Listed as one of America’s poorest nursing facilities, Wentworth Rehab in Chicago has a reputation for miserably insufficient maintenance and patient care, as reported in the Chicago Tribune. It’s known for events like the death of Letasha Mims, whose family finds Wentworth to blame for her passing after she became desperately ill during her time there.

Even more recently, a 79 year old man was allowed to smoke while using an oxygen machine at Wentworth, which eventually caused a fire that killed him and caused massive damage in the nursing home. It was reported that the man had a history of destructive behavior and should have been more carefully surveyed for such danger, and also that the staff had acted in a dangerously negligent manner, with one nurse looking on carelessly as the man was burning to death and another nurse attempted to save him.

To those familiar, these kinds of events would not be surprising. None of this even mentions the seeming inescapability of insects and rodents in Wentworth Rehab. Inspectors have reported unidentifiable food being served to patients. Residents can be seen plainly in areas of the nursing home with unimaginably poor personal hygiene. When asked about any of this, Wentworth’s parent company, Alden Management Services, will either deny its facility’s negligence or decline to comment altogether.

There are plenty of bad nursing homes in the United States, many on the same lists as Wentworth. There are even plenty of other bad nursing homes in Chicago, where it’s not hard to imagine a need for affordable or accessible nursing homes. But with its history of lying, neglecting, and ignoring, Wentworth Rehab stands out as a hallmark of bad behavior in nursing homes and a way of looking at any facility’s character.

The Star Tribune reported that nursing home employee Francisco Javier Ramirez, a nursing assistant at the Good Samaritan Society nursing home, was transferring a female resident, Evelyn Augusta Schweim, out of a bathtub using a mechanical lift chair but failed to follow correct procedures. The resident slid out of the chair — which was raised to its highest level of about 5 feet — and then sustained multiple fractures. The fall was so severe that the woman’s left foot was almost detached from her leg, and the bones of her left leg were visible, according to a Minnesota Department of Health investigation last year of the incident. When she was found, pools of blood had formed around the woman’s ankle and she was complaining of knee and neck pain, the report said.

 After the fall, Ramirez again violated safety protocols by moving the resident away from the door by pulling on her gown, and then leaving her alone in the bathroom as he went to get help, state investigators found.  Schweim, died on Sept. 17 from complications of multiple skeletal fractures resulting from the fall.
 The state Health Department investigation concluded that Ramirez violated multiple safety protocols and was responsible for neglect. The violations include failing to obtain assistance from a second staff person, as required; failing to operate the mechanical lift properly; and leaving the resident alone in the bathroom instead of using his phone or walkie-talkie to call for help. Ramirez also violated protocol by raising the woman to the highest level on the lift. Standard procedure was to lift the chair no higher than 1 to 2 feet, according to the criminal complaint.
Ramirez has been charged with second-degree manslaughter, two counts of criminal neglect and one count of mistreatment of patients.

The Toronto City News reported the tragic and preventable death of Danny McNeill trapped in his bed rail, his 69-year-old body fighting desperately to escape the very rails that were supposed to protect him.  Danny McNeill died alone at the Maple Manor Long Term Care Home in Tillsonburg.

According to Health Canada there have been 25 reported incidents involving bed entrapment over the past two years, seven were fatal. Since 2008 Health Canada has issued several safety communications about the use of bed rails as restraints in hospitals and long term care homes — most recently in April 2017 — yet they are still used in most homes and hospitals.  The home has been cited for safety violations involving both the use of restraints and bed rails in the past — including in 2016 when inspectors found that the “licencee (had) failed to ensure that no resident of the home was restrained by the use of a physical device.”

In 2015, the home was cited for failing to ensure that where bed rails were “used in the home (it) had taken steps to avoid patient entrapment” and later that year, 36 of 108 beds were identified as “failed” — in some cases because of a lack of mattress keepers or rails that required ongoing tightening.

“That’s why I’m here, to let people know that they’re being used. Our family members are using them and getting their heads trapped in them,” Kevin McNeill told CityNews. “I’m disgusted.”

“He got trapped between the bars of his bed rail and mattress. That was the call. They said he had died and that was pretty much it,” McNeill says, recalling the phone call he got from the home last Sunday.

McNeill doesn’t know why the restrains were in use. He says an alarm should’ve sounded when his father fell from the bed.

“If he was to fall off the bed or make a movement, the alarm would go off and notify the nursing station and buzz at the bed as well. In the case of falling, the alarm goes off,” he explains.

“The alarm should have been going off as soon as he probably left the area of the pad. He made it to the floor and got his head trapped for too long. That was the case. We really don’t know how long it took until that alarm was heard. I don’t know if they heard.”

Staff at the home told Ministry of Health inspectors that they had received no training on rail safety.

McNeill is still very much grieving the loss of his father but says the practice of using bed rails has to be re-examined.

“Maybe they’ve got to change those rails and make sure we’re not using them as restraints, just using them for getting out of bed. i didn’t know what they were used for until I did some research myself. gotta let people know.”

It’s no secret that some nursing homes will neglect their residents in the interest of their own greed for profits and wealth, but less well known is the fact that those nursing homes are often rewarded by the government for that mistreatment. NPR recently published an article on this topic, citing statistics like one in five nursing home residents sent from hospitals on Medicare are returned to the hospital within thirty days.

Rather than taking care of their patients to the best possible extent, hospitals and nursing homes choose to send them back and forth to one another because it benefits them financially. For one thing, it’s cheaper for each facility to treat a patient as little as possible. For another, both hospitals and nursing homes have historically received encouragement from the government for this behavior, getting financial rewards for things like admission, readmission, and discharge to and from the facility.

As an example, an elderly woman could be admitted to a hospital for a severe injury. She could then be transferred from there to a nursing home earlier than the injury demands because it’s in the hospital’s financial interest to move her out as fast as possible. Then, at the nursing home, she doesn’t receive the care she needs because the place is understaffed and it costs more money than they wish to pay to properly treat and rehabilitate her. So she gets sicker and they eventually send her back to the hospital. This act of “boomeranging” patients back and forth is well known in the world of health policy.

Noticing this trend, the government has begun its efforts toward fixing the situation. According to NPR, “In 2013, Medicare began fining hospitals for high readmission rates in an attempt to curtail premature discharges and to encourage hospitals to refer patients to nursing homes with good track records.” There are also plans to incentivize nursing homes to improve in similar ways.

These moves are a step in the right direction, but most believe there’s still a lot to do here in the interest of patient care.

The Stamford Advocate reported that St. Camillus Center was fined only $6,000 by Connecticut’s health department and three employees were fired following the death of a resident who hadn’t been checked on for 12 hours.  The footage also showed staff had not opened the door to the resident’s room or checked on the resident between 6:26 p.m. on Feb. 15 and 5:19 a.m. on Feb. 16.

In the Feb. 16 incident in Stamford, a resident with lung cancer was found unresponsive and without a pulse, according to DPH, and video footage subsequently showed staff waited 10 minutes to administer CPR.  The resident was taken to the hospital and later pronounced dead. A registered nurse, licensed practical nurse and nurse aide subsequently were terminated, DPH said.

Past incidents at St. Camillus

2016 – Inspectors report observing 40 violations at the nursing home over the past year, including an incident in which a nursing aide called patients fat. As a result of the observations from unannounced visits in 2015 and 2016, the nursing home failed to meet certain state Department of Health standards during annual licensing inspections.

2014 – The facility receives a $1,680 fine related to protection of patients’ rights and/or failure to monitor patient condition.

2010 – The state Department of Social Services threatened to shut down the center and revoke its eligibility to collect Medicaid after investigators find patients’ health in immediate jeopardy.

According to Medicare’s website, St. Camillus has 124 beds and has not received any federal penalties or payment denials by Medicare in the last three years. However, the site received a lower-than-average health inspection rating a year ago after being cited nine times for deficiencies in quality of life and care as well as other issues.

 

 

Signature Healthcare is a national for-profit nursing home chain with more than two dozen facilities in Tennessee.  The government started an investigation in 2014 when two whistleblowers started collecting evidence on their own.  LeeAnn Holt and Kristi Emerson, both of whom are occupational therapists from Columbia, collected reams of anecdotes — in part, because they were concerned they might get in trouble themselves.  That evidence is the basis of the $30 million settlement in the Medicare fraud case between the federal government and Louisville-based Signature Healthcare, which operates more than 100 facilities in 17 states.

According to court documents, state and federal investigators discovered Signature was “knowingly submitting false claims to Medicare for rehabilitation therapy services that were not reasonable or necessary” at 115 of its facilities. Investigators said that led to a total of $232 million in false claims. The company also allegedly forged documents submitted to Tennessee’s Medicaid or Tenncare program, leading to another $12 million in fraudulent reimbursements.  So they stole $232 million but only had to pay a settlement of $30 million.  Who says crime doesn’t pay?

The complaint against Signature Healthcare (download here) accuses the company of systematically administering occupational, physical and speech therapy when it wasn’t warranted and withholding care when government reimbursements were already maxed out. According to the suit, the unnecessary therapy pushed patients into a category where the facility was reimbursed more per day for those patients, often hitting precisely the 720-minute per week threshold for maximum payment.  Holt and Kristi Emerson are the whistle-blowers who exposed a company-wide system of over-billing the federal government by Signature Healthcare.

“There were a couple of times when things happened with patients where we would just look at each other and say, ‘We can’t do this. We just cannot do this any more,'” LeeAnn Holt recalled.  Holt recalls a patient with advanced cancer who just wanted to spend time with her family rather than continue with therapy.

“She just put her hand on the therapist and said, ‘Honey, you need to go work with somebody that can really benefit from this.’ And you know, when you have a patient that is telling you that, you really have to stop and take inventory of what is going on here.”

Emerson says she hopes the case will still inspire other health care workers to push back when they feel pressured to do procedures they deem medically unnecessary.

“We can’t just blame these corporations for all of this,” she says. “We have to shoulder as therapists some of the responsibility because we’ve allowed this to get this bad.”

The women say before filing their suit, they repeatedly went to administrators all the way up to the corporate office.

“And no one was doing anything. And the more we reported, the more they came in and just started pushing back on us,” Emerson explained.

Emerson and Holt were let go amid the investigation and have found it difficult to find stable work. “No one really wants a whistleblower in their building,” Emerson says.

But now they will split roughly $6 million as their share of the settlement. Whistleblowers are entitled to 15 percent to 25 percent of the total.

 

Certified nursing assistants that bathe, dress and provide 95% of the care to residents at New Jersey nursing homes may get some help from Gov. Phil Murphy.  An identical bill cleared the state Legislature two years ago but was vetoed by former Gov. Chris Christie.

Legislation is progressing that will increase of staffing levels of these unlicensed caregivers.  Under the proposed law, nursing homes would have staffing ratios to meet: Facilities would be required at a minimum to having one certified nursing assistant on staff for every eight residents on a morning shift, no more than 10 per aide in the afternoon and no more than 16 per aide overnight.  This is great news for the residents and caregivers in New Jersey.

By the way, South Carolina only requires ratios of at least 1 CNA to 9 residents on first shift; 1 CNA to 13 residents on second shift; and 1 CNA to 22 residents on third shift.  This were established in the mid-1980s and are now considered insufficient and unsafe.  That is why the regulations include the following language:  “Additional staff members shall be provided if the minimum staff requirements are inadequate to provide appropriate care and services to the residents of a facility.”

The legislation would send a message to nursing home operators “that they need to staff adequately in their facilities,” given that the Garden State ranks among the bottom in the nation for average nursing aide staffing-hours per patient.

Several states have passed similar staffing ratio laws but they need to pay a living wage so the jobs are attractive to qualified and compassionate caregivers.  “Despite how difficult it is, it’s a very low paying job — with many (nursing assistants) only making $12 or $13 per hour,” CNA Lloyd-Bollard said. “It’s not right that caregivers have to do two or three jobs to make ends meet. These are the people responsible for caring for our state’s most vulnerable people; we should support them.”

Jeanitha Louigene, a certified nursing assistant of 27 years, is certain it’s having an effect on the quality of care provided by nursing facilities. “I really feel sorry for the residents,” she said. “With the amount of residents we have at once, we really don’t have time for them — they may want to talk, but we can’t do that. We have one person taking care of sometimes 15 or more residents, who are needing the bathroom, water or are in pain. We have multiple people calling for us. But we can only be in one place at one time.”

McKnight’s had an interesting article regarding the arrests of operator-owner Joseph Zupnik and Daniel Herman, a top-level manager.  The men ran Focus Ostego, which was operated by CCRN, which was owned almost entirely by Zupnik, according to The Daily Star.  They were arraigned May 31 on three counts of first-degree endangering the welfare of an incompetent or physically disabled person, a felony; two counts of second-degree endangering the welfare of an incompetent or physically disabled person, a class A misdemeanor; and three counts of willful violation of health laws, an unclassified misdemeanor.

In 2014, the Ostego County nursing home had 298 employees. By 2016 — under new, private ownership — that number was down to 225, despite immediate jeopardy findings and plenty of other regulatory and staff warnings about quality of care.  Short-staffing always affects the quality of care.

“Upon taking ownership and control of the home’s operation in October 2014, Zupnik, Herman and CCRN cut staff payroll, cut staffing and cut other necessary services and supplies needed to provide safe and adequate care to more than 200 individual residents who were in the care of Focus through at least November 29, 2016, when Focus was designated as a Special Focus Facility by the Centers for Medicare & Medicaid Services,” read the state’s complaint.

The Attorney General’s office said CCRN disregarded communications from local and federal officials and senior staff “that residents were at risk for harm.”   Those missed opportunities for improvement included:

  • State health inspection surveys and reports that contained immediate jeopardy findings in 2015 and 2016.
  • Warnings from senior managers about the defendants’ 50% cuts in payroll and staffing and required double shifts.
  • Six arrests between May 2015 and August 2016 of Focus staff for crimes at the facility involving healthcare offenses. These included neglect of a 91-year-old fall victim and a 94-year-old woman who developed a pressure sore after 41 hours in a recliner.

Otsego County owned and operated the nursing home in question before selling it to Focus for $18.5 million. Focus has since been resold to Centers Health Care, which renamed it Cooperstown Center for Rehabilitation and Nursing.

McKnight’s reported that a judge has ordered the appointment of a special prosecutor to investigate an $80,000 wire transfer from a nursing home owner to a former state senator’s construction company — money that allegedly moved just days after the lawmaker introduced an amendment to limit negligence claims in Arkansas.

Sebastian County Prosecutor Dan Shue asked for an outside investigator to avoid any potential conflict of interest. The Times-Record also reported that Shue has asked the local U.S. Attorney to determine whether the wire transfer violated any federal law.

Jake Files (R), the one-time Fort Smith lawmaker at the center of the case, pleaded guilty in January to unrelated charges and is scheduled to be sentenced June 18. He faces counts of wire fraud, bank fraud and money laundering in relation to improper use of state improvement funds intended for a local sports complex.

The Times Record first discovered the 2014 nursing-home related transfer in civil court documents last year.

The money came from David Norsworthy, part owner in a dozen Arkansas nursing homes. It followed on the heels of a constitutional amendment that sought to limit damage lawsuits — like negligence claims commonly pursued against nursing homes — to $500,000.

That amendment failed then, but it found new life in the current session, before Files resigned in January.

Neither Files nor Norsworthy have explained the $80,000 transfer with media or in court.

The Arkansas Times reports the case has become an issue for those who support  limiting lawsuits through Issue 1, a bill that has been publicly backed by nursing homes, doctors and chambers of commerce.

Fox25Boston reported a tragic incident that occurred at a Rhode Island nursing home.  Frank Palin, age 67, was arrested for sexually assaulting a patient with dementia in a nursing home. Palin is charged with a single count of indecent assault and battery on a person over age 65, stemming from an incident through his work with Old Colony Hospice.

According to the police report, on May 19th, Palin showed up to Cornerstone without an appointment, asking and employee to unlock the secured facility where the victim stays.  According to authorities, the woman’s children had installed a video camera inside her room, so they could check in on her, which helped them find out what was happening.

Palin is a contract employee with Old Colony but was working as a nurse practitioner at Cornerstone at Canton, where the victim is a resident of the facility. She reportedly suffers from dementia and lives in the memory care unit at Cornerstone.

Bob Larkin, the president of Senior Living Residences, the management company in charge of operations at Old Colony Hospice and Cornerstone at Canton, issued the following statement on Friday afternoon:

“The alleged violation of a vulnerable elder is appalling beyond words. We support the victim’s family and the police department in seeking criminal prosecution to the fullest extent of the law. Nothing is more important to us than the safety and well being of our residents. The accused nurse practitioner was not an employee of our company; he worked for a third-party local hospice agency that has no contractual or other relationship to our assisted living community. Any questions about the individual’s employment or exact duties should be directed to his employer, Old Colony Hospice in West Bridgewater, 321 Manley St, West Bridgewater, MA,  781-341-4145. Also please call the Canton Police for any information about the ongoing investigation. Please note, HIPAA patient privacy and confidentiality standards preclude me from providing specific information about any resident. “