FLOYD COUNTY — Inspections of the lowest rated nursing homes in Floyd County show a history of issues such as staffing shortages, lack of proper supervision, sexual abuse among residents and inadequate medical care.
These problems are among those detailed in deficiency reports of one-star rated nursing homes in Southern Indiana in recent years, as well as issues related to COVID-19 protocols.
In Floyd County, Lincoln Hills Health Center and New Albany Nursing and Rehabilitation Center both have one-star rankings — average is three stars — by Medicare.
These Medicare rankings are based on health inspections, staffing and quality-of-care measures.
This story uses reports from the U.S. Centers for Medicare and Medicaid Services, which are compiled in a database by ProPublica.
NEW ALBANY NURSING AND REHABILITATION
The facility at 201 E. Elm St. in New Albany has been flagged as a “special focus facility candidate.”
This means the home “has a history of serious quality issues but has not been formally flagged by the government,” according to the database.
New Albany Nursing and Rehabilitation is ranked one star for health inspections; two stars, or below average, for quality of resident care; and three stars, or average, for staffing.
The health inspections rating is based on the three most recent annual inspections, as well as on substantiated findings from complaint investigations during the past three years.
The data used for the quality of resident care rating is based on the three most recent quarters for which data are available. The staffing is rated based on the total nursing hours per resident per day and the total registered nurse hours per resident per day.
New Albany Nursing and Rehabilitation has 68 residents and 122 certified beds.
The nursing home had 37 combined deficiencies reported from April 19, 2017, to Oct. 22, 2020, including four infection-related deficiencies, or violations of federal standards protecting residents from spread of infections.
In that time frame, the nursing home faced a total of $153,000 in fines.
During the pandemic, 23 COVID-19 cases and 10 COVID-19 deaths have been reported among staff and residents at the facility.
The News and Tribune reached out to New Albany Nursing and Rehabilitation multiple times this week. A staff member with the facility said the request for comment had been sent to the Chosen Healthcare, the company that operates the nursing home, but she had not received a reply from the corporate office as of Friday afternoon.
Two deficiency reports are related to COVID-19 precautions at the facility.
The Oct. 22, 2020, report states the “facility failed to ensure infection control practices were followed during the COVID-19 pandemic for residents related to isolation precautions for 4 of 5 residents reviewed for infection prevention.”
- These deficiencies were related to actions after residents were readmitted to the facility following time in the hospital.
- In an interview for the inspection, the report said, the executive director and director of nursing both indicated they did not have a yellow unit, or a unit for transmission-based precautions.
- Residents in this situation should be isolated from residents with a known COVID-19 status (both positive and negative), according to the report.
The Aug. 12 report states the nursing home “failed to ensure appropriate social distancing of six feet or more and mask usage for 8 of 9 residents observed for infection prevention.”
The reports also show a history of serious issues at the facility prior to the pandemic. The deficiencies from June to July in 2019 included several identified as “immediate jeopardy to resident health or safety.”
The June 5, 2019, report states that undercooked meatloaf served to residents resulted in a deficiency categorized as “immediate jeopardy.”
- “This deficient practice had the potential to affect 86 of 87 residents,” the report reads.
- This was one of six deficiencies listed in the report, which resulted in a $152,850 fine and one payment suspension from Medicare.
There are also several incidents of cognitively impaired residents leaving the facility without supervision included in the June 20, 2019 report.
- The report states an “immediate jeopardy” deficiency occurred when the nursing home failed to provide adequate supervision for a resident with dementia, who was later returned to the facility.
- Around 4:15 p.m. on June 6, 2019, the resident, who lived in the facility’s secure locked unit, followed a vendor out of the unit, down an elevator, past a nurse’s station and out of the building.
- The resident then walked four blocks away from the facility to a high-rise apartment building located across the street from an interstate exit ramp.
- The director of nursing and health facility administrator were alerted at 4:37 p.m.
The July 19, 2019, report also indicates an “immediate jeopardy” citation due to a resident with dementia leaving the building due to inadequate supervision on July 14, 2019.
- The resident left through the side door of the facility without supervision at 5:25 p.m., and she then walked 0.7 miles before she was found at 6:53 p.m. by the facility’s activity director.
- The report says the resident had a Wanderguard bracelet on her wrist, which is a tracking device to alert staff when a resident exits the facility, and her care plan showed she was at risk for elopement, or wandering.
The nursing home was also cited for failing to protect a resident from sexual abuse, according to an Oct. 16, 2019 report.
- In an incident report from Oct. 4, 2019, a male resident was observed touching a female resident inappropriately without her consent and was immediately removed from the female resident’s room.
In a Jan. 8, 2019 report, deficiencies included “abuse related to verbal and physical actions.”
- In one instance, a resident reported that two certified nursing assistants were “making fun of his genital area” while providing care, and the resident was “upset and embarrassed about the incident.”
- Another incident indicated that a licensed practical nurse kicked against a resident’s wheelchair to move him out of the way, causing the chair to veer and hit the metal meal cart, according to the report.
According to the Medicare reports, “an approved plan of correction” is required from facilities unless “it is determined that other safeguards provide sufficient protection to the patients.”
The nursing home at 326 Country Club Drive in New Albany is ranked one star in terms of health inspections and staffing, and two stars, or below average, for quality of resident care.
The nursing home has 107 residents and 156 certified beds. The facility had 45 deficiencies reported from Jan. 9, 2018, to Nov. 17, 2020.
This includes two infection-related deficiencies, which are violations of federal standards to protect residents from the spread of infections.
During that time frame, Lincoln Hills faced federal fines totaling $332,000.
During the pandemic, 124 COVID-19 cases and four COVID-19 deaths have been reported at the nursing home.
The News and Tribune reached out to Lincoln Hills multiple times for comment and was directed to CarDon & Associates Inc., the company that operates the facility. As of Friday evening, the News and Tribune had not received a response from CarDon.
In a Sept. 7, 2018, report, which resulted in a $27,671 fine to the facility, an “immediate jeopardy” deficiency included the facility’s failure to “provide immediate assessment and care to a resident in an emergency situation resulting in excessive bleeding and death.”
- During an interview included in the report, a a registered nurse said about 10 minutes after a resident was given medications, he heard her yell for help and saw that “blood was everywhere,” according to the report.
- “There was nothing in the room that I thought would be useable as a pressure dressing and there was nobody in sight,” the interview reads.
- The nurse ran down the hall and told a nurse to call 911, the report says. The nurse grabbed abdominal pads, yelled for immediate help from all licensed staff, returned to the room and applied pressure to the resident.
- A qualified medical assistant then took over applying pressure, and the report states the nurse left the resident because “he could not identify anything that could be used as a pressure dressing and no one would have heard him yell for help,” according to the report.
- The EMS care record indicated the resident was showing symptoms of cardiogenic shock, and the hospital emergency evaluation report said there was bleeding from the left groin fistula site, and the resident had died from the incident, according to the report.
- Lincoln Hills later completed staff training on emergency protocols for residents in similar situations of active bleeding from the fistula site, according to the deficiency report.
- The nursing home “failed to ensure staff remained with a resident in an emergency situation without a resident assessment being completed,” the report states.
One deficiency report was related to a lack of adherence to proper COVID-19 safety protocols. The Nov. 17, 2020, report states the facility failed to ensure “prompt isolation and testing of a resident who was symptomatic of COVID-19” for one resident reviewed for infection control.
- The resident was in the lobby of the facility with labored breathing, and he stated that felt like he had a cold, the report states.
- The nursing home’s clinical record didn’t include documentation for isolation or COVID-19 testing for this resident at the time, the report showed. The resident was later transferred to the hospital and was tested for COVID-19, “which resulted as detected.”
The reports also noted ongoing issues with staffing prior to the pandemic.
A report from March 2, 2020, includes nine deficiencies and shows a number of issues related to insufficient staffing levels at Lincoln Hills.
One deficiency listed is a failure “to ensure sufficient staff were available” in a particular hall to “provide ADL (activities of daily living) care, dignity, and nutrition for residents in a timely manner for 19 of 103 residents residing at the facility.”
- The report indicates the facility’s “H Hall” did not have enough staff to “provide incontinent care for residents in a timely manner,” and observations included residents in soiled briefs that “had not been changed for several hours and with strong odors of urine.”
The report also states that the hall did not have enough staff to help residents requiring assistance with dining to be fed in a timely manner.
- Residents were “observed receiving breakfast up to two and a half hours late and a half hours late, and one resident did not receive a breakfast tray at all,” according to the report.
Another finding included issues related to the dignity of residents:
- “Resident call lights were not answered in a timely manner, which resulted in residents having to urinate in their briefs. A resident was also left exposed, in a brief, with the window blinds open. The resident was covered only with a towel, did not have linens, was disheveled, and had had food and beverages spilled on her,” the report reads.
In the Jan. 28, 2019, report, one deficiency was categorized as “immediate jeopardy” due to the facility failing to provide the care needed to prevent the worsening of a stage IV pressure ulcer and/or the development of multiple pressure ulcers for two observed residents.
- The Jan 28, 2019, inspection resulted in a $271,170 fine to Lincoln Hills.
- Lack of adequate staffing was attributed to this deficiency, according to interviews with staff included in the report. Multiple staff used the word “horrible” to describe the staffing.
- One nurse was quoted in the report saying it was the “worst I had ever seen the wounds in the facility, and staff were not turning the resident.”
- A CNA was quoted in the report saying “sometimes the jobs are just quickly done for the resident and the care is not done perfectly.”
- One CNA said in “it is hard to get everything done” and was the only CNA working in the area on some days. The CNA was also quoted saying “we can’t watch all the residents.”
A report dated Jan. 3, 2020, includes seven deficiencies and a $33,046 fine to the facility.
One citation from the Jan. 3, 2020, report states Lincoln Hills “failed to protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody” in reference to incidents between residents.
- The report includes an account of a resident with dementia facing physical violence from other residents, including punching and kicking.
- The resident was observed with a skin tear on her hand and bruising on her face.
- In an interview cited in the Jan. 3, 2020, report, a certified nursing assistant stated that it was difficult for one CNA and one nurse or qualified medication aide to watch the residents in reference to that incident.
Another deficiency included in the Jan. 3, 2020, report details an incident where a resident was observed inappropriately touching and kissing another resident, who had a moderate level of cognitive impairment and was not able to give consent.
- The facility received a citation for failing to report this incident of resident-to-resident sexual abuse in a timely manner, according to the report.
A clinical specialist said in an interview included in the report that the incident was not reported because “they had not considered it abuse.”