Uihlein draws major fine
Inspection after accidental overdose, death last summer found widespread deficienciesBy JESSICA COLLIER, Enterprise Staff Writer
Adirondack Medical Center's Uihlein nursing home in Lake Placid has been fined $75,497 for a number of quality-of-care issues, including a death following an accidental drug overdose last summer.
The penalty, levied by the federal Centers for Medicare & Medicaid Services, was originally $116,150 but was reduced by 35 percent after AMC waived its right to a hearing.
That $75,497 fine is almost two times as much as any of the other federal fines levied on 18 New York nursing homes between Dec. 1, 2008 and Feb. 28, 2009, as reported by the Long Term Care Community Coalition, and advocacy group.
The Aug. 8, 2008 inspection, done by the state in response to a complaint, found nine violations that constituted immediate jeopardy to residents' health and safety, one violation that caused actual harm to residents and three that had the potential for more than minimal harm.
Most of the violations were deemed to affect more than a limited number of residents, and six were ruled to be widespread problems caused by deficiencies throughout the facility and have the potential to affect a large portion of Uihlein's residents.
Since then, AMC has started doing monthly audits and is recruiting more staff for the nursing home.
Most of the violations were tied to the death of an 81-year-old man in the summer of 2008, according to the Statement of Deficiencies issued in November 2008 by the state Department of Health.
The man was admitted to Uihlein from AMC's main hospital in Saranac Lake. An order from the hospital prescribing 0.125 milligrams of Xanax, an anti-anxiety drug, every two hours was mistakenly transcribed as 1.25 mg every two hours, according to the document.
The resident was given two 1.25 mg doses of Xanax and fell into a coma that took five hours for nurses to report to a physician.
A clinical pharmacology report for alprazolam, the generic form of Xanax, recommended that elderly people not exceed a dose of 0.75 mg a day "unless higher for functional status."
The DOH report does not specify that the overdose was the cause of death but makes it clear that an overdose was the reason the patient was readmitted to the hospital from Uihlein.
AMC spokesman Joe Riccio could not comment on the specific case due to patient privacy laws, but he said that since that incident, AMC has started doing monthly audits that span a wide range of areas "to make sure that educational efforts we're offering to staff are providing the intended outcome."
He said the audits are reported monthly to the AMC Board of Trustees, and they've shown Uihlein making significant progress. For one thing, Riccio said, Uihlein hired more staff at a recruitment fair last week.
The August inspection was followed by one in November that resulted in nine violations, but none were for actual harm done to residents; they were all deemed to only have a potential for more than minimal harm. None of them were widespread. A December inspection turned up one isolated violation.
LTCCC Executive Director Richard Mollot said that studies have found that inspectors often don't find the worst problem.
"Quite often, it's the tip of the iceberg at a facility," said Mollot.
Riccio noted that AMC self-reported the incident to the DOH and fully disclosed information about it to residents and the families involved at the time.
"We welcome these opportunities for quality improvement, and our number-one goal is resident safety and enhanced quality of life," said Riccio.
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Hanuman
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06-19-09 10:56 PM
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My mother passed away this past Oct. after being at Uihlein for 3 years. She had Alzheimer's disease. When she was in the last stages of her dementia someone at Uihlein took advantage of her situation and robbed her of her engagement ring/wedding band. It was the only piece of Jewelry my mom had to remind her of her deceased husband. Uihlein denies any culpability in this incident despite a state police investigation. No one person could be singled out, so the case remains open and Uihlein refuses us any compensation for our loss. This on top of less than quality care forcing us to hire extra help, outside the agency for our own peace of mind. Unfortunately on the day of the incident our help was not working. What a coincidence. I know how hard it is on the health care workers who do the messy work there as they are always been understaffed and mandated to unhealthy overtime hours. I would like to think that the administration would at least face up to it's responsibilitys.
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Denise
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06-18-09 4:00 PM
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Yes, the Administration SHOULD be on top of all issues. I complained for years over my loved one's care and was made out to be the "bad guy". I've spoken with staff - they are afraid to speak up for fear of losing their jobs... and, Shipsaint, I did volunteer. I spent as many hours as I could over there, even though I lived 20 miles away and work full time. All I got was dirty looks from the Administrator because I called it as I saw it. I can't tell you how many times I left there in tears. I felt so helpless because I couldn't help all the poor, old, fragile folks that needed help. Volunteering is a wonderful thing to do and we should all help, HOWEVER, the ultimate decision making is up to the Administration and they have to make sure that there is enough trained staff on duty.
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hockeylover
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06-18-09 1:31 PM
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Where is the administrator in all this? Isn't it their job to oversee all of the care. My mom died there and I had to be there everyday as the care wasn't good. unfortunately we couldn't care for her at home we weren't qualified but we were constantly complaining and had to be there as the administrator was deaf to our complaints. It is about time someone is doing something but it should start with the one in the facility who is in charge.
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shipsaint
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06-18-09 10:14 AM
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instead of everyone shooting the place down,VOLUNTEER,everyone has so much to say but no efforts to help.and yes these kinds of mistakes happen all over this country,the staff is human,humans make mistakes.fish crek,im not trying to make you mad,but if you were umhappy with the care your mom got,take her home and care for her yourself.,you can turn a patient every hour but once a bed sore arrives on a person whos bed ridden,its almost in possible to ride them,uihliens is short staffed and doing the best they can.
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Denise
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06-18-09 8:08 AM
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It's about time that the State got in there and did some serious investigating! I personally have witnessed too much resident neglect (over years) as a result of understaffing. I applaud the staff that is there, but they are stretched way too thin. This travesy is a direct result of poor management and administration. I hope the State stays on top of them.
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contrary1
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06-18-09 8:06 AM
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It would have been nice to hear Mr. Riccio express a little sympathy for the mans family, before he called his death a great opportunity.
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graymare47
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06-18-09 1:39 AM
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What about the pharmacy...didn't they pick the error up??
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GUFFSHENE
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06-17-09 10:25 PM
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My mom died in uihlein 3 yrs ago at the age of 96. In my visits to her she always seemed well taken care of and happy. I`m sure that there are cases in ALL nursing homes of mistakes or causes by uncaring or unqualified employees, but i don`t think uihlein is a blantent screw up and gives quality care 99.9% of the time. Accidents happen in every area of life. I wonder if nursing homes carry malpractice insurance?
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FishCric
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06-17-09 7:39 PM
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its not the company its the savages they employ. my moms bedsores haunt me till this day. age sux
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mittymick
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06-17-09 3:54 PM
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"We welcome these opportunities for quality improvement...." Is Riccio really that moronic? Is he saying without the med error and the old guy dying AMC wouldn't have had an opportunity for "quality improvement"? All I have to say is the hot mess AMC is currently experiencing is due to management. From the top down. Shame, shame on them.
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NativeTransplant
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06-17-09 3:02 PM
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I would imagine this report will lead to a lawsuit against Uihlein as well? That will surely cost them more than 75k. Ah, misplaced decimal points... the downfall of those guys from "Office Space" and Uihlein alike.
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