LEE COUNTY CARE & REHABILITATION CENTER (Nursing Home) located 246 EAST MAIN STREET, BEATTYVILLE, KY 41311 was recently cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES as of 2013 for the following: Protect each resident from all abuse, physical punishment, and being separated from others, 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, Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property, Make sure services provided by the nursing facility meet professional standards of quality, Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%, Be administered in an acceptable way that maintains the well-being of each resident, Keep accurate, complete and organized clinical records on each resident that meet professional standards, Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
The following highlighted are only direct quote portions of the report. The full report can be found here.
PLEASE NOTE: THERE WERE TOO MANY VIOLATIONS TO LIST HERE; ONLY A FEW WERE POSTED.
the facility failed to have an effective system in place to ensure one of twenty-nine sampled residents (Resident #1) was free from abuse. On 02/17/13 at approximately 7:35 AM, staff observed Resident #1 sitting in a wheelchair located in the dining room next to the nurses’ station, crying in pain, and requesting to go to bed. Licensed Practical Nurse (LPN) #1 refused to allow staff to take Resident #1 to bed and stated the resident would remain seated in the wheelchair until the resident quit crying, hollering, and/or whining. LPN #1 placed a radio near Resident #1’s head and turned up the volume. Interviews revealed LPN #1 continued to be in charge of resident care and remained on the floor with residents during the time the Staff Development Coordinator/Nurse Manager initiated the investigation, talked with the other staff, and attempted to get direction from the Social Worker/Abuse Coordinator, Director of Nursing, and Nurse Consultant on what action to take. LPN #1 remained in direct resident care until 12:30 PM, approximately five hours after staff observed the abuse.
Continuing:
LPN #1 did not return to the facility and was terminated from the facility on 02/25/13 related to falsification of documentation. The facility’s failure to have an effective system in place to ensure residents were free from abuse caused, or was likely to cause, serious injury, harm, impairment, or death
Continuing:
One staff member reported LPN #1 made a comment that indicated she was going to teach the resident a lesson.
Continuing:
7:35 AM, LPN #1 made a comment that Resident #1 was not going to bed because the resident was whining and crying. According to Housekeeper #1, Resident #1 repeatedly said, I want to go to bed, I’m hurting, take me to bed. Housekeeper #1 stated LPN #1 had a tendency to be loud and used a tone that was a combination of hateful and rude. According to Housekeeper #1, on the morning of 02/17/13, LPN #1 was more than just loud and was verbally abusive to Resident #1. Housekeeper #1 further stated LPN #1 wheeled Resident #1 to the nurses’ station, placed a radio near Resident #1’s head, and turned up the volume of the radio. Review of Housekeeper’s #1’s written statement signed and dated 02/17/13 revealed after breakfast on the morning of 02/17/13 Resident #1 was crying and wanting to go to bed. LPN #1 told Resident #1 that as long as (he/she) whined and cried, the resident was not going to bed. Further review of the witness statement revealed staff attempted to take the resident to bed and LPN #1 told staff no. The witness statement went on to say LPN #1 obtained a radio, placed it at the nurses’ station, and turned it up to drown out Resident #1 crying. Interview with Housekeeper #2 on 03/01/13 at 11:47 AM revealed on the morning of 02/17/13 LPN #1 would not allow facility staff to assist Resident #1 to bed. According to Housekeeper #2, Resident #1 did cry and holler that he/she was in pain and wanted to go to bed. However, according to the housekeeper, LPN #1 stated to the resident that he/she had to sit in front of the desk until the resident quit hollering. Housekeeper #2 further stated LPN #1 obtained a radio, placed it at the nurses’ station near the resident’s head, and turned the volume up real loud.
Continuing:
A review of a facility’s investigation revealed on 03/24/13, Resident #30 alleged that SRNA #13 had repeatedly sprayed cold water on the resident during a shower and had wrapped a sheet around the resident’s neck too tight following the shower on 03/22/13 from 8:00 PM to 9:00 PM.
Continuing:
Additional review on 04/09/13 revealed the facility had not completed the investigation and had failed to report the allegation to the appropriate State Agencies until 04/09/13, sixteen (16) days after the alleged incident was reported. In addition, there was no evidence the alleged perpetrator had been suspended.
Continuing:
Six allegations of resident abuse were reported to Facility Administration from 02/17/13 to 04/04/13, involving Residents #1, #4, #19, #29, #30, and #31. Interview and record review revealed administrative staff failed to thoroughly investigate/report these allegations of abuse and failed to protect residents. The facility failed to recognize that their established abuse policy for reporting abuse was not effective, and therefore failed to implement any corrective actions to correct these problems. (Refer to F223, F225, F226, and F490.) The facility’s failure to identify quality deficiencies and failure to develop and implement appropriate plans of action to correct identified deficiencies regarding protecting residents from abuse and reporting/investigating allegations of abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility.
Continuing:
Administrator #2 stated he was half paying attention when he heard a comment about doing late notes. Administrator #2 stated he then came to the conclusion the DON was going to have RN #8 take the nurse’s notes out of Resident #4’s medical record regarding the alleged abuse on 03/24/13 and rewrite the nurse’s note. Administrator #2 stated he asked the DON, Is that not part of the record? Further interview revealed the DON
stated to the Administrator that since that was the only note on the page the nurse could write a clarification note. Administrator #2 stated the DON said the nurse’s note was not part of the medical record, and then removed the note from the record, and RN #8 rewrote the nurse’s note for 03/24/13. Further interview revealed Administrator #2 did not agree with the rewriting of the nurse’s note; however, he stated the DON has been a nurse for 18 to [AGE] years so he assumed she knew what she was doing. Interview with the DON on 04/02/13 at 8:45 PM revealed during an interview with RN #8 on 03/27/13 that she explained to the RN she needed to document Resident #4’s noncompliance, and told her what to document. The DON stated she had RN #8 to write it down on a new nurse’s note since the original note only had one entry written on it. The DON
stated she pulled the original nurse’s note out of the chart and asked Administrator #2 what to do with the original note. Administrator #2 stated to the DON that he would shred it, so the DON stated she tore it up.
Personal Note from NHAA Advocates: We here at NHAA share 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 other than our-self. We live our lives thinking our loved ones are being 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 which go unpunished and continue to turn a blind eye to our elders’ safety and well being.
You can make a difference. If you have a loved one living in this nursing home or any other nuring 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 abuse and/or neglect attorney or help you find a more suitable location for your loved one.
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