Published Saturday | May 12, 2007
Beatrice care center gets second scare
LINCOLN
- Once again, the Beatrice State Developmental Center has come within days of
losing Medicare and Medicaid funding after federal inspectors concluded that
residents were in danger.
The inspectors lifted the latest threat to the center's funding Friday, said
Kathie Osterman, a spokeswoman for the Health and Human Services System.
Federal officials had given the center until Sunday to correct problems they
said were putting residents in "immediate jeopardy."
The problems involved failure to properly investigate and respond to cases of
abuse, neglect and mistreatment.
Findings by federal inspectors
Inadequate investigations of abuse,
neglect and mistreatment
Example: Center investigators did not review surveillance video promptly
after receiving an allegation that one resident had assaulted another. The delay
meant the staff person who was to have monitored the perpetrator was not
suspended promptly.
Example: Investigators took no action to protect two residents after
receiving allegations they had been pushed by a staff person. The investigators
said the resident making the allegations had a history of making false
accusations. The lack of action allowed the same staff person to push a third
resident.
Inadequate response to injuries of unknown origin
Example: A resident was found with a red, raised area on the right shin,
which investigators believed resulted from bumping it against the bedrail. The
investigators did not consider putting padding on the bedrail.
Inadequate response to resident-to-resident abuse if the resulting injuries
were minor.
Example: Investigators did not report an incident to the center
administrator in which one resident used his key chain and key as "brass
knuckles" to punch another resident, nor did investigators take action to
protect the victim while investigating the incident. Staff instead took the key
chain and redirected the two residents to other activities.
That
also was one of three "immediate jeopardy" problems cited during a September
inspection.
Under federal regulations, "immediate jeopardy" may be cited when there are
risks of serious harm, injury, impairment or death that require immediate
attention. The risks may have occurred in the past or present, or be likely to
occur in the very near future.
The Beatrice center is a state-owned institution that serves 340 people with
mental retardation and other developmental disabilities. Many have additional
physical or mental disabilities.
Federal inspectors discovered the problems during a two-week inspection in
April.
Their visit was a follow-up to the one completed seven months earlier. Other
problems identified at that time were failure to supervise residents adequately
and failure to make sure restraints are used safely.
Deborah Weston, executive director of the Arc of Nebraska, a developmental
disabilities advocacy group, said the new citation raises questions about how
much has changed at the center since the September inspection.
"It's unfortunate we're seeing the continued problems of abuse," she said. "More
than that, it's unacceptable."
The immediate jeopardy citation and the state's response were released by the
Centers for Medicare and Medicaid Services after the Omaha World-Herald filed a
Freedom of Information Act request.
State officials have refused to release details or comment about the citation or
their response.
However, Health and Human Services System officials sent an e-mail to state
senators and center staff April 20 touting comments made by the inspectors about
seeing "amazing change" and "tremendous progress" since the September visit.
"They noted that every interaction they observed between the staff and clients
was truly amazing," Larry Pezley, acting center administrator, said in the
e-mail.
During the September inspection, the center failed to meet seven of eight
requirements for receiving Medicare and Medicaid payments.
The eight requirements are client protection, facility staffing, active
treatment, client behavior, health services, physical environment, governing
body and dietary services. The only requirement met was one dealing with
physical environment.
This time, the center failed only two requirements - client protection and
governing body.
"At this time, we can tell you that the facility has made substantial progress.
However, problems remain which the facility is working to correct," said Julie
Brookhart, a spokeswoman with the Kansas City, Mo., regional office of the
Centers for Medicare and Medicaid Services.
Osterman said state officials had not expected to get an immediate jeopardy
citation because the staff has made tremendous efforts to turn the center
around.
But she acknowledged that more needs to be done to satisfy federal standards.
She said that recruiting and keeping enough staff remains a major difficulty.
Pezley issued a staffing emergency declaration this week, under which employees
can be asked to work more overtime than their union contract normally allows.
The center also is borrowing employees from the Hastings Regional Center and is
continuing efforts to fill vacancies, Osterman said.
Weston said the amount of overtime and the vacancies are troubling, because the
pressure on employees can affect the care of residents. She said attention needs
to be paid to the working environment at the center, as well as wages.
Pezley was named acting administrator in December. He formerly worked at the
Woodward Resource Center in Iowa, a developmental disabilities institution. The
Beatrice center's former administrator, Vince Benjamin, resigned the day that
federal inspectors left in September.
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