Officials mum about Idaho State Veterans Home chief's resignation
Lewiston Tribune, Idaho
Earlier this year, a state team found 17 deficiencies during an inspection of the Idaho State Veterans Home in Lewiston, some of which put residents in immediate jeopardy.
According to the inspection report, the most serious violations were corrected immediately. Veterans home administrator Sarah Yoder resigned a month later, but officials at the state Division of Veterans Services did not give an explanation at the time, and are still unwilling to talk about why Yoder left.
"Like any organization, we have some turnover," said Tracy Schaner, the division's human resources officer and the person who took over the Lewiston vets home on an interim basis after Yoder left. "This is not unusual."
Schaner noted that turnover is high at long-term care facilities nationwide because of the difficult nature of the work performed there. And while Yoder's resignation in March was followed by turnover at several other positions, Schaner would not say whether it was related to the problems revealed in the inspection.
"These inspections are essential as they assist us in performing incremental quality improvements that help serve and benefit our veterans," Schaner wrote in a follow-up email. "Additionally, when we feel change is needed to improve care to our veterans and meet our mission, we will do so."
Attempts by the Lewiston Tribune to reach Yoder were not successful.
The Division of Veterans Services statewide administrator, David Brasuell, did not respond to requests for interviews about the Lewiston vets home, nor did Yoder's permanent replacement, Kenneth Shull. District 2 Veterans Affairs Commission member Leo Dub of Orofino said he didn't know anything about why Yoder resigned, but commission Chairman Donald G. Riegel of Coeur d'Alene had one comment before declining to discuss the issue further.
"It just had to be done," Riegel said.
Surveyors find some violations could cause 'immediate harm'
Many of the 17 deficiencies found by the Department of Health and Welfare Bureau of Facility Standards were relatively minor, and only threatened to cause "minimal harm," according to the February inspection. Examples include not making the results of the most recent inspection easily available for residents, and improperly securing medications.
But others had the potential for what surveyors call "immediate harm." One deficiency involved a nurse who allegedly carried on a verbally and emotionally abusive relationship with a resident for more than a year before she was investigated and fired last September.
Staff members who repeatedly reported the abuse were ignored, and eventually gave up, according to the inspection. And even after the investigation, the vets home did not report the abuse to the Bureau of Facility Standards as required by state regulations, and did not provide evidence that corrective action was taken with all employees involved, including management.
There are several documented incidents between the nurse and the resident, but in general, she would alternatively flirt with and verbally abuse him, according to the report.
"These things are said to have often left (the resident) crying and feeling confused," according to the report.
And even after the nurse - who is referred to only as "LN #19" - was fired, she frequently returned to the home to visit a relative. On these visits, she would continue to tease the resident in a sexual nature, according to the report.
"The Idaho State survey team determined the facility failed to protect a resident from further abuse when they allowed a facility staff member, who was terminated for the abuse, (to) enter the facility without structured guidelines and/or supervision," according to the report. "It was determined the facility failed to ensure all allegations of abuse, neglect and/or mistreatment were immediately reported, residents were immediately protected, allegations were thoroughly investigated, and appropriate corrective action was taken."
The resident was even put on suicide watch at one point due to his interactions with the nurse, according to the report.
When interviewed by the state survey team, Yoder claimed she was unaware of the extent of the situation until the September investigation.
Surveyor observes staff using residents' blankets to wipe mouths
Other deficiencies involved how staff at the home failed to care for the residents in a way that builds dignity and respects individuality. For example, staff members would sometimes use residents' clothing protectors or blankets to wipe their mouths.
"(Certified nursing assistant) #17 was observed to reach for the right hand corner of the blanket covering the resident's right shoulder, wiped the resident's mouth with the blanket, and placed the corner of the soiled blanket back on the resident's right shoulder," one surveyor wrote of observations on Feb. 14. "CNA #17 did not replace the resident's blanket."
Surveyors also cited the vets home for failing to make sure one resident's end-of-life directives were clear; failing to develop policies that prevent mistreatment, neglect or abuse, or theft of residents' property; failing to ensure a resident's comprehensive care plan was revised after an assessment; failing to provide adequate assistance for some residents who need total help with personal hygiene; failing to ensure each resident's drug regimen was free of unnecessary drugs; and failing to keep the rate of medication errors lower than 5 percent.
The home was also cited for not making sure all services meet professional standards. Examples included failing to have a resident rinse her mouth after inhalation of a steroid medication, which can lead to oral fungal infections; signing that medications had been administered before they were actually administered; and leaving medications unlocked and unattended.
It also failed to provide necessary care and services to maintain the highest well-being of each patient by not ensuring residents received interventions for pain control, bowel care or breathing issues, according to their plan of care.
Ultimately, the survey team found that the home was not administered in an acceptable way that maintained the well-being of each resident.
"Based on staff interviews, review of the facility's abuse investigations, review of the facility's policies and procedures on abuse, and record review, it was determined the Administrator, (director of nursing), and management team failed to manage the facility to ensure the safety and well being of each resident," the team wrote.
The director of nursing during the inspection is among those who no longer work at the Lewiston vets home.
The most serious violations were corrected immediately, while lesser violations were the subject of a correction plan that was successfully implemented by an April 15 follow-up visit by two members of the survey team, according to the report.
Lewiston site fairs poorly compared to state, national averages
According to the website www.medicare.gov/nursinghomecompare, the Lewiston vets home compares unfavorably to its counterparts in Boise and Pocatello. The Boise home carded five deficiencies after its May inspection, and the Pocatello home had 10 deficiencies after its March inspection.
The state average is 11 deficiencies per inspection, and the national average is 6.8.
"So 17 is high," said Niki Forbing-Orr, a spokeswoman for the Department of Health and Welfare, which conducts the inspections at both public and private nursing homes.
Lewiston scored an overall two-star (below average) rating, compared to Boise's five stars (much above average) and Pocatello's three stars (average). On health inspections, Lewiston scored one star (much below average), while Boise and Pocatello scored four and three, respectively.
According to two earlier inspections of the Lewiston vets home, quality there had been declining since Yoder took over in 2010. An inspection in September 2010 found eight deficiencies, and an inspection in November 2011 found 11 deficiencies.
There was also a gap of nearly 16 months in between the November 2011 inspection and the February inspection this year when problems at the home seemed to mount. Forbing-Orr said recertification inspections are required to be performed at least every 15.9 months, so the survey team scheduled the February inspection to meet that deadline.
Forbing-Orr said the length of time between inspections was the result of staffing shortages.
"We've had a number of retirements and some turnover in our facilities and standards program," she said in an email to the Tribune. "Training for surveyors is pretty extensive, and it takes some time for them to get up to speed and be able to carry a full load. So we were not as current as we'd like to be."
Forbing-Orr declined to make anyone from the Bureau of Facility Standards available for an interview to put the violations at the Lewiston home in context. She said the bureau's manager was reluctant to compare facilities because "sometimes good facilities have bad things happen, and then there are just bad facilities."
She said a better measure of a facility's quality is how it responds when something bad happens.
"It looks like the VA really stepped up and cleaned up what they needed to," Forbing-Orr said.
Mills may be contacted at firstname.lastname@example.org or (208) 848-2266.