Molalla Manor Care Center (SFF) Abuse and Neglect Attorneys

Oregon personal injury lawyers are handling more nursing home neglect and abuse cases than ever before. This change is because the Centers for Medicare and Medicaid Services (CMS) and state regulators are identifying more deficiencies, violations and health hazards than normal during their surveys and inspections.

In egregious cases, regulators are adding nursing homes identified with serious problems on the Medicare deficiency watch list and classified the Center as a Special Focus Facility (SFF). With this undesirable designation, the nursing home must make significant changes the level of care they provide or lose their opportunity to provide care and services to Medicaid and Medicare-funded patients.

Nearly two years ago, regulators designated Molalla Manor Care Center as a Special Focus Facility. Some of the serious concerns, problems, violations, and deficiencies involving this Nursing Home are detailed below.

This Nursing Center is a ‘for profit’ facility providing services and cares to residents of Molalla and Clackamas County, Oregon. The Medicaid/Medicare-approved 92-certified bed Nursing Home is located at:

301 Ridings Avenue
Molalla, OR 97038
(503) 823-5591

In addition to providing around-the-clock skilled nursing care, the facility also offers rehabilitative care, memory care, and long-term care.

Over the last three years, regulators have levied one $1300 fine on May 12, 2016, against Molalla Manor Care Center. During the same time, regulators handled two formally filed complaints and two facility-reported issues that after investigations all resulted in citations.

To be fully informed on the level of care nursing homes provide, families routinely research the Medicare.gov database system for a complete list of filed complaints, health violations, opened investigations, safety concerns, incident inquiries, and dangerous hazards. This data provides valuable content to make a well-informed decision of where to place a loved one who requires a high level of nursing care and hygiene assistance.

Currently, Molalla Manor Care Center maintains an overall four out of five stars compared to all nursing homes in the United States. This ranking includes four out of five stars for health inspections, four out of five stars for staffing issues, and four out of five stars for quality measures. Some serious concerns, violations, and deficiencies involving this facility include:

• Develop, Implement and Enforce Policies That Prevent Mistreatment, Neglect, or Abuse of Residents

In a summary statement of deficiencies dated May 12, 2016, a state surveyor opened the complaint investigation against the facility to identify violations and failures. The surveyor noted the facility’s failure “to implement written policies for reporting suspected abuse [promptly].” In one incident, a resident “experienced a fall with multiple fractures, increased pain and delay treatment.” The state investigator interviewed the facility’s Administrator on May 12, 2016, who indicated “it is the intent of [our] facility’s Abuse Policies and Procedures [that] all staff immediately report suspected abuse.”

The investigator reviewed a resident’s Progress Note dated January 13, 2016, that revealed the resident “had pain and bruising and swelling to the resident’s right ankle.” The cause of the injury “was undetermined, the resident’s physician was notified, and an x-ray requested.” A review of the resident’s Incident Report dated January 14, 2016, indicated that nurses reported on January 13, 2016, that the resident was in pain and a Certified Nursing Assistant “reported bruising and swelling covering the resident’s right anterior ankle. However, the Certified Nursing Aides responsible for providing that resident care on that date “did not reveal knowledge of any causative incident [for the resident’s] bruising and swelling…”

The Certified Nursing Assistant (CNA) stated at 8:40 AM on May 6, 2016, that after the resident’s “injuries were discovered [she] denied knowing why the resident had fractures until January 25, 2016, when [she] acknowledged she knew about the incident and did not report it.” The CNA acknowledge that “she should have reported the accident immediately [and] did not report the accident [promptly].”

• Failure to Provide Necessary Care and Services to Ensure the Resident Maintains Their Highest Well-Being

In a summary statement of deficiencies dated June 21, 2016, a state surveying agency opened a formal complaint against the nursing home to identify failures and violations. The survey team noted the facility’s failure “to follow physician’s orders [involving a resident] reviewed for wound care.” The deficient practice by the nursing staff “placed residents at risk for worsening symptoms.”

The surveyor reviewed the resident’s Discharge Summary documentation associated with admittance to the facility that revealed the resident had a medical condition that led to localized fluid retention and tissue swelling to the legs.” The resident’s physician’s orders indicated that the resident was to have “wraps every other day after [their] discharge from the hospital.”

However, reviewing the resident’s February 2016 Treatment Administration Record (TAR), the surveyor noted that the document “did not include [that] wraps were performed to the legs. The March 2016 TAR indicated the order for [the resident’s] wraps was initiated on March 1, 2016, five days after the resident was admitted to the facility…”

• Failure to Provide Residents an Environment Free of Accident Hazards to Ensure Their Safety

In a summary statement of deficiencies dated June 21, 2016, state investigators opened a complaint investigation against the facility to identify failures. The surveyor documented that the facility had failed to “ensure a resident was not left unattended in a recliner when the resident was not able to lower the recliner leg rests.” The deficient practice by the nursing staff “placed residents at risk for injuries.”

The state investigator reviewed the resident’s Hospital H & P (History and Physical) dated April 27, 2016, that “indicated the resident had severe dementia that progressed after the resident had a stroke. The resident was brought to the hospital for evaluations after the resident fell twice at home.” The resident’s Preliminary Care Plan initiated on April 29, 2016, indicated that “the resident was a high risk for falls and interventions.” Guidance “included to remind the resident asked for assistance for transfers, keep the bed and low position and provide non-skid footwear.”

The resident’s, Progress Notes from April 30, 2016, to May 6, 2016 documented that the resident “sat or slept in recliner located in the TV room during the night shift. A May 6, 2016, at 3:18 AM note indicated the resident did not sleep and was awake in the TV room.” At 9:30 AM that same morning, it a note indicated that a staff member (a Licensed Practical Nurse) “was called immediately to go to the TV room.” The resident “was in the recliner with blood dripping down the right side of his head and neck, and there was some dried blood on the resident’s chest. The resident was assessed to have a 3.5 cm hematoma to the back of the head and a 0.5 cm laceration. The wound was cleaned, and a pressure dressing was applied. The resident’s cognition was assessed to be unchanged from the resident’s baseline cognition.”

• Failure to Immediately Notify the Resident’s Doctor of a Serious Decline in Their Medical Condition That Jeopardizes Their Health and Well-Being

In a summary statement of deficiencies dated January 13, 2017, a state surveying agency opened a formal complaint against the nursing home to identify violations and failures. The surveying team identified a facility deficiency of a failure “to notify the physician for refusals of an ordered treatment and low capillary blood glucose [levels].” The deficient practice by the nursing staff “placed residents at risk for unmet medical needs.”

In one incident, a resident was admitted to the facility with a geriatric dentist order to use an anti-infection mouthwash every evening. However, the November and December 2016 medication administration record “revealed the resident refused the mouthwash on 23 occasions. There was no documentation [that] the facility notified [the resident’s] physician of the refusals.” The resident care manager verified this failure on the morning of January 13, 2017, who indicated that “staff did not notify the physician of [the resident’s] refusals.”

• Failure to Ensure Residents Receive Proper Treatment to Prevent New Bedsores or Heal Existing Pressure Sores

In a summary statement of deficiencies dated January 13, 2017, state surveyors opened a formal complaint against the facility to identify deficiencies and failures. The survey team noted the facility’s failure “to provide treatment for a resident’s pressure ulcers.” The deficient practice by the nursing staff “placed two residents at risk for unmet treatment needs.”

One incident involved a resident with an Admission Minimum Data Set Assessment dated December 11, 2016, who indicated that the resident “had one Stage IV pressure ulcer (full-thickness tissue loss with exposed bone, tendon or muscle) and four Stage III pressure ulcers.” The state investigator reviewed the resident’s Nutritional Notations made by the registered dietitian and progress Notes that identified when the resident received ordered Prosource (nutritional supplement) twice per day to aid in wound healing.”

However, reviewing the resident’s Meal Monitoring Report from December 6, 2016, through January 11, 2017, indicated “meal monitoring was in place for that the resident [only] 43 out of 99 possible meals (no information was found for 56 meals).” Additionally, a review of the resident’s December and January 2017 Medication Administration Records (MAR) “indicate the resident was to receive Prosource twice per day beginning on December 27, 2016. The MARs indicated the supplement was not administered on 23 occasions from December 27, 2016, through January 10, 2017, due to [the ordered item not being available].”

• Failure to Ensure That the Drug Regimen of Every Resident Is Free of Unnecessary Medications to Promote Their Highest Well-Being

In a summary statement of deficiencies dated July 13, 2017, state surveyors opened a formal complaint investigation against the facility to identify failures and violations. The surveying team noted the facility’s “failure to complete a gradual dose reduction for [eight residents] reviewed for unnecessary medications.” The deficient practice by the nursing staff “placed residents at risk for excessive medication dosing.”

Part of the findings included information on a resident who was admitted to the facility 2015 with physician’s orders for medications. A review of the resident’s psychoactive drug review dated April 27, 2016 “indicated that [the resident] received a decreased dose of [the medication at] 5 mg from twice daily to once [per day] beginning February 11, 2016. On June 16, 2016, the resident’s medication “was increased to 5 mg twice daily.” A review of the resident’s “clinical record indicated the gradual dose reduction was not completed in the past thirteen months.”

• Failure to Follow Protocols and Procedures to Prevent the Spread of Infection throughout the Facility

In a summary statement of deficiencies dated July 13, 2017, state surveyors opened a complaint investigation against the facility to identify violations and failures. The survey team noted the facility’s failure to “perform proper hand hygiene during [capillary blood glucose] check observations. This [failure] placed residents at risk for cross-contamination.”

An observation was made of a staff member on the morning of July 11, 2017 “as to gather supplies for capillary blood glucose [test], performed the procedure on the resident and disinfected the glucometer afterward. During the observation, [the staff member] donned and removed gloves multiple times without performing proper hand hygiene between each club change as required.” The staff member “acknowledge she did not perform hand hygiene between the glove changes.”

Was your loved one abused, neglected or mistreated while a resident at any nursing facility, including Molalla Manor Care Center? If so, hiring a law firm that specializes in nursing home neglect and abuse cases could help. An attorney working on your family’s behalf can file the necessary documents in the appropriate Oregon county courthouse before the statute of limitations expires.

You will not be required to make any upfront payment to receive immediate legal services. The fees are paid only after your lawyers have successfully resolved your nursing home abuse case by negotiating an out of court settlement on your behalf or by winning your case at trial.

Sources:

• Molalla Manor Care Center
• Inspection Report - 07/13/2017
• Inspection Report - 01/13/2017
• Inspection Report - 06/21/2016
• Inspection Report - 05/12/2016
• Inspection Report - 05/12/2016