Tucson Arizona Nursing Home Abuse Attorneys

Tucson Nursing Home Abuse AttorneyEntrusting the care of a loved one in the hands of medical personnel in a nursing facility is never an easy decision. Often times, the assurances that family members are given by the administrator or an admissions team at the nursing home regarding the level of care the facility will provide is misleading. In many incidences, the elder, infirm or disabled individual suffer serious harm before the family is ever made aware that a problem exists. The Tucson nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC have seen a significant rise in the number of civil cases filed against nursing staff and nursing home administrators involving incidences of mistreatment, abuse and neglect.

Approximately one million residents live within the borders of Pima County, of which more than 160,000 are senior citizens 65 years and older. The number of elderly citizens in the county is almost equal to the number of retirees living in Phoenix (Arizona’s largest city with four times the number of residents overall).

Pima County Nursing Home Health Concerns

Our Pima County based legal team of accomplished attorneys remains devoted to serving as legal advocates for nursing home residents to expose abuse and neglect while holding perpetrators financially accountable. We strive to protect the rights of all residents to ensure the conditions are improved so others are not harmed by unacceptable actions of the nursing staff and administrator in the future. Our Tucson elder abuse lawyers conduct thorough investigations and gather evidence to build compelling successful cases that are resolved through trial verdicts and out-of-court settlements.

It is through genuine care that our proven Arizona legal team cares what happens to nursing residents all throughout the state. To help, we continuously review health concerns, filed complaints and opened investigations involving nursing facilities statewide. We publish this publicly available information gathered through national databases including Medicare.gov in an effort to assist families who are facing the unwanted decision of placing a loved one in the hands of professional caregivers.

Comparing Tucson Area Nursing Facilities

The list below outlines nursing facilities throughout the Tucson area that currently maintains below average rating. In addition, our Pima County elder abuse lawyers have posted their primary concerns detailing hazardous conditions, acts of abuse and patterns of neglect involving nursing staff and residents.

VILLA MARIA CARE CENTER
4310 East Grant Road
Tucson, Arizona 85712
(520) 323-9351

A “For-Profit” 83-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Make Sure That Residents Are Safe from Serious Medication Administration Errors

In a summary statement of deficiencies dated 07/23/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure that to residents were free of significant medication errors.”

The deficient practice was noted after a review of a resident’s 06/02/2015 Nursing Progress Notes revealing of the resident had a serious change in condition at 4:05 AM “which lasted approximately 30 seconds.” The note included that “vital signs were stable and will continue to assess and monitor.”

The state surveyor conducted a review of the resident’s 05/27/2015 Physician Order Sheet (POS) and June 2015 MAR (Medication Administration Record) indicating that the resident was to receive a specific medication on Tuesday, Thursday and Saturday. The MAR of June 2015 indicated that the resident had not received the medication.

Clinical record reviews at the facility “did not reveal any documentation for June and July 2015, that the physician was notified that the resident did not receive their medication on the morning when the resident was [sent to the hospital], nor were there any orders to hold the [resident’s medication]. There was also no documentation of any [diagnostic result] that was done from admission through 07/11/2015.

The state surveyor conducted a 07/11/2015 review of the facility’s Nursing Progress Note noting that the resident had been “taken by ambulance to the emergency room (ER].”

According to the 07/11/2015 Hospital emergency room documentation the resident was having medical treatment at 5 o’clock in the morning and “was dialyzed until about 7 AM, when she “became unresponsive.”

The hospital documentation included that the resident’s “medication blood level was found to be sub-therapeutic and she was given [specific] medication intravenously and was then discharged back to the facility.

The state surveyor conducted a 07/23/2015 12:30 PM interview with the facility’s Licensed Practical Nurse “if it was important to notify the physician when medication was not administered three times a day as ordered because the resident was out of the building [at the hospital receiving medical treatment], and replied ‘No I do not think it is important.”

The state surveyor then conducted a 07/23/2015 1:00 PM interview with the Facility’s Director of Nursing “who confirmed that per policy, if the medication is held, the physician is notified and must order the hold.

The state surveyor conducted a 07/22/2015 8:40 AM interview what the facility’s registered nurse who stated “she missed those doses.”

The Director of Nursing revealed in a 07/22/2015 interview with the state surveyor “that you would expect the nurse to give the correct amount of medication and that the nurse is responsible to ensure the right medication, the right dose, right resident, right time, and the right route are followed.”

Our Tucson nursing home neglect attorneys recognize that failing to follow protocols and administering physician ordered medicine could cause direct harm and potential death to the resident. The failure of the facility to follow established policies might be considered negligence or mistreatment, especially the facility’s policy title Medication Administration that reads in part:

“Medications must be administered in accordance with the orders, including any required timeframe. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time in the right method (route) of administering before giving the medications.”

SANTA ROSA CARE CENTER
1650 North Santa Rosa Avenue
Tucson, Arizona 85712
(520) 795-1610

A “For-Profit” 144-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Report and Investigate Any Act or Report of Abuse, Neglect, Mistreatment or Financial Exploitation of Residents

In a summary statement of deficiencies dated 06/05/2015, a complaint investigation against the facility was opened for its failure to “ensure that allegation of misappropriation of resident property involving [a resident] was reported to the State Agency.”

The deficient practice was noted after the state surveyor conducted a review of facility documentation, clinical records and interviews. This includes a 05/19/2015 investigative documentation from Santa Rosa Care Center of a resident reporting “to the unit manager that money had been stolen out of her wheelchair the night before. Although the facility conducted an investigation regarding the missing money, the allegation of the misappropriation of resident property had not been reported to the State Agency.”

The state surveyor conducted a 06/01/2015 interview with the resident who “reported that approximately two weeks ago, she had $60 stolen from her wheelchair. According to the resident, she put the $60 in the side pocket of her wheelchair instead of her locked drawer in her room, and the next morning, the money was missing. Per the resident, she reported the missing money to the unit manager, but the money had not been found.”

The state surveyor immediately conducted another interview with the Unit Manager “confirm that the resident had reported the missing money to her […and] confirm that the resident’s allegations had not been reported to the State Agency.”

The facility’s Director of Nursing was interviewed by the state surveyor on 06/02/2015 “confirm that the resident had reported an allegation that money had been stolen [… but] the allegation was not reported…”

Our Tucson elder abuse attorneys recognize that the facility failed to follow their own policy titled: Abuse Prevention Program that reads in part:

“Our residents have the right to feel free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion.”

… and that the Abuse Prevention Program provides at a minimum… The reporting and filing of accurate documents role to incidences of abuse.

THE HEALTH CARE CENTER – FORUM TUCSON
2500 North Rosemont Boulevard
Tucson, Arizona 85712
(520) 795-7892

A “For-Profit” 67-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 Report of Abuse, Neglect or Mistreatment of Residents

In a summary statement of deficiencies dated 04/15/2015, a complaint investigation was opened against the facility for its failure to “complete a thorough investigation regarding an allegation of staff to resident abuse and [a failure] to submit the results of an investigation regarding missing narcotics for [5 residents] to the state survey and certification agency.”

The complaint investigation was initiated in part after the state investigator review the facility’s 12/10/2014 Reportable Event Record/Report documenting that on the evening of 12/09/2014, the resident’s “daughter came to the charge nurse and said her mother told her that someone hit her crossed her legs last night.” The allegedly injured resident “was interviewed and does not recall any information to support that she made that statement.” However, the Certified Nursing Assistant in charge of providing her care was “suspended pending investigation. Allegation found to be unsubstantiated.”

The state investigator reviewed 12/09/2014 and 12/10/2014 Investigatory Interview Forms revealing that even though the facility interviewed the resident, the alleged perpetrator and the Certified Nursing Assistant along with the resident’s daughter “regarding the allegation. There was no evidence that other residents were interviewed regarding the allegation.”

The state investigator conducted on 04/14/2015 interview with the facility’s Director of Nursing who stated “that if an allegation of abuse is received by the facility that Social Services would interview random residents regarding treatment by staff members.” The state investigator asked “if random residents were interviewed regarding the allegation of abuse.” The Director of Nursing indicated that “if it was not documented, it was not done.” The state surveyor also conducted in 04/15/2015 interview with the facility Administrator who stated “that other resident should have actually been interviewed during the facilities abuse investigation.”

Our Tucson nursing home abuse lawyers recognize that any failure to follow protocols to report an allegation of abuse to the state agency could cause additional harm to the resident. The failure the facility might be considered neglect, mistreatment or abuse.

AVALON SOUTHWEST HEALTH & REHABILITATION Center
2900 East Milber Street
Tucson, Arizona 85714
(520) 294-0005

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 Report or Investigate Any Act or Report of Abuse, Neglect or Mistreatment of the Facility’s Residence

In a summary statement of deficiencies dated 06/09/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “ensure that final investigative reports were submitted to the State Agency for four residents [at the facility and a failure] to initially report an abuse regarding [one resident at the facility].”

The deficient practice was noted after the state surveyor reviewed the State Agency Intake form revealing a case of “resident to resident abuse was received from the facility on 02/02/2015. The facility reported that [a resident] was witnessed grabbing and pulling the hair of [another resident] while yelling at her. The incident occurred on 02/01/2015 at 9:15 AM. The residents were immediately separated and placed on 15 minute checks… However, no facility report was received as of 02/12/2015.”

The Director of Nursing of the facility provided the state investigator 02/01/2015 Incident Reports that indicated that “both residents revealed that a message was left for the state agency regarding the incidence.” However, the state surveyor requested to see the facility’s Final Investigative Report. The Director of Nursing stated “they were still reviewing their papers to locate the information… [And by 06/04/2015 at 12:15 PM the Director of Nursing] stated she could not locate the Final Investigative Report on the incident involving [both residents].”

The Director of Nursing also indicated that the “Administrator would be responsible to write the five day investigative report and fax this to the State Agency.”

Our Tucson elder neglect attorneys recognize that any failure to report an allegation of resident to resident abuse to the state agency might be considered mistreatment or neglect and cause resident’s additional harm. The facility also failed to follow their own policies including the March 2004 policy titled Abuse – Allegation and Reporting that reads in part:

“The administrator or his/her designee will complete the investigation within five working days… The results of all internal investigations must be reported to the Administrator or his/her designated representative and to other officials in accordance with state law… Within five working days of the incident.

The results of the investigation and the complaint number will be sent to the State Health Department… This information will also be kept in the investigation file.”
FOOTHILLS REHABILITATION CENTER
2250 North Craycroft Road
Tucson, Arizona 85712
(520) 733-8700

A “For-Profit” 149-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Provide Care and Services to Residents to Ensure Each Resident Maintains or Builds Their Dignity and Respect of Individuality

In a summary statement of deficiencies dated 10/21/2015, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “promote care for five residents [at the facility] in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality, by failing to answer the resident’s call lights in a timely manner.”

The deficient practice was noted after the state investigator reviewed a resident’s admission MDS (Minimum Data Set) revealing the resident had a Brief Interview for Mental Status (BIMS) “score of 14 on a scale of 0 to 15.” A score of 13 through 15 indicate that “the resident was cognitively intact.”

The state investigator conducted a 10/06/2014 12:22 PM interview with the resident who stated “that the staff sometimes took 1 to 2 hours to respond to his call light.” On 10/09/2014 at 10:55 AM, an additional interview was conducted with the resident who stated “that one time he had to wait for over an hour for a staff member to answer his call light. He also stated that he had to turn on his call light because he was thirsty and was out of water […and] that he felt dehydrated and his lips and mouth were dry as he waited for the staff to respond was calling.”

In a separate incident, the state surveyor reviewed another resident’s MDS (Minimum Data Set) and Brief Interview for Mental Status (BIMS) revealing the resident scored “15 on a scale of 0 to 15” indicating she was “cognitively intact.”

That resident revealed that “she had to wait for one hour for staff to answer call light […and] that she had turned her call light on because she had soiled yourself and had to sit in her own feces for an hour.”

In a separate incident the state surveyor conducted another interview with a different resident on 10/06/2014 at 12:37 PM with a Brief Interview for Mental Status (BIMS) score of 15 who was cognitively intact.” This resident indicated that it sometimes “took staff 40 minutes to answer the call light […and] that a couple times she had turned on her calling to request an as needed breathing treatment and had to wait 40 minutes. The resident also stated that her anxiety would increase the longer she had to wait to get her breathing treatments.”

The state surveyor conducted a 10/09/2014 11:40 AM interview with the facility’s Certified Nursing Assistant in charge of providing the resident’s care who stated “that she answered call lights as soon as she could, but sometimes if she was busy with one resident others in the area had to wait to have their call lights answered.”

The state surveyor conducted in 10/09/2014 1:00 PM interview at the facility’s Director of nursing who “stated that call light should be answered as possible.” The state surveyor pressed to determine “how long as soon as possible was” the Director of Nursing replied “no more than 15 minutes”.

Our Tucson elder abuse lawyers recognize the failing to follow protocols in providing timely services that meets the needs of residents might be considered neglect or mistreatment. The deficient practice of the facility does not follow their own policy titled Call Lights that reads in part:

“To meet the resident’s requests and needs within an appropriate time period. The policy and procedure also revealed [to] monitor lights and answer promptly.

VILLA CAMPANA REHABILITATION HOSPITAL
6651 East Carondelet Drive
Tucson, Arizona 85710
(520) 731-8500

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

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Report and Investigate an Act of Abuse, Neglect or Mistreatment of Residents

In a summary statement of deficiencies dated 01/15/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure that an allegation of abuse was thoroughly investigated.” This deficient practice involved one resident at the facility.

The deficient practice was noted after the state surveyor conducted a review of a resident’s records including the undated Nursing Admission Assessment that revealed that “the resident was alert, oriented and able to communicate.”

The facility’s 02/26/2014 Nursing Note revealed that “the resident reported that a black man was going into her room at night and threatening her.” In addition, you 02/27/2014 Social Service Note revealed that “the resident was making accusations against staff and the description that the resident gave did not match any staff members. Despite the allegation of abuse, the facility was unable to provide any documentation that a thorough investigation had been completed.”

The state investigator conducted a 01/14/2015 7:45 AM interview with the facility’s Director of Nursing who stated “she was not the Director at the time it was not for me with the allegation of abuse.” Immediately afterwards, the state surveyor conducted an interview with the facility’s Social Service Director who stated “that she was unable to recall if she or the previous [Director of Nursing] conducted an investigation [but that] it was the facility practice for either the [Director of Nursing] or herself conduct investigations of allegations of abuse. she also said that the Administrator keeps records of the investigations.

The state surveyor then conducted a 01/14/2015 interview with the facilities interim Administrator “who had no knowledge of the alleged incident was unable to locate any documented evidence that a complete and thorough investigation had been conducted.”

Our Pima County nursing home abuse attorneys recognize that any failure to follow protocols to report or investigate an active abuse thoroughly could cause additional harm to the resident. The deficient practice of Villa Campana Rehabilitation Hospital does not follow the established procedures and protocols adopted by the facility and violates both state and federal nursing home regulations.

LIFE CARE CENTER OF TUCSON
6211 North La Cholla Boulevard
Tucson, Arizona 85741
(520) 575-0900

A “For-Profit” 162-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Ensure That All Medical Services and Care Provided by the Nursing Facility Meet Professional Standards of Quality

In a summary statement of deficiencies dated 01/30/2015, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “ensure there was a physician’s order for treatment for [a resident at the facility and a failure] to administer a medication as ordered for [another resident].”

The deficient practice was noted after the state surveyor conducted a review of a resident’s November 2014 physician’s orders revealing that the resident was to receive a medication patch “to be applied to the resident’s spine at 10:00 AM and be removed at 6:00 PM daily and for the application of a foam dressing to the resident’s mid back daily with orders to not discontinue.”

The state surveyor then conducted a review of the facility’s December 2014 in January 2015 recapitulation orders revealing that the treatment was included in the orders “however, the order for the foam dressing to the resident’s mid back was not on the recaps.” Further review of the resident’s clinical records did not show that “a physician’s order was written to discontinue the foam dressing.”

The investigation is in response to a review of the resident’s care plan “for the potential for skin breakdown reflected in interventions to minimize pressure over bony prominences, as the resident will allow.”

The state surveyor conducted a 01/29/2015 interview with the facility’s Licensed Practical Nurse and Wound Care Nurse who explained “the foam dressing treatment to the resident’s back was not carried over onto the recap orders or the [MAR (Medication Administration Record) and TAR (Treatment Administration Record)] for December 2014 in January 2015 and that there was no order to discontinue the treatment.”

State surveyor conducted a 01/28/2015 interview with the facility’s Director of Nursing who stated “that the resident should have been administer the [medication] but it was not transcribed into the Medication Administration Record.”

Our Tucson elder abuse lawyers recognize the failing to follow physician’s orders could be detrimental to the health and well-being of the resident. The deficient practice of Life Care Center of Tucson might be considered mistreatment or negligence because it does not follow established procedures and policies adopted by the facility including the policy titled: Physician’s Order/Transcription that reads in part:

“Proper channels of communication are used to ensure accurate delivery of medications and treatments to all residents. This is achieved by using the Order Sheet, Telephone Order Form, Medication Administration Record.”

LA CANADA CARE CENTER
7970 North La Canada Drive
Tucson, Arizona 85704
(520) 797-1191

A “Not for Profit” 128-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Follow Protocols and Providing Treatment to Heal a Resident’s Facility Acquired Pressure Sore

In a summary statement of deficiencies dated 10/17/2014, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “consistently assess and monitor [a resident at the facility with a] pressure ulcer.”

The deficient practice was noted after the state surveyor conducted a review of a resident’s close clinical record revealing that the Initial Data Collection Tool that identify the resident had three open areas on the lower buttocks.” However, “there were no measurements or any other descriptive data noted on this form. The state surveyor then reviewed the resident’s 10/25/2013 Non-Pressure Skin Condition Record documenting that the wound had MASD (Moisture Associated Skin Damage) measuring 2 cm X 3 cm describing the damage as excoriated and denuded.

The state surveyor conducted a review of the resident’s 10/25/2013 Impaired Skin Integrity Care Plan revealing that the “resident was at risk for breakdown due to fragile, dry skin. The goal included the resident’s disruption of skin service will remain free of infection and show evidence of healing. Approaches included to complete weekly skin checks and observe signs and symptoms of infection or delayed healing and report to the physician.” However, the resident’s Care Plan “did not reflect the open areas to the lower buttocks area that were identified upon admission” even though the 10/30/2013 Wound Note revealed “there is an area of excoriation with denuded tissue of the left posterior fold.” However, even that report failed to make any “other documentation related to the wound.”

By 11/22/2013, the resident’s three Weekly Skin Integrity Data Collection sheets (November 1, 8 and 15, 2013) have no descriptive information concerning the resident’s pressure sores. The state investigator then reviewed the resident’s closed clinical records that did not reveal any completed assessments until 11/27/2013 which by then shows a wound that measures 1.0 centimeter by 0.5 centimeter by 0.1 centimeter with “a large amount of drainage. The documentation included the wound had deteriorated. The one bed was described as pale yellow, with new depth.”

By 12/05/2013, the resident’s Pressure Ulcer Record notes that the resident’s bedsore has become unstageable and now measures 2.5 centimeters by 2.0 centimeters by 1.5 centimeters and that “the wound had slough and necrotic tissue present, with a large amount of drainage. The note further included the physician had debrided the wound.” The physician’s Progress Note made on the same day (12/05/2013) “revealed the resident had a stage 3-4 decubitus ulcer to the left ischial tuberosity.”

The state surveyor conducted in 10/17/2014 interview with the facility’s Wound Nurse who stated “that weekly skin checks should identify all areas of the resident’s non-intact skin, even if the resident has wounds that are being followed by the Wound Nurse.” The state surveyor asked to see facility policies on pressure ulcers. However, the facility’s Corporate Nurse indicated that “the facility did not have that policy”.

Our Tucson elder abuse lawyers recognize that any failure to follow procedures and protocols when treating existing bedsores has the potential of causing additional harm or life-threatening injury to the resident. In addition, La Canada failed to follow the established procedures, protocols and policies adopted by their facility. The deficient practice violates both federal and state nursing home regulations.

GOOD SAMARITAN SOCIETY – QUIBURI MISSION
850 South Highway 80
Benson, Arizona 85602
(520) 586-2372

A “Not-For-Profit” 60-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Follow Procedures and Protocols to Prevent Existing Bedsores from Developing or Treating Existing Bedsores to Promote Healing

In a summary statement of deficiencies dated 08/14/2014, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “ensure care and services were provided for [a resident] with a pressure ulcer.”

The deficient practice was noted after a state investigator reviewed a resident’s 07/17/2014 Weekly Wound Documentation that revealed the resident “had an unstageable pressure ulcer to the right inner heel, which measures 1.8 centimeters by 1.0 centimeters with eschar.

The resident’s Health Care Plan addresses “the unstageable pressure ulcer, one of the interventions included to float heels. Clinical record documentation showed that the right heel pressure ulcer continued to be assessed weekly.

By 08/07/2014, the resident’s wound “measured 1.4 centimeters by 0.7 centimeters with black eschar.” The wound was then observed on 08/12/2014 while the resident was in bed. “However, the heels were not being floated. The wound care was provided by license staff. The right heel pressure ulcer measured 1.7 centimeters by 0.9 centimeters and had black eschar.

The state investigator conducted in 08/13/2014 interview with the facility’s Licensed Practical Nurse who stated “that this resident’s heels are never floated in did not know that the resident’s heels were supposed to be floated.”

The state surveyor then conducted in 08/13/2014 interview with the facility’s Director of Nursing who stated “that the pressure ulcer Care Plan is completed by the Staff Development Coordinator after input is received from several staff members […and] that the interventions of the Care Plan are then put into a cardex for Certified Nursing Assistants […and] that she did not know why this was not being done.”

Our Benson nursing home neglect attorneys recognize it any failure to follow protocols and procedures to treat a resident’s existing bedsores could cause a resident additional harm or life-threatening injury. In addition, the deficient practice by the nursing staff at Good Samaritan Society – Quiburi Mission failed to follow the established procedures, protocols and policies adopted by the nursing home, especially the facility’s policy titled: Policy On Pressure Ulcers that reads in part:

“Provide appropriate assessment and intervention of pressure ulcer as well as treatment when necessary. A resident who has a pressure ulcer receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing.”

LIFE CARE CENTER OF SIERRA VISTA
2305 East Wilcox Drive
Sierra Vista, Arizona 85635
(520) 458-1050

A “For-Profit” 152-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Provide a Safe Environment Where Individuals Are Protected from Resident to Resident Abuse

In a summary statement of deficiencies dated 08/04/2015, a complaint investigation against the facility was opened for its failure to “ensure [a resident] was free from abuse from another resident.” This failure directly affected one resident the facility whose MDS (Minimum Data Set) assessment revealed that the resident was “cognitively intact and had no aggression behaviors toward others.”

The complaint investigation was initiated due to an incident documented in the 07/10/2015 7:35 AM Nursing Note revealing that the resident “was not adjusting well to her new roommate. The note included that [the resident] continually expresses discontent with her roommate related to the roommate’s behaviors and continuously yelling out. [The resident] frequently argues with [the] roommate and yells at her to shut up. Both residents need repeated reassurance to calm them down […and both residents] can barely go five minutes without calling out. Residents and surrounding rooms or becoming agitated and upset due to disturbed sleeping pattern related to lack of peace.”

The state surveyor indicates that even though there is ample documentation on the problem, “there were no interventions that were implemented to address the above concerns at this time.”

The state surveyor reviewed the facility’s 07/10/2015 11:00 AM Reportable Event Report that revealed “that a Nursing Assistant heard aggressive yelling coming from the resident’s room. Upon entering the room, the [Nursing Assistant] witnessed [one resident puncturing the other resident’s] clavicle multiple times with the end of a fake flower stem. Another staff member came into the room and escorted [the assaulting resident] out of the room. Later the same day, [the assaulting resident] was discharged to another facility, due to aggressive behaviors.”

The state surveyor conducted a 09/01/2015 3:05 PM interview with the facility Administrator who stated “it is the facility’s policy that all residents should be free from abuse.”

Our Sierra Vista nursing home abuse attorneys recognize that failing to follow procedures and protocols to protect individuals from resident to resident abuse places the resident’s life in jeopardy. The facility’s failure to develop and implement interventions might be considered negligence or mistreatment of the resident who was aggressively punctured with the end of a fake flower stem. The deficient practice by Life Care Center of Sierra Vista does not follow the established policies adopted by the facility especially the policy titled: Abuse Policy and Procedure because they did not intervene and stop the abuse immediately. That policy reads in part:

“The facility does not condone resident abuse or neglect by anyone, including other residents.”

KINDRED NURSING AND REHABILITATION – HACIENDA
660 South Coronado Drive
Sierra Vista, Arizona 85635
(520) 459-4900

A “For-Profit” 100-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Provide Residents a Safe Environment Free of Sexual Assault

In a summary statement of deficiencies dated 07/27/2015, a complaint investigation against the facility was opened for its failure to “protect [a resident] from sexual abuse by [another resident].” The allegedly assaulting resident’s MDS (Minimum Data Set) documents of the resident “was cognitively intact […and] had no speech or communication difficulties and had moderate hearing impairment.”

The complaint investigation was initiated after “the resident was found in a female resident’s room [stating] he was talking to the female resident and gave her a kiss. The resident was redirected away from the female resident’s room.” This event was documented in the 05/19/2015.

A 05/21/2015 Incident Progress Note documents that “the resident was found on the floor in the female resident’s room, with his brief ripped off. Per the note, [the assaulting resident] stated that he had walked over to her room and lost his balance when he stepped on the fall mat.”

The state surveyor reviewed the 05/22/2015 Social Services Note that documents “a discussion had taken place with [the assaulting resident] regarding his inappropriate behavior going into a female resident’s room. The note included that the resident acknowledged that he was not allowed to be in the female’s room.”

The state surveyor conducted a review of the facility’s Abuse Investigative Report that revealed “on 07/01/2015 [the injured resident] reported that [the assaulting resident] had touched her in a sexual manner without consent. The report included [that the assaulting resident] had run his hand up her leg, under her nightgown, up to her brief. The police were called and [the assaulting resident] was sent out to the hospital for a psychological evaluation.”

A 07/21/2015 interview with the [injured resident] revealed that “she was in her room after dinner on July 1, when [the assaulting resident] came into her room and talk to her about moving with him to another facility. She said she told him to leave […and] said she then went to the television allowed for the front hallway nurse’s station and [the assaulting resident] followed her.” At that point, “he began touching her arm and then ran his hand up her leg, under her nightgown up to her brief. She stated that she told him to stop and he left the area […and] she then reported the incident to the staff […and] she said that the incident made her feel violated.”

An interview was conducted with the facility’s Physical Therapy Director who stated that the assaulting resident “had approached her on May 30 and asked about arranging a private room for him and the female resident. The Director stated that [the assaulting resident] said that the room did not need beds as both residents were in wheelchairs, but asked if the cushion could be removed from the female resident’s wheelchair to make it easier for him.” The Physical Therapy Director stated “she told the resident that it was a safety concern and it would have to be discussed with the Executive Director.” The Director indicated that no further contact was made with the resident.”

The state surveyor reviewed the 05/16/2015 Care Plan of the assaulting resident that indicated the resident “had a behavioral problem relating to roaming in and out of residents rooms and touching other residents inappropriately. Interventions included the following: anticipate and meet the resident’s needs; discuss resident’s behavior and explain and reinforce why behavior was inappropriate and/or unacceptable; intervene as needed to protect the rights and safety of others; divert attention; remove from situation and take to alternative location as needed; and minimize potential for resident’s disruptive behaviors of roaming in and out of other residents rooms and touching other residents inappropriately, by offering tasks which divert attention.”

Our Sierra Vista elder sexual abuse attorneys recognize that failing to follow protocols and procedures that protect residents against sexual assault might be considered additional abuse, mistreatment or neglect. In addition, the failure of Kindred Nursing and Rehabilitation – Hacienda does not follow their own establish policies and procedures including the facility’s policy titled: Abuse Prevention that reads in part:

“Resident should be free from abuse, including sexual abuse. The policy included that residents with a personal history that renders them at risk for abusing other residents are identified and that intervention strategies are developed to prevent and/or reduce occurrences, and changes that would trigger abusive behaviors are monitored, and that interventions are reassessed on a regular basis.”

Is Your Loved One Suffering Because of Negligence or Abuse?

Many nursing home residents in Arizona become victims of understaffing, lack of supervision, improper training, outright wrongdoing or other form of abuse and neglect. It may be that your loved one has been abused, mistreated or neglected because the signs and symptoms are not always so obvious, it is difficult to tell. The most common forms of abuse and neglect involve:

  • Facility Acquired Bedsores – Often described as decubitus ulcers, pressure ulcers or pressure sores, bedsores acquired after being admitted to the facility is usually a sign of neglect through malnutrition, dehydration for a failure to assist a resident who requires repositioning or movement due to being bedridden or wheelchair bound.
  • Falling Accidents – Nursing facilities are required to assess every resident for the potential risk of falling at the facility. Many of the most serious accidents that occur in nursing facilities are the result of falling due to a hazardous environment, slippery surface or lack of assistance when required.
  • Lack of Medical Attention – Failing to follow physician’s orders, provide adequate treatment or medication mistakes often lead to preventable serious injuries or death of the resident.

Hiring a Lawyer

If you recognize the signs or symptoms of neglect or suspect your loved one is suffering mistreatment or abuse while residing in any Arizona nursing facility, The Tucson nursing home abuse attorneys at Rosenfeld Injury Lawyers LLC want to help now. Our accomplished Our Pima County team of skillful attorneys have represented many clients within the community.

We urge you to call our Arizona elder abuse law office at (888) 424-5757 today to schedule your appointment. Speak with one of our reputable attorneys through a no obligation case review to determine the merits of your claim.

For additional information on Arizona laws and information on nursing homes look here.

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
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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