Nashville Tennessee Nursing Home Abuse Lawyer - Part 2

WEST MEADE PLACE
1000 St Luke Drive
Nashville, Tennessee 37205
(615) 352-3430

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

Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Provide Residents an Environment Free of Accident Hazards and Provide Adequate Supervision to Prevent an Avoidable Accident from Occurring

In a summary statement of deficiencies dated 04/30/2015, a complaint investigation was opened against the facility for its failure to “investigate falls completely; [and a failure] to put interventions in place to further prevent falls and [a failure] to supervise residents appropriately to prevent falls for [6 residents at the facility].” This deficient practice by the nursing staff at West Meade Place resulted in actual harm to [the resident] who sustained a complicated fracture of the femur.”

The investigation involved a review of a resident’s Quarterly MDS (Minimum Data Set) revealing that the resident’s Brief Interview for Mental Status (BIMS) score was seven out of 15 “indicating the resident was alert but moderately cognitively impaired.” Further review of the records indicated that the “resident required extensive assistance of one person for transfers, dressing, eating and grooming; was dependent for bathing; and was occasionally incontinent of bowel and bladder.”

The state investigator reviewed the resident’s 11/11/2010 Comprehensive Care Plan revealing a problem that the “resident is at risk for falls related to limited mobility, cognitive defects, diagnosis of Parkinson’s, left humerus fracture, history of falls, seizure disorder, history of osteoporosis and osteoarthritis.”

The resident’s revised 05/30/2013 Care Plan also reveals the resident requires two person assist with transfers and gait belt with transfers. A data entry on the resident’s Care Plan on 10/06/2013: Non-Skin Footwear.”

The investigation was initiated because of an Incident Log into the 11/28/2014 Risk Management Incident Report revealing that the resident “was lowered to the floor because her knees became weak during transfer from bed to wheelchair.” Additional documentation revealed that for safety reasons, the nurse assisting the resident “lowered her to the floor and got [assistance from the nursing supervisor] for help.”

The state investigator noted that there were no new interventions documented in the incident report to determine the root cause of the incident except those noted in the 11/28/2014 Comprehensive Care Plan revealed that “the only intervention was – if resident’s legs become weak during transfers, slowly lower resident to the floor. Medical record review revealed no new interventions into place after the fall; no root cause analysis of the incident, and no extra precautions were implemented with the resident.”

On 12/22/2014, the Director of Nursing received a phone call “from the resident’s son to inquire about her status [and was informed] that the fracture was inoperable and that his mother was going to [hospice].”

A meeting between the facility’s Director of Nursing and Administrator was held with the resident’s son on 01/05/2014 where the Director “explained what the staff said occurred. At the present time [the Director of Nursing was] unable to determine when the fracture occurred. There were not any injuries noted from 4:00 AM through 8:15 AM and the patient did not complain of pain until approximately 8:15 AM.”

However, the state investigator notes that there is no documentation the Licensed Practical Nurse providing care to the resident assesses the resident’s leg “every two hours for pain and or swelling as stated in the analysis documented by the Director of Nursing.” Additionally, the state investigator noted that there was no documentation in the resident’s medical record noting any “swelling of the resident’s left leg until noticed by the Licensed Practical Nurse at 8:30 AM on 12/20/2014.”

However, a review of the resident’s 12/23/2014 hospital discharge summary revealed that the resident “suffered a comminuted [when a bone is broken into three pieces or more] oblique [angle break across the shaft] fracture through the distal femoral diametaphysis with moderate distraction (separation) of fractured segments.”

An interview was conducted at 3:25 PM on 04/20/2015 with the facility’s Director of Nursing that revealed that the Director “shared investigation results with the son and did not see the facility did anything wrong. Continued interview with the [Director of Nursing] revealed the son insisted his mother be transferred with one person only and ‘we were following what [the son] wanted’.”

However, upon a further interview with the facility’s Director, it was revealed that “she had documented several communications with the son regarding transferring [the resident] but she failed to produce [communications] during the survey.”

The surveyor noted that the facility failed to follow their own protocols especially their 11/01/2010 policy titled Falls that reads in part:

“It is the policy of this facility to provide a safe and hazard-free environment as is possible.” “Identify residents at risk for falls. Implement a Plan of Care based on identifying risk factors. In the event of a fall, conduct an assessment aid in identifying, complete risk management form, complete pain assessment and post-fall assessment.”

Our national nursing home neglect attorneys recognize that failing to follow protocols to ensure residents remain accident-free from falls could place the health and well-being of the resident in jeopardy. The deficient practices by the nursing staff at West Meade Place might be considered negligence or mistreatment because their actions resulted in the bone fractures due to a “one-person” assist instead of two persons as per physician’s orders.

GOOD SAMARITAN HEALTH AND REHABILITATION CENTER
500 Hickory Hollow Terrace
Antioch, Tennessee 37013
(615) 731-7130

A “For-Profit” 110-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Report and Investigate Any Act or Suspicion of Abuse, Neglect, Mistreatment or Injury of Unknown Origin to the Appropriate Agencies According to Law

In a summary statement of deficiencies dated 02/11/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “report injuries of unknown origin to the state survey and certification agency.”

The deficient practice was noted by state investigator reviewed medical records and interview nursing staff. A review of the resident’s Admission MDS (Minimum Data Set) documented that the resident had a Brief Interview for Mental Status (BIMS) score of 2, indicating “severe cognitive impairment.”

The state investigator reviewed the resident’s 08/17/2015 Nursing Notes that documented: “Observed large hematoma on the left side of [the resident’s] forehead. No possible cause found.” The facility’s 08/17/2014 Incident Investigation Form documented: “Type of Incident: Hematoma. Unwitnessed.”

A further review of the facility’s Nurse’s Notes dated on 09/26/2014 documented: Hematoma on left forehead noted by Certified Nursing Assistant while doing ADL (activities of daily living).” On that day (09/26/2014) the facility’s Incident Investigation Form documented: Type of Incident: Hematoma. Unwitnessed.”

The state investigator noted that the “facility failed to report hematoma injuries of unknown origin to the state certification survey within five days of the occurrence.” As a result, the investigator conducted a 9:30 AM 02/11/2015 interview with the facility Administrator in the Director of Nursing’s office and was “asked if there was an injury of unknown origin, should be reported to the State?” The Administrator responded, “if it is unknown origin we have to follow the rules to report. We have to do an investigation to make sure all possibilities have to be looked at until a cause is found. Then you follow the guidelines.”

Our Antioch nursing home neglect attorneys recognize that failing to follow policies procedures and guidelines to properly investigate any injury of unknown origin could place the health and well-being of the resident in immediate jeopardy. The deficient practice by the nursing staff at Good Samaritan Health and Rehabilitation Center might be considered mistreatment or negligence because their actions failed to follow the facility’s 06/01/2012 policy titled Abuse that reads in part:

“Capture a suspected violation or substantiated incident (injury of unknown source) be reported, the facility Administrator or his/her designee will promptly notify the following persons or agencies of such incident: The state licensing/certification agency responsible for surveying/licensing the facility. Notification to the above agencies will be made as soon as it has been substantiated within five working days of the occurrence of such incident.”

NHC HEALTHCARE – HENDERSONVILLE
370 Old Shackle Island Rd
Hendersonville, Tennessee 37075
(615) 824-0720

A “For-Profit” 122-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 or Keep Infection from Spreading throughout the Facility

In a summary statement of deficiencies dated 04/28/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “ensure five [Certified Nursing Assistants] served food under sanitary conditions during dining.”

The deficient practice was noted by state investigator conducted an observation 11:20 AM on 04/26/2015 of the facility’s 300-400 Day Room that revealed a Certified Nursing Assistant “touch the back of the wheelchair handles pushed the wheelchair to the table, open the silverware, touched the top of the knife, touched the food on the tray with a knife and then open the straws, touching the tip of the straw without performing hand hygiene.”

At 12:50 PM on the same day 04/26/2015, the state surveyor made observations in the 300 Hall and witnessed a Certified Nursing Assistant who “touch the handles of the chair, pulled the resident over in the bed, then fed the resident three bites of mashed potatoes, bring the potatoes close to her mouth and blowing on potatoes without performing hand hygiene.” In addition, another Certified Nursing Assistant “while feeding a resident pulled on her uniform pants legs and continue to feed the resident without performing and hygiene.”

Later that same day, and observation at 1:22 PM was conducted in a resident’s room that revealed a Certified Nursing Assistant “took the water pitcher from [the resident’ is] room, then went to [another resident’s] room to help another Certified Nursing Assistant assist the resident.” While in the other resident’s room, the Certified Nursing Assistant took the water bottle back from the first resident’s room and “place it in her pocket as she assisted the [2nd Certified Nursing Assistant] with that resident.”

The state investigator performed a 4:55 PM 08/20/2015 interview with the facility’s Director of Nursing who “was asked if the staff should enter the kitchen without a hair restraint […and] was asked should food be touch with bare hands […and] was asked if staff in place a tray on the over bed table with urinals.” The Director of Nursing responded, “No” to every question. The state investigator then asked the Director of Nursing “what should be done after touching objects and passing meal trays.” The Director of Nursing responded that the CNA “should wash hands.” Finally, the state investigator asked the Director of Nursing “if staff should blow on food before feeding a resident.” The Director responded, “No.”

Our Hendersonville nursing home neglect attorneys recognize that failing to follow procedures and protocols to prevent the spread of infection throughout the facility could place the health and well-being of all residents in jeopardy. The deficient practice by the nursing staff that NHC Healthcare – Hendersonville might be considered negligence or mistreatment because their actions failed to follow the facility’s policies including the policy titled: Transmission-based Procedures Policy and the Glove Use policy that both read in part:

“Gloves and Handwashing: remove gloves before leaving the room and wash hands immediately with an antimicrobial agent. Patient Care Equipment: if equipment must be used among patients, then they must be adequately cleaned and disinfected before another patient use.”

“There should be no bare hand contact with ready to eat foods.”

NHC PLACE AT COOL SPRINGS
211 Cool Springs Blvd
Franklin, Tennessee 37067
(615) 778-6800

A “For-Profit” 180-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 Policies That Permit Mistreatment, Neglect or Abuse of Residents Involved in Inappropriate Sexual Behavior/Possible Sexual Abuse

In a summary statement of deficiencies dated 08/14/2015, a complaint investigation was opened against the facility for its failure to “assess and implement appropriate interventions and services to protect all cognitively impaired vulnerable residents residing in the Courtyard (secured memory unit) from potential abuse / neglect situations involving inappropriate sexual behaviors when on repeated occasions [one resident at the facility] demonstrated inappropriate sexual comments and actions directed at staff and residents.”

The complaint investigation was initiated by state inspector/surveyor’s noted that the “facility transferred a resident residing in the facility, who exhibited inappropriate sexual behaviors (comments and gestures) to the Courtyard Unit (a secured memory unit that housed 26 vulnerable residents).” The complaint investigation also noted that “this transfer created the potential for the 26 residents residing in that secured unit to be at risk for harm from abuse of a sexually inappropriate nature.”

The investigator noted that their findings “resulted in Immediate Jeopardy, (a situation in which the facility’s noncompliance has caused or is likely to cause serious harm, injury, impairment or death to the resident).” The investigator also noted that the immediate Jeopardy “resulted in a substandard quality of care” provided to the residents at NHC Place at Cool Springs.

The incident involved in the complaint investigation was documented in the 03/18/2015 Investigation Report revealing that “on 02/11/2015 at 7:00 PM, a male resident was escorted from a central bath back into his room by a nurse. After the resident was escorted to his room, the nurse went back to the central bath to retrieve the resident’s wheelchair that had been left behind. Upon entering the central bath, the nurse discovered a female resident on the floor of the central bathing area with her Depends and pants to her shins lying in front of the toilet.” At that time, the female resident “was assessed by the nurse and found to have no injuries. The physician, family local authorities were notified of the occurrence.”

The state investigator reviewed the facility’s 02/12/2015 Staff Drawing to determine the resident’s “position when found in the central bathroom, show the resident lying sideways in front of the toilet, her head facing the door. The drawing also showed a pair of eyeglasses on the floor in the corner of the bathroom to the right of the toilet. The glasses were identified to be worn by [another resident at the facility].”

“The investigation report also revealed a series of resident observations on the staff interviews and additional record reviews were implemented on 02/12/2015, to evaluate [the male resident’s] behaviors and to determine if a sexually inappropriate incident had occurred in central bathroom.”

The investigator reviewed the male resident’s Admission MDS (Minimum Data Set) Assessment revealing that the “resident’s function capabilities and identification of health problems dated 02/09/2015 revealed [that the male resident] had a Brief Interview for Mental Status (BIMS) score of 15, which indicated independent cognitive skills for daily decision-making.” In addition, the document noted that the “resident had unrestricted ability to express ideas and wants along with understanding and interpreting verbal communication […and] utilized a walker or self-propelled in a wheelchair and was coded to need limited assistance of one staff member as needed to move between locations in his room and adjacent corridors in the same unit.”

As a part of the investigation into the complaint involved a document dated 02/08/2015 it documented the resident “repeatedly made sexual comments toward staff and asked the nurse to sit on his lap so he could scratch her back which was immediately reported to the nurses. The nurse reminded the resident about being inappropriate. Later the resident told the tech (technician) he wanted to lick her and all of her friends all over. The resident was again reminded by the nurse about inappropriate comments.”

The facility’s 02/08/2015 Nurses Notes revealed that the male resident “asked the nurse if she wanted to get into bed with him and exercise. The resident was once again reminded of the inappropriate behavior and instructed to call for help when getting out of bed or getting back into bed. The resident took apart all alarms in place used to notify staff of his rising.”

The facility conducted a family orientation meeting at 10:00 AM on 02/09/2015 where family members “reported past occurrences of the resident displaying some socially/sexually inappropriate behaviors that may carry over to his present environment. During the meeting, the Social Worker obtain consent from the family for the resident to receive psychiatric services. There is also discussion regarding the resident be transferred to the Courtyard Memory Care Unit.”

A notation was made in the 02/12/2015 Discharge Note indicating that the male resident “was transferred to a Psychiatric Unit that day for evaluation related to inappropriate sexual behavior directed toward facility residents and staff […and the] resident did not return to the facility.” However, the resident had been at the facility for nine days.

The state investigator conducted an interview with Administrative staff members who were asked why the male resident “was not sent out for a psychiatric evaluation when he first exhibited sexually inappropriate behaviors on 02/07/2015. Also, they were asked why the decision was made to transfer [the male resident] to the Courtyard Memory Unit on 02/11/2015.”

A member of the administrative staff responded that the “resident was transferred to the Courtyard related to his elopement risk.” However, the investigator noted that “no answer was given regarding why [the male resident] was not sent out for a psychiatric evaluation when the sexually inappropriate sexual behaviors were first reported by the nursing staff on 02/07/2015,” or four days before the female resident was found in front of the toilet and the men’s bathroom at the facility.

Our Franklin nursing home sexual abuse attorneys recognize failing to follow procedures and protocols to thoroughly investigate and take appropriate actions involving residents a resident sexual abuse could place the health and well-being of all residents in jeopardy. The deficient practices of the nursing staff and administrators at NHC Place at Cool Springs might be considered abuse or mistreatment because their actions failed to follow the facility’s 05/01/2010 policy titled: Resident Protection a Response for Allegations/Incidences of Abuse, Neglect and Misappropriation of Property that reads in part:

“[Sexual abuse is defined] to include, but not limited to, sexual harassment, sexual coercion or sexual assault. Any alleged acts of sexual abuse will be investigated and dealt with to ensure resident safety and freedom from the risk of abuse or neglect.”

HILLCREST HEALTHCARE CENTER
111 E Pemberton Street
Ashland City, Tennessee 37015
(615) 792-9154

A “For-Profit” 95-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Ensure That All Residents Remain Free from Physical Restraints Unless Needed and Authorized for Medical Treatment

In a summary statement of deficiencies dated 06/11/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure the resident was assessed by staff for the use of the least restrictive restraint possible to ensure the resident safety and [a facility failure] to release the restraint during a meal.” This deficient practice by the nursing staff at Hillcrest Healthcare Center affected one resident at the facility.

The deficient practice was noted by state surveyor after a review of a resident’s Admission MDS (Minimum Data Set) documenting that the resident “required the extensive assistance of one staff for dressing and eating. Staff did not document the resident’s cognitive condition. Staff did not code the resident for the use of a restraint.”

Additionally, the state investigator also reviewed the resident’s Quarterly MDS (Minimum Data Set) that reveal that the resident “had short and long-term memory problems. The staff [again] did not code the resident for using a restraint.”

The investigator reviewed the resident’s 10/19/2014 (revised 10/21/2014) Care Plan for Falls that “directed staff on the use of self-release seatbelt with an alarm to the resident’s chair. The resident also had a bed alarm beginning 11/18/2014, and a door alarm by the bathroom door beginning 11/18/2014.” However, again, “the Care Plan did not direct staff on the reason for the seatbelt or have any further interventions related to the restraint use.”

A review was conducted of the resident’s 06/11/2015 Medical Record that “reveal the lack of documentation related to any attempts to reduce the use of restraint since initiated [back in] December 2014.

The state investigator noted that the staff documented on 05/20/2015 on the facility’s Body Alarm and Special Order Log that “the resident was able to self-release the seatbelt; however, observations on 06/10/2015 revealed the resident was not able to self-release the seat belt.” That same day on 06/10/2015 at 3:15 PM, a member of the licensed nursing staff was observed “in the hall with the resident who sat in a wheelchair with a seat belt. The resident was not able to demonstrate removal of the seat belt.”

The state investigator conducted an interview at that time with the License Nurse who acknowledged that the resident “was not able to remove the seat belt when she prompted the resident to do so; however, the resident was probably tired.”

Later that same day at 5:36 PM, an interview was conducted with the facility’s Direct Care Staff who reported: “the resident did not often attempt to transfer independently and was able to get up from the wheelchair alone when the seatbelt was not fastened to keep the resident in the chair.”

The following day, the date investigator conducted a 9:20 AM 06/11/2015 interview with the Licensed Nurse who had provided the resident care. The Licensed Nurse “reported staff did not consider the belt on the wheelchair as a restraint because the resident could release the belt, so a restraint assessment was not completed.”

In addition, the investigator noted that “a reduction in the use of the seatbelt was not attempted as indicated on the Body Alarm and Special Order catalog because staff documented the resident could release the seatbelt.”

However, the investigator noted that the Licensed Nurse “acknowledged staff failed to assess the resident to determine the most restrictive restraint device that was appropriate for the resident to prevent [her] from falling out of the wheelchair […and] did not provide a recent therapy evaluation for other safety devices or interventions to prevent falls.” The investigator documented that the “staff needed to also release the seatbelt for meals and acknowledged the Care Plan was not developed to address the use of the seat belt.” As a result, the state investigator concluded that “the facility failed to ensure [the resident’s] environment was free of the use of an unwarranted restraint.”

Our Ashland City nursing home neglect attorneys recognize that failing to follow procedures and protocols when using restraints violates federal and state nursing home regulations. The deficient practice by the nursing staff at Hillcrest Healthcare Center might be seen as abuse or mistreatment because their actions failed to follow the facility’s 03/02/2012 policy titled: Restraint Policy that reads in part:

“The facility would assess, implement and evaluate a Plan of Care to decrease or eliminate entirely the use of restraint for a resident.”

Getting the Justice Your Loved One Deserves

Abuse and neglect against the elderly take many forms. In many cases, family members want vindication to hold those legally accountable for the harm they’ve caused a vulnerable loved one who could not stand up for themselves.

The vast majority of cases of abuse against the elderly involve physical argumentation, sexual assault, emotional trauma and financial exploitation. Unfortunately, many cases of mistreatment go unreported for various reasons. In some cases, the resident no longer has the capacity to communicate what is going on due to their medical or mental condition. Other times, the resident is simply too scared to speak out in fear of retaliation or reprisal by the perpetrator.

Family members are often unaware of the ten most common indicators that a loved one is being abused or neglected. These include:

  • Unexplained bruising
  • Medication errors including not following physician’s orders
  • Hazardous conditions and/or a lack of supervision that leads to a fall with injuries
  • Unexpected weight loss
  • The staff or employees refusing to allow the resident access to normal activities or visitors
  • Unexpected changing behaviors including biting, rocking or sucking
  • Facility-acquired bedsores that get worse due to a lack of proper treatment
  • Financial exploitation through theft of the resident process personal belongings were funds
  • Starvation and dehydration
  • Unnecessary sedation (chemical restraint) or improper restraint using physical devices including belts without authorization

Tragically, many nursing home residents die from abuse and neglect every year. If your loved one was harmed, injured or has died while under the care of nursing professionals, it is important to seek the legal representation of our compassion personal injury attorneys today.

Holding medical doctors and nursing staff legally accountable not only protects the rights and dignity of the resident that was harmed; but, protect all future residents who might not be aware of the unacceptable actions and level of care provided by the facility. Having an attorney on your side is typically the best solution to ensure that your loved one receives the financial compensation they deserve.

Hiring an Attorney

The Nashville nursing home abuse attorneys at Nursing Home Law Center LLC have assisted many families in navigating the legal system to file a complaint and claim against a nursing facility. Our Tennessee elder abuse law office fights aggressively to ensure that the injuries of our clients are immediately addressed and take fast legal action to stop the abuse now.

If your elder, disabled or rehabilitating loved one has suffered injury through negligence or abuse of another, contact our law office today at (800) 926-7565. Our Tennessee elder abuse law firm handles cases on a contingency fee arrangement. This agreement provides immediate legal services without the need for an upfront fee. All information discussed with our law offices remains confidential.

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.

Client Reviews
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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