Request A Free Consultationcat-right

WINCHESTER, TN – Controlled Substance Theft, Amputation from Pressure Sores, Unclean Conditions, Falls, Widespread Jeopardy

WILLOWS AT WINCHESTER CARE & REHABILITATION CENTER

Located 32 MEMORIAL DRIVE WINCHESTER, TN 37398 was cited for the following deficiencies by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES as of November 2013.

PLEASE NOTE: The following highlighted portions are only part of the full report. The full report in its entirety can be found here.

WARNING: SOME MATERIAL SHOWN HERE CAN BE DISTURBING.

Based on medical record review, facility policy review, observation, interview and facility document review, the facility administration failed to ensure staff provided the necessary care to prevent pressure ulcers and prevent pressure ulcers from worsening. The facility’s failure resulted in amputation of resident #95’s left leg and resulted in the need for surgery on the resident’s right leg to remove necrotic (dead) tissue. The facility’s failure to ensure systems and processes were in place and consistently followed by staff for the provision of necessary care and services to prevent development of avoidable pressure ulcers and worsening of identified pressure ulcers placed Resident #95, #114, #35, and #73 and potentially any resident at risk for pressure ulcers in Immediate Jeopardy (a situation in which the provider’s noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). The facility administration failed to ensure residents were safe in the facility by not investigating accidents; not determining causes of falls; not devising new interventions to prevent future falls; and not evaluating the new interventions. The facility failed to provide a system for management of falls and failed to follow the facility’s fall policy, resulting in 22 residents experiencing 93 falls in 2013. This failure placed Resident #35 in Immediate Jeopardy who, after multiple falls, no investigation of the cause of the falls, and no new interventions, sustained a [MEDICAL CONDITION]. This failure placed Resident #73 in Immediate Jeopardy who, after several falls with no investigation of the cause of the falls, and no new interventions, sustained a clavicle fracture. The facility’s failure placed all residents at risk for falls in Immediate Jeopardy (a situation in which the provider’s noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). The facility Administrator failed to ensure a systematic approach was followed by nursing staff for receipt and destruction of medications which provided an environment to allow Licensed Practical Nurse #4 to potentially divert narcotics from any resident who was receiving narcotics. The Administrator’s failure to implement a system to prevent diversion of narcotics constitutes Substandard Quality of Care.

Continuing:

Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents’ property.

Based on medical record review, review of facility policy, review of facility investigations, and interview, the facility failed to prevent misappropriation of controlled substances for thirteen residents (#10, #72, #79, #87, #71, #47, #116, #66, #39, #118, #100, #69, and #91) of forty-three residents receiving controlled substances. The facility’s failure to follow a systematic approach for receipt and destruction of narcotics placed all residents receiving narcotics at risk for drug diversion and misappropriation of narcotics. The facility’s failure to follow policy and procedure and have a systematic approach for receipt and destruction of narcotics constitutes Substandard Quality of Care.

Continuing:

Review of a facility e-mail from the Consultant Pharmacist dated September 9, 2013, revealed a nurse was diverting controlled substances by several different methods in order to avoid detection. The nurse was diverting by taking the entire card and declining the inventory sheet upon delivery by the courier; taking the balance of the card and inventory sheet on medications when a new sheet had arrived from the pharmacy; and had also documented giving PRN pain medications to several residents (11) and not actually administering the pain medications.

Continuing:

Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

Based on medical record review, review of facility investigation, observation, review of facility policy, and interview, the facility failed to follow policy and procedures for a sexual abuse investigation for two residents (#77, #42) and failed to investigate an attempted removal of a pain patch for one resident (#33) of sixty-five residents reviewed. Medical record review of a Triage from the hospital dated August 2, 2013, revealed, .Chief Complaint: ‘tried to have sex with me.
touch along my vagina with his hand’.denied penetration by penis.

Continuing:

Interview with the Administrator on October 1, 2013, in the Administrator’s office confirmed there were no causative factors, interventions, or corrective actions included in the investigation for the sexual altercation between residents #77 and #42. Continued interview confirmed the facility had failed to follow the policy and procedure for investigating allegations of resident to resident sexual abuse.

Continuing:

Interview with the DON on October 3, 2013, at 2:30 p.m., in the Administrator’s office confirmed CNA #8 had been terminated due to an alleged attempt to remove a pain patch from resident #33. Interview with the Administrator on October 3, 2013, at 2:35 p.m., in the Administrator’s office, confirmed the facility had failed to investigate and report to the appropriate State Agency the attempted removal of a pain patch from a sleeping resident.

Continuing:

Allow the resident the right to participate in the planning or revision of the resident’s care plan.

Based on medical record review, review of facility documentation, observation, review of facility policy, and interview, the facility failed to revise the care plan following falls to include interventions for the staff to implement to prevent future falls for nine residents (#35, #73, #62, #120, #26, #93, #100, #52, #119) of twenty-two residents reviewed with falls; failed to revise the care plan addressing pressure ulcers for staff to implement care plans for four (#35, #73, #114, #79) of fourteen residents reviewed with pressure ulcers; and failed to revise the care plan with interventions for staff to implement after a sexual altercation for two residents (#77, #42) of sixty-five residents reviewed. The facility’s failure to address interventions on the care plan for pressure ulcers for three residents (#35, #73, and #114) resulted in staff unfamiliar with the care to be provided placing residents in Immediate Jeopardy (a situation in which the provider’s non-compliance has caused or likely to cause serious injury, harm, impairment, or death). The failure of the facility to revise the care plans addessing falls with new interventions resulted in a [MEDICAL CONDITION] for one resident (#35) and a fractured clavicle for one resident (#73) placing the residents in Immediate Jeopardy. The Immediate Jeopardy was effective on November 26, 2012, and is ongoing.

Continuing:

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

Based on medical record review, review of facility policy, observation, and interview, the facility failed to prevent the development of avoidable pressure ulcers for four residents (#95, #114, #35, #73) of fourteen residents with pressure ulcers reviewed. The facility’s failure to perform accurate assessments and obtain physician’s orders placed residents #95, #114, #35 in Immediate Jeopardy (a situation in which the provider’s non-compliance caused or is likely to cause serious injury, harm, impairment, or death). The systemic failure to ensure orders physician’s orders for a medical device was obtained; skin assessments were performed correctly; pressure ulcers were assessed accurately; and treatments ordered by the physician were documented, was likely to place any resident at risk for pressure ulcers in Immediate Jeopardy.

Continuing:

Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents.

Based on review of facility policy, medical record review, review of the Fall Risk Evaluation forms, review of the facility fall reports, review of facility documentation, interview, and observation, the facility failed to investigate and develop new interventions to address falls for fourteen residents (#35, #73, #17, #24, #42, #119, #100, #62, #120, #26, #23, #113, #52, and #89) of twenty-two residents with falls reviewed. The facility’s failure to investigate and develop new interventions to address falls placed residents #35 and #73 in Immediate Jeopardy (a situation in which the provider’s non-compliance has caused or likely to cause serious injury, harm, impairment or death).

Continuing:

Store, cook, and serve food in a safe and clean way.

Based on observation and interview, the facility failed to maintain a clean hand sink area; maintain sanitary food preparation equipment; ensure pots, pans and utensils were appropriately sanitized in the three compartment sink; sanitize the food thermometer between food items; serve food in a sanitary manner; appropriately wash and sanitize serving utensils prior to use; maintain a sanitary dish room; and maintain a sanitary dietary department.

Continuing:

Further observation revealed dietary employee #1 used the same cloth to wipe the thermometer between each food item: hamburger patties, ground hamburger, pureed hamburger, tater tots, and mashed potatoes. Further observation revealed the food was removed from the dining room tray line at 12:26 p.m., and taken to the dietary department to reheat. Further observation revealed the thermometer was rinsed under running water in the sink and the temperature was taken for the reheated food without sanitizing the thermometer between each food item. Further observation revealed the food was returned to the dining room steam table at 12:49 p.m. Further observation at 12:51 p.m., revealed the CDM touched the tomato slices, lettuce leaves, and onion slices with the same gloved hand at the dining room steam table.

Continuing:

Interview on September 30, 2013, at 1:20 p.m., in the dietary department with dietary employee #2 confirmed the employee had not washed, rinsed, or sanitized the serving utensils. Further interview confirmed the utensils were stored on a soiled plate. Further interview confirmed the serving utensils had not been washed, rinsed, or sanitized appropriately. Further interview confirmed the utensils were stored on a soiled plate.

Continuing:

Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist.

Based on medical record review, and interview, the facility failed to provide pharmaceutical services to relieve pain and anxiety for one resident (#33), of sixty-five residents reviewed. This failure resulted in harm to resident #33. Interview with the Director of Nursing (DON) on September 26, 2013, at 10:35 a.m., in the conference room, revealed the resident complained of pain and anxiety on admission. Continued interview confirmed the facility failed to provide the resident’s pain and anxiety medications for six hours and twenty minutes after the resident’s complaint of pain and anxiety.

Continuing:

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Based on review of facility documentation, review of facility policy, interview, and observation, the facility failed to manage controlled drugs for thirteen of forty-three residents receiving narcotics.

Controlled Drug Records removed from Licensed Practical Nurse (LPN) #4’s truck by a police officer on August 27, 2013, revealed a total of 586 doses of controlled substances was diverted from thirteen residents from June 2013, through August 2013.

Continuing:

Have a program that investigates, controls and keeps infection from spreading.

Based on observations, interview, and review of the facility policy, the facility failed to separate clean and dirty items and contain dirty linen on one of three wings; failed to complete [DIAGNOSES REDACTED] (TB) screenings for five of five employee health records; and failed to contain dirty razors for one of three shower rooms.

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, www.nursinghomesabuseadvocate.com 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.

Click Here To Request A Free Consultation Today!


4 Responses to “WINCHESTER, TN – Controlled Substance Theft, Amputation from Pressure Sores, Unclean Conditions, Falls, Widespread Jeopardy”

  1. Betty says:

    I am glad that there are people out there yo follow ip and help people that have bad experience with nursing homes. I have been in several nursing homes in the area on my 24 years of being a CNA and there are only a hand full of people that really care about their jobs and love what they do , I really wish there were more ways to be able to let people stay in homes and not in nursing home . We need more people that can stand up for the few people that choose to really love there jobs and the people they take care of , I can turely say when I did work in the nursing homes I gave everything I had to make sure the people I had each day had the best each day I worked with them ,

  2. James says:

    That is totally despicable! Those patients deserve much better care than what they were given!

  3. This is tragic what happened to those residents and for the family members.Is this nursing home still open with the over whelming definces?Did the nursing home have enough of Cnas on the halls during day shift and during night shift?The nurse had to been taking the meds.for herself,that Cna must have a drug problem.I hve been a Cna for 21 yrs.Ifeel like nursing homes don’t hire enough of Cnas to take care of residents and night shift does not give enough of Cnas to take care of residents.Cnas @ night are taking care any where of 16 to 18 residents @ night thats with 3 Cnas working skill halls and none skilled residents and alot of falls occur @ night.There needs to be more Cnas on nights to keep residents turned and changed on schedule also to have enough eyes to keep the ones that are going to get up and not use the call light to prevnet alot of falls.Last hire good nurses…………

  4. Betty says:

    I have been in both sides of the doors at nursing homes I have worked the halls and in the office as a scheduler . The state gives them a number that they can work per CNA and most places go by that it’s not enough staff to take proper care of people and than I can tell you 75 percent of the people that work in nursing home are only there for the money and the company are also looking at the money . If places where able to tell the truth about people work habits they would not get hired so fast at another place to continue to do crappy work and not really care about there people that need them . I think everyone job should be able to tell why that person was let go and if they would hire them again .this would cut down on people going from nursing home to nursing home .

LEAVE A MESSAGE or REQUEST SUPPORT

Your email address will not be published. Required fields are marked *

*

*

*

*

*