Ann Arbor-area nursing home where maggots infested patient also had more-serious violations

The documents, obtained by AnnArbor.com in a Freedom of Information Act request, also show that a nursing assistant said maggots were still in the genital area of a 66-year-old woman unable to get out of bed on her own three days after their initial discovery. Staff members told a state inspector they had observed flies on and near the woman about two weeks before the discovery of the maggots and one staffer even reported telling a supervisor “she’s gonna get maggots.”

The documents shed more light on conditions at the 102-bed nursing home, which has been identified through state inspections as among the worst in Michigan.

Whitehall was thrust into the public spotlight earlier this month when the Michigan Protection and Advocacy Service, a federally funded agency that advocates for the disabled, publicized the discovery of maggots on the patient at Whitehall and a patient at Cambridge South Nursing Home in Beverly Hills.

Whitehall, 3370 East Morgan Road, was fined $17,000 for the violations, and the state recommended other penalties to the Centers for Medicare & Medicaid Services.

A follow-up visit from the state in October found all problems at the nursing home cited in the September inspection had been corrected, a state official said Thursday. However, another inspection on Oct. 27 found several new violations, although none as serious as several of those in the September report.

Marsha Austin, a communications specialist representing the nursing home, said some employees were terminated following the investigation into the discovery of the maggots, but the facility declined comment beyond a statement issued earlier this month by administrator John DeLuca.

That statement said: “At Whitehall Healthcare Center of Ann Arbor, the comfort, care and well-being of our residents and patients are our top priority. While federal regulations prevent us from providing detail on this specific patient, we can tell you that the matter was addressed immediately after it was identified. Any substandard care is unacceptable. We have and will continue to work with our caregivers and regulators to review all of our practices to ensure our residents receive the highest quality of care.”

A plan of correction the nursing home submitted to the state mentioned that one employee, a unit manager, had been discharged from the nursing home. It also noted the correction of all physical problems found at the nursing home and detailed retraining and procedures implemented to address the other violations in the state’s report.

The recent inspection findings have allowed Whitehall to move up a notch on a federal agency’s list of “special focus facilities.” Whitehall, which had been in the not-improved category on the list, has now been moved into the category called “facilities that have shown improvement.”

• Download the Special Focus Facility list.

Howard Schaefer, director of the state’s division of nursing home monitoring, said Whitehall could be considered for removal from the list in April if another standard inspection of the nursing home finds no serious problems.

Special focus facilities are those identified as having have had a pattern of serious problems over three years. The Centers for Medicare & Medicaid Services maintains the list. Michigan has four out of about 440 nursing homes on the list at any one time.

Mike Pemble, director of the state’s Bureau of Health Systems, which conducts the state inspections, said the agency would continue to monitor Whitehall, but after the October visit found no serious violations at the nursing home, he believes Whitehall can meet standards of proper care.

“We have confidence or we wouldn’t clear them that they’re doing things right,” he said.

Angil Tarach-Ritchey, a registered nurse who runs her own private-duty nursing company in the Ann Arbor area and who has worked in elder care and advocacy for more than 30 years, is not convinced.

“This isn’t a problem that just happened and this isn’t a problem that’s going to go away,” she said. “How the care is provided in a facility stems from the ownership and administration.”

Shocking discovery

A nursing assistant found maggots in the genital area of a 66-year-old woman who had a urinary catheter at 5:59 a.m. on Aug. 13, 2011. A nursing home incident report said the patient “was offered a shower, which she refused, so she was ‘immediately’ given a bed bath by staff.”

However, in interviews with a state inspector on Aug. 30 and 31, a nursing assistant and the charge nurse said the woman did not get a shower because the nursing home did not have enough staff. Both the nursing assistant and the charge nurse told the state inspector the nurse used saline solution to rinse the area. But not all of the maggots came off, the assistant said.

Two nursing assistants told state inspectors that they had seen flies in wounds on the woman’s legs about two weeks before the maggots were discovered. One of them reported telling the unit manager and the director of nursing “she’s gonna get maggots.” The aide reported being instructed to document that the woman refused showers. The state report quotes the aide saying, “They let her lay there and they didn’t change her wounds (dressings) and they didn’t want to argue with her.”

A nurse manager came to the facility around noon to give the resident a shower the day the maggots were discovered. She told the inspector she saw “one or two maggots, but I think there were more.” She also said a “clinical corporate person” wanted her to document the discovery on the incident report as debridement. “They wouldn’t let me put maggots down on the incident report,” she said.

Another nursing assistant reported observing a nurse manager removing maggots from the woman’s genital area three days after the discovery of the maggots.

The woman was sent to the hospital on Aug. 28 and diagnosed with septic shock secondary to a urinary tract infection, chronic skin ulcers and kidney stones. Later tests and examinations revealed she had a broken hip likely due to bone thinning and extensive skin changes due to poor hygiene and refusing to be turned.

The patient, interviewed at the hospital and later back at the nursing home, admitted that she had refused showers, but said she did not refuse bed baths and that the staff would not give her bed baths. She reported suffering from severe leg and hip pain. She said a mechanical lift used to transfer her to a shower chair caused pain and sitting on the hard shower chair hurt her back.

The state report indicated the woman had a history of chronic pain and leg ulcers, severe osteoarthritis, anxiety, depression, obesity, chronic urinary tract infections, high blood pressure and heart failure.

The woman told the state inspector that she was embarrassed by the maggot incident. She said she had told staff at the nursing home about seeing flies in her room and in the hall but no one did anything. She also said she told staff her catheter needed cleaning, but “they wouldn’t wash my catheter. There were times it was weeks before they cleaned my catheter.”

In its plan of correction, the nursing home stated the resident is now offered daily bed baths and her doctor and a family member will be notified if she refuses. Regular catheter care is also provided.

While the poor care that allowed the maggot infestation is perhaps the most shocking of the violations detailed in the September report, the state regards it as less serious than others cited. Violations are ranked on a scale for severity and scope, providing a measure of how many residents were affected and how many times a violation has occurred. Grades are given, with A being the least serious and L being the worst.

The discovery of maggots in the patient’s genital area ranked as a D, while the failure to provide a sanitary environment and failure to maintain the records were ranked Fs. The failure to monitor the fluid intake and output of a resident and failure to supervise residents in wheelchairs ranked as Gs.

• Download the Sept. 20, 2011 report on deficiencies at Whitehall Healthcare Center.

Wheelchair injuries

Nursing home staff left a 40-year-old woman at risk for bone fractures alone in an electric wheelchair on July 4, 2011. She drove the wheelchair unsupervised and ran it into a door, fracturing her leg. The wheelchair has since been removed from the resident's room.

On Aug. 3, 2011, a man who had had his left leg amputated because of poor circulation fell out of his wheelchair while a private contractor was transporting him from his doctor’s office to the nursing home. The state inspector determined the driver secured the wheelchair to the van floor but did not use a seat belt for the resident, and he slid out of the wheelchair and suffered an abrasion to his right toe. The resident had decreased circulation and an ulcer on his right foot, putting him at increased risk for infection.

Both the resident and the van driver said the resident was transported in the wheelchair in a reclining position. The van driver said he did not secure the seatbelt because he feared it would choke him because the wheelchair was in a reclining position.

The nursing assistant and an administrator denied any responsibility for the accident, saying it was the driver’s responsibility to properly secure the patient. The facility’s plan of correction for the incident said the transportation company is no longer being used.

Dirt and disrepair

The state cited Whitehall for failing to maintain a sanitary environment in 20 patient rooms, three resident showers, a public restroom, the front lobby, a breezeway and the activity room/main dining room, “resulting in the potential for rodent infestation and the spread of communicable disease.”

Among the problems noted:

• At least 11 patient rooms as well as the activity room/dining room, entrance hallway and resident breezeway had air conditioners with filters caked with dust and dirt and with large gaps around the units enabling flies and other insects to enter the facility.
• In one resident’s room several Depends diapers, two broken hangers, soiled clothes and a used medical glove were on the floor.
• Dirty floors were noted in some residents’ rooms and bathrooms. At least one resident told an inspector. “I don’t like it here. It’s dirty.”
• The nursing home’s ice machine was broken and had been that way for months. Residents complained about the lack of ice and lack of cold water provided for drinking.
• The director of maintenance at the nursing home, who told the inspector he was new to the facility, agreed the nursing home “was in poor condition, unsafe for residents, families and visitors and needed repair and agreed all the facility air conditioners needed to be cleaned.” The director of housekeeping also agreed the facility was "dirty, unsafe ... and in need of cleaning and repair” and said “we are aware and are working on it.”

The plan of correction stated all air conditioners have been cleaned and gaps filled. All other cleanliness and maintenance issues were also addressed, it said.

Failure to keep and provide records

The state cited Whitehall for failure to maintain complete staff personnel files and complete certification, license and background checks. The nursing home also refused to turn over some records the state inspector requested.

Among the findings:

• One nurse’s personnel file had no proof of a nursing license.
• One nurse’s file had no proof of a background check.
• One nurse’s file had no proof of any orientation or competency check.
• The personnel files of two certified nursing assistants did not have proof of certification.
• One aide’s certification was expired.
• The inspector requested sheets showing documentation of residents’ showers but was told, “corporate is not letting us release the shower sheets to you because they are not part of the record.”

In the plan of correction for the violations, the nursing home said all files and certifications have been updated. The nursing home has also changed the way it documents showers.

Aftermath

Tom Masseau, government and media relations director for the Michigan Protection and Advocacy Service, said enforcement actions taken against the nursing home don’t go far enough. He said there should be more serious consequences for those who fail to take proper care of patients and that the maggot discovery should have been reported to Adult Protective Services or local law enforcement.

He acknowledged that one person was fired and that the nursing home has said it has retrained staff but said that’s not enough.

”If these are health-care professionals, they should know these things. If we continue to retrain and re-educate, it’s just a slap in the face to residents. Down the road there will be another violation.”

But Pemble, the Bureau of Health Systems director, said the state will be visiting again under the Special Focus Facility program to make sure the problems don't resurface.

"Sure you can correct it and you can put resources behind this issue, but we want to make sure that you’re going to continue that after we leave," Pemble said. “I think there’s a significant amount of oversight.”