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State documents detail patient care violations at Eureka nursing home
One patient who fell out of bed in the middle of the night in a Eureka nursing home reportedly had to pull herself back into bed on her own. When the patient told nursing staff about her fall, she was told to “go back to bed.”
She wasn’t evaluated until five days later, according to the state, during which time she complained of chronic pain that was later found to have been improperly treated.
Another patient sat in soiled clothes after waiting more than 30 minutes for a nurse to answer their calls and assist them to the bathroom.
Another patient fell in the bathroom and was sitting in their urine before being found by staff, according to state documents.
Released Friday, the documents detail how a lack of staffing and oversight at a Eureka nursing home last year led to repeated patient injuries and lack of care that had the potential of causing serious harm or deaths.
In its review of the Eureka Rehabilitation and Wellness Center, the California Department of Public Health found that as much as three times more staff time was needed to provide adequate care for the residents. Nursing home staff also acknowledged in interviews with the state that more care providers were needed.
“(One unlicensed staff member) stated they were not able to check residents as frequently as they would (sic) to prevent residents from falling,” one document states.
The documents obtained by the Times-Standard on Friday detail the circumstances behind six patient care, staffing and administration violations at Eureka Rehabilitation and Wellness Center. The state fined the facility $160,000 for the violations Feb. 28. The nursing home plans to appeal the penalties.
“The facilities strongly disagree with the citations issued against Eureka Rehabilitation and Wellness Center,” Amad Nazifi — the Redwood Region vice president of operations for the nursing home’s administrative company Rockport Healthcare Services — said Thursday. “The citations are being appealed and we are confident that we will prevail.”
Department of Public Health spokesman Corey Egel confirmed in an email to the Times-Standard that the facility has not paid the fines as of Friday.
The six violations occurred between May and November 2016, with most concerning patient falls.
One high-risk dementia patient fell five times between August and September. One fall led to the patient having to be hospitalized after he hit his head, according to the state.
The state found that the nursing facility did not update this resident’s care plan to increase supervision after the falls, which it states could have resulted in serious injury or death of the patient. The same patient fell three more times in the following months, according to the state.
There were also multiple citations of the facility failing to prevent accidents.
A blind patient fell while walking unassisted to the bathroom in August, the documents state. The patient fell and fractured their arm after leaning their weight on an insecure spring rod that was accidently left in the doorway by a housekeeping employee, according to the state.
The woman who was told to “go back to bed” by an employee after reporting her fall in October was also found to have not been provided adequate treatment for chronic pain in her left leg, according to the state.
The woman had a known addiction to pain medication and was on a physician-prescribed plan to wean her off it, according to the documents. The patient told a state investigator that a nursing staff member accused her of reporting the fall only because she wanted more pain medication.
“(The patient) stated that staff were mad at her and acted like she was ‘a drug addict,’” the document states.
After the patient fell from her bed and was X-rayed days later, a physician found the patient needed a hip replacement due to blood loss in her hip bone, which was lethal if left untreated. The physician told the state that this blood loss was not the result of the fall.
However, the physician stated that the staff should have notified her of the fall earlier as it could cause “increasing pain” and would require that the patient remain on pain medication.
When the state interviewed the facility’s director of nursing in November, the director stated “she was not aware of an evaluation of the underlying cause of the (patient’s) pain” when the patient was admitted, the documents state.
The state also found the facility failed to follow through with one patient’s ear wax removal treatment, which caused the patient to temporarily lose hearing in her left ear.
The investigation determined a nursing home committee responsible for working to correct and prevent any violations had not developed a plan to prevent patient falls or address staffing issues.
For each citation, the nursing home submitted a plan of correction as is required by law.
“The department verifies that the facility implemented the plan of correction through various methods such as documentation review and/or on-site visit,” Egel wrote in an email to the Times-Standard.
The Eureka Rehabilitation and Wellness Center is owned by the Los Angeles-based Brius Healthcare Services.
Will Houston can be reached at 707-441-0504.