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Home  /  Medication Errors  /  Palm Gardens Center Cited over Resident Deaths

Palm Gardens Center Cited over Resident Deaths

by Law Offices of Thomas L. Gallivan, PLLC 27 Aug2020

Palm Gardens Center for Nursing and Rehabilitation received 26 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 21, 2020. The Brooklyn nursing home’s citations resulted from a total of five surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not keep resident drug regimens free from unnecessary psychotropic drugs. Section 483.45 of the Federal Code stipulates that nursing homes must ensure resident drug regimen include no unnecessary medications that affect “brain activities associated with mental processes and behavior.” An April 2019 citation found that Palm Gardens Center for Nursing and Rehabilitation failed to ensure such in an instance in which a resident was prescribed a psychotropic medication without a clearly defined indication or use of non-pharmacological approaches. The citation goes on to state that interviews with facility nursing staff “did not substantiate the psychiatrist’s evaluation that the resident had behaviors or delusions that necessitated the use of an antipsychotic medication.” The facility states that this deficiency had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the discontinuation of the medication and the educational counseling of the psychiatrist assigned to the resident.

2. The nursing home did not ensure adequate respiratory care and services. Section 483.25 of the Federal Code stipulates that nursing home facilities must provide to respiratory care and services to residents who require such in a manner consistent with professional standards of practice. A June 2018 citation found that the facility failed to ensure such to two residents. The citation states that the nursing home did not “provide continuous mechanical ventilation on ventilator dependent residents,” specifically describing an incident in which two residents’ ventilators received an Operational Ventilation Procedure after which they were “found unresponsive and were pronounced dead at the facility within 10 minutes of each other.” An investigation found that after the procedure was conducted, the residents’ mechanical ventilation “was not resumed.” As such, one resident had no ventilation for an hour and 20 minutes, while the other resident had no ventilation for two hours and 14 minutes. The citation describes this deficiency as having “Immediate jeopardy to resident health or safety.”

3. The nursing home did not properly implement food safety practices. Under 483.60 of the Federal Code, nursing homes are required to “Store, prepare, distribute and serve food in accordance with professional standards for food service safety.” A March 2016 citation found that the facility did not comply with this section in an instance in which staff “did not ensure that the kitchen floor, freezer floor and walls on refrigerator were maintained adequately and in good repair, in the food storage areas.” The citation describes a freezer floor as well as a refrigerator wall that were coated in rust; wall metal sheets that were “bent with gaps”; and a kitchen floor that was missing tiles. In an interview, the facility’s Food Service Director told an inspector that the kitchen and flooring are old and require maintenance, and that he would inform facility administration of such.

The attorneys at the Law Offices of Thomas L. Gallivan, PLLC work diligently to protect the rights of nursing home residents.  Please contact us to discuss in the event you have a potential case involving neglect or abuse.

Posted in: Medication Errors, Neglect, Nursing Home Abuse, Nursing Home Violations

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