not help.

That afternoon at 5:00 PM, the state investigator interviewed the facility’s Director of Nursing who said that “staff should reorder medications when the medication supply got down to the last eight days […and] staff should remove the medication reorder label from the medication package and fax the reorder to the pharmacy to assure it there is time for the medication to be delivered prior to the resident running out.” The Director of Nursing also indicated that she “was not aware the resident did not have [their] medications for three days.”

Our Kansas City nursing home neglect attorneys recognize that failing to ensure that medication administration procedures are followed could cause extensive pain and diminish the health and well-being of the resident. The deficient practice by the nursing staff at Carondelet Manor might be considered negligence or mistreatment because their actions fail to follow the facility’s 10/30/2012 policy titled: Medication Administration Policy that revealed in part:

“Nursing staff to notify the ordering physician when medications or refuse or withheld consistently.”

8575 North Granby Ave
Kansas City, Missouri 64154
(816) 436-8575

A “For-Profit” 156-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Develop, Implement and Enforce Programs That Investigate, Control or Keep Infections from Spreading throughout the Facility

In a summary statement of deficiencies dated 12/09/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure staff followed infection control protocols to prevent the spread of infection when staff did not remove soiled gloves and wash their hands during resident care and medication administration.” The failures by the nursing staff at Garden Valley Nursing and Rehabilitation Center affected five residents at the facility.”

The deficient practice was noted by state investigator after a review of a resident’s Quarterly MDS (Minimum Data Set) showing that the resident “required extensive assistance with hygiene and bathing; continent of bowel and bladder.” In addition, the resident’s 10/27/2015 Care Plan showed that the resident had a “Problem: Altered bowel elimination pattern related to cognitive impairment. Approach: toilet every two hours; staff to monitor skin daily during assisting with activities of daily living (ADLs).”

At 9:30 AM on 12/08/2015, the state investigator observed the Certified Nursing Assistant (CNA) entering the resident’s room to perform perineal care. The CNA wash their hands and wipe both groin areas on the resident and use several disposable wipes to remove fecal matter that had dried in the rectum the buttocks area. At that point, the Certified Nursing Assistant removed her gloves, wash their hands and reapplied the gloves, continuing “to wipe away visible stool and ran out of disposable wipes.”

“Wearing the same soiled gloves, [the Certified Nursing Assistant] touched and rolled the resident on to [their back] cover the resident with the bedding, removed [their] soiled gloves, wash [their hands] and left the room.” The Certified Nursing Assistant returned to the room with a new package wipes, they did not wash their hands before applying clean gloves and rolling the resident on to the right side to begin wiping away visible stool.

The state investigator also noted that “without removing the soiled gloves, [the Certified Nursing Assistant] touched the resident, a new brief, [the resident’s] pants, shirt, socks and slippers, then assisted the resident to stand up and allowed the resident to leave the room.”

A 4:10 PM 12/08/2015 interview was conducted with that Certified Nursing Assistant who said that they “should not touch anything with dirty gloves and wash [their] hands” after removing soiled gloves.

Our Kansas City nursing home neglect attorneys recognize that failing to follow procedures and protocols that control or maintain infection from spreading throughout the facility could jeopardize every resident in the nursing facility. The deficient practice by the nursing staff at Garden Valley Nursing and Rehabilitation Center might be considered negligence or mistreatment because their actions fail to follow the facility’s 09/01/2010 policy titled: Handwashing and Gloving Policy that reads in part:

“It is the policy of this facility to ensure a safe, sanitary and comfortable environment for residents and help prevent the development and transmission of disease and infection.”

The staff is to wash their hands “before and after contact with each resident; before and after glove use; after contact with any waste or contaminated materials; before and after toileting residents; when any visible dirt is on your hands. Never leave a resident room and walk down the corridor with gloves on.”

6515 W 103rd St
Overland Park, Kansas 66212
(913) 642-5545

A “For-Profit” 120-certified bed Medicaid/Medicare-participating facility

Overall Rating – 3 out of 5 possible stars

3 stars rating

Primary Concerns –

Failure to Investigate and Report Any Act or Allegation of Abuse, Neglect or Mistreatment of Residents

In a summary statement of deficiencies dated 05/20/2015, a complaint investigation was opened against the facility for its failure to “ensure potential incidences of mistreatment or neglect were thoroughly investigated and reported to the State Agency.”

As a part of the complaint, state investigator reviewed a resident’s five-day Admission MDS (Minimum Data Set) that revealed the resident’s Brief Interview for Mental Status (BIMS) score of 14. This indicates that the [resident’s cognition was intact. The resident required supervision of one staff member with most activities of daily living including transfers and ambulation, was continent of bowel and bladder, had no recent history of falls, received anti-anxiety medication… and hospice services.”

The investigator also reviewed the resident’s Activities of Daily Living Care Area Assessment (CAA) that recorded that “the resident required at least stand by assistance to complete cares and would require increased assistance as [their] condition worsened.” The resident’s fall CAA revealed that “the resident’s gate was unsteady and [they] received narcotic pain medication and [other medications] which placed [them] at risk for falls.”

It was also noted that “the facility would develop a Care Plan to address the resident’s fall risk.” However, the electronic record lacked any documentation of a fall risk assessment since the resident was admitted to the facility. The investigator found on the resident’s Initial Admission Care Plan was that “the resident had a potential for falls due to [their] decreased safety awareness and was to remain free of injury.” However, there was no documentation in the Care Plan “of any interventions to decrease the resident’s fall risk potential.”

The complaint investigation was initiated because of the 7:27 AM Nurses progress note that recorded that “a nurse’s aide reported to the nurse that the resident was on the floor. The nurse went to the room and found the resident lying face down in a pool of blood from the nose and mouth. The resident was unresponsive, no pulse and there were no detectable vital signs. The supervisor was notified to come to the room and the resident was transferred from the floor to the bed.

The facility notified hospice, the family and physician and hospice would come to the facility.” A second nurse’s note entry recorded at 9:51 AM documented that “the resident passed away at 6:30 AM.

In an interview with one of the administrative nurses, it was revealed that “the resident was agitated at times staff placed [them] in a wheelchair and had [them] city the nurse’s station.” That nurse also stated that “the facility did not conduct a fall investigation because it was obvious the resident fell or crawled from the bed […and that] the resident did not have a fall report but said fall measurements were in place for the resident.” The nurse also indicated that “the incident was not reported to the State Agency because the resident was low to the ground, hospice services followed” and that they were “at the end of life.”

The state investigator noted that “the facility failed to conduct a thorough investigation and report to the State Agency a fall with injury for this resident who the facility found dead on the floor in [their] room.”

Our Overland Park nursing home neglect attorneys recognize that failing to investigate and report any allegation of mistreatment, neglect, abuse or injury of unknown origin does not follow state and federal nursing home regulations. The deficient practice by the nursing staff at Indian Creek Healthcare Center might be considered negligence or mistreatment because their actions fail to follow the facility’s policy title: Abuse and Neglect Prohibition Policy that reads in part:

“The facility will conduct an investigation of any alleged abuse, neglect, injuries of unknown origin or misappropriation of resident property in accordance with state law.”

Nursing Home Abuse, Neglect and Mistreatment

Unfortunately, there are endless news stories every month of nursing home residents suffering the abuse, neglect or mistreatment of their caregivers or other residents at the facility. Many vulnerable seniors lack the capacity to speak out against those who are causing them harm and suffer various injuries as a result. In some cases, even family members do not report the signs and symptoms of neglect or abuse because of a lack of knowledge of the victim’s rights and the obligation the nursing home has to the residents.

Sadly, many signs of abuse and neglect go unnoticed or undetected because many family members are not close enough to visit on a timely basis or their lives are too hectic to look in on a loved one residing in a nursing home.

However, it is crucial to serve as your loved one’s legal advocate. Taking time to recognize less obvious signs of neglect and abuse can help. The most common types of cases our Missouri elder abuse attorneys handle in filing a claim for compensation against nursing facilities will involve:

  • Facility-acquired bedsores (pressure sores; decubitus ulcers; pressure ulcers)
  • Sudden weight loss caused by malnutrition or dehydration
  • Unexplained injuries involving burns, bruises, cuts, puncture wounds and welts
  • Unexplained changes in personality and behavior
  • Missing personal items including money and jewelry
  • Unexpected signs of depression or anxiety
  • Unsanitary conditions
  • Outward display of agitation or sudden fear, especially when a caregiver or another resident is present
  • Elopement from the facility or wandering away due to a lack of supervision or detection
  • Infections involving sepsis (blood infection) or osteomyelitis (bone infection)
  • Failure of the nursing staff to follow physician’s orders
  • Substandard care caused by negligent in hiring, understaffing, poorly trained nurses or incompetence
  • Medication errors where the resident receives the wrong medication, medication belonging to another resident or missed doses
  • Verbal abuse
  • Physical assault, sexual abuse or battery
  • Financial exploitation
  • Mental/psychological abuse
  • Failure to develop, implement and enforce a comprehensive Care Plan to ensure the resident’s health and safety
Take Action Now

If you know or suspect that your loved one is the victim of neglect or abuse in a nursing facility in Missouri, it’s imperative to take action immediately to ensure their health and well-being. Filing a claim or lawsuit against the facility is not only just the pathway to obtaining compensation but also to correct harmful, erroneous and unacceptable practices occurring within the facility. However, taking a stand against the facility requires comprehensive knowledge of Missouri legal procedure and the complexities of the state’s tort laws. Because of that, many families will hire a Missouri nursing home abuse attorney to handle their case.

The Kansas City nursing home abuse attorneys at Nursing Home Law Center LLC can handle every aspect of your case to ensure that specific legal requirements are followed to establish liability and to hold all parties responsible legally accountable. Our team of dedicated nursing home attorneys can preserve the evidence to serve as a legal document, gather eyewitness testimony and build a solid case to advocate on your behalf.

We encourage you to contact our law offices today at (800) 926-7565 to speak with one of our Kansas City elder abuse attorneys. Through our efforts, we can ensure that your rights are protected and you obtain fair compensation for your injuries, damages and losses. All cases involving nursing home abuse, neglect and mistreatment are handled through contingency fee arrangements, so you are not required to pay any upfront fee.

[i] https://en.wikipedia.org/wiki/Lymphedema

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

Nursing Home Abuse & Neglect Resources

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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