Both the Certified Nursing Assistant (CNA) and the state of Utah conduct and unscheduled surveys and unannounced investigations at every nursing facility in the state. Their efforts help to identify serious concerns, health violations and major deficiencies that violate established nursing home law. As a result, Utah personal injury lawyers are now handling significantly more cases of abuse and neglect for clients mistreated in nursing homes statewide.
In the most challenging cases, the regulators will designate the nursing home as a Special Focus Facility (SFF). The centers are typically added to the national Medicare deficiency watch list where surveyors will conduct additional inspections throughout the year. If the facility is unable or unwilling to make significant changes to the level of care they provide and adjust their policies and procedures, they could suffer serious monetary consequences.
More than one year ago, regulators designated Lomond Peak Nursing and Rehabilitation Center as a Special Focus Facility. Now that the Home has been placed on the deficiency watch list, the Center will remain under the watchful eye of regulators and investigators. Some of the serious concerns involving this facility are detailed below.
This Nursing Facility is a Medicaid/Medicare-approved 85-certified bed Center providing services to residents of Ogden and Weber County, Utah. The ‘for profit’ Home is located at:
524 East 800 North
Ogden UT 84404
(801) 782-3740
In addition to providing 24-hour skilled nursing care, Lomond Peak Nursing and Rehab also offers:
To ensure families remain fully informed of the level of care every nursing home provides, the federal government and the state of Illinois routinely update their nursing home database system. This information reflects a complete list of dangerous hazards, opened investigations, health violations, safety concerns, filed complaints, and incident inquiries posted on numerous websites including Medicare.gov.
Currently, Lomond Peak Nursing and Rehabilitation 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, two out of five stars for staffing issues, and one star for quality measures. Over the last three years, regulators have investigated 29 formally filed complaints that all resulted in citations. Some of the serious concerns, health violations, dangerous hazards and deficiencies involving this facility include:
In a summary statement of deficiencies dated August 10, 2015, a state survey team opened the complaint investigation against the facility to identify failures. The state investigator documented that the facility had failed to “report the result of all investigations to the State Survey Agency within five working days of the incident.”
One incident involved in abuse allegation that “was called into the State Surveying Agency” on June 10, 2015. The “allegation reported was that [a resident] suffered a ground-level fall that resulted in a femur fracture. The results of the abuse investigation were to be reported to the State Survey Agency by June 17, 2015.” However, “on August 10, 2015, the Regional Nurse Consultant was interviewed” and stated that “the Final Abuse Investigation for the resident was not reported to the State Survey Agency as required.”
A separate incident involved in abuse investigation that was called into the State Survey Agency on July 13, 2015.” The allegation involved a report “that [a resident] had eloped from the facility and was missing for approximately twelve hours.” The results “of the abuse investigation was to be reported to the State Surveyor Agency by July 20, 2015. The results of the abuse investigation were not submitted to the State Survey Agency.” The same Regional Nurse Consulted stated during an interview that “the final abuse investigation for [this resident] was not reported to the State Survey Agency as required.”
In a summary statement of deficiencies dated September 10, 2015, a state surveyor opened a complaint investigation against the facility to identify violations. The surveyor determined that for to individuals, but the residents have the right to be free from any chemical restraints imposed for …discipline or convenience, and not required to treat the resident’s medical symptoms.” The surveyor noted that specifically, the facility administered a medication injection “and started a resident on additional antipsychotic medications without adequate documentation.”
Documentation reveaedl that the goal was developed so the “resident will have fewer episodes of screaming and crying to have her needs met by the next review. There were no interventions developed to achieve the goal.” The resident has “the potential to be verbally aggressive” that was first developed on July 10, 2015. The goal of the Plan of Care “was developed to have the resident verbalize the understanding of the need to control verbal heat abusive behaviors to the review date.”
The Plan of Care involved different interventions including providing choices of care and activity to the resident and monitor behaviors. However, the state surveyor interviewed the Licensed Clinical Social Worker on the afternoon of September 9, 2015, who stated that “she had not been contacted regarding the resident’s behaviors” and did not know why the resident’s medications and Klonopin had been increased or that she received [her medications] intramuscularly.
The facility’s Director of Nursing stated that “an in-service on how to manage behaviors had not been conducted.” The Director was “unable to provide additional information as to why the resident’s [antipsychotic] medications were increased.”
In a summary statement of deficiencies dated September 10, 2015, a state surveyor opened a formal complaint against the facility to identify failures. The surveyor documented that the facility “did not immediately consult with the resident’s physician” when there “was a significant change in the resident’s physical, mental or psychosocial status.”
The incident involved a resident who “had verbalized extreme pain and the Physician did not return the nurse's phone call. There was no documentation that the Physician was contacted when two residents had eloped from the facility, and the Physician was not contacted when another resident [was identified with a medical condition].”
In another incident, an observation was made of a resident at 1:17 PM September 2, 2015, who “was observed to be yelling and screaming out that she was in pain.” The resident “was observed to continue yelling out until 4:00 PM”. An agency Registered Nurse stated at 3:30 PM that day that the resident “appeared to be going through withdrawals from pain medication.” The Registered Nurse stated that “she called the resident’s physician at 12:30 PM and the Physician had not returned her phone call.” The nurse stated that the resident “was experiencing a lot of pain and that she administered pain medication, but the pain medication was not effective.”
The resident’s Nursing Note dated 5:40 PM on September 2, 2015, revealed that the resident was “crying in the room requesting to go to the emergency room. The medical doctor was notified of pain management.” By 6:34 PM, the facility was “still awaiting a call from the patient’s primary doctor at the care facility. There was no additional information that the resident’s physician returned the phone call before 5:40 PM” on that date.
In a summary statement of deficiencies dated September 10, 2015, a state surveyor opened a formal complaint investigation against the facility to identify failures. The surveyor documented that the facility had failed to “properly assess and provide supervision to residents who were elopement risks” that were identified at the facility to include six residents. However, “the deficient practice identified for [two residents] was found to have occurred at an Immediate Jeopardy level,” meaning significant actual harm has occurred or could occur.
In one incident, a severely cognitively impaired resident was documented in their Minimum Data Set Assessment upon admission to wander daily. However, “the facility staff had not developed a plan of care relating to [the resident’s] assessed wandering and elopement risk.”
The incident was documented to have occurred on June 26, 2015, at 10:36 AM when “the facility nurse documented that the resident was found quite ‘a ways’ down the street. The facility staff returned the resident to the facility. There is no documentation to indicate the facility’s staff assess the resident’s condition following her elopement. The facility staff did not document an incident report or investigate circumstances surrounding the resident’s elopement” as required by law. The resident was spotted by an off-duty employee approximately one mile south of the facility at a busy intersection. The resident was returned to the facility by the employee.”
In a summary statement of deficiencies dated December 7, 2015, a state surveying agency opened a formal complaint investigation to identify failures. The investigator documented the facility had “not implemented the facility’s policies and procedures that prohibit mistreatment, neglect, and abuse of residents. Specifically, a facility Registered Nurse administered [a medication] at 120 mg instead of the ordered 5 mg and did not report the air to the State Surveying Agency as required.”
In a separate summary statement of deficiencies dated September 27, 2016, the state investigator opened a formal investigation over a complaint of failures. The surveyor determined that the facility “did not implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents. Specifically, one resident with the bruise of unknown origin and one resident with a swelling of the cheek of unknown origin was not investigated.”
In a summary statement of deficiencies dated December 7, 2015, the state surveyor initiated a formal investigation over a complaint of failures. The State Agency determined that the facility “did not promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect and full recognition of [their] individuality.”
Specifically, “one resident did not receive incontinent care [and] one resident did not receive assistance for a change in clothing.” And additional failure involved a third resident who “was continent [who] chooses to wear a brief at night because the staff is unable to help her, and [a fourth] resident does not get assistance with his urinary catheter.
The state investigator interviewed one resident involved in the nursing staff deficiencies on August 24, 2016. The resident stated that “she wets herself (urinates in her incontinent briefs) all the time and was wet at the time of the interview, but had not reported to the facility staff because it does not do any good.” The resident told the staff surveyors that “I am not happy here at all. They ignore me.” The resident stated that “she usually has to wait 35-40 minutes for assistance to be taken to the toilet after she turned on her call light.” The resident told the surveyor’s “I want to die.”
The same resident was re-interviewed on September 13, 2016, who stated that “she urinated on the floor that morning because she could not get the staff to assist with taking her to the toilet.” The resident stated that “that this a major problem with me!” The resident “reported that the Certified Nursing Assistants will not answer her called. The night nurses ignore me completely.” The resident said that “she had been crying an awful lot and that she had recently been sent to the emergency room at the local hospital” to treat her medical condition] because no one would listen to me. I just wanted someone to talk to.”
In a summary statement of deficiencies dated February 10, 2016, a state surveying agency opened a formal complaint investigation to identify failures. The investigator noted that “interventions were not implemented to prevent the development of a pressure ulcer. Interventions were not implemented which resulted in the pressure sore getting worse.”
The state investigator observed the resident “sitting in her wheelchair [who] did not have any pressure relieving cushion in place.” Because of that, the state investigator interviewed the facility’s Registered Nurse who stated that the resident “had two pressure ulcers on the back portion of her thighs [and that the] wheelchair does not fit her properly.”
In a summary statement of deficiencies dated February 10, 2016, a state survey team opened the complaint investigation against the facility to identify violations and failures. The surveyor “determined that the facility did not ensure that a resident who was fed by a nasogastric (NG) tube was receiving appropriate treatment and services to prevent complications.” The surveyor said that “specifically, a Licensed Practical Nurse did not ensure the proper placement of the nasogastric tube [before] the administration of medication and did not irrigate the NG tube [before] or after the administration of medications.”
According to procedures, “maintaining to function as an ongoing responsibility of the nurse, patient, or primary caregiver. To ensure patency and to decrease the chance of bacterial growth, crushing, or occlusion of the tube, 20-30 mL of water is to be administered in each of the following incidences: before and after each dose of medication and each tube feeding. After checking for gastric residuals and gastric pH.
If you believe your loved one is the victim of mistreatment, neglect or abuse while residing at Lomond Peak Nursing and Rehabilitation Center or any nursing facility, hiring a lawyer can help. An attorney working on your behalf can file all the necessary paperwork in the appropriate Utah county courthouse before the statute of limitations expires. The law firm can ensure you receive adequate compensation to recover your monetary damages.
You will not be required to make any upfront payment for legal services because personal injury law firms accept all nursing home neglect cases through contingency fee agreements. This arrangement means the fees are paid only after the lawyers have successfully resolved your claim for compensation by negotiating an acceptable out of court settlement or by winning your case at trial.
Sources:
Chicago Nursing Home Injury Attorney Nursing Home Law Center LLC Home