Memphis Tennessee Nursing Home Abuse Attorney - Part 2

Signature HEALTHCARE AT SAINT FRANCIS
6007 Park Ave
Memphis, Tennessee 38119
(901) 765-3110

A “For-Profit” 197-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Develop, Implement and Enforce Programs That Control Infection from Spreading throughout the Facility to Ensure the Safety and Well-Being of All Residents

In a summary statement of deficiencies dated 04/15/2015, a complaint investigation was opened against the facility for its failure to “ensure practices to prevent the potential spread of infection when [a Certified Nursing Assistant at the facility] failed to follow isolation guidelines.”

The deficient practice was noted by the state surveyor after reviewing a resident’s 08/01/2014 laboratory report documenting the resident had an “Acinetobacter baumannii multiple drug resistant organism. The physician reviewed the lab report and documented, colonized.” The surveyor noted that the 04/01/2015 Physician’s Progress Note documented that “the patient remains in isolation for respiratory colonization with Acinetobacter.” The resident’s 05/23/2014 Care Plan [some 11 months prior the resident’s recent laboratory report] documents that the resident “has colonized infection in his sputum required contact isolation.”

However, the state investigator made an observation of the resident’s room at 12:03 PM on 04/13/2015 and interview the resident. The observation “revealed a CNA (Certified Nursing Assistant) put on a disposable gown and gloves and enter the room. After washing [the resident’s] face with a washcloth, she pulled up the disposable gown and reached into her uniform pocket with her contaminated glove to obtain a clear plastic bag to place the soil washcloth and. The plastic bag was on the residents bed.”

The state investigator also noted that the Certified Nursing Assistant then “place a washcloth into the point clear plastic bag […and] remove the tape fasteners of the wet adult diaper including the perineal area with disposable wipes. Her gown was not tied at the neck and continuously fell off her shoulders onto the contaminated surfaces and she used contaminated gloved hands to pull her gown back up to on her shoulders, touching her uniform.”

The Certified Nursing Assistant then placed the soiled diaper “in the clear plastic bag with the washcloth and the disposable wipes, closed with a knot and placed in an open trash can in the resident’s room.” The surveyor noted that the Certified Nursing Assistant then “remove the soiled gloves and washed her hands, re-gloved and then applied a clean adult brief. She removed the resident’s gown, pulled up her disposable gown, reached into her uniform pocket with her contaminated glove for a clear plastic bag, place it on the residents bed and placed the gown into the clear plastic bag. She placed the clear plastic bag with the contaminated linen on a table in the room.”

The investigator also noted that there “was no isolation linen barrel in the room.” The Certified Nursing Assistant “then removed her gloves and disposable gown and washed her hands.” When asked “what she should do with the linen bag” the Certified Nursing Assistant replied, “oh, I forgot.” At that point, the Certified Nursing Assistant “picked up the contaminated bag with her ungloved hand and took it out of the isolation room in place in the linen hamper and rolled the hamper down the hall.”

As a part of the investigation, the state surveyor conducted an interview at 10:00 AM on 04/16/2015 with the facility’s Director of Nursing who “was informed of the observation and asked what would she expect for the care of residents in contact isolation.” The Director of Nursing replied, “she [the Certified Nursing Assistant] should not have gone back into get the bag of linen without re-gloving and the bag shouldn’t have been brought out of the isolation room, and should have gone in the barrel in the room.”

Our Memphis nursing home neglect lawyers recognize failing to follow protocol when providing care and services to residents with communicable infections could place the health and well-being of other residents and employees in immediate jeopardy. The deficient practice by the nursing staff at Signature Healthcare at St. Francis might be considered negligence or mistreatment of the residence because their actions did not follow established procedures, protocols and policies including the facility’s policy title: Isolation-Initiating Transmission-Based Precautions that reads in part:

“Transmission based precautions will be initiated when there is a reason to believe that a resident has a communicable infectious disease. Transmission-based precautions may include contact precautions. Ensure that appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident’s room.”

GOLDEN LIVINGCENTER – SOUTHAVEN
1730 Dorchester Dr.
Southaven, Mississippi 38671
(662) 393-0050

A “For-Profit” 140-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Provide Necessary Services Including Quality Lab Services and Tests in a Timely Manner to Meet the Needs of the Residents

In a summary statement of deficiencies dated 09/30/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “obtain lab as ordered for [3 residents at the facility].”

The deficient practice was noted by the state investigator after a review of a resident’s lab results result of that there was “no Urine C&S [urine culture and sensitivity study] results on the chart for 08/21/2015.” The investigator asked the facility’s Director of Nursing to “provide the results of the ordered lab test.”

In a 12:00 PM 08/29/2015 interview with the facility’s Director of Nursing, it was revealed that the “facility failed to obtain the urine C&S as ordered […and] the resident was at [a different facility receiving treatment] the day it was ordered, and it appears it was not obtained upon her return.”

The state investigator then reviewed the resident’s Significant Change in Status Minimum Data Set with Assessment Reference Date (ARD) on 07/09/2015 revealing that the resident “had a Brief Interview for Mental Status (BIMS) score of 15, which indicated [the resident] was cognitively intact.”

During an investigation and review record of another resident at the facility, it was revealed that that resident’s lab results documented “that there were no hemoglobin A1c results in the chart for January 2015.” Again, “the Director of Nursing attempted to locate the results, but was unable to do so.”

The state investigator conducted a. 08/30/2015 interview with the facility’s Director of Nursing who “confirm that the hemoglobin A1c due in January 2015 for [that resident] was not drawn, confirming that the physician’s orders [were not followed].”

A review of the resident’s Annual Comprehensive Minimum Data Set with Assessment Reference Date (ARD) of 08/07/2015 revealed “a Brief Interview for Mental Status (BIMS) score of nine, which indicated [the resident’s] cognitive is moderately impaired.”

The investigator then reviewed the resident’s 09/22/2014 laboratory results revealing “there were no hemoglobin A1c results on the chart.”

Our Southaven nursing home neglect attorneys recognize failing to follow protocols and provide necessary services including quality lab services and tests according to the physician’s orders could place the health and well-being of the resident an immediate jeopardy. The deficient practice by the nursing staff at Golden Living Center – Southaven might be considered negligence or mistreatment because their actions did not follow established protocols enforced by federal and state nursing home regulations.

GRACE HEALTHCARE OF CORDOVA
955 Germantown Pkwy
Cordova, Tennessee 38018
(901) 754-1393
A “For-Profit” 240-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Provide Every Resident Proper Treatment to Prevent the Development of a New Bedsore or Allow an Existing Bedsore to Heal

In a summary statement of deficiencies dated 09/24/2015, a complaint investigation against the facility was opened for its failure to “put preventative measures in place prior to the development of bedsores.” The complaint investigation also included the facility’s failure “to put preventative measures in place prior to the development of elbow pressure sores […and a failure to] timely identify, accurately assess and or treat pressure ulcers [that] resulted in actual harm to [a resident at the facility].”

As a part of the investigation, the state surveyor conducted a review of the resident’s quarterly MDS revealing that the resident’s Brief Interview for Mental Status (BIMS) score was “3” indicating the resident “as severely impaired cognitively and did not have any documented ones at that time.”

The resident’s 07/04/2013 (revised 08/14/2015) care plan documented: Has actual potential for skin breakdown related to mobility and incontinence. Left elbow Stage III, Stage IV on right elbow. Approaches: teach family/significant others risk factors for the development of pressure ulcers. Report any changes in skin condition. Pressure relief mattress. Administer medication as ordered to manage contact. Turning repositioned routinely and PRN (as needed). Ear protectors. Podus boots. Incontinence care as needed. Treatment as ordered 08/14/2015. Vitamins and supplements as ordered. Laboratory test as ordered.

The state investigator reviewed the resident’s 05/13/2015 and 08/17/2015 Braden Scale risk assessment reports that indicate the risk the resident has for developing pressure ulcers that indicated that “the resident was at high risk for developing pressure ulcers.”

However, the investigator noted that the resident’s “bath roster did not document bathing or skin assessments from 08/07/2015 until 08/14/2015.” This is important because the resident’s 08/03/2015 shower/skin assessment form “completed by a Certified Nursing Assistant documented: Wound on the right elbow and on 08/05/2015 documented: sore on right elbow.”

The Director of Nursing indicated that she had spoken to the Licensed Practical Nurse on 08/14/2015 who acknowledged “they should have been made aware of the area on the elbow [by the Certified Nursing Assistant] stated, I just forgot, I missed it.” The Director of Nursing indicated that she then spoke to a registered nurse “loss of knowledge that she was made aware of the area on the elbow and stated, ‘I signed the sheet and really did not look at it (the elbow) because I was so busy.’ No new interventions or treatment were implemented on 08/03/2015 or 08/05/2015 when the pressure ulcers were discovered.”

The surveyor noted that a 2:41 AM 08/14/2015 Nurses No documented “when the resident was turned to clean and change, a 3.0 centimeter by 2.0 centimeter wound was noted to the area but right elbow, wound is tan color, slough tissue noted.” Later that same morning at 7:36 AM, the nurses notes revealed: “skin assessment completed, was found both elbows, an open area to sacral, and a sealed scratch to the right buttock.”

Later that day at 12:09 PM, the Nurse’s Notes document: “open area to the right elbow, yellow slough present with purulent drainage. Left elbow has abrasions and scabbing, shearing noted to left buttocks. A wound assessment documented unstageable pressure ulcers to the left and right elbows.”

The wound care specialist evaluating the resident’s pressure ulcers noted that the left and right elbows at Stage IV pressure ulcers that are recognized as advanced stage, life-threatening bedsores.

At a 40 a.m. on 09/23/2015, observations were made of the resident in the resident’s room will reveal the resident “had a healing Stage IV wound on her left elbow dry and no color with granulation tissue present. The right elbow had a wound 3.0 centimeters in diameter appear to have the same undermining at the edge toward the upper arm with some yellow slough noted on the wound bed and no older.”

In an interview with the Certified Nursing Assistant providing the resident care the nurse revealed that “I did notify the nurse there was a wound on her right elbow.” The Certified Nursing Assistant was then asked if the resident “had any protectors on her elbows on 08/14/2015.” The CNA responded, “No, nothing on her elbows. She had nothing else in place.”

The Director of Nursing and the Nurse Consultant were interviewed at 2:15 PM on 09/23/2015 who was asked: “if there were no shower sheets provided, did that mean there were no skin assessments performed.” The nurse consultant replied, “if not documented, not done.”

At the conclusion of the investigation, the state surveyor noted that the facility “failed to put preventative measures in place prior to the development of pressure sores, nurses failed to timely identify, accurately assess and or treat pressure ulcers [which] resulted in actual harm when [the resident] developed unstageable pressure ulcers to the right and left elbows.”

Our Cordova nursing home neglect attorneys recognize a failing to follow protocols when providing treatment to prevent the development of a bedsore has the potential of causing life-threatening bedsores on the skin of the resident. The deficient practice by the nursing staff at Grace Health Care of Cordova might be considered negligence or mistreatment because their actions failed to follow established procedures and protocols enforced by federal estate nursing home regulations.

THE KINGS DAUGHTERS AND SONS
3568 Appling Road
Bartlett, Tennessee 38133
(901) 272-7405

A “Not for Profit” 108-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Provide Every Resident Proper Treatment to Prevent the Development of a New Bedsore or Allow an Existing Bedsore to Heal

In a summary statement of deficiencies dated 10/21/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “document weekly skin assessment with a description was stage, size depth, width or presence or absence of drainage”. The deficient practice by the nursing staff at The Kings Daughters and Sons affected two residents at the facility with pressure ulcers.

The deficient practice was noted by state surveyor conducting a review of a resident’s medical records noting that the resident “was admitted to the facility in May 2015. As a part of the resident data collection and mission assessment, it was revealed that the resident had a “reddened area the sacrum.”

The resident’s Nurse’s Notes also revealed a 05/14/2015 document noting the reddened sacral/coccyx area and “Medical Doctor present with new orders noted.” The 06/05/2015 Nurse’s Notes indicate that an open area was noted on the resident’s buttocks and treatment was implemented. Three days later on 06/08/2015, the Nurse’s Notes revealed the resident now had a Stage II sacral bedsore related to incontinence associated damage.

By 06/17/2015, notations are made in the Nurse’s Notes that assessments have been taken indicating a rash in the perineal area with noted right buttocks wound measuring 1.4 centimeters by 0.8 centimeters by 0.1 centimeters.

The following day, the Physician’s Progress Note documents that there is “open area to the sacrum.” Another notation made in the Physician’s Progress Note’s on 05/29/2015 indicate a Stage II pressure ulcer.

However, the state investigator notes that on specific days including 05/24/2015, 06/07/2015 and 07/04/2015 on the weekly skin assessments that “skin assessments were performed with no wound measurements documented. No other weekly skin assessments or wound assessment reports were provided by the facility for [that resident].”

The state investigator interviewed the facility’s Director of Nursing at 5:52 PM on 10/21/2015 and “was asked if weekly skin assessments were performed for [the resident].” The Director of Nursing replied, “No, not that I can see.”

A full review was then performed on the resident’s departmental notes when assessment reports, Weekly Pressure Ulcer Record, physician progress notes and wound care notes dated between 06/01/2015 and 10/19/2015. However, there were “no weekly assessments or wound measurements for the sacral and left posterior thigh pressure ulcers for weeks of 06/22/2015, 08/03/2015 08/17/2015.”

The state investigator then conducted an interview with the facility’s Director of Nursing and the MDS Coordinator at 4:45 PM on 10/21/2015, where the Director of Nursing “was asked how often wound assessment should be done.” The Director replied, “Weekly.” When asked if measurement should be taken, the Director replied, “Yes.”

Our Bartlett nursing home neglect attorneys recognize a failing to follow procedures and protocols when providing treatment to residents with developing bedsores could place their health and well-being in grave danger. The deficient practice by the nursing staff at The Kings Daughters and Sons might be considered negligence or mistreatment because their actions failed to follow the NPUAP [National Pressure Ulcer Advisory Panel] quick reference guide that reads in part:

“Ongoing assessment of the skin is necessary to detect early signs of pressure damage. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if necessary. Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals.”

RAINBOW HEALTH and rehabilitation OF MEMPHIS
8119 Memphis-Arlington Road
Bartlett, Tennessee 38133
(901) 743-1135

A “For-Profit” 115-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Ensure That Therapeutic and Special Diets Were Provided to the Residents as Ordered by the Attending Doctor

In a summary statement of deficiencies dated 08/26/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “provide the correct therapeutic diets as ordered by the physician.” This deficient practice affected “three residents observed during dining observations.”

The deficient practice was noted by the state investigator reviewing the resident’ as medical records noting that the resident “was admitted to the facility with a developed Care Plan on 07/29/2015 that documents: “Provide me my diet as ordered. The physician ordered: Diet Order: Regular. The nutritional therapy assessment dated 07/22/2015 documented: Diet Order: Regular.

The state investigator observed the resident’s room at 12:25 PM on 08/24/2015 revealing that a Certified Nursing Assistant “brought in a meal tray and set up it up for the resident [consisting] of turkey and gravy, noodles, water, cranberry juice and a roll.

The meal ticket on the tracer to the resident documented in part: “No salt added. Monday: lunch 8/24/2015, roast turkey, turkey gravy, noodles, water eight ounces, cranberry juice four ounces send extra four ounces of fluid.”

A few minutes later at 12:29 PM, an interview was conducted with the Licensed Practical Nurse providing the resident care who works at the 100 Hall Nurses Desk who “was asked to check the meal ticket on [that resident’s] tray.” The Licensed Practical Nurse entered the resident’s “room, looked at the resident’s armband and then check the meal ticket.” At that point, the Licensed Practical Nurse called for the Certified Nursing Assistant who “entered the resident’s room and stated to the resident, ‘Hold on, because you have the wrong tray. I’m going to take this, and I’ll give you another one. Sorry about that’.” The CNA removed the tray of food from the room.

The state investigator interviewed the facility’s Registered Dietitian at 9:10 AM on 08/26/2015 who “was asked what the difference was between and NAS diet and regular diet.” The Registered Dietitian responded that “the NAS does not have the salt packet.”, The Registered Dietitian “was asked whether based on physician’s orders [the resident should have received that meal tray?]. The Registered Dietitian responded, “Absolutely not.”

An interview was then conducted 11:06 AM on the same day with the facility’s Director of Nursing who “was asked whether she expected the staff to always identify the resident before serving the meal.” The Director of Nursing then replied, “Yes they should.” The Director of Nursing also agreed that it was unacceptable to bring the NAS diet to the resident.

Our Bartlett nursing home neglect attorneys recognize a failing to follow procedures and protocols when providing special diets and therapeutic care to residents could place their health and well-being in jeopardy. The deficient practice by the nursing staff at Rainbow Health and Rehabilitation of Memphis might be considered negligence or mistreatment because their actions did not follow the resident’s physician’s orders.

Obtaining Justice in a Nursing Home Abuse Case

While the majority of nursing facilities provide an excellent level of care to their residents, the number of cases involving neglect, mistreatment and abuse are far too high. Unfortunately, many nursing facilities place profits ahead of quality care by cutting corners and reducing staff that is often to the detriment of the nursing home resident. The desire of the administrator, corporation and management at the nursing home to obtain huge profits often places the elderly loved one in harm’s way.

Any change in the resident’s health conditions can diminish their quality of life and even cause premature death. Many residents suffer physically, mentally and emotionally from neglectful, abusive situations. Identifying abuse and neglect can be frustrating and challenging, especially for residents who lack the capacity to speak up to protect themselves.

Unfortunately, many families are unaware of the warning signs and symptoms of an elderly individual experiencing abuse, neglect and mistreatment. The most common signs involve:

  • Facility acquired pressure ulcers
  • Unusual weight gain or weight loss
  • Poor hygiene and/or unsanitary conditions
  • Hazardous areas including slippery floors
  • Unauthorized physical or chemical restraint used as a convenience to assist the nursing staff
  • Indicators of dehydration and malnutrition
  • Unexplained bruises, broken bones, fractures, lacerations or other injuries
  • Withdrawal of the resident from normal activities that might involve a sudden onset of depression or significant change in mood
  • Medication error

A nursing home abuse case does not always involve physical trauma. Many times, caregivers, administrators and nursing facilities are held legally accountable because they simply ignored the needs of their residents. However, proving a case in court to obtain justice, financial recompense and accountability is complex. Because of that, many families will hire a personal injury lawyer who specializes in nursing home abuse cases.

Hiring a Lawyer

The Memphis nursing home abuse attorneys at Nursing Home Law Center LLC are aggressively competent in fighting for the rights of nursing home residents seeking financial compensation and justice for their harm. Our Tennessee elder abuse law firm remains dedicated to ending the neglect, abuse and mistreatment occurring in nursing facilities all across the state. We have a personal understanding of the family’s desire to protect and preserve their loved one’s respect, dignity and quality of life during this difficult time of their life.

If you suspect your loved one is the victim of neglect, abuse or mistreatment, we encourage you to call our law offices today at (800) 926-7565. We accept every nursing home neglect, personal injury and wrongful death case through a contingency fee arrangement. This is our no recovery, no payment guarantee. All of our services are paid only after we have negotiated an acceptable out of court settlement or win your case at trial.

For additional information on Tennessee 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.

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