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| Mary Ellen Sharp with her daughter, Tarynn Willson, left, and
granddaughter Krysten Schmidt as she celebrates her 90th birthday at
Schmidt's house in Batavia on Jan. 11. (Sharon Cantillon/Buffalo News) |
By Lou Michel
When Krysten Schmidt visited her 89-year-old grandmother at a Batavia
nursing home, an aide pulled her aside to say there were maggots on her
grandmother’s foot.
Schmidt started to cry and wondered if maybe she misheard the aide.
She hadn’t.
Staff at Premier Genesee Center for Nursing and Rehabilitation later
described the Sept. 25 incident to a state Health Department
investigator in graphic terms. On Mary Ellen Sharp’s left foot, there
was “something wiggling between her toes,” a nurse's aide told
investigators.
The state cited Premier Genesee for violations related to the maggots but did not fine the nursing home.
Schmidt said that if it hadn’t been for the aide, she might never have known that maggots –
fly larva that look like small worms
– were infesting her grandmother’s leg wounds at Premier Genesee not only that day but also four days earlier.
Two nurses who responded to Schmidt’s demands for an explanation downplayed the maggots, the granddaughter said.
“My mother had just arrived for the visit and took off the shoe and
sock and three or four maggots fell to the floor,” Schmidt said. "They
proceeded to tell me the maggots were in her shoe and not her sock. I
mean, does it really matter? Are maggots supposed to be anywhere? They
were trying to downplay it.”
Later that same day, Schmidt said, she filed a complaint with the
state Health Department, which initiated an investigation in early
October.
An inadequate pest control program to prevent flies from entering and
spreading maggots at the 160-bed nursing home was cited by the Health
Department as the culprit.
The investigation found flies in residents’ rooms, a third-floor
dining room, the main kitchen and elsewhere. Doors to the outside were
ajar or too small, creating spaces for flies to enter. Screens were
improperly installed, allowing for gaps, and bug light traps were not
plugged into outlets.
The state cited other problems:
• An unsanitary situation occurred when a wound doctor, after
treating one of Sharp’s wounds, failed to place a dressing on it. For
hours, the wound was openly exposed, making it a target for flies.
• Officials at the nursing home failed to comply with a federal
regulation requiring they immediately notify a physician and relatives
when there has been a change in a resident’s condition.
• Breakdowns in communication among employees, ranging from the nursing staff to maintenance workers.
"What happened is inexcusable and horrifying,"
said Lindsay Heckler, supervising attorney at the Center for Elder Law
and Justice in Buffalo. "Had staff followed basic standards of care and
timely notified the physician, maggots would not have infested the
resident’s leg for additional multiple days. Maggots should not have
infested her leg on Sept. 21, and the resident should not have been left
to suffer from further infestation."
Mary Ellen Sharp's left leg is still bandaged because the wounds have not yet healed. (Sharon Cantillon/Buffalo News)
Heckler and two other advocates said it is rare for a nursing home in New York to be cited for maggots found on a resident.
Richard J. Mollot, executive director of the Long Term Care Community
Coalition, a national nursing home watchdog organization, suggested New
York should have levied a substantial fine against Premier Genesee.
"Needless to say, a maggot infestation on a nursing home resident’s
body is a very disturbing violation of minimum care standards. Sadly,
this nursing home has a long history of these types of violations, which
raises serious questions about what is being done to truly hold it
accountable for substandard care and resident harm. In the absence of
meaningful fines or penalties, there is little to stop a facility from
relapsing, putting current and future residents at risk," Mollot said.
Health Department spokesman Jeffrey Hammond said the state has fined
Premier Genesee $12,000 since 2017 for other violations, but it imposed
no fine for the maggots.
“While no fines were issued for the deficiencies cited in this
instance, the facility was required to implement a plan of correction to
ensure that this type of incident does not occur in the future," he
said.
Premier Genesee has taken a number of steps to improve conditions at
the facility since it was cited. They include making sure screens remain
properly fitted in windows and eliminating gaps in doors to block flies
from entering, making sure bug light traps are plugged in and that
monthly recommendations for repairs from a pest control company are
promptly addressed.
Premier Genesee Center for Nursing and Rehabilitation in Batavia. (Sharon Cantillon/Buffalo News)
In addition, a new guideline and training on how the nursing staff
can reach nursing supervisors has been put in place. Nurses and nurse
supervisors have also been re-educated on the policy for notifications
to physicians and relatives when there is a change in a resident’s
condition.
In 2015, Genesee County legislators approved selling the nursing home
for $15.2 million to Premier Healthcare, a for-profit Long Island
company that owns nursing homes in New York and Pennsylvania.
The federal government rates the nursing home at an overall two stars, below average.
Sharp’s family moved her to another Batavia nursing home on Oct. 3
and on Dec. 19 filed a lawsuit in State Supreme Court against Premier
Genesee.
“You don’t really think it could be true or it could ever happen,"
Schmidt said of the maggots. "How would anyone feel having that happen
to a loved one?”
Lisa Sofia, the chief executive officer of Premier Genesee, declined
to comment on what happened to Sharp because of the pending lawsuit.
Discovery of maggots
Sharp, now 90, lacks mobility and has mild dementia, which was why
her family placed her in the nursing home in June 2014 when the facility
was known as the Genesee County Nursing Home.
A retired homemaker and grandmother, Sharp had lived in Erie County's
Southtowns most of her life and served as a volunteer bringing library
books to an East Aurora nursing home. About 20 years ago, she moved to
Attica to be closer to her only child, Tarynn Willson, who is Schmidt’s
mother.
Four days before Schmidt’s visit to see her grandmother, on Sept. 21,
maggots were discovered in wounds on Sharp’s lower left leg, according
to the Health Department investigation.
The wounds were caused by ruptured blisters from cellulitis bacterial
infections. A licensed practical nurse hired through a staffing agency
was changing old dressings on the wounds when the nurse “observed five –
six maggots” on the wounds, flushed them down the toilet, completed
treatment of the wounds and unsuccessfully attempted to alert the
facility’s nursing supervisor of the situation, according to the Health
Department investigation.
An additional two days passed before a wound specialist provided
hands-on treatment. Even then, there was a mistake, the state
determined.
The doctor told investigators that after removing dead tissue from
Sharp's wounds, he did not have time to apply a new dressing and
expected a nurse would complete the task. Instead, the wound was left
uncovered for “five to nine hours,” allowing “enough time for a fly to
have laid eggs on the resident’s leg causing the maggots,” the
investigation stated.
Schmidt says the doctor should have taken the initiative and applied a fresh dressing.
“If a doctor comes in and debrides the wound, why can’t he spend a
few moments and dress it for infection control?” said Schmidt, who is a
nurse practitioner herself.
The facility’s director of nursing, in a statement to the Health
Department investigator, said the time period of exposure was
“unacceptable and provided ample time for a fly to lay eggs causing the
maggots on Resident 1’s leg.”
Sharp’s medical file
Schmidt said that her training as a nurse practitioner and the
behavior of the staff during her Sept. 25 visit raised her suspicions
that there was more to the story.
“The director of nursing came to my grandmother’s room about 20
minutes later and acts like this is brand-new to her. They are trying to
figure out what to do. They are saying, ‘We’re going to get
housekeeping up here. We’re going to get the wound doctor. We’re going
to put grandma in the shower and disinfect the room.' At the same time,
there’s a roommate present with a family member. It was chaotic,"
Schmidt said.
“But I knew the maggots couldn’t have just happened that day,” she said.
On Sept. 26, Schmidt tried calling the director of nursing but was
informed the director was out of the office. “I then asked to speak with
the nursing home administrator. We spoke briefly on the phone and I
felt she was disregarding the situation,” Schmidt said.
Schmidt said she returned to the nursing home after work later that
day and received her grandmother’s written permission to review her
medical chart.
“That’s when I found out that this started on Sept. 21,” Schmidt said
of the maggots, adding that she went to nursing home administrator
Carole Francis’ office. “I had to wait 30 minutes, and in that time my
mother arrived.”
Schmidt said the administrator refused to answer any questions during a five-minute meeting.
Sofia, the nursing home CEO, said that no staff members, including Francis, are allowed to speak to The News.
A scapegoat?
In the state investigation report, the director of nursing told an
investigator that the licensed practical nurse who initially discovered
the maggots has been banned from working at the facility “for lack of
nursing supervision notification.”
The licensed practical nurse, however, told the investigator she not
only recorded the incident in Sharp’s file, but also informed a
registered nurse and tried “many times” to alert the nursing supervisor
by phone, pages and texts, but could not reach her. The nursing
supervisor told the investigator that her phone was not working that
day, but that she had told personnel at different nursing stations she
could be reached by page or text.
Schmidt and attorney Dean P. Smith, who represents Sharp in the
lawsuit, say they believe the facility’s decision not to rehire the
licensed practical nurse amounts to making her a scapegoat.
“The whole event when you look at the details of the state’s
investigation is as nauseating as it is shocking to the conscience,”
Smith said. “The excuses are absurd."
[Read the lawsuit against Premier Genesee]
Full Article & Source:
Nursing home cited after maggots found on 89-year-old woman's wound
