Mission Oaks Manor

3030 Roosevelt Avenue, San Antonio, TX 78214-2337 (210) 924-8151

Nursing homes' problems continue

A review of low-performing Bexar County nursing homes by the Express-News shows residents at some of the most troubled facilities continue to suffer at the hands of their caregivers. February's report: Slow action on nursing home problems

By Karisa King and John Tedesco

On a May morning last year at Mission Oaks Manor nursing home, an aide who was not trained to hand out medicine stirred a powerful mixture of crushed pills into the oatmeal of a resident with dementia.

The combination of drugs, which included 10 different types of medication for depression, psychosis and behavioral disorders, appeared to fit medical orders, except for one flaw: The aide gave it to the wrong resident.

The overdose, which sent the elderly man into respiratory failure, was hardly unforeseen. It came a year after state investigators warned Mission Oaks to fix alarming mistakes with how it dispensed medication.

In the months leading up to the incident, some residents received the wrong doses of mood-altering medication, while some others didn't receive their medicine at all or took painkillers and sleeping pills from workers who didn't document how they dispensed the drugs.

Mission Oaks is among the 10 lowest-performing Bexar County nursing homes with chronic problems that risk the safety of residents.

A San Antonio Express-News examination of those facilities in February showed residents were injured and suffered deadly lapses in care while the state imposed few or no penalties. In some cases, nursing homes that were cited for failing to protect residents promised to correct the problems, only to later violate the same rules.

A review of the facilities since then shows residents at some of the most troubled homes continue to suffer at the hands of their caregivers.

Nursing home workers unnecessarily subjected elderly residents to mechanical restraints. Staff members left bedsores untreated and failed to follow through on lab tests ordered by doctors.

State investigators also found nursing homes infested with flies, while workers at other facilities left residents to contend with bathrooms, beds and shower stalls smeared with feces.

At San Pedro Manor, several workers sued the facility in June, claiming they were demoted and fired for sharing concerns about the nursing home with a state inspection team.

The nursing home's administrator at the time, Joe Dawson, tried to stop employees from talking to the inspectors, the workers claim. In court papers, the company denied the allegations.

"Everybody was afraid of retaliation," said Christina Gonzalez, one of the plaintiffs in the lawsuit.

More oversight

The problems continue at a time when the state agency that oversees nursing homes has stepped up the pace of abuse and neglect investigations.

In an effort that coincided with the Express-News inquiry in February, which found that inspectors often arrive at facilities weeks after required deadlines, the Department of Aging and Disability Services, or DADS, added 41 new investigators to improve the agency's response times.

Before the new hires, the department had failed to respond to two out of three cases within a required 14-day deadline in instances when nursing home residents were likely harmed, according to state statistics. Since March, investigators have responded on time to nearly all such cases.

"Just having the extra bodies really allows us to not get behind on any of these complaint investigations," said Cecilia Fedorov, a spokeswoman for DADS.

The agency beefed up its staffing levels during a time of budgetary belt-tightening in Texas. Yet problems at some nursing homes persist.

"It is frustrating," Fedorov said. DADS will do what it can to make sure all nursing homes are meeting minimum requirements, she said, but ultimately it's up to the nursing homes to provide top-notch care.

"There is absolutely no substitute for providers who are committed to providing the highest quality of care for nursing home residents," Fedorov said.

Despite the quicker state response, investigators continue to substantiate few complaints against nursing homes. Of the 16,200 reports of poor treatment in Texas last year, investigators substantiated just one in five cases.

Although that ratio hasn't changed as a result of the new hires, officials said the faster response times help investigators root out the cause of problems and make it easier to intervene on behalf of residents who may be in harm's way.

"You're going to have better outcomes for residents who could be in potentially hazardous situations," said David Wright, who heads the Texas branch of the Centers for Medicare and Medicaid Services, or CMS.

While the long-term impact of the quicker investigations remains unclear, nursing homes such as Mission Oaks offer insight into the difficulties of cracking down on chronically troubled nursing homes.

Mission Oaks' administrator declined to comment on past problems, but he said the nursing home is improving. Despite those efforts, however, in April CMS placed the facility on a watch list of the nation's worst nursing homes.

The decision came after three years of severe safety violations, including the overdose of the elderly man who nearly died last year. State records show a dangerous cycle continues to repeat at the nursing home. Inspectors turn up dozens of safety lapses, managers promise to improve and the same problems surface again.

In one case, investigators in 2008 raised alarms about a practice of strapping restless residents into chairs as a matter of discipline or convenience for staff. The facility promised to minimize the use of restraints and avoided any further penalty.

But less than a year later, the ongoing problem would leave a 61-year-old man dead.

Mission Oaks

An inspector who visited the squat, stucco nursing home on South Roosevelt Avenue in June 2008 first cited the facility for its use of restraints after spotting two residents unnecessarily belted into chairs.

One of the residents, who was severely impaired and needed help to stand, had been strapped to the chair with a belt tied behind his back. Records showed a doctor had ordered staff to stop using the restraint three months earlier. But workers continued to strap him into the chair despite signs it was problematic.

A few weeks before the inspector arrived, records showed the resident had been found lying on his back on the patio with the wheelchair on top of him, still belted in.

During the same inspection, the investigator also found workers kept sloppy medical records and failed to follow pharmacist orders to lower doses of antidepressants and mood-altering drugs.

By January 2009, the nursing home's use of mechanical restraints had spread and more residents were getting hurt, state records show.

Prompted by the death of a man who'd been bound to a geriatric chair, an investigator returned to Mission Oaks and found 11 residents who were subjected to similar restraints. Of those, six had tipped over while tied to chairs, and two had been injured - one of them suffering a fractured skull.

In the case of the man who died, staff members in the previous weeks had watched him make several attempts to knock himself over in the chair. He succeeded twice.

On the night of his fatal crash, a nurse caught him trying to jump out of bed, restrained him to the chair and left him in the dining room to watch TV. About half an hour later, another nurse heard something smack into the floor and found him tipped over in the chair, unconscious and gripped by a seizure.

He survived at a hospital for four days before being taken off life support. Hospital records indicated he died from bleeding in the brain. No one at the home reported the death to the state, as required by law.

As a result of the nursing home's improper use of restraints, the Medicare and Medicaid agency fined Mission Oaks $10,000.

Assault by residents

Less than five months after the death, another complaint sent investigators back to Mission Oaks. This time, they found several elderly residents had been suffering ongoing physical abuse at the hands of two violent residents for months.

State records show the attacks began in February 2009. Several residents suffered black eyes, bruises, torn skin or bloody noses. One victim was beaten with a walking cane.

A San Antonio police report identified one of the assault victims as Mary Alan, a 91-year-old suffering from dementia who was beaten April 12, 2009. Officer Daniel Pue arrived at Southwest General Hospital and saw Alan's face was "severely swollen" and bruised. Her nose and an eye socket were fractured.

Workers told investigators they had seen the two violent residents hitting others, but attempts to control the beatings had been difficult. Nor did staff make any attempts to counsel the aggressive men, records show. Instead, one nurse said the staff had tried "to keep an eye on them."

The nursing home's failure to protect residents from the attacks prompted an additional $6,000 fine from the Centers for Medicare and Medicaid.

The facility's administrator, Cain Smith, declined to comment on any past problems, saying he didn't take over until August 2009. Since then, he said, the nursing home has made great improvements.

He and a newly appointed director of nursing personally screen every new resident before coming to the facility, which specializes in treating behavioral problems like schizophrenia, dementia and bipolar disorder.

"We don't just admit residents to fill beds," Smith said.

The facility also stopped using restraints of any kind, and Smith pointed out that the most recent inspection resulted in no fines and found no residents had suffered any harm.

"We're trying to do a 180 and get a whole new attitude," Smith said.

Despite those efforts, the Medicare and Medicaid agency classifies Mission Oaks Manor as a nursing home that has not improved since it was designated as a "special focus facility" in April.

The previous violations landed the nursing home on the list, but the most recent survey in June fell short of winning it an "improved" status, said Wright with CMS.

Nursing homes placed in the program face tighter scrutiny, with two annual inspections instead of just one. About 135 nursing homes are included on the list at a given time. Facilities typically have 18 months to improve. Those that fall short of the higher standards can be terminated from the Medicaid and Medicare program.

Nick Monreal, ombudsman for the Bexar Area Agency on Aging who advocates for the safety of nursing home residents, said Mission Oaks has gone through a "tremendous series of transitions and staff turnovers," which could explain the medication error and other avoidable mistakes.

"I gotta tell you, staffing is a major issue," Monreal said. "One of the biggest problems today is there are not enough trained and skilled front-line care workers."

Monreal said Mission Oaks serves a crucial role in the community by taking in residents who might not be accepted at other facilities.

"My hat's off to them for doing that," Monreal said. "But with that comes responsibility."