A report released Monday cites the Fayetteville Veterans Home for failure to promptly assess patients labeled skip-out risks after a patient left unnoticed last month, but Arkansas Department of Veterans Affairs officials said steps are being taken to correct the complaints that have been lodged against the home this year.
Monday’s report released by the state Department of Human Services’ Office of Long Term Care - a state agency that monitors nursing homes - was the fourth this year that substantiated a complaint against the Fayetteville facility.
It details a Nov. 15 skipout of a patient who was gone from his room for at least two hours without members of the nursing staff realizing he had left the housing area. The report also details similar cases this year when three other patients made attempts to duck out of the home and notes that few preventative measures were taken until the investigation in November.
When the Office of Long Term Care substantiates a claim against a nursing home, the home must submit a plan of correction, and that plan is either accepted or denied by the office.
Arkansas Department of Veterans Affairs Director Cissy Rucker said she received notification Monday that the Fayetteville home’s correction plan was accepted.
“I am totally convinced that we can get this home turned around,” she said in a phone interview Tuesday. “You can’t change everything overnight.You really can’t. You can’t even do it in a few months. It’s a long-term process. It didn’t get this way overnight. Very slowly, but surely, I think we are making some progress.”
Rucker, a retired Arkansas National Guard colonel, has been Veterans Affairs director since May 2012, when Gov. Mike Beebe appointed her to take over an agency troubled by lax budgetary and inventory oversight.
A month after she became agency director, Rucker closed the deteriorating Little Rock Veterans Home, which had been cited for poor oversight as well as illegally collecting fees from its most disabled residents. The state reimbursed the veterans or their families and is planning to build a new central Arkansas veterans home.
The Fayetteville home has come under public scrutiny this year after the Office of Long Term Care substantiated several complaints.
In February, the office released a report that cited the facility for neglect in the Jan. 15 death of a patient. In that case, a licensed practical nurse didn’t heed an occupational therapist’s warnings that a patient wasn’t breathing properly and didn’t immediately check on the patient.
The nurse fired, but fought the neglect tag on her nursing license and successfully had it removed, Rucker said. She is now working as a nurse elsewhere.
In April, the Long Term Care Office cited the Fayetteville home for a Dec. 8, 2012,restraint of a patient that ended in the patient’s arm being broken. Four employees were fired after the veterans agency found that they filed false reports.
In October, the facility was cited again after a patient complained that his wounds would tear and bleed when staff members replaced the Vaseline-treated gauze pads that covered them. The tearing and bleeding continued for days before treatment was changed. The Arkansas State Nursing Board is investigating the nurse involved.
One nurse involved in the Nov. 15 “elopement” incident was dismissed. Two others were given disciplinary marks.
The state Department of Veterans Affairs also fired the home’s administrator, Sarah Robinson, after the incident.
But Rucker said Monday that it wasn’t because Robinson was incompetent. Rucker called Robinson a “great nurse” and said she’s written the former administrator a letter of recommendation for a new position elsewhere.
“I highly recommend her as a director of nursing or an assistant administrator. I don’t think she had the management experience this home needs right now. But she was the outstanding candidate when the applications were reviewed,” Rucker said.
Robinson had been the administrator of the home since December 2012 and had worked as the director of nursing since 2006.
She was fired Nov. 20. At the time, state Department of Veterans Affairs spokesman Kelly Ferguson said Robinson’s termination was the result of “a negative trend in administrative decision-making on her part.”
Rucker confirmed Monday that she’s made an offer to an applicant for the administrator position, but said paperwork has yet to be completed. The department will announce when a hire has been made and confirmed, she said.
Monday’s Department of Human Services report cites the facility for failing to promptly assess patients defined as elopement risks and failing to ensure that the Quality Assessment and Assurance Committee met quarterly to identify and respond to quality assessment and assurance issues.
On Nov. 15, a patient was found in the downstairs lobby by police officers asleep in a chair between 5 a.m. and6 a.m. The patient was last checked by his nurse at 2:30 a.m. and last seen by another nurse at 3 a.m., the report said. No one knew he was missing.
The patient was easily coaxed back up to the sixth floor from where he was not supposed to have been able to leave. Nursing home housing is on the fifth and sixth floors of the building, which the Department of Veterans Affairs leases from the University of Arkansas for Medical Sciences.
Even though the patient was marked as a risk for elopement, there were no care orders related to that in his care plan, the report said. He also was not wearing a Wanderguard bracelet that sounds when he goes past certain areas.
The resident, who is diagnosed with Alzheimer’s disease, exited the nursing floor through the west service elevators, which were not visible from nursing stations and not monitored around the clock.
“What we immediately did - and I don’t know why this wasn’t done before - we got Wanderguard bracelets for those who are at a risk of leaving,” Rucker said.
Three other residents were noted in the report as showing exit-seeking tendencies in the past year. In one case, a volunteer at the home allowed a resident diagnosed with psychosis, delirium and dementia to exit the east tower elevator from the sixth floor. Alarms sounded and when a nurse responded, the volunteer said he mistook the resident for a visitor.
Despite those residents being defined as elopement risks, their care plans did not initially document specific steps to prevent further attempts at elopement, the report said.
Now all elevators are key-activated, according to the home’s plan of correction. A nurse has to manually unlock the elevator to exit or enter. In addition, the residents labeled as elopement risks will wear bracelets that sound when they pass certain bars placed in areas where the patient shouldn’t be unaccompanied.
The home’s plan of correction also included having the west elevators visually monitored at all times and contracting with a security company to have officers provide alternate staffing for oversight of the elevators. Employees were retrained in certain areas and four people were placed on paid administrative leave during the investigation.
Other incidents known as “reportables” - or complaints that have to be sent to the Office of Long Term Care - at the home during November include missing money, medication count errors, an unopened syringe left in a resident’s room and a resident being given hot sauce. One resident said 80 cents was stolen from him, but the money was later found. These complaints were not substantiated by the Office of Long Term Care.
In an email from administrative assistant Carole Blanks to Assistant Director Charles Johnson notifying him of the November complaints, Blanks indicated that morale among employees at the Fayetteville home is low.
“The workers on the floors have asked about the home shutting down. I think the [ Little Rock] home and the issues with the bad press up here has them scared,” Blanks wrote. “I have tried to assure them that none of [us] are working for closure. We want the best care possible for the veterans and their families and they need to be on that team.”
The more than 60-year-old Little Rock Veterans Home was closed in June 2012 after the department found out it would cost more than $10 million to repair the leaking roof, collapsed sewers and outdated heating system and to get the facility up to housing code. The home’s residents were moved to other nursing homes.
In the email, Blanks notes that regulations mandate when the complaints have to be reported and said that the final written report is to be completed within five days of the initial reporting. She said up to three of the incidents mentioned were “overdue.”
The email ends with, “Hopefully the night can go by without another reportable.”
In response to the staff’s questions about the Fayetteville home shutting down, Rucker said in an interview Tuesday that there are no plans to do so.
“Sometimes, if you’re not exactly sure of what’s going on it brings morale down, and I understand that. We have no plans for the home to close,” Rucker said. “I think a new administrator will be a positive influence. I have visited with the employees myself. I’ve been up there several times lately. I think a very positive person that has a strong management background will really help.”
Front Section, Pages 1 on 12/25/2013