Tucson Arizona Nursing Home Abuse Attorneys - Part 2

LIFE CARE CENTER OF TUCSON
6211 North La Cholla Boulevard
Tucson, Arizona 85741
(520) 575-0900

A “For-Profit” 162-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Ensure That All Medical Services and Care Provided by the Nursing Facility Meet Professional Standards of Quality

In a summary statement of deficiencies dated 01/30/2015, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “ensure there was a physician’s order for treatment for [a resident at the facility and a failure] to administer a medication as ordered for [another resident].”

The deficient practice was noted after the state surveyor conducted a review of a resident’s November 2014 physician’s orders revealing that the resident was to receive a medication patch “to be applied to the resident’s spine at 10:00 AM and be removed at 6:00 PM daily and for the application of a foam dressing to the resident’s mid back daily with orders to not discontinue.”

The state surveyor then conducted a review of the facility’s December 2014 in January 2015 recapitulation orders revealing that the treatment was included in the orders “however, the order for the foam dressing to the resident’s mid back was not on the recaps.” Further review of the resident’s clinical records did not show that “a physician’s order was written to discontinue the foam dressing.”

The investigation is in response to a review of the resident’s care plan “for the potential for skin breakdown reflected in interventions to minimize pressure over bony prominences, as the resident will allow.”

The state surveyor conducted a 01/29/2015 interview with the facility’s Licensed Practical Nurse and Wound Care Nurse who explained “the foam dressing treatment to the resident’s back was not carried over onto the recap orders or the [MAR (Medication Administration Record) and TAR (Treatment Administration Record)] for December 2014 in January 2015 and that there was no order to discontinue the treatment.”

State surveyor conducted a 01/28/2015 interview with the facility’s Director of Nursing who stated “that the resident should have been administer the [medication] but it was not transcribed into the Medication Administration Record.”

Our Tucson elder abuse lawyers recognize the failing to follow physician’s orders could be detrimental to the health and well-being of the resident. The deficient practice of Life Care Center of Tucson might be considered mistreatment or negligence because it does not follow established procedures and policies adopted by the facility including the policy titled: Physician’s Order/Transcription that reads in part:

“Proper channels of communication are used to ensure accurate delivery of medications and treatments to all residents. This is achieved by using the Order Sheet, Telephone Order Form, Medication Administration Record.”

LA CANADA CARE CENTER
7970 North La Canada Drive
Tucson, Arizona 85704
(520) 797-1191

A “Not for Profit” 128-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Follow Protocols and Providing Treatment to Heal a Resident’s Facility Acquired Pressure Sore

In a summary statement of deficiencies dated 10/17/2014, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “consistently assess and monitor [a resident at the facility with a] pressure ulcer.”

The deficient practice was noted after the state surveyor conducted a review of a resident’s close clinical record revealing that the Initial Data Collection Tool that identify the resident had three open areas on the lower buttocks.” However, “there were no measurements or any other descriptive data noted on this form. The state surveyor then reviewed the resident’s 10/25/2013 Non-Pressure Skin Condition Record documenting that the wound had MASD (Moisture Associated Skin Damage) measuring 2 cm X 3 cm describing the damage as excoriated and denuded.

The state surveyor conducted a review of the resident’s 10/25/2013 Impaired Skin Integrity Care Plan revealing that the “resident was at risk for breakdown due to fragile, dry skin. The goal included the resident’s disruption of skin service will remain free of infection and show evidence of healing. Approaches included to complete weekly skin checks and observe signs and symptoms of infection or delayed healing and report to the physician.” However, the resident’s Care Plan “did not reflect the open areas to the lower buttocks area that were identified upon admission” even though the 10/30/2013 Wound Note revealed “there is an area of excoriation with denuded tissue of the left posterior fold.” However, even that report failed to make any “other documentation related to the wound.”

By 11/22/2013, the resident’s three Weekly Skin Integrity Data Collection sheets (November 1, 8 and 15, 2013) have no descriptive information concerning the resident’s pressure sores. The state investigator then reviewed the resident’s closed clinical records that did not reveal any completed assessments until 11/27/2013 which by then shows a wound that measures 1.0 centimeter by 0.5 centimeter by 0.1 centimeter with “a large amount of drainage. The documentation included the wound had deteriorated. The one bed was described as pale yellow, with new depth.”

By 12/05/2013, the resident’s Pressure Ulcer Record notes that the resident’s bedsore has become unstageable and now measures 2.5 centimeters by 2.0 centimeters by 1.5 centimeters and that “the wound had slough and necrotic tissue present, with a large amount of drainage. The note further included the physician had debrided the wound.” The physician’s Progress Note made on the same day (12/05/2013) “revealed the resident had a stage 3-4 decubitus ulcer to the left ischial tuberosity.”

The state surveyor conducted in 10/17/2014 interview with the facility’s Wound Nurse who stated “that weekly skin checks should identify all areas of the resident’s non-intact skin, even if the resident has wounds that are being followed by the Wound Nurse.” The state surveyor asked to see facility policies on pressure ulcers. However, the facility’s Corporate Nurse indicated that “the facility did not have that policy”.

Our Tucson elder abuse lawyers recognize that any failure to follow procedures and protocols when treating existing bedsores has the potential of causing additional harm or life-threatening injury to the resident. In addition, La Canada failed to follow the established procedures, protocols and policies adopted by their facility. The deficient practice violates both federal and state nursing home regulations.

GOOD SAMARITAN SOCIETY – QUIBURI MISSION
850 South Highway 80
Benson, Arizona 85602
(520) 586-2372

A “Not-For-Profit” 60-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Follow Procedures and Protocols to Prevent Existing Bedsores from Developing or Treating Existing Bedsores to Promote Healing

In a summary statement of deficiencies dated 08/14/2014, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “ensure care and services were provided for [a resident] with a pressure ulcer.”

The deficient practice was noted after a state investigator reviewed a resident’s 07/17/2014 Weekly Wound Documentation that revealed the resident “had an unstageable pressure ulcer to the right inner heel, which measures 1.8 centimeters by 1.0 centimeters with eschar.

The resident’s Health Care Plan addresses “the unstageable pressure ulcer, one of the interventions included to float heels. Clinical record documentation showed that the right heel pressure ulcer continued to be assessed weekly.

By 08/07/2014, the resident’s wound “measured 1.4 centimeters by 0.7 centimeters with black eschar.” The wound was then observed on 08/12/2014 while the resident was in bed. “However, the heels were not being floated. The wound care was provided by license staff. The right heel pressure ulcer measured 1.7 centimeters by 0.9 centimeters and had black eschar.

The state investigator conducted in 08/13/2014 interview with the facility’s Licensed Practical Nurse who stated “that this resident’s heels are never floated in did not know that the resident’s heels were supposed to be floated.”

The state surveyor then conducted in 08/13/2014 interview with the facility’s Director of Nursing who stated “that the pressure ulcer Care Plan is completed by the Staff Development Coordinator after input is received from several staff members […and] that the interventions of the Care Plan are then put into a cardex for Certified Nursing Assistants […and] that she did not know why this was not being done.”

Our Benson nursing home neglect attorneys recognize it any failure to follow protocols and procedures to treat a resident’s existing bedsores could cause a resident additional harm or life-threatening injury. In addition, the deficient practice by the nursing staff at Good Samaritan Society – Quiburi Mission failed to follow the established procedures, protocols and policies adopted by the nursing home, especially the facility’s policy titled: Policy On Pressure Ulcers that reads in part:

“Provide appropriate assessment and intervention of pressure ulcer as well as treatment when necessary. A resident who has a pressure ulcer receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing.”

LIFE CARE CENTER OF SIERRA VISTA
2305 East Wilcox Drive
Sierra Vista, Arizona 85635
(520) 458-1050

A “For-Profit” 152-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Provide a Safe Environment Where Individuals Are Protected from Resident to Resident Abuse

In a summary statement of deficiencies dated 08/04/2015, a complaint investigation against the facility was opened for its failure to “ensure [a resident] was free from abuse from another resident.” This failure directly affected one resident the facility whose MDS (Minimum Data Set) assessment revealed that the resident was “cognitively intact and had no aggression behaviors toward others.”

The complaint investigation was initiated due to an incident documented in the 07/10/2015 7:35 AM Nursing Note revealing that the resident “was not adjusting well to her new roommate. The note included that [the resident] continually expresses discontent with her roommate related to the roommate’s behaviors and continuously yelling out. [The resident] frequently argues with [the] roommate and yells at her to shut up. Both residents need repeated reassurance to calm them down […and both residents] can barely go five minutes without calling out. Residents and surrounding rooms or becoming agitated and upset due to disturbed sleeping pattern related to lack of peace.”

The state surveyor indicates that even though there is ample documentation on the problem, “there were no interventions that were implemented to address the above concerns at this time.”

The state surveyor reviewed the facility’s 07/10/2015 11:00 AM Reportable Event Report that revealed “that a Nursing Assistant heard aggressive yelling coming from the resident’s room. Upon entering the room, the [Nursing Assistant] witnessed [one resident puncturing the other resident’s] clavicle multiple times with the end of a fake flower stem. Another staff member came into the room and escorted [the assaulting resident] out of the room. Later the same day, [the assaulting resident] was discharged to another facility, due to aggressive behaviors.”

The state surveyor conducted a 09/01/2015 3:05 PM interview with the facility Administrator who stated “it is the facility’s policy that all residents should be free from abuse.”

Our Sierra Vista nursing home abuse attorneys recognize that failing to follow procedures and protocols to protect individuals from resident to resident abuse places the resident’s life in jeopardy. The facility’s failure to develop and implement interventions might be considered negligence or mistreatment of the resident who was aggressively punctured with the end of a fake flower stem. The deficient practice by Life Care Center of Sierra Vista does not follow the established policies adopted by the facility especially the policy titled: Abuse Policy and Procedure because they did not intervene and stop the abuse immediately. That policy reads in part:

“The facility does not condone resident abuse or neglect by anyone, including other residents.”

KINDRED NURSING AND REHABILITATION – HACIENDA
660 South Coronado Drive
Sierra Vista, Arizona 85635
(520) 459-4900

A “For-Profit” 100-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Provide Residents a Safe Environment Free of Sexual Assault

In a summary statement of deficiencies dated 07/27/2015, a complaint investigation against the facility was opened for its failure to “protect [a resident] from sexual abuse by [another resident].” The allegedly assaulting resident’s MDS (Minimum Data Set) documents of the resident “was cognitively intact […and] had no speech or communication difficulties and had moderate hearing impairment.”

The complaint investigation was initiated after “the resident was found in a female resident’s room [stating] he was talking to the female resident and gave her a kiss. The resident was redirected away from the female resident’s room.” This event was documented in the 05/19/2015.

A 05/21/2015 Incident Progress Note documents that “the resident was found on the floor in the female resident’s room, with his brief ripped off. Per the note, [the assaulting resident] stated that he had walked over to her room and lost his balance when he stepped on the fall mat.”

The state surveyor reviewed the 05/22/2015 Social Services Note that documents “a discussion had taken place with [the assaulting resident] regarding his inappropriate behavior going into a female resident’s room. The note included that the resident acknowledged that he was not allowed to be in the female’s room.”

The state surveyor conducted a review of the facility’s Abuse Investigative Report that revealed “on 07/01/2015 [the injured resident] reported that [the assaulting resident] had touched her in a sexual manner without consent. The report included [that the assaulting resident] had run his hand up her leg, under her nightgown, up to her brief. The police were called and [the assaulting resident] was sent out to the hospital for a psychological evaluation.”

A 07/21/2015 interview with the [injured resident] revealed that “she was in her room after dinner on July 1, when [the assaulting resident] came into her room and talk to her about moving with him to another facility. She said she told him to leave […and] said she then went to the television allowed for the front hallway nurse’s station and [the assaulting resident] followed her.” At that point, “he began touching her arm and then ran his hand up her leg, under her nightgown up to her brief. She stated that she told him to stop and he left the area […and] she then reported the incident to the staff […and] she said that the incident made her feel violated.”

An interview was conducted with the facility’s Physical Therapy Director who stated that the assaulting resident “had approached her on May 30 and asked about arranging a private room for him and the female resident. The Director stated that [the assaulting resident] said that the room did not need beds as both residents were in wheelchairs, but asked if the cushion could be removed from the female resident’s wheelchair to make it easier for him.” The Physical Therapy Director stated “she told the resident that it was a safety concern and it would have to be discussed with the Executive Director.” The Director indicated that no further contact was made with the resident.”

The state surveyor reviewed the 05/16/2015 Care Plan of the assaulting resident that indicated the resident “had a behavioral problem relating to roaming in and out of residents rooms and touching other residents inappropriately. Interventions included the following: anticipate and meet the resident’s needs; discuss resident’s behavior and explain and reinforce why behavior was inappropriate and/or unacceptable; intervene as needed to protect the rights and safety of others; divert attention; remove from situation and take to alternative location as needed; and minimize potential for resident’s disruptive behaviors of roaming in and out of other residents rooms and touching other residents inappropriately, by offering tasks which divert attention.”

Our Sierra Vista elder sexual abuse attorneys recognize that failing to follow protocols and procedures that protect residents against sexual assault might be considered additional abuse, mistreatment or neglect. In addition, the failure of Kindred Nursing and Rehabilitation – Hacienda does not follow their own establish policies and procedures including the facility’s policy titled: Abuse Prevention that reads in part:

“Resident should be free from abuse, including sexual abuse. The policy included that residents with a personal history that renders them at risk for abusing other residents are identified and that intervention strategies are developed to prevent and/or reduce occurrences, and changes that would trigger abusive behaviors are monitored, and that interventions are reassessed on a regular basis.”

Is Your Loved One Suffering Because of Negligence or Abuse?

Many nursing home residents in Arizona become victims of understaffing, lack of supervision, improper training, outright wrongdoing or other form of abuse and neglect. It may be that your loved one has been abused, mistreated or neglected because the signs and symptoms are not always so obvious, it is difficult to tell. The most common forms of abuse and neglect involve:

  • Facility Acquired Bedsores – Often described as decubitus ulcers, pressure ulcers or pressure sores, bedsores acquired after being admitted to the facility is usually a sign of neglect through malnutrition, dehydration for a failure to assist a resident who requires repositioning or movement due to being bedridden or wheelchair bound.
  • Falling Accidents – Nursing facilities are required to assess every resident for the potential risk of falling at the facility. Many of the most serious accidents that occur in nursing facilities are the result of falling due to a hazardous environment, slippery surface or lack of assistance when required.
  • Lack of Medical Attention – Failing to follow physician’s orders, provide adequate treatment or medication mistakes often lead to preventable serious injuries or death of the resident.
Hiring a Lawyer

If you recognize the signs or symptoms of neglect or suspect your loved one is suffering mistreatment or abuse while residing in any Arizona nursing facility, The Tucson nursing home abuse attorneys at Rosenfeld Injury Lawyers LLC want to help now. Our accomplished Our Pima County team of skillful attorneys have represented many clients within the community.

We urge you to call our Arizona elder abuse law office at (800) 926-7565 today to schedule your appointment. Speak with one of our reputable attorneys through a no obligation case review to determine the merits of your claim.

For additional information on Arizona laws and information on nursing homes look here.

Nursing Home Abuse & Neglect Resources

If you are looking for information on a specific facility or an attorney, please see links below to respective locality pages.

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