The state of Indiana and the Centers for Medicare and Medicaid Services (CMS) conduct routine investigations, surveys, and inspections of every convalescent center statewide. Their efforts help to identify serious violations, concerns, and deficiencies. When significant problems are detected, surveyors and regulators provide numerous opportunities and guidance on how the facility can adjust their policies and procedures and improve their level of care.
In the most egregious cases, regulators will designate the Center as a Special Focus Facility (SFF) and add the Home to the National Medicare deficiency watch list. If the convalescent home fails to make necessary corrections promptly, they could lose their contract to provide care and services to Medicaid- and Medicare-funded patients.
Recently, regulators designated Lawrence Manor Health Care Center as a Special Focus Facility. Now that the Center has been added to the watch list, the Home will remain under the watchful eyes of regulators in the years ahead. Some of the most egregious concerns, violations, and deficiencies occurring in the last few years at this facility are documented below.
This nursing Center is a “government-owned” Home providing services to the residents of Indianapolis and Marion County, Indiana. The 55-certified bed convalescent facility is located at:
8935 E. 46th St.
Indianapolis, IN 46226
(317) 898-1515
In addition to providing long-term skilled nursing care, the facility also offers specialized services including hospice and respite care, and rehabilitation services including occupational, physical and speech therapies and Rehab to Home Care.
The state of Indiana regularly updates their convalescent home database system with complete details of every dangerous hazard, opened investigation, health violations, safety concerns, filed complaints, or incident inquiries. This regulatory agency makes the information publicly available to allow families to make informed decisions about where to place a loved one who requires the highest level of convalescent care and hygiene assistance.
Currently, Lawrence Manor Health Care Center maintains an overall one out of five stars compared to all nursing homes in the US. This ranking includes one out of five stars for health inspections, one out of five stars for staffing issues, and three out of five stars for quality measures. Over the last three years, regulators have investigated 20 formally filed complaints and one facility-reported issues that all resulted in citations. Some concerns, violations, and deficiencies involving this facility in recent years include:
In a summary statement of deficiencies dated August 31, 2016, the state investigator documented the “to protect residents during an abuse investigation, report allegations timely, identify allegations as potential abuse, and investigate allegations thoroughly, after allegations of abuse were reported to them.”
The deficient practice by the nursing staff “had the potential to affect all forty-four residents in the facility.” The surveyor documented that an Immediate Jeopardy “began on August 23, 2016, when the facility was notified about the allegations of abuse and failed to protect residents during an abuse investigation, report allegations timely, identify allegations of potential abuse, and investigate allegations thoroughly.”
The incident involved a cognitively intact resident. During an interview, the resident indicated that at approximately “3:00 AM on August 23, 2017, a heavyset CNA (Certified Nursing Assistant) who works the third shift, wears her hair in a bun, and discolored, refused to reposition him in the way he insisted her to do so. She proceeded to tell [the resident] that she was not answering his call light anymore for the rest of the shift.”
The resident stated that the Certified Nursing Assistant “stood in the doorway of his room with the pen pointed at him and stated the following ‘I am tired of running around for you [the resident].’ He then stated that the CNA was standing in the doorway outside his room conversing with another CNA and stated the following to the other CNA, ‘he [the resident] wants me to run in and out of the bedroom every five minutes, and he is pulling the alarm.’”
The resident then stated that the CNA called him a foul word “while conversing with another CNA in the doorway of his room.” The resident “had not told anyone about the language expressed by the CNA [and stated that] he was terrified of his health and well-being because of the CNA’s actions.”
During an interview with the facility’s Administrator, it was revealed that the administrator “was made aware of the verbal allegation of abuse expressed by the resident, along with three other allegations from other residents. The Administrator indicated he was not aware of the alleged verbal abuse from a CNA to [the resident].” The Administrator indicated that “the night shift CNA was suspended pending investigation immediately … and he identified the night shift CNA…”
In a separate summary statement of deficiencies dated October 20, 2017, the state investigator documented the facility’s failure “to ensure [a cognitive] resident was free from verbal abuse.” The state investigator interviewed the resident on the afternoon of October 19, 2017, who indicated that a CNA “called her fat, several times.” The resident “indicated she did not know what verbal abuse was until someone explained it to her. She now feels that she was verbally abused. The remarks upset her at the time.”
The state surveyor reviewed an incident report dated October 13, 2017, that documents the resident stated a Certified Nursing Assistant “has a hateful attitude toward her roommate [and] has made remarks about the resident’s weight and eating habits, which the resident considered hurtful.”
The facility’s Administrator interviewed the resident’s roommate who corroborated the report. The Administrator stated that the allegedly abusive CNA “denied making remarks that were hurtful.” The CNA “was terminated for failure to follow facility policies.”
In a summary statement of deficiencies dated August 31, 2016, the state investigator documented the facility’s failure “to maintain a resident’s dignity by keeping a urine collection bag covered, sit at eye level while assisting the resident with eating, including a proposal of urine timely for [two residents].”
In one incident, observations were made of a resident in the front dining room with a “urine collection bag noted to be visible to other residents in the facility.” Surveyors observed the deficiencies on August 23, 2016, between 11:06 AM and 12:42 AM, and again at 9:33 AM on August 24, 2016. Additionals observations were made between 8:57 AM and 10:38 AM on August 25, 2016, where the resident’s urine bag was in full view of others.
The facility’s Regional Director of Clinical Operations observed the resident’s “urine collection [bag] uncovered in the front dining room. She indicated at this time; the urine collection bag should be placed in a dignity bag to promote dignity for the resident.”
In a summary statement of deficiencies dated August 31, 2016, the state investigator documented the facility’s failure to perform “weekly assessments of a pressure ulcer.” While there was documented evidence indicating measurements were obtained for the resident’s pressure ulcer on August 6, 2016, August 10, 2016, and August 17, 2016, “there were no other weekly wound measurements that could be located in [the resident’s] clinical record.”
During an interview with the facility’s Director of Nursing on the afternoon of August 31, 2016, she “indicated there is no further documentation in regards to measurements of [the resident’s] pressure area [and] further indicated measurements should be completed weekly.”
In a summary statement of deficiencies dated August 31, 2016, the state surveyor identified failures. One deficiency involved the facility’s failure “to implement interventions for a resident identified as at risk for elopement, per policy, and to ensure a maintenance cart containing tools and chemicals was not left unattended for [a resident] in the front hall of the facility.” The incident involved a hazardous threat to a resident diagnosed as “at risk of getting into dangerous places” due to wandering.
The surveyor interviewed the Minimum Data Set Coordinator on the afternoon of August 30, 2016, who stated that “the resident does wander around the facility, and I have seen her going into residents’ rooms.” The facility’s Social Services Director stated on the same day that the resident “wanders into other residents’ rooms, follows staff and visitors around the building.” The resident’s Elopement Risk Assessment dated June 29, 2016 “indicated she was at risk for elopement [wandering away].”
A review of the facility’s Missing Person Report Form for the resident was missing a photo. “Above the missing photo area of the form was the physical characteristics area. The entries for height, weight, eye color, hair color, mental status, and other identifying factors were not completed. The Contact Information Section was missing the Responsible Party’s address and phone number.”
The form stated that “the purpose of this binder is for the staff to be aware of who is at risk and can keep an eye out for the resident, and if they go missing, so all pertinent information is there.”
In a separate incident, observations were made of “and unattended maintenance cart” in the doorway of two residents’ room. “The cart contained pain, floor patch, some tools, a trough runner, paintbrush, two cans of close paint, one can of opened paint, dust cleaner, and WD-40.” The surveyor noted that information on the WD-40 can stated: “DANGER! Flammable aerosol. Contents under pressure. Harmful or fatal if swallowed.…”
In a separate summary statement of deficiency dated July 18, 2017, the state investigator noted the facility’s failure “to ensure the resident was protected from injury when a Certified Nursing Assistant acted alone to provide care for a resident who required two or more staff or personal care.” The deficient practice by the nursing staff “resulted in the resident falling from bed during care in receiving a laceration above his right eye, which required an emergency room visit where nine sutures were required to close the wound.”
In a third summary statement of deficiencies dated October 20, 2017, the state investigator documented the facility’s failure “to implement a resident’s fall intervention for [one resident] reviewed for accidents and also failed to have the interdisciplinary team evaluate circumstances and probable causes of a fall.”
During an interview with the Director of Nursing on October 11, 2017, it was indicated that the resident “had no falls in the last thirty days.” However, the resident Nurses Note from October 1, 2017, indicated that the resident “was found sitting on buttock in the dining room.” The document states that the resident was alert when found and had a range of motion in all extremities. The resident’s doctor was notified, and the family was notified, with neurological checks started.
In a summary statement of deficiencies dated August 31, 2016, the state investigator documented the facility’s failure “to ensure a resident’s catheter tubing and collection bag remained off the floor and infection control practices were maintained during incontinent care and wound care for [one resident].” The surveyor documented that the facility had also “failed to maintain an infection control log. This [deficiency] had the potential to affect [forty-four] residents that reside at the facility.”
In a summary statement of deficiencies dated October 20, 2017, the state investigator documented the facility’s failure to “provide sufficient staffing to meet the needs of residents that [required] assistance with bathing.” The deficient practice by the nursing staff affected to residents reviewed for assistive daily living [needs], to follow Plan of Care with catheter care for [another resident] reviewed for or urinary catheter, and to ensure a Plan of Care was followed for splinting and range of motion for [another resident].”
The surveyor interviewed multiple residents at the facility. Many residents indicated that the facility was short all the time, on weekends, and on the evening shift. One resident reported that “no one helps” indicating “there have been times they are that they had only one person for the entire shift, [with a] short staff mostly on second shift.” The Director of Nursing stated that at that time 11:31 AM on October 16, 2017 “there was only [one] Certified Nursing Assistant on the floor, but Social Services Director herself or assisting with the residents.
If you believe your loved one has suffered serious injuries or died prematurely while residing at Lawrence Manor Health Care Center, or any nursing home, contacting a personal injury attorney could be a wise decision. A seasoned lawyer could assist your family in successfully resolving your monetary compensation claim against the nursing staff and administration. The law firm working on your behalf can handle every aspect of the case to ensure the appropriate documentation is filed before the Indiana statute of limitations expires.
Personal injury attorneys provide no obligation comprehensive compensation case evaluation at no charge. Your attorney fees are paid only after the case is successfully resolved through a negotiated out-of-court settlement or at the conclusion of a successful jury trial.
Sources:
Attorney Jeffrey D. Powless
Licensed in Indiana
Chicago Nursing Home Injury Lawyer Nursing Home Law Center LLC Home