Nursing homes fined over lapses
Three Capital Region nursing homes have been fined by the state Department of Health for infection-control issues and other lapses during the coronavirus pandemic, state health records show.
The Grand Rehabilitation and Nursing at Barnwell in Columbia County received one of the largest fines statewide: $22,000 for multiple violations that had “potential to cause more than minimal harm,” according to inspection reports. Violations centered on inadequate or improper use of personal protective equipment, failure to clean hands, improper groupings of suspected
COVID -19 patients, and failure to notify residents of positive cases or deaths.
Two other facilities in the region — the Glens Falls Center for Rehabilitation and Nursing in Queensbury and Eddy Memorial Geriatric Center in Troy — received smaller fines of $6,000 and $4,000, respectively, for violations related to PPE use, hand hygiene and disinfection protocols.
Both Barnwell and the Glens Falls Center have experienced the region’s deadliest known coronavirus outbreaks, with at least 20 resident deaths in each facility. The Eddy center in Troy has lost at least three residents to the virus.
The state Department of Health has conducted 1,908 on-site inspections (1,165 at nursing homes and 743 at adult-care facilities) since March to ensure facilities are following proper infection prevention and control protocol, spokeswoman Jill Montag said. It has issued 95 citations to 77 nursing homes and levied $328,000 in fines against 23 facilities as a result.
“This only represents a portion of the total number of cases for which we are actively pursuing fines,” Montag said. “The department will continue to hold providers who violate regulations accountable for their actions.”
Barnwell
State health inspectors cited the Barnwell nursing home, a 236-bed facility located in the village of Valatie, for a number of regulatory violations that were allegedly observed during two visits in May, inspection reports show.
On a May 11 visit, inspectors said they observed at least four different members of staff violate PPE and hand hygiene protocols.
In one instance, a resident assistant was seen moving between residents’ rooms, including several marked with signs to indicate a COVID -19 patient inside, without changing PPE, despite being within six feet of the residents.
Inspectors said they observed another resident assistant deliver meal trays to a COVID -positive room, then a COVID - negative room, then a COVID -positive room, and then a COVID -negative room — all without donning fresh PPE or washing their hands in between. A certified nurse aide did the same thing when passing lunch trays, inspectors wrote.
An activities aide, meanwhile, was observed moving from a COVID - positive room to a COVID -negative room and speaking within six feet of a resident who was not wearing a mask. They then moved to a COVID - positive room, sat on the resident’s bed and read to the resident, who was seated in a wheelchair less than six feet away not wearing a mask. The aide wore a gown and face mask, but no gloves, and did not change PPE or wash their hands in between visits, inspectors wrote.
A number of staff members who were interviewed afterward said either that they couldn’t recall what they learned during infection control and PPE trainings or weren’t sure what to do because they had been given differing instructions over the previous weeks. The certified nurse aide said she was told she didn’t need to change PPE when passing meal trays, and a licensed practical nurse said she always wore the same PPE throughout a shift unless performing a treatment on a resident.
On a separate visit May 20, inspectors said they observed residents with COVID -19 symptoms staying in the same rooms as residents who had tested negative for the disease. Rooms were not marked with signage alerting staff they must wear PPE, the report says.
A regional administrator for the home and two nursing directors told inspectors residents were supposed to be grouped together by COVID status — positive, negative and unknown/suspected.
On the same visit, inspectors said they observed a licensed practical nurse fail to disinfect a glucometer after using it on a resident and before placing it on a medication cart.
Barnwell was additionally cited for violating Gov. Andrew M. Cuomo’s executive order requiring 24-hour notification to residents and family members every time a new COVID -19 case was discovered. Two residents who were interviewed said they were never given written or verbal notification of positive cases, but instead learned of them whenever a PPE sign went up next to a resident’s door.
At least 174 cases of coronavirus have been linked to the Barnwell nursing home, which has come under intense scrutiny for its handling of the outbreak. Propublica reported in August that county officials believed the home was pushing dying residents into hospitals so that their deaths would not be attributed to the facility. New York counts as nursing home deaths only those that actually occur inside a senior facility, and has to date declined to reveal how many nursing home residents died after being transferred to a hospital.
A spokesperson for the Barnwell nursing home did not respond to a Times Union request seeking comment for this story.
Inspection reports show the state Health Department approved plans in late spring designed to correct issues uncovered by the inspections.
As part of those plans, the facility said it would immediately educate staff on correct protocol and ensure they demonstrate proper PPE usage. The facility ’s infection-control nurse would also audit 10 random staff members from each department on the use of PPE and hand washing. Anyone who failed would be required to pass a competency test.
The facility also agreed to immediately move suspected COVID -19 patients to their own rooms, place signage on their doors, and educate staff with respect to the proper grouping, or cohorting, of patents. The infectioncontrol nurse would conduct random room audits to ensure cohorting was taking place.
Similarly, staff would be educated and audited on the procedures for when to disinfect equipment.
The facility also agreed to have social workers notify residents and family members of positive cases within the facility. It also agreed to implement a tracking system for such notifications.
Glens Falls Center
State health inspectors also cited the Glens Falls Center for infection control violations that they said they observed during an April 30 visit to the 117-bed facility in Warren County.
In a report, inspectors wrote that they observed an aide delivering laundry to a room that had been marked with a blue sign to indicate the presence of a COVID -19 patient and then to a room without a sign. The aide did not change into fresh PPE or wash her hands between these visits, they wrote.
In an interview afterward, the aide said she had touched a closet door in the COVID -19 patient’s room to hang up clothes. When asked what she had been taught regarding entering and exiting COVID -positive rooms, the aide said she didn’t have to do anything between rooms but that “the housekeepers do all the NON-COVID rooms and then COVID rooms, I guess that’s what I should do.”
A registered nurse who was informed of the breach admitted it was a violation but “did not attempt to immediately stop and reeducate” the aide, who continued down the hall delivering laundry, inspectors wrote.
Jeff Jacomowitz, a spokesperson for the facility ’s parent company, said no residents were harmed as a result of the incident. All clinical staff, from the CNA level to upper management, were reeducated about the best ways to stop virus spread in the facility, including PPE usage and instructions for moving from COVID - positive to COVID -negative rooms.
“Glens Falls Nursing & Rehabilitation Center has been in compliance since the Department of Health issued deficiencies against the facility at the end of April,” he wrote in an email. “Upon returning to the facility, the Department of Health found that the facility was in compliance by May 18. The DOH returned again in July and issued zero citations.”
Jacomowitz noted that the facility successfully contained its outbreak and has been COVID -free for months. At least 57 residents and three staff members were infected during the outbreak and have since recovered. Twenty residents, however, died of suspected or confirmed COVID -19 cases, according to state records.
Eddy Memorial Geriatric Center
The 80-bed Eddy center in Troy was cited for failing to make sure equipment used on multiple residents was cleaned after each use, according to a May 14 inspection report.
During a May 13 visit, inspectors wrote that they observed a gloved nurse use a pulse oximeter, used to check blood-oxygen levels, on a resident and then place it on top of a medical cart. The nurse, still wearing the same gloves, then proceeded to use a laptop, mouse, and multi-use pill crusher, pudding container and thickened liquid container.
In an interview afterward, the nurse said she should have cleaned the pulse oximeter, removed her gloves and washed her hands prior to touching a clean area or containers intended for multiple residents.
Anthony Gianotti, interim executive director at the center, told the Times Union in an email that additional hygiene training was immediately provided to the employee, and said the center used the opportunity to provide more training and education to all staff.
“We are closely monitoring all of our employees, and the state health department has approved of the swift action we took,” he wrote. “Eddy Memorial Geriatric Center takes resident safety very seriously, and we're proud of our long history of providing high quality care. We're continuing to provide exemplary care even with the many challenges COVID has created, and the evolving nature of the regulations we're required to follow."
At least 10 residents and three employees were infected during an outbreak at the facility, according to statistics maintained by Rensselaer County. Three of the residents died.