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Palatine Nursing Home received 29 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on August 26, 2022. The Palatine Bridge nursing home’s citations resulted from a total of five inspections by state surveyors. The violations they describe include the following:
1. The nursing home did not adequately protect residents from sustaining accidents.
Under Section 483.25 of the Federal Code, nursing homes are required to ensure residents receive an environment “as free of accident hazards as is possible” and in which employees provide “adequate supervision and assistance devices to prevent accidents.” A May 2021 citation found that Palatine Nursing Home failed to ensure such. The citation specifically describes a resident identified as “at high risk for choking” whom the nursing home “did not ensure… was not kept in their room with the door closed.” It goes on to identify several instance in which the resident was left alone in their room with the door shut during meals. In an interview, the facility’s Director of Nursing said that the resident’s speech therapist had recommended the resident receive close supervision, and that letting them eat alone in their room was a choking hazard. A plan of correction undertaken by the facility included the education of nursing staff regarding the resident’s care plan for meals.
2. The nursing home did not undertake adequate measures to prevent infection.
Section 483.80 of the Federal Code requires nursing homes to create and maintain “an infection prevention and control program” designed to stave off diseases and infections. A May 2021 citation found that Palatine Nursing Home failed to ensure such. The citation specifically describes staff who did not “consistently” wear personal protective equipment before “direct contact with residents” in a unit on contact protections. It also describes a failure to prevent employees from performing hand hygiene “after assisting a resident to ambulate, after administering injectable medications, or after checking a blood glucose level, [or] before touching clean multi-resident areas.” A plan of correction undertaken by the facility included the re-education of staff on hand hygiene.
3. The nursing home did not provide adequate pressure ulcer care.
Under Section 483.25 of the Federal Code, nursing home facilities “must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable.” A May 2021 citation found that Palatine Nursing Home failed to ensure such. The citation specifically describes a resident identified as at risk for developing pressure ulcers for whom the facility “did not ensure interventions were developed and provided to prevent the development of pressure sores.” According to the citation, the resident later developed a pressure ulcer. In an interview, the facility’s Director of Nursing said that the resident should have had a plan in place before they developed the pressure ulcer, and that the lack of a plan “could have contributed to the pressure ulcer.” A plan of correction undertaken by the facility included the education of all licensed nursing staff.
Palatine Nursing Home has received 24 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on May 20, 2021. The facility also received a fine of $12,000 in 2021 in connection to findings of rule violations. The Palatine Bridge nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following:
4. The nursing home did not adequately protect residents from accidents.
Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with adequate supervision to prevent accidents and maintain resident environments as free as possible of accident hazards. An April 2019 citation found that Palatine Nursing Home failed to ensure such. The citation states specifically that a resident did not receive “the recommended swallowing precautions, potentially increasing his risk of aspiration pneumonia.” It goes on to describe an observation in which a nurse was feeding the resident lunch but did not have the resident’s swallowing precaution cue card on the resident’s food tray. In an interview, the nurse said that “the resident did not have a cue card with instructions for feeding” and that she knew how to feed the resident. In a separate interview, the facility’s Speech Language Pathologist said the resident “should have had a cue card on his tray and was unaware it was missing.” A plan of correction undertaken by the facility included the education of necessary staff.
5. The nursing home did not adequately prevent medication errors.
Section 483.45 of the Federal Code requires nursing homes to keep residents free from “significant medication errors.” An April 2019 citation found that Palatine Nursing Home failed to ensure such. The citation states specifically that the nursing home did not ensure one resident’s medication orders “included an active sliding scale orders for insulin use.” In an interview, one of the facility’s Licensed Practical Nurses said that she “has given insulin coverage before and was not aware there was no order for the sliding scale because she was not the nurse who checked the orders.” A plan of correction undertaken by the facility included the discontinuation of the order for the resident and the education of nursing staff.
6. The nursing home did not implement adequate infection control measures.
Under Section 483.80 of the Federal Code, nursing homes are required to create and maintain an infection prevention and control program. An April 2019 citation found that Palatine Nursing Home failed to ensure such. The nursing home infection control citation states specifically that the nursing home did not ensure the maintenance of standard precautions during a dressing change to a resident’s right heel pressure ulcer. It goes on to describe a Licensed Practical Nurse who placed supplies on a table without first cleansing the table, donning gloves without washing her hands, changing gloves without washing her hands, and setting the resident’s foot directly down on a pillow without using a barrier. In an interview, the LPN said “she was very nervous having a surveyor watch her do the dressing change.” A plan of correction undertaken by the facility included the education of nursing staff on nursing practices during dressing changes.
Contact the Law Offices of Thomas L. Gallivan, PLLC
The attorneys at the Law Offices of Thomas L. Gallivan, PLLC work diligently to protect the rights of nursing home residents. If your loved one suffered from pressure ulcers, medication mistakes, or poor infection control at a nursing home, our attorneys can help you seek accountability. Please contact us to discuss if you have a potential case involving neglect or abuse.
