Patient harm allegations raise red flags at Boulder City veterans home

One resident suffered heat stroke and blistering on his thighs after Nevada State Veterans Home staff left him in the summer sun.

Another was given medication without his family’s consent.

And when one man was struck by his wife, who also slapped another resident, police weren’t called and nothing was done for two days. Staff eventually did meet with the visitor to discuss what happened.

These are a few of the allegations substantiated by state investigators in recent months at the veterans home in Boulder City, Nevada’s only state-run nursing home for veterans.

The problems that also have drawn the attention of the state attorney general’s office jeopardized residents’ safety and the long-term care provider’s federal funding, a situation that largely has been eclipsed by high-profile troubles at other state medical campuses, such as Rawson-Neal Psychiatric Hospital.

State officials say they are keeping close watch on the veterans home, which opened in 2002 and has the capacity for 180 residents. The facility is open to veterans, spouses of veterans and parents of those killed in action. It offers a range of services for those who require special care or supervision, but the quality of that care has been called into question.

Gov. Brian Sandoval’s office directed questions about the veterans home to other state officials. Although asked repeatedly when Sandoval was made aware of the issues, spokeswoman Mary-Sarah Kinner did not provide an answer.

“Policies were not followed and corrective action has been taken,” Kinner said Tuesday. “While disciplinary actions have already occurred, (Sandoval) is receiving regular updates and will take additional action should it be necessary.”

Frank Bellinger, administrator at the facility, said Tuesday he was advised not to comment by the Nevada attorney general’s office, which is investigating the veterans home.

The attorney general’s spokeswoman wouldn’t confirm whether an investigation has been launched.

In May and June, state investigators were at the facility looking into a Medicare complaint with three allegations, including the slaps by a visitor. All three allegations were substantiated, and several deficiencies were identified.

In August, state investigators returned to the facility for a follow-up and to look into an additional patient safety complaint. One of two allegations was substantiated, the case of the resident who was left outside in extreme heat.

The most serious deficiencies were isolated incidents resulting in harm to patients, according to a letter dated Aug. 19 sent to Bellinger by the Nevada Department of Health and Human Services’ Division of Public and Behavioral Health.

The Centers for Medicare and Medicaid contracts with states to investigate facilities that participate in its programs.

In August, the Centers for Medicare and Medicaid sent an “enforcement notice” to the veterans home, imposing a denial of payment for new patient admissions effective Sept. 14 and a civil penalty of $425 per day effective June 18, according to Jack Cheevers, spokesman with the federal centers.

At the beginning of September, officials sent an amended notice to the facility delaying the start of the civil monetary penalty to Aug. 9. It also informed veterans home officials that it would be terminated from the Medicare program on Feb. 19, 2014, unless it complied with Medicare regulations, Cheevers said.

The Nevada State Veterans Home submitted a plan of correction and, as of Oct. 21, was found to be back in compliance with federal participation requirements for nursing homes participating in the Medicare and/or Medicaid programs. The home’s administrators had until Thursday to pay $20,165 in accumulated fines to the federal agency.

Kat Miller, director of the Nevada Department of Veterans Services, which oversees the veterans home, said last week the payment would be made on time. She would not comment on whether any employees have been terminated or disciplined in relation to the case.

“Personnel matters are confidential pursuant to state law,” she said.

In fact, that information is already public. Investigation documents posted on state government websites show at least one certified nursing aide was fired. They also show the departure of a nurse manager was related to investigators finding that clinical records lacked documentation that family consent had been obtained before a resident was given a psychoactive medication.

Policy changes were made. Employees were trained on when to report suspected abuse to appropriate agencies, such as the police. Employees also were disciplined, counseled or trained as part of the corrective action at the facility, according to reports from the June investigation.

State Sen. Joe Hardy, R-Boulder City, said he wasn’t aware of the specific problems. A family doctor, Hardy said problems are not uncommon at medical facilities. Outcomes of neglect always make everybody feel bad, he said.

“It’s certainly sad when we find that we dropped the ball,” he said.

Hardy, who toured the facility about four months ago, said he was impressed with the staff and its work. He said problems will only motivate staff to continue “to take care of people and avoid having people fall through the cracks.”

Assemblyman Elliot Anderson, D-Las Vegas, said he is still trying to put the facts together. He is an appointed member of the Nevada Veterans Services Commission.

“I just don’t have a clear picture,” said Anderson, who is a veteran. “I certainly think it’s a serious matter, and I’m doing my due diligence now.”

Robert Garlow, state commander for the Veterans of Foreign Wars and chairman of the Nevada Veterans Assistance League, said he volunteers about once a week at the home and believes the incidents are isolated.

Garlow said most residents feel “extremely happy with the care that they are receiving.”

“My wife and I volunteer,” he said. “We pass out ice cream. We get to see pretty much every single one of the residents.”

In late 2012, the facility had a Medicare recertification survey during which problems were also found. Those included at least two contract employees who had not gone through background checks and had no abuse-prevention training.

On Nursing Home Compare, a website where people can review nursing homes, the Nevada State Veterans Home receives four stars. However, the latest inspection reports are not included.

Boulder City Mayor Roger Tobler said he couldn’t comment on the complaints, but said he hopes the facility is able to get past those issues.

“In the past they’ve had an excellent rating. We are still very glad they are in our community and they are part of our community. It reminds us of our veterans every day.”

One of the few things Bellinger said about the facility to a Review-Journal reporter last week: “What I will say is that we are proud of our home and proud of our care.”

Reporter Yesenia Amaro can be reached at 702-383-0440, or yamaro@reviewjournal.com.