Emer­ald South fined $10,000 over death

Nurs­ing home cited in pa­tient’s fa­tal fall

The Buffalo News - - CITY&REGION - By Mike McAn­drew NEWS STAFF

A Buf­falo nurs­ing home’s staff was warned an el­derly res­i­dent might be try­ing to es­cape out of his third-floor win­dow in the weeks lead­ing up to his fa­tal fall, but it did not take suf­fi­cient steps to pro­tect him, state Health Depart­ment in­spec­tors con­cluded in a crit­i­cal re­port.

New York State fined Emer­ald South Nurs­ing and Re­ha­bil­i­ta­tion Cen­ter $10,000 for vi­o­la­tions re­lat­ing to the June 4 death of Wil­liam Strasner, 87, a res­i­dent in its de­men­tia unit who fell 34 feet while us­ing a makeshift rope to climb out his win­dow. The $10,000 fine is the max­i­mum the state can levy.

The nurs­ing home’s di­rec­tor of main­te­nance told state in­spec­tors that he had warned the nurs­ing home ad­min­is­tra­tor and nurs­ing staff lead­ers that Strasner had re­peat­edly re­moved screws that pre­vented the win­dow in his room from open­ing more than 6 inches, ac­cord­ing to the re­port. The main­te­nance staff in­stalled bolts on Strasner’s


win­dow 10 times af­ter his ar­rival, but they could not find out how Strasner was re­mov­ing them.

Strasner had been home­less and was di­ag­nosed as lack­ing de­ci­sion­mak­ing ca­pac­ity when he was dis­charged from a hos­pi­tal to Emer­ald South. A nurse there iden­ti­fied Strasner in his ad­mis­sion re­port as be­ing at risk for es­cape, but the staff did not put on his wrist an


elope­ment bracelet that would sound an alert if he wan­dered.

Strasner was a dif­fi­cult res­i­dent, ac­cord­ing to the re­port. He re­fused all hands-on care and med­i­ca­tions at the nurs­ing home, would not change his clothes or shower, and fre­quently stated, “I’m go­ing out of here,” ac­cord­ing to a so­cial worker’s re­port.

But in­spec­tors found the nurs­ing home’s care plan for Strasner did not in­clude a plan for pre­vent­ing elope­ment. The care plan doc­u­mented that Strasner be­lieved he was in jail, but it did not in­clude a method to ob­serve his where­abouts.

Dur­ing a psy­chi­atric eval­u­a­tion at the nurs­ing home, Strasner said, “I didn’t do no crime so I don’t know why they hi­jacked me and put me here,” ac­cord­ing to the re­port.

Strasner’s death is one of many prob­lems that have oc­curred at Emer­ald South.

An­other res­i­dent, Ruth Mur­ray, was beaten to death in the fa­cil­ity in 2016. The state fined Emer­ald South $10,000 for that death.

The nurs­ing home was the fo­cus of a Buf­falo News story on Oct. 21 that de­tailed how 16 of the 47 nurs­ing homes in Erie and Ni­a­gara coun­ties had been pur­chased in the past 11 years by out-of-town in­vestors. Most of those homes are among the worst rated in the re­gion. In its lat­est rat­ing, the fed­eral gov­ern­ment called Emer­ald South a two-star nurs­ing home, or “be­low aver­age.”

Emer­ald South had been op­er­ated since 2012 by a com­pany owned by Judy Landa, a Long Is­land res­i­dent with no ex­pe­ri­ence in health care who was only a pas­sive in­vestor, ac­cord­ing to a spokesman. The state ap­pointed a re­ceiver, Grand Health­care Sys­tem of New York City, to take over op­er­at­ing the two Emer­ald nurs­ing homes on Oct. 29, for up to 18 months.

A cer­ti­fied nurs­ing aide on her way into work found Strasner on the ground out­side the 1175 Delaware Ave. nurs­ing home at 5:52 a.m. June 4, with blood pour­ing from his right foot. Strasner was mum­bling and ly­ing down. A rope made of pants and shirts tied to­gether hung from Strasner’s win­dow to the ground. Strasner stopped breath­ing at about 6:25 a.m. while he was in an am­bu­lance at the site.

Strasner had last been seen in­side the nurs­ing home, sit­ting on his bed, at 4:30 a.m. by a dif­fer­ent cer­ti­fied nurs­ing aide, ac­cord­ing to the re­port.

Some mem­bers of the nurs­ing staff who at­tended to Strasner on a daily ba­sis told state in­spec­tors af­ter the ac­ci­dent that they were unaware that Strasner had pre­vi­ously re­moved win­dow bolts.

The Health Depart­ment re­port also al­leged that Emer­ald South im­peded the Health Depart­ment’s in­ves­ti­ga­tion of Strasner’s death by ob­struct­ing the in­spec­tors’ ac­cess to the staff. The nurs­ing home’s at­tor­ney told in­spec­tors on mul­ti­ple oc­ca­sions that no in­ter­views with staff could be con­ducted un­less the at­tor­ney was present. That de­layed the in­ves­ti­ga­tion, in vi­o­la­tion of state reg­u­la­tions, the Health Depart­ment re­port said.

Emer­ald South vi­o­lated other reg­u­la­tions by fail­ing to pro­vide a res­i­dent en­vi­ron­ment free of ac­ci­dent haz­ards and fail­ing to pro­vide each res­i­dent with ad­e­quate su­per­vi­sion, the re­port said.

The state cited the nurs­ing home for other vi­o­la­tions, as well, in­clud­ing fail­ing to des­ig­nate a reg­is­tered nurse to serve as the full-time di­rec­tor of nurs­ing for ap­prox­i­mately 11 days in May. The di­rec­tor of nurs­ing gave her res­ig­na­tion no­tice May 8 and worked her last day at Emer­ald South on May 18. A new act­ing di­rec­tor of nurs­ing was not ap­pointed un­til May 30.

Emer­ald South was also cited for fail­ing to em­ploy a so­cial worker with a mas­ter’s de­gree in so­cial work. There was a lack of med­i­cally re­lated so­cial ser­vices pro­vided to res­i­dents, in­clud­ing Strasner, the state con­cluded. The Health Depart­ment has also rec­om­mended the fed­eral Cen­ters for Med­ic­aid and Medi­care Ser­vices fine the fa­cil­ity. The fed­eral agency can levy fines that are much higher than the state’s $10,000 max­i­mum. Ac­cord­ing to the fed­eral agency’s web­site, the agency is also con­sid­er­ing deny­ing Emer­ald South pay­ments for new ad­mis­sions, a se­vere penalty. N.Y. Evening Num­ber: N.Y. Mid­day Num­ber: Win Four Evening: Win Four Mid­day: Take Five: 6 10 11

Pick 10: Mega Mil­lions: Mega Ball: Me­gaplier:

Pick 3 Evening: Pick 3 Day:

Pick 4 Evening: Pick 4 Mid­day: Take Five 2 081 318 9211 0167 12 23 5 30 31 39

Robert Kirkham/Buf­falo News

Wil­liam Strasner was fa­tally in­jured try­ing to es­cape his third-floor room at Emer­ald South on a makeshift rope.

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