Walla Walla nursing home cited for injury to patient

A resident suffered burns after he apparently fell out of bed and was lying with his shoulder against a wall heater.


WALLA WALLA -- A nursing home has been cited by the state of Washington for its care of a patient.

As a result of a February incident, Park Manor Rehabilitation Center on Plaza Way was found to have failed to provide care and services for an extended time to city resident Vern Studer, who has since died.

The incident was also investigated by Kathy Stevenson from the Walla Walla-based office of the Eastern Washington regional state ombudsman program for long-term care. Stevenson confirmed the incident and the patient's name.

The nursing home received a "G" rating, noted David Moon, regional administrator of Aging and Disability Services Administration for the Department of Social and Health Services.

The letter rating means harm was caused to a patient, Moon said.

After an investigation following the injury to Studer, the state found the patient was in declining health and had recently been hospitalized at the time of the incident, which happened between 9:30 p.m. on Feb. 13 and 3:10 a.m. on Feb. 14.

Besides being partially paralyzed and experiencing fluctuating mental alertness, Studer had developed a respiratory infection. The door to his room was being kept shut to prevent spread of the bacteria. He was on "comfort care" measures and had asked to spend most of his time in bed. However, chronic back pain dictated the patient not be placed on his back according to the state's report, which does not name Studer.

A plan of care called for Studer to be checked and turned by staff every two hours, Moon said.

A response by Park Manor employees indicated staffing was short that night, with one nursing assistant caring for 27 residents. Studer's primary caregiver told investigators she had gotten "sidetracked with other residents that night, got busy" and "forgot" to check on Studer until 3:10 a.m.

That was four hours and 40 minutes after shift change, the report noted. It was then the employee found Studer lying on his back on the floor, with his shoulder up against a wall heater. He had suffered second-degree burns.

With his door closed, no one had heard Studer's calls for help, the state's report said.

The investigation also revealed he was lying on his back at the 9:30 p.m. check, despite written instructions he be positioned on his sides. The nurse in charge did not change Studer's position, nor instruct other staff to do so.

"Despite the resident's declining change of condition and need for repositioning every two hours, no staff checked on the resident for approximately 5.5 to 6 hours, during which time he fell from his bed and sustained burns on his back," the investigation summarized.

Studer was hospitalized. He died Feb. 25. The report does not connect the injury to his death, Moon said.

Park Manor, which has traditionally done well in periodic inspections, has taken corrective action. That includes addressing facility policy for routine monitoring and repositioning of patients, and keeping nursing assistants supervised by licensed nurses, according state, which accepted Park Manor's plan.

Chris Bohnsack, administrator for the nursing home, said the Studer family indicated to her they were supportive of the care he received as a resident and while receiving end-of-life care, and "have not been critical in any way."

While the state has the obligation to "make certain findings under regulations," she maintains overall care to every resident is "entirely appropriate," Bohnsack said this morning. "We're very proud of and stand behind the care of our staff, and the work they do on a daily basis. We work very hard to meet the needs of residents."

When employees are unable to come to work, "we do everthing in our power to make sure their duties are covered by others," she said.

Having appropriate staffing is a huge issue in skilled nursing facilities, Stevenson, the ombudsman, explained. Events such as Studer's injury draw attention, she said, "but how many little things are not reported?"

She worries nursing homes that remodel for and focus on rehabilitation may pay less attention to residents on the traditional nursing home wings, Stevenson explained. "There can be huge discrepancies in the ways they are treated."

Sheila Hagar can be reached at sheilahagar@wwub.com or 526-8322. Check out her blog at blogs.ublabs.org/fromthestorageroom.


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