After spending a lifetime of contributing to the community and making Nashville the wonderful place it is, senior citizens have earned the right to receive the highest quality care. Unfortunately, many nursing home residents are victimized by caregivers who are given the responsibility to ensure their health and well-being. The Nashville nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC have handled many cases where the victim is left only with the severe consequences of mistreatment that might involve physical injury, emotional trauma, mental anxiety, depression and, at times, death.
Nearly 650,000 residents live within the Nashville city limits, where more than 80,000 our senior citizens. The aging population is even higher when accounting for all of the retirees living throughout Davidson County. The number of elders in the community has risen significantly over the last few decades as many individuals in the baby boomer generation have chosen to make Nashville the ideal place to live during their retirement years.
Unfortunately, this increase of seniors has placed a significant burden on nursing homes, assisted living centers and rehabilitation facilities throughout the county. As a result, many nursing homes of become overcrowded and unable to meet the needs and demands of all of their residents. In addition to the overcrowded conditions, many facilities are understaffed by overworked doctors, nurses, nurses aides and employees who often become frustrated in their workplace to the detriment of their residents.
Nashville Nursing Home Resident Health Concerns
Even though nursing facilities and assisted-living homes are designed to provide a high level of care to the residents, the reality is often much different. Too many nursing personnel and staff members choose to neglect or abuse the residents under their care in various ways. Some cases of abuse are obvious where the resident suffers broken bones through a deliberate act or unsupervised fall. Other cases are not as obvious where the victim is neglected due to the facility’s conditions, minimal staffing or the uncaring nature of one or more nurses, doctors or employees at the home.
For years, our Nashville elder abuse law firm has guided family members to the complex legal system when their loved one has become a victim of mistreatment. In addition, we routinely evaluate and assess publicly available information from federal and state databases including Medicare.gov that rates every nursing facility across the nation. Our Davidson County nursing home neglect lawyers review nursing home opened investigations, filed complaints, safety hazards, state surveys and health violations involving nursing facilities all throughout Tennessee.
Comparing Nashville Nursing Area Facilities
The list below outlines the Nashville nursing area facilities that currently maintain below average ratings compared to other facilities throughout the United States. In addition, our team of elder abuse lawyers have posted primary concerns about the facility and have detailed our concerns about specific cases that directly or indirectly cause the resident harm, injury or death. Many families use this information as an effective tool before placing a loved one in a nursing facility to ensure they receive the highest care available.
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:
- Tennessee Nursing Home Bed Sore Case Valuation
- Tennessee Nursing Home Abuse Valuation
- Tennessee Nursing Home Fall Cases
Signature Healthcare Natural Rehabilitation & Wellness Center
832 Wedgewood Avenue
Nashville, Tennessee 37203
A “For-Profit” 119-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Provide Adequate Nursing Staff to Ensure That the Needs of the Residents Are Met
In a summary statement of deficiencies dated 10/05/2015, a complaint investigation was opened against the facility for its failure to “provide sufficient nursing staff to meet resident’s needs for nursing care in accordance with the resident Care Plan.” This deficient practice by the nursing staff at Signature Healthcare Natural Rehabilitation and Wellness Center affected five residents at the facility.
A state investigator reviewed a resident’s medical records and Quarterly MDS (Minimum Data Set) that revealed that “the resident was moderately cognitively impaired; required extensive assistance for transfers, bed mobility, toilet use and bathing; extensive [one person] assistance for hygiene; and was frequently incontinent of bladder.”
The state investigator reviewed the resident’s 04/17/2015 Care Plan revealing that the resident was self-sufficient for ADL (activities of daily living) and “is at risk for complications related to deficient approach staff to provide only the amount of assistance/supervision to meet the resident’s needs for all ADL (activities of daily living).”
The complaint investigation involved in incident logged in the 09/14/2015 Complaint / Grievance Report that revealed in part: Reports this morning that there is not enough staff. “My people are hearing from your people that there is not enough (staff) and that sometime over the last couple of days the Nurse reported there were no CNAs [Certified Nursing Assistants] available. This is looking like a pattern.”
The state investigator conducted a 9:04 AM 09/21/2015 interview with the resident in the “resident’s room. When asked about the care and staff stated, ‘there isn’t enough staff to meet the needs of the residents. I have to wait hours to get the call light answered’.” The resident was asked “how long she had to wait a long time, the resident stated three times in the past month. I can’t do anything by myself.”
The state investigator then asked, “if she had been incontinent due to the long wait.” The resident replied, “I’ve been wet about three times because they didn’t answer the call light. I feel terrible. Dirty. Raised all your life not to soil yourself.” When asked what time of day she had to wait for assistance the resident stated, ‘More later at night. Second shift’.”
The investigator reviewed the Nurse Staff Schedule and Assignments at the facility between the 7:00 PM and 7:00 AM shifts along with the 09/08/2015 Time Detail for the Nurse Staff listed on the schedule. The information revealed “on the 600 unit with a census of 34 residents, [the facility had] two Licensed Practical Nurses working for a total of 20.5 hours and one CNA [Certified Nursing Assistant] working for a total of 3.5 hours.”
A closer review of a Certified Nursing Assistant’s time detail record revealed that the CNA “clocked out at 10:30 PM leaving the unit with no CNA [on-duty] from 10:30 PM until 7:00 AM.”
The investigator then reviewed the same set of schedules and assignments documented on 09/18/2015 revealing that the same 600 unit with a census of 39 residents in the facility and that unit had only two Licensed Practical Nurses “working a total of 23.7 hours and one [Certified Nursing Assistant] working 10.8 hours.”
An interview was conducted by the state investigator at 4:54 AM on 09/22/2015 with the facility’s Licensed Practical Nurse (LPN) in the 600 unit dining room. The LPN was asked, “if there had been a night with only one CNA or none.” Licensed Practical Nurse answered, “Yes, it has happened. We had a CNA and were not sure what time she left (at 9:30 PM or 10:00 PM) we were looking for her but we couldn’t find her.”
When the state investigator asked the Licensed Practical Nurse why the Certified Nursing Assistant left the facility, the LPN replied, “She was the only one here. Someone called off or someone was a no call/no show. We notified supervisor [but] we didn’t get any help.” During the interview, the LPN also stated that “The other units were working with less staff also and we did not have anyone to send to help on the 600 unit.
An interview was conducted at 1:20 PM on 09/22/2015 with the facility Administrator who was asked: “if there had been a time recently when the unit worked with no CNAs.” The Administrator responded, “No. I can’t recall anything like that happening.” The investigator then asked the Administrator if “it would surprise her to know that it happened and it was recent?” The Administrator replied, “We have a lot of staff and is not something I would want to happen. I find it hard to believe.”
The Administrator reply during the interview that she was not made aware of the staffing problem. The Administrator also said that the residents could receive necessary care to meet their needs because when required, “the nurses pitch in and change people, answer call lights.” The state investigator then asked the Administrator “if it was acceptable to have a unit of 39 residents staffed with one Certified Nursing Assistant.” However, “the Administrator did not respond.”
The following week, the Administrator was interviewed again at 11:15 AM on 09/29/2015 in regards to a 09/08/2015 Call Light Audit and “was asked if the times were acceptable according to the policy [in the amount of time to for the nursing staff to answer the resident’s call light].” The Administrator responded, “No, the times are not acceptable. Should be 3 to 5 minutes.”
Later that day the Administrator was again interviewed at 12:30 PM and was “asked about staffing and while she presented a staff posting, stated “We are way over. We have a lot of staff.” The investigator then asked if the Administrator “had ever broken [the data] out and looked at the night shift only?” The Administrator replied, “No, we are more staff-challenge on that shift.”
The administrator was then asked about “what the expectation of incontinence care for the residents [would be] and the situation expressed by [the resident interviewed by the state investigator].” The Administrator responded, “Even two hours is not acceptable if you’re alert and aware.”
Our national nursing home neglect attorneys recognize the failing to provide adequate staffing to meet the needs of every resident could place a health and well-being of the resident in jeopardy. The deficient practice by the nursing staff failed to follow multiple policies of the facility including their October 2009 facility policy title: Answering the Call Light along with the facility’s policy title: Call Light Response Time and Toileting that both read in part:
“Answer the resident’s call soon as possible. Do what the resident asks of you, if permitted. If you have promised the resident that you will return with an item or information. Do so promptly.”
“Respond to the resident’s call light/needs immediately (3 to 5 minutes). Response time to all residents call light is 3-5 minutes. All nursing staff is responsible for ensuring all residents are toileted in a timely manner.”
CRESTVIEW HEALTH AND REHABILITATION CENTER
2030 25th Ave North
Nashville, Tennessee 37208
A “For-Profit” 111-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Ensure the Nursing Home Is Free of Accident Hazards and Adequate Supervision Is Provided to Prevent Avoidable Accident from Occurring
In a summary statement of deficiencies dated 10/08/2015, a complaint investigation against the facility was opened for its failure to “conduct and provide a fall investigation and complete neurological (neuro) check for [3 residents at the facility].”
The investigation included a review of a resident’s Admission MDS (Minimum Data Set) revealing that the resident had a Brief Interview for Mental Status (BIMS) score of nine indicating “moderate cognitive impairment. The assessment confirmed [the resident] had fallen last month prior to admission […and that the resident] had a fall 2 to 5 months prior to admission and [that the resident] had a fracture related to a fault in the six months prior to admission to the facility.”
At the investigator reviewed the resident’s Quarterly MDS (Minimum Data Set) confirmed that the resident “had a fall since admission.” The incident reports revealed that the resident had a witnessed no injury fall occurring on 05/10/2014 and an unwitnessed fall on 05/19/2015 causing a left iliac crest, abrasion left elbow, a hematoma to the left ear. The next documented an unwitnessed no injury fall occurred on 07/10/2014 followed by a witnessed, no injury fall on 07/16/2014, followed by an unwitnessed fall on 08/01/2014 and two unwitnessed, no injury falls on 09/30/2014 and 10/03/2014.
The state surveyor noted that there were no investigations conducted by the facility for the fall stated above.
At 10:53 AM 10/06/2015, the state inspector interviewed the facility’s Acting Director of Nursing who was asked “about the investigations for [the resident’s] falls. The acting Director of Nursing stated, ‘I can’t find the investigation for all these falls’.”
The investigator then asked the Acting Director of Nursing at 3:30 PM two days later on 10/08/2015, “What do you expect of your staff when a fall occurs?” The Director of Nursing replied, “I expect them to put interventions in the computer, assess the resident, do a pain assessment, fall assessment, and an SBAR (Situation, Background, Assessment, Recommendation) Change of Condition form.”
The Acting Director of Nursing also stated, “If it is an unwitnessed fall, we do the neuro checks. If we know they hit their head, we send them out for an evaluation. When they come back we should continue them (neuro checks) if they were not admitted to the hospital. We usually review every fall in the morning meetings.”
The acting Director of Nursing stated that during the morning meetings, “we go over the falls, and we go over the investigation reports […and] determine if the intervention is accurate and if they need another intervention. The care plan should be done immediately with the fall, but if a better one (intervention) is determined, we change it.” The Acting Director of Nursing stated that the Director of Nursing, Social Worker and Wound Care Nurse along with the MDS Coordinator and Nurse Educator attend the morning meetings.
Our Nashville nursing home neglect lawyers recognize that failing to follow procedures and protocols when a resident has a single fall could place the health and well-being of the resident in jeopardy. The deficient practices of the nursing staff at Crestview Health and Rehabilitation Center might be considered negligence or mistreatment because no interventions, assessments or evaluations were performed on the resident who had numerous repeated falls between 05/10/2014 and 10/03/2014.
In addition, the actions of the nursing staff failed to follow the facility’s policy title: Procedure Post-Fall that reads in part:
Do neuro checks for all unwitnessed falls any time resident is witnessed or reported hitting their head during the fall. Nursing to complete. Start investigation report process to determine the root cause of the fall.”
NASHVILLE COMMUNITY CARE and REHABILITATION AT BORDE
1414 County Hospital Rd
Nashville, Tennessee 37218
A “For-Profit” 419-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Assemble an Ongoing Quality Assessment and Assurance Group to Review Quality Deficiencies on a Quarterly Routine to Develop Corrective Plans of Action
In a summary statement of deficiencies dated 03/26/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s quality assessment and assurance committee’s failure to “identify and address quality assurance issues to identify and implement plans of actions to correct concerns when nurses failed to complete weekly skin assessments and identify pressure ulcers timely, identify the correct anatomical location of a pressure ulcer […and] obtain a physician’s orders.”
This deficient practice by the nursing staff at Nashville Community Care Rehabilitation at Borden affected nine residents at the facility with pressure ulcers.
The deficient practice was noted by a state investigator who outlined the facility’s “failure of the facility staff to complete weekly assessments on residents who are at risk for developing pressure ulcers and identify pressure ulcers before residents develop an unstated pressure ulcer.” The failure of the nursing staff resulted in actual harm for four residents at the facility.
The state investigator conducted a 4:23 PM 03/26/2015 interview with the facility’s QA (Quality Assurance) Coordinator who “was asked what were the concerns discussed in the January 2015 QA meeting [including] what did you do and was it effective?”
The Quality Assurance Coordinator replied, “we did the in-service [training] for the handwashing from December 2014 meeting and that was effective and we had no other issues.” The investigator then asked “what issues were identified in the February 2015 QA meeting [including] what did you do and wasn’t effective?” The QA Coordinator wasn’t there because a member of the nursing staff returned to school to obtain a Registered Nurse license, the facility “has been losing leads and money, so we hired someone in her place. We did an event manager update and did nurse training, now all the falls go in the event manager and they do not give me any paperwork.” The QA coordinator also stated that the computer program used by the Certified Nursing Assistants “was out of compliance, so we educated staff and put announcements in place.”
Less than two hours later, the state investigator conducted an interview with the facility’s Director of Nursing at 5:48 PM. When the Director of Nursing “was asked if the QA committee had identified a trend in pressure ulcers, the Director replied ‘No’.”
Our Nashville elder abuse attorneys recognize that failing to establish an ongoing Quality Assessment and Assurance Group could place the health and well-being of the residents in jeopardy. In fact, the deficient practice by the administration and nursing staff at Nashville Community Care Rehabilitation at Borde might be considered negligence or mistreatment because their actions resulted in actual harm of four residents who developed pressure sores while residing at the facility.
GREENHILLS HEALTH AND REHABILITATION CENTER
3939 Hillsboro Circle
Nashville, Tennessee 37215
A “For-Profit” 150-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Follow Procedures, Practices and Protocols When Administering Medications through Gastronomy Tube
In a summary statement of deficiencies dated 09/24/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “ensure the acceptable standards of nursing care were followed in administering medication via a [gastronomy tube].”
The state surveyor observed a resident in a resident’s room at 4:00 PM on 08/24/2015 where it was revealed that the third floor Registered Nurse “administered pain medication via [the resident’s gastronomy tube].” During the procedure, the Registered Nurse “used a large syringe and attempted to aspirate stomach contents from the resident but nothing was obtained […and] proceeded to administer the medication without having verified the correct placement of the [gastronomy tube].”
An interview was conducted at 4:10 PM on 09/21/2015 with that Registered Nurse who revealed that “she sometimes listens for placement with a stethoscope but not always […and] the resident only gets meds through the tube and not feedings. It is a brand-new [gastronomy tube]. The resident was having a lot of pain and she went to the hospital and got a new [gastronomy tube] placement and now it’s working much better.”
The following day at 9:30 AM on 09/22/2015 the facility’s Director of Nursing provided the state surveyor “the facility policy on Enteral Nutrition and stated it doesn’t say the nurse has to check placement any certain way.” However, a review of the facility’s revised January 2013 policy for Enteral Nutrition “revealed the nurse checks gastronomy placement prior to flushes or medication administration. The policy did not provide how the nurse was to check for placement.”
The state investigator noted that a review of the standards of nursing care for administering medication via the gastronomy tube reveals in part:
“Step one. Check placement by auscultating [listening to] the resident’s abdomen about three inches below the sternum with a stethoscope; gently insert can CC (cubic centimeter) of air into the two. You should hear the bubble entering the stomach. If you hear the sound, gently draw back on the piston of the syringe. The appearance of gastric content implies the two is patent and in the stomach. If no gastric contents appear, the tube may be against the lining of the stomach or the tube may be obstructed.”
Our Nashville elder abuse lawyers recognize that failing to follow procedures, practices and protocols when administering medication through gastronomy tube could place the health and well-being of the resident an immediate jeopardy. The deficient practices by the nursing staff at Greenhills Health and Rehabilitation Center and their established policies might be considered negligence or mistreatment because it does not follow established procedures and protocols adopted by state and nursing home regulators to ensure the resident is provided the highest quality of care.
CUMBERLAND HEALTH CARE AND REHABILITATION CENTER
4343 Ashland City Hwy
Nashville, Tennessee 37218
A “For-Profit” 124-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Efficiently Investigate How a Cognitively Impaired Resident Eloped from the Facility without Supervision or Setting off an Alarm
In a summary statement of deficiencies dated12/9/2015 a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “complete an investigate to determine the root cause of the elopement of [a resident at the facility].”
The deficient practice was noted by state investigator reviewed a resident’s quarterly MDS (Minimum Data Set) revealing that the resident “was severely cognitively impaired […and] ambulatory, wandered daily and his wandering had worsened.”
The failure was revealed in a 5:54 PM 02/05/2015 Nurses Event Note documenting that the resident was “found walking outside the building. At around 2:25 PM, a nurse and a technician saw him walking outside the building. He almost got to the stop sign on the highway.”
The state investigator reviewed the resident’s 02/05/2015 Occurrence Investigation Statement documented by a Licensed Practical Nurse who revealed that the resident “was seen approximately 2:25 PM to 2:30 PM outside the facility walking toward the main street, walking outside on the street beside the facility.” Further review indicated that the Occurrence Investigation form revealed that there was no indicator of the causation or location of the occurrence noted in the form.
A review of the administrator’s 02/05/2015 written statement noted that the resident’s “elopement documented. It is believed [the resident] exited the front door when some visitors left. No one heard the front door alarm that should have been triggered by the Wander Guard. Bracelet intact on [the resident]. The system is tested weekly (without) indication of malfunction.” Further notations were made that the wander guard was in place and functioning from 10/07/2014 until the day that the resident wandered away from the facility.
The state investigator then interviewed the Licensed Practical Nurse at 1:30 PM on 07/01/2015 who witnessed the event by confirming “she observed [the resident] walking on the side of the street on 02/05/2015 at approximately 2:30 PM. The resident was approximately 150 feet from the facility on the side road headed toward the main highway […and] confirmed the wander guard in place on the resident’s ankle and no alarm was sounding prior to [the Licensed Practical Nurse] exiting the facility.”
A 07/01/2015 interview was conducted with the facility’s Maintenance Director and Administrator. The interview was conducted by “the double doors leading to the maintenance area/staff entrance door.” During the interview, it was noted that the “doors were accessible for two minutes after the keypad was punched; then the alarm sounded and the doors were locked.” Later that afternoon, “the surveyor notified the Administrator that the accessibility of two minutes after the pad was punched on the double doors leading to the maintenance area was unacceptable and would have to be changed to accessibility of 30 seconds before the survey team left the facility [at the conclusion of their investigation].”
At the conclusion of the investigation, the state surveyor team concluded that “the facility failed to check every door/alarm after the resident eloped; [and that the] “Occurrence Investigation was incomplete; and the facility failed to determine exactly how the resident was able to elope when the documentation confirmed all doors, alarms and wander guard were functioning.”
Our Nashville nursing home abuse attorneys recognize the failing to follow procedures and protocols before, during and after a cognitively impaired resident elopes from the facility without supervision could place the resident’s life in immediate jeopardy. The deficient practice by the nursing staff, Maintenance Director and Administrator at Cumberland Health Care and Rehabilitation Center might be considered mistreatment or neglect because their actions failed to follow established procedures and protocols enforced by state and federal nursing home regulators.
WEST MEADE PLACE
1000 St Luke Drive
Nashville, Tennessee 37205
A “For-Profit” 120-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Provide Residents an Environment Free of Accident Hazards and Provide Adequate Supervision to Prevent an Avoidable Accident from Occurring
In a summary statement of deficiencies dated 04/30/2015, a complaint investigation was opened against the facility for its failure to “investigate falls completely; [and a failure] to put interventions in place to further prevent falls and [a failure] to supervise residents appropriately to prevent falls for [6 residents at the facility].” This deficient practice by the nursing staff at West Meade Place resulted in actual harm to [the resident] who sustained a complicated fracture of the femur.”
The investigation involved a review of a resident’s Quarterly MDS (Minimum Data Set) revealing that the resident’s Brief Interview for Mental Status (BIMS) score was seven out of 15 “indicating the resident was alert but moderately cognitively impaired.” Further review of the records indicated that the “resident required extensive assistance of one person for transfers, dressing, eating and grooming; was dependent for bathing; and was occasionally incontinent of bowel and bladder.”
The state investigator reviewed the resident’s 11/11/2010 Comprehensive Care Plan revealing a problem that the “resident is at risk for falls related to limited mobility, cognitive defects, diagnosis of Parkinson’s, left humerus fracture, history of falls, seizure disorder, history of osteoporosis and osteoarthritis.”
The resident’s revised 05/30/2013 Care Plan also reveals the resident requires two person assist with transfers and gait belt with transfers. A data entry on the resident’s Care Plan on 10/06/2013: Non-Skin Footwear.”
The investigation was initiated because of an Incident Log into the 11/28/2014 Risk Management Incident Report revealing that the resident “was lowered to the floor because her knees became weak during transfer from bed to wheelchair.” Additional documentation revealed that for safety reasons, the nurse assisting the resident “lowered her to the floor and got [assistance from the nursing supervisor] for help.”
The state investigator noted that there were no new interventions documented in the incident report to determine the root cause of the incident except those noted in the 11/28/2014 Comprehensive Care Plan revealed that “the only intervention was – if resident’s legs become weak during transfers, slowly lower resident to the floor. Medical record review revealed no new interventions into place after the fall; no root cause analysis of the incident, and no extra precautions were implemented with the resident.”
On 12/22/2014, the Director of Nursing received a phone call “from the resident’s son to inquire about her status [and was informed] that the fracture was inoperable and that his mother was going to [hospice].”
A meeting between the facility’s Director of Nursing and Administrator was held with the resident’s son on 01/05/2014 where the Director “explained what the staff said occurred. At the present time [the Director of Nursing was] unable to determine when the fracture occurred. There were not any injuries noted from 4:00 AM through 8:15 AM and the patient did not complain of pain until approximately 8:15 AM.”
However, the state investigator notes that there is no documentation the Licensed Practical Nurse providing care to the resident assesses the resident’s leg “every two hours for pain and or swelling as stated in the analysis documented by the Director of Nursing.” Additionally, the state investigator noted that there was no documentation in the resident’s medical record noting any “swelling of the resident’s left leg until noticed by the Licensed Practical Nurse at 8:30 AM on 12/20/2014.”
However, a review of the resident’s 12/23/2014 hospital discharge summary revealed that the resident “suffered a comminuted [when a bone is broken into three pieces or more] oblique [angle break across the shaft] fracture through the distal femoral diametaphysis with moderate distraction (separation) of fractured segments.”
An interview was conducted at 3:25 PM on 04/20/2015 with the facility’s Director of Nursing that revealed that the Director “shared investigation results with the son and did not see the facility did anything wrong. Continued interview with the [Director of Nursing] revealed the son insisted his mother be transferred with one person only and ‘we were following what [the son] wanted’.”
However, upon a further interview with the facility’s Director, it was revealed that “she had documented several communications with the son regarding transferring [the resident] but she failed to produce [communications] during the survey.”
The surveyor noted that the facility failed to follow their own protocols especially their 11/01/2010 policy titled Falls that reads in part:
“It is the policy of this facility to provide a safe and hazard-free environment as is possible.” “Identify residents at risk for falls. Implement a Plan of Care based on identifying risk factors. In the event of a fall, conduct an assessment aid in identifying, complete risk management form, complete pain assessment and post-fall assessment.”
Our national nursing home neglect attorneys recognize that failing to follow protocols to ensure residents remain accident-free from falls could place the health and well-being of the resident in jeopardy. The deficient practices by the nursing staff at West Meade Place might be considered negligence or mistreatment because their actions resulted in the bone fractures due to a “one-person” assist instead of two persons as per physician’s orders.
GOOD SAMARITAN HEALTH AND REHABILITATION CENTER
500 Hickory Hollow Terrace
Antioch, Tennessee 37013
A “For-Profit” 110-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Report and Investigate Any Act or Suspicion of Abuse, Neglect, Mistreatment or Injury of Unknown Origin to the Appropriate Agencies According to Law
In a summary statement of deficiencies dated 02/11/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “report injuries of unknown origin to the state survey and certification agency.”
The deficient practice was noted by state investigator reviewed medical records and interview nursing staff. A review of the resident’s Admission MDS (Minimum Data Set) documented that the resident had a Brief Interview for Mental Status (BIMS) score of 2, indicating “severe cognitive impairment.”
The state investigator reviewed the resident’s 08/17/2015 Nursing Notes that documented: “Observed large hematoma on the left side of [the resident’s] forehead. No possible cause found.” The facility’s 08/17/2014 Incident Investigation Form documented: “Type of Incident: Hematoma. Unwitnessed.”
A further review of the facility’s Nurse’s Notes dated on 09/26/2014 documented: Hematoma on left forehead noted by Certified Nursing Assistant while doing ADL (activities of daily living).” On that day (09/26/2014) the facility’s Incident Investigation Form documented: Type of Incident: Hematoma. Unwitnessed.”
The state investigator noted that the “facility failed to report hematoma injuries of unknown origin to the state certification survey within five days of the occurrence.” As a result, the investigator conducted a 9:30 AM 02/11/2015 interview with the facility Administrator in the Director of Nursing’s office and was “asked if there was an injury of unknown origin, should be reported to the State?” The Administrator responded, “if it is unknown origin we have to follow the rules to report. We have to do an investigation to make sure all possibilities have to be looked at until a cause is found. Then you follow the guidelines.”
Our Antioch nursing home neglect attorneys recognize that failing to follow policies procedures and guidelines to properly investigate any injury of unknown origin could place the health and well-being of the resident in immediate jeopardy. The deficient practice by the nursing staff at Good Samaritan Health and Rehabilitation Center might be considered mistreatment or negligence because their actions failed to follow the facility’s 06/01/2012 policy titled Abuse that reads in part:
“Capture a suspected violation or substantiated incident (injury of unknown source) be reported, the facility Administrator or his/her designee will promptly notify the following persons or agencies of such incident: The state licensing/certification agency responsible for surveying/licensing the facility. Notification to the above agencies will be made as soon as it has been substantiated within five working days of the occurrence of such incident.”
NHC HEALTHCARE – HENDERSONVILLE
370 Old Shackle Island Rd
Hendersonville, Tennessee 37075
A “For-Profit” 122-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Develop, Implement and Enforce Programs That Control or Keep Infection from Spreading throughout the Facility
In a summary statement of deficiencies dated 04/28/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “ensure five [Certified Nursing Assistants] served food under sanitary conditions during dining.”
The deficient practice was noted by state investigator conducted an observation 11:20 AM on 04/26/2015 of the facility’s 300-400 Day Room that revealed a Certified Nursing Assistant “touch the back of the wheelchair handles pushed the wheelchair to the table, open the silverware, touched the top of the knife, touched the food on the tray with a knife and then open the straws, touching the tip of the straw without performing hand hygiene.”
At 12:50 PM on the same day 04/26/2015, the state surveyor made observations in the 300 Hall and witnessed a Certified Nursing Assistant who “touch the handles of the chair, pulled the resident over in the bed, then fed the resident three bites of mashed potatoes, bring the potatoes close to her mouth and blowing on potatoes without performing hand hygiene.” In addition, another Certified Nursing Assistant “while feeding a resident pulled on her uniform pants legs and continue to feed the resident without performing and hygiene.”
Later that same day, and observation at 1:22 PM was conducted in a resident’s room that revealed a Certified Nursing Assistant “took the water pitcher from [the resident’ is] room, then went to [another resident’s] room to help another Certified Nursing Assistant assist the resident.” While in the other resident’s room, the Certified Nursing Assistant took the water bottle back from the first resident’s room and “place it in her pocket as she assisted the [2nd Certified Nursing Assistant] with that resident.”
The state investigator performed a 4:55 PM 08/20/2015 interview with the facility’s Director of Nursing who “was asked if the staff should enter the kitchen without a hair restraint […and] was asked should food be touch with bare hands […and] was asked if staff in place a tray on the over bed table with urinals.” The Director of Nursing responded, “No” to every question. The state investigator then asked the Director of Nursing “what should be done after touching objects and passing meal trays.” The Director of Nursing responded that the CNA “should wash hands.” Finally, the state investigator asked the Director of Nursing “if staff should blow on food before feeding a resident.” The Director responded, “No.”
Our Hendersonville nursing home neglect attorneys recognize that failing to follow procedures and protocols to prevent the spread of infection throughout the facility could place the health and well-being of all residents in jeopardy. The deficient practice by the nursing staff that NHC Healthcare – Hendersonville might be considered negligence or mistreatment because their actions failed to follow the facility’s policies including the policy titled: Transmission-based Procedures Policy and the Glove Use policy that both read in part:
“Gloves and Handwashing: remove gloves before leaving the room and wash hands immediately with an antimicrobial agent. Patient Care Equipment: if equipment must be used among patients, then they must be adequately cleaned and disinfected before another patient use.”
“There should be no bare hand contact with ready to eat foods.”
NHC PLACE AT COOL SPRINGS
211 Cool Springs Blvd
Franklin, Tennessee 37067
A “For-Profit” 180-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Develop, Implement and Enforce Policies That Permit Mistreatment, Neglect or Abuse of Residents Involved in Inappropriate Sexual Behavior/Possible Sexual Abuse
In a summary statement of deficiencies dated 08/14/2015, a complaint investigation was opened against the facility for its failure to “assess and implement appropriate interventions and services to protect all cognitively impaired vulnerable residents residing in the Courtyard (secured memory unit) from potential abuse / neglect situations involving inappropriate sexual behaviors when on repeated occasions [one resident at the facility] demonstrated inappropriate sexual comments and actions directed at staff and residents.”
The complaint investigation was initiated by state inspector/surveyor’s noted that the “facility transferred a resident residing in the facility, who exhibited inappropriate sexual behaviors (comments and gestures) to the Courtyard Unit (a secured memory unit that housed 26 vulnerable residents).” The complaint investigation also noted that “this transfer created the potential for the 26 residents residing in that secured unit to be at risk for harm from abuse of a sexually inappropriate nature.”
The investigator noted that their findings “resulted in Immediate Jeopardy, (a situation in which the facility’s noncompliance has caused or is likely to cause serious harm, injury, impairment or death to the resident).” The investigator also noted that the immediate Jeopardy “resulted in a substandard quality of care” provided to the residents at NHC Place at Cool Springs.
The incident involved in the complaint investigation was documented in the 03/18/2015 Investigation Report revealing that “on 02/11/2015 at 7:00 PM, a male resident was escorted from a central bath back into his room by a nurse. After the resident was escorted to his room, the nurse went back to the central bath to retrieve the resident’s wheelchair that had been left behind. Upon entering the central bath, the nurse discovered a female resident on the floor of the central bathing area with her Depends and pants to her shins lying in front of the toilet.” At that time, the female resident “was assessed by the nurse and found to have no injuries. The physician, family local authorities were notified of the occurrence.”
The state investigator reviewed the facility’s 02/12/2015 Staff Drawing to determine the resident’s “position when found in the central bathroom, show the resident lying sideways in front of the toilet, her head facing the door. The drawing also showed a pair of eyeglasses on the floor in the corner of the bathroom to the right of the toilet. The glasses were identified to be worn by [another resident at the facility].”
“The investigation report also revealed a series of resident observations on the staff interviews and additional record reviews were implemented on 02/12/2015, to evaluate [the male resident’s] behaviors and to determine if a sexually inappropriate incident had occurred in central bathroom.”
The investigator reviewed the male resident’s Admission MDS (Minimum Data Set) Assessment revealing that the “resident’s function capabilities and identification of health problems dated 02/09/2015 revealed [that the male resident] had a Brief Interview for Mental Status (BIMS) score of 15, which indicated independent cognitive skills for daily decision-making.” In addition, the document noted that the “resident had unrestricted ability to express ideas and wants along with understanding and interpreting verbal communication […and] utilized a walker or self-propelled in a wheelchair and was coded to need limited assistance of one staff member as needed to move between locations in his room and adjacent corridors in the same unit.”
As a part of the investigation into the complaint involved a document dated 02/08/2015 it documented the resident “repeatedly made sexual comments toward staff and asked the nurse to sit on his lap so he could scratch her back which was immediately reported to the nurses. The nurse reminded the resident about being inappropriate. Later the resident told the tech (technician) he wanted to lick her and all of her friends all over. The resident was again reminded by the nurse about inappropriate comments.”
The facility’s 02/08/2015 Nurses Notes revealed that the male resident “asked the nurse if she wanted to get into bed with him and exercise. The resident was once again reminded of the inappropriate behavior and instructed to call for help when getting out of bed or getting back into bed. The resident took apart all alarms in place used to notify staff of his rising.”
The facility conducted a family orientation meeting at 10:00 AM on 02/09/2015 where family members “reported past occurrences of the resident displaying some socially/sexually inappropriate behaviors that may carry over to his present environment. During the meeting, the Social Worker obtain consent from the family for the resident to receive psychiatric services. There is also discussion regarding the resident be transferred to the Courtyard Memory Care Unit.”
A notation was made in the 02/12/2015 Discharge Note indicating that the male resident “was transferred to a Psychiatric Unit that day for evaluation related to inappropriate sexual behavior directed toward facility residents and staff […and the] resident did not return to the facility.” However, the resident had been at the facility for nine days.
The state investigator conducted an interview with Administrative staff members who were asked why the male resident “was not sent out for a psychiatric evaluation when he first exhibited sexually inappropriate behaviors on 02/07/2015. Also, they were asked why the decision was made to transfer [the male resident] to the Courtyard Memory Unit on 02/11/2015.”
A member of the administrative staff responded that the “resident was transferred to the Courtyard related to his elopement risk.” However, the investigator noted that “no answer was given regarding why [the male resident] was not sent out for a psychiatric evaluation when the sexually inappropriate sexual behaviors were first reported by the nursing staff on 02/07/2015,” or four days before the female resident was found in front of the toilet and the men’s bathroom at the facility.
Our Franklin nursing home sexual abuse attorneys recognize failing to follow procedures and protocols to thoroughly investigate and take appropriate actions involving residents a resident sexual abuse could place the health and well-being of all residents in jeopardy. The deficient practices of the nursing staff and administrators at NHC Place at Cool Springs might be considered abuse or mistreatment because their actions failed to follow the facility’s 05/01/2010 policy titled: Resident Protection a Response for Allegations/Incidences of Abuse, Neglect and Misappropriation of Property that reads in part:
“[Sexual abuse is defined] to include, but not limited to, sexual harassment, sexual coercion or sexual assault. Any alleged acts of sexual abuse will be investigated and dealt with to ensure resident safety and freedom from the risk of abuse or neglect.”
HILLCREST HEALTHCARE CENTER
111 E Pemberton Street
Ashland City, Tennessee 37015
A “For-Profit” 95-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Ensure That All Residents Remain Free from Physical Restraints Unless Needed and Authorized for Medical Treatment
In a summary statement of deficiencies dated 06/11/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure the resident was assessed by staff for the use of the least restrictive restraint possible to ensure the resident safety and [a facility failure] to release the restraint during a meal.” This deficient practice by the nursing staff at Hillcrest Healthcare Center affected one resident at the facility.
The deficient practice was noted by state surveyor after a review of a resident’s Admission MDS (Minimum Data Set) documenting that the resident “required the extensive assistance of one staff for dressing and eating. Staff did not document the resident’s cognitive condition. Staff did not code the resident for the use of a restraint.”
Additionally, the state investigator also reviewed the resident’s Quarterly MDS (Minimum Data Set) that reveal that the resident “had short and long-term memory problems. The staff [again] did not code the resident for using a restraint.”
The investigator reviewed the resident’s 10/19/2014 (revised 10/21/2014) Care Plan for Falls that “directed staff on the use of self-release seatbelt with an alarm to the resident’s chair. The resident also had a bed alarm beginning 11/18/2014, and a door alarm by the bathroom door beginning 11/18/2014.” However, again, “the Care Plan did not direct staff on the reason for the seatbelt or have any further interventions related to the restraint use.”
A review was conducted of the resident’s 06/11/2015 Medical Record that “reveal the lack of documentation related to any attempts to reduce the use of restraint since initiated [back in] December 2014.
The state investigator noted that the staff documented on 05/20/2015 on the facility’s Body Alarm and Special Order Log that “the resident was able to self-release the seatbelt; however, observations on 06/10/2015 revealed the resident was not able to self-release the seat belt.” That same day on 06/10/2015 at 3:15 PM, a member of the licensed nursing staff was observed “in the hall with the resident who sat in a wheelchair with a seat belt. The resident was not able to demonstrate removal of the seat belt.”
The state investigator conducted an interview at that time with the License Nurse who acknowledged that the resident “was not able to remove the seat belt when she prompted the resident to do so; however, the resident was probably tired.”
Later that same day at 5:36 PM, an interview was conducted with the facility’s Direct Care Staff who reported: “the resident did not often attempt to transfer independently and was able to get up from the wheelchair alone when the seatbelt was not fastened to keep the resident in the chair.”
The following day, the date investigator conducted a 9:20 AM 06/11/2015 interview with the Licensed Nurse who had provided the resident care. The Licensed Nurse “reported staff did not consider the belt on the wheelchair as a restraint because the resident could release the belt, so a restraint assessment was not completed.”
In addition, the investigator noted that “a reduction in the use of the seatbelt was not attempted as indicated on the Body Alarm and Special Order catalog because staff documented the resident could release the seatbelt.”
However, the investigator noted that the Licensed Nurse “acknowledged staff failed to assess the resident to determine the most restrictive restraint device that was appropriate for the resident to prevent [her] from falling out of the wheelchair […and] did not provide a recent therapy evaluation for other safety devices or interventions to prevent falls.” The investigator documented that the “staff needed to also release the seatbelt for meals and acknowledged the Care Plan was not developed to address the use of the seat belt.” As a result, the state investigator concluded that “the facility failed to ensure [the resident’s] environment was free of the use of an unwarranted restraint.”
Our Ashland City nursing home neglect attorneys recognize that failing to follow procedures and protocols when using restraints violates federal and state nursing home regulations. The deficient practice by the nursing staff at Hillcrest Healthcare Center might be seen as abuse or mistreatment because their actions failed to follow the facility’s 03/02/2012 policy titled: Restraint Policy that reads in part:
“The facility would assess, implement and evaluate a Plan of Care to decrease or eliminate entirely the use of restraint for a resident.”
Getting the Justice Your Loved One Deserves
Abuse and neglect against the elderly take many forms. In many cases, family members want vindication to hold those legally accountable for the harm they’ve caused a vulnerable loved one who could not stand up for themselves.
The vast majority of cases of abuse against the elderly involve physical argumentation, sexual assault, emotional trauma and financial exploitation. Unfortunately, many cases of mistreatment go unreported for various reasons. In some cases, the resident no longer has the capacity to communicate what is going on due to their medical or mental condition. Other times, the resident is simply too scared to speak out in fear of retaliation or reprisal by the perpetrator.
Family members are often unaware of the ten most common indicators that a loved one is being abused or neglected. These include:
- Unexplained bruising
- Medication errors including not following physician’s orders
- Hazardous conditions and/or a lack of supervision that leads to a fall with injuries
- Unexpected weight loss
- The staff or employees refusing to allow the resident access to normal activities or visitors
- Unexpected changing behaviors including biting, rocking or sucking
- Facility-acquired bedsores that get worse due to a lack of proper treatment
- Financial exploitation through theft of the resident process personal belongings were funds
- Starvation and dehydration
- Unnecessary sedation (chemical restraint) or improper restraint using physical devices including belts without authorization
Tragically, many nursing home residents die from abuse and neglect every year. If your loved one was harmed, injured or has died while under the care of nursing professionals, it is important to seek the legal representation of our compassion personal injury attorneys today.
Holding medical doctors and nursing staff legally accountable not only protects the rights and dignity of the resident that was harmed; but, protect all future residents who might not be aware of the unacceptable actions and level of care provided by the facility. Having an attorney on your side is typically the best solution to ensure that your loved one receives the financial compensation they deserve.
Hiring an Attorney
The Nashville nursing home abuse attorneys at Rosenfeld Injury Lawyers LLC have assisted many families in navigating the legal system to file a complaint and claim against a nursing facility. Our Tennessee elder abuse law office fights aggressively to ensure that the injuries of our clients are immediately addressed and take fast legal action to stop the abuse now.
If your elder, disabled or rehabilitating loved one has suffered injury through negligence or abuse of another, contact our law office today at (888) 424-5757. Our Tennessee elder abuse law firm handles cases on a contingency fee arrangement. This agreement provides immediate legal services without the need for an upfront fee. All information discussed with our law offices remains confidential.
For additional information on Tennessee laws and information on nursing homes look here.
If you are looking for information on a specific facility or an attorney, please see links below to respective locality pages.