A Hyattsville nursing home could lose its Medicare certification this week after Maryland health officials found "serious" violations, including faulty medical reporting that may have led to the deaths of two elderly men.
Carroll Manor Nursing Home has been under a state-imposed ban on admissions since August, when a state inspection found "significant and serious" violations, said Carol Benner, acting director of licensing and certification for the Maryland Department of Health and Mental Hygiene.
The report found that the facility was unsanitary and that nurses had failed to relay crucial medical information to doctors.
Benner said health officials will decide this week whether the home, which is run by the Catholic Church, will remain eligible for Medicare and Medicaid. The nursing home had until Oct. 13 to correct its problems, and Benner said health inspectors launched a reinspection last week that should conclude tomorrow. "Usually, we will issue a ban on admissions when there are life-threatening situations," Benner said.
The 33-year-old home is jointly owned and operated by the Catholic Archdiocese of Washington and the Carmelite order of nuns. About 60 percent of the 215 residents are on Medicare or Medicaid, the federal health insurance program for the elderly or low-income; the remainder have private insurance.
G. Richard Fowler, a spokesman for the archdiocese and a member of Carroll Manor's board of trustees, said the board is "very concerned" about the state's findings and partially blamed the rising cost of labor, the shortage of qualified nurses and increased government regulation for the problems.
"Obviously, the quality of the care there is our first priority. We are trying to work to provide the best care we can," Fowler said.
Inspectors visited the home in August after receiving complaints.
In one case, the inspectors reported, a 73-year-old man died July 27, two days after nurses found him short of breath, with a racing pulse and very low blood pressure. Nurses failed to tell the man's doctor that X-rays had revealed pneumonia in the left lung, and treatment was never started, according to the inspection report.
On June 3, a 67-year-old man with a persistent temperature of 103 degrees was treated for a urinary infection by his physician, who prescribed the antibiotic Keflex. However, five days elapsed before the doctor was informed by Carroll Manor nurses that a lab report showed the organism causing the infection was resistant to Keflex, the report said. The doctor switched medication, but the man died two days later, the report said.
In another case, nurses gave an 82-year-old woman twice the amount of a prescribed heart medication for nine days. In another, nurses failed to follow a doctor's order to monitor an 82-year-old woman's pacemaker monthly and then did not tell the doctor of the woman's low pulse rate and lethargy. The woman eventually was hospitalized; her pacemaker battery was depleted, the report said.
In several cases, patients dramatically lost weight because they were underfed, the report said.
The inspection found that cooked food often was served cold and that patients were not fed between 5:30 p.m. and 8:30 or 9 a.m. the next morning. Food was stored incorrectly and at improper temperatures. Flies swarmed in through open windows that compromised air control, and odors from bathrooms and residents' rooms blew into dining rooms and corridors.
Record keeping was so inadequate that nurses continued to document care, feeding and exercise for one resident for four days after the patient died.
Since the inspection, the nursing home's administrator, Sister Jeanette Lindsay, has stepped down and seven other nuns who helped run the facility have been reassigned to other facilities, Fowler said.
This is not the first time Carroll Manor has run into trouble with state requirements. In March 1988, the home faced the loss of its Medicare certification, Benner said. In March of this year, a routine inspection found some problems.