Residents of a Nampa nursing home were left to sit in their own urine and feces, sometimes for hours at a time. One patient became so frustrated that he stopped eating.
Some residents were underfed and dehydrated. One woman’s head had to be shaved, because her hair became too matted from lack of brushing.
Some cried out for help. One man died after being rushed to the hospital.
These are among the troubles cited in a state report by a team of seven inspectors sent in July to Holly Lane Rehabilitation and Healthcare Center, a 120-bed nursing home at 2105 12th Ave. Road.
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The Idaho Health and Welfare Department team spent five days at Holly Lane after receiving complaints. The team reported that it found a widespread pattern of problems that threatened the health and safety of residents and failed to protect them from abuse and neglect.
The inspectors said eight residents were “in immediate jeopardy of serious harm, impairment or death,” and Holly Lane’s practices “resulted in serious harm, injury or death for three of four sampled residents.”
“Residents pee on themselves and cry,” one nursing assistant told an inspector. (The inspection records identify residents or employees only by number, not by name.)
Despite the findings, the nursing home remains open.
Orianna Health Systems, the Bartlett, Tennessee company that owns Holly Lane, takes the “allegations submitted by the state very seriously,” said Mikki Meer, chief operating officer.
“We don’t necessarily agree with all of the allegations,” Meer said. Nonetheless, the company responded to the state with a compliance plan. Inspectors returned Aug. 2 and confirmed that residents were no longer in immediate jeopardy.
Holly Lane still has until Jan. 18 to prove it has corrected all its problems. Otherwise, Health and Welfare will recommend termination from Medicare and Medicaid.
Asked whether Holly Lane should remain open, Department of Health and Welfare spokesman Tom Shanahan said shutting it down would be difficult. It is the only nursing home in the Treasure Valley to provide care to people who need ventilator machines to breathe, Shanahan said.
“This one is a real concern, because it is the only one in the Valley” equipped to provide that level of care, he said.
The department would not call police to seek criminal charges at a nursing home unless it found a crime such as theft, Shanahan said.
“But for issues such as neglect, we report that to the Attorney General’s Office,” whose Medicaid Fraud Control Unit would handle it, he said. “If it’s understaffing, who would they prosecute? ... I think that’s the question. You really can’t prosecute a worker there.”
The Idaho Attorney General’s Office would not say whether it is investigating or has received any complaints about Holly Lane. The office has pursued cases of abuse and neglect, such as a 2014 case against a Garden City man who pleaded guilty to felony abuse and neglect of a vulnerable adult (his mother) and felony Medicaid provider fraud. The Statesman could find no recent cases against nursing homes.
The Health and Welfare Department banned Holly Lane — known until recently as Trinity Mission Health & Rehab of Holly — from taking new Medicare and Medicaid patients starting in July. Holly Lane takes Medicaid, Medicare, privately insured and out-of-pocket patients.
The state also recommended that the U.S. Centers for Medicare and Medicaid Services impose a fine, with the amount left up to CMS to decide.
One employee said nursing employees “were directed to assist less cognitively impaired residents before those residents with greater impairment, as the more cognitive residents were more likely to ‘complain about the lack of care.’”
Another employee confirmed that allegation, adding that “during one recent shift, nonverbal residents did not have their adult briefs changed or [were not] repositioned from 4 p.m. until 1 a.m. the next day.”
One night, they were shorthanded. I was left on the bed pan for four hours. Sometimes, I have to wait an hour to go pee. What if I had an emergency? I am just scared for the others [residents]. Something is going to happen.
Holly Lane Resident #9’s statement to state inspectors in July
Holly Lane has been found in noncompliance with several rules in the past two years, when the state investigated earlier complaints similar to problems found in July. The state also visited the nursing home in March and June of this year to inspect for building and fire safety.
Someone complained last year that the nursing home was not properly administering tube feedings. The state looked into it. Its May 2015 report said a patient died after vomiting, with oxygen deficiency “likely” due to breathing in the vomit as the cause of death.
The state found the complaint substantiated but did not cite the nursing home, because the incident predated Holly Lane’s last recertification. The nursing director told inspectors that the nurse who conducted the improper tube feeding no longer worked there.
During the July visit, a state inspector met a man identified as Resident 15, who was crying in his wheelchair next to his bed. Resident 15 knew he smelled of urine. He told the inspector “he did not know what he did to deserve this, he had lived a good life, raised his kids, made good money, and now he was here.”
‘A DISASTER IS GOING TO HAPPEN’
Holly Lane has operated since 1983. The only other nursing home in Idaho that provides ventilator-machine care is in Coeur d’Alene.
Residents in ventilator units need care from specially trained nursing staff members, and the building must have special electrical and backup systems, according to the department.
Relocating fragile ventilator patients carries a “very high” mortality rate, said Shanahan, the Health and Welfare spokesman.
The inspectors went to Holly Lane on Monday, July 11, and spent the week there. That Friday, they notified Holly Lane of “immediate jeopardy” violations, including a lack of sufficient around-the-clock nursing staff and a failure to protect residents.
Holly Lane filed its compliance plan with Health and Welfare 12 days later, on July 27. The plan listed Holly Lane’s compliance date as Aug. 12. Inspectors are expected to make an unannounced visit to confirm compliance.
Holly Lane said its response to the state was not “an admission or agreement ... of the truth of the facts alleged or the correctness of the conclusions set forth” by the inspectors.
“The plan of correction is prepared and submitted solely pursuant to the requirements under state and federal laws. Furthermore, none of the actions taken in this plan of correction are an admission that additional steps should have or could have been taken by the facility to prevent the alleged deficiency. These steps are only included because a plan of correction is required by law.”
The plan consists mainly of conducting audits, educating staffers and submitting reports; meeting with residents to find out their concerns; taking no corrective action for incidents with residents who no longer live at the nursing home; and generally addressing concerns.
Meer, the Orianna executive, declined to say which allegations Orianna disputes. She cited “ongoing legal issues” and “privacy issues” as reasons she could not discuss details of Holly Lane’s plan to ensure the health and safety of patients.
Please help us. We are suffering.
A Holly Lane resident’s statement to state inspectors in July
Meer said the company went through a change in executive leadership in September 2015, rebranded Holly Lane, brought in the current administrator from another location and is “focusing on quality and outcomes.” The nursing home has gone through “some transitions,” she said.
“The staff and leadership at Holly Lane is very engaged in resident care,” Meer said. “They are providing great quality of care.”
She turned down the Statesman’s request to tour the nursing home.
The new administrator, Michael Borup, told inspectors in July that “he knew the facility had some ‘serious problems’ but had not had a chance to address them due to the short time he had been in the facility,” according to the state’s report.
He said Holly Lane was relying on temporary nurses from four agencies to meet staffing needs and expected through recruitment to be fully staffed with regular employees by Aug. 1. He counted respiratory therapists toward nursing-staff numbers because, he said, they helped with residents.
The administrator in July told an inspector that Holly Lane had experienced turnover in recent months, “starting with a longtime administrator and a number of staff in leadership positions leaving the facility en masse.”
“A disaster is going to happen,” a nurse told an inspector. “There are residents on ventilators back here on the 500 [room numbers] hall. Two nurses can’t manage this hall at night.”
Borup — the nursing home’s third administrator since last year, following Monica Brutsman and Gerald Bosen — declined to be interviewed without permission from Orianna leadership. However, he then told the Statesman by phone, “I can assure you that our residents are being taken care of the best that they can be.”
Asked if Holly Lane has achieved compliance with staffing levels, he said the nursing home “always” has been adequately staffed.
At least once, Holly Lane’s plan of correction to the state says “changes will be made ... to ensure sufficient numbers of qualified RNs, LPNs and CNAs to meet the residents’ needs.”
‘I WOULD RATHER BE DEAD’
Some of the harmed residents no longer lived at Holly Lane by the time inspectors arrived. At least one had died.
Inspectors interviewed those who remained and looked at medical charts.
“One resident in the group stated that if they re-activated their call light ‘too much’ it was taken away from them. ... Other residents in the group reported their call lights were often placed out of reach, prompting them to call out when they needed assistance,” the report said.
“The group stated they suspected this happened to other residents as well, as they could often hear residents ‘hollering out’ for assistance at night. Residents who resided on the 500 hall stated they could hear residents calling out from other units in the facility, and that this was so loud and so frequent their sleep was often disrupted.”
I had to yell and yell, and that got old fast. I was left alone in here, and they took away all my communication.
Holly Lane Resident #8’s statement to state inspectors in July
A 28-year-old male resident was excited to live at Holly Lane when he arrived in May, hoping to live as independently as possible. By June, he had stopped allowing nurses to give him food and water.
The man, identified in the report as Resident 13, did not like being incontinent when nobody answered his call for help getting to the toilet, and the long waits that followed when he needed employees to change his soiled undergarments. Eventually, he refused almost all care, even respiratory therapy.
“He told me, ‘If I have to piss and s--- on myself, I would rather be dead,’” a family member told the state inspector. “I have been in tears a lot of times to see him that way.”
A nursing assistant told the inspector that Resident 13 needed help from two people to go to the bathroom and, because of short staffing, it was easier to just change his soiled clothes than to help him avoid being incontinent.
One of the most horrific findings involved a patient identified as Resident 11.
Resident 11, whose age was not in the report, arrived at Holly Lane on Oct. 15, 2015 and died 14 weeks later.
He was paralyzed and had a bladder disorder, trouble swallowing, chronic kidney disease, pressure ulcers (bed sores), a history of urinary tract infections and respiratory failure. Because of his conditions, he was totally reliant on others to eat. He had a feeding tube and urinary catheter and breathed with a ventilator.
Despite his risk of urinary tract infections, the report said the nursing staff did not monitor his urine output. Monitoring helps assure a patient gets enough water.
The inspection report chronicled the nursing home’s records leading up to his death:
Oct. 29, 2015: A medical record said that Resident 11’s long-term use of a catheter, and the catheter becoming dislodged, had eroded the tip of his penis.
Nov. 8 and 9: The catheter was found dislodged both days.
Nov. 11 and Dec. 18: A nurse practitioner said he was at risk for more injury “and ordered the facility to ensure the catheter was secured.” The inspector found no evidence that Holly Lane staff did that.
Jan. 7, 2016: A nurse practitioner who examined him said Resident 11’s feeding tube was unplugged the day before. “I was never notified, and he did not receive his feeds or meds,” the nurse practitioner wrote. By then, he had lost about 10 percent of his body weight — 17 pounds — since arriving at Holly Lane three months before.
Jan. 13: His family met with nursing-home staff, worried the man was not getting enough fluid. His agent — his legal decision-maker with power of attorney — asked Holly Lane to give him ice chips and let him eat and drink despite a choking risk.
Jan. 18: He was alert but confused. His catheter was leaking.
Jan. 21: Resident 11 was sent to the emergency room with a possible stroke. The ER doctor’s notes from that afternoon said Resident 11 was severely dehydrated. His oral hygiene was poor, and his mouth was “significantly dry with brownish crusting.”
Jan. 23: He died in the hospital.
Resident #11 was harmed when the facility failed to identify, treat and monitor significant changes in his condition, which culminated in his hospitalization and subsequent death two days later.
July 19 report by Idaho Department of Health and Welfare
His medical records showed “severe dehydration, severe hypernatremia, acute kidney injury and acute urinary tract infection.” Hypernatremia is an elevated sodium level in the blood caused by inadequate fluid intake.
Resident 11’s hospital discharge paperwork said the causes of death were a brain mass, urinary tract infection, bacteria in his blood, hypernatremia with dehydration, encephalopathy and acute kidney injury.
His agent later said the ER doctor “didn’t know how Resident 11 could get so dehydrated. His electrolytes were through the roof. It was like he had been in the desert for weeks. Nobody bothered giving him fluids.”
One of Holly Lane’s nursing assistants told the inspector that Resident 11’s urine had “a lot of sediment.” Three members of the nursing team told the inspector that the man asked constantly for ice chips, but they were told not to give them due to a doctor’s order.
As part of the nursing-home inspection in July, the state inspector talked to Resident 11’s longtime caretaker. The caretaker said the man had been thirsty, had cracked and dry lips during the week leading up to his death and “was denied fluids, ice chips and food.”
NOT ENOUGH NURSES?
The inspectors concluded that Holly Lane failed to employ enough trained and qualified nurses.
Meer told the Statesman that Holly Lane is not staffed according to ratios, such as one nurse per 10 patients. Instead, she said, it staffs based on “acuity,” or the level of needs for each patient. Idaho does not have state-mandated nursing ratios.
Residents complained that Holly Lane “suffered from a lack of sufficient staff for quite some time, but ‘it is getting worse instead of better,’” the report said.
The center has “above average” staffing and “average” registered-nurse staffing scores from the Centers for Medicare and Medicaid Services, according to the federal Nursing Home Compare website, based on data from before July.
Holly Lane employed enough licensed nurses to provide two hours and 24 minutes of care per resident per day, which is 22 percent more than average for Idaho, federal data show.
Holly Lane received a “much below average” rating on quality measures, according to the data. For short-term patients, it outperformed Idaho’s average in most areas. For long-term residents, Holly Lane did worse than average in most areas.
Residents said there were “many times” when the ventilator and tracheostomy floor would have only two to three nursing assistants, when it needed five. Some of those residents needed more than one person’s help with routine things like getting into bed, which left no staff members to help everyone else.
One certified nursing assistant who reported a litany of problems to the inspector — identified as CNA No. 1 in the report — said “there was not enough staff to take care of the residents.”
That nursing assistant said she brought her concerns to nursing-home administration but was “threatened” with having her shifts cut.
Resident #25’s mouth was dry with a white substance around her lips, and a foul odor emanated when she spoke. ... When asked if she was provided oral care and baths, she said, ‘No.’
July 19 report by Idaho Department of Health and Welfare
When patients were admitted to Holly Lane, they signed a nine-page agreement. Inspectors questioned that agreement in July, noting that it seemed Holly Lane was trying to shirk its responsibility to employ enough competent workers.
“The parties specifically understand and agree that the quality of care provided by the facility is limited by staffing levels provided and quality of staff,” the agreement said. “Therefore, if the resident and/or responsible party desire to reduce the risks of injury associated with staffing provided by the facility, they shall arrange for and provide supplemental private duty nursing.”
A patient legally can hire extra nursing staff, but most insurers will not pay for it, according to Health and Welfare.
Holly Lane administrators said the agreement was not meant to let them off the hook for complying with the law. Instead, they said, it was to let patients and their families know that if they wanted one-on-one care from a private nurse, they would need to pay for it out of pocket. However, after the nursing home’s legal counsel reviewed it, Holly Lane pulled that wording from the admission agreement.
RULES HOLLY LANE BROKE
Some of the 30 violations listed on the nursing home’s inspection report:
▪ Prohibit the mistreatment, neglect and abuse of residents and misappropriation of resident property.
▪ Maintain and enhance dignity and respect, recognizing each patient’s individuality.
▪ Listen to, and act on, residents’ or families’ grievances and recommendations.
▪ Provide a safe, clean, comfortable and homelike environment.
▪ Provide assistance when needed with daily living activities such as grooming and oral hygiene.
▪ Prevent and heal pressure sores.
▪ Do not catheterize unless necessary, prevent urinary tract infections, restore as much bladder function as possible.
▪ Do not put residents on naso-gastric feeding tubes unless it is unavoidable. Properly perform tube feeding.
▪ Maintain proper nutrition.
▪ Keep residents sufficiently hydrated.
▪ Provide sufficient 24-hour nursing staff.
Got a complaint?
Do you have complaints about a local nursing home? Contact reporter Audrey Dutton at firstname.lastname@example.org or (208) 377-6448.