Eleven Tennessee Nursing Homes
Considered Persistent Providers
of Sub-Standard Quality of Care
A report from the U.S. Senate Special Committee on Aging that focused on the nation’s most underperforming nursing homes listed nearly 400 facilities as candidates for the Centers for Medicare & Medicaid Services (CMS) Special Focus Facility program. Eleven of those nursing homes were in Tennessee. The report labeled these facilities as persistent “sub-standard quality of care” providers.
Some of the deficiencies cited for these eleven involved such things as—
- A medication error where an agency nurse misread the physician’s order and gave a resident an insulin dose that was twenty-five times greater than prescribed.
- The unsafe discharge of a man with head trauma for breaking the facility’s smoking rules when he may not have been made aware of the rules. He was taken to a motel where staff paid for a 3-day stay, but left him with no money, no phone, and no food except the free breakfast and some peanut butter crackers. Medications were brought to him the next day, but he couldn’t manage them without assistance. The ombudsman and the insurance company covering the man’s stay in the nursing home were not notified of the involuntary discharge.
- A 65% medication error rate — 60% greater than federal regulations which allow no more than a 5% medication error threshold.
- Residents with multiple falls — one resident had nine falls during a period of 12 months, including a fracture; another had nine falls in four months; a third resident had four falls in two months. The state survey team cited the nursing home with placing residents in immediate danger for failing to put interventions into place after every fall in order to prevent the occurrence of more falls.
- Failing to prevent accidents during transfers, failing to prevent the development of pressure sores, and staffing issues related to people not wanting to work for facilities with known serious deficiencies.
These reports are public records, and consumers have access to them.
Compliance Perspective
Continual provision of sub-standard quality care that places residents in immediate jeopardy in spite of frequent state inspections where repeated citations for deficiencies in care were issued may be considered the basis for becoming a Special Focus Facility program candidate and may result in suspension of a facility’s ability to receive reimbursement from Medicare and Medicaid.
Discussion Points:
- Review policies and procedures regarding the facility’s commitment to providing high-level quality of care.
- Train staff on the importance of providing high-level quality of care and developing and implementing interventions to prevent violations of state and federal regulations.
- Periodically audit to determine if survey citations for deficient practices issued by state inspectors have been corrected and if plans of correction are consistently implemented.
