A Brevard County nursing home was fined $36,000 after committing numerous clerical and medical errors involving a patient who eventually died, a state agency recently reported.
The Agency for Health Care Administration fined West Melbourne Health & Rehabilitation Center after finding the infractions during an administrative complaint inspection on Dec. 27.
The home will be subjected to inspections every six months for two years, the report, filed April 29, said.
A phone call to the nursing home administrator, listed as Randall Blue on the AHCA website, was not returned to FLORIDA TODAY.
During the December inspection, AHCA reported staff from the 180-bed facility failed to follow physician orders, assess bruising from an unknown source and properly administer blood-thinning drugs given to the patient.
Staff members also did not consistently update the patient’s medical charts.
AHCA questioned the use of three blood-thinning medications prescribed to the patient at the same time.
“Physicians’ notes . . . did not indicate any documentation of the rationale for the three blood-thinning medications ordered with similar effects, which would increase risk of bleeding/hemorrhage,” the report stated.
“This noncompliance (among others),” the report stated, “caused or is likely to cause, serious injury, harm, impairment or death.”
The agency’s 37-page report went on at length about bruising on the patient’s abdomen and inner thighs, an indication of internal bleeding. The nursing home staff noticed the purplish-colored skin on the patient and even discussed it, but rarely reported it on medical records or attempted any treatment for it, according to the report.
“It’s really unfortunate, because you have someone here who’s dying from neglect in the nursing home,” said Brian Lee, executive director of Families For Better Care, a national advocacy group for nursing home and assisted-living residents based in Tallahassee. “So you have a state fine of $36,000. That’s what a resident’s life has come down to in this case.”
The are no national fines for such cases, Lee said.
But, he said, the state is telling the nursing home “you have really dropped the ball here.”
The patient was admitted to the facility on Sept. 13 with heart disease, diabetes, high blood pressure and a blood clot in the legs, among other disorders.
Various tests ordered by physicians were not verified on medical records, including tests to determine whether the blood-thinning medications were working.
The patient became unresponsive and was sent to a hospital Dec. 3, the report said, and likely was unconscious, suffered a severe stroke and respiratory failure related to deep-vein thrombosis (a blood clot). The patient died at the hospital Dec. 13.
A representative with AHCA said 88 Florida nursing homes were served adminstrative complaints in 2013.
The home is operated by Northport Health Services, based in Tuscaloosa, Alabama. NHS operates 42 homes across the Southeast, including three others in Florida: Crystal River Health and Rehabilitation Center, Ocala Health and Rehabilitation Center and St. Augustine Health and Rehabilitation Center.
A representative of the Florida Health Care Association, an advocacy group for more than 500 long-term care facilities in the state, would not comment on the case.
Contract McClung at cmcclung@floridatoday.com or 321-242-3776.
The Agency for Health Care Administration fined West Melbourne Health & Rehabilitation Center after finding the infractions during an administrative complaint inspection on Dec. 27.
The home will be subjected to inspections every six months for two years, the report, filed April 29, said.
A phone call to the nursing home administrator, listed as Randall Blue on the AHCA website, was not returned to FLORIDA TODAY.
During the December inspection, AHCA reported staff from the 180-bed facility failed to follow physician orders, assess bruising from an unknown source and properly administer blood-thinning drugs given to the patient.
Staff members also did not consistently update the patient’s medical charts.
AHCA questioned the use of three blood-thinning medications prescribed to the patient at the same time.
“Physicians’ notes . . . did not indicate any documentation of the rationale for the three blood-thinning medications ordered with similar effects, which would increase risk of bleeding/hemorrhage,” the report stated.
“This noncompliance (among others),” the report stated, “caused or is likely to cause, serious injury, harm, impairment or death.”
The agency’s 37-page report went on at length about bruising on the patient’s abdomen and inner thighs, an indication of internal bleeding. The nursing home staff noticed the purplish-colored skin on the patient and even discussed it, but rarely reported it on medical records or attempted any treatment for it, according to the report.
“It’s really unfortunate, because you have someone here who’s dying from neglect in the nursing home,” said Brian Lee, executive director of Families For Better Care, a national advocacy group for nursing home and assisted-living residents based in Tallahassee. “So you have a state fine of $36,000. That’s what a resident’s life has come down to in this case.”
The are no national fines for such cases, Lee said.
But, he said, the state is telling the nursing home “you have really dropped the ball here.”
The patient was admitted to the facility on Sept. 13 with heart disease, diabetes, high blood pressure and a blood clot in the legs, among other disorders.
Various tests ordered by physicians were not verified on medical records, including tests to determine whether the blood-thinning medications were working.
The patient became unresponsive and was sent to a hospital Dec. 3, the report said, and likely was unconscious, suffered a severe stroke and respiratory failure related to deep-vein thrombosis (a blood clot). The patient died at the hospital Dec. 13.
A representative with AHCA said 88 Florida nursing homes were served adminstrative complaints in 2013.
The home is operated by Northport Health Services, based in Tuscaloosa, Alabama. NHS operates 42 homes across the Southeast, including three others in Florida: Crystal River Health and Rehabilitation Center, Ocala Health and Rehabilitation Center and St. Augustine Health and Rehabilitation Center.
A representative of the Florida Health Care Association, an advocacy group for more than 500 long-term care facilities in the state, would not comment on the case.
Contract McClung at cmcclung@floridatoday.com or 321-242-3776.
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