Wednesday, Aug. 22, 2007

Bethesda nursing home cited in an earlier death

State fined operator for ignoring patient’s problems breathing

E-mail this article \ Print this article

The Bethesda nursing home where a woman choked to death in May was fined the same month for ignoring another woman’s breathing difficulties. That woman died from respiratory failure.

The state’s Office of Health Care Quality fined Bethesda Health and Rehabilitation $20,000 on May 4, in part for the case of ‘‘Resident #25,” who had turned blue from lack of oxygen. An April state inspection report — which refers to residents by number, not name — blamed the charge nurse who worked the 3-11 p.m. shift for failing to monitor the elderly woman for five hours.

The blood oxygen of Resident #25 had slipped to 69 percent; a normal reading would be 95 percent or greater.

The incident occurred Jan. 27. She was sent to a hospital, then referred to a hospice, where she died Jan. 28. The state included a description of the death in its April 17 inspection of Bethesda Health.

The nursing home was appealing the state’s penalties when Resident #13 died on May 29. According to a separate report from the Office of Health Care Quality, Resident #13 choked to death because the nursing staff failed to clear her tracheotomy tube of mucus.

Care records for the woman, however, say the staff regularly cleaned the woman’s breathing tube. State licensing boards have been notified of the discrepancies, said Karen Black, a spokeswoman for the Department of Health and Mental Hygiene.

Because of the May 29 death, on top of the one on Jan. 17, the nursing home could lose its ability to accept Medicare and Medicaid payments.

Wendy Kronmiller, director of the Office of Health Care Quality, said the state will conduct an unannounced inspection of Bethesda Health sometime before Oct. 17. The results of that inspection would determine the nursing home’s fate.

‘‘Annual skilled nursing facility inspections are extremely thorough and tough, as they should be for those whom we are privileged to serve; and we take the results of all inspections very seriously,” according to a statement from John Spadaro, a regional vice president with Bethesda Health’s parent company, Sava Senior Care.

‘‘In terms of the initial survey conducted more than four months ago, although we respect the thoroughness of the surveyors, we do not agree with all of the findings, some of which have been deleted or reduced by the Department since the original inspection took place,” Spadaro’s statement reads. ‘‘We will continue to aggressively move forward with our action plan; and we fully anticipate being in compliance with all applicable requirements at the time of the next revisit. We will also continue to cooperate fully with all involved parties.”

Bethesda Health and Rehabilitation is at 5721 Grosvenor Lane. Sava Senior Care, based in Atlanta, is a privately held company operating 185 nursing homes in 18 states, including nine others in Maryland. It also operates Arcola Health and Rehabilitation Center in Silver Spring. It is not clear whether Arcola is receiving the same level of scrutiny as the Bethesda nursing home.

The April report also describes how at least three patients were inappropriately sent to the hospital in taxis, as opposed to an ambulance. No staffer would accompany the patients on the trips, nor did the driver have CPR or first aid training, according to the report.

In one case, a woman called Resident #16 had been admitted to Bethesda Health after a hip fracture, with impaired kidney function and congestive heart failure. On Jan. 24, the resident was lethargic with a decrease in appetite. The next day, the nurse practitioner believed Resident #16 appeared weaker. Tests that arrived 5:30 p.m. showed her kidneys failing. At 8 p.m., the nurse practitioner ordered the resident to be sent to the hospital for evaluation.

She arrived at the hospital by taxi at 9:35 p.m., according to the report.

‘‘When asked why the resident was sent by cab, the evening charge nurse stated it was because the nurse practitioner did not write in her order to transfer to the hospital via 911. ... [T]he nurse practitioner assumed that any nurse would know to send a resident with acute renal failure to the hospital via 911,” the report says.

Kronmilller said the facility has stopped using taxis.

Resident #16 appears elsewhere in the report. She was administered an antibiotic to combat a bacterial infection, but records showed she received the antibiotic for five days after she tested negative for the infection.

The nursing home also was cited because Resident #16’s physician did not develop a treatment plan when her kidney function was worsening. Under federal regulations, a nursing home is responsible for the actions of physicians within the facility, whether they are employed by the nursing home or not.