Bremerton nursing home fined $550k following death of resident

June 24--BREMERTON -- Sometime after midnight on a chilly morning last October, a resident wandered unseen out the doors of a Bremerton nursing home.

At 2:25 a.m. an employee found the man lying in the parking lot with his head resting on a curb. Hours later, he was dead.

State Department of Social and Health Services surveyors who investigated the incident found Forest Ridge Health and Rehabilitation Center had few safeguards in place to prevent vulnerable residents from leaving the facility unsupervised and botched medical care for the resident after he returned to the home, directly contributing to his death.

Based on the findings of the survey, the U.S. Centers for Medicare and Medicaid Services penalized the Marion Avenue nursing home $552,109 on Dec. 12, said a spokeswoman for the agency.

Forest Ridge completed a mandatory correction plan in January, addressing the problems identified in the state investigation.

According to a statement provided to the Kitsap Sun on Friday by Forest Ridge administrators, the facility immediately reported the incident to the state last fall and fully cooperated with the ensuing investigation. Administrators said Forest Ridge made changes needed to improve building safety and better educate staff.

"Our team was close with this long term resident, and we were honored to provide care to this resident for many years," according to the statement. "Our deepest sympathies and condolences have gone out to the resident's family and friends, and we continue to keep them in our thoughts."

Documents from the case were recently made available online, though the penalty has not yet to been posted on Medicare's Nursing Home Compare website -- a key information source for consumers.

Resident left unseen

A December report from the Department of Social and Health Services surveyors -- called a statement of deficiencies -- describes the events that led up to the resident's death, though details such as his name and medical conditions were redacted.

According to the report, the man had some level of cognitive impairment and experienced hallucinations and delusions. He had expressed a desire to leave the facility and often sat in the lobby, looking out the front door. Despite these potential red flags, the nursing home had not flagged the resident as a risk for "elopement" (the word used by officials) and he was allowed to move freely within the facility.

A Forest Ridge nurse told surveyors she remembered seeing the resident sitting near the front doors at about midnight on Oct. 10, 2016. Later, the nurse noticed the resident had disappeared. She assumed he'd gone to bed but didn't check his room.

At 2:25 a.m., a pharmacy worker found the man lying in the parking lot, his head propped against a curb, shivering in the 40-degree weather.

Botched care

The man was taken to an emergency room for treatment and returned to Forest Ridge at 6 a.m., according to the report. After he arrived back at the nursing home, investigators determined facility staff made critical mistakes while administering care that directly contributed to his death.

The man was suffering from low oxygen blood levels and was fitted with an oxygen mask. Staff didn't supply adequate oxygen flow to the mask, however, allowing excess carbon dioxide to remain in his bloodstream -- a condition that can lead to organ failure.

The man also was breathing rapidly and staff noted abnormal noises coming from his lungs. Despite this, caregivers continued to rapidly administer intravenous fluids, causing liquid to build up in his lungs and making it difficult for him to breath, according to the survey report.

The man's condition worsened and he died at 2 p.m. The cause of his death was redacted from the survey report.

An outside source involved in the case told surveyors the man was not in bad health before the incident and was "not ready to die."

Few safeguards

Investigators found Forest Ridge had few safeguards in place to prevent residents from leaving the facility without warning. There also was no easy way for residents to reenter the building if they walked out at night.

The front doors of the facility could be locked to prevent outsiders from coming in but could still easily be opened from the inside. There were no alarms to warn staff when a door was opened and no cameras monitoring exits. Staff weren't sure if the doors had been locked on the night of the fatal incident.

The facility had a doorbell, however the button was white and mounted on white trim, making it difficult to see. Several residents told investigators they didn't know the building had a doorbell. One said they might break a window to get back in if they were stuck outside at night.

Slow response

After the man died in October, Forest Ridge completed a cursory internal investigation, according to the Department of Social and Health Services report.

The facility's review -- filed 15 days after the man's death -- did not include witness statements. The report ruled out abuse on the part of the nursing home and ignored issues of neglect that allowed the resident to leave and mistakes made during treatment after he returned from the emergency room. The Forest Ridge report labeled the event as an "unexpected death."

State surveyors noted the delayed and incomplete internal review prevented staff from making changes necessary to protect other residents.

Corrections made

Surveyors made six visits to Forest Ridge in November and December, and notified the facility of an "immediate jeopardy," based on the elopement incident as well as an unsecured construction area in the building.

The facility responded by implementing a number of changes to keep residents safe, including making doorbells visible, installing alarms on doors and ensuring doors were locked. Staff and residents received additional education and audits were completed to check compliance.

Forest Ridge corrected the deficiencies identified by investigators by mid-January, according to a Department of Social and Health Services notice dated Feb. 1.

According to the statement from Forest Ridge: "We realized areas for improvement and immediately enhanced our building security and provided further education for our staff both on building safety and providing respiratory assessments. As a result, our center is currently in full regulatory compliance."

Problems persisted

Even as the nursing home dealt with the fallout from the resident's death, new complaints emerged.

According to a survey report filed in March, Forest Ridge failed to take steps to prevent multiple suicide attempts by a resident in December. The suicide attempts were not immediately reported to the state as required, or investigated by the facility.

The Centers for Medicare and Medicaid Services fined Forest Ridge$10,757 based on the state's investigation of the incidents.

Most facilities above average

It's not uncommon for the federal government to penalize nursing homes, but the $552,000 fine levied against Forest Ridge was the largest in recent years.

Six of Kitsap's nine nursing homes were fined in the past three years, according to Nursing Home Compare. Aside from the penalty against Forest Ridge, the largest fine handed down was an $18,200 penalty against Stafford Healthcare at Belmont in Bremerton in early 2016.

Seven of the county's nine homes were rated "above average" or "much above average" in the latest Nursing Home Compare rankings. Forest Ridge was rated "below average," while LifeCare Center of Port Orchard carried a "much below average" rating.

The ratings system is based on surveys of health and safety, staffing and quality of care.

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