Colton Villa cited in state report

January 16, 1999|By BRUCE HAMILTON

The Colton Villa nursing home in Hagerstown was forced to stop taking Medicare and Medicaid patients in December, following a state report that said it failed to prevent accidents among its residents.

The home's executive director, James Mitchell, disputes the report and has appealed for a reversal.

In a nursing home with 133 residents, he said, "It's impossible to state that no one will ever have an accident."

"Colton Villa feels we have provided more than adequate supervision for our residents," he said.

Last November, a Maryland Department of Health and Mental Hygiene inspector found the nursing home could have prevented a accident in which a female resident fell out of bed and broke her hip.

The state also said the home failed to investigate another case in which a woman choked on a potato. Because her brain was deprived of oxygen, the woman lost the ability to communicate. She left the hospital with a permanent feeding tube, according to the state.


After the inspection, the state recommended that the federal Health Care Financing Administration stop funding new Medicare and Medicaid admissions to the home.

The agency imposed the ban on Dec. 23 and Colton Villa stopped taking those patients the same day.

Colton Villa requested an "informal dispute resolution" from the state to appeal its citation, according to Mitchell.

The nursing home has 150 employees and 160 beds.

Among other safety devices, it uses bed and chair alarms to detect movement, according to Mitchell. The alarms can let nurses know when a resident is trying to rise.

Federal regulations require the facility to "assure that each resident has adequate supervision and assistance devices to prevent accidents."

A state inspector cited Colton Villa for supervision "deficiency" on Aug. 21, 1998.

In a follow-up November inspection, an inspector found more problems. According to a report, an 82-year-old woman slipped out of her wheelchair several times. The resident had a history of dementia and frequently became agitated. She often disconnected her alarm.

On Sept. 8, a doctor recommended evaluation for a "low bed" in order to minimize injury, the report says. The woman did not receive the bed and the doctor's order was rescinded Sept. 26 "due to resident not falling out of bed," according to the inspector.

Although she was given a "wedge cushion," the woman fell out of her wheelchair on Oct. 16 and 18, the report says. Although staff recommended "one-on-one supervision," according to the report, she fell out of bed and fractured her hip on Oct. 24.

"We found the nursing home could have prevented the accident," said Licensing and Certification Administration Director Carol Benner.

The state also cited Colton Villa for failing to fully investigate an Aug. 30 incident in which an 85-year-old woman went to the emergency room after an employee noticed she had turned blue during lunch.

Doctors noted "a piece of potato was stuck in the area of the rear pharynx," the report says.

The woman was previously on a "mechanical soft diet." The state inspector found she was served whole boiled potatoes on the day of the accident. A nursing assistant was unsure whether anyone cut up the potatoes, according to the report.

A Nov. 11 interview of administrative staff revealed Colton Villa conducted "no formal investigation" to prevent a recurrence, the report says.

Mitchell would not comment on the details of the incidents, citing patient confidentiality.

He said Colton Villa provides excellent care. A survey sent to residents' families found 90 percent were either satisfied or very satisfied with the nursing home, according to Mitchell.

"There are a lot of family members very pleased with the service out there," he said.

The state has not scheduled a date for the dispute resolution, but Mitchell said he is confident he will win the appeal.

Colton Villa is owned by Beverly HealthCare, a national company with more than 500 facilities.

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