Wednesday, Nov. 25, 2009 | 2 a.m.
Related Document (.pdf)
- Man says care of his mother at facility left her hospitalized (11-12-2009)
- Las Vegas adult group care home under fire (11-10-2009)
- State faults facility for care of seniors (10-29-2009)
Employees at a Las Vegas assisted-living and Alzheimer’s facility may face criminal neglect charges in connection with an ongoing investigation into the horrific care of elderly residents — some of whom were hospitalized because they did not receive their medication.
The Nevada Division of Aging and Disability Services investigated and confirmed a complaint of elder neglect at Chancellor Gardens of the Lakes and referred it to the attorney general’s office to determine whether criminal charges will be filed, officials said Tuesday.
The accusations stem from an ongoing investigation by the Nevada State Health Division of Chancellor Gardens, where the state previously found that dozens of the elderly residents had gone without their medications — resulting in three hospitalizations — and had suffered neglect at the hands of unqualified employees.
In the newest report, released Monday, the state found:
• Hundreds of pills that should have been administered to residents were instead discovered discarded in containers intended for needles and other sharp objects.
• A resident suffering from dementia — and unable to care for her colostomy — should not have been admitted to the facility because there were no medical personnel to provide care.
• Employees were unable to explain how to look for urinary tract infections or care for patients who had catheters.
• The facility failed to notify a patient’s guardian when the resident was admitted to the hospital.
• A patient with a history of seizures suffered four falls and required hospitalization.
The problems at Chancellor Gardens have been ongoing, even though state inspectors have been present or in contact with the facility for months.
Chancellor Gardens is owned by Utah-based Senior Management Concepts. One of the owners, Vaughn Pulsipher, told the Sun he is aware of the problems, taking them seriously and correcting them.
“I understand the extent of the problems,” Pulsipher said. “That’s why we’ve marshaled all our resources and our corporate team to solve the problem.”
Pulsipher said his company owns 14 facilities across the country and has a “fine reputation.” The problems at Chancellor Gardens came as a surprise, he said. He said it’s unacceptable that patients did not receive their medications.
“Unfortunately, we relied on some people to perform and they did not,” he said.
Carol Errisson, the former administrator at Chancellor Gardens, now faces disciplinary action from her licensing agency, the Nevada State Board of Examiners for Long-term Care Administrators. The board filed a complaint Oct. 13 alleging, among many charges, that she admitted patients who should not have been at the facility, did not ensure residents received their medications and failed to provide supervision for two residents who ran away. One of them died after being found dehydrated and in a diabetic coma.
Errisson did not return a call for comment.
Marla McDade Williams, chief of the health division’s Bureau of Health Care Quality and Compliance, said another survey that spanned three days was concluded Friday and still found problems — even though the operators knew they were under the state’s scrutiny.
Officials are now weighing what action to take against the facility, which has been in and out of compliance with state regulations throughout the year. The state imposed a ban on admissions Nov. 6 and could suspend or revoke the facility’s license, install a temporary manager or impose a limitation on admissions.
McDade Williams said it’s not easy to shutter a facility because Nevada law allows operators of elder care facilities to reapply and receive licenses even if they have been previously disciplined. Thus, it’s ideal to work with a facility to correct its problems, she said.
State inspectors have been at Chancellor Gardens at least a half-dozen times this year. Their latest report, released Monday and covering an Oct. 20-Nov. 2 survey, details conditions for the 110 residents at the facility, some of whom pay up to $4,000 a month to stay there.
The state found that even though some patients pay a $300 monthly surcharge to have medicines administered, none had received them, according to the new executive director.
The state had found medication problems in previous surveys, but the Nov. 2 report goes into detail about the extent to which patients went without their drugs. About 43 pages of the 58-page report include a case-by-case explanation of hundreds of medication errors for dozens of patients. Technicians were not accurately keeping the records in a computerized system, prescriptions were not refilled and patients’ doctors were not contacted for updated prescriptions, the report said.
The former wellness director confirmed with state inspectors that medication technicians were throwing away pills when they did not administer them.
The most recent sample of 30 residents’ medical records showed significant medication errors, the report said.
For instance, a resident taken to University Medical Center on Oct. 21 with dehydration, nausea, vomiting and a urinary tract infection had missed drugs for gastric ulcers and gastroesophageal reflux disease 22 times during the month. The resident had also missed 48 anti-nausea doses in September and October. The resident’s prescription for treatment of gastrointestinal infections was listed as unavailable from Sept. 1 to 20. The failure of Chancellor Gardens was a likely contributing factor to the resident’s hospital visit, the state report said.
A resident who suffered from Alzheimer’s and dementia did not receive 22 doses of the antibiotics prescribed for cellulitis, a potentially serious bacterial skin infection. The problem persisted and the resident was taken to Valley Hospital & Medical Center.
In a third case a Chancellor Gardens resident was found to be in congestive heart failure, in part because of the facility’s failure to administer cardiac medication, the report said.
McDade Williams, the bureau chief from the state, said she did not know the current condition of the patients.