Following an investigation into patient safety violations at Laughlin Healthcare Center, the state has halted new patient admissions at the Greeneville nursing home.
A news release issued Tuesday afternoon by the Tennessee Department of Health said Health Commissioner John Dreyzehner, MD, MPH, ordered the suspension, effective Aug. 11. In addition to stopping new admissions, Dreyzehner has also imposed “four state civil monetary penalties in the amount of $1,500 each for a total assessment of $6,000,” the release said.
A special monitor has also been appointed to review the facility’s operations.
Located at 801 E. McKee St., the 90-bed nursing home “was ordered not to admit any new residents based on conditions found during a complaint survey conducted July 11-21, 2018. The investigation was completed Aug. 11.”
“During the investigation, surveyors found violations of the following standards: administration, performance improvement and nursing services,” the release said.
A July 20 article in The Greeneville Sun cited concerns raised by relatives of residents regarding declining staffing levels. It also detailed a July 3 incident in which an elderly resident, who suffers from dementia, reportedly walked unaccompanied outside through the nursing home’s main entrance.
The state inspection report of the incident was provide to The Greeneville Sun by the Department of Health. The report stated that the resident, who was wearing a “wander guard” — a device worn by residents that triggers an alarm when they attempt to exit the facility — did exit through the front doors alongside contracted landscapers.
The report noted that the resident’s “wander guard” triggered an alarm, and that the nursing home’s receptionist reportedly “heard the alarm, left her desk and walked to the front lobby, looked out through the doors without exiting the building and because she did not see anyone, reset the alarm and returned to her desk,” the report said.
One of the landscapers “returned to the receptionist desk and reported he thought a resident had gotten out of a facility and had fallen down the embankment into the woods,” the report said.
According to the report, the incident was “an avoidable accident” in which the resident “fell down an embankment and received injuries to his body.”
State investigators found that the nursing home’s “administrator failed to ensure all employees and contractors were trained/in-serviced on the supervision of residents at risk for elopement; failed to ensure the staff properly responded to the wander guard alarm when [the resident] eloped; and failed to follow facility policy” to protect the safety and well-being of the residents.
The report went on to state that “the nursing home must ensure that there is an effective, facility-wide performance improvement program to evaluate resident care and performance of the organization.”
The incident was self-reported by Laughlin Healthcare’s parent company, Ballad Health. Company officials issued a statement in response to the announcement Tuesday:
“The suspension of admissions at Laughlin Healthcare Center stems from an incident that occurred on July 3 during which a patient left the dedicated patient care area at the nursing home for a period of a few minutes, but did not leave the facility property,” the statement says. “The facility voluntarily self-reported this event to the state on the same day. By regulation, this type of event triggers both a state and federal investigation, and both regulatory bodies require written corrective plans from the facility. In Tennessee, the Tennessee Department of Health administers the investigations on behalf of both the state and the federal government.
“The plan of corrective action submitted to both state and federal agencies included procedures to improve the security and monitoring of patients who are at risk of wandering,” the statement continues. “No citations were made regarding staffing at the facility.
“The nursing home received notice on Aug. 9 that the federal government had accepted the written corrective actions. The facility is now working with the Tennessee Department of Health to obtain approval of the corrective actions at the state level. As outlined in the corrective plan, the nursing home has taken steps to update security procedures that we believe will improve the safety of residents and mitigate the opportunity for any similar event to occur in the future.”
According to the state’s news release, the state Commissioner of Health may suspend admissions to a nursing home “when conditions are determined to be, or are likely to be, detrimental to the health, safety or welfare of the residents.
“The order to suspend admissions remains effective until conditions have been and continue to remain corrected. A copy of the order must be posted at the public entrance where it can be plainly seen,” the release added.
The nursing home has the right to a hearing regarding the suspension of admissions before the Board for Licensing Health Care Facilities or an administrative judge.
Complaints regarding nursing homes in the state can be filed with the Tennessee Department of Health online at www.tn.gov/health under the health professionals link, according to TDH media spokesperson Elizabeth Hart.
Laughlin Healthcare Center has been a subsidiary facility of Laughlin Memorial Hospital since the nursing home’s opening by the hospital in 1991. Last August, the nursing home marked the completion of a $1.1 million expansion to house a new rehabilitation unit. In 2017 Laughlin merged into the Mountain State Health Alliance system, which earlier this year completed its merger with Wellmont Health System to form Ballad Health, a new company.