When federal inspectors dropped by San Antonio nursing home Emeritus at Lincoln Heights last summer they discovered a laundry list of problems. They noted several instances of unsafe nursing practices, saying staff was “carelessly failing, repeatedly failing, or exhibiting an inability” to conform to minimum nursing standards. The facility, inspectors wrote, failed to develop care plans for nine of its 29 residents, increasing the risk that serious medical issues could slip through unaddressed.
Inspectors noted that one nurse, while dressing a wound for a resident, wore her bloody glove while grabbing gauze from a container. She then went on to treat another resident with contaminated gauze from the jar. Inspectors flagged the facility for failing to develop a plan to control infections and keep them from spreading, while also citing the possibility of frequent medication error. When one nurse went to give a patient his needed three units of insulin, she instead drew five – the inspector stepped in before the nurse gave the wrong dose. On second try, the nurse again botched the dosage.
For its deficiencies, the federal Centers for Medicare and Medicaid Services gave Emeritus a severity rating of “L,” the worst possible, meaning the conditions at the nursing home constituted a widespread and immediate threat to resident health and safety.
What have inspectors uncovered at a nursing home near you? CMS put its inspection reports online in July, and this week the nonprofit investigative journalism outfit ProPublica created its own easily searchable database of those CMS reports. You can search by severity of problems noted by CMS, by city and state, or conduct your own keyword search.
According to the database, Texas nursing homes saw far more serious deficiencies than any other state, with 183. New York State, the next down the list, logged only 78.
Records show Pflugerville Care Center got an "L" rating when inspectors found staff had allowed a resident to smoke with an oxygen tank running from her wheelchair. At Azalea Place in Tyler, inspectors reported one resident died when her ventilator came unplugged and staff couldn't hear the alarm (three other ventilator-dependent residents at the facility had alarms that couldn't be heard more than 10 feet from their rooms).
At the Senior Care Health and Rehabilitation Center in Denton, an inspection report states a female resident fell and hit her head during a morning transfer last year when a safety restraint wasn't used. Her blood pressure rose throughout the day the day and she began to vomit. Facility staff didn't phone her physician until the woman became unresponsive that evening. “These failures contributed to a delay in emergency intervention for [the resident] that may have contributed to [her] death and could place the census of 38 at risk,” inspectors noted.
