Nursing Home Had Record of Violations: It Had Most Health Violations in County Among 22 Centers
By Fred Kelly, The Charlotte Observer, N.C.
Jan. 29–The nursing home where an Alzheimer’s patient was missing for four days and who died after she was found in a storage room had more health violations than any of the 21 other such centers in Mecklenburg County, a federal report shows.
State inspectors cited Liberty Nursing and Rehabilitation Center on Shamrock Drive for 30 health deficiencies during an inspection in February, including one violation that includes failure to monitor residents. The state average for health deficiencies during an inspection is six.
In the past year, state and federal officials have fined the nursing home $150,000, threatened to revoke its certification to care for Medicaid and Medicare patients and stopped it from admitting new patients for one month, Jeff Horton, an administrator for the N.C. Department of Health and Human Services, said Saturday.
Mary Cole’s daughter, who placed her in the facility nearly two years ago, said she was shocked when the Observer informed her about Liberty’s previous problems.
“This is breaking my heart,” said Tammy Terry of Gastonia. “If I had known, I would not have put her in there.”
Charlotte-Mecklenburg police are now investigating the death of Cole, who had been missing since Monday when she was found alive Friday inside the 289-bed facility in east Charlotte. Cole, 66, was taken to Presbyterian Hospital but died a short time later.
State nursing home inspectors visited the nursing home for two days last week to find out how Cole escaped supervision.
The incident marks the second time in about a year that a patient has been missing from the nursing home, Horton said. The previous patient was found alive the same day, he said.
Liberty administrator John Gryglewicz declined comment Saturday.
The Observer reviewed the latest inspection reports from the federal Centers for Medicare and Medicaid Services for the 22 Mecklenburg County nursing homes that the agency lists as certified to take Medicare- and Medicaid-eligible patients.
The inspections took place from late 2004 through 2005.
Inspectors visited the Liberty center on Feb. 10. They reported finding violations that included failure to protect residents from mistreatment and neglect and theft and failure to make sure residents who cannot care for themselves receive help with eating, drinking, grooming and hygiene.
The severity of 11 of the violations were listed as actual harm or posing an immediate jeopardy to residents’ health and safety, the report says.
Following the inspection, federal officials threatened to revoke Liberty’s certification to care for Medicaid and Medicare recipients unless it corrected the violations in 23 days, Horton said. The nursing home complied with the federal request and appealed a fine, he said.
Asked why the state has not taken more severe disciplinary action against Liberty, Horton said the nursing home has corrected problems since April and changed management.
There have been three complaints against Liberty since April and all were found to be unsubstantiated, he said.
But problems at the center underscore those at nursing homes throughout North Carolina, said John Suddath, a member of the board of directors for Friends of Residents in Long Term Care, a Raleigh-based advocacy group.
State administrators are too lenient on nursing homes that break the rules, Suddath said.
“The fact is they are very reluctant to shut a facility down or take action against them,” he said.
In the Cole case, Liberty workers were supposed to closely supervise her because “she was a known wanderer,” Horton said.
Cole lived in three nursing homes before Liberty and tried to escape from all of them, her daughter, Terry, has said.
Terry said she recently considered moving her mother to a nursing home closer to her Gastonia home, but found it difficult to find a facility that would accept an Alzheimer’s patient.
The staff appeared responsive and concerned, she said.
“I saw good care,” Terry said. “I had a good rapport with the nurses. They always gave me hugs.”
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TO FILE A NURSING HOME COMPLAINT
Call the N.C. Division of Facility Services complaint hotline at (800) 624-3004.
Fred Kelly: (704) 358-5027.
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