Deaths, Abuse At NJ Nursing Home Prompt State Take Over: Report
SUSSEX COUNTY, NJ — One nursing home resident was found "visibly blue" and another was "unresponsive," yet the staff at the troubled center did nothing, according to a scathing report by state officials. Both of those residents later died without any attempt to use an automated external defibrillator, attempt CPR or call 911.
The list of troubling deaths and abuse at the facility, which was formerly known as Andover Subacute and Rehabilitation II, has prompted New Jersey's Department of Health to step in on Thursday.
The facility, since renamed Woodland Behavioral Health and Nursing Center, previously came under scrutiny and state monitoring after 17 bodies were discovered crammed into a makeshift morgue in April 2020 during the early portion of the COVID-19 pandemic.
One of the residents' deaths in the latest report occurred on New Year’s Day. The patient was found "unresponsive without a pulse or respirations" and was pronounced dead 10 minutes later. The 55-year-old resident had previously been alive an hour and 35 minutes before, the report said. Staff did not use an automated external defibrillator, attempt CPR or call 911.
The other resident was found dead on Oct. 8 after last being seen alive by staff 90 minutes earlier. The medical staff did not perform CPR because the resident appeared "visibly blue," "had a locked jaw" and was "far too expired," the report said.
This resident's family had requested "aggressive, life-saving treatment despite medical decline," according to the state’s findings.
State officials observed and reported other issues from a visit by the Health Facility Survey and Field Operations group between Jan. 31 and Feb. 2. The issues included the following, according to the report:
Two residents died in November after not receiving Regeneron monoclonal antibody infusions that had been ordered for them.
A phlebotomist verbally abused and cursed at a resident on Jan. 11. The director of nursing was aware of the incident on Jan. 21 but never reported the incident.
In January, a resident was left in “soiled feces" for 10 hours, from 11 p.m. to 9 or 9:30 a.m. the following morning, "despite the resident having a pressure ulcer wound to the sacrum.” The director of nursing was aware and continued to allow the certified nursing assistant who worked with the resident to work on 36 shifts in three different units through Jan. 31, the report stated.
A resident was ignored on Jan. 16 after calling for help because a catheter got stuck in a motorized wheelchair. The director of nursing was aware of the incident on Jan. 21 but did not initiate an investigation until 11 days later.
The state surveyor saw a certified nursing assistant verbally abuse a resident on Jan. 26, telling the resident they had "sneaky eyes." The employee told the resident they were going to quit their job because of them.
The facility was cited for not properly locking medications that were stored near the behavioral unit, where about 23 residents “with a history of suicidal ideations” were able to walk freely.
The facility did not use appropriate infection control after a COVID-19 outbreak between Dec. 23 and Jan. 1, with 102 new staff and 131 new resident cases.
There were deficiencies in certified nursing assistant staffing on all 14 day shifts observed, seven of 14 evening shifts and 10 of 14 overnight shifts.
The state's Department of Health ordered that a management consulting firm "with expertise in nursing home administration, finance and clinical operations" monitor the facility for 90 days. The state has not appointed a monitor yet, according to Donna Leusner, a spokesperson for New Jersey’s Department of Health.
If the facility does not comply with the state's corrective measures, which include notifying residents' families of the action, the facility could face other penalties, per the report.
The state Division of Certificate of Need and Licensing, Office of Program Compliance, sent the border to the facility’s administrator, Menachem Spiegel on Thursday.
Spiegel did not respond to Patch's request for comment.
New Jersey State Sen. Joe Pennacchio (R-Parsippany) and Nia H. Gill (D-Montclair) on Friday co-sponsored a bill, SR48, that called for the establishment of a “New Jersey Nursing Home Pandemic Response Investigation Committee,” according to a news release. Pennacchio previously called for an investigation into the executive branch’s pandemic response in May 2020.
"The only way that we can ensure the public receives the answers they deserve is to have this committee in the legislature,” Gill said. “We must have a comprehensive report on how our system of care failed seniors and their families and how we can improve these systems going forward."
Questions or comments about this story? Have a news tip? Contact me at: jennifer.miller@patch.com.
This article originally appeared on the Hopatcong-Sparta Patch
