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The Grand Rehabilitation and Nursing at Barnwell Cited for Pressure Ulcers
The Grand Rehabilitation and Nursing at Barnwell received 66 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on September 17, 2021. It has also received eight fines totaling $78,000 since 2012. The Valatie nursing home’s citations resulted from a total of 17 surveys by state inspectors. The violations they describe include the following:
The nursing home did not adequately protect residents from neglect. Section 483.12 of the Federal Code ensures nursing home residents the right to be free from neglect. A December 2018 citation found that The Grand Rehabilitation and Nursing at Barnwell failed to ensure such. The citation specifically describes the nursing home’s failure to timely provide one resident with interventions for skin, incontinence, and pressure ulcer care; to timely provide another resident with planned interventions with skin and bladder incontinence care; and to timely provide a third resident with planned interventions for pressure ulcer development and incontinence. According to the citation, the facility left the first resident uncared for for a period of 6 hours and 10 minutes, the second resident uncared for for a period of 11 hours and 37 minutes, and the third resident uncared for for a period of 11 hours and 51 minutes. A plan of correction undertaken by the facility included the educational counseling of nurses and nursing aides.
The nursing home did not adequately prevent accidents. Under Section 483.25 of the Federal Code, nursing homes are required to ensure that resident environments are as free of accident hazards as possible and that residents receive adequate supervision to prevent accidents. A January 2020 citation found that The Grand Rehabilitation and Nursing at Barnwell failed to ensure such. The citation specifically describes the facility’s failure to ensure a resident who was “totally dependent for eating” received food of the correct consistency, documented in their care plan as “regular diet w/ pureed texture.” Despite this requirement, the resident was observed being fed ground sausage and scrambled egg, with no pureed food available for them. In an interview, a nurse said that the resident should not be eating ground food; in another interview, the facility’s Food Service Director said that “a blender was used for modified consistencies, which can make it difficult to get the consistency correct.” A plan of correction undertaken by the facility included the re-education of nursing and dietary staff.
The nursing home failed to prevent medication errors. Section 483.45 of the Federal Code stipulates that nursing home residents have the right to be “free of any significant medication errors.” An October 2018 citation found that The Grand Rehabilitation and Nursing at Barnwell failed to ensure such. The citation specifically describes medication errors connected to two residents: one of whom “did not receive insulin in a timely manner per physician orders,” and the second of whom “had multiple incidents of receiving the wrong dose” of an anti-anxiety medication. A plan of correction undertaken by the facility included the educational counseling of the nurses responsible for the errors.
Video Camera Captures Two Nurse Aides Taunting and Abusing Elderly Dementia Patient
Two certified nursing assistants (CNAs) at the Barnwell Nursing and Rehabilitation Center, a 228-bed facility located in Valatie, New York, were caught on camera taunting and abusing an elderly dementia patient in August 2013. According to a New York State Department of Health investigation report, the two CNAs kicked, hit and yanked at dolls that the dementia patient carried; he believed that the dolls were his grandchildren. The video shows the elderly resident becoming visibly upset and starts kicking at one of the CNAs, who then runs into a closet while laughing. The resident then began kicking at the closet door.
After conducting an internal investigation when the resident’s son complained about the incident, the facility concluded that the CNAs failed to “maintain an environment that protects the resident from abuse, neglect or mistreatment.” While the incident occurred on August 19, 2013, the facility didn’t notify the DOH or the police until a week later. Moreover, even though the facility terminated both of the employees over the incident, one of the CNAs continued to work at the nursing home as a private aide. As a result, a high-functioning resident reported that she saw the CNA taunt the dementia patient again by “hitting and throwing” his dolls. An administrator told investigators that she had instructed her staff not to allow the CNA back into the building. Moreover, DOH investigators revealed that the dementia patient was never assessed by staff members for physical or psychological harm after being taunted.
In another instance, a CNA threw a bedpan at a resident twice. On August 24, 2013, a CNA was helping a resident who suffered from spinal stenosis go to the bathroom in a bedpan. After the CNA adjusted the resident’s body, the resident became upset and threatened to throw the bedpan at the CNA. After the CNA said, “go ahead, I dare you,” the resident picked up the bedpan and threw it at the staff member, who then threw the bedpan back at the resident. The resident then tossed the bedpan back at the CNA, who threw the bedpan at the resident for a second time. The CNA then walked out of the room. The facility reported the incident to the DOH three days later.
A third incident involved a resident who was diagnosed with clostridium difficle (C-diff), a bacterial infection that causes diarrhea. Over a period of six days, the 84-year-old resident had diarrhea 13 separate times. Not only did staff members fail to administer medications to alleviate the condition, they also failed to notify the physician of the patient’s worsening condition. After family members finally complained, the woman was transferred to the hospital, where she was diagnosed with dehydration, severe C-diff, and sepsis. The resident died shortly thereafter. The DOH concluded that the resident suffered “actual harm” as the result of receiving inadequate care.
According to the “Nursing Home Compare” website, the Barnwell Nursing facility received a much below average rating. The facility also received much below average ratings for health inspection results and staffing levels.
The Grand Rehabilitation and Nursing at Rome Cited for Burns
The Grand Rehabilitation and Nursing at Rome received 31 citations for violations of public health code between 2018 and 2021, according to New York State Department of Health records accessed on May 20, 2022. The Rome nursing home’s citations resulted from a total of nine inspections by state surveyors. The violations they describe include the following:
The nursing home did not adequately implement accident-prevention measures. Section 483.25 of the Federal Code requires nursing homes to ensure resident environments are as free as possible of accident hazards, with adequate supervision to prevent accidents. A May 2021 citation found that The Grand Rehabilitation and Nursing at Rome failed to ensure such. The citation specifically describes an instance in which a resident with a history of looking for showers in the facility, and who required supervision for bathing and ambulation, was found in a shower with first and second degree burns. A plan of correction undertaken by the facility included the suspension of two nursing aides and a licensed practical nurse “as there was no documentation completed that they did their hourly rounds that was part of their job, and failed to properly know the whereabouts of their residents at all times.”
The nursing home did not adequately prevent medication errors. Section 483.45 of the Federal Code requires nursing homes to ensure residents “are free of any significant medication errors.” A March 2022 citation found that The Grand Rehabilitation and Nursing at Rome failed to ensure such. The citation specifically describes an instance in which a resident did not receive 13 doses of one medication and 15 doses of another medication, per orders. A plan of correction undertaken by the facility included the education of licensed staff on “what to do if a medication is not available.”
The nursing home did not adequately vaccinate staff against Covid-19. Section 483.80 of the Federal Code stipulates that nursing homes must “develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19.” A March 2022 citation found that The Grand Rehabilitation and Nursing at Rome failed to ensure such. The citation specifically describes one licensed practical nurse at the facility who was not fully vaccinated for Covid-19 and for whom the facility “did not implement additional precautions, intended to mitigate the transmission, and spread of” the virus, including testing and wearing N95 masks. A plan of correction undertaken by the facility included the education of staff and the full vaccination of the LPN in question.
The Grand Rehabilitation and Nursing at Guilderland: Medication Errors
The Grand Rehabilitation and Nursing at Guilderland has received 88 citations for violations of public health code between 2018 and 2021, according to New York State Department of Health records accessed on January 29, 2022. The recipient of $78,000 in fines since 2015, the facility was placed on the Center for Medicare and Medicaid Services’ list of Special Focus Facilities candidates, nursing homes with a record of quality issues. The Altamont nursing home’s citations resulted from a total of eight surveys by state inspectors. The deficiencies they describe include the following:
The nursing home did not adequately prevent medication errors. Under Section 483.45 of the Federal Code, nursing homes are required to ensure that residents “are free of any significant medication errors.” An August 2021 citation found that The Grand Rehabilitation and Nursing at Guilderland failed to ensure such. The citation states specifically that the facility failed to ensure one resident received their prescribed medications. It goes on to describe several instances in which the resident’s medications were not given as ordered, noting that there was no documentation that the resident’s doctor or nurse practitioner were notified of the missing doses. In an interview, the facility’s Director of Nursing said that “the expectation is that the medical provider would be notified that a dose was not given and a note placed in resident’s medical record to reflect the notification.” A plan of correction undertaken by the facility included the re-education of nurses and providers regarding medication administration policies and procedures.
The nursing home did not maintain adequate nursing staff. Section 483.35 of the Federal Code states that nursing homes must maintain sufficient nursing staff to assure resident safety and well-being. An August 2019 citation found that The Grand Rehabilitation and Nursing at Guilderland failed to ensure such. The citation specifically describes the nursing home’s failure to ensure minimum Certified Nursing Assistant staffing levels on 7 of 11 days between August 9, 2019 and August 19, 2019. It states further that the nursing home failed to “ensure there was sufficient staff to provide assistance/supervision during breakfast and did not ensure sufficient staff to provide individualized activity programs according to the comprehensive care plan.” A plan of correction undertaken by the facility included an audit by the facility’s Director of Nursing.
The nursing home did not adequately prevent infection. Section 453.80 of the Federal Code states that nursing homes must establish and maintain an infection prevent and control program to stave off the development and transmission of disease. An August 2021 citation found that The Grand Rehabilitation and Nursing at Guilderland failed to ensure such. The citation states specifically that the nursing home failed to take adequate Covid-19 prevention measures. It goes on to describe an instance in which “a Licensed Practical Nurse and two Dietary Aides did not wear facemasks in accordance with Centers of Disease Control guidance,” and a separate instance in which an LPN and a Certified Nursing Assistant “wore their face masks in a manner that did not cover their nose and mouth.” A plan of correction undertaken by the facility included the re-education of facility staff on mask use and infection control policies.
The Grand Rehabilitation and Nursing at Rome: Infection Citations, Coronavirus Deaths
The Grand Rehabilitation and Nursing at Rome suffered 8 coronavirus deaths as of May 17, 2020, per state records. The nursing home also received 36 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on May 18, 2020. The facility has additionally received one enforcement action: a 2019 fine of $10,000 in connection to findings in a 2019 inspection that it violated unspecified health code provisions. The Rome nursing home’s citations resulted from a total of seven surveys by state inspectors. The deficiencies they describe include three alleged violations of Section 483.80 of the Federal Code, which requires nursing homes to maintain an infection prevention and control program that helps mitigate the development and transmission of communicable diseases and infections. Those three citations include:
A January 2020 citation states that an inspector observed that a resident’s IV access had no cap placed on its port, and that staff were touching the end of the access with ungloved hands. The inspector also observed a treatment in which a resident “did not have a barrier placed between bare feet and the floor and clean supplies and a soiled dressing were placed on the resident’s bed.” A plan of correction undertaken by the facility included the reeducation of relevant staff members on proper infection control technique, including the capping of IV tubing and the need for a barrier between residents’ feet and the bare floor during treatment.
A September 2018 citation found that The Grand Rehabilitation and Nursing at Rome failed to adequately uphold infection control measures during medication administration for several residents. An inspector specifically observed a staff members fail to perform proper hand hygiene while administering medication and treating a resident’s wound dressing; the inspector also observed a resident “three times with his urinary catheter bag on the floor in his room,” in contravention of best practices and facility policy.
A May 2017 citation found that facility staffers failed to uphold proper infection control techniques during a treatment observation for one resident or during a medication pass observation for another resident. The citation also states that a resident’s scabies symptoms were not promptly reported to state authorities, and that the nursing home “not properly implement an effective infection control program to assess and treat residents and staff” once scabies symptoms were discovered. With respect to the treatment observation, the citation states that a nurse did not properly disinfect equipment, removed equipment from her pocket in contravention of policy, and failed to properly perform hand hygiene during the observation. With respect to the medication pass, the citation states that a nurse did not perform proper hand hygiene before or after administering residents’ medications.
The Grand Rehabilitation and Nursing at Barnwell Cited for Falls and Medication Errors
The Grand Rehabilitation and Nursing at Barnwell received 102 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on September 23, 2022. The Valatie nursing home’s citations resulted from a total of 23 surveys by state inspectors. The violations they describe include the following:
The nursing home did not adequately prevent accidents. Under Section 483.25 of the Federal Code, nursing home facilities must provide an environment as free as possible from accident hazards, and to provide necessary supervision to prevent accidents. A January 2022 citation found that The Grand Rehabilitation and Nursing at Barnwell failed to ensure such. The citation specifically describes the facility’s failure to “identify and evaluate hazards and risks associated with other residents” entering a resident’s room; to identify and assess risks associated with a resident providing care for other residents; and to ensure an adequate environment for a resident with a visual impairment, who “subsequently had a fall and sustained a right femoral fracture.” A plan of correction undertaken by the facility included the re-education of staff and the placement of a sign outside the first resident’s room to prevent other residents from entering.
The nursing home did not take adequate steps to prevent medication errors. Section 483.45 of the Federal Code requires nursing homes to keep residents “free of any significant medication errors.” A May 2022 citation found that The Grand Rehabilitation and Nursing at Barnwell failed to ensure such. The citation specifically describes an instance in which the facility failed to ensure three residents received medications in a timely manner. A plan of correction undertaken by the facility included the immediate assessment of the residents by a medical professional and the re-education of relevant staff.
The Grand Rehabilitation and Nursing at Barnwell was also cited for failing to prevent medication errors under Section 483.45 of the Federal Code in January 2022. This citation describes an instance in which the facility failed to ensure a resident “in a hypercoagulable state,” meaning they had “an increased tendency to develop blood clots,” received a blood thinner as ordered, “resulting in four missed doses.” In an interview, a Nurse Practitioner said that the medication “should have never gone more than 1 dose being late, let alone not receiving a dose at all.” A plan of correction undertaken by the facility included the immediate re-education of nursing staff.
Contact the Law Offices of Thomas L. Gallivan, PLLC
The Law Offices of Thomas L. Gallivan, PLLC represent victims of nursing home neglect, medication errors, and unsafe conditions across New York. Our New York nursing home abuse attorneys thoroughly investigate Department of Health reports, medical records, and facility histories to build strong cases for accountability and justice.
If your loved one suffered a preventable injury at a facility like The Grand Rehabilitation and Nursing at Barnwell, contact our firm today. We offer a free consultation and charge no legal fees unless we recover compensation on your behalf.
