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Tulsa, OK – Mistreatment, Pain Ignored, Forced to Remain in Bed for One Year, Call Lights Ignored, Cockroaches; Multiple Citations

MAPLEWOOD CARE CENTER

Located: 6202 EAST 61ST STREET, TULSA, OK 74136

MAPLEWOOD CARE CENTER was recently cited in February of 2014 and December of 2013 by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

Please note: The following highlighted text quotes are only a small portion of the full report/survey. The full report/survey can be found here and here and here.

WARNING: The following can be disturbing to some readers.

TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES – 34 RESIDENTS HAVING PRESSURE ULCERS

Based on observation,  interview, and record review, it was determined the facility failed to identify and implement interventions to aid in the healing and/or prevention of pressure ulcers for one (#12) of eight sampled residents who were reviewed for pressure ulcers. The facility identified 34 residents as having pressure ulcers.

On 12/10/13 at 2:16 p.m., a resident interview was conducted. The resident stated the staff did not answer his call light. He also stated staff would put him on the bed pan and not come back. He was asked how long staff left him on the bed pan. He stated, “One time it was two hours. I timed it once, and  it was one hour and fifty minutes.” He was asked if he had turned his call light on. He stated, “Yes, It was on the whole time.”

SUFFICIENT 24-HR NURSING STAFF PER CARE PLANS

Based on observation, interview, and record review, it was determined the facility failed to ensure there were sufficient staff to meet the needs of the residents.

Cont: Based on observation, interview, and record review, It was determined the facility failed to ensure CNAs were trained

PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

Based on observation,interview, and record review, it was determined the facility failed to Recognize pain, develop and/or implement pain management interventions, and/or monitor the effectiveness of pain management interventions.

Cont: The facility’s failure to manage pain resulted in actual harm for residents #3 and #16.

REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES

Based on observation and interview, it was determined the facility failed to answer call lights in a timely manner and/or ensure call lights were accessible

Cont: The resident was asked how long it usually took staff to respond to her call light. She stated, “20 to 30 minutes, sometimes over an hour.”

Cont:It was observed that it took 51 minutes for staff to respond to resident#15’s call light.

MISTREATMENT/NEGLECT/MISAPPROPRIATION

Based on observation, interview, and record review, it was determined the facility failed to prohibit verbal mistreatment

Based on observation, interview, and record review, It was determined the facility failed to Report an Incident of verbal mistreatment to the administrator

Cont: Failed to conduct thorough investigations related to resident to resident abuse or staff to resident verbal mistreatment

Cont: Based on observation, in1erview, and record review, It was determined the facility failed to treat seven (#27, #30, #35, #37, #39, #40,  and #41) of fifteen residents who were observed for wake up times with dignity and respect when staff awakened the residents and got them out of bed beginning at 4:30 a,m.

Cont:The administrator was asked if residents #27, #30, and #37 could tell staff they did not want to get up that early. She stated, “No.” The administrator and DON were asked why resident #35 was dressed at 4:30 a.m. and left in bed. There was no comment.

MAINTAINS EFFECTIVE PEST CONTROL PROGRAM

Based on observation, interview, and record review, it was determined the facility failed to have an effective pest control system for roaches at the facility.

DIGNITY AND RESPECT OF INDIVIDUALITY

RESIDENT #1

Based on observation, interview, and record review, it was determined the facility failed to:

Treat one (#1) of three residents who was observed for personal hygiene and grooming with dignity and respect when the resident refused bathing due to a language barrier. This resulted In actual harm when the resident vocalized his demise due to lack of self-worth.

Cont: The resident was asked how he felt about his life at the facility. He stated, “I have no life, no money, they are taking my things. I just as soon be dead.”

RESIDENT #2

Cont: Resident #2 was admitted to the facility on 11/13/03 

Cont: On 02/18/14 at 11:55 a.m., resident #2 was observed in her room in a bariatric bed with the head of the bed raised to a sitting position.

Cont: She stated she had not been out of her bed in over a year. Stated she had been able to stand with a walker at one time but her leg muscles are not strong enough now.

Cont: On 02/19/14 at 6:50 p.m., the resident stated, “Nobody’s listening to me.” She stated, “No one comes and talks to me.”

NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

Based on observation, interview, and record review, it was determined the facility failed to notify the physician of increased pain

Cont: This resulted in actual harm for resident

Cont: It was also documented the resident’s pain was frequent with an intensity of eight, on a pain scale of one to ten. It was also documented the resident had three stage III pressure ulcers and one stage four pressure ulcer. There were three unstaged slough/eschar pressure ulcers.

Cont: On 12/13/13 at approximately 9:50 a.m., Dr. [name withheld] was asked if staff had informed him that the resident had increased pain with pressure ulcer dressing treatment. He stated, “I’m not too sure about that.”

Cont: He was informed that the resident’s routine pain medication was Aleve. He stated, “That’s nothing.” He was asked what he would have done if he had known the resident was having increased pain with her pressure ulcer treatments. He stated, ” I would have increased her pain medication.”

RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

Based on interview and record review, It was determined the facility failed to have accurate and complete clinical records

Cont: No documentation was provided for dressing changes being performed on 12/04/13 and 12/09/13.

 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! 

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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2 Responses to “Tulsa, OK – Mistreatment, Pain Ignored, Forced to Remain in Bed for One Year, Call Lights Ignored, Cockroaches; Multiple Citations”

  1. Jamyeyy says:

    Check out Ambassador Manor…med errors not addresses, wound dressings not changed, never enough staff, res not treated with respect, res psych issues not adequately addressed. The DON handled issued by not following up and always manages to lose paperwork; if she ignores repeateded errors repeatedly by the same nurse and loses support paperwork, then it never occurred . Very bad place to be a bed fast res

  2. Kathy says:

    You need to check out Senior Suits in Tulsa, just about killed my Dad in less than a week, and Glennpool Nursing home did murder my grandma, and got by with it. (He who has the most money$$$WINS!!!

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