Nursing home regulators from the state of Indiana and Centers for Medicare and Medicaid Services (CMS) conduct routine investigations, surveys, and inspections at every facility statewide. Surveyors review medical records, policies, and procedures while conducting observations and interviews during unannounced visits to nursing homes that could last for days. Their efforts often identify serious deficiencies, dangerous violations and safety concerns that require prompt correction.
In the most egregious cases, the regulators will designate the facility as a Special Focus Facility (SFF) that automatically places the Home on a national Medicare watch list. These facilities are often required to make significant changes to their policies and improve the level of care they provide to the residents. Typically, these facilities can remain on the watch list for many years due to significant underlying conditions, a lack of quality management and organization, or a failure to ensure the nursing staff is adequately trained.
More than 30 months ago, nursing home regulators placed South Shore Health and Rehabilitation Center on the Federal watch list and designated the Home as a Special Focus Facility. Even though the facility has shown some significant improvements in the level of care they provide, investigators and surveyors are still conducting more than the standard number of surveys every year. Some serious concerns involving violations and efficiencies at this facility are detailed below.
This Nursing Center is a ‘for profit’ facility providing services and cares to residents of Gary and Lake County, Indiana. The 100-certified-bed Long-Term Care Nursing Home is located at:
353 Tyler St.
Gary, IN 46402
(219) 886-7070
In addition to providing short-and long-term skilled nursing care the facility also offers diabetes care, hospice and respite care, orthopedic rehabilitation, and complex wound care.
Both the Centers for Medicare and Medicaid Services and the state of Indiana have the legal authority to levy monetary fines against any nursing facility identify with serious deficiencies and violations. The imposed fines are designed to alert the nursing care facility that any abuses in providing high-quality care will not be tolerated.
Nearly three years ago, South Shore Health & Rehabilitation Center received two substantial monetary penalties including a $14,105 fine on September 22, 2015, and a $1300 fine on June 21, 2016. During this time, there were 33 formally filed complaints and four facility-reported issues that resulted in citations and required investigations.
The federal government and Indiana care home regulatory agencies routinely update their nationwide nursing facility database system. The Medicare.gov website information contains historical details of health violations, dangerous hazards, safety concerns, incident inquiries, opened investigations, and filed complaints of every facility in the state.
Currently, South Shore Health and Rehabilitation Center maintains an overall one out of five stars compared to all nursing homes in the US. This ranking includes one out of five stars for health inspections, two out of five stars for staffing issues, and two stars for quality measures. Some serious deficiencies, violations and health concerns involving this facility are listed below.
In a summary statement of deficiencies dated February 23, 2017, the state investigator noted the facility’s failure “to ensure residents remained free of physical restraints related to staff applying gait belts around residents and around wheelchairs in which they were seated.” This deficiency was revealed after a review of a Facility Incident Report initiated on February 22, 2017, involving an incident occurring on February 2, 2017.”
A Certified Nursing Assistant had observed two residents “sitting in their wheelchairs with gait belts strapped around them and their wheelchairs.” An investigation was initiated at this time. The facility video footage was viewed, and staff members were interviewed on February 20, 2017. It was noted that the [Certified Nursing Assistant (CNA)] applied the gait belt around the resident and [another CNA] applied a gait belt to [that resident].”
Surveyors reviewed the residents’ physician’s orders and found that there “were no physician’s orders for physical restraints to be utilized.” The Certified Nursing Assistant “informed the Administration wanted her to be aware of something that occurred at the start of the evening shift on February 2, 2017.” The CNA reported that she had witnessed a resident “in a wheelchair with the sheet over her lap. The sheet [had] slipped, and the CNA observed a gait belt [clipped around the back] around the resident and the wheelchair.” The CNA then observed a second resident who also had a gait belt strapped around their body and wheelchair.
The Certified Nursing Assistant reported the incident to the Receptionist saying “what had occurred and that it had been taken care [when reported to] the Receptionist leaving at 5:00 PM. No staff members informed the Administrator of the above occurrence on February 19, 2017.” During an interview with the receptionist it was revealed that they had “not witnessed the CNA taking off the gait belts” and upon returning home at approximately 5:30 PM that day called the Registered Nurse (on-call nurse) who indicated “she was going to contact the facility. The receptionist did not call the Director of Nursing or the facility Administrator.
The state surveyor interviewed the facility Administrator, Director of Nursing and a Registered Nurse (RN). The RN “verified that the facility was a restraint free facility and restraints were not to be used, and she confirmed she should have notified the Director of Nursing and Facility Administrator upon receiving a phone call from the Receptionist on Sunday, February 19, 2017.”
In a summary statement of deficiencies dated July 27, 2017, the state investigator noted the facility’s failure “to ensure adequate supervision was maintained related to ensuring ‘wander guard’ and exit door elopement prevention devices were in working order, and exit door alarms were on.” This deficiency resulted in two “cognitively impaired residents exiting the facility unnoticed and found by staff outside the facility.”
Surveyors placed the facility in Immediate Jeopardy beginning on May 30, 2017 “when a cognitively impaired resident exited the front door of the facility unnoticed and was found by incoming staff on the sidewalk outside the building. Upon return to the facility, the ‘wander guard’ was observed not to be functioning for one side of the doorway.”
“The door involved was fixed, and staff alerted to check both sides of the doorway, but no other systemic monitoring or resident evaluations were completed.” This deficiency allowed “for another resident to elope from the building unnoticed in the side parking lot and into an employee’s parked vehicle on July 14, 2017.”
In a summary statement of deficiencies dated August 11, 2017, the state investigator noted the facility’s failure “to ensure a resident’s physician was notified of elevated blood sugar [levels].” The surveyor also documented that the facility had failed to “ensure the resident’s responsible party was notified of supplemental orders for [the resident].”
A review of the resident’s June 2017 Medication Administration Record revealed that on June 9, 2017, at 11:00 AM “the resident’s blood sugar was 409.” A review of the resident’s medical records revealed that there was “no documentation to indicate that the resident’s Physician had been notified of elevated blood sugars.”
The surveyor interviewed the resident’s son, “who is her responsible party, on August 8, 2017 [who] indicated that he was not always notified when treatment orders were changed.” There “was no documentation to indicate the resident’s responsible party was notified of the new supplement orders.”
An interview with the facility’s Director of Nursing revealed that “if the resident did not have blood sugar parameters ordered by the doctor, she would expect her staff to notify the doctor if [their] blood sugar was below 60 or greater than 400.” The facility’s policy supported this action where it states that “residents whose blood sugar is monitored with no high/low parameters or sliding scale parameters, the MD will be notified when the blood sugar is below 70, and 400 or greater.”
In a summary statement of deficiencies dated October 19, 2017, the state investigator noted the facility’s failure “to ensure therapy …used by a resident in isolation was disinfected after use and staff not following the protocol for entering an isolation room.” This incident involved a resident who was observed in bed on October 19, 2017, at 9:41 AM.
During the observation, it was noted that “an isolation supply set up was by the room door. The occupational therapist was in the room also assisting the resident with therapy. The resident [in isolation due to contagious infections] was holding a long green bar and completing exercises with the bar per the occupational therapist’s instructions. The bar touched the resident’s gown and linens during some of the exercises.”
Ten minutes later, “the Therapy Director entered the resident’s room and walked to the bedside without washing hands, putting on an isolation gown, and applying disposable gloves upon entering the room.” The Therapy Director then “talked to the residents and stood next to the resident’s bed.”
The surveyor witnessed the Therapy Director picking up bed linens that covered the resident’s right leg, removing their isolation gown and gloves and disposing of them “in the resident’s room [before picking up] the green bar.” The Director then exited “the room without cleaning or disinfecting the bar and carrying [the bar] down the hall to the Therapy Room.”
In a separate summary statement of deficiencies dated August 11, 2017, the state surveyor noted the facility’s failure to “ensure an infection control program was followed related to a lack of a water management policy and plan to protect high-risk residents …” The deficiency included a failure to “not properly disinfect the glucometer and dispose of lancets and test strips for [a resident] …, and the improper storage of reusable equipment such as wash basins and urinals on two of four units (Unit 3 and Unit 5).”
The surveyor interviewed the facility Administrator on August 8, 2017, who “indicated there was no water management system policy to monitor for Legionella (bacteria) in the water at the current time. The Administrator …asked the Maintenance Director, who was also not aware that there needed to be a water management plan and testing policy in place for the [highly contagious deadly infection].” It was also documented that the Corporate Plant Operations Manager [was] unaware there had to be a water management system put in place to test for Legionella.”
If you, or your family, believe that your loved one was victimized by caregivers while a patient at South Shore Health & Rehabilitation Center, or any facility, contacting a personal injury lawyer could help. With an attorney working on your behalf, your family can expect to file a claim for compensation to hold those at fault both legally and financially accountable.
Typically, the law firm will not require an upfront payment because most personal injury attorneys accept every wrongful death lawsuit, nursing home abuse case and medical malpractice compensation suit through contingency agreements. This arrangement means all legal fees are paid only after your lawyers have won your case at trial or negotiated an out of court settlement on your behalf.
Sources:
Attorney Jeffrey D. Powless
Licensed in Indiana
Chicago Nursing Home Injury Attorney Nursing Home Law Center LLC Home