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Hoarded pills, burned patients at Erie-area nursing homes lead to six-figure fines

In World
June 11, 2024

LECOM Senior Living Center has been fined $182,160 after an incident Jan. 30 in which a resident attempted suicide after hoarding about 100 muscle-relaxing pills.

It comes less than a year after the Pennsylvania Soldiers’ and Sailors’ Home was fined $176,348 after two residents suffered second-degree burns when physical therapy staff used an electrical stimulation device with a defective cord.

These are the two highest fines imposed by the Centers for Medicare and Medicaid Services on Erie County nursing homes since at least 2021, and rank among the highest CMS fines imposed statewide over the past two years.

“Medicare may impose penalties on a nursing home when there’s a serious health or fire safety citation, or if the nursing home fails to correct a citation for a long period of time,” a CMS spokeswoman said.

The incident at LECOM Senior Living Center, identified as Millcreek Manor by CMS and the Pennsylvania Department of Health, was reported during a state Health Department survey Feb. 23.

LECOM Senior Living Center resident hoarded muscle relaxers

A review of the facility’s records showed that the resident, who was not identified in the report, was found unresponsive in their room Jan. 30, according to the survey. They were taken to a local hospital and successfully treated for an overdose of the muscle relaxer Tizanidine.

In a state Health Department interview Feb. 20, the resident said they would pretend to take their regular doses of the medication and hide the tablets.

“(It) wasn’t hard, as many nurses didn’t stay in the room while he/she took the pills and he/she easily slipped them into the sheets,” the state Health Department report stated.

Sometimes the nurse would remain in the room, so the resident came up with a way to have their pills delivered in separate cups. The resident would stack an empty cup on top of the one with the pill in it, then fish it out of the trash after the nurse tossed away the cups.

After the suicide attempt, staff found a box in the resident’s room with about 100 Tizanidine tablets in it.

The staff knew this particular resident was a suicide risk, according to the survey. The resident had been diagnosed with major depression and had attempted suicide three previous times, including twice in the previous five months.

The policy at LECOM Senior Living Center is that staff remain at bedside with a resident until all medications are taken.

LECOM Senior Living Center officials declined comment for this article. In the survey, the facility’s administrator confirmed Feb. 20 that there were no staff competencies (special qualifications) for medication administration.

Because the facility had failed to implement sufficient safety measures to prevent hoarding pills and there were two other residents with histories of suicide attempts, the state Health Department determined there was what it calls an Immediate Jeopardy situation.

Changes were immediately put into place. Staff members were required to observe and ensure medications were swallowed, psychiatric services were offered for all residents with suicidal thoughts, mental health inpatient services were offered, and all nurses were trained on proper medication administration.

Soldiers’ and Sailors’ Home residents burned with E-stim device

The state Health Department also declared an Immediate Jeopardy situation at the Pennsylvania Solders’ and Sailors’ Home in May 2023 after two residents were burned by a malfunctioning electrical stimulation device, according to a May 23, 2023, state Health Department survey.

The first resident’s burn was not documented until April 30, 2023 — 33 days after it occurred — “when nursing staff was made aware by the resident that the scab over the burn reopened, and that he/she had been burned by the E-stim device when staff ‘hit the wrong button and it went zap,'” according to the state Health Department survey.

The second resident’s burns were detected by physical therapy staff on April 19, when they noticed blisters on the resident’s back due to the E-stim pads. This discovery launched an investigation in which the first resident’s burns were found.

Both residents suffered second-degree burns, which included blisters, a darker skin tone, and a shiny, moist appearance, according to the survey.

The Pennsylvania Soldiers' & Sailors' Home, 560 E. Third St., was fined $176,348 by the Centers for Medicare & Medicaid Services following an incident where two residents were burned by a malfunctioning electrical stimulator.

The Pennsylvania Soldiers’ & Sailors’ Home, 560 E. Third St., was fined $176,348 by the Centers for Medicare & Medicaid Services following an incident where two residents were burned by a malfunctioning electrical stimulator.

A document review determined that nine other residents were treated with the E-stim device but did not suffer burns. An inspection of the E-stim devices determined that one of the devices had a “bad cord,” meaning it had an open connection.

Even when the burns were discovered, the malfunctioning E-stim device remained in service until May 1, 2023. There was no evidence that the therapy staff had completed safety checks of the device before using it on residents, the survey reported.

Because the malfunctioning device was not immediately removed from use after the two incidents, an Immediate Jeopardy situation was declared, according to the survey.

The facility’s corrective plan included not using E-stim until new devices were obtained, educating staff on how to respond to adverse effects of the device, updating staff on E-stim procedures, and evaluating residents who receive E-stim for adverse reactions.

Messages left with the Soldiers’ & Sailors’ Home were not returned. The facility was also fined $8,500 by the state Health Department in connection with the incident.

Nursing home advocate: Inspections, fines tell part of the story

Families who have relatives in a nursing home or who are looking to place them in one shouldn’t rely solely on inspection reports and fines when making a decision, said Shamberg, the Pennsylvania Health Care Association CEO.

“You also should contact the facility and talk with the administrator or members of leadership to find out what is really happening,” Shamberg said.

Shamberg, whose organization advocates for Pennsylvania long-term care facilities and their residents, said the large fines can cause problems as well as serve as a deterrence.

More: Sarah Reed Senior Living fined $201,769 since 2021 for incidents injuring four patients

His staff pointed to a CMS proposal that would allow a facility to be fined per day and per instance at the same time.

“When you see large fines and penalties like what you have at those two facilities, it is less revenue for patient care, less for frontline staff,” Shamberg said. “It could hurt the quality of care.”

Contact David Bruce at dbruce@timesnews.com. Follow him on X @ETNBruce.

This article originally appeared on Erie Times-News: Nursing homes fined for serious lapses in patient care

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