Man says care of his mother at facility left her hospitalized

By Marshall Allen

Thursday, Nov. 12, 2009 | 2 a.m.

When David Bornstein checked his elderly mother into Chancellor Gardens of the Lakes, she was able to carry on a conversation, walk with assistance and go on day trips.

Two months later Yvette Bornstein, 79, was admitted to a hospital. Her buttocks were covered in bed sores, David Bornstein said, and hospital nurses said it appeared she had been lying in urine-soaked garments for days. Her dementia had been controlled by medications before her stay, but now she was combative and disoriented. Her blood pressure was irregular and a wound on her back that had been managed with regular care had become severely infected. She was dehydrated, and her weight had dropped by about 20 percent to 102 pounds.

Two months at Chancellor Gardens had taken his mother to the brink of death, Bornstein said.

“She wasn’t getting her medications there,” he said. “They weren’t making an attempt to see that she received them.”

David Bornstein’s mother left Chancellor Gardens about two weeks ago and is recovering at a different facility. She was apparently one of many patients who were not receiving their medication at Chancellor Gardens. State officials on Tuesday placed a temporary ban on admissions at the 150-bed facility until officials there can ensure that residents receive their drugs. Patient record reviews by state authorities found that of 32 patients whose folders were checked at random, not one had received his or her medicines for the month, suggesting that perhaps no patients received the medications they needed for months.

The 72-hour admissions ban could be extended, according to Nevada Bureau of Health Care Quality and Compliance authorities.

The bureau reported that three residents were hospitalized because they did not receive their medications, though officials could not say whether Bornstein’s mother was one of them. Marla McDade Williams, the bureau’s chief, said the actual number could be higher.

State officials started their in-depth probe of Chancellor Gardens after receiving complaints in September. During the investigation, the facility’s wellness director told investigators that she knew caregivers were not administering drugs to residents and that some were throwing the medications away because they did not have time to administer them, officials said. Other staff members told state officials this was common practice.

Staff reported to the state that almost every resident was missing one or more medications. The state sampled 23 residents in September and found none receiving prescribed medications. In response, the facility’s executive director said arrangements would be made with a pharmacy to correct the problem.

In October additional complaints were received by the state, and a subsequent investigation revealed that all 28 residents sampled were not receiving their medications as prescribed, state officials said. Chancellor Gardens has since hired two registered nurses and a consultant to correct the problems. The executive director has resigned and been reported to her licensing board, officials said.

Williams, from the state, said Chancellor Gardens appears to be correcting the problems. If the situation is not rectified, the state could appoint a temporary manager of the facility, or suspend or revoke its license, she said.

Lon Records, whose stepmother was a resident at Chancellor Gardens, criticized the state’s slow response. He complained in December 2008 that Jean Records was not receiving her medication and was living in squalid conditions.

Jean Records was from Las Vegas and wanted to live in her hometown. Her children lived elsewhere and liked Chancellor Gardens when she was admitted in December 2005, said Lon Records, president of a wholesale distribution company in Riverside, Calif. The problems were not immediately apparent because the children could only make phone calls and occasional visits.

When Jean Records was admitted, her physician assessment said she was forgetful and unable to administer her own medications. The family’s $4,000 in monthly fees to the facility included about $300 to administer her medication, Lon Records said.

Records had a cat, and on Sept. 9, 2008, her visiting daughter found the room stinking and filled with garbage, including stacks of newspapers soaked with cat urine in the closet. A plastic bag containing several months of her medications was in a dresser drawer.

Records’ daughter asked the staff about the medication and was told, incorrectly, that she was a “self medicator,” according to the complaint filed with the state. The staff members told her that Records would not allow them to clean her room.

Jean Records died of pneumonia four days after the visit, Lon Records said. The facility failed to provide her with medication, proper care and a clean environment, and the filth and toxic odors contributed to her illness, he said.

The state investigated the complaint but could not substantiate it because of a lack of evidence. Williams, the state bureau chief, said there are many factors that determine whether a complaint can be substantiated, but sometimes the problems are hard to verify.

Lon Records blames Chancellor Gardens and the state for his stepmother’s death. He requested a $9,900 refund for the 33 months of medication fees, but received nothing. Records said a lawsuit should be filed against Chancellor Gardens.

“They need to pay for their neglect of these people,” Records said. “You’re giving your loved ones to them for care and maintenance and paying a steep price. When they (neglect residents) it’s just criminal.”

Two former staff members who worked briefly at Chancellor Gardens this fall told the Sun the executive director was inexperienced and prevented other managers from doing their jobs. The former wellness director, who worked at the facility in July and August, said the facility was short-staffed, employing only a single technician to administer medications for 110 residents. She said she often received calls from doctors, wondering why the lab results of their patients were not reflecting medications. Sometimes technicians initialed records as if medication had been administered when it had not, she said.

The former wellness director said when it became clear that her boss would not help rectify the problems, she quit and filed a complaint with the state.

“I knew I had to make that complaint because of the condition of the residents there,” she said. “They entrusted their well-being to the (facility).”