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Nursing homes cited for defects

Inspections show federal violations at 27 of 33 centers

By Susan Squires
Post-Crescent staff writer November 27, 2005

Human error is responsible for most mistakes at nursing homes. Someone misunderstands instructions. Someone overlooks vital information. Or someone skips a step.

Such mistakes are widespread among skilled nursing centers in the Fox Valley, according to recent state inspection reports. But the vast majority result in no physical harm to patients, they show.

A Post-Crescent review of recent reports documenting federal violations for the 33 nursing homes in Calumet, Outagamie, Waupaca and Winnebago counties shows 117 deficiencies among 27 of the facilities.

Six of the centers were free of violations.

Most deficiencies were considered minor, some including improper filing of paperwork. But others were more serious.

Among deficiencies cited by inspectors at multiple facilities:

Several patients’ blood-sugar counts dropped to dangerous levels.

A patient was left on a toilet for two hours and other patients had incontinence accidents because workers didn’t respond to their call lights promptly.

Workers replaced soiled adult diapers without cleaning patients first.

Surveyors found expired drugs, gunk-caked pill crushers, a grimy stove and a sticky substance oozing through the floor of a cooler.

One of the most serious deficiencies involved a woman whose caregivers failed to detect a broken hip, despite her cries from pain. By the time the woman underwent an X-ray, her hip had been broken, doctors said, for five or six days.

Inspectors cited Crystal River Nursing and Rehabilitation Center, Waupaca, for failing to notify the woman’s doctor that her condition had changed in the August 2004 incident.

Carrie Russert, executive director at Crystal River, defended her facility’s care. Inspectors surveyed Crystal River again this month, and found one, minor federal deficiency.

“Our primary concern is, and has always been, the health and well-being of our residents,” Russert said in a written statement to The Post-Crescent. “We will continue to focus our efforts on providing quality care to the people we serve.”

Care report card

The surveys are the report cards state inspectors compile during approximately annual, unannounced inspections. They are the government’s primary tool for regulating nursing homes that get money from Medicare and Medicaid.

Unlike a report card, however, surveys only document a facility’s faults, not its attributes.

If inspectors find deficiencies, nursing homes are required to file plans for correction. Inspectors verify that deficiencies have been corrected.

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