After state health inspectors visited the one 514-bed nursing home in February, they were clearly alarmed. Inspectors found resident screaming, biting and kicking as four
attendants held them down for bathing or treatment. Often, the
inspectors found, patients received improper doses of powerful
psychotropic drugs. Also, an investigation never happened when a staff member reported
concerns about physical abuse of a resident.
"The administrator and director of nursing were not fulfilling their
essential job duties to ensure the safety and proper health care
services for residents," the inspectors concluded in a 37-page report. The U.S. Department of
Health and Human Services rated the facility below average in meeting
inspection requirements, giving them a ranking of only one out five stars.
Officials with the state Department of Military and Veterans
Affairs, which runs the homes, acknowledged the seriousness of the
inspection reports. But they said agency staff resolved outstanding
State officials point to patient satisfaction surveys they conducted, which show a high approval rate. However, the inspection reports tell another story at the nursing home. A review of reports for the past five years shows the most serious violations occurred repeatedly at the facility.
The situation at home was serious enough to prompt one state senator to make two unannounced visits. "It was pretty serious," said the senator, adding that state health inspectors "uncovered some real problems."
The violations of state and federal rules included failure to notify
physicians and family members about changes in patients' conditions;
unsanitary incontinence care; and overuse of side rails, which caused
patients to become trapped and suffer injuries. For more on state run nursing homes, read the story.