Northern Riverview Health Care Center, Inc. in Rockland County, NY was fined $24,000 as a result of a Department of Health Certification Survey dated April 8, 2010. The survey noted no less than 14 deficiencies that contributed to the substantial fine.
Among the shortcomings noted by the surveyors were failures with respect to comprehensive care plans (a repeat deficiency for Northern Riverview), the failure to keep the facility free of accidents hazards, and failure to take proper measures to treat and prevent/heal pressure sores.
A facility must develop, review, and revise a comprehensive care plan for each resident. With respect to two patients, Northern Riverview failed to do this according to the DOH. In one case, the patient did not have a care plan in place for dehydration treatment, despite the fact that the patient was being monitored for dehdration. In the second instance, a patient had no care plan for limited functionality in her left hand, although it was observed that the resident was unable to unclench that hand.
A facility must also ensure that the resident environment remains as free from accident hazards as possible. On March 22 of last year, a resident eloped from Northern Riverview. The resident had been diagnosed previously with both Alzheimer’s Disease and Depressive Disorder. Needless to say, the potential dangers of an elderly resident leaving a facility unattended are amplified when additional diagnoses such as Alzheimer’s and depression are added to the situation. Fortunately, in this instance the resident was returned to Northern Riverview unharmed. However, without diligent checks on residents with the potential to wander, occurrences such as this could lead to much more serious consequences in the future.
As this blog has discussed frequently, a facility is required to ensure that a resident who enters a facility without pressure sores does not develop them unless the sores are clinically unavoidable, and a resident with pressure sores receives the necessary treatment to promote healing, prevent infection, and prevent new sores from developing. In the DOH report, it is noted that a resident, although noted to be at moderate risk for the development of pressure sores, still developed several pressure ulcers between Stages II and IV. Although the patient’s care plan called for turning and positioning every two hours, it is not noted in the nursing notes that this was performed consistently. Additionally, the survey details departure from protocal while cleaning and dressing the wounds, such as a failures by LPN’s to wash hands during the process and placing an undressed wound directly on bed linens. In limited instances, skin breakdown in an elderly person is an unavoidable side effect of underlying disease processes. Failing to take all necessary steps to avoid this breakdown is certainly avoidable, however, as is failing to properly clean and dress wounds.
Documentation of Northern Riverview’s fine can be found here. The full DOH survey results are linked below.
Website Resource: Northern Riverview Health Care Center, Inc.
