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State uncovered many problems at Carriage Hill
Unannounced inspections of Carriage Hill nursing home turned up 'actual-harm' citations by state

Date published: 5/24/2007


Carriage Hill Rehabilitation and Nursing Center was dropped from the federal Medicare program this month, 10 days after a resident strangled to death on a nurse-call cord.

But the resident's death was just one factor in the federal action. Carriage Hill's regulatory problems began more than six months ago when a resident fell from her bed and broke her nose.

Soon after that fall, inspectors from the Virginia Department of Health made a series of unannounced visits to the Spotsylvania County home. They inspected the home four times, beginning in December 2006, and each time they found problems.

"This facility tended to have 'actual-harm' citations almost every time we were there, so that drove us to go back to check on things," said Connie Kane, director of the state health department's division of long-term care.

Finally, on May 10, a federal official in Philadelphia notified Carriage Hill that it "no longer meets the requirements" of the Medicare program and would lose its federal payments for patients, beginning in early June.

Carriage Hill officials informed residents last week about Medicare's action and said that they also expect to lose Medicaid funding next month.

a pattern of problems

The incident that started this spiral happened on Nov. 1, 2006, when a certified nursing assistant, or CNA, was transferring a resident from her wheelchair to her bed, according to a December inspection report.

The CNA left the resident alone on the side of the bed for an instant. The resident fell from the bed and landed face first on the floor. The resident was taken by ambulance to the hospital, where she was treated for a broken nose and cuts on the forehead.

The resident was dependent on the staff for transferring to and from her bed, according to the inspection report. The state found that the CNA should have used a mechanical lift to transfer the resident.

Carriage Hill later fired the CNA when she continued to transfer patients improperly, according to the report.

Located on State Route 3 near Five-Mile Fork, Carriage Hill is home to about 140 people. It is one of the region's largest nursing homes and is operated by MediCorp Health System, parent company of Mary Washington Hospital.

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What about staffing? The last four inspection reports for Carriage Hill Rehabilitation and Nursing Center do not mention the word "staffing."

State surveyors found fault with several aspects of Carriage Hill's operation, but they did not comment on whether the home had enough nurses and nurse assistants working there.

That's because neither the state nor the federal government sets staffing ratios for nursing homes.

"People want to pin the hat on staffing levels all the time," said Connie Kane, director of the division of long-term care for the Department of Health.

But staffing is one of "many, many things" that determines the quality of care offered by a nursing home, Kane said.

Just as important are the training and supervision of the staff and how much care the residents require, she said.

"I could find you a facility that had twice as much staff as the one down the street, but if they weren't well trained and they weren't well supervised, you might as well not have them in there," Kane said.

--Jim Hall