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BY JIM HALL
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.
In addition to the December inspection, employees of the Office of Licensure and Certification visited the home in January, March and earlier this month. The surveyors walked the halls, read patient charts, watched how residents were cared for, and talked with staff and families.
Their reports describe a home where the staff was not always properly trained, and where residents sometimes did not get the help they needed.
In April, a resident, who was described as demented and at risk for falling, accidentally moved her bed to the high position, then fell from it when she tried to stand.
A nurse heard her screaming and found her on the floor with a fractured femur. She was hospitalized and died of a pulmonary embolism while in the hospital.
The inspectors criticized the staff for not monitoring the resident more closely.
In November, a resident received second- and third-degree burns on his inner thighs and scrotum when he spilled hot chocolate in his lap during breakfast.
The resident had no use of his left arm and limited use of his right arm because of a stroke. The resident should have been fed by a staff member, or given a cup with a lid, according to the report.
In 13 rooms, inspectors discovered that the call-bell system was not working. Residents use the call-bells to summon help. Inspectors checked the call bells after a resident became entangled in his call-bell cord and strangled on May 1. The state report of that fatality became public last week and found that the cord had been improperly tied to the resident's bed rail.
The inspectors also found that residents' respiratory equipment was not stored in closed containers when not in use. Closed containers are said to control infection.
When reviewing a sampling of patient charts, the inspectors found that patients had not received protective equipment or clothing ordered by their doctors.
These included a bed alarm, floor mat and "trough" mattress to prevent falls, and a "bunny boot" and "geri sleeve" to reduce irritation to the skin.
Another resident did not receive oxygen in the amount prescribed by her physician. Another had not been receiving aspirin in the ordered dose.
A resident also was not receiving the "sitz" baths ordered by her surgeon. The surgeon wanted her hips and buttocks soaked in salt water three times a day to relieve the discomforts of surgery.
Employees apparently stopped giving her the baths when they decided that her surgical wounds were healed, according to the report. However, they did not notify her physician.Seeking perfection
Termination from the Medicare program occurs somewhere in Virginia about once a year, said Stephen Morrisette, president of the Virginia Health Care Association, the trade group of nursing homes and assisted-living facilities.
The termination comes after six months of visits and revisits by state inspectors, who check 200 areas of concern, Morrisette said.
"Perfection is what they're looking for," he said. "There is very little forgiveness in the survey process."
After each inspection at Carriage Hill, MediCorp officials offered the state a "plan of correction," showing how they would improve operations at the home.
Officials promised added training and education for the staff, closer monitoring by nurse supervisors and better review of patient charts.
"In the past two weeks, we have made and continue to make significant changes to bring Carriage Hill back into regulatory compliance as soon as possible," said Kathleen Allenbaugh, MediCorp spokeswoman.
MediCorp officials assured residents last week that they can continue to live in the home and would not have to pay the costs now covered by Medicare or Medicaid.Jim Hall: 540/374-5433
|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