Legacy cited for poor care; Hilo nursing home fined, could lose certification

Legacy Hilo Rehabilitation &Nursing Center will lose its Medicare certification in March if it does not fix problems found during recent inspections.

Hawaii state surveyors inspected the 100-bed nursing home Sept. 19 and cited it for “actual harm in the areas of quality of care and nursing services,” according to the Centers for Medicare and Medicaid Services.

According to the inspection report, widespread problems with “substandard quality of care and harm” occurred at Legacy, including poor attention to personal privacy.

Jack Cheevers, a spokesman for CMS, said fines of $1,953 per day began accruing against Legacy in September.

If Legacy had not had a good outcome from a re-inspection this month, it would have faced a “mandatory denial of payment for new (resident) admissions effective 12/19/16.”

Results of the re-inspection, during the week of Dec. 12, will not be made public until inspectors finalize a report of their findings.

“The facility’s Medicare certification will be terminated on 3/19/17 if the facility fails to come back into compliance,” Cheevers said. Essentially, that would doom its future as a nursing home.

Those payments are used for payroll and to pay for services such as rubbish removal, electricity and water. Without them, a nursing home cannot survive.

When nursing homes fail to meet federal standards of care, federal and/or state authorities have the options of imposing civil fines upon a nursing home, requiring in-service training for staff, declining to pay for additional admissions temporarily, removing the home’s Medicare certification, imposing temporary management, requiring a nursing home to follow a plan of correction created by regulatory officials instead of the one normally created by a nursing home, mandating in-house state regulatory monitoring, and banning payments to the nursing home for any resident.

Findings of “actual harm” — meaning actual physical or psychological injury to residents occurred — with “immediate jeopardy” (meaning residents were at risk of further physical or mental injury right at that moment) were found in November.

But the immediate jeopardy “was removed later that day,” Cheevers said.

The November inspection led to continuation of daily fines, plus an additional fine of $9,591 for the single day of immediate jeopardy. The fines continued at $2,353 per day starting “11/5/16 and each day thereafter.”

Such daily fines cease once a facility is found to have rectified its deficiencies and come back into compliance with federal requirements for taking care of vulnerable adults.

Some of the Legacy findings were for “widespread” problems, meaning many residents were affected rather than an isolated incident happening to a single individual.

Resident dignity, falls and feeding were among the “deficiencies” in care cited by inspectors.

In one example, a resident with dementia “wandered out the front doors” and the receptionist had to alert staff to retrieve the individual. Health providers did not document the resident’s short-term elopement, as they are required to do. And the facility did not have procedures in place “to report all alleged violations and all substantiated incidents” to the state.

In another example of substandard performance, the facility, which has only been open since February, did not provide notice to residents and their families of where to find inspection reports. Residents of nursing homes have the right, under federal mandate, to review the most recent inspection report and previous reports under which the home continues to work on its required “plans of correction.”

One resident was observed by inspectors struggling to self-feed because of the distance the person had been left, by staff, from the facility’s dining table.

“The distance caused the resident to feed self by leaning forward, reaching with a spoon to scoop food from the entree plate. Observed spilled food on the chest and lap of the resident’s clothing,” inspectors wrote.

Staff, alerted to the problem by inspectors, moved the resident closer to the table, and the individual was later observed by inspectors to be self-feeding without difficulty.

The daughter of another resident complained because the resident’s dentures were repeatedly left out, affecting the person’s facial appearance and ability to eat.

One resident, who needed help to get up from sitting on a bed, was left unattended with the call light for nurses out of reach. An inspector found the resident nearly ready to try standing without assistance and got the nursing home’s staff to intervene in time to prevent a fall. However, other residents experienced falls without updates of their resident care plans. Updates to a person’s care plan are an accepted standard of care that is required whenever a fall occurs.

Inspectors also found health providers had not drawn a privacy curtain for a resident who was nearly naked, even though passing residents, staff and visitors could see in.

In November, inspectors did a “re-visit” inspection to see if problems were resolved at Legacy.

But during that survey, additional problems were discovered including patterns and isolated cases of immediate jeopardy to resident health or safety. A pattern is a situation is which multiple residents are at risk.

There also were isolated cases and widespread patterns of actual harm.

All together, Legacy received 27 “deficiencies” in September for substandard performance, according to Keith Ridley, chief of the Office of Health Care Assurance within the state Department of Health.

During the November inspection, Legacy received 16 deficiencies.

Of those, Ridley said, Legacy had 13 that were repeats of the same types of deficiencies found in September.

The goal, when a nursing home writes and follows its plan of correction, is to prevent the same type of deficiency from happening again. Although not all the Legacy deficiencies in September were solved, Ridley said it’s a good sign that the number decreased by September.

During the week of Dec. 12, inspectors returned to Legacy for a second re-inspection.

Johnalyn Nosaka, Legacy administrator, said she was told by inspectors during the normal inspection exit interview that the most recent inspection found only three deficiencies, and that none of them were repeats from the previous two inspections.

The Tribune-Herald received telephone and electronic communication suggesting the state of Hawaii was about to take over management of Legacy. But the Department of Health said the state never does that. There also was suggestion that Legacy might be shut down.

“We did have a survey. But we’re not close to shutting down,” Nosaka said.

Attorney Ben Meeker, an owner of Legacy’s parent company, said “they verbally told the administrator there that there were three (deficiency) tags. They are minor tags.”

But he emphasized an inspection result isn’t verified or final until the written document is received. Sometimes, for example, the inspection team’s in-depth analysis of the circumstances might lead to recognition that only two items qualify as deficiencies rather than three.

“Until we see it in writing, I’m hesitant to draw any hard conclusion,” Meeker said.

The key is to recognize that each inspection is considered a snapshot in time by surveyors, meaning the 27 September deficiencies represent that survey’s snapshot and they’re separate from the 16 in November.

Between the two inspections, Ridley said, “there was some improvement — not as good as we would have liked, but some improvement.” Of most concern are the 13 deficiencies that were “continuing” problems during the November re-inspection.

“We’re often very pleased with the way facilities react to our inspections. We expect that Legacy wants to do the same,” Ridley said.

When a facility writes a plan of correction, the state can decline to accept it and request a new plan.

But, Ridley said, “I believe in this case we accepted their plan of correction.”

Essentially, he said, Legacy cut its deficiencies in half between September and November.

And, Ridley confirmed, the Legacy administrator after the most recent December re-inspection “was told that, preliminarily, there would be three citations.”

“There does seem to be some good improvement, going from 27 to 16 to a lower number,” Ridley said. “The trend seems to be in the right direction. We are hopeful and expecting the facility will bring themselves back into compliance.”

Residents and loved ones can help, Ridley said.

“If any resident or family member has any ongoing concerns, they should raise them with the home directly, or they should raise them with us,” he said. “That’s the best way I think they can help us.”

Email Jeff Hansel at jhansel@hawaiitribune-herald.com.