One of the biggest problems at any nursing home is bed sores. Bed-ridden residents tend to develop them, and they require attention. One resident, whom I understand is a difficult person to begin with, has this problem. On August 10, he was treated with a pressure dressing, which is common.
What is uncommon, and frankly inexcusable, is that this resident's dressing went unchanged until September 7, nearly a month later. During this time, as many as 14 nurses falsely claimed to have changed it.
This possible criminal negligence was caught by Gracedale's Risk Manager. The dressing had to be double-bagged because it stunk so horribly.
The resident was immediately placed on antibiotics. Fortunately, he needed no additional medical treatment.
When I first heard this story, I declined to write about it because it seemed so contrary to everything I know abut Gracedale. So I contacted county officials, who looked into the matter.
Unfortunately, it's true.
Once made aware of the situation, county officials undertook a thorough investigation.
The first question is why this matter was never reported to the Department of Health. The Risk Manager, who discovered this matter, said there was no need to contact state officials because the resident required no hospitalization. I understand that Executive Lamont McClure, unhappy with this answer, reported it anyway. He was willing to see Gracedale's ratings drop rather than be dishonest. He learned that the Risk Manager was correct. The state Department of Health declined an investigation because there was no need to hospitalize the resident.
The second question is how the County responded to this gross dereliction of duty. This is what I've learned:
* Six of the nurses who falsely claimed to have changed the pressure dressing were "agency" nurses, not Gracedale employees. They are brought in from the outside to make up for manpower shortages. They have been banned from Gracedale.
* Two Gracedale nurses who falsely claimed to have changed pressure dressings resigned after being told they would be terminated.
* One Gracedale nurse of lesser culpability was suspended without pay for five days, and others have received reprimands.
Gracedale's Administrator, Jennifer Stewart King, released this statement:
The rebound to the census at Gracedale, as well as the improved quality ratings, demonstrate that the majority of the staff do their work with consummate professionalism. However, from time to time, there are some instances where individuals do not always fully complete the job they are supposed to do. That is unacceptable.I agree, and believe this should also be referred to the state licensure board and District Attorney's office.