Several elder-care facilities fined for violations

An 86-year-old man with dementia died after falling, cutting his head and breaking a hip in March — the fifth time he had fallen in 2 1/2 months.

An exhausted and exasperated caregiver was fired one morning in February, immediately after slapping an elderly man twice across the face.

Those incidents constituted some of the most serious violations over the past year of state rules meant to protect the vulnerable people who live in assisted-living centers and nursing homes. The violations cost the facilities — all of them in Tucson — more than $15,000 in penalties.

They illustrate a sad truth here and across the country, said a leading advocate for seniors.

Despite the sweeping changes mandated by the 1987 Nursing Home Reform Act, "these kinds of incidents are still occurring," said Stewart Grabel, ombudsman for the Pima Council on Aging. "That's because we're not willing to take a look at the root causes, which are inadequate staffing and training, and marketplace reimbursement."

Alan Oppenheim, manager of assisted-living licensing for the Arizona Department of Health Services, said the violations his staff documented demonstrate problems with hiring highly skilled workers and making sure they have ongoing training.

"Not in all cases, but in some, simply not having enough staff can be an issue," Oppenheim said.

Atria Campana del Rio, 1580 E. River Road, was fined $3,800 — $200 for each of the 19 days the state could prove that the assisted-living center's staff erroneously gave an elderly woman the wrong pills.

State authorities believe the woman, whose name was not released, actually received the wrong medication for 38 days, from Nov. 10, when she was admitted to Campana del Rio, until Dec. 18, when she died.

When the woman was admitted to Campana del Rio in November, a nurse confused her medication orders with those of her husband, who lived in a separate part of the facility. The nurse faxed a form listing the husband's medications to the woman's doctor, who failed to detect the error, OK'd the form and faxed it back.

The woman's condition had so deteriorated by Nov. 27 that she was hospitalized for two days. State investigators confirmed that she received the wrong drugs from Nov. 29 through Dec. 17.

The Pima County Office of the Medical Examiner said the woman died of bleeding in her brain, the result of taking the blood-thinning drug prescribed for her husband to reduce his risk of stroke.

"It was a very serious matter that has been resolved with the family, and we have a number of systems that have been implemented and enforced to make certain that type of event doesn't recur," said Doug Armstrong, Atria attorney and senior vice president.

He declined to discuss the terms of the settlement. But in a March 31 letter to the Health Department, included in the facility's public file, Armstrong described new policies and procedures designed to prevent such mistakes in the future.

"We have new, extensive policies and procedures whereby medication verifications are done," Armstrong said.

Neither he nor Oppenheim would comment on the doctor's possible role in the woman's death. The doctor was not named in the Health Department's report.

Encore Senior Village at Tucson, 2675 N. Wyatt Drive, did not return calls regarding the 86-year-old man who died after falling five times, on Jan. 15, Jan. 16, Feb. 19, March 1 and March 27. The last fall resulted in a broken hip. The man "passed away shortly thereafter," the state found.

Encore was fined $2,500 — $500 for each time the man fell. The state found that Encore failed to provide adequate supervision for the man, even though the facility and the man's wife both knew he was considered at high risk for falls.

"They needed to increase their oversight of this person and assess what could be done to mitigate those falls," Oppenheim said.

Falls also led to the death of one resident, and were known to have injured another, at Posada del Sol Health Care Center, the county-owned nursing home at 2250 N. Craycroft. Posada del Sol was fined $2,250 for failing to provide the two residents with adequate supervision.

A woman who had lived at Posada del Sol since October 2003 died after falling on Aug. 21, 2005. She had nosebleeds for three days afterward and became bruised and swollen on her face. She was found to be unresponsive around 3 a.m. on Aug. 25, and was taken to Tucson Medical Center where doctors diagnosed hemorrhaging around her brain. She died at 6:15 p.m.

An elderly man at Posada del Sol fell five times between July 1 and Aug. 15 last year and suffered "minor injuries" from three of the falls, the state report says. He also had a known history of falls.

While falls are common with the elderly, steps can be taken to prevent them. State law does not allow physical or chemical restraints in assisted-living settings, but they can be used in nursing homes. But at all times, the resident's rights are supposed to be given the highest consideration.

Bed rails, alarms that sound when people get out of their beds and lap belts for people sitting in wheelchairs are some accepted forms of fall prevention.

"It's a real balancing act between ensuring that someone doesn't fall, protecting their safety, and ensuring they aren't restrained needlessly," said Karen Fields, director of Pima Health Systems, which includes Posada del Sol.

"Restraints are really, really frowned upon by the state, by family members, by society in general," Fields said. "We don't restrain at Posada del Sol. So it's a real balancing act between protecting their safety and protecting their independence."

Like other elder-care facilities, Posada del Sol has a falls committee, which now meets more frequently, Fields said, "in order to come up with the best possible plan for each individual who is in danger of falling … We see something positive going forward from these incidents."

The owner of Desert Villa Home, 250 S. Vozack Lane, said he immediately dismissed the staff member who slapped an elderly man twice across the face. "She was very sorry and understood that I had to let her go," said H. Stanley Young.

The state fined Desert Villa $750 for the incident and for waiting four days to report it to the Health Department; abuse incidents are supposed to be reported within 24 hours.

Such incidents are so rare that Bob Ohlfest, the Health Department's assisted-living manager in Tucson, said he could not remember another case in the last 14 years.

The state took those and other enforcement actions against licensed health-care facilities in April, May and June of this year but reported them on the Health Department's Internet site within the last two weeks. Other enforcement actions include:

● Casa de Esperanza, 8102 E. Sixth St., fined $1,600 for failing to prevent and provide treatment for a resident's bedsores. Staff members at the home first noticed the man had bedsores on both heels on Dec. 19. But the man's chart indicates the home made no effort to contact his doctor about the sores until Jan. 10. By then, one of the sores had deteriorated to a wound 2 inches wide and an inch deep.

Casa de Esperanza owner John Haines would not comment on the incident.

● M&S Assisted Living, 5848 E. Hampton St., was fined $2,910 for not having a manager at the facility for almost a year. The home was fined $1,500 and put on a one-year provisional license last September for failing to get fingerprint clearances on three caregivers.

Attempts to reach an administrator at the home for comment were not successful.

● Care Haven, 1625 S. San Joaquin Ave., was fined $1,000 for having 10 residents, two more than the home is licensed for. Attempts to reach the home's administrator were not successful.

● Broadmoor House, 2801 E. Exeter, was fined $500 for not having a manager at the home from Jan. 10 until May 31. Owner Anthony Romeo told the Star he was unaware that the previous manager had left in January. "We were just left hanging," Romeo said.

● If you have a complaint or want information about a nursing home, assisted-living home or other licensed health-care facility, contact the Arizona Department of Health Services.

l The department's Tucson office is at 400 W. Congress St. Call 628-6965 for the health-care licensing office, which keeps files on assisted-living and other care facilities.

l Learn about enforcement actions taken against facilities at www.azdhs.gov/ als/index.htm

● The Pima Council on Aging offers information on assisted living, nursing-home care and other options for those who need some level of support.

l Call the council at 790-7262, or visit in person at 8467 E. Broadway, west of Camino Seco.

l You can visit the council online at www.pcoa.org