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Many Violations, Little Punishment at Troubled Nursing Home


The east Charlotte nursing home where a resident disappeared and later died last week has been assessed $316,000 in federal fines since it was bought by a Wilmington chain in April 2003.

But the company has paid less than $23,000 for its violations at Liberty Nursing and Rehabilitation Center during that time period, the Observer has learned.

The two heftiest fines, totaling about $287,000, remain under appeal, a process that can take up to three years. Two smaller fines were reduced, while a fifth stood as imposed.

Liberty Healthcare Services bought the 289-bed facility on Shamrock Drive in April 2003. Liberty paid $1 million for the property, according to county records.

Since the sale, deficiencies cited by state inspectors on their annual reports have tripled, from 10 in 2003 to 30 in 2005, making the home one of the most cited in the state last year.

"I think that's bad," said Linda Miller, the nursing home ombudsman for Mecklenburg County, who investigates complaints and helps families deal with problems.

A review of state records from the past two years found several dozen complaints, from failing to control a violent resident who threatened other patients, to dispensing the wrong doses of medication, to diapering a man for the sake of convenience.

The problems grew so bad on at least three occasions that the state determined residents were in "immediate jeopardy" and required quick corrective actions.

Employees often blamed high turnover or a heavy workload for the problems found by inspectors, according to the records reviewed by the Observer.

Teresa Watts of Concord, whose father lived at the home from April 2002 through May 2004, said she noticed a big change when Liberty took over.

"It got to be a skeleton crew," she said. "It looked like they cut back on the nurses."

Liberty again fell under scrutiny last week after 66-year-old Mary Cole, an Alzheimer's patient with a history of wandering, was lost for four days.

She was found last Friday in a storage room down the hall from where she lived. She was rushed to the hospital, where she died a half-hour later.

Other than a two-sentence statement issued a week ago, Liberty's owners and nursing home administrator John Gryglewicz have refused to talk to reporters since Cole's death. They did not return calls again Thursday.

State inspectors started a new investigation of the nursing home after Cole's disappearance. Results are expected in about two weeks. No foul play is suspected.

State officials wouldn't comment on their previous inspections while the new investigation is ongoing, but Jim Jones, spokesman for the Department of Health and Human Services, said: "As you can see, we've been there quite a bit. The numbers speak for themselves."

Problems found by state surveyors during their annual inspections are grouped into eight categories, ranging from mistreatment to incorrectly dispensing medication.

In seven of those eight, Liberty did worse in 2005 than two years before, when Presbyterian Healthcare operated the facility.

In a March 2003 survey, taken one month before the sale, inspectors found 10 deficiencies. That rose to 12 in May 2004, then tripled to 30 in February 2005.

The state average for deficiencies is six, so any time a home scores in the 20s or worse, Miller considers that troubling - although not unheard of. "It seems like every year we have one or two in Mecklenburg County that get in that high range," she said.

Liberty is one of the largest nursing homes in the state. But a center in Huntersville with the same number of beds scored half as many deficiencies last year as Liberty. None of the 15 was rated as causing actual harm or putting residents in immediate jeopardy.

Twelve of Liberty's 30 deficiencies fell into those categories. The most deficiencies in the state last year was 34.

Among the problems cited by state inspectors at Liberty last year: failing to respond to patients' call buttons; not informing families of bedsores; leaving residents restrained in wheelchairs for more than two hours without repositioning them; failing to place mats beside the beds of patients with a history of falling; and a shortage of nursing staff.

The federal Medicare program uses monetary penalties to force nursing homes to correct problems. Fines can accrue daily until fixes are made.

On at least two occasions over the past two years, inspectors fined Liberty $3,050 a day until violations were fixed, in one case stretching for 44 days.

After corrections are made, nursing homes can appeal those fines to the U.S. Centers for Medicare and Medicaid Services and frequently receive reductions, experts said.

The fines are split by the state and federal government, with states using their share to help train inspectors and pay for related programs, according to federal guidelines.

After the 2005 inspection at Liberty and follow-up visits that found ongoing problems, officials took the extra steps of halting new admissions and warning Liberty they would cut off Medicare and Medicaid funding on July 4 if problems weren't fixed.

That likely would have shut down the facility.

Corrections were made and a new administrator hired, holding off the government's action. The facility has had a clean record since last summer, until Cole's death.


Among the violations listed in state inspection reports at Liberty Nursing and Rehabilitation Center of Mecklenburg County during the past two years:

: Employees allowed a patient to physically threaten other residents and staff members on at least 10 occasions over a period of four months in early 2004 without properly treating him for his outbursts. They included entering female patients' rooms, exposing himself to women, swinging a belt buckle at patients, threatening to kill them and brandishing a red hammer. Several residents said they were terrified of him. He eventually had to be taken to the emergency room and discharged from the nursing home after hitting and kicking two nurses.

Seat belts
: A resident complained in November 2004 that wheelchair users weren't always strapped in place using seat belts when riding in the facility's van. Inspectors found the van was lacking two of four seat belts for wheelchair users, and an administrator told drivers to "use some type of belt" to hold them in. The substitute belts used by the drivers recommended that the straps "NEVER" be used "as a seatbelt in a moving vehicle. Products are not designed to withstand the force of a crash." The van was replaced in January 2005 after inspectors told the administrator that patients at the facility were in "immediate jeopardy."

Fire doors
: Inspectors found doors that were improperly wedged open or wouldn't close and latch as required in July 2004. The doors were part of the fire-protection system designed to prevent fires from spreading. The facility said it corrected the problem by replacing hinges and instructing staffers not to wedge the doors open.

: In May 2004, inspectors found that a resident who had fallen out of bed at least four times that year hadn't been provided with a personal alarm to notify employees if he fell again, or a floor mat beside the bed to break his fall. Another patient fell twice in the same week in May 2004 before the alarms and mat were used, inspectors said.

Wrong drugs
: Employees were cited in October 2004 for administering incorrect doses of medication, including drugs to manage pain, to three patients. In one case, a staff member changed a doctor's order for four pills to two, saying she "thought I saw it somewhere" in the physician's orders.

: In February 2005, a resident complained that employees forced him to wear a diaper, causing a rash and bleeding, even though he was capable of going to the bathroom on his own and listed as "continent" on his assessment form. Staffers said the resident was new and they were unfamiliar with his needs.

--Staff writers Pam Kelley, Andrew Shain and Danica Coto contributed.