TN Nursing Home Gets Top Fine, Critical Inspection

By Walter F. Roche

A Memphis, Tenn. nursing home has been hit with record fines after inspectors found widespread neglect resulting in actual harm to multiple patients including one who died after transfer to a hospital where an exam showed he had widespread untreated wounds infested with maggots.
The fines totaling $50,000 were imposed on the Ashton Place Health and Rehabilitation Center, a 211 bed facility. It was the highest such penalty ever imposed.
In addition to the fines Tennessee Health Commissioner John Dreyzehner ordered a freeze on any new admissions to the facility and appointed a monitor to oversee its operations.
The 98-page inspection report, which prompted Dreyzehner's action, cites multiple cases of patients suffering actual physical harm due to failure to follow a physician's orders, failure to administer prescribed drugs and failure to inform physicians' of their patients deteriorating condition.
A male patient who was admitted to the home on July 26 of this year with no visible wounds ended up being transferred to a hospital multiple times for ulcers and ultimately died on Oct. 11. Hospital staffers found maggots in wounds that appeared to be untreated.
The state surveyors noted that the records of wounds on the patient recorded at the nursing home when he was placed in an ambulance omitted at least five wounds that were found by hospital staffers minutes later.
The report states that nursing home records indicated the patient also was not given the pain medications his doctor had prescribed.
"He was not assessed regularly nor did he receive his pain medication regularly," the report states.
Neglect and poor care was also detailed for other patients, including a female patient suffering from ovarian cancer whose worsening condition was not reported to her doctor. She died on Oct. 24.
When a state surveyor asked a home employee what she did when the patient vomited, the worker said, "No I didn't give her anything. If they only vomit once, we watch them."
In that patient's case, the report states she was apparently given a medication that wasn't prescribed.
The report was highly critical of managers at the facility and noted that top officials contended they were unaware of the problems reported by direct care staffers.
Home managers "failed to ensure that care was provided as called for in care plans for five of 16 residents," the report states.
According to the report, the home's medical director stated, "I have support, no direction. I have talked (to them) about the staff they have here. I don't have much confidence in them."
One resident, the report states, was left sitting in her own stools for five hours. Another was found choking after she pulled out her oxygen tube.
Records showed another patient apparently did not get 37 of 106 prescribed doses of Lyrica and 29 of 106 prescribed doses of morphine.
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