St. Louis Missouri Nursing Home Abuse Lawyer
When family members entrust the care of their loved one to caregivers in a nursing facility, they are often promised that their spouse, parent or grandparent will be treated with dignity and respect, and protected from harm and injury. Even with strict nursing home regulations and the high cost of keeping a loved one in a nursing facility, hundreds of thousands of Americans who are 65 years and older suffer abuse and neglect every year. In fact, the St. Louis nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC have represented many nursing home residents who are victimized by caregivers and others at the facility.
More than 1 million residents live within the boundaries of St. Louis County. Out of that number, more than 16.5 percent, or approximately 165,000 are 65 years and older. The number of seniors within the county has grown significantly over the last five years and is likely to continue to rise as many more enter their retirement years. In all likelihood, this will put an even greater burden on nursing facilities who are already overworked, overcrowded and lack sufficient staffing to meet the needs of their residents now.
Many of today’s nursing facilities are operated by huge corporations that tend to focus more on profits than providing quality resident care. Family members hoping that their loved one receives the very best care are often horrified to learn that substandard care, mistreatment, neglect or outright abuse has caused the one they love significant harm, injury or death.St. Louis Nursing Home Resident Health Concerns
Our St. Louis nursing home attorneys have handled many cases involving Missouri nursing home residents who have been injured, exploited, mistreated or neglected by a staff member or employee they depend upon to provide their protection and care. To assist families, our law firm continuously assesses, evaluates and reviews filed complaints, safety violations, health hazards and opened investigations against nursing facilities all throughout the day. We gather this information from publicly available sources including Medicare.gov and have posted our results below.Comparing St. Louis Area Nursing Facilities
The list below was compiled by our legal team detailing St. Louis area nursing facilities that currently maintain below average ratings compared other nursing homes throughout the United States. In addition, we have added our primary concerns by outlining specific cases that have cause significant harm, damage or death to the facility’s residents.
GRAND MANOR NURSING and REHABILITATION CENTER
3645 Cook Ave
Saint Louis, Missouri 63113
A “For-Profit” 120-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Develop, Implement and Enforce Policies That Prevent Abuse, Neglect or Mistreatment of Residents
In a summary statement of deficiencies dated 01/22/2016, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “direct staff to notify the Department of Health and Senior Services (DHSS) within 24 hours of alleged or actual abuse and/or neglect.” In addition, the state investigator noted the facility’s failure “to direct staff on all the appropriate steps to take during an abuse and/or neglect investigation.” The deficient practice by the nursing staff at Grand Manor Nursing and Rehabilitation Center “has the potential to affect all  residents at the facility.”
The deficient practice was noted by state surveyor after a review of an 11/08/2015 Licensed Practical Nurse (LPN) written statement that indicated that they were “call the facility at approximately 4:00 PM through 4:15 PM” and asked to talk with one of the facility’s Registered Nurses (RNs). Even though the phone was set down, it was not placed on hold, and the Licensed Practical Nurse could hear the resident crying and heard “someone say, ‘shut up, shut up! Girl, just ignore [them. They] just want attention. I’m sick and tired of [them]. Just ignore [them].”
The Licensed Practical Nurse indicated that the resident “continue to cry.” As an LPN spoke with the Registered Nurse, they “asked who told the resident to shut up.” The Registered Nurse replied, “Girl, it was me that said that. I’m so frustrated.” The Licensed Practical Nurse told the Registered Nurse that what they said “was verbal abuse […and said that] the tone used by [the Registered Nurse] was very harsh and it shook me up bad. I could not get to work fast enough.”
The Licensed Practical Nurse revealed that after getting off work the next day at 7:45 AM on 11/08/2015 they “could not sleep because of what [they] heard said over the phone by an RN supervisor and how [the Registered Nurse] spoke to the resident.” The Licensed Practical Nurse made up their mind “to report the incident because [they] needed to be the resident’s advocate.” Notations were made that “the resident is able to communicate but it can be difficult to understand at times.”
The facility conducted an investigation on 11/16/2015 and concluded that the Registered Nurse did tell the resident to “shut up” and that the Registered Nurse admitted that they “were frustrated, tired and ready to go home.” Documentation also shows of the Registered Nurse “was informed that [they] cannot tell a resident to shut up and that it is verbal abuse and it is not example [they] should set for being a supervisor.” At the conclusion of the facility investigation, the Registered Nurse was terminated.
The state surveyor noted that “staff is expected to report incidences of abuse and neglect to the Nursing Supervisor, Director of Nursing, Assistant Director of Nursing and/or Administrator. However, the incident was not reported until “the following Tuesday” indicating that the incident was not reported, “immediately because it was the weekend.”
The state investigator conducted an 8:55 AM 01/19/2016 interview with the facility’s Director of Nursing who said that “the incident occurred over the weekend. Management was not notified until 11/11/2015 because the person who heard it was struggling with what to do. If she [the Director of Nursing] would have been made aware of the incident the same day, she would’ve notified DHSS the same day.”
The Director of Nursing also indicated that the Registered Nurse “was only allowed to work after the incident because she was not aware of the accusation. There are other Certified Nursing Assistants who saw/heard the incident too and they should have notified the Charge Nurse. Since the accused person was the Charge Nurse, then they should have notified [the Director of Nursing].” The Director also indicated that between the Assistant Director of Nursing, the Administrator and themselves, “someone is available 24 hours a day, seven days a week.”
Our St. Louis nursing home abuse attorneys recognize it failing to follow procedures and protocols to prevent abuse, neglect or mistreatment of residents places all residents in Immediate Jeopardy. The deficient practice by the nursing staff and administration at Grand Manor Nursing and Rehabilitation Center may be considered further abuse, mistreatment or negligence because the facility’s 01/01/2000 policy titled: Abuse and Neglect Policies and Procedures failed to provide guidance on how to identify staff member responsibility for initial reporting and investigating alleged violations of abuse and neglect. In addition, the policy failed to provide guidance on how to report alleged violations to the State Survey Agency immediately, which means “as soon as possible, but not to exceed 24 hours after the discovery of the incident.”
NATHAN HEALTH CARE CENTER
5050 Summit Avenue
East Saint Louis, Illinois 62205
A “For-Profit” 146-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Ensure That Every Resident Is Free from Physical Restraints Unless the Restraints Are Required for Medical Treatment and Approved by Physician
In a summary statement of deficiencies dated 07/01/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “assess and document the risks versus benefits” when providing treatment and care to the resident.
The deficient practice was noted by state investigator after reviewing a resident’s Physician Order Sheet and 06/20/2015 Care Plan that revealed that the resident “is at risk for injury, requires a lap belt restraint for safety. The restraint is to be removed at bedtime and at least every two hours.” In addition, the investigator noted that the resident’s Care Plan documented the resident “had falls on 01/26/2015 and 02/03/2015.” The resident’s 02/20/2015 Site Reassessment documents that under additional considerations the resident “has a waist restraint.” However, the investigator notes that “the assessment does not document risk versus benefits” to determine the best method to provide adequate care for the resident.
An observation was made of the resident 11:00 AM on June 20 15,015 when the resident “was sitting in her room in her wheelchair with a waist restraint tied to the back of the wheelchair.” At that time, the resident “was sliding downward in the wheelchair, pulling the waist restraint taut over the abdomen […and] had a bilateral foot drop with both feet turned inward. At that time, [the resident] stated, ‘it’s hooked on so good, I can’t get it off. It’s tight. I have begged to get out of this.’ [The resident] reported there was no way she could turn around and untie the restraint belt from the back of the wheelchair.”
30 minutes later at 11:30 AM, a Certified Occupational Therapy Assistant from the facility stated, “We take her restraint off quarterly and observe [her]. She is not re-directable at all.”
At 10:30 AM on 06/25/2015, and interview by the state investigator was conducted with the Director of Nursing who “was asked if the facility had any assessments to include the risk versus the benefits of the use of any safety device.” In response, the Director of Nursing “reported that their assessments fail to address this issue.”
Our East St. Louis nursing home neglect attorneys recognize that failing to ensure that every resident is free from unnecessary physical restraints could place their health and well-being in immediate jeopardy and diminish their quality of daily living. The deficient practice by the nursing staff at Nathan Health Care Center could be considered mistreatment, abuse or neglect because their actions fail to follow the facility’s policy titled: Restraints-Physical that reads in part:
“Practices that are not permitted include placing a resident in a chair that prevents the resident from rising. Their restraint use is temporary, and the resident will not be restrained for an indefinite amount of time. The resident placed in a restraint will be observed at least every 30 minutes by nursing personnel and an account of the resident’s condition shall be recorded in the resident’s medical record.”
“The resident’s Care Plan must indicate that the continued use of the restraint has been re-evaluated and that a re-order from the physician is noted.”
ROYAL OAK NURSING AND REHABILITATION CENTER
4960 Laclede Avenue
Saint Louis, Missouri 63108
A “For-Profit” 168-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Ensure That Every Resident Receives Proper Care and Treatment to Prevent the Development of a New Bedsore or Allow an Existing Bedsore to Heal
In a summary statement of deficiencies dated 09/18/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “provide appropriate care and services to identify, assess, measure and help heal pressure ulcers.” While eight residents at the facility were identified with pressure ulcers, this problem affected one resident.
The deficient practice was noted by state surveyor after a review of a resident’s Quarterly MDS (Minimum Data Set) that revealed that the resident was “admitted to hospice care on 02/17/2015 […and was totally dependent] on staff for ADL (activities of daily living), was incontinent of bowel and bladder and at risk for pressure ulcers.” The documentation also shows that the resident required a gastronomy tube – a surgically inserted tube into the stomach to provide nutrition, fluids and medications.
The state investigator also reviewed the resident’s physician order sheets all throughout September 2015 until 10/14/2015 that revealed in 08/07/2015 physician’s orders requiring “weekly skin assessments every Thursday, no order for Duoderm to coccyx and sacrum wound.”
A review of the resident’s Hospice Interdisciplinary Team (IDT) Care Plan Patient Summary Notes revealed that the resident had a new wound on 07/29/2015. The wound was noted as a “coccyx pressure wound [measuring] 2.5 centimeters by 1.0 centimeters and a sacrum [wound measuring] 3.0 centimeters by 0.5 centimeters, using Duoderm no description or stage noted.”
Just one week later on 08/05/2015, the resident’s coccyx pressure ulcer had changed in size and now measured “2.8 centimeters by 0.8 centimeters, sacrum [wound measuring] 0.5 centimeters by 0.5 centimeters, using Duoderm [with] no description or stage noted.”
On numerous days including 08/08/2015, 08/12/2015, 08/26/2015 and 09/02/2015, notations are made that the previously reported Stage II pressure ulcers are being treated with Duoderm, but no measurements, stage or descriptions are noted.
At that point, the state investigator reviewed the resident’s Handwritten Hospice Visit Communication Notes that revealed on 08/14/2015, during a Registered Nurse visit notations were made of the resident’s Stage II coccyx pressure ulcer. However, when the Registered Nurse visits on 08/18/2015, 08/21/2015 and 08/24/2015 there are no mentions of the resident’s wounds in the documentation.
By 08/28/2015, the Registered Nurse notes that the resident’s coccyx wound has worsened and now measured 4.0 centimeters by 6.0 centimeters. However, there is still no stage or description noted in the documentation. During the next six visits between 08/29/2015 and 09/09/2015, no measurements, description or stage noted on the resident’s pressure ulcers. By 09/15/2015, the Registered Nurse records that the resident’s Stage II coccyx pressure ulcer now measures 5.0 centimeters by 3.0 centimeters by 0.1 centimeters and that Duoderm is being used. However, no description of the wound is noted other than the measurements.
When the state investigator reviews the facility’s Weekly Wound Reports between 08/18/2015 and 09/07/2015, there is no documentation or entry noting the resident as having wounds. The investigator that conducted a 1:30 PM 09/17/2015 interview with the facility’s Administrator who said that “she expected staff to obtain and document a resident’s medical record, weekly measurements of pressure ulcers. Prior to 08/08/2015, the facility did not do skin assessments on the resident. The resident’s physician should have been contacted when the wound looked worse. Duoderm was no longer an appropriate treatment for [the resident’s pressure ulcers].”
Our St. Louis nursing home neglect attorneys recognize that failing to ensure that every resident receives the proper level of care and treatment to prevent the development of a new pressure ulcer or allow an existing pressure ulcer to heal could place their health and well-being in Immediate Jeopardy. The deficient practice by the nursing staff at Royal Oak Nursing and Rehabilitation Center might be considered negligence or mistreatment because their actions failed to follow established procedures and protocols enforced by state and federal nursing home regulations.
CARRIE ELLIGSON GIETNER HOME
5000 South Broadway
Saint Louis, Missouri 63111
A “For-Profit” 130-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Hire Only Individuals That Have No Legal History of Abuse, Neglect or Mistreatment of Residents
In a summary statement of deficiencies dated 10/08/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “check the Employee Disqualification List (EDL, a list maintained by the state, of staff that are banned from working with the residents of skilled nursing facilities due to abuse or neglect) quarterly.” The deficient practice by the administration and staff at Carrie Elligson Gietner Home resulted in one staff person being allowed to work at the facility, providing direct resident care, who had been placed on the EDL for abuse/neglect.” The failure of the facility had the potential of affecting all 85 residents.
The deficient practice was noted by state investigator after review of a Certified Nursing Assistant’s personnel record revealing an Employee Disqualification List check on 04/06/2015 followed by a hire date noted as 04/13/2015 and a termination date of 08/21/2015 that included and “employee final written warning. Employee failed to call or show up for a shift on 08/20/2015.” The state investigator noted that there were “no quarterly EDL checks completed.”
The Employee Disqualification List revealed that the Certified Nursing Assistant was placed on the list effective 06/17/2015 “and would remain on the list for 18 months until 12/17/2016.”
The state investigator conducted an 8:42 AM 10/06/2015 interview with the facility’s Administrator who said that “she and the front office staff are responsible for checking the EDL list on employees […and] the EDL list should be checked on hire and quarterly […and] the facility routinely checks the EDL for all staff quarterly, based on the facility schedule and not staff hire date.” The Administrator also said that the Certified Nursing Assistant “was on the list of employees to be checked on 07/10/2015.
During the interview, the Administrator said that “they do not have a written policy that says to check the EDL on hire or quarterly but they know they should have.” The Administrator noted that the Office Assistant “never checked the EDL for [that Certified Nursing Assistant] in July […and that they] missed it and it should have been checked.”
In an interview with the Office Assistant at 8:52 AM 10/06/2015, it was revealed that the Assistant “is responsible for checking the EDL list quarterly […and that the Certified Nursing Assistant was on the list] to be checked on 07/10/2015 and should have been checked then.”
Our St. Louis Missouri nursing home abuse lawyers recognize that hiring individuals that have a legal history of abuse, neglect and mistreatment of residents places the health and well-being of all residents at the facility in Immediate Jeopardy. The deficient practice by the front office and Administrator at Carrie Elligson Gietner Home could be considered abuse or mistreatment because their actions fail to follow the facility’s August 2016 policy title: Abuse Prevention Program Policy that reads in part:
“Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion.”
“Comprehensive Policies and Procedures Have Been Developed to aid our Facility Preventing Abuse, Neglect or Mistreatment.”
ALEXIAN BROTHERS LANSDOWNE VILLAGE
4624 Lansdowne Avenue
Saint Louis, Missouri 63116
A “Not for Profit” 145-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Ensure That Every Resident Receives the Proper Care to Prevent the Development of a New Bedsore or Allow an Existing Bedsore to Heal
In a summary statement of deficiencies dated 07/21/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “identify report to open areas on a resident, resulting in the delay of treatment for one [resident].”
The deficient practice was noted by the state investigator who reviewed the resident’s medical records that showed a 10/17/2015 order that the resident “may be up in a chair. If in bed, turn every two hours.” In addition, there are other physician’s orders including the 02/17/2014 order that instructed the staff to turn the resident “every two hours around the clock.” In addition, there was an updated order revealing that staff should have the resident “up for meals and activities only, two hours maximum per event.”
The investigator also reviewed the resident’s 04/20/2015 Annual MDS (Minimum Data Set) revealing that the resident “sometimes understood, sometimes understands.” The resident’s Brief Interview for Mental Status (BIMS) score of three out of a possible 15 indicates that the resident “has severely impaired cognition”. In addition, the documentation revealed that the resident’s “required extensive assistance with bed mobility, transfers, dressing, toileting, bathing and personal hygiene; always incontinent of bowel and bladder; [and is at] risk for pressure ulcers.”
The resident’s interdisciplinary notes revealed that a notation on 06/11/2015 show the resident has no decubitus ulcers (severe pressure sores). Again on 07/08/2015, there are no decubitus ulcers noted. A review of the resident’s Shower Sheet indicated that on 06/30/2015, “old area on buttocks, ointment applied.” Again on 07/03/2015 the Shower Sheet says “no skin issues.” On 07/14/2015, notations made that there is “an area on the buttock. Ointment. (The note did not specify whether the area was older or a new open area).”
No skin assessments were available for July other than the 07/01/2015 Skin Assessment Form that revealed the resident had “dry skin to the bilateral lower extremities, soft heels, buttocks red.” The resident’s 07/16/2015 Care Plan revealed that “potential for skin breakdown related to immobility and incontinence. Interventions included reposition every two hours, pressure reducing mattress and monitor skin weekly.”
However, upon observation at 1:32 PM on 07/16/2015 by the state investigator, it was revealed the resident was “in bed receiving personal care […and] had two open areas, one in the inner aspect of each buttock.” Even with the observation by the state investigator, the resident’s interdisciplinary notes show “no documentation of any open areas noted until 07/20/2015.”
A follow-up observation of the resident was conducted at 9:25 AM on 07/20/2015 when the resident was in bed, during the observation it was noted that the resident “had two open areas, one on the inner aspect of each buttock. The open area on the left buttock measured approximately 3.0 centimeters by 2.0 centimeters. The open area on the right buttock measured approximately 1.0 centimeters by 1.0 centimeters.”
The state investigator conducted a 9:40 AM 07/20/2015 interview with the facility’s Wound Nurse who indicated that “she was made aware of the open areas earlier that morning. She called the physician and obtained an order after checking the resident’s skin. The staff did not report that there was an open area, they told her DHSS [Department of Health and Senior Services] staff wanted to do a skin assessment, so she went to check the resident and found the areas.”
The Wound Nurse also revealed that “she thought the areas might be a Stage II pressure ulcer (partial thickness loss of the inner layer of skin, presenting a shallow open ulcer with a red or pink wound bed, without dead tissue. May also present as an intact or open/ruptured blister), but did not do the staging.” The Wound Nurse stated that the “Director of Nursing stages pressure ulcers. The usual policy of the facility was that the Certified Nurse’s Aide noticed an open area, they reported to the Charge Nurse, who assesses and calls the physician to get a treatment order. They would then enter the information into the computer and that would trigger a message to go to the Wound Nurse so she could also assess the wound and begin managing it.”
That morning, the Wound Nurse measured the resident’s wounds noting that the “right buttock measured 1.2 centimeters by 0.9 centimeters by 0.1 centimeters. The left buttock wound measured 3.1 centimeters by 1.1 centimeters by 0.2 centimeters.”
The state investigator conducted a 9:40 AM 07/20/2015 interview with the facility’s Director of Nursing who said that “he felt the wounds were Stage II pressure ulcers […and] there was no dead tissue noted.” The Director of Nursing also indicated that “the white spot on one area of the wound, he felt was a scar tissue. This resident had a history with [their] skin opening and closing, and could be seen from the scar tissue around the two open areas.”
At 2:00 PM that same day, the Director of Nursing said “when a resident has an open area, whoever finds it needs to report it immediately. The Charge Nurse should assess it, report to the physician and the report the area to the Wound Nurse.”
Our St. Louis nursing home neglect law firm recognizes that failing to provide proper treatment to residents suffering from pressure ulcers could place their health and well-being in Immediate Jeopardy should the wound be allowed to degrade. The deficient practice by the nursing staff at Alexian Brothers Lansdowne Village might be considered negligence or mistreatment because their actions fail to follow established procedures and protocols enforced by federal and state nursing home regulators.