Independence Missouri Nursing Home Abuse Lawyer

Independence Nursing Home Abuse AttorneysMoving a loved one into a nursing facility is never an easy choice when families are no longer able to provide their loved one the care they require. The families trust that they made the right decision in placing their spouse, parent, grandparent in a safe environment in a facility provides a safe environment with loving and compassionate care. However, the Independence nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC have handled many nursing home neglect and abuse cases involving society’s most vulnerable citizens.

Many nursing homes cut corners to stay in business by operating with minimal staff, improperly trained nurses or hiring employees who are not qualified to provide acceptable standards of care. In many incidences, the residents who are being treated poorly are too afraid to speak up in fear retaliation or are incapable of communicating at all due to their health challenges.

The number of cases involving abuse and neglect in nursing facilities is on the rise in Jackson County. Of the more than 685,000 residents in the county, approximately 92,000 are senior citizens. This number has risen significantly in the last five years. However, the number of nursing homes throughout the community has remained stable. This places an increased demand on a limited number of beds available for senior citizens who require the highest level of care. Overcrowded conditions usually result in poor standards of care, cases of neglect and abuse that lead to preventable injuries and death.

Independence Nursing Home Resident Health Concerns

Our Missouri elder abuse attorneys work aggressively to ensure that elderly parents, grandparents and spouses receive the highest level of care available. We serve as advocates for every nursing home resident throughout the state who require legal assistance in stopping the abuse and holding those responsible for the harm legally and financially accountable.

In addition, we continuously update our findings of filed complaints, safety hazards, opened investigations and health concerns occurring in nursing facilities all throughout Missouri. We gather this information from various public available resources including Medicare.gov. Many families use this information as a valuable tool before placing a loved one in a nursing facility who requires the best health care, medical treatment and hygiene assistance.

Comparing Independence Area Nursing Facilities

The list below was compiled by our Jackson County nursing home attorneys outlining Independence area nursing facilities that currently maintain substandard ratings compared with other nursing homes throughout the United States. In addition, we have published our primary concerns that details specific cases where residents in nursing facilities throughout the Independence community have suffered harm, injury or death through negligence, mistreatment or abuse.

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ROSEWOOD HEALTH AND REHABILITATION CENTER
1415 West White Oak
Independence, Missouri 64050
(816) 254-3500

A “For-Profit” 300-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Develop, Implement and Enforce Policies to Prevent Abuse, Neglect or Mistreatment of Residents

In a summary statement of deficiencies dated 08/07/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “complete an incident report and conduct an investigation regarding a resident to resident altercation for [a resident] at the facility.”

The deficient practice was noted by state investigator after reviewing a resident’s Facility Face Sheet that showed that the resident was admitted to the facility with dementia with behavioral disturbance (loss of thinking, remembering and reasoning so severe that it interferes with the individual daily function and may cause changes in personality, mood and behaviors).”

In addition, the Face Sheet revealed that the resident suffers from anxiety and “an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks.”

The investigator also reviewed the resident’s 04/12/2015 Quarterly MDS (Minimum Data Set) that reveals of the resident “was sometimes able to make [themselves] understood and sometimes was able to understand others; had severe cognitive impairment with short-term and long-term memory problems; had disorganized thinking and impairment when making daily decisions; and wandered around the unit.”

The resident’s 02/26/2015 Care Plan indicated that “the resident wandered into unsafe/inappropriate areas; the intervention was for the staff to redirect the resident to a safe location, using a calm approach; no documentation of any updates developed after a resident to resident altercation [occurred] on 07/12/2015 at 8:30 PM.”

A review of the resident’s 8:45 PM 07/12/2015 Nurses Progress Notes revealed that a Certified Nursing Assistant “notify the nursing staff that the resident had been wandering the unit and went into another resident’s room.” At that time, [the other resident was upset that [the wandering resident was in their room].” As a result, staff members redirected the resident “to come out of the other resident’s room.” That is when the other resident hit the wandering resident’s “left hand on the thumb side of [their] cane.”

As a result of the altercation, the wandering resident was seen with a “furrowing of the brow (facial sign of pain or discomfort) when [their] left hand was touched by a staff member.” When the nursing staff assessed the resident’s left hand, the resident winced “during passive and active range of motion of [their] hand.” To provide treatment, the nursing staff applied ice to the hand and notify the House Supervisor, the resident’s doctor and their spouse.”

However, the state investigator noted that the “resident’s medical record found no further documentation related to the resident to resident altercation and no documentation to determine the root cause of the incident.”

The investigator conducted a 12:15 PM 08/06/2015 interview with the facility’s Licensed Practical Nurse who verified that “an incident report should be completed with any [any incident involving a] resident fall, bruising or skin tears and resident to resident altercation.” The Licensed Practical Nurse also indicated that “incident reports are completed by the Licensed Practical Nurse or Supervisor and then report is sent to the Assistant Director of Nursing for review and then passed on to the Director of Nursing, and [that] the resident incidents are reviewed and discussed during the facility morning meetings in which starts the investigation process.”

30 minutes later 12:45 PM, the investigator conducted an interview and record review with the facility’s Director of Nursing who verified that they “were unable to locate any witness statements, incident reports or investigation dated for 07/12/2015, related to the resident’s altercation with another resident.” The Director of Nursing also verified that the nursing staff is responsible for completing and documenting an incident report and that the Director would expect staff members to complete the incident report of any resident to resident altercation.”

Our Independence nursing home neglect attorneys recognize that failing to develop, implement and enforce policies that prevent abuse, neglect or mistreatment of residents could place the health and well-being of every resident in Immediate Jeopardy. The deficient practice by the administration and nursing staff at Rosewood Health and Rehabilitation Center might be considered negligence or mistreatment because their actions fail to follow the facility’s updated October 2012 policy title: Abuse and Neglect Policy and Procedure that reads in part:

“All accidents are incidences where there is an injury or potential to result in injury, unexplained bruise or abrasion, allegations of theft, abuse, neglect or misappropriation of funds will be reported to the accident/incident report and/or the resident protection report.

These reports are initiated immediately by the Charge Nurse, House Supervisor, Nursing Administrator or Administrator and are then reviewed by the Administrator, Nursing Administration and Social Services by the next working day to monitor for multiple occurrences, patterns and/or trends that may constitute abuse and determine the direction of the investigation.”

INDEPENDENCE MANOR CARE CENTER
1600 South Kings Highway
Independence, Missouri 64055
(816) 833-4777

A “For-Profit” 99-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Follow Acceptable Procedures When Transferring Residents Between Beds and Wheelchairs to Minimize the Potential of an Avoidable Accident or Injury

In a summary statement of deficiencies dated 10/26/2015, a complaint investigation was opened against the facility for its failure to “use the appropriate transfer method to ensure the resident was transferred safely.” The deficient practice by the nursing staff at Independence Manor Care Center affected three residents at the facility.

The complaint investigation involved a review of a resident’s Face Sheet that show the resident was admitted to the facility with osteoporosis and hypertension. A review of the resident’s 06/01/2015 Care Plan revealed that the “resident required assistance of one staff person with a gait belt to transfer; staff were to remind the residents to ask for assistance for all transfer; staff were to monitor for a change of condition that may warrant increased staff supervision and assistance and notify the resident’s physician as needed.”

The investigator also reviewed the resident’s 06/14/2015 Admission MDS (Minimum Data Set) that shows that the resident “was moderately cognitively impaired; required extensive staff assistance for transfers, dressing, toileting and personal hygiene […and] required limited staff assistance for locomotion.”

The investigator made a 10:30 AM 10/21/2015 observation of the resident who was “sitting in [their] wheelchair in [their] room.” At the time of the observation, “the resident was in contact isolation precautions” which are guidelines used to reduce the potential risk of spreading infection throughout the facility.

During the observation, two Certified Nursing Assistants placed themselves on either side of the resident while facing the resident. At that point, each Certified Nursing Assistant “hooked one arm under the resident’s arm and with their other hand, grabbed the resident’s pants waistband […and] then lifted the resident from the wheelchair to pivot the resident to the bedside.”

At that time, the resident did not bear any weight on their lower extremities nor did they place their feet completely on the floor during the transfer process. However, the observer noted that both Certified Nursing Assistants “did not use a gait belt (a canvas belt use to assist for transfers] for this transfer” as directed by the resident’s Care Plan.

The state investigator conducted a 10:35 AM 10/21/2015 with both Certified Nursing Assistants who informed the surveyor that “the resident did not bear weight and they did all the lifting during the transfer […and] the resident had not been bearing weight during the transfer since [the resident] got sick a few weeks ago.” The Certified Nursing Assistants also admitted that “they did not notify the nurse or Physical Therapy of the change in the resident’s transferability [of no longer being able to bear] weight during the transfer.”

The Certified Nursing Assistants performing the transfer indicated that they “did not use a gait belt because of the resident was on isolation precautions and they did not want to contaminate their personal gate belts […and] the resident did not have a dedicated gait belt to use for [their] transfers.”

A few minutes later at 10:50 AM, the Physical Therapist was interviewed by the state surveyor and revealed that they were “not notified that the resident was not bearing weight during the transfers.” The Physical Therapist also indicated that the staff “should always use a gait belt to transfer the resident who can bear weight […and] should never use a resident’s clothing to assist with transfer.” The Physical Therapist also verified that the “staff should not pull up on the resident’s arms/shoulders to assist with the transfer […and] if the resident no longer bears weight, the staff to notify the nurse and the nurse will notify the Physical Therapist so the resident could be evaluated for proper transfer technique.”

Our Independence nursing home neglect lawyers recognize that failing to use appropriate methods and techniques when transferring residents between the bed and wheelchair could cause additional harm or injury. The deficient practice by the nursing staff at independence Manor Care Center that might be considered negligence or mistreatment because their actions fail to follow the facility’s October 2009 policy title: Safe Lifting and Movement of Residents Policy that reads in part:

“The nursing staff, in conjunction with the rehabilitation staff, should assess the individual resident’s needs for transfers on an ongoing basis […and] staff will document the resident’s transferring and lifting needs in the Care Plan.”

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The REHABILITATION CENTER OF INDEPENDENCE
1800 S Swope Drive
Independence, Missouri 64057
(816) 257-2566

A “For-Profit” 130-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Provide Every Resident the Necessary Services and Care to Maintain Their Highest Well-Being

In a summary statement of deficiencies dated 05/26/2015, a complaint investigation against the facility was opened for its failure to “provide an intervention for pain to administer pain medication in a timely manner for one supplemental resident, and respond to a resident’s needs to maintain their highest practical well-being.”

The complaint investigation involved a review of a resident’s medical records that revealed that the resident was receiving narcotic medications used to relieve moderate to severe pain. The physician’s orders indicated that one tablet was to be administered every six hours as needed (PRN) for moderate/severe pain.

An observation of the resident occurring between 4:28 AM and 5:00 AM on 05/20/2015 revealed that at 4:28 AM, “the resident’s call light was on. The laboratory technician who was coming from the resident’s room told the Certified Nursing Assistant the resident requested pain medication.” At that time, the Certified Nursing Assistant “enter the resident’s room, the resident told [the Certified Nursing Assistant that they] needed pain medication.” In response, the Certified Nursing Assistant “turned the call light off.”

One minute later at 4:29 AM, the Certified Nursing Assistant “walked to the nurse’s station but did not see the nurse and went back to the hall without telling the nurse that the resident requested pain medication.” Nine minutes later at 4:38 AM, “the resident walked to the nurse’s station and asked [the Licensed Practical Nurse] for pain medication. The nurse did not offer any type of non-pharmacological intervention.” The LPN then asked the resident for their name and check the MAR (Medication Administration Record). Over the next few minutes, Licensed Practical Nurse attempted to find the keys to the Certified Medication Technician’s medication cart.

At 4:40 PM, the Licensed Practical Nurse told the resident that they “could not find the keys to the medication cart and that [they] would bring the medication to the resident.” Even though the Licensed Practical Nurse located the keys to the medication cart with the assistance of the Corporate Nurse they instead answered a resident distress call from another hall. By 4:52 AM, the resident turned their call light on again and asked the CNA that responded: “if the nurse found the keys to the medication cart.” In response, the Certified Nursing Assistant said that they had not seen the nurse.

“As a 5:00 PM, the resident had not received [their] pain medication and continued to wait in [their] room for response to the request for the medication to relieve [their] pain.”

The state investigator interviewed the resident 11:55 AM two days later on 05/22/2015 where the resident revealed that they had finally gotten their pain medication “but it took a long time to get it.”

Interviewed the facility’s Director of Nursing at 9:50 AM the following morning on 05/23/2015 along with the facility’s Administrator who said: “were going to begin to in-service right away and on responding to call lights, not just turning the call lights off without the needs being met.” In a separate interview with the Director of Nursing at 2:45 PM on 05/26/2015, the Director revealed that they “would expect what has to be performed if at all possible when the call light is turned off […and] if the staff member had to have someone else assist the resident, [they] would expect the staff member to tell the resident […and that they] would expect the resident to have [their] needs met within no more than 10 to 15 minutes.”

The VILLAGES OF JACKSON CREEK
3980 South Jackson Drive
Independence, Missouri 64057
(816) 795-1433

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

Overall Rating – 3 out of 5 possible stars

3 star rating

Primary Concerns –

Failure to Provide Residents Services and Care to Ensure Their Highest Well-Being Is Maintained

In a summary statement of deficiencies dated 12/14/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “offer, provide and/or document non-pharmacological interventions prior to the administration of pain medication for one resident and to assess and monitor pain after a fall for another resident. The deficient practice of the nursing staff at The Villages of Jackson Creek affected two residents at the facility.

The deficient practice was noted by state investigator after a review of a resident’s 11/14/2015 Quarterly MDS (Minimum Data Set) that revealed the resident “was cognitively intact, had no difficulty hearing, [their] speech was clear, was able to make [themselves] understood and was able to understand others.” In addition, the documentation revealed that the resident “required limited physical assistance from one staff member for transfers, dressing, toileting and personal hygiene and had received scheduled pain medicine in the last five days.”

The investigator also reviewed the resident’s 11/30/2015 Care Plan that revealed that the resident “had problems with pain […and] would exhibit relief of pain after administration of ordered medications and alternative comfort measures.” In an effort to help, the “staff was instructed to position [the resident] frequently as needed to promote comfort […and] to administer medications as ordered to monitor for side effects and effectiveness […and] to use supported devices to promote and sustain a comfortable position.” In addition, the staff was also instructed to encourage mobility and physical activity as tolerated […and] to assess and treat pain and discomfort as ordered by the resident’s physician and to notify the physician of pain unrelieved by the order interventions.”

The investigator reviewed the resident’s 12:25 AM 12/04/2015 Post Falls Nursing Assessment Form that revealed that a falling “incident occurred on 12/04/2015 at 12:25 AM […and] the resident complained of some back pain [… with a] pain intensity of two [on a pain scale between 1 and 10].”

“The Post Falls Nursing Assessment Form did not show up the staff had offered any non-pharmacological or medication related to the resident’s complaints of pain.”

A review of the resident’s medical records revealed that the last pain evaluation had been completed in December 2015. In addition, the resident’s 11/15/2015 through 12/14/2015 Physician Order Sheets revealed that the physician had ordered a narcotic pain medication patch to be applied every 72 hours. In addition, the resident was to receive two tablets of the pain medication by mouth three times every day PRN (as needed for pain) and additional pain medication was to be given by mouth every six hours as needed for temperature or pain.

However, the state investigator noted that the resident’s MAR (Medication Administration Record) documenting pain administration between 11/15/2015 and 12/14/2015 did not show that any medications for pain were administered after the resident’s fall occurred on 12/04/2015.

The state investigator conducted at 2:45 PM 12/07/2015 interview with the resident who informed the surveyor that they had fallen “about two weeks ago and [that their] back pain had been worse since then […and] had pain in [their] back every day.” In a follow-up interview at 12:15 PM the following day on 12/08/2015 the resident told the surveyor “my back hurts really bad. It’s really bad.”

An interview was conducted at 9:50 AM on 12/14/2015 with the facility’s Registered Nurse who “said when a resident falls, nurses note should be completed every shift for 72 hours after the resident falls to monitor [their] condition after the fall.” The nurse also said that “pain should be assessed after the fall […and] the staff should always ask the resident if [they are] in pain. The resident had not told the nurse that [they were] in pain after [their] fall.”

The investigator interviewed the Director of Nursing later that afternoon at 12:05 PM who “said staff should have assessed the resident’s pain after [their] fall on 12/04/2015 […and] a resident’s pain should be addressed with either non-pharmacological interventions or as needed medications if needed.”

Our Independence nursing home abuse law firm recognizes that failing to provide residents necessary medications and care to minimize their pain could place their health and well-being in jeopardy. The deficient practice by the nursing staff at The Villages of Jackson Creek might be considered negligence or mistreatment because their actions failed to follow physician’s orders that resulted in unnecessary pain experienced by the resident under their care.

MONTEREY PARK REHABILITATION and HEALTH CARE CENTER
4600 Little Blue Parkway
Independence, Missouri 64057
(816) 795-7888

A “For-Profit” 122-certified bed Medicaid/Medicare-participating facility

Overall Rating – 3 out of 5 possible stars

3 star rating

Primary Concerns –

Failure to Ensure That Every Resident Is Provided an Environment Free of Accident Hazards and Provide Adequate Supervision to Prevent an Avoidable Accident from Occurring

In a summary statement of deficiencies dated 01/29/2016, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “transfer a resident in a safe manner using a gait belt (a campus belt use to help staff transfer a weight-bearing resident).” The deficient practice by the nursing staff at Monterey Park Rehabilitation and Health Care Center affected one resident at the facility.

The deficient practice was noted by state surveyor after a review of a resident’s Face Sheet that showed the resident suffered from, Cerebrovascular Disease [where the disease affects the flow circulation to the brain], osteoarthritis [aid degenerative disease that affects the joints and bones], pain, COPD [Chronic Obstructive Pulmonary Disease that increases the lungs ability to perform ventilation], edema [swelling caused by the buildup of abnormally large fluid volume in the body’s circulatory system or between tissue cells], falls, difficulty in walking, urinary tract infection, dementia, glaucoma, asthma, fatigue and hypertension [high blood pressure].”

The investigator also reviewed the resident’s 01/25/2016 Order Summary Report that revealed that the resident was “full weight-bearing” as of 01/14/2016. In addition, the resident’s 11/18/2015 Quarterly MDS (Minimum Data Set) revealed that the resident “had mild impairment in cognition […and] required extensive assistance with a staff member of one for transfer, bed mobility, dressing, toileting and bathing; did not walk; and required supervision with a staff member of one for locomotion on and off the unit.”

The incident in question was documented at 5:30 AM on 11/07/2015 in the resident’s Occurrence Report revealing that the resident “had a witnessed fall in [their room while being] transferred to the toilet by staff using a gait belt when the resident’s feet began to buckle causing the staff to lower the resident to the floor.” The documentation showed that the resident was wearing fitted shoes and “had preventative measures in place at the time of the fall.”

The resident’s Occurrence Report on the following day at 8:15 AM on 11/08/2015 revealed that the resident had another “witnessed fall in [their room while being] transferred to the toilet, and when [the resident] stood up from the toilet [their] legs gave out. The Certified Nursing Assistant lowered the resident to the floor.”

An additional record review of the resident’s Occurrence Report documented a 9:00 AM 12/26/2015 “unwitnessed fall in [the resident’s] room.” At this time, the resident was found lying on their right side and “was sent to the emergency room due to a complaint of right hip pain.” The notations indicate that the resident “had fallen asleep in [their] wheelchair and woke up [while] sliding and then falling out [of the wheelchair.” Notations also show that the resident was wearing TED hoses and slipper socks and had “nighttime toileting needs.” Upon return from the hospital, it was “recommended that [the resident’s] wheelchair be evaluated for safety and [a nonslip mat] place into the seat of the wheelchair.”

An observation of the resident was made at 5:40 AM on 01/26/2016 during a transfer. The observation revealed that the Certified Nursing Assistant (CNA) “had the resident place [their] arms around the CNA, [while the Certified Nursing Assistant Pl. their] arms under the resident’s arms and saying ‘one, two, three’ led to the resident under [their] arms and then transferred [the resident to the] wheelchair without using a gait belt.”

The state surveyor conducted an interview with the Certified Nursing Assistant 10 minutes later at 5:50 AM when the CNA revealed that “the resident usually used a grab bar and was standby assist […and] since the resident’s illness [date] had become a pivot transfer […and] the resident did not need a gait belt as a resident place more weight on [the CNA].”

A subsequent interview was conducted two days later at 8:30 AM on 01/20/2015 with both the Occupational Therapist and Assistant Occupational Therapist. During the interview, it was revealed that “a resident who is extensive assist require 1 to 2 person staff assistance for changes of the environment […and] staff should use a gait belt for all hands on assistance.” In addition, the therapists said that “a gait belt is used for residents who are a fall risk to provide a handle for staff to assist and should the resident lose balance to ensure safety.” The therapist also indicated that “a gait belt should be used even when a resident required only supervision for optimal safety. The therapist noted that this resident “is maximum assist with an assistance of one person using a gait belt.”

Our Independence nursing home neglect attorneys recognize that every resident requiring assistance during transfer should be provided an environment free of accident hazards and provide adequate supervision and equipment to ensure avoidable accidents are prevented. The deficient practice by the nursing staff at Monterey Park Rehabilitation and Health Care Center might be considered negligence or mistreatment because their actions fail to follow the resident’s Care Plan that had been revised after numerous falls had occurred.

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AUTUMN TERRACE HEALTH and rehabilitation Center
6124 Raytown Road
Raytown, Missouri 64133
(816) 358-8222

A “For-Profit” 154-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Follow Procedures and Protocols to Maintain a Rate of Medication Errors to Less Than 5% to Avoid Administering the Wrong Dose, Wrong Drug or at the Wrong Time

In a summary statement of deficiencies dated 10/07/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure their medication pass error rate was less than five percent. There were 10 medication errors out of 41 opportunities for a 21.9% medication error rate, affecting four residents at the facility.”

The deficient practice was noted by state investigator after a review of a resident’s Admission Records showing that the resident was admitted to the facility with Cardiovascular Disease (a thickening of arterial walls), swelling, COPD, a disease that decreases the lungs ability to perform ventilation and hypertension (high blood pressure).

The state investigator also reviewed the resident’s October 2015 physician’s order sheet and MAR (Medication Administration Record) that revealed that the resident was administered six out of their seven medications at the time frame greater than one hour before the scheduled administration time.

The investigator interviewed the facility’s Certified Medication Technician at 9:04 AM on 10/02/2015 who verified that “medication should be administered according to the resident’s physician’s instructions and [that] medication should be administered no earlier than one hour before and no later than one hour after the scheduled administration time.”

During a subsequent interview at 10:55 AM on 10/07/2015 with the facility Director of Nursing, the Director also verified that the medications according to physician’s orders “should not be administered with any other medications, especially not a proton pump inhibitor [taken by the resident, and that the] staff have one hour before and one hour after a scheduled medication administration time to administer [the resident’s] medications.”

Our Raytown nursing home neglect attorneys recognize that failing to follow procedures and protocols to minimize medication errors has the potential of jeopardizing the health and well-being of all residents receiving medication. The deficient practice by the nursing staff at Autumn Terrace Health and Rehabilitation Center might be considered mistreatment or negligence because their actions fail to follow physician’s orders, and failed to follow the facility’s 2015 policy title: Medication Management Program Policy that reads in part:

“Medications are administered no more than one hour before or one hour after the designated medication pass time.”

HIDDEN LAKE CARE CENTER
11400 Hidden Lake Drive
Raytown, Missouri 64133
(816) 737-1010

A “For-Profit” 112-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Ensure That Every Resident Is Provided an Environment Free of Accident Hazards and Provide Adequate Supervision to Prevent an Avoidable Accident from Occurring

In a summary statement of deficiencies dated 11/06/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure they completed a comprehensive fall investigation and updated the resident’s Care Plan to show current fall interventions for [2 residents at the facility].”

The deficient practice was noted by state investigator after a review of a resident’s Admission Face Sheet that revealed that the resident was admitted to the facility with “osteoarthritis involving multiple sites; difficulty walking; and generalized muscle weakness.” In addition, the resident’s 07/09/2015 Admission MDS (Minimum Data Set) reveal that the resident was “severely cognitively impaired […and] required extensive assistance by one staff member for bed mobility, toileting, dressing and personal hygiene.”

The Admission MDS (Minimum Data Set) also revealed that the resident “required extensive assistance by two staff members for transfers, required a wheelchair for mobility […and] was frequently incontinent of bowel and bladder […and] in the areas of falls, had no documentation [that the resident had fallen] on 08/05/2015, 08/07/2015 […and] two falls on 10/05/2015 and a fall on 10/14/2015.”

The state investigator reviewed the resident’s 07/16/2015 Care Plan that showed that the resident “was at risk for falls related to impaired mobility/balance issues and decrease safety awareness, and [their] interventions included: wear properly fitted nonskid shoes; verbal reminders not to ambulate or transfer without assistance; […and] notified the physician of changes in the resident’s condition.” The staff was instructed to “place frequently used items within reach; [use the] assistance of two staff members with the use of a gait belt for transfers.” An addition was made in the resident’s Care Plan involving falls on 08/05/2015 when a non-skid mat to the wheel chair cushion was added as an intervention.

Documentation in the resident’s 08/17/2015 INVESTIGATION revealed that “the resident was found lying on the dining room floor curled into a fetal position. Contributing factors were behavior, neuropathy, antipsychotics and prior fall in the last 30 days.” The documentation also reveals that “the resident was alert with confusion prior to [their] fall.” At the time of the incident “there was no environmental, or footwear/equipment documented as contributing factors.”

The state surveyor notes that the investigation handled by the facility “did not show what the root cause of the resident’s fall was, what interventions staff were going to implement to prevent the resident from sliding out of [their] wheelchair, or monitoring to help prevent the resident from getting up and putting [themselves] onto the floor.”

The investigator also noted that there “were no recommendations documented to prevent further falls (nothing was documented under the section recommendations to prevent further falls), and interventions initiated immediately after the fall including nonskid to [their] wheelchair.” In addition, the facility’s 08/18/2015 Nurse’s Notes “did not address the resident’s fall on 08/17/2015″ nor were there any updates in the resident’s Care Plan “that showed any changes in fall interventions after the resident’s fall on 08/17/2015.”

However, the resident’s 1:00 AM 10/05/2015 Nurse’s Notes revealed that the resident “was yelling out for help [when the] staff found the resident sitting up on the floor mat beside the bed.” At that time, “the resident was unable to explain what happened [however] the resident’s roommate said the resident was sitting up on the side of the bed when [they] went into the bathroom.” However, these notes did not document “the root cause of the fall […and there was] no documentation of any new interventions.”

Our Raytown nursing home neglect law offices recognize that failing to provide adequate supervision and take all necessary precautions to prevent an accidental fall from occurring could place the health and well-being of the resident in Immediate Jeopardy. The deficient practice of the nursing staff at Hidden Lake Care Center might be considered negligence or mistreatment because their actions fail to follow established procedures and protocols enforced by federal and state nursing home regulatory agencies.

EDGEWOOD MANOR NURSING HOME
11900 Jessica Lane
Raytown, Missouri 64138
(816) 358-7858

A “For-Profit” 66-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Ensure That Every Resident with Reduced Range of Motion Receives the Proper Care and Services to Increase Their Range of Motion

In a summary statement of deficiencies dated 10/23/2015, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “ensure restorative services were provided a scheduled to [one resident at the facility] in order to maintain [their] current level of mobility in range of motion.”

The deficient practice was noted by state surveyor reviewed a resident’s October 2015 Physician’s Order Sheet that revealed “physician’s orders to transfer the resident using a sit-to-stand lift (a hydraulic lift used to assist in moving persons with limited mobility from one location to another), for the resident to be out of the bed in [their] wheelchair daily, and to provide assistance bars for transfers and bed mobility. There were no physician’s orders for therapy or rehabilitative services.”

The surveyor also reviewed the resident’s 07/21/2015 Quarterly MDS (Minimum Data Set) that revealed that the resident “was cognitively intact without any behavioral symptoms […and] needed extensive assistance with transfers and transferred with a mechanical lift and used a wheelchair for mobility.”

A review of the resident’s 07/30/2015 Physical Therapy Discharge Summary revealed that “the resident should get out of [their] bed 75% of the time with the use of the mechanical lift, with assistance to increase the resident’s health and skin integrity.” The discharge summary statement also recommended, “the resident to be up in [their] wheelchair no longer than three hours at a time.”

The state surveyor reviewed the resident’s 08/04/2015 Nursing Notes that revealed that “the resident had been discharged from physical therapy on 07/30/2015 and was to continue on the restorative program twice weekly for 90 days.”

The surveyor observed the resident and 8:54 AM on 10/20/2015 and noted that the resident “was alert and oriented and was sitting up in [their] bed watching television.” At that time, the resident said that they “had entered the facility after having back surgery and was there for rehabilitation […and] was initially receiving physical therapy and occupational therapy three times weekly but it had stopped.” The resident told the surveyor that they “did not remember how long it had been since [they had] received therapy services, but it had been a while since anyone was working with [them].”

During the interview the resident also said that they were supposed to continue exercising, lose 30 pounds as a condition to be placed on a liver transplant list […and that they] “usually try to get up in the afternoon and since [they started their] pain regimen, the pain had been controlled very well.”

The investigator then conducted a 12:42 PM interview with the facility’s Physical Therapy Assistant on the same day of 10/20/2015. At the time, the Physical Therapy Assistant said that “the resident had been receiving therapy services since 07/30/2015 and [they] were supposed to start [their] restorative program [four days later] for transfers, to put on and take off [their] back brace and [for] range of motion/strengthening.”

During the interview, the Assistant also said that “the restorative program was to be from 08/03/2015 to 11/01/2015 […and] about three weeks ago, the Restorative Aide had quit and they were in the process of hiring another one […and] no one had been receiving restorative services for the last three weeks.” Upon review of the resident’s Restored Care Documents, the assistant said that “the Restorative Aide had not documented anything showing [they] provide restorative services to the resident or that the resident declined services [because every document sheet was blank].” The Assistant verified that “the resident should have been receiving restorative services since 08/03/2015 and it seemed that the resident had not been receiving it.”

The physician’s order showing physical therapy for the resident including evaluation and treatment three times every week for four weeks was verified by the state investigator by a physician’s telephone orders documentation dated 10/21/2015.

The state investigator then conducted a 12:42 PM 10/23/2015 interview with the facility’s Director of Nursing who verified that “restorative services had been inconsistent since the Restorative Aide was no longer working in the facility […and] residents were not receiving restorative services as they should and they were in the process of hiring a Restorative Aide”.

Our Raytown nursing home neglect law firm recognizes that failing to follow physician’s orders when providing restorative care to a resident at the facility for rehabilitation could place their health and well-being in jeopardy. The deficient practice by the nursing staff to provide much-needed care to the resident was a failure to follow established procedures and protocols enforced by federal and state nursing home regulatory agencies.

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WILSHIRE AT LAKEWOOD
600 N E Meadowview Drive
Lees Summit, Missouri 64064
(816) 554-9866

A “For-Profit” 170-certified bed Medicaid/Medicare-participating facility

Overall Rating – 3 out of 5 possible stars

3 star rating

Primary Concerns –

Failure to Follow Procedures and Protocols When Reporting and Investigating Any Act or Allegation of Abuse, Neglect or Mistreatment of Residents

In a summary statement of deficiencies dated 04/06/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “follow their facility policy and procedure to determine if an allegation of abuse had occurred for [one resident the facility].”

The deficient practice was noted by a state investigator after reviewing a resident’s Face Sheet showing the resident was admitted to the facility with a fracture of [their] lower leg. The Face Sheet also showed the resident was susceptible to falls and suffered from “spinal stenosis, urinary incontinence, urinary tract infection, mononeuritis (a disorder of the nervous system that affects two areas and can result in severe pain, loss of motor ability in a loss of sensation into random areas of the body), and muscle weakness.”

The state investigator also reviewed the resident’s Annual MDS (Minimum Data Set) that revealed that the resident “had no cognitive deficits” but “required one person assist with dressing, toileting bathing […and] was independent with personal hygiene.”

The state investigator reviewed a facility 04/02/2015 CNA Employee Disciplinary Form showing an infraction date of 08/02/2015. The form revealed an infraction description noting “threatening, coercing, intimidating or interfering with employee or resident.”

The infraction involved a report by the resident that the Certified Nursing Assistant “was rough with [them] during cares and cause pain.” It also shows the Certified Nursing Assistant had let the resident’s “leg drop roughly after transferring [them to their] chair instead of gently putting them down as requested.”

The report also indicated that the resident stated the Certified Nursing Assistant told the resident, “you don’t have to yell at me like an animal” when the resident asked the Certified Nursing Assistant “to get [their] cell phone from the counter.”

The report also indicated that on 08/02/2015, the Certified Nursing Assistant “had forced the resident to change into [their] pajamas at 4:00 PM as [the Certified Nursing Assistant] did not want to change the resident at a later time. The resident was fearful of [the CNA] and told Social Services that [they] did not want [the CNA] to answer [their] light when it was on.” The document also notes that the disciplinary action led to the termination of the Certified Nursing Assistant.

The facility’s 04/03/2015 Investigation Report documented that “there was no injury to the resident […and] the Administrator was notified on 04/02/2015 at 2:00 PM.” However, the incident had occurred on 04/01/2015. The documentation in the report also shows “the nature/location of the incident was not likely to have been accidental or self-inflicted […and] the initial facility staff [member] to become aware of the incident was the social worker on 04/02/2015.”

There was ample evidence to show that “the resident was capable of reporting abuse and problems with care.” Documentation also shows that “the resident was interviewed by the Social Worker on 08/02/2015.” The Director of Nursing at the facility interviewed the Licensed Practical Nurse involved in the incident on 4/2/2015 and that the Certified Nursing Assistant “was sent home on our 04/02/2015″ and interview by telephone the following day. The documentation also noted that “the investigation found no abuse or neglect to have occurred.”

The investigator interviewed the facility’s Administrator 1:25 PM on 04/03/2015 who revealed that “the investigation with the resident had been completed […and that the Certified Nursing Assistant] was terminated.” In a subsequent interview at 1:14 AM on 04/06/2015, the Administrator verified that “the resident was interviewed by the Director of Nursing […and that the Certified Nursing Assistant] was interviewed by telephone.” However, the state investigator notes that no additional residents were interviewed “as part of the investigation.”

Our Lees Summit nursing home abuse attorneys recognize that failing to follow procedures and protocols when investigating and reporting any act or allegation of abuse could place the health and well-being of the resident in Immediate Jeopardy. The deficient practice of the nursing staff and Administrator at Wilshire at Lakewood might be considered negligence or mistreatment because their actions failed to follow procedures and protocols to protect the resident, investigate the incident by interviewing other residents and reporting the incident to state agencies as required by law.

The Warning Signs of Nursing Home Neglect and Abuse

Many families are unaware of the obvious and not so obvious warning signs of abuse and neglect occurring in nursing facilities. Unfortunately, many residents suffer undue pain, insufficient care, abandonment, intimidation or premature death.

When family members understand the warning signs, it’s possible to save the life of their loved one from harm, serious pain or preventable injury. The signs include:

  • Restraint – Nursing home residents can become victims of two specific types of restraints – physical or chemical. Many residents are restrained without authorization by physical straps or other equipment in an effort to provide a level of convenience for the nursing staff in charge of providing them care. Other times, the nursing home will use chemical restraints or the victim is over medicated in an effort to control their behavior or diminish the amount of care the staff must provide to meet the resident’s needs.
  • Staff Inattention – Failing to respond to a resident’s needs in a timely manner is a serious problem in many nursing homes throughout Missouri. This is especially true for residents who require special care. Any lack of attention in providing health care, medical treatment or hygiene assistance can diminish the quality and comfort of the resident’s life and place their health and well-being in jeopardy.
  • Falls – Many falling accidents occurred in nursing facilities are the result of a lack of supervision. Falling is a serious issue because many individuals in later years suffer from a variety of medical conditions including poor vision and muscular degeneration. It is the duty and responsibility of nursing facilities to develop, implement and enforce a Plan of Care that eliminates the possibility that a resident can fall and suffer serious, life-threatening injuries.
  • Pressure Sores – Every facility-acquired pressure sore (bedsores; pressure ulcers; decubitus ulcer) is preventable. Without early detection or necessary treatment, an early stage bedsore can easily degrade to a life-threatening condition where the wound becomes open to expose the bone, muscle and tendons below. Within days, the wound can become infected leading to osteomyelitis (bone infection) and/or sepsis (blood infection), which can easily claim the life of the resident.
  • Bruises – Family members should never ignore a bruise on the skin of their loved one residing in a nursing facility. Any bruise, cut, laceration or skin injury that requires medical attention should be always evaluated to ensure that the root cause has been determined. In some cases, bruising is a first indicator of neglect or abuse.
  • Weight Loss – Any unexplained weight loss is usually an alarming warning sign of abuse or mistreatment. In many cases, the contributing factors to weight loss involve poor quality food, illness, dehydration or lack of care.

The warning signs listed above are not in any special order. Each type of neglect, mistreatment, and abuse can be equally harmful. It is imperative that family members take immediate action at the first sign or suspicion that their loved one is being mistreated.

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What to Do

It only takes a single voice to make a change when a nursing facility is providing substandard care to a resident. The legal actions taken by the Independence nursing home abuse attorneys at Rosenfeld Injury Lawyers LLC have brought to light many of the horrors of unsanitary conditions, poor quality of care and abuse occurring in nursing homes throughout Missouri. Our Jackson County elder abuse attorneys fight aggressively to protect our clients’ rights and seek legal avenues to obtain the financial compensation they deserve for their injuries, damages and losses.

If you suspect your loved one has been victimized by the nursing home, nursing staff, employees, visitors or other residents, we encourage you to contact our law offices at (888) 424-5757 today. By scheduling a free, no-obligation consultation, we can discuss the merits of your case and provide a variety of legal options on how best to proceed. No upfront fee is required because we accept all nursing home cases through contingency fee arrangements.

For additional information on Missouri 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.

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