When a family member places a loved one in a nursing facility, they never imagine that the become a victim of abuse or neglect. Unfortunately, many incidences of mistreatment occur every day in nursing facilities nationwide. In fact, the Kansas City nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC have handled many cases of inadequate supervision, inadequate staffing or a lack of training that causes serious life-threatening problems and even claims the lives of many nursing home victims in Missouri.
Because of the residents in nursing facilities have certain limitations on their capacity to provide their own care, family members are often called upon to serve as their advocate. Watching out for a loved one in a nursing home is crucial because negligence and abuse can leave the victim physically, mentally or emotionally scarred for the remainder of their precious last few years.
Out of the more than 470,000 residents living within the city limits of Kansas City, approximately 60,000 are senior citizens. The high percentage of retirees in the community and the limited number of available beds at nursing facilities all throughout Jackson County has placed a significant burden on nursing homes that are unable to meet the needs of the growing aging population. As a result, the incident rates involving abuse, neglect and mistreatment have risen substantially over the last few years. This number is likely to increase as more older Americans enter their retirement years.
Kansas City Nursing Home Resident Health Concerns
In an effort to provide legal assistance, our Kansas City nursing home neglect attorneys continuously review, assess and evaluate publicly available nursing home information from a variety of sources including Medicare.gov. This information contains opened investigations, filed complaints, health hazards and safety concerns occurring in nursing home facilities all throughout Jackson County.
Our Missouri elder abuse law firm has represented victims who have been denied general appropriate care or suffered injury due to a safety or health hazard. Many of these victims have suffered facility acquired bedsores, broken hips, dehydration/malnutrition, and other injuries that cause severe medical complications or claim their lives.
Our law firm publishes this information in an effort to provide assistance to families who either have a loved one already placed in a nursing facility or those who are attempting to find the best location that provides the highest level of care.
Comparing Kansas City Area Nursing Facilities
The list below has been compiled by our Missouri elder abuse lawyers outlining Kansas City area nursing facilities that currently maintain substandard ratings compared to the level of care given at other nursing facilities nationwide. In addition, our law firm is added our primary concerns by detailing specific cases of neglect, abuse or mistreatment that caused actual or indirect harm to the facility’s residents.
CLARA MANOR NURSING HOME
3621 Warwick Boulevard
Kansas City, Missouri 64111
A “For-Profit” 90-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Develop, Implement and Enforce Policies That Prevent Abuse, Mistreatment or Neglect of Residents
In a summary statement of deficiencies dated 09/15/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “implement their Abuse/Neglect Policy when the staff did not complete an investigation of an injury of unknown origin that resulted in a left distal radius (wrist fracture).” The failure by the nursing staff at Clara Manor Nursing Home affected one resident at the facility.”
The deficient practice was noted by the state investigator after reviewing the resident’s medical records including the resident’s Face Sheet that shows the resident was admitted to the facility with a closed subtrochanteric fracture, osteoporosis (thinning bones that become brittle and weak) and “rheumatoid arthritis disorder that attacks joints and other body parts.”
In addition, a review of the resident’s 05/11/2015 Care Plan revealed that the “resident had a potential for falls […and required] staff to assist with hygiene, bathing and toileting, staff to monitor for proper function and device use; the resident used a wheelchair for locomotion.” However, the state investigator noted that the resident’s “Care Plan did not show how the staff was to assist the resident with transferring from one surface to another.”
The resident’s 04/30/2015 Nurse’s Notes revealed that “a Licensed Practical Nurse documented that at 8:00 AM, the resident was up in [their] wheelchair and take into the dining room […and] had to be fed during breakfast.” The Certified Nurses’ Aide providing the resident care noted that “the resident’s left thumb was swollen and bruised; medication was given to the resident for pain; the resident was very restless; the resident’s physician was called and ordered an x-ray and at 2:40 PM, a mobile x-ray company came to the facility to complete the x-rays.”
The result of the 04/30/2015 X-ray revealed that the resident “had a fractured distal radius (wrist).”
An interview conducted at the facility by a state investigator with the facility’s LPN revealed that even though they were not present when the incident occurred, they “recognize the documentation in the Nurses’ Notes on 04/30/2015 as an injury that should have been documented in an incident report and [that] the resident was injured and the incident report was completed.”
At 11:40 AM 09/14/2015 interview with the facility’s Administrator revealed that the Administrator did not investigate any recent incidences although they are required to investigate “all injuries of unknown origin and [that day] did not have any reports related to the resident’s injury.”
Our Kansas City nursing home abuse attorneys recognize that failing to develop, implement and enforce policies to prevent abuse, mistreatment or neglect has the potential of causing resident’s additional harm. The deficient practice of the nursing staff and Administrator at Clara Manor nursing home might be considered negligence or mistreatment because their actions fail to follow the facility’s 06/01/2015 policy titled: Abuse and Neglect Policy that reads in part:
“The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the Administrator or to other officials in accordance with State law through established procedures.”
“Anything that appears even remotely suspicious should be reported immediately including all unexplained incidences of physical and/or verbal abuse.”
“The suspected incident will be investigated immediately. Division of Health and Senior Services will be contacted if the investigation is found valid.”
“The Administrator/Director of Nursing will initiate an investigation immediately upon the incident reported.”
GLENNON PLACE NURSING CENTER
128 North Hardesty
Kansas City, Missouri 64123
A “For-Profit” 120-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Take All Necessary Precautions to Minimize the Potential of Serious Medication Errors Including the Wrong Dose, Wrong Drug, Wrong Time, Etc.
In a summary statement of deficiencies dated 12/15/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “ensure the medication administration rate was less than five percent. There were six errors in 24 opportunities [with] an error rate of 25%.”
The deficient practice was noted by the state investigator after an observation at 6:48 AM on 12/09/2015 revealing that a “Certified Medication Technician dispense the resident’s aspirin into a medication cup and left it unattended on the top of the medication cart while [they] enter the resident’s room to obtain [the resident’s] blood pressure and pulse. There was another resident standing next to the medication cart while this medication was unattended.”
The state investigator also noted that the medication that had been dispensed in place in the medication cup with an aspirin was refused by the resident who would not take the laxative. The Certified Medication Technician (CMT) said that they “did not know if the resident’s physician was aware of this.”
At a later point, the Certified Medication Technician was observed entering the resident’s room before placing a couple of the drugs and an inhaler “onto the seat of the resident’s walker (in front of the resident)” at that point, the Certified Medication Technician informed the resident that they needed to take their drugs. The technician indicated that they usually “just left the medication for the resident to take because the resident would not take it while the CMT stood there and that the resident took [their] medications at [their] own pace.”
The state investigator conducted an interview with the Certified Medication Technician at 8:35 AM on 12/11/2015. The CMT indicated that “staff should not leave medication on top of the medication cart unattended […and] staff was supposed to stand by and not leave the resident side until the resident took all of [their] medications […and] never left any of [that resident’s] medication at [their] bedside, including [the] inhaler.” The CMT indicated that they always “stood by and waited until the resident took them before walking away, otherwise [they] couldn’t be sure all the medication was consumed.”
An 11:30 AM 12/15/2015 interview by the state investigator was conducted with the facility’s Director of Nursing who said that they “would not expect staff to leave medication unattended on the top of the medication cart, especially if there was another resident nearby. Staff to take it with [them] if [they] had to leave the area or secure it until [they] could return.”
The Director of Nursing also indicated that the staff “should stay with the resident to ensure the resident took all the prescribed medication, only then should the staff leave.” Also, the Director of Nursing indicated that “if a resident was refusing [their] medications, [they] expect the staff to relay this information to the nurse and/or physician.”
Our Kansas City nursing home neglect attorneys recognize that failing to take all necessary precautions to minimize the potential of a medication error could place the health and well-being of the resident in immediate jeopardy. The deficient practice by the nursing staff at Glennon Place Nursing Center might be considered negligence or mistreatment because their actions fail to follow the May 2010 Certified Medication Technician Student Manual that reads in part:
“Never allow an unlocked medication cart out of your site. Lock the cart if you cannot see it; never leave medications unattended on top of the cart; make necessary resident observations prior to administering medications, i.e. check pulse prior to dispensing [the resident’s medicine] or check blood pressure according to physician’s orders.”
“Stay with the resident (as necessary) until all medications [have been taken] never leave medications at the resident’s bedside to be taken later.”
“Report to the Licensed Nurse any time a resident refuses to take a medication or if there is suspicion the resident is not swallowing [their] medications.”
The PLAZA REHABILITATION and HEALTH CARE CENTER
Kansas City, Missouri 64111
A “For-Profit” 154-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Follow Procedures and Protocols When Providing Specialty Care to Ensure That the Resident Maintains Their Highest Level of Well-Being that Led to Actual Harm
In a summary statement of deficiencies dated 05/27/2015, a complaint investigation was opened against the facility for its failure to “follow physician’s orders for a resident who require continuous (24 hours a day seven days a week) oxygen therapy to support the resident with [their] needs.” The state investigator also noted the facility’s failure “to monitor the resident’s oxygen level and to report to license nursing staff that the resident had episodes of respiratory distress during [their] care.” The failure of the nursing staff at The Plaza Rehabilitation and Healthcare Center affected one resident at the facility.”
The complaint investigation involved a review of the resident’s medical records that revealed the resident suffered from lymphatic obstruction, a condition of localized fluid retention and tissue swelling and lymphedema (lymphatic obstruction), a condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system. Typically, “the condition normally returns interstitial fluid to the thoracic duct and then the bloodstream.”
These conditions are often the result of a birth defect or are inherited, though it can be caused by cancer treatments and parasitic infections. Even though the condition is progressive and incurable, various treatments are available. However, lymphedema tissues are often highly susceptible to infection.[i] The investigator also noted that the resident suffered from dementia.
A review of the resident’s 05/16/2015 Plan of Care revealed that oxygen therapy was to be provided to the resident as per physician’s orders and that “nursing staff were to monitor and document the resident for signs and symptoms of respiratory distress and report to the resident’s physician as needed.”
The Care Plan also revealed that “the resident’s oxygen saturation was to be monitored by nursing staff every shift and as needed for signs and symptoms of shortness of breath; the resident’s oxygen was to be set for [them] to receive continuous oxygen at 2 to 3 liters per nasal cannula to maintain [their] oxygen level above 90% saturation.
However, when the state investigator interviewed a family member of the resident on 05/18/2015, the family member indicated that during their “visit with the resident, the resident complained that [they] could not breathe. The complainant observed that the resident had oxygen equipment on [their] person, but the oxygen machine was not turned on.”
In addition, it was noted that a Certified Medication Technician (CMT) and Certified Nursing Assistant “remove the resident’s oxygen nasal cannula, and the Certified Medication Technician undress the resident for [their] shower.” During the process, the resident’s oxygen nasal cannula “remained off at the beginning of [their] shower; at 1:50 PM, the resident became short of breath with labored breathing during [the] shower.”
During that event, the Certified Nursing Assistant “said if the resident does have a physician’s order for oxygen therapy they could be used during [the shower, and that during the shower the Certified Nursing Assistant] did notice that the resident had difficulty breathing and assisted the resident and placing [their] nasal cannula on to help with [their breathing].”
During the event, the Certified Medication Technician “continue with the resident shower. At 2:00 PM, the resident became more labor using [their] abdominal muscle to assist in [their] breathing (labored breathing is an abnormal respiration characterized by evidence of increased effort to breathe, including the use of accessory muscles). During the observation, the resident’s portable oxygen tank was turned to the off position.”
The CMT was asked, “how can you tell the portable tank was delivering oxygen to the resident?” The CMT “look at the tank and set the tank was not turned on and proceeded to turn the knob to the on position and check to make sure it was set to deliver three liters of oxygen.” At that point, the resident responded that they “could feel air coming through [their] nasal canola […and] became less labored after the portable oxygen was turned on and run for several minutes at three liters per nasal cannula.”
The state investigator conducted an interview with the Director of Nursing at 8:45 AM on 05/27/2015 who said “the CNAs [at the facility] had training on the set up to use the oxygen concentrator, portable tanks and placement of the nasal cannula […and that they] expected the nursing staff to monitor the resident’s oxygen therapy for proper functioning including placement of the nasal cannula and ensure the oxygen machine or tanks are turned on.” In a follow-up interview with the Director of Nursing at 11:20 AM on 06/04/2015, the Director said that they “would expect the CNA and CMT to have oxygen on the resident during [their] shower […and] if the resident became short of breath, the care staff should check to make sure the resident’s oxygen device was working properly and to notify the nurse if the resident continued to have shortness of breath.” In addition, the director of nursing expected that “the nursing staff would notify the resident’s physician of the resident’s respiratory issue did not improve or an acute change in condition [occurred].”
Our Kansas City nursing home neglect lawyers recognize that any failure to follow procedures and protocols when providing specialty care could place the health and well-being of the resident in immediate jeopardy. The deficient practice by the nursing staff at The Plaza Rehabilitation and Health Care Center might be considered negligence or mistreatment because their actions fail to follow the facility’s revised October 2010 policy titled Oxygen Administration Policy and Procedure that reads in part:
“The nursing staff should assess the resident while receiving oxygen therapy for signs and symptoms of difficulty breathing, slow or shallow rate of breathing. Monitor the resident oxygen saturation’s as ordered.”
“Check the oxygen tanks to be sure they are in good working order and so staff activates the resident’s oxygen delivery device.”
MYERS NURSING and CONVALESCENT CENTER
2315 Walrond Avenue
Kansas City, Missouri 64127
A “For-Profit” 84-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Develop and Follow a Complete Care Plan to Meet All of the Resident’s Requirements Including Actions and Timetables That Can Be Measured
In a summary statement of deficiencies dated 12/22/2015, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “develop a comprehensive Care Plan for [a resident at the facility].”
The deficient practice was noted by state investigator reviewed a resident’s Admission Record Face Sheet that showed that the resident suffers from paralysis/weakness affecting one side of the body.” In addition, review of the resident’s 10/20/2015 Nurse’s Notes revealed that the resident “had an unwitnessed fall to the floor. Staff did not document where the fall occurred, where the resident was found, and what the resident fell from.”
The state investigator also noted that the documentation indicated that the resident hit their head and “requires several staff [members] to assist the resident off the floor and was sent to the emergency room for evaluation.”
A review of the resident’s 10/30/2015 Admission MDS (Minimum Data Set) reveal that the resident “was severely cognitively impaired; required staff supervision for bed mobility; required extensive staff assistance for locomotion […and] total staff assistance for transfers, dressing, toileting and bathing.” In addition, the MDS revealed that the resident “has impaired range of motion in both upper extremities in both lower extremities […and] had one non-injury fall and one injury fall since admission.”
The investigator also reviewed the resident’s 11/06/2015 Nurse’s Notes that showed that the resident “was found sitting on the floor in front of [their] wheelchair.” The document says that the resident’s “fall was unwitnessed; three staff members assisted the resident from the floor to [their] wheelchair […and] reminded the resident to ask for assistance and wait for staff to assist [them].” The documentation also indicates that the resident’s “retention level is not very good.”
Nurse’s Notes documented four days later on 11/10/2015 revealed that the resident’s “hospice provider was going to provide an electric bed with half side rails for positioning and assist with transfers and pads on the floor for safety.”
That led to state investigator to review the resident’s 11/10/2015 Evaluation of Side Rail Usage documentation that revealed that the resident “did not have any falls from [their] bed and cannot get in and out of bed safely without any human assistance or assistive device […and] has decreased safety awareness and [their] bed rails are not a restraint due to the resident is unable to get out of bed without assistance.”
The investigation involved a review of the resident’s 11/16/2015 Nurses Notes that revealed that “the resident was found on the floor during shift change rounds […and that the resident’s] fall was unwitnessed by facility staff and [that] the resident required 3 to 4 staff to assist the resident from the floor to the bed.”
The investigator conducted a 1:00 PM 12/14/2015 observation of the resident who was noted as being in bed “with two half side rails up on either side of [their] bed; a floor mat was on the floor on the right side of the bed. No mat was on the floor on the left side of the bed; the resident was unable to pull [themselves] using the side rails; […and the resident] said the side rail was to keep [them] from falling out of bed.”
The investigator also noted that the resident said that they “did not have enough strength to pull themselves up with the side rail.” A notation was made of the resident’s “teeth were discolored, chipped and broken.”
Upon an interview with the facility’s MDS Coordinator and Director of Nursing, it was discussed that “the resident should have a Care Plan for [their falls and side rails and… that] any change in the resident’s condition should be reflected in the Care Plan.”
Our nursing elder abuse lawyers recognize that any failure to develop and follow a complete Care Plan that meets the resident’s requirements that involve measurable actions and timetables could place the health and well-being of the resident in jeopardy. The deficient practice by the nursing staff at Myers Nursing and Convalescent Center might be considered negligence or mistreatment because their actions fail to follow established procedures and protocols enforced by state and federal nursing home regulations.
PARKWAY HEALTH AND REHABILITATION CENTER
2323 Swope Parkway
Kansas City, Missouri 64130
A “For-Profit” 97-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Follow Procedures and Protocols When Administering Wound Care Treatment That Cause the Resident Extensive Pain during the Procedure
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 “assess the resident’s pain level and administer pain medication prior to performing wound care when the resident told the staff it really hurts when [their] dressing was changed to [their] foot, and to stop the wound care procedure when the resident showed signs of pain such as grimacing, tensing up, squirming and making faces.”
The state surveyor making the notations also noted that “the resident saying to the staff that it was hurting and staff proceeded to hold the resident’s leg held down during wound care for a worsening Stage III pressure ulcer.”
The deficient practice was noted by the state surveyor after a review of a resident’s 06/03/2015 Annual MDS (Minimum Data Set) that revealed the resident “was cognitively intact for making daily decisions, required the total assistance of one person with dressing and hygiene; needed limited assistance with one person for bed mobility; require total assistance of two or more people for transferring […and] had impaired range of motion of [their] upper and lower extremities on one side.”
The state investigator also noted that the resident “was frequently incontinent of bowel and always incontinent of urine.” Notations were made that the resident “had one worsening Stage III pressure ulcer” that involves full thickness tissue loss. A Stage III pressure ulcer might have subcutaneous fat that has become visible inside the open wound however at this point, muscles, tendons and bones are not yet exposed. However, there is often tunneling and undermining.
A complete review of the resident’s August 20 15,015 Care Plan revealed that the resident was “at risk for a wound infection, was being treated for multiple conditions, and should receive weekly wound consultations.” The documentation also revealed the resident “should be monitored for wound redness, odor and pain; and should be assessed for pain every shift.”
The investigator noted that there was a 09/16/2015 Physician’s order for the staff to “cleanse the wound on the resident’s left heel with wound cleanser, apply powder to the wound bed, cover with silver alginate and foam dressing and wrap with Kling. The order was to change the dressing daily and as needed until healed.”
The state investigator made an observation at 12:55 PM on 11/03/2015 noting that the “resident was in bed, resting on [their] low air loss mattress [when a Registered Nurse] enter the resident’s room to administer wound care/treatment on the resident’s left heel.” A few minutes later “the resident said it really hurts when the dressing is changed.” At that point, the Registered Nurse “asked the resident about [their] pain and the resident confirmed [that they] had pain.” The Registered Nurse then asked the Certified Medication Technician “if the resident had received any pain medication.”
The Certified Medication Technician responded that they “had not given the resident anything for [their] pain, because the resident had not told [them] about [their] pain. At this point, the Registered Nurse continued performing wound care on the resident including removing the old dressing and wrap.
During this part of the procedure when the Registered Nurse “began removing the resident’s old dressing, the resident grimaced, became tense and said the wound was hurting.” The resident’s wound bed was covered with necrotic (dead) tissue, slough and the edges were calloused. The resident continued “squirming in making faces while the wound was being cleansed and the treatment applied.”
The Certified Medical Technician “held the resident’s leg in place [while] the resident was pulling and moving [their] legs. At this time, both the Registered Nurse and the Certified Medical Technician “tried to encourage the resident to keep still so that the treatment could be completed. The resident kept stating it was hurting.”
The state investigator conducted 11:25 AM 11/06/2015 interview with the Registered Nurse who said “the resident usually complains because [they do] not want the wound treatment done and [they] should have stopped, assessed and treated the resident’s pain before continuing the wound treatment and dressing change.”
Later that afternoon at 5:15 PM, the state investigator conducted an interview with the facility’s Director of Nursing who said that they “would have expected the treatment to be stopped and pain medication to be administered.”
The investigator also conducted a 10:32 AM 11/19/2015 interview with the facility physician who said “usually a pain medication has been ordered that can be administered prior to the treatment that the resident is in pain; the resident is verbal and can make it known if pain is present and pain medication should have been given to the resident when [they said they] had pain, prior to dressing change and treatment being continued.”
Our Kansas City nursing home neglect lawyers recognize that failing to follow procedures and protocols when administering wound care treatment that causes pain could be harmful to the health and well-being of the resident. The deficient practice by the nursing staff at Parkway Health and Rehabilitation Center might be considered negligence or mistreatment because their actions fail to follow the facility’s revised March 2015 policy titled: Wound and Skin Care Policy and Protocol that reads in part:
“Resident should be assessed for pain, related to pressure ulcer or its treatment per policy. Manage pain by eliminating or controlling the source when possible wound covering, support services, repositioning. Try to prevent or relieve pain associated with or made worse during dressing changes and debridement.”
621 Carondelet Drive
Kansas City, Missouri 64114
A “Not for Profit” 162-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Ensure That Medication Administration Procedures Met Professional Standards of Quality in Accordance with State and Federal Regulations
In a summary statement of deficiencies dated 02/01/2016, a complaint investigation against the facility was opened for its failure to “ensure staff follows the acceptable standard of practice for providing care to [one resident at the facility].” In addition, the state investigator also noted the facility’s failure “to ensure the medication was reordered in a timely manner, [and a failure] to notify the physician when the staff did not give the ordered medications […and a failure] to assure the medication administration record reflected that.”
The complaint investigation included a review of a resident’s medical documents including their 12/23/2015 Care Plan that showed that the “resident will be free of skin breakdown. Staff should inspect resident skin for signs and symptoms of breakdown.” In addition, it was noted that the “resident was at risk for complications related to the use of antidepressant medications. Monitor for depressive behavior and document interventions.” A review of the resident’s 12/30/2015 Admission MDS (Minimum Data Set) noted that the resident “was cognitively intact.”
The state investigator reviewed the resident’s MAR (Medication Administration Record) which noted that the resident did not receive their physician ordered cream on three occasions including 01/09/2016, 01/10/2016 and 01/11/2016.
In addition, the investigator noted that the interdisciplinary notes between 01/09/2016 of 01/11/2016 “did not show that the staff notified the resident’s physician when the resident ran out of [their medication] cream.”
The state investigator interviewed the facility’s Registered Nurse at 3:15 PM on 01/25/2016 who said that they had ordered the resident’s medication cream on 01/11/2016 after noticing that [the resident ran out of these medications. The resident complained of itching and seemed more withdrawn than usual. The staff should reorder medications by placing the reorder sticker on a fax and fax the request to the pharmacy to assure the medication is delivered before the resident runs out of the medication.”
The Registered Nurse also noted that “if a medication runs out the nurse is to notify the physician, get a dose from the emergency kit if it is available or call the pharmacy and request a STAT order and delivery. The resident should not have to go without their medication.” The Registered Nurse had said that they had “been off work for two days prior to noticing the resident ran out of the medication […and] reorder the medications when [they] return to work.”
The state investigator interviewed the resident a few minutes later 3:15 PM who said that they “it’s so bad when [they] did not receive [their medication] cream and felt like [they were] scratching their arms off.” The resident indicated that they felt sad and hopeless and cried because of the miss medication doses and did not know why they did not receive their medication for three days. The resident indicated that family members had brought in another cream because it was not being supplied by the facility. However, that cream did not help.
That afternoon at 5:00 PM, the state investigator interviewed the facility’s Director of Nursing who said that “staff should reorder medications when the medication supply got down to the last eight days […and] staff should remove the medication reorder label from the medication package and fax the reorder to the pharmacy to assure it there is time for the medication to be delivered prior to the resident running out.” The Director of Nursing also indicated that she “was not aware the resident did not have [their] medications for three days.”
Our Kansas City nursing home neglect attorneys recognize that failing to ensure that medication administration procedures are followed could cause extensive pain and diminish the health and well-being of the resident. The deficient practice by the nursing staff at Carondelet Manor might be considered negligence or mistreatment because their actions fail to follow the facility’s 10/30/2012 policy titled: Medication Administration Policy that revealed in part:
“Nursing staff to notify the ordering physician when medications or refuse or withheld consistently.”
GARDEN VALLEY NURSING and REHABILITATION CENTER
8575 North Granby Ave
Kansas City, Missouri 64154
A “For-Profit” 156-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Develop, Implement and Enforce Programs That Investigate, Control or Keep Infections from Spreading throughout the Facility
In a summary statement of deficiencies dated 12/09/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure staff followed infection control protocols to prevent the spread of infection when staff did not remove soiled gloves and wash their hands during resident care and medication administration.” The failures by the nursing staff at Garden Valley Nursing and Rehabilitation Center affected five residents at the facility.”
The deficient practice was noted by state investigator after a review of a resident’s Quarterly MDS (Minimum Data Set) showing that the resident “required extensive assistance with hygiene and bathing; continent of bowel and bladder.” In addition, the resident’s 10/27/2015 Care Plan showed that the resident had a “Problem: Altered bowel elimination pattern related to cognitive impairment. Approach: toilet every two hours; staff to monitor skin daily during assisting with activities of daily living (ADLs).”
At 9:30 AM on 12/08/2015, the state investigator observed the Certified Nursing Assistant (CNA) entering the resident’s room to perform perineal care. The CNA wash their hands and wipe both groin areas on the resident and use several disposable wipes to remove fecal matter that had dried in the rectum the buttocks area. At that point, the Certified Nursing Assistant removed her gloves, wash their hands and reapplied the gloves, continuing “to wipe away visible stool and ran out of disposable wipes.”
“Wearing the same soiled gloves, [the Certified Nursing Assistant] touched and rolled the resident on to [their back] cover the resident with the bedding, removed [their] soiled gloves, wash [their hands] and left the room.” The Certified Nursing Assistant returned to the room with a new package wipes, they did not wash their hands before applying clean gloves and rolling the resident on to the right side to begin wiping away visible stool.
The state investigator also noted that “without removing the soiled gloves, [the Certified Nursing Assistant] touched the resident, a new brief, [the resident’s] pants, shirt, socks and slippers, then assisted the resident to stand up and allowed the resident to leave the room.”
A 4:10 PM 12/08/2015 interview was conducted with that Certified Nursing Assistant who said that they “should not touch anything with dirty gloves and wash [their] hands” after removing soiled gloves.
Our Kansas City nursing home neglect attorneys recognize that failing to follow procedures and protocols that control or maintain infection from spreading throughout the facility could jeopardize every resident in the nursing facility. The deficient practice by the nursing staff at Garden Valley Nursing and Rehabilitation Center might be considered negligence or mistreatment because their actions fail to follow the facility’s 09/01/2010 policy titled: Handwashing and Gloving Policy that reads in part:
“It is the policy of this facility to ensure a safe, sanitary and comfortable environment for residents and help prevent the development and transmission of disease and infection.”
The staff is to wash their hands “before and after contact with each resident; before and after glove use; after contact with any waste or contaminated materials; before and after toileting residents; when any visible dirt is on your hands. Never leave a resident room and walk down the corridor with gloves on.”
INDIAN CREEK HEALTHCARE CENTER
6515 W 103rd St
Overland Park, Kansas 66212
A “For-Profit” 120-certified bed Medicaid/Medicare-participating facility
Overall Rating – 3 out of 5 possible stars
Primary Concerns –
Failure to Investigate and Report Any Act or Allegation of Abuse, Neglect or Mistreatment of Residents
In a summary statement of deficiencies dated 05/20/2015, a complaint investigation was opened against the facility for its failure to “ensure potential incidences of mistreatment or neglect were thoroughly investigated and reported to the State Agency.”
As a part of the complaint, state investigator reviewed a resident’s five-day Admission MDS (Minimum Data Set) that revealed the resident’s Brief Interview for Mental Status (BIMS) score of 14. This indicates that the [resident’s cognition was intact. The resident required supervision of one staff member with most activities of daily living including transfers and ambulation, was continent of bowel and bladder, had no recent history of falls, received anti-anxiety medication… and hospice services.”
The investigator also reviewed the resident’s Activities of Daily Living Care Area Assessment (CAA) that recorded that “the resident required at least stand by assistance to complete cares and would require increased assistance as [their] condition worsened.” The resident’s fall CAA revealed that “the resident’s gate was unsteady and [they] received narcotic pain medication and [other medications] which placed [them] at risk for falls.”
It was also noted that “the facility would develop a Care Plan to address the resident’s fall risk.” However, the electronic record lacked any documentation of a fall risk assessment since the resident was admitted to the facility. The investigator found on the resident’s Initial Admission Care Plan was that “the resident had a potential for falls due to [their] decreased safety awareness and was to remain free of injury.” However, there was no documentation in the Care Plan “of any interventions to decrease the resident’s fall risk potential.”
The complaint investigation was initiated because of the 7:27 AM Nurses progress note that recorded that “a nurse’s aide reported to the nurse that the resident was on the floor. The nurse went to the room and found the resident lying face down in a pool of blood from the nose and mouth. The resident was unresponsive, no pulse and there were no detectable vital signs. The supervisor was notified to come to the room and the resident was transferred from the floor to the bed.
The facility notified hospice, the family and physician and hospice would come to the facility.” A second nurse’s note entry recorded at 9:51 AM documented that “the resident passed away at 6:30 AM.
In an interview with one of the administrative nurses, it was revealed that “the resident was agitated at times staff placed [them] in a wheelchair and had [them] city the nurse’s station.” That nurse also stated that “the facility did not conduct a fall investigation because it was obvious the resident fell or crawled from the bed […and that] the resident did not have a fall report but said fall measurements were in place for the resident.” The nurse also indicated that “the incident was not reported to the State Agency because the resident was low to the ground, hospice services followed” and that they were “at the end of life.”
The state investigator noted that “the facility failed to conduct a thorough investigation and report to the State Agency a fall with injury for this resident who the facility found dead on the floor in [their] room.”
Our Overland Park nursing home neglect attorneys recognize that failing to investigate and report any allegation of mistreatment, neglect, abuse or injury of unknown origin does not follow state and federal nursing home regulations. The deficient practice by the nursing staff at Indian Creek Healthcare Center might be considered negligence or mistreatment because their actions fail to follow the facility’s policy title: Abuse and Neglect Prohibition Policy that reads in part:
“The facility will conduct an investigation of any alleged abuse, neglect, injuries of unknown origin or misappropriation of resident property in accordance with state law.”
Nursing Home Abuse, Neglect and Mistreatment
Unfortunately, there are endless news stories every month of nursing home residents suffering the abuse, neglect or mistreatment of their caregivers or other residents at the facility. Many vulnerable seniors lack the capacity to speak out against those who are causing them harm and suffer various injuries as a result. In some cases, even family members do not report the signs and symptoms of neglect or abuse because of a lack of knowledge of the victim’s rights and the obligation the nursing home has to the residents.
Sadly, many signs of abuse and neglect go unnoticed or undetected because many family members are not close enough to visit on a timely basis or their lives are too hectic to look in on a loved one residing in a nursing home.
However, it is crucial to serve as your loved one’s legal advocate. Taking time to recognize less obvious signs of neglect and abuse can help. The most common types of cases our Missouri elder abuse attorneys handle in filing a claim for compensation against nursing facilities will involve:
- Facility-acquired bedsores (pressure sores; decubitus ulcers; pressure ulcers)
- Sudden weight loss caused by malnutrition or dehydration
- Unexplained injuries involving burns, bruises, cuts, puncture wounds and welts
- Unexplained changes in personality and behavior
- Missing personal items including money and jewelry
- Unexpected signs of depression or anxiety
- Unsanitary conditions
- Outward display of agitation or sudden fear, especially when a caregiver or another resident is present
- Elopement from the facility or wandering away due to a lack of supervision or detection
- Infections involving sepsis (blood infection) or osteomyelitis (bone infection)
- Failure of the nursing staff to follow physician’s orders
- Substandard care caused by negligent in hiring, understaffing, poorly trained nurses or incompetence
- Medication errors where the resident receives the wrong medication, medication belonging to another resident or missed doses
- Verbal abuse
- Physical assault, sexual abuse or battery
- Financial exploitation
- Mental/psychological abuse
- Failure to develop, implement and enforce a comprehensive Care Plan to ensure the resident’s health and safety
Take Action Now
If you know or suspect that your loved one is the victim of neglect or abuse in a nursing facility in Missouri, it’s imperative to take action immediately to ensure their health and well-being. Filing a claim or lawsuit against the facility is not only just the pathway to obtaining compensation but also to correct harmful, erroneous and unacceptable practices occurring within the facility. However, taking a stand against the facility requires comprehensive knowledge of Missouri legal procedure and the complexities of the state’s tort laws. Because of that, many families will hire a Missouri nursing home abuse attorney to handle their case.
The Kansas City nursing home abuse attorneys at Rosenfeld Injury Lawyers LLC can handle every aspect of your case to ensure that specific legal requirements are followed to establish liability and to hold all parties responsible legally accountable. Our team of dedicated nursing home attorneys can preserve the evidence to serve as a legal document, gather eyewitness testimony and build a solid case to advocate on your behalf.
We encourage you to contact our law offices today at (888) 424-5757 to speak with one of our Kansas City elder abuse attorneys. Through our efforts, we can ensure that your rights are protected and you obtain fair compensation for your injuries, damages and losses. All cases involving nursing home abuse, neglect and mistreatment are handled through contingency fee arrangements, so you are not required to pay any upfront fee.
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.