Nursing Home Fined After Probe Of Resident's Care

May 25, 2018

A Sarasota nursing home has agreed to pay $26,000 in fines and increased licensure fees after the facility failed to notify the daughter of a resident that her mother’s health was deteriorating.

The state Agency for Health Care Administration issued a final order this month citing Beneva Lakes Healthcare and Rehabilitation for failing to inform a resident or a resident’s representative about a serious medical condition and for failing to have adequate programs to ensure quality of care and quality of life in nursing homes.

The facility will be on the state’s nursing-home watch list until about February 2020, according to AHCA spokesman Shelisha Coleman. The final order imposed a $6,000 fine to cover costs of increased surveying, which is required for protection of public health, safety and welfare.

AHCA’s order essentially implemented a settlement agreement. The nursing home, part of the Consulate Health Care chain, did not acknowledge fault or admit wrongdoing as part of the settlement.

Jennifer Trapp, a spokeswoman for Consulate Health Care, told The News Service of Florida in a statement that it is the facility’s “heartfelt mission to do our very best by the patients, residents, and families” that it serves.

An administrative complaint the state filed against the nursing home said “resident 66” was admitted to the facility in January 2017 for treatment of chronic ulcers on both legs. She had multiple health problems, including congestive heart failure, but was not considered terminal. The goal, according to the daughter, was that the mother’s wounds would heal and that she’d get stronger. Instead, she died within a month.

Discrepancies were found during a survey, which included a review of the deaths of three residents “who died unexpectedly at the facility.”

Resident 66 ---whose name was not disclosed --- had undergone vascular surgery and was referred to the nursing facility for treatment of the ulcers on her lower legs. The daughter signed paperwork authorizing medical treatment if necessary.

After the woman’s ulcers failed to improve, she was referred to a dermatologist who, on Jan. 31, 2017, told a physician assistant who was treating the woman that the ulcers could be due to a systemic disease.

The medical record also showed that on Feb. 6, a wound doctor said she couldn’t be treated at the center because the wounds were too large and that a palliative consult should be scheduled.

But a “review of the facility record failed to reflect this discussion with Resident 66 or her daughter,” according to the administrative complaint. Instead, the physician assistant who contacted the daughter on Feb. 6 advised her that her mother was depressed and that she needed follow-up appointments with a vascular surgeon and the dermatologist.

In an interview with state regulators, the unidentified daughter said end-of-life care was never discussed with her or her mother.  

“I didn’t know they would even be thinking about this,” the daughter told AHCA investigators, adding that had she known about the severity of her mother’s condition she would have authorized hospital care. “I relied on what they were telling me. My mother had ulcers on her legs, but that was it.”

AHCA also discovered that a licensed practical nurse did not follow protocol hours before the patient died when the nurse, among other things, failed to ask the resident if she wanted to be treated at a hospital. The licensed practical nurse also canceled a follow-up dermatologist appointment that had been scheduled for the resident and did not seek the help of a registered nurse.

The director of nursing told AHCA regulators examining the incident that “some things we should have done differently.”

The circumstances surrounding resident 66’s death contributed to the state’s decision to cite the facility for failing to have an effective quality assessment and assurance program.

The administrative complaint noted that the facility did not fully investigate and identify an incident of potential neglect for the woman’s unexpected death. “As result of the failures resident 66 expired in the facility. The situation resulted in immediate danger,” the complaint said.

The nursing home administrator is also the director of the quality assurance program.

But the death of the woman wasn’t the only circumstance leading to the citation, according to documents. AHCA discovered nurses erroneously withheld potassium medication from a resident and sanitary violations including dripping air-conditioning vents in the kitchen, a soiled ice machine and floors and a crumbling wall.

During their review, AHCA regulators noted nurses withheld potassium medication from “resident 50.” The medication had been ordered for him following surgery for a pacemaker. Nurses didn’t notify a physician they had held the medication four days in a row, and there was not follow up of the resident’s potassium level. Resident 50 required potassium because he took Lasix, a diuretic that lowers potassium levels.

The facility’s consulting pharmacist twice advised the facility that nurses were withholding potassium medication from the resident.