Memphis Tennessee Nursing Home Abuse Attorney

Memphis Nursing Home Abuse LawyersNearly every day, the Memphis nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC speak to family members whose loved one has been abused, neglected or exploited at the hands of nursing healthcare professionals in charge of providing them care. Cases involving elder abuse involve some of the most heinous acts where caregivers cause serious harm to the most vulnerable members of society. Without proper oversight and advocacy, any resident can fall victim to mistreatment even while living in the highest rated nursing facilities in the community.

More than 650,000 individuals live within the city limits of Memphis Tennessee, of which approximately 75,000 are 65 years and older. This number more than doubles when counting the seniors living all throughout Shelby County. The total number of elders has risen substantially over the last few decades because many members of the baby boomer generation have chosen to remain in Tennessee to live out their retirement years.

As the oldest generation continues to age, more individuals are relocating to nursing homes, assisted living centers and rehabilitation facilities throughout the Memphis community. Like all humans, these elders deserve to be treated with dignity and respect of their individuality. Unfortunately, statistics reveal that one out of every ten nursing home residents will be victimized at some point during their stay by caregivers, other residents, family members, friends and visitors.

Memphis Nursing Home Resident Health Concerns

Our Tennessee elder abuse law firm has long served as an advocate for every nursing home resident in the state. In an effort to provide a public service, we continuously assess, review and evaluate opened investigations, filed complaints, safety concerns and health violations handled by federal and state regulators, surveyor’s and inspectors.

We publish this information to assist family members in need of placing a loved one in the hands of professional caregivers who require the utmost quality care. This publicly available information gathered from national databases including Medicare.gov gives families insight to the activities, problems, concerns and issues many nursing home residents face in the Memphis area.

Comparing Memphis Area Nursing Facilities

The detailed information below lists every Memphis area nursing facility currently maintaining below average ratings compared to other homes nationwide. In addition, our attorneys have posted their primary concerns and highlighted specific cases where residents have been seriously injured or harmed due to the action or inaction of a medical doctor, nursing staff or employees.

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Information on Tennessee Nursing Home Abuse & Negligence Lawsuits

Our attorneys have compiled data from settlements and jury verdicts across Tennessee to give you an idea as to how cases are valued. Learn more about the cases below:

SIGNATURE HEALTHCARE AT ST PETER VILLA
141 N Mclean
Memphis, Tennessee 38104
(901) 276-2021

A “For-Profit” 180-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Provide Necessary Care and Treatment Prevent Avoidable Bedsores from Developing for Five Residents at the Facility That Led to Life-Threatening Wounds

In a summary statement of deficiencies dated 08/28/2015, a complaint investigation was opened against the facility for its failure to “identify, assess and provide preventative measures to prevent the development of avoidable pressure ulcers.” The deficient practice affected five residents.

The failure of the nursing staff at Signature Health Care at St. Peter Villa to “identify, assess, and/or provide care and treatment for pressure ulcers resulted in an immediate jeopardy when [5 residents at the facility] developed avoidable in-house acquired pressure ulcers that became unstageable before they were first identified by the staff.”

An Immediate Jeopardy is defined as “a situation in which the provider’s noncompliance has caused, or is likely to cause, serious harm, injury, impairment or death to the resident.” In this case, the facility was cited for an immediate jeopardy due to providing residents’ substandard quality of care.”

As a part of the investigation, the state surveyor reviewed the resident’s Initial Nursing Assessment documenting stating the resident had Braden Score of 13 which indicates “a moderate risk for skin concerns,” and proceed to the interim Plan of Care.” The assessment also documented “a surgical wound with staples to the right hip, bruising on bilateral hands, and a red/purple area on the left shin. The assessment documented no concerns with the resident’s heels.”

This resident’s 07/01/2015 Interim Care Plan notes Alteration in skin integrity. Will not develop skin breakdown. Skin assessment weekly. Incontinence care is needed. Turn and position or reposition every two hours. Treatment as ordered.

A Certified Nursing Assistant bathing report was documented six days later on 07/07/2015 at 3:23 AM. However, “the facility was unable to provide the CNA skin care alert for this resident’s wound to be reported to the Charge Nurse and Assistant Director of Nursing/designee.”

That same day at 10:00 AM, a new nursing assessment report documents: “Newly developed Pressure Ulcer specific information, location, and description of the ulcer: BLACK AREA NOTED TO RIGHT HEEL. Wound bed: Eschar (Thick, Hard, Leathery, Black Neurotic Tissue). Nursing interventions: incontinence management/protection of body prominences.”

The state investigator notes that even though a review of the resident’s 07/07/2015 “Pressure Ulcer Record revealed the wound measured 0.8 centimeters by 2.0 centimeters, the depth was unable to be determined. An intervention for prevalent boots was put into place.” However, the surveyor notes that the “intervention was not put into place until after the development of the avoidable pressure ulcer.”

The following month on 08/10/2015, the resident’s Pressure Ulcer Record documents: Unstageable. Measuring 2.5 centimeters by 2.0 centimeters and no depth documented.

As a part of the investigation, the state surveyor notes the facility’s failure “to accurately assess skin conditions, failed to implement preventative measures, and failed to identify the pressure ulcer before it became unstageable black eschar. This placed [the resident] in Immediate Jeopardy.” This unstageable pressure ulcer wasn’t avoidable in-house acquired pressure ulcer that developed within one week of the resident’s admission.”

The state investigator also noted the facility’s failure “to accurately assess skin conditions, [failure] to implement preventative interventions and a [failure] to identify pressure ulcer before became unstageable with eschar.”

The investigator conducted a 5:18 PM 08/26/2015 interview with the facility Director of Nursing who “was asked if it was acceptable pressure ulcers to be identified when they were unstageable due to the presence of eschar.” The Director of Nursing replied, “I would hope that it would be found earlier.”

A telephone interview was conducted by the state surveyor with the facility’s Medical Director at 1:58 PM on 08/26/2015 who “was asked if he expected the facility to notify him of pressure ulcers.” The medical director responded, “normally we would be notified when the skin changes start.” When asked “if the notification should have been before the wound progressed unstageable” the medical director replied, “yes, before it (pressure ulcer) got to that stage.”

Our Memphis nursing home neglect attorneys recognize that failing to follow protocols and provide adequate treatment and care to prevent an avoidable bedsore from developing could place the health and well-being of a resident in immediate jeopardy. The deficient practice by the nursing staff, Medical Director and Administrator at Signature Health Care at St. Peter Villa might be considered negligence or mistreatment because their actions failed to follow their Skin Management and Prevention Policy that reads in part:

“If a skin alteration identified, the nurse will notify the physician to obtain a treatment order. On shower/bath days, the Certified Nursing Assistant (CNA) will complete total body skin observations. If the new skin issue is identified, the CNA will report it to the Charge Nurse and a copy of the form will be given to the Assistant Director of Nursing/designee.”

POPLAR POINT HEALTH and REHABILITATION Center
131 N Tucker
Memphis, Tennessee 38104
(901) 726-5600

A “For-Profit” 169-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Protect Every Resident from Abuse and Sexual Assault

In a summary statement of deficiencies dated 10/29/2015, a complaint investigation against the facility was opened for its failure to “address an incident resulting in a sexual encounter for [a resident at the facility.” In addition, “the surveyor found that [the resident] was identified to be on the National Sex Offender Registry […and] was allowed to run the facility unsupervised. This placed [another resident] and other cognitively impaired residents in Immediate Jeopardy.” There are “52 female residents residing at the facility.”

By definition in the nursing industry, “Immediate Jeopardy is a situation in which the provider’s noncompliance has caused or is likely to cause, serious harm, injury, impairment or death of the resident.”

On 08/13/2015, an interview was conducted by Social Services that reveal the resident “was involved in a sexual act with [another resident] and did not give consent. The facility failed to protect [the nonconsenting resident] and other cognitively impaired female residents during and after the investigation. The facility’s investigation included a statement from the male perpetrator in which the resident denies any sexual contact with the female resident.”

The state surveyor conducting an investigation into the complaint review the nonconsenting resident’s Annual Comprehensive MDS (Minimum Data Set) that revealed that the resident “scored “00″ on their Brief Interview for Mental Status (BIMS), indicating the resident was severely cognitively impaired.” Additionally, the document revealed the resident “scored 1 for mood with no behaviors exhibited during the assessment.”

As a part of the assessment, “the nonconsenting resident was coded as having unclear speech and sometimes able to make yourself understood by others […and] required limited assistance with one person physical assist with mobility and eating. […and] required extensive assistance with two person assist on transfers, toilet use; supervision with one physical assist for locomotion on and off the unit; and extensive assistance with one person assist with personal hygiene and dressing.”

The assessment concluded that the resident “was totally dependent on the staff with two assist for baths […and] was not steady when transferring moving on and off the toilet.” In addition, “the resident utilizes a wheelchair for mobility.”

The investigator reviewed the alleged perpetrator’s 08/21/2015 Quarterly MDS (Minimum Data Set) revealing that the resident scored 13 on their Brief Interview for Mental Status (BIMS) assessment “indicating the resident was cognitively intact […and] did not exhibit any aggressive behaviors during the assessment. […and] required limited assistance with one person physical assist with bed mobility; for transfers extensive assistance with 2+ persons physical assistance; locomotion on unit-limited assistance with one person physical assistance.…”

The incident was documented in the facility’s investigations log revealing that on 08/12/2015 at approximately 10:00 PM, a Certified Nursing Assistant (CNA) “was making rounds and observed [the alleged perpetrator resident] in the [nonconsenting resident’s] room. The CNA informed [the mail resident] that it was getting late and he should return to his room.”

The Certified Nursing Assistant continued with making rounds but returned a few hours later at 1:52 AM to the female’s “room and noticed the door was closed. The CNA entered the room and observed [the male resident] on top of the [nonconsenting female resident].” The alleged perpetrator’s] pants were pulled down in his buttocks exposed.” At this time the Certified Nursing Assistant observed the male resident’s “buttocks making up and down motions [while the female’s] genitalia were exposed.”

At that time, “the CNA observed a tear coming from the [female’s] eye and the female resident look sad.” The male resident “stopped as soon as he realized the CNA entered into the room.” The Certified Nursing Assistant responded by getting help from the nurses. Only when the Certified Nursing Assistant relayed that “the resident was crying did the nurses get up and check on the resident.”

A representative from Social Services obtained a statement from the female resident on 08/13/2015 “regarding the incident. The resident was asked the following questions: Did a man come into your room last night? [The resident] responded, ‘Yes’. Did you have sex? [The resident] responded, ‘I could Yes>. Did you give consent? [The resident] responded, ‘No’. Did you say stop or no? [The resident] responded, ‘Yes’.”

The state investigator reviewed the facility’s 08/13/2015 9:30 AM Progress Notes that confirmed that the female resident “was interviewed by the Assistant Director of Nursing and Director of Nursing who documented that the resident “was aphasic and denied any male intimate contact.”

“The facility providing a handwritten note documenting the police interviewed [the female resident] on 08/13/2015. The handwritten notes dated the police interviewed [the female resident] and that the resident told the police officers it was not rape and she would do it again if she wanted to.”

The state investigator noted that the resident’s statement taken by the Social Worker was read to the Assistant Director of Nursing who “was not sure about that statement but can only go by what the resident had told her on 08/13/2015, that she did not have sexual contact with the [male resident] and she was going by what the resident told the police officers during the interview.” The state “surveyor brought up the concerns of the [resident’s] ability to consent to sex with impaired cognition.” At that point, the Assistant Director of Nursing stated that [the residen]t did not change her response regarding the incident […and] that she determined sexual activity did occur between both but it was consensual.”

“The surveyor reviewed the National Sex Offender Registry and identified [the male resident] was listed as a sexual offender. After this incident occurred the facility never reviewed the Sex Offender Registry as part of their investigation.”

“It was determined the facility failed to respond appropriately to the 08/13/2015 incident involving” both residents at the facility and that the facility also “failed to protect [the female resident] from the [male resident] during the investigation […and] failed to supervise [the male resident] around the other cognitively impaired female residents in the facility which resulted in an Immediate Jeopardy.”

Our Memphis nursing home abuse attorneys recognize a failing to follow procedures and protocols to protect every resident from sexual assault places that resident in immediate jeopardy along with all the other female residents at the facility. The deficient actions of the nursing staff and Administrator at Poplar Point Health and Rehabilitation Center might be considered abuse, mistreatment or negligence because their practices did not follow the facility’s September 2015 policy title: Abuse Policy that reads in part:

“The definition of sexual abuse was any abusive sexual nature including harassment, coercion or assault. The policy also stated all allegations of abuse or neglect must be thoroughly investigated by the facility and a verbal notification to the State Department of Health or other regulatory agencies.”

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QUALITY CARE CENTER OF MEMPHIS
1755 Eldridge
Memphis, Tennessee 38108
(901) 278-3840

A “For-Profit” 48-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Provide All Necessary Treatment to Prevent the Development of a Facility Acquired Bedsore or Allow an Existing Bedsore to Heal

In a summary statement of deficiencies dated 04/02/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure the weekly skin assessments include the stage of the pressure ulcer.” In addition, the state investigator noted the facility’s failure “to follow the physician’s treatment order for two [residents at the facility] with a pressure ulcer.”

The deficient practice was noted by state investigator reviewed a facility’s 12/10/2014 Pressure Ulcer Risk Evaluation Assessments that revealed the resident “was at high risk for developing pressure ulcers.” The investigator also reviewed the 03/16/2015 One Practitioner Note that documented the resident had an “unstageable pressure ulcer right heel wound with eschar.”

The investigator noted that the weekly Wound Progress Notes and weekly one assessment notes performed every week from October 2014 through February 2015 “did not always include the stage” of the resident’s bedsore.

An interview was conducted by the state investigator with the facility’s Director of Nursing at 10:04 AM on 04/02/2015 where the Director was asked about the resident’s “right heel. The Director of Nursing stated, ‘when it first started out as an abrasion? I don’t remember when it started, had a small abrasion on heel. By looking at these notes, it doesn’t look like it healed’.”

The investigator made observations of wound care provided to the resident at 1:32 PM on 03/31/2015 by Licensed Practical Nurse providing care to the resident’s left heel. The Licensed Practical Nurse “took a skin prep wipe and wiped the left heel […and] then left the skin prep on the heel and wrapped with Kerlix.” Licensed Practical Nurse “did not follow the physician’s orders.”

In an 8:02 AM 04/01/2015 interview, the state investigator asked the Director of Nursing if “she looked at the [resident’s heel] left wound.” The Director of Nursing replied, “I redressed it. It has scabbed over.” However, when the Director was informed “the nurse cleaned his left heel wound with skin prep during the wound care on 03/31/2015 and there was an order on 03/30/2015 [by the resident’s physician] to discontinue the skin prep to the left heel and apply Vaseline.” The Director of Nursing replied, “I wrote that order. It is supposed to be Vaseline.”

Our Memphis nursing home neglect lawyers recognize a failing to follow protocols and provide all necessary treatment to allow an existing bedsore to heal could place the health and well-being of the resident in immediate jeopardy. The deficient practice by the nursing staff at Quality Care Center of Memphis might be considered negligence or mistreatment because their actions failed to follow state and federal nursing home protocols.

ASHTON PLACE HEALTH and rehabilitation CENTER
3030 Walnut Grove Rd
Memphis, Tennessee 38111
(901) 458-1146

A “For-Profit” 211-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Provide Every Resident Necessary Services and Care to Ensure Their Highest Well-Being Is Maintained

In a summary statement of deficiencies dated 05/11/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “follow a physician’s order for restorative nursing therapy.” This deficient practice of the nursing staff at Ashen Place Health and Rehabilitation Center affected one resident “reviewed for restorative nursing services.”

The deficient practice was noted by the state investigator who reviewed the resident’s 02/15/2015 physician’s orders for restorative physical therapy and occupational therapy making reference that the resident was “non-ambulatory.” However, the “facility was unable to provide documentation [that the restorative therapy had been provided].”

The investigator reviewed the resident’s Quarterly Minimum Data Set with Assessment Reference Date (ARD) of 03/02/2015 documenting that the resident “had a cognitive summary score of 14 out of a possible 15.” This score indicates that the “resident was cognitively intact, required extensive assistance of staff or transfer, hygiene and bathing, was non-ambulatory, was unsteady while standing and transfer and had no impairment in a functional range of motion.”

As a part of the investigation, the state surveyor interviewed the resident 11:55 AM on 05/05/2015 in the resident’s room revealing the resident “to be alert and oriented to person, place, time and situation. The resident was asked if she was able to get up and about.” The resident replied, “I can’t stand by myself, my legs are very small. I get up and go to the beauty shop, I can stand and pivot with the CNA’s (Certified Nursing Assistant) help to the wheelchair. I’m supposed to be having therapy.”

The surveyor conducted a 1:00 PM 05/08/2015 interview with the B-Wing Nurse’s Station nurse who was “asked how the facility process physician’s orders for restorative nursing services.” The nurse replied, “the nurse will place a physical order in [the physical therapy’s] box.” The surveyor then asked, “how did restorative nursing did not get started for [the resident].” The nurse replied, “I’m not sure.”

An interview was conducted with a different nurse and 9:30 AM three days later on 05/11/2015 in the transitional room who “was asked why the restorative nursing did not start working with [the resident] when the order was written on 02/15/2015.” That nurse replied that the physician “wrote the order in February 2015. The weekend nurse let the ball drop there. The order never made it into the restorative or rehab [logs].”

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WHITEHAVEN COMMUNITY LIVING Center
1076 Chambliss Road
Memphis, Tennessee 38116
(901) 396-8470

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

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

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

In a summary statement of deficiencies 6/10/2015 a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “ensure residents at risk for falls were adequately supervised, had appropriate interventions implemented for each fall.” This deficient practice effective for two residents at the facility.” In addition, the state investigator noted the facility’s “failure to provide adequate supervision to prevent injuries from falls resulting in actual harm to [a resident].”

The deficient practice was noted after state investigator reviewed a resident’s 01/13/2014 Fall Risk Care Plan documenting “fall risk related to attempts at unassisted ambulation with a history of Falls and throwing herself out of bed and or chair, seizure disorder, schizophrenia, vascular dementia with depression. The goal for this problem documented: Will minimize risk for falls and injuries through next review on 04/14/2015. The approaches for this problem include [keeping] the resident in travel areas/staff view when up.”

However, even though the risk fall Care Plan noted that the resident should remain in view of the staff in travel areas to minimize the potential of falling, the surveyor noted that a review of the 11:30 AM 01/20/2015 Nurses’ Progress Note: Heard noise from room, observed resident on the floor in front of Geri-chair.” Notations made in the facility’ is investigation documented: Conclusion: Resident can’t be left unattended while up in chair even with safety measures in place.”

The 1:00 PM 03/25/2015 Nurses Progress Note documents: Heard noise from room observed resident on the bottom in front of the chair, crying, no apparent injury, denies hitting the head.”

Later that same day at 6:00 PM, the nurses progress note documents that the resident has “increased pain to left-hand little finger area upon observation site swollen with some bruising noted. Also, pain voiced with hand movement. Received new order for an x-ray of the left hand.” Later that evening at 10:00 PM, the nurses progress notes documents: x-Ray: acute: acute fifth metacarpal fracture.”

The state investigator he interviewed the Director of Nursing at 10:15 AM on 06/10/2015 and asked, “what you would expect the nursing staff to do when the resident was up in the Geri-chair to prevent falls.” The Director of Nursing replied, “I would expect them to have her in bed if she were in her room and have her in sight if up in a Geri-chair.”

At the conclusion of the investigation, the investigator noted the facility’s failure to provide adequate supervision to prevent injuries from falls resulted in the actual harm of [the resident].”

Our Memphis nursing home neglect attorneys recognize that failing to follow protocol to ensure that every resident is provided an environment free of accidents and provide adequate supervision to prevent an avoidable accident could place the health and well-being of the resident in immediate jeopardy. The deficient practices of the nursing staff at Whitehaven Community Living Center failed to follow established procedures and protocols including the facility’s policy title: Fall Risk Management that reads in part:

“Residents will be assessed for fall risk potential. Interventions will be implemented as needed to help manage the potential for falls and assist in minimizing the risk. Interventions will be re-evaluated for effectiveness during Care Planning and as needed. The Fall Risk Care Plan is to be updated after each fall, quarterly and with any significant change in condition.”

Signature HEALTHCARE AT SAINT FRANCIS
6007 Park Ave
Memphis, Tennessee 38119
(901) 765-3110

A “For-Profit” 197-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 Programs That Control Infection from Spreading throughout the Facility to Ensure the Safety and Well-Being of All Residents

In a summary statement of deficiencies dated 04/15/2015, a complaint investigation was opened against the facility for its failure to “ensure practices to prevent the potential spread of infection when [a Certified Nursing Assistant at the facility] failed to follow isolation guidelines.”

The deficient practice was noted by the state surveyor after reviewing a resident’s 08/01/2014 laboratory report documenting the resident had an “Acinetobacter baumannii multiple drug resistant organism. The physician reviewed the lab report and documented, colonized.” The surveyor noted that the 04/01/2015 Physician’s Progress Note documented that “the patient remains in isolation for respiratory colonization with Acinetobacter.” The resident’s 05/23/2014 Care Plan [some 11 months prior the resident’s recent laboratory report] documents that the resident “has colonized infection in his sputum required contact isolation.”

However, the state investigator made an observation of the resident’s room at 12:03 PM on 04/13/2015 and interview the resident. The observation “revealed a CNA (Certified Nursing Assistant) put on a disposable gown and gloves and enter the room. After washing [the resident’s] face with a washcloth, she pulled up the disposable gown and reached into her uniform pocket with her contaminated glove to obtain a clear plastic bag to place the soil washcloth and. The plastic bag was on the residents bed.”

The state investigator also noted that the Certified Nursing Assistant then “place a washcloth into the point clear plastic bag […and] remove the tape fasteners of the wet adult diaper including the perineal area with disposable wipes. Her gown was not tied at the neck and continuously fell off her shoulders onto the contaminated surfaces and she used contaminated gloved hands to pull her gown back up to on her shoulders, touching her uniform.”

The Certified Nursing Assistant then placed the soiled diaper “in the clear plastic bag with the washcloth and the disposable wipes, closed with a knot and placed in an open trash can in the resident’s room.” The surveyor noted that the Certified Nursing Assistant then “remove the soiled gloves and washed her hands, re-gloved and then applied a clean adult brief. She removed the resident’s gown, pulled up her disposable gown, reached into her uniform pocket with her contaminated glove for a clear plastic bag, place it on the residents bed and placed the gown into the clear plastic bag. She placed the clear plastic bag with the contaminated linen on a table in the room.”

The investigator also noted that there “was no isolation linen barrel in the room.” The Certified Nursing Assistant “then removed her gloves and disposable gown and washed her hands.” When asked “what she should do with the linen bag” the Certified Nursing Assistant replied, “oh, I forgot.” At that point, the Certified Nursing Assistant “picked up the contaminated bag with her ungloved hand and took it out of the isolation room in place in the linen hamper and rolled the hamper down the hall.”

As a part of the investigation, the state surveyor conducted an interview at 10:00 AM on 04/16/2015 with the facility’s Director of Nursing who “was informed of the observation and asked what would she expect for the care of residents in contact isolation.” The Director of Nursing replied, “she [the Certified Nursing Assistant] should not have gone back into get the bag of linen without re-gloving and the bag shouldn’t have been brought out of the isolation room, and should have gone in the barrel in the room.”

Our Memphis nursing home neglect lawyers recognize failing to follow protocol when providing care and services to residents with communicable infections could place the health and well-being of other residents and employees in immediate jeopardy. The deficient practice by the nursing staff at Signature Healthcare at St. Francis might be considered negligence or mistreatment of the residence because their actions did not follow established procedures, protocols and policies including the facility’s policy title: Isolation-Initiating Transmission-Based Precautions that reads in part:

“Transmission based precautions will be initiated when there is a reason to believe that a resident has a communicable infectious disease. Transmission-based precautions may include contact precautions. Ensure that appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident’s room.”

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GOLDEN LIVINGCENTER – SOUTHAVEN
1730 Dorchester Dr.
Southaven, Mississippi 38671
(662) 393-0050

A “For-Profit” 140-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Provide Necessary Services Including Quality Lab Services and Tests in a Timely Manner to Meet the Needs of the Residents

In a summary statement of deficiencies dated 09/30/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “obtain lab as ordered for [3 residents at the facility].”

The deficient practice was noted by the state investigator after a review of a resident’s lab results result of that there was “no Urine C&S [urine culture and sensitivity study] results on the chart for 08/21/2015.” The investigator asked the facility’s Director of Nursing to “provide the results of the ordered lab test.”

In a 12:00 PM 08/29/2015 interview with the facility’s Director of Nursing, it was revealed that the “facility failed to obtain the urine C&S as ordered […and] the resident was at [a different facility receiving treatment] the day it was ordered, and it appears it was not obtained upon her return.”

The state investigator then reviewed the resident’s Significant Change in Status Minimum Data Set with Assessment Reference Date (ARD) on 07/09/2015 revealing that the resident “had a Brief Interview for Mental Status (BIMS) score of 15, which indicated [the resident] was cognitively intact.”

During an investigation and review record of another resident at the facility, it was revealed that that resident’s lab results documented “that there were no hemoglobin A1c results in the chart for January 2015.” Again, “the Director of Nursing attempted to locate the results, but was unable to do so.”

The state investigator conducted a. 08/30/2015 interview with the facility’s Director of Nursing who “confirm that the hemoglobin A1c due in January 2015 for [that resident] was not drawn, confirming that the physician’s orders [were not followed].”

A review of the resident’s Annual Comprehensive Minimum Data Set with Assessment Reference Date (ARD) of 08/07/2015 revealed “a Brief Interview for Mental Status (BIMS) score of nine, which indicated [the resident’s] cognitive is moderately impaired.”

The investigator then reviewed the resident’s 09/22/2014 laboratory results revealing “there were no hemoglobin A1c results on the chart.”

Our Southaven nursing home neglect attorneys recognize failing to follow protocols and provide necessary services including quality lab services and tests according to the physician’s orders could place the health and well-being of the resident an immediate jeopardy. The deficient practice by the nursing staff at Golden Living Center – Southaven might be considered negligence or mistreatment because their actions did not follow established protocols enforced by federal and state nursing home regulations.

GRACE HEALTHCARE OF CORDOVA
955 Germantown Pkwy
Cordova, Tennessee 38018
(901) 754-1393
A “For-Profit” 240-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Provide Every Resident Proper Treatment to Prevent the Development of a New Bedsore or Allow an Existing Bedsore to Heal

In a summary statement of deficiencies dated 09/24/2015, a complaint investigation against the facility was opened for its failure to “put preventative measures in place prior to the development of bedsores.” The complaint investigation also included the facility’s failure “to put preventative measures in place prior to the development of elbow pressure sores […and a failure to] timely identify, accurately assess and or treat pressure ulcers [that] resulted in actual harm to [a resident at the facility].”

As a part of the investigation, the state surveyor conducted a review of the resident’s quarterly MDS revealing that the resident’s Brief Interview for Mental Status (BIMS) score was “3” indicating the resident “as severely impaired cognitively and did not have any documented ones at that time.”

The resident’s 07/04/2013 (revised 08/14/2015) care plan documented: Has actual potential for skin breakdown related to mobility and incontinence. Left elbow Stage III, Stage IV on right elbow. Approaches: teach family/significant others risk factors for the development of pressure ulcers. Report any changes in skin condition. Pressure relief mattress. Administer medication as ordered to manage contact. Turning repositioned routinely and PRN (as needed). Ear protectors. Podus boots. Incontinence care as needed. Treatment as ordered 08/14/2015. Vitamins and supplements as ordered. Laboratory test as ordered.

The state investigator reviewed the resident’s 05/13/2015 and 08/17/2015 Braden Scale risk assessment reports that indicate the risk the resident has for developing pressure ulcers that indicated that “the resident was at high risk for developing pressure ulcers.”

However, the investigator noted that the resident’s “bath roster did not document bathing or skin assessments from 08/07/2015 until 08/14/2015.” This is important because the resident’s 08/03/2015 shower/skin assessment form “completed by a Certified Nursing Assistant documented: Wound on the right elbow and on 08/05/2015 documented: sore on right elbow.”

The Director of Nursing indicated that she had spoken to the Licensed Practical Nurse on 08/14/2015 who acknowledged “they should have been made aware of the area on the elbow [by the Certified Nursing Assistant] stated, I just forgot, I missed it.” The Director of Nursing indicated that she then spoke to a registered nurse “loss of knowledge that she was made aware of the area on the elbow and stated, ‘I signed the sheet and really did not look at it (the elbow) because I was so busy.’ No new interventions or treatment were implemented on 08/03/2015 or 08/05/2015 when the pressure ulcers were discovered.”

The surveyor noted that a 2:41 AM 08/14/2015 Nurses No documented “when the resident was turned to clean and change, a 3.0 centimeter by 2.0 centimeter wound was noted to the area but right elbow, wound is tan color, slough tissue noted.” Later that same morning at 7:36 AM, the nurses notes revealed: “skin assessment completed, was found both elbows, an open area to sacral, and a sealed scratch to the right buttock.”

Later that day at 12:09 PM, the Nurse’s Notes document: “open area to the right elbow, yellow slough present with purulent drainage. Left elbow has abrasions and scabbing, shearing noted to left buttocks. A wound assessment documented unstageable pressure ulcers to the left and right elbows.”

The wound care specialist evaluating the resident’s pressure ulcers noted that the left and right elbows at Stage IV pressure ulcers that are recognized as advanced stage, life-threatening bedsores.

At a 40 a.m. on 09/23/2015, observations were made of the resident in the resident’s room will reveal the resident “had a healing Stage IV wound on her left elbow dry and no color with granulation tissue present. The right elbow had a wound 3.0 centimeters in diameter appear to have the same undermining at the edge toward the upper arm with some yellow slough noted on the wound bed and no older.”

In an interview with the Certified Nursing Assistant providing the resident care the nurse revealed that “I did notify the nurse there was a wound on her right elbow.” The Certified Nursing Assistant was then asked if the resident “had any protectors on her elbows on 08/14/2015.” The CNA responded, “No, nothing on her elbows. She had nothing else in place.”

The Director of Nursing and the Nurse Consultant were interviewed at 2:15 PM on 09/23/2015 who was asked: “if there were no shower sheets provided, did that mean there were no skin assessments performed.” The nurse consultant replied, “if not documented, not done.”

At the conclusion of the investigation, the state surveyor noted that the facility “failed to put preventative measures in place prior to the development of pressure sores, nurses failed to timely identify, accurately assess and or treat pressure ulcers [which] resulted in actual harm when [the resident] developed unstageable pressure ulcers to the right and left elbows.”

Our Cordova nursing home neglect attorneys recognize a failing to follow protocols when providing treatment to prevent the development of a bedsore has the potential of causing life-threatening bedsores on the skin of the resident. The deficient practice by the nursing staff at Grace Health Care of Cordova might be considered negligence or mistreatment because their actions failed to follow established procedures and protocols enforced by federal estate nursing home regulations.

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THE KINGS DAUGHTERS AND SONS
3568 Appling Road
Bartlett, Tennessee 38133
(901) 272-7405

A “Not for Profit” 108-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Provide Every Resident Proper Treatment to Prevent the Development of a New Bedsore or Allow an Existing Bedsore to Heal

In a summary statement of deficiencies dated 10/21/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “document weekly skin assessment with a description was stage, size depth, width or presence or absence of drainage”. The deficient practice by the nursing staff at The Kings Daughters and Sons affected two residents at the facility with pressure ulcers.

The deficient practice was noted by state surveyor conducting a review of a resident’s medical records noting that the resident “was admitted to the facility in May 2015. As a part of the resident data collection and mission assessment, it was revealed that the resident had a “reddened area the sacrum.”

The resident’s Nurse’s Notes also revealed a 05/14/2015 document noting the reddened sacral/coccyx area and “Medical Doctor present with new orders noted.” The 06/05/2015 Nurse’s Notes indicate that an open area was noted on the resident’s buttocks and treatment was implemented. Three days later on 06/08/2015, the Nurse’s Notes revealed the resident now had a Stage II sacral bedsore related to incontinence associated damage.

By 06/17/2015, notations are made in the Nurse’s Notes that assessments have been taken indicating a rash in the perineal area with noted right buttocks wound measuring 1.4 centimeters by 0.8 centimeters by 0.1 centimeters.

The following day, the Physician’s Progress Note documents that there is “open area to the sacrum.” Another notation made in the Physician’s Progress Note’s on 05/29/2015 indicate a Stage II pressure ulcer.

However, the state investigator notes that on specific days including 05/24/2015, 06/07/2015 and 07/04/2015 on the weekly skin assessments that “skin assessments were performed with no wound measurements documented. No other weekly skin assessments or wound assessment reports were provided by the facility for [that resident].”

The state investigator interviewed the facility’s Director of Nursing at 5:52 PM on 10/21/2015 and “was asked if weekly skin assessments were performed for [the resident].” The Director of Nursing replied, “No, not that I can see.”

A full review was then performed on the resident’s departmental notes when assessment reports, Weekly Pressure Ulcer Record, physician progress notes and wound care notes dated between 06/01/2015 and 10/19/2015. However, there were “no weekly assessments or wound measurements for the sacral and left posterior thigh pressure ulcers for weeks of 06/22/2015, 08/03/2015 08/17/2015.”

The state investigator then conducted an interview with the facility’s Director of Nursing and the MDS Coordinator at 4:45 PM on 10/21/2015, where the Director of Nursing “was asked how often wound assessment should be done.” The Director replied, “Weekly.” When asked if measurement should be taken, the Director replied, “Yes.”

Our Bartlett nursing home neglect attorneys recognize a failing to follow procedures and protocols when providing treatment to residents with developing bedsores could place their health and well-being in grave danger. The deficient practice by the nursing staff at The Kings Daughters and Sons might be considered negligence or mistreatment because their actions failed to follow the NPUAP [National Pressure Ulcer Advisory Panel] quick reference guide that reads in part:

“Ongoing assessment of the skin is necessary to detect early signs of pressure damage. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if necessary. Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals.”

RAINBOW HEALTH and rehabilitation OF MEMPHIS
8119 Memphis-Arlington Road
Bartlett, Tennessee 38133
(901) 743-1135

A “For-Profit” 115-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Ensure That Therapeutic and Special Diets Were Provided to the Residents as Ordered by the Attending Doctor

In a summary statement of deficiencies dated 08/26/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “provide the correct therapeutic diets as ordered by the physician.” This deficient practice affected “three residents observed during dining observations.”

The deficient practice was noted by the state investigator reviewing the resident’ as medical records noting that the resident “was admitted to the facility with a developed Care Plan on 07/29/2015 that documents: “Provide me my diet as ordered. The physician ordered: Diet Order: Regular. The nutritional therapy assessment dated 07/22/2015 documented: Diet Order: Regular.

The state investigator observed the resident’s room at 12:25 PM on 08/24/2015 revealing that a Certified Nursing Assistant “brought in a meal tray and set up it up for the resident [consisting] of turkey and gravy, noodles, water, cranberry juice and a roll.

The meal ticket on the tracer to the resident documented in part: “No salt added. Monday: lunch 8/24/2015, roast turkey, turkey gravy, noodles, water eight ounces, cranberry juice four ounces send extra four ounces of fluid.”

A few minutes later at 12:29 PM, an interview was conducted with the Licensed Practical Nurse providing the resident care who works at the 100 Hall Nurses Desk who “was asked to check the meal ticket on [that resident’s] tray.” The Licensed Practical Nurse entered the resident’s “room, looked at the resident’s armband and then check the meal ticket.” At that point, the Licensed Practical Nurse called for the Certified Nursing Assistant who “entered the resident’s room and stated to the resident, ‘Hold on, because you have the wrong tray. I’m going to take this, and I’ll give you another one. Sorry about that’.” The CNA removed the tray of food from the room.

The state investigator interviewed the facility’s Registered Dietitian at 9:10 AM on 08/26/2015 who “was asked what the difference was between and NAS diet and regular diet.” The Registered Dietitian responded that “the NAS does not have the salt packet.”, The Registered Dietitian “was asked whether based on physician’s orders [the resident should have received that meal tray?]. The Registered Dietitian responded, “Absolutely not.”

An interview was then conducted 11:06 AM on the same day with the facility’s Director of Nursing who “was asked whether she expected the staff to always identify the resident before serving the meal.” The Director of Nursing then replied, “Yes they should.” The Director of Nursing also agreed that it was unacceptable to bring the NAS diet to the resident.

Our Bartlett nursing home neglect attorneys recognize a failing to follow procedures and protocols when providing special diets and therapeutic care to residents could place their health and well-being in jeopardy. The deficient practice by the nursing staff at Rainbow Health and Rehabilitation of Memphis might be considered negligence or mistreatment because their actions did not follow the resident’s physician’s orders.

Obtaining Justice in a Nursing Home Abuse Case

While the majority of nursing facilities provide an excellent level of care to their residents, the number of cases involving neglect, mistreatment and abuse are far too high. Unfortunately, many nursing facilities place profits ahead of quality care by cutting corners and reducing staff that is often to the detriment of the nursing home resident. The desire of the administrator, corporation and management at the nursing home to obtain huge profits often places the elderly loved one in harm’s way.

Any change in the resident’s health conditions can diminish their quality of life and even cause premature death. Many residents suffer physically, mentally and emotionally from neglectful, abusive situations. Identifying abuse and neglect can be frustrating and challenging, especially for residents who lack the capacity to speak up to protect themselves.

Unfortunately, many families are unaware of the warning signs and symptoms of an elderly individual experiencing abuse, neglect and mistreatment. The most common signs involve:

  • Facility acquired pressure ulcers
  • Unusual weight gain or weight loss
  • Poor hygiene and/or unsanitary conditions
  • Hazardous areas including slippery floors
  • Unauthorized physical or chemical restraint used as a convenience to assist the nursing staff
  • Indicators of dehydration and malnutrition
  • Unexplained bruises, broken bones, fractures, lacerations or other injuries
  • Withdrawal of the resident from normal activities that might involve a sudden onset of depression or significant change in mood
  • Medication error

A nursing home abuse case does not always involve physical trauma. Many times, caregivers, administrators and nursing facilities are held legally accountable because they simply ignored the needs of their residents. However, proving a case in court to obtain justice, financial recompense and accountability is complex. Because of that, many families will hire a personal injury lawyer who specializes in nursing home abuse cases.

Hiring a Lawyer

The Memphis nursing home abuse attorneys at Rosenfeld Injury Lawyers LLC are aggressively competent in fighting for the rights of nursing home residents seeking financial compensation and justice for their harm. Our Tennessee elder abuse law firm remains dedicated to ending the neglect, abuse and mistreatment occurring in nursing facilities all across the state. We have a personal understanding of the family’s desire to protect and preserve their loved one’s respect, dignity and quality of life during this difficult time of their life.

If you suspect your loved one is the victim of neglect, abuse or mistreatment, we encourage you to call our law offices today at (888) 424-5757. We accept every nursing home neglect, personal injury and wrongful death case through a contingency fee arrangement. This is our no recovery, no payment guarantee. All of our services are paid only after we have negotiated an acceptable out of court settlement or win your case at trial.

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