State faults facility for care of seniors

By Marshall Allen

Thursday, Oct. 29, 2009 | 2 a.m.

All 139 elderly patients at an assisted-living and Alzheimer’s facility may have gone without their medications for weeks, according to a Nevada State Health Division report obtained by the Sun.

Health authorities reached this conclusion after randomly inspecting the case files of 23 residents at Chancellor Gardens of the Lakes. In every instance caregivers either did not have the drugs available, or did not have the time to administer them and threw away the medications, according to a report delivered to the facility Tuesday by inspectors from the state’s Bureau of Health Care Quality & Compliance.

The problems have persisted since Sept. 19, said Marla McDade Williams, the bureau’s chief. The state is considering a takeover of the facility, a ban on admissions or limiting its occupancy. The facility will also be fined by the state at the conclusion of its investigation, she said.

Representatives from Chancellor Gardens, at 2620 Lake Sahara Drive in Las Vegas, did not return phone calls seeking comment.

Acting on a complaint, officials from the Health Division, which licenses the facility, inspected the home between Sept. 19 and Sept. 24. The precise nature of the complaint was not disclosed. Inspectors reviewed the records of 23 of the patients and discovered the collapse of protocol in each.

Inspectors have since visited the facility multiple times a week and the ongoing problems are causing serious concern about the well-being of all 139 elderly residents, McDade Williams said.

“Their health issues could escalate to the point where they could be hospitalized,” McDade Williams said.

She said the investigation has not yet determined whether any patients have been harmed.

Health inspectors often find problems when they inspect assisted-living facilities. But rarely do they discover problems as severe and widespread as what’s been detected at Chancellor Gardens.

Carol Cable, chief operations officer for Senior Management Concepts, the company that owns Chancellor Gardens, did not return calls for comment. The Health Division reported Cable to her licensing agency, the Nevada Board of Examiners for Long Term Care Administrators, which is now investigating the case. The board fined Cable in May for neglect of patients and using unqualified staff.

Chancellor Gardens is the company’s only facility in Nevada. It owns one in Seattle and nine in Utah.

Many of the 23 residents whose case files were reviewed were supposed to be taking multiple medications. For example, Patient No. 1 in the report was not receiving aspirin, calcium and drugs for Alzheimer’s, diabetes, schizophrenia and high cholesterol.

According to the state’s report, the facility’s executive director admitted to inspectors that the facility was negligent in administering the medicine to that patient.

In an interview, McDade Williams said multiple factors contributed to the breakdown. Sometimes family members were responsible for providing the drugs, she said. In other cases management and staff were disorganized, or there were problems with physicians and pharmacies, she said.

The facility’s former wellness director, a registered nurse, told inspectors that she knew that caregivers were not dispensing the drugs and were “throwing the medications away because they did not have time” to administer them, the report said.

The patients’ families have not been notified, McDade Williams said.

Sylvia Healy, founder of the advocacy group Citizens for Patient Dignity, was not familiar with the current investigation at Chancellor Gardens, but said the findings are similar to problems she’s seen in other nursing homes.

“The patients are either are not given their medication or they’re overdosed,” Healy said. “It seems like there’s no happy medium.”

The primary problem in the homes is insufficient or unqualified staffing, Healy said.

The state’s September inspection revealed other violations:

• In late August a caregiver performed CPR on a resident who was still breathing and had a heart rate.

• The facility is licensed for 30 Alzheimer’s patients, but had 34 in the unit.

• Medical records were inconsistent or did not indicate when patients received medication or were discharged.

According to a separate Health Division report filed in July, a 72-year-old resident went missing from the facility on July 16 and was found five days later, dehydrated and in a diabetic coma. The man died.

When officials investigated the incident, the Chancellor Gardens executive director could not find records related to the incident or any evidence it was reported to the state.

Another resident left an outside porch at the facility on June 12, the July report said, and was found unharmed the same day.

The July report also noted two of nine sampled cases where residents did not receive medication.