In response to a complaint made in August 2013 against St. Luke’s Home, a 202-bed nursing home located in Utica, New York, officials from the New York State Department of Health (DOH) determined that the facility failed to provide appropriate care to residents suffering from respiratory illnesses. One affected resident had suffered from a stroke and was in a vegetative state. The patient had a tracheotomy, was dependent upon a ventilator for breathing, and required constant oxygen. Despite these requirements, health inspectors observed that the resident was not receiving oxygen for most of the day and noted that the patient was wheezing and having difficulty breathing.
Another affected resident was a quadriplegic who was dependent on a ventilator and also required constant oxygen. The patient had a portable ventilator and was able to use an electric wheelchair. During an event for the residents, the patient told a DOH inspector that his oxygen tank had run out. Several minutes later, a staff member assisted the resident and provided him with a new oxygen tank. A supervisor asked about the incident stated that the patient usually notifies a staff member if he runs out of oxygen. She stated that the facility had no formal system in place to perform routine checks of patient’s oxygen tanks. DOH officials also observed a similar situation involving a resident suffering from COPD, a chronic lung disease.
During the course of the complaint inspection, health department officials also discovered that the facility made numerous mistakes involving patients’ advance care directives. In one instance, a diabetic patient had indicated that she wanted to be resuscitated in the event of a medical emergency. Although the resident should have been wearing a green bracelet to indicate that she required CPR, health inspectors observed that she was wearing a blue bracelet, which indicated that the resident had a DNR in place. In another instance, a patient who had suffered from a stroke had also indicated that he wanted CPR in an emergency. The resident, was not wearing any bracelet, and the name plate outside of his room failed to indicate his advanced directives.
The facility was also cited for failing to provide patients with assistance for their daily living needs. One patient who was paralyzed was frequently incontinent and needed the assistance of two staff members to use her bed pan. While at the nursing home, health inspectors observed that the resident had asked staff members to help her go to the bathroom. However, staff members repeatedly ignored the patient’s requests until she was finally helped after waiting for an hour. The DOH inspection report concluded that the delay was caused by lack of adequate staff. The report stated that the “facility did not ensure sufficient nursing staffing levels to maintain the highest practical level of well-being of each resident.”
