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Nursing home penalized for not giving medication to patients with serious health issues

Original source:

The Modesto Bee
DECEMBER 19, 2015

Vintage Faire Nursing and Rehabilitation Center makes a good first impression, with its clean stucco exterior, a green awning over the entrance and a lobby decorated this month with holiday trees.

But the appearance is deceptive. The Dale Road facility has a below-average rating from a federal government service that rates nursing homes for consumers.

State regulators spent an unusual amount of time at the 99-bed nursing home this past year, and not just to investigate patient transfers.

In May, the California Department of Public Health called what’s known as an “immediate jeopardy” at Vintage Faire and assessed a $12,740 fine for violations.

An investigation found Vintage Faire failed to administer prescribed medication for patients who had serious health conditions such as blood infections, epilepsy, heart arrhythmia and breathing problems.

State public health investigated other complaints at Vintage Faire and completed three other reports from Feb. 18 to July 31. Those reports documented problems including not verifying the licenses or certificates of new hires, failure to maintain the dignity of residents, lapses in care for patients given oxygen and poor infection control.

Health officials call an immediate jeopardy in a small percentage of nursing home inspections, when regulatory violations threaten to result in death or serious harm to patients. Facilities are required to make immediate corrections to remove the threat to patient safety.

The order at Vintage Faire was called on May 6 and lifted two days later. An inspector concluded that three patients could have died or suffered serious injury from not receiving their prescribed medication. Four others could have suffered health complications.

In addition, Vintage Faire failed to notify patients’ doctors when prescribed medication was not administered.

A hospital patient transferred to Vintage Faire in April was supposed to receive an intravenous antibiotic to treat a blood infection and sepsis, according to government records. The order from his physician called for the antibiotic therapy every four hours for four weeks. But Vintage Faire nurses stopped the treatments after three days due to an error in transcribing the instructions from the hospital.

According to the state’s report, a Vintage Faire nurse typed three days instead of four weeks into the man’s electronic medical record. The patient missed 33 doses of the antibiotic over a six-day period before the mistake was caught.

A state inspector spoke with the patient’s physician, who said Vintage Faire had told him the patient had missed some doses of the antibiotic. But the doctor was never told 33 doses were missed.

Without treatment, the blood infection could have rebounded and caused serious harm to the patient, who was diagnosed with inflammation of his heart lining, high blood pressure, chronic airway blockage, heart disease and asthma. Sepsis, a toxic reaction to an infection in the bloodstream, kills more than 258,000 people in the U.S. each year, according to the Centers for Disease Control and Prevention.

The patient’s doctor told the state inspector the first 10 days of antibiotic therapy were crucial for treating the infection. The patient missed 70 percent of those doses.

Nurses also failed to administer doses of a heart rhythm medication and drugs to treat the man’s breathing problems, the state report said. The identity of patients is not revealed in the state inspection reports.

During interviews with nurses and other employees at Vintage Faire, the state investigator found that medications were not given to other patients with serious health issues because the drugs were not available in the facility. The nursing home simply ran out of the medications when nurses failed to reorder drugs from the pharmacy service.

According to Vintage Faire’s plan for correcting the issues, the antibiotic therapy was resumed for the patient with sepsis when the error was discovered. Staff members made sure his medications were available and administered on schedule. The patient was discharged in stable condition May 25, the report said.

The nursing home created a process of double-checking instructions for patients transferred from hospitals.

Tony Chicotel, staff attorney for California Advocates for Nursing Home Reform, said the investigation uncovered fundamental problems with medication management and delivery at Vintage Faire.

“They messed up in multiple ways. It is troubling,” Chicotel said. “Most troubling was that the nurses dispensing the medication said they knew all of this and didn’t do anything. It seems like they were afraid to say or do anything. To me, that speaks to the culture in the facility.”

The administrator of the Vintage Faire center did not return phone calls from The Bee. A legal representative of Covenant Care, the Southern California company that owns the facility, did not return calls or respond to emailed questions.

The May investigation also focused on a woman admitted to Vintage Faire in February who had a history of non-Hodgkin’s lymphoma of the brain, cancer treatment, seizures, pneumonia and an eye infection.

Twice, she was not given a medication prescribed to control seizures, the state survey said, despite strict doctor’s orders that she take the medication at 7 a.m. and 7 p.m. every day.

A review of the patient’s care plan showed her daughter became concerned when the evening dose was missed March 15. A nurse discovered Vintage Faire had run out of the medication and a new bottle would not arrive until late the next morning; as a result, the patient missed the 7 a.m. dose as well.

For more than a month, the facility also failed to give the woman a drug to prevent acid reflux and ulcers and, for nine days, she wasn’t given drops for her eye infection, the state report said.

In April, another patient diagnosed with epilepsy went without three consecutive doses of a seizure-control medication because it was not available in the nursing home, the report said.

A few days later, the patient was unresponsive and foaming at the mouth, and was taken by ambulance to a hospital. The patient was treated for seizures and returned to Vintage Faire.

According to the state report, nurses told an investigator the facility had an ongoing problem with running out of medication that patients needed. Nurses said drugs were not reordered before the supply ran out. There wasn’t a single nurse who was responsible for placing orders with the pharmacy for medication.

In its correction plan filed with the state, Vintage Faire said it held employee training on the process of ordering medications from the contracted pharmacy service. The director of nursing was put in charge of reviewing daily reports that show if patients received medications and was ordered to conduct quality assurance reviews for the next three months.

Chicotel said he hopes the state is following up with monthly audits on the medication issues. Corey Egel, a Department of Public Health spokesman, said the agency revisited the nursing home and determined its medication management was back in compliance.

The federal government has an online service called Nursing Home Compare to give consumers information on quality of care, staffing levels, safety and the regulatory track record of care facilities.

Vintage Faire has an overall 2-Star rating, or “below average,” on Nursing Home Compare. When it comes to health inspections, the facilities rating is 1 Star or “much below average.”

The Modesto area has 11 nursing homes with the top 5-Star rating from Nursing Home Compare, including Casa de Modesto, Evergreen Nursing & Rehabilitation Care Center, Crestwood Manor and Hy-Lond Health Care Center in Modesto; Ha-Le Aloha Convalescent Hospital in Ceres; Oakdale Nursing and Rehabilitation Center; Brandel Manor and Bel-Air Lodge Convalescent Hospital in Turlock; and Bethany Home Society in Ripon.

Covenant Care’s Turlock Nursing and Rehabilitation Center is a 5-Star facility. Covenant Care is not related to the nonprofit Covenant Village Care Center in Turlock, which also has five stars.

English Oaks Convalescent Hospital and Garden City Healthcare Center in Modesto have four stars and Riverbank Nursing Center has three.

As a condition of receiving Medicare and Medicaid funds, nursing homes are required to meet regulatory standards designed to protect patients. California’s health department has an agreement with the federal government to do health inspections at nursing homes and investigate complaints.

In the past year, state inspections documented 19 deficiencies at the Vintage Faire nursing center, far higher than the state average of 11 and three times the national average for nursing homes.

In reports back to 2010, more than 75 deficiencies were documented regarding facility issues, patients’ dietary requirements and a previous violation for not following medication orders.

According to a report in July, family members complained about Vintage Faire employees not responding to patient calls for assistance.

One patient was left on a bed pan for more than an hour, and the investigation found that staff members told two patients to “go in the bed” when they asked for assistance with toileting.

One family complained that a loved one was left on a bed pan multiple times for more than an hour.

In its correction plan, Vintage Faire said training was held for employees on addressing patients’ needs and proper response to patient call lights.

Chicotel said he could not recommend Vintage Faire to consumers, given its 2-Star rating and poor history of health inspections. He recommended that individuals or families searching for a nursing home consider other facilities.

Families may consider moving a loved one from a poorly rated nursing home, but the process is complicated and a move can be traumatic for a frail patient, he cautioned.

“If they have a family member (at Vintage Faire), I think they need to crack open the medical records and make sure the care plan is what it needs to be and is implemented,” Chicotel said. “There needs to be a lot of (looking) over the shoulder of staff to make sure care is delivered.”

Joyce Gandelman, director of the Senior Law Project in Stanislaus County, said she believes stiffer fines would influence nursing homes to comply with regulations and improve their quality of care.

She noted that patients in nursing homes or residents in assisted-living facilities tend to receive better care if they have frequent visits from family members or friends. For nursing home residents with limited support, the Senior Law Project has begun the Friends for Your Folks service, which will charge $30 to check on a patient for 90 minutes.

“When my father was in assisted living, we would help feed him. We were there all the time and he got excellent care,” Gandelman said.