Leg fracture brings citations

Dropped state report lists

deficiencies at nursing home

Medical records were not  “in accordance with accepted 

professional standards and practices.” state found

By David Baker

Posted November 7, 2014

730 words

The guardian of a man who was found to have a broken bone in his leg a day after a fall in a nursing home has filed a lawsuit that initially included a copy of a state Department of Health report that cites the home for deficiencies, but which is not included or referred to in an amended complaint filed two months later.

The lawsuit was filed against St. Peter’s Nursing and Rehabilitation Center in Albany on August 27 by Jeanette Whitbeck on  behalf of James F. Whitbeck. Attached to the first complaint is a copy of a ‘statement of deficiencies’ dated November 1, 2012 in which state investigators cite regulations and how they were found to have been violated.

According to the report, Whitbeck had been admitted to the home for rehabilitation therapy following a knee replacement. A week later, on the afternoon of August 21, 2012, he was found on the floor by his bed.

“Based on medical record review, and staff interviews during a complaint investigation it was determined that the facility did not ensure that incidents or accidents were thoroughly investigated ... specifically, the facility did not thoroughly investigate a resident’s fall that was initially determined to be without injury and on the following day the resident was diagnosed with a fracture of the femoral neck the required re-hospitalization and surgery,” the report says. 

Investigators wrote that after Whitbeck fell and before the fracture was discovered, an occupational therapist attempted to have him walk but noticed that he was not moving well and was wincing in pain.

“At that point the OT stopped, left the resident in bed and went to a licensed nurse standing outside the resident’s room and asked if there had been any change in the resident’s condition over the prior week. LPN told the OT the resident was ‘a little out of it’ but offered no other information.” 

According to the report, the therapist then returned to the room, got Whitbeck out of bed and started walking him to a bathroom using a walking frame. “While walking, the resident appeared to have pain and great difficulty weight bearing on his right leg,” the report says. 

The therapist placed Whitbeck in a wheelchair. A short time later, the therapist saw Whitbeck’s daughter in a hallway; the daughter told the therapist about the fall and later told her that an ex-ray had been ordered.

The report says that the director of nursing told investigators that she had been told by the rehab director that occupational and physical therapists do not have access to patients’ electronic medical records, including nursing notes.

“The (director of nursing) stated that she herself did not have access to the resident’s physical and occupational therapy notes and would to rely on one of therapists to print a note if she need to review one,” the report says.

The therapist told investigators that if she had known about Whitbeck’s fall she was not have had him walk.

“(OT) stated if she had been able to review nurses notes she might have seen that the resident had fallen the evening before and on the morning of 7/22/12, as soon as he winced in pain, she would have discontinued the residents therapy session.”

The report also addresses the home’s handling of medical records.

“Based on medical record review, and staff interviews during a complaint investigation it was determined that .. the facility did not maintain clinical records in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized. Specificaly, the facility did not document  assessments of and/or monitoring of a resident’s condition after a fall that was initially determine to be without injury and the following day the resident was diagnosed with a fracture of the femoral neck that required re-hospital and surgery.”

The 20-page document is referenced in the August 2014 complaint and attached to it as an exhibit. But it is not included with an amended complaint filed in October 2014 and the two paragraphs referring to it are gone.  It is otherwise unchanged. 

The complaint alleges  “.. recklessness, willful malfeasance and neglect,” and demands unspecified compensatory damages and punitive damages of $250,000 on each of three causes of action, as well as costs, disbursement and attorneys’ fees.  It was filed by the Latham law firm Hacker Murphy. Representing St. Peter’s Nursing and Rehabilitation Center is Maguire, Cardona of Menands. 

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