Veterans Home Cited in Death

Patients, visitors and staff walk Wednesday outside the Fayetteville Veterans Home.
Patients, visitors and staff walk Wednesday outside the Fayetteville Veterans Home.

Fayetteville Veterans Home administrators didn’t report a patient’s death from suspected neglect for three weeks in violation of state law, state regulators found.

Veterans home administrators also discussed the patient’s Jan. 15 death and its circumstances with their superiors at the state Department of Veterans Affairs office in Little Rock before reporting the matter Feb. 5 to the state Office of Long-Term Care, the investigation found. State law requires reporting all suspected neglect to the office by 11 a.m. the next business day.

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Regulators’ Report

Read the report from state regulators at nwaonline.com.

Cissy Rucker, Veterans Department director, acknowledged in a statement the report was late.

“We have a new administrator, and we are still looking into this at this time,” Rucker said Wednesday. “The Office of Long-Term Care has all the information on this matter.”

The department had no further comment, spokeswoman Kelly Ferguson said Wednesday.

Immediate steps are required by law in neglect cases to ensure the safety of other patients. These weren’t followed, investigators found. The nurse found responsible for the neglect remained in charge of 50 patients until she was suspended Feb. 6, according to the long-term care office. The nurse has been fired.

State law requires any in-house investigation on neglect be completed within five working days.

Long-Term Care inspectors declared patients were in “immediate jeopardy” at the nursing home Feb. 8, the most severe level of violation. The agency then turned its report over to federal health administrators. If the federal Center for Medicare and Medicaid Services agrees with the findings, the Office of Long-Term Care can take over the home temporarily while the federal government assesses fines or other penalties.

The state Department of Human Services, which oversees Long-Term Care, had no statement Wednesday on how severe a fine or other action could be.

“Where is the supervision? Where is the oversight?” said Martha Deaver, president of the Arkansas Advocates for Nursing Home Residents. “Why did this happen so quickly after new leadership was put in place to fix these problems?”

The Veterans Department closed a nursing home in Little Rock in October after years of mismanagement, which included charging fees to residents the agency couldn’t legally charge, according to a state audit.

The Fayetteville home was cited for 22 violations in a March 19 inspection by Long-Term Care, with problems ranging from medication errors, unsanitary conditions, inaccurate recordkeeping and cold or inedible food. A followup visit in June found five more medication-error and sanitation issues.

The Office of Long-Term Care compiled a report on the Jan. 15 death in Fayetteville. No names of those interviewed or the deceased veteran were released.

According to the report, an occupational therapist entered the patient’s room about 11:30 a.m. The patient’s only response when called was to open his eyes. Severe rattling accompanied his breathing.

The therapist informed the licensed practical nurse on duty, referred to in the report as “LPN #1.” The nurse, who was eating lunch, said she had seen the patient earlier that day and he had been up for breakfast. The therapist insisted something was wrong. The nurse didn’t check on the patient and disputed in her statement the therapist expressed urgency.

The therapist found a certified nursing assistant on duty and requested she check the patient’s vital signs. That nursing assistant confirmed the therapist’s account. She informed the nurse vital signs were low. The nurse didn’t respond, according to the report. By this time, the therapist said, he “noticed very shallow breathing and congested sounds. I attempted to wake (the patient) by shaking him on (the right) shoulder without any response.”

The therapist then went to the nurse’s station, called the nurse by name and they went to the patient’s room.

“I noted one breath taken, then no chest movement as (he) stopped breathing,” the therapist said. Veterans home records cited in the report give the patient’s time of death as 11:50 a.m.

The therapist went to the fifth floor to begin writing a statement of events when one of his supervisors walked by, according to the report. The therapist and the supervisor talked to an administrator within 15 minutes of the death, according to the therapist’s statement.

Investigators asked the home’s director of nursing why this incident wasn’t reported. The director replied she and home administrators “batted this back and forth and talked with the Little Rock (administrators of) Arkansas Department of Veterans Affairs on doing disciplinary counseling with LPN #1.”

“Did you identify then that the (therapist) was alleging neglect?” regulators asked in the report. “The DON (director of nursing) stated ‘No, I felt he was saying LPN #1 didn’t respond timely enough.’”

Regulators replied failure to respond in a timely fashion is neglect under state and federal regulations. The director of nursing acknowledged that was the case, according to the report.

Regulators interviewed the administrator who was first told of the circumstances of the patient’s death. The home administration didn’t change the nurse’s duties; assess other patients under the nurse’s care to see if they had suffered neglect; investigate to see if there were other “condition changes” that weren’t responded to, or do any added staff training on what to do if a patient condition changes, according to the report.

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