Nursing Home Abuse

Officials unable to prove who acknowledged injured woman’s alarm

By Tom Tolan of the Journal Sentinel

Sept. 1, 2010

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No charges were filed in a death last February in a Clement Manor independent living apartment because it couldn’t be proved who had acknowledged an alarm from the apartment, an assistant district attorney says.

Assistant District Attorney Denis Stingl provided information Wednesday that shed new light on the Feb. 15 death of Sylvia Ploszay.

A lawsuit was filed Monday in the death of Ploszay, 87, who experienced a cut on a varicose vein near her ankle, pulled an emergency cord requesting help, and then bled to death over the four hours it took staff members to respond to the call.

According to the lawsuit and an extensive Greenfield police report on the death, Ploszay pulled an alarm cord in her room at 12:25 a.m. on the 15th, and a nurse didn’t respond to the alarm until 4:20 a.m. or after. The alarm was acknowledged at a nursing station within a minute, the documents say, but not acted upon until later.

None of the Clement Manor staff members who were interviewed by police remembered acknowledging the alarm, according to the district attorney’s office, although one nurse, Suzette Gorski, told police she acknowledged an alarm from the complex’s loading dock between 1 and 2 a.m.

Records from the alarm system showed no such alarm, and Stingl speculates it might have been the call from Ploszay that Gorski acknowledged then. But investigators couldn’t determine what was displayed on the alarm screen at that time, Stingl said.

In addition, Stingl clarified the responsibilities of a nursing assistant who was watching television when she received a call from a hallway neighbor of Ploszay’s reporting her alarm. Her job was to field emergency calls from the assisted living facility at Clement Manor, not the independent living building, according to Stingl, and it was her practice to watch TV while waiting for those calls. Stingl and the police report said she’d told the caller to contact the complex’s health office, given him a number to call and returned to watching TV. Neither she nor the caller apparently followed up.

The lawsuit complaint incorrectly identified the woman as a nurse; she’s a certified nursing assistant.

Richard Rau, chief executive officer of the Clement Manor complex, wouldn’t say Wednesday whether any staff member had been fired as a result of what happened, but did say, “Appropriate counseling or disciplinary action was taken.” Greenfield police Detective David Leon, whose investigation at the complex lasted until May, said that “to the best of my knowledge,” no one had been fired.

Finally, as was reported Wednesday, alarms from independent living units like Ploszay’s now go to a private alarm company, which informs Greenfield emergency dispatchers. In addition, though, the internal alarms at Clement Manor have been reorganized so that an alarm from a room goes off every five minutes until it’s reset in the resident’s room, according to Stingl.

Also, Stingl said, work rules have been changed so that any staff member who acknowledges an alarm or receives a call about an alarm has to immediately contact the shift supervisor.

Alert answered four hours after cord pulled

By Tom Tolan of the Journal Sentinel

Aug. 31, 2010

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Workers at the Clement Manor complex in Greenfield “inexcusably and unconscionably” ignored for four hours an emergency alarm set off in an apartment at the complex as the resident bled to death, according to a lawsuit filed this week.

One nurse’s aide received a call about the alarm while she was watching TV and instead of following up, went back to watching TV, according to the complaint filed Monday in Milwaukee County Circuit Court and a Greenfield police report.

The lawsuit names Clement Manor Inc., two Franciscan sisters’ communities and Cincinnati-based insurance companies in the death of 87-year-old Sylvia Ploszay on Feb. 15.

Ploszay was a resident of a 101-unit independent living building at 9405 W. Howard Ave. that is part of Clement Manor, which also has assisted-living units and a nursing home.

The independent apartments have cords to pull to summon help in emergencies, and Ploszay pulled hers at 12:25 a.m. on Feb. 15. A nursing supervisor and a nursing assistant finally arrived at the apartment at 4:34 a.m., according to the lawsuit, and found her dead in her bathroom.

The Milwaukee County medical examiner’s office found that she’d experienced a cut in a varicose vein and had died of loss of blood. The Greenfield police report indicates she’d had more than one case in which she’d experienced bleeding in the past.

The lawsuit and police report say that a sound alarm and visual alarm went off at a nursing station in the complex and were acknowledged within a minute by someone at the station. The acknowledgment turned off the sound alarm at the station, but not a light alarm.

The suit also said a resident later heard a sound alarm in a hallway of the independent living unit and made a phone call that was answered by a nurse’s aide who said she was watching television. The resident, Richard Stobbe, said the woman told him she’d take care of it, the lawsuit says. The lawsuit calls the woman a nurse, but she’s a nurse’s aide, according to the police report.

The nurse’s aide — whose job was to monitor calls in the complex’s assisted living center — told police she had directed the caller to contact the complex’s health center and speak to a supervisor. In any case, no one followed up on the call and the aide went back to watching TV, the lawsuit says.

The suit also said the facility was short-staffed that night.

Greenfield police conducted an extensive investigation of the death and presented it to the Milwaukee County district attorney’s office, which decided not to issue charges.

Stephanie Smiley, spokeswoman for the state’s Department of Health Services, said the department’s Division of Quality Assurance, which regulates nursing homes and assisted living facilities, did not get involved in this case because it doesn’t oversee independent living apartments.

But she said the division has investigated only three complaints against the nursing home and assisted living facility since 2005, and no citations were issued as a result.

“It appears to be a facility where they follow state codes and regulations,” she said.

Dennis Ferger, administrator of Clement Manor, said he couldn’t comment on the lawsuit, but he said the complex in March changed the procedure for independent living residents to report emergencies.

Now, according to Ferger and the Greenfield police report, when residents pull the alarm cord, it goes straight to a private alarm company, which notifies the Greenfield emergency dispatchers, who dispatch firefighters to the complex.

Ferger referred questions about the lawsuit to the local representative of the Cincinnati Insurance Co., who did not return a phone call.

Jeff Pitman, the attorney who filed the suit on behalf of Ploszay’s estate, said he handled “a ton of nursing home stuff,” but had never sued Clement Manor before.

But he wasn’t handing out praise in this case.

“This was a callous disregard for this woman’s safety and her life,” he said. “Their choice not to respond to this alarm led to her death.”

Ferger said Clement Manor is an independent, religious-affiliated corporation, with sponsorship from the School Sisters of St. Francis, one of the groups named in the lawsuit.

Another named group, the Franciscan Sisters of St. Clare, is not involved in running Clement Manor, he said.

MetLife Foundation Healthy Living Initiative at Dance Exchange, Residency at Saint John’s On The Lake, June 21-25, 20 from Keith Knox on Vimeo.

Countryside Nursing Home in Jefferson has been renamed Alden Estates of Countryside Rehabilitation and Health Care Center.

Chicago-based Alden Management Services assumed ownership of the home July 1. The nursing home, at 130 Collins Road, had been owned by Jefferson County since 1856, but voters in September overwhelmingly rejected a proposal to boost the county tax levy by $1.9 million for four straight years to help fund the 120-bed facility, constructed in 2003. The Jefferson County Board agreed to sell the nursing home to Alden in February for about $8 million.

Medicare’s Nursing Home Compare website gave the facility 1-star rating. The one-star rating is defined as “Much Below Average.”

The Eureka (CA) Times-Standard (7/7, Drange) reports, “The jury in the class-action lawsuit against” nursing home chain Skilled Healthcare “returned to Humboldt County Superior Court and rendered a verdict on Tuesday, opting to impose the maximum amount of damages totaling nearly $619 million for health code violations.” Along with “the statutory damages, the jury awarded an additional $58 million for a violation of the California Consumer Legal Remedies Act, bringing the total damages to nearly $677 million.” The issue “at the heart of the case is a California statute that mandates 3.2 nursing hours per patient per day.”

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The following is an article entitled, “Mt. Carmel Faces Seven Lawsuits Over Care” written by Tom Kertscher of the Milwaukee Journal Sentinel as it appeared on July 4, 2010.

Mt. Carmel Faces Seven Lawsuits Over Care

State’s largest nursing home accused of negligence care that led to injuries, death

Greenfield – Mount Carmel Health and Rehabilitation Center, which has been cited for 35 care violations this year, is now in compliance with state regulations.

But the state’s largest nursing home is fighting allegations of substandard care made in seven lawsuits, including six filed in the past six months.

The Journal Sentinel reported last month that Mount Carmel had been issued 35 citations – nearly matching the 40 violations it had been cited for all of 2009.

In one case, staff repeatedly reported seeing a resident for more than 10 hours, even though he had fled the facility and was arrested for prowling.

Having responded to the citations, Mount Carmel is now in compliance with state regulations, according to Beth Kaplan, spokeswoman for the Wisconsin Department of Health Services.

The seven pending lawsuits, however, allege that Mount Carmel chronically is understaffed and that residents in the 473-bed home at 5700 W. Layton Ave. are not getting adequate care.

Staffing levels criticized

Kindred Healthcare, the Louisville, Ky., company that owns Mount Carmel, simply is trying to maximize profits, said Jeff Pitman, a Milwaukee lawyer whose firm is handling four of the seven lawsuits.

“It costs to put (staff) on the floor,” he said.

The Milwaukee County Circuit Court lawsuits generally allege that lack of care led to an injury or condition for an elderly resident that resulted in death. One suit accuses Mount Carmel of keeping “staffing levels that created recklessly low nurse- and nurse aid-to-resident ratios.”

Milwaukee attorney Patrick Sullivan, who is defending Mount Carmel in four of the lawsuits, said state investigators exonerated Mount Carmel in one of the cases and that his initial review of another case indicates Mount Carmel met the required standard of care.

He said the other two cases he is handling are new, and he has not had time to review them.

Sullivan said the recent surge in lawsuits against Mount Carmel is at least partly the result of plaintiffs’ attorneys filing more cases against all nursing homes.

“I think the plaintiffs’ lawyers see this as a very lucrative field,” he said.

Among the allegations in the lawsuits:

• Lack of care led Vicenta Hernandez, 94, to suffer a fall and broken hip, which resulted in her death in November 2007.

• Mary Eva Richey, a one-month resident, developed multiple pressure sores that led to her death in January 2009.

• Edmond Strehlow, who lived at Mount Carmel for 3  1/2 months until April 2007, suffered multiple pressure sores that led to his death.

Richard Abel of Muskego said he visited his late wife, LaVerne, five days per week at Mount Carmel and that staff often ignored her pleas for help in getting to the bathroom and failed to keep a brace on her knee. Abel said he complained to staff and their supervisors on the floor, and then to administrators.

“They said, ‘We’ll look into it,’ but nothing ever happened. Nobody ever followed through on anything,” he said.

Mount Carmel nearly was shut down by state regulators 12 years ago.

In 1998, the state revoked the license of Vencor Inc., Mount Carmel’s owner at the time, after discovering serious and widespread health violations. Benedictine Health System of Minnesota took over management.

In January 2009, Kindred Healthcare, a successor of Vencor, resumed operation of Mount Carmel. After operating with a probationary license for one year, Kindred was given a full license in January of this year.

The citations issued this year include allegations that Mount Carmel:

• Failed to provide appropriate supervision and assistive devices to five out of 10 residents identified by the nursing home as being at risk for falls.

• Failed to assess and treat pain, depression and other problems experienced by a 51-year-old woman who speaks Spanish and who had part of her right leg amputated last December.

• Did not treat 16 of 32 residents reviewed “in a manner that maintained their dignity.”

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Lawsuits pending against Mount Carmel

Families on the following dates filed lawsuits alleging substandard care of these relatives, who later died:

June 22: Vicenta Hernandez, two-year resident, died at 94 on Nov. 2, 2007. Suit alleges that broken hip Hernandez suffered Aug. 20, 2007, led to her death.

June 3: Wardean Colbert. Details not available.

May 4: Irvin Wesolowski, 1  1/2 year resident, died at 90 on May 17, 2007, after a fall.

Feb. 25: Fatahy Agayby, 1  1/2 year resident, died at 69 on Jan. 13, 2008. Suit alleges death was result of pressure ulcer.

Feb. 19: Mary Eva Richey, one-month resident, died Jan. 13, 2009, after developing multiple pressure sores.

Jan. 6: Edmond Strehlow, 3  1/2 -month resident until April 20, 2007. Died after developing multiple pressure sores.

July 18, 2008: Agripina Gerena, 15-month resident, died at 93 on March 14, 2006, after suffering subdural hematoma – a head injury that leads to blood filling the brain – in a fall six weeks earlier.

Source: Milwaukee County Circuit Court records

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Pitman, Kyle & Sicula, S.C. is a Wisconsin law firm with a devoted nursing home abuse practice. Our Nursing Home Abuse Team, consisting of attorneys, nurse attorneys and paralegals, is the largest in the state and has successfully represented abused and neglected nursing home residents throughout Wisconsin.

The following information is from the Wisconsin Board on Aging and Long Term Care:

How does the Ombudsman Program differ from the Division of Quality Assurance?

The Division of Quality Assurance provides the regulatory oversight to long term care facilities.  The Ombudsman Program, while working within the boundaries of the regulatory requirements, provides advocacy to long term care consumers, insuring that their concerns are heard and considered.

Does the Ombudsman Program serve the entire state of Wisconsin?

Yes. Each county in the State of Wisconsin has a Regional Ombudsman.  In addition, Ombudsman coordinate access to services for out of state residents who will be moving to Wisconsin.

The following information is from the Wisconsin Board on Aging and Long Term Care:

What types of concerns do ombudsmen address?

Ombudsmen serve persons age 60 and older who live in Wisconsin nursing homes and assisted living facilities, or who are receiving community-based services under the Family Care or the Community Options Program.  Most frequently expressed concerns are about substandard care, complaints about access to providers or services of choice, providers not treating consumers with dignity and respect, inappropriate discharge of a resident from a facility, as well as how to make a choice in long term care service providers.

The following information is from the Wisconsin Board on Aging and Long Term Care:

My father lives in a nursing home, but the staff hints that he may have to leave if his behavior does not improve. How can the Ombudsman Program help?

Persons may not be discharged from a nursing home without thorough preparation, planning and notice, and may only be discharged to what will be considered a safe and permanent setting. This would include persons who are transferred from a nursing home to a hospital for treatment of behavioral challenges. This transfer may not be considered a discharge from the facility, and the facility has the above obligation.

The Ombudsman Program may be of assistance to the facility in terms of assisting with problem-solving the behavioral challenges and assisting with referrals to other community education and support agencies. Residents and families served with a notice of involuntary discharge under these circumstances should call the Ombudsman Program immediately.

What is a Long Term Care Ombudsman?

An Ombudsman (Om-budz-man) is an advocate for long term care consumers aged 60 and over who reside in nursing homes or group homes or are participants of the Community Options Program.

An article as it appeared on stltoday.com

A group led by Illinois Attorney General Lisa Madigan walked into theVirgil Calvert Nursing & Rehabilitation Centerfor a surprise inspection this morning, one of series of such inspections she has been doing around the state to see of nursing homes are following a state law requiring special precautions for potentially dangerous residents.

They didn’t find the numerous apparent violations that they have found at other homes, Madigan said in a news conference a short time later.

What they did find was one resident of the home who was wanted in St. Louis on a drug warrant. This apparently is a common issue out there now: older people with active criminal warrants, effectively hiding out in the nursing homes.

“He knew he was wanted. He seemed perfectly able-bodied,” said Madigan spokesperson Cara Smith. “These nursing homes have been turning out to be the perfect place for hiding out. We’ve found wanted people in every one.”

In fact, the nursing-home inspection program through Madigan’s office–which started in December and wasn’t specifically about catching wanted felons–has so far led to the discoveries of 61 people under active warrants living in the homes, and 17 arrests, in the 12 homes inspected so far.

Nursing homes are required to do background checks on their residents and make special arrangements to separate and monitor those with dangerous criminal histories, such as sex offenders and other who could pose a threat to fellow residents.

Madigan said her office began undertaking the surprise inspections — along with state police and state health and professional regulation officials — after complaints that residents in some homes around the state were being victimized by fellow residents.

“They’re our parents and our grandparents . . . One day they could be one of us,” Madigan said.

The East St. Louis nursing home has come under scrutiny in the past for health-and-safety issues. Madigan said her impression during the 10 a.m. inspection was that “they seem to be much better than they had been in the past.”

When asked whether she would put one of her own parents in that home, Madigan (daughter of Illinois House Speaker Michael Madigan) quipped, “It would be geographically inconvenient.”