Last month, the Senate Special Committee on Aging members conducted a survey on the underperforming nursing homes of America. Sens. Bob Casey, D-Pennsylvania, and Pat Toomey, R-Pennsylvania released a report of that survey that endeavored to explore the extent of nursing home deficiency in America. The results of this study were captured and reported on by Knox News to empirically prove the extent Tennessee’s nursing home neglect issues.
Revealing The Extent of Tennessee’s Nursing Home Neglect
Following the release of the senate report, the Federal Centers for Medicare and Medicaid Services agreed to release a list of nursing homes that are candidates for its Special Focus Facility (SFF) program to the public. This program was designed to target substandard nursing home facilities that have a “persistent record of poor care” in order to deliver extra oversight and attention to these problem facilities. In the report, 400 nursing homes, or 2.5% of the 15,700 homes in America, are listed as candidates. Of these 400, only 88 homes can be selected to be members of the SFF.
Nursing homes who are not selected as SFF members will now for the first time be revealed to the public and although they will still not receive extra inspections, consumers will no longer have to screen hundreds of pages of inspection reports to find out which nursing homes are classified as deficient. Out of the 400 nursing homes considered for candidacy, 11 of them are located in Tennessee. These homes were noted by Knox News as being emblematic of Tennessee’s nursing home neglect issues throughout the state.
The 11 Tennessee nursing homes implicated in the SFF report are in the following regions:
- Bartlett, Rainbow Rehab and Health
- Columbia, Life Care Center of Columbia
- Dyersburg, Dyersburg Nursing and Rehabilitation Center
- Humboldt, Bailey Park Community Living Center
- Johnson City, Cornerstone Village
- Kingsport, Brookhaven Manor (now Orchard View)
- Knoxville, Westmoreland Health and Rehabilitation Center
- Madison, Creekside Center for Rehabilitation and Health
- Maryville, Asbury Place
- Nashville, Greenhills Health and Rehabilitation Center
- Ripley, Lauderdale Community Living Center
To showcase the extent of Tennessee’s nursing home neglect, it was noted that two of those 11 facilities, Brookhaven Manor and Lauderdale Community Living Center, are also current members of the SFF.
Examining The Worst Offenders of Tennessee’s Nursing Home Neglect
The report noted several instances of Tennessee’s nursing home neglect in broad and specific incident accounts. Some instances Tennessee’s nursing home neglect issues noted in several nursing homes included
- Delays in response to incontinent patients exceeding an hour which resulting in self-soiling
- Failure to isolate patients with contagious infections or diseases
- Assault of residents
- Failure to prevent bedsores
- Poor staffing numbers
- Inadequate oversight
- Failure to make or schedule appointments with outside physicians
These, however, were simply the common and superficial instances of Tennessee’s nursing home neglect problems. There were also several accounts of severe neglect included and pursued in the senate report.
One such account occurred at Dyersburg Nursing and Rehabilitation Center. According to the report, in 2017, a blind double amputee in a wheelchair was not sent to a doctor’s appointment with an escort. As a result, the amputee’s wheelchair upended backward off the back of the van he was riding in. The man suffered a hemorrhage when his head impacted on the concrete, entered into a coma, and later died in the hospital.
When questioned about the negligent nature of their course of action, Dyersburg Nursing and Rehabilitation Center defended its choices by citing 59 other instances in which the amputee was sent without an escort and had survived without incident.
Another instance of Tennessee’s nursing home neglect occurred at Creekside Center for Rehabilitation and Health. According to the senate report, the facility had a medication error rate of over 65%, more than 13 times the federal threshold for medication errors. This medication error report detailed 23 medical errors including incorrectly administering blood glucose tests, incorrectly administering insulin injections, failing to distribute cardiac and blood pressure medication, failing to distribute antidepressant and anti-anxiety medication as directed, and ignoring guidelines for a resident’s vacuum-assisted wound closure.
Despite the Creekside Center’s disregard for patient treatment, the most egregious incident of Tennessee’s nursing home neglect of medication occurred at the facilities of Bailey Park. There, the report indicates, a nurse “read the dosage wrong” when administering insulin and gave 100 units of insulin (equal to 1 mL/0.2 tsp) when the required dosage was four units of insulin. This dosage immediately put the resident in a coma.
Among the worst examples of Tennessee’s nursing home neglect crisis is the former Brookhaven Manor. A member of the SFF since 2016, Brookhaven sparked recent controversy after it discharged a resident for breaking rules related to smoking. Although the resident had no documented evidence that he understood these rules, and was staying for treatment of a severe head injury, he was discharged without the notification of state Long-Term Care Ombudsman or the TennCare CHOICES program paying for his care.
The report stated that staff drove the resident to a hotel and paid for three days they did not give the resident any money, food, phone access, or a supply of any of his numerous medications. Though staff did later deliver medication to him, the resident’s file indicated that he could not independently manage his own medication and reported having only eaten peanut butter crackers, candy, and the hotel’s complimentary breakfast since being abandoned there. For their infractions, Brookhaven is under criminal investigation by the Tennessee Board of Investigation.
Despite the abuses committed by Brookhaven Manor in the past, the facility has now been renamed Orchard View and is under new management and ownership by Plainview Healthcare Partners of New York. The organization allegedly specializes in reforming “troubled nursing homes” and Administrator Norman Haley has said that Plainview has put a “strategic plan to change the deficient care and services” into place and he expects Orchard View to come off the SFF list with the next survey.
The Long-Term Issue of Tennessee’s Nursing Home Neglect
While the steps taken by senators Casey and Toomey to decrease Tennessee’s nursing home neglect issues may help to improve transparency in nursing home reviews, this is far from the sole issue. As Trudy Lieberman printed in an article for the Rural Health News Service, consumers can view nursing home reports, which are public record, but may not have the choice to avoid poorly performing facilities, especially in rural parts of the state. The key issue to fix Tennessee’s nursing home neglect issues is not just to increase transparency in these homes, but to also endeavor to increase reform and accountability for the establishments that are meant to safeguard our most vulnerable population in their final decades.
For more information about nursing home neglect, visit the National Association of Nursing Home Attorney’s Neglect Page.