The most recent inspection of a Maryland veterans home found the private operator failed to report abuse allegations after staff “forcibly” sat a resident in a chair and left them there for hours and also failed to implement its own procedures for reporting abuse, causing the home to fall out of compliance with state and federal requirements.
The state Office of Health Care Quality initiated the February survey in response to complaints filed on the treatment of Charlotte Hall Veterans Home residents, according to Carter Elliott IV, a spokesperson for Gov. Wes Moore.
While inspections dating back to 2018 found abuse and neglect at the home and top officials in Gov. Larry Hogan’s administration acknowledged the worsening conditions were “well documented,” this review marks the first where the contractor running the home had failed to report abuse allegations to state officials as required by federal regulations.
Also among the findings: Private operator HMR of Maryland LLC failed to implement policies and procedures for reporting abuse claims, also a federal requirement. In addition, inspectors found staff neglected patients, ignored individualized care plans and failed to maintain a “rodent free environment.”
HMR of Maryland LLC Vice President Russell Keogler said the February report’s findings are preliminary and under review.
“HMR’s internal investigation does not support the details in the report, and we have submitted our findings to the Office of Health Care Quality,” Keogler wrote in an email. “We have policies and procedures in place to prevent abuse and neglect, and we follow them.”
Skilled nursing homes across the country must be in compliance with federal requirements to remain eligible for Medicare and Medicaid reimbursement. In Maryland, the Office of Health Care Quality, a division of the state health department that inspects nursing homes across the state, performs the inspections. But because the state in essence inspects itself, the regional office of the Centers for Medicare and Medicaid Services provides additional oversight.
Serious health and fire safety violations result in financial penalties, and for the last three years, the Centers for Medicare and Medicaid has fined Charlotte Hall $265,567.
In February, inspectors with the Office of Health Care Quality surveyed 52 residents’ medical records, interviewed residents and staff and observed facility operations over several weeks.
Surveyors found the home’s non-compliance resulted in actual harm to patients.
Despite multiple nurses telling administrators that staff kept a resident confined to a chair pushed up to a table for hours, the facility managers did not report the abuse allegations to the veterans affairs department. Federal regulations require a facility manager to report abuse allegations within two hours.
The resident, who suffered dementia and needed “total care,” including help using the bathroom, had a care plan which instructed caregivers to frequently check the resident’s skin for cuts, ulcers, blisters and other injuries and walk with them and talk to them for stimulation. The patient had a history of wandering and falls and wore a soft helmet for protection.
During four recorded incidents in 2022, staff kept the resident in a hard reclining chair, sometimes forcibly and despite the resident’s protests. In one instance, the resident was in this seated position for 7 1/2 hours.
Staff failed to take the resident to the bathroom or change continence garments. In one video, the inspector could see the resident had wet themselves.
Weeks later, open pressure sores appeared on the resident’s lower back.
An assistant administrator, an HMR employee, who reviewed the video of the resident sitting for 7 1/2 hours, told inspectors they did not find abuse. And the allegation was not reported to the veterans affairs department, according to the report.
An inspector’s interview with HMR leadership revealed “the facility had offered no rationale for their failure to implement their abuse policies and procedures,” according to the report.
Federal code says long-term care facilities ”must not” involuntary seclude residents and residents have a right “to be free from any physical or chemical restraints imposed for purposes of discipline or convenience.”
And they also must keep the physical environment free of pests and rodents.
But that is not what inspectors found. Four residents said they frequently saw mice. One told of mice scurrying from one room to the next picking up crumbs of food. Another resident told an inspector that “a mouse had come out often in his/her room, however, recently s/he had not seen that particular mouse but it had been replaced by 2 more,” according to the report.
And inspectors observed mouse droppings in four residents’ rooms.
After the veterans affairs department was notified by HMR, they hired a new pest control company in January, according to Elliott. When asked, HMR did not say whether the issues had been resolved.
Since the reports of abuse and neglect have surfaced and Moore announced he’ll hire a new operator, legislators in the General Assembly have taken swift action that requires contractors running state-owned nursing homes to report allegations of abuse within 30 days to the governor, the legislature and the Maryland Department of Veterans Affairs.
Elliott, the Moore spokesperson, said that for the home to get back in compliance, the Maryland Department of Health must first approve HMR’s corrective action plans. Then an unannounced follow-up survey must be conducted.
“After the nursing home resolves any deficiencies on the follow-up survey, it will be back in compliance,” Elliott wrote in a statement.
On March 31, a team of nurses hired by the Moore administration completed health and wellness assessments on 213 patients. The veterans affairs department is currently reviewing the results, according to Elliott.