Kentucky Nursing Home Slapped With Two "Type A" Citations Within Two Months of Opening
Only open two months, a Covington, Kentucky nursing home has already been slapped with two "Type A" citations. "Type A" citations are the most serious citation that can be assessed by the Inspector General for the Cabinet for Health and Family Services.
Providence Pavilion began accepting residents in early January 2010. On January 27, 2010, a resident was sent to a local hospital to treat "an open area" that would not stop bleeding. The resident returned to the facility later that day and a physician ordered that the resident should not receive a regular dose of Coumadin, a blood thinner. The physician also ordered a blood test to monitor the resident on January 28. Reportedly, facility staff failed to transcribe the doctor's orders and gave the resident the normal dose of Coumadin.
No one from the facility contacted the doctor with any blood test results on January 28 and when the physician was contacted on January 29, the resident's labs showed life-threatening bleeding levels. The resident was found dead on January 30, 2010 around 4:00 a.m.
The negligent care of a second resident led to a second citation. The resident normally had an average blood pressure of 134/70 and an average blood sugar of 255. On January 20, 2010 the blood pressure was 228/108 and the blood sugar was 522. The nursing home advised the resident's physician of the elevated blood sugar, for which he prescribed insulin. The physician advised state officials that he had never been told about the high blood pressure. If he had known, the physician said he would have ordered the resident to go to the hospital. There is no written evidence that the facility assessed the second resident nor that the resident's blood pressure was monitored for the next two hours and 25 minutes after finding the elevated blood pressure.
On January 21 at 12:45 a.m., the resident was unable to move the left hand, had difficulty moving the left leg, had a limp arm, and a weak grasp. After being examined at the hospital, the resident was diagnosed with a stroke and paralysis on the left side.
According to the citation issued in this matter, the facility had no formal orientation for competency evaluation for their nursing staff, in violation of their own policy. The facility could not provide evidence that it had developed and implemented a policy of physician notification. Additionally, nurses had not been trained on physician notification.
According to Sue Schuman, the spokesperson for Providence Pavillion, the facility is going "above and beyond" to meet state requirements and has made the appropriate changes to the policies and procedures, although they dispute some of the findings in the citations. According to Schuman, "There's a lot more to the story than what's on paper."
