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Gangrenenous Genitals and Radical Surgery Caused by Nursing Failures; Cited for Understaffing One Month Earlier


Located: 400 East 33rd Street, Vancouver, WA 98663


Gangrenous Genitals and Radical Surgery Caused by Nursing Failures

Please Note: The highlighted quotes listed here and the survey may be disturbing to some readers. This second full report/survey (3/25) can be found here.

Based on interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable level of physical, mental and psychosocial well-being when they failed to complete a timely assessment and respond to reported concerns for 1 of 9 residents (#4) whose overall condition was in decline. This failure resulted in unnecessary pain and delayed treatment for the resident.

Continuing: During interview LN F stated ” The agency nurse reported in morning report on 3/13 that he {Resident #4} had been moaning and groaning all night and had a low blood sugar. When I went into his room about 7:30 that morning, he didn’t look right. He looked confused and more pale. When we went to move him up in bed, I saw his testicles. His penis and testicles were very swollen, maybe about 6-8 inches across. And he had no urine output.

According to staff interview and resident record review, the facility day nurse LN F did not assess the Resident not feeling well and having elevated blood sugars and extreme constipation. LN G did not assess Resident #4 on the evening shift of 3/12 despite receiving information from the day shift regarding blood sugar problems, bowel problems and resident complaints of not feeling well, and despite receiving NAC reports of swollen genitals, apparent pain and low urine output.

Continuing: On the morning of 3/13, the agency nurse reported the resident had been moaning during the night shift but no interventions were recorded. The night shift nursing assistant reported on the morning of 3/13 that the resident had been moaning during the night shift. By the time the day shift Licensed Nurse assessed the resident on the morning of 3/13, the resident was experiencing signs and symptoms of acute infection and required emergency transfer to the hospital. The Resident experienced unnecessary pain and a delay in treatment because of lack of assessment for at least 3 shifts.

On 3/15 at 3:25 p.m., the Director of Nursing stated, ” We heard from the Physician that Resident (34) was found to have a type of gangrene. I am continuing to investigate, but I don’t think we did anything wrong. The Resident was found to have Fournier’s Gangrene and had to have radical surgery. He was transferred to the burn unit for extensive skin grafting. He will be there for several months.”

This facility was cited with the above after they were cited for under-staffing and care deprivation a month earlier. Specifically, the facility failed to provide appropriate treatment and services to maintain or improve resident abilities for 4 of 4 residents. This failure placed the residents at risk for continuing decline in physical functioning.

Please Note: The highlighted quotes listed here and the survey may be disturbing to some readers. The complete report/survey (3/1) can be found here.

Findings Include:  In reviewing the records of 4 residents who had been assessed as needing nursing services to maintain or restore abilities (for example with standing, walking, or transferring) it was found that during the months of January and February 2013, the services had been delivered on a reduced number of days compared to previous months. Residents #4, 5, 8 & 9 did not receive their individual nursing restorative programs for multiple periods of consecutive days during the 2 months having more days without services than with them. For example, none of the 4 residents had restorative programs from 2/121/13 to 2/28/13 or 5 days in a row.

Continuing: during interview, the Director of Nursing (DNS) stated that “With the exodus of staff that I’ve had I’ve had to pull the staff.” {from working as Restorative Aides to working as Nursing Assistants}

Then she stated “Normally I would have moved somebody else in but I was already short {staffed}”

Continuing: Based on interview and record review, the facility failed to have sufficient nursing staff available to meet the needs of the residents.

Continuing: Staff have expressed concerns to me about resident care.

Continuing: Staffing records were reviewed for the period of 02/01/13 through 02/28/13 and showed the facility was staffed to the Administrator’s expectations on 19 of 28 of the days shifts (or 68%) of the time, 11 of 28 of the evening shifts (or 40%) of the time and 2 of 28 of the night shifts (or 70%)  of the time.

Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Share your story with us, spread the word and HELP STOP THE ABUSE AND NEGLECT! Stop the companies who hire inadequate and poorly trained staff in order to gain profits from our helpless elderly.

Contact us through our CONTACT FORM located on our website here or call our toll free hot line number: 1-800-645-5262

You can make a difference even if your loved one has already passed away



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