Appendix — O'Bannon v. Town Court Nursing Center
Supreme Court brief1980
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EILED
JUN 11 1979
APPENDIX ‘ond “wiouaet RODAK, JR., », CLERK _
(VOLUME I—Pages 1a-190a)
in the Supreme Court of the
Unjted States
oct.
GED Term, 1979
No. 78-1318
HELEN B. O’BANNON, SECRETARY OF
PUBLIC WELFARE,
Petitioner
VS.
TOWN COURT NURSING CENTER, et al... > .
Respondents
\
’
. “
On Writ of Certiorari to the-United States Court
of Appeals for the Third Circuit.
i%
= aE —
Murrelle Printing Co., Box 100, Sayre, Pa. 18840—(717) 882-0401
Petition for Certiorari Filed February 26, 1979
Certiorari Granted April 16, 1979
TABLE OF CONTENTS
PAGE
VOLUME I:
Rit DORM hd it er i a la
I. Verified. Complaint . 0. 0.05.6 6 See ees 7a
III. Motions for Temporary Restraining Or-
der and Preliminary Injunction ........ 15a
IV. Order Dated July 21, 1977 ............ 22a
[Scheduled Hearing Transcript of Testi-
mony and Exhibits Appear in Vol-
ume II. ]
V. Defendant Beal’s Motion To Dismiss ..... 24a
VI. Defendant Califano’s Motion To Dismiss 26a
VII. Plaintiffs’ Motion for Extension and Re-
newal of Preliminary Injunction ........ 28a
VIII. Opposing Affidavit of Claudette V.
COR eee re ee BE eR iG 30a
PE FF 5a 5 ie alee Relde warns Ca 36a
EE Feo av cahoneteyeoaen 54a
PNG Og CA aN i oe Sreree 58a
Re rs a. ee Sas 61a
Attachment 5 ........ cic, Soe . 108 ia
[Hearing Transcript and Exhibits Ap-
pear in Volume II.]
IX. Order Dated September 15, 1977 ...... 117a
X. Further Order Dated September 15, 1977 118a
i
XI. Notice of Appeal of Plaintiffs, Emma
Cooper, Mary Crawford, Hazel Kemp,
Arnold L. Phillips, Delphine Taddei and
NRE PRUE ed eas b Otecen bake eae ew g
XII. Notice of Appeal of Town Court Nursing
CHORE, TRG oye ee acre petty eet
XIII. Motion for Injunction Pending Appeal
XIV. Order of Court of Appeal Granting
Town Court’s Motion ................
XV. Opinion Announcing the Judgment of the
Ss RS A, NAY CA oh to Or aaa aa
Concurring Opinion ...............
Dissenting Opinion ................
XVI. Order Amending Opinion ...........
XVII. Order Extending Time To File Petition
for Writ of Certiorari ...............,
XVIII. Order Further Extending Time To File
Petition for Writ of Certiorari
VOLUME II:
XIX. Preliminary Hearing, July 26, 27, 1977
19la
PLAINTIFF, TOWN CouRT NursING CENTER,
INc’s EVIDENCE:
Donald Lewis:
Direct Examination
Cross-Examination
Tobias Bund:
Direct Examination
Cross-Examination
William J. Jones:
Direct Examination
Cross-Examination
tat, Pdi cx, a AE. Ek oe ee
eeeeteee@oseceeweeeeee
noida ela
ee See ee ee eee
ee ee ee
John E. Cuminskey:
Direct Examination .............++. 229a
Cross-Examination .............5:: 248a
Dr. Maurice E. Linder:
Direct Examination .............-+. 25la
Cross-Examination .............+.- 253a
Jesse Gaynor: Pie
Direct Examination ............... 254a
Cross-Examination ..........e.508- 259a
Edward J. Zelkovitz:
Direct Examination ............--- 262a
Cross-Examination ...........++++- 263a
Redirect Examination ............-- 267a
DEFENDANT CALIFANO’S EVIDENCE:
Gerald Szuc:
Direct Examination ............--. 269a
Cross-Examination ...........++++. 282a
PLAINTIFFS’ EXHIBITS:
1—Photograph, Cobbs Creek Nursing Home 290a
2—Photograph, Town Court Nursing Center 290 12a
3—Letter Dated 5/20/77, to Donald Lewis,
Administrator, Town Court Nursing Cen-
ter, from the Commonwealth of Pennsyl-
vania, Department of Public Welfare ... 29la
4—Letter Dated 5/17/77, to Town Court
Nursing Center from the Department of
Health, Education and Welfare ........ 294a
Report by Professor Tobias Bund entitled
at “Analysis of Statement of Deficiencies
Resulting fromm Survey Conducted March
B11, 1977" vi cece new cee econ gaees 300a
6—Report by William J. Jones entitled “An
Evaluation of the Town Court Nursing
Center; June 19777") ec en
7—Report by John E. Cuminskey, Dated 6/
(MERE: Cae ear Reece et ola
8—Report by Mr. Gaynor to Mr. Jones Dated
Ts + 9 £ Se UUENr snCn Ee ermine oe eras AS
9—Report by Mr. Gaynor to Mr. Coyle, Dated
TPIDTIE ie weeks
10—Report by Dr. Finkelstein to Mr. John W.
Francks, Executive Director, Geriatric and
Medical Centers, Inc., Dated 7/12/77 ..
11—Letter from the Department of Health,
Education and Welfare to Town Court
Nursing Center, Dated July 19, 1976 ....
DEFENDANTS’ EXHIBITS:
1—Letter With Attachment Dated 5/26/77
to Donald Lewis, Administrator, Town
Court Nursing Center, from Roger A. Cutt,
Commissioner for Medical Programs,
Commonwealth of Pennsylvania, Depart-
ment of Public Welfare ..............
2—Letter Dated 6/23/77, to Roger A. Cutt,
Cormmissioner for Medical Programs,
Commonwealth of Pennsylvania, Depart-
ment of Public Welfare from Donald
Lewis, Administrator, Town Court Nurs-
Sine CORE ios ah-sse weiner + A ame WA
3—Letter With Attachment Dated 2/7/77 to
John Holbrook, Administrator, Town
Court Nursing Center, Inc., From Roger
A. Cutt, Commissioner for Medical Pro-
grams, Commonwealth of Pennsylvania,
Department of Public Welfare .........
iv
318a
343a
357a
365a
369a
378a
380a
387a
eee Lo
4—Document Entitled “Statement of Defi-
ciencies and Plan of Correction” for Town
Court Nursing Center ................
5—Document Concerning Town Court Nursing
Center Entitled ““Medicare/Medicaid Cer-
tification and Transmittal” ............
6—Report Concerning Town Court Nursing
Center Entitled ‘Medicare/Medicaid
Skilled Nursing Facility Survey Report”
XX. Transcript of Hearing Before Hon. John
P. Fullam, J. on September 15, 1977 ....
DEFENDANT'S EVIDENCE:
Claudette V. Campbell:
Direct Examination ...............
Cross-Examination .............05.
Redirect Examination ..............
PLAINTIFFS’ EVIDENCE:
Donald Lewis:
Direct Examination ...............
William J. Jones:
Direct Examination ..............:
Cross-Examination ................
Opinion and Order ................
PLAINTIFFS’ EXHIBITS:
12—Letter From Mr. Laff, Pennsylvania De-
partment of Health, to Mr. Lewis, Ad-
ministrator, Town Court Nursing Home,
Dated July 29, 1977, With Attached Re-
ME co wh GWEN CRORE NES ee ne a
13—Report From William Jones to Leonard
Coyle, Undated . .. 2.2... ee ees ce ene.
400a
423a
424a
495a
50la
512a
518a
522a
523a
526a
531a
534a
DEFENDANTS’ EXHIBITS:
7—Affidavit of Claudette V. Campbell . . .30a, 550a
8—Document Entitled ‘Fourth Presentment”
-by the Special Investigating Grand Jury
of April Term, 1976 Court of Common
Pleas of Philadelphia County, Trial Divi-
sion, Criminal Section’... 6s. eee. 55la
vi
il a oy ne S
Sitti alin Pema
— Ae I Alin eli ca. .
Oe oes i A tp ele eaten aise te
Docket Entries la
VOLUME |
APPENDIX
i.
DOCKET ENTRIES
Plaintiffs
TOWN COURT NURSING CENTER, INC.
and
COOPER, EMMA; CRAWFORD, MARY; KEMP.
HAZEL; PHILLIPS. ARNOLD L.;' TADDEI, DEL-
PHINE; TRUITT, NANCY, individually and on be-
half of the class of patients eligible for Pennsylvania
Medical Assistance Program benefits at Town Court
Nursing Center, Inc.
Vv.
Defendants
BEAL, FRANK S.., individually and in his capacity
as Secretary of Public Welfare of the Commonwealth
of Pennsylvania,
and
CALIFANO, JOSEPH A., JR., individually and in his
capacity as Secretary of the United States Department
of Health, Education and Welfare
2a Docket Entries
Cause
Civil Rights
Attorneys \ )
William F. Coyle, 1430 Land Title Bldg., Phila.,
Pa. 19110, for: All plffs. EXCEPT Town Court
Nursing Center, Inc.
Nathan L. Posner, Jeffrey D. Albert, Fox, Roths-
child, O’Brien and Frankel, 1401 Walnut St., 10th
Fir., Phila., Pa. 19102, for: Town Court Nursing
Center, Inc.
Robert deLuca, Asst. United States Attorney.
M. Faith Angell, Deputy Attorney General, 206
State Office Bldg., Phila., Pa. 19130, for: Frank S.
Beal.
Proceedings
Date Nr.
1977
1 July—-20 Complaint filed.
—July—20 Summons Exit. (2 sets) .
2 July—20 Plffs’ motions for temporary restraining
order and preliminary injunction, memorandum
of law in support and affidavit, filed.
—July—21 The sum of $100.00 deposited into Regis-
try of Court.
3 July—21 Motion and. Order appointing James
Bray, Jr. to serve the complaint and summons
upon the defts., filed.
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Docket Entries 3a
’
4 July—-21 Order that defts, agents, et al., are en-
joined and restrained until 7/26/77 from dis-
continuing or withholding payments to plff.
Town Court Nursing Center, Inc. for the care of
Medicare and Medicaid beneficiaries; plffs shall
file with this Court security to the Clerk of Court
in the amount of $100, motion for preliminary
injunction heard on 7/26/77 at 2:00 p.m. in
courtroom 15A, etc., filed. JF 7/22/77 en-
tered and copies mailed.
5 July—27 Entry of appearance of William F. Coyle
on behalf of plffs and withdrawal of appearance
of Jeffrey B. Albert on behalf of plffs., filed.
6 July—27 Hearing re: Preliminary injunction,
7/26/77, filed.
7 July—27 Hearing re: preliminary injunction,
7/27/77, T.R.O. remains in effect pending final
administrative review, filed.
8 July—-27 Defts’ brief in opposition to plff’s motion
for preliminary injunction and in support of
deft’s motion to dismiss and certification, filed.
9 July—29 Summons returned “with affidavit of
Patricia S. Jantorna re: served Dept. of HEW—
Deputy General Counsel and Joseph A. Cali-
fano, Jr. by cert. mail on 7/25/77, filed.
10 July—29 Summons Returned “with affidavit of
James Bray, Jr. re: served U.S. Attorney on
7/22/77”, filed.
11 July—29 Acceptance of Service of James R. Adams
for Frank S. Beal, of summons, complaint, etc.,
filed.
4a Docket Entries
12 August—3 Summons Returned “with affidavit of
Patricia C. Jantorna re: served Attorney General
by cert. mail on 7/28/77”, filed.
13 August—19 Deft. Frank S. Beal’s motion to dis-
miss, memorandum of law in support, certificate
of service, and notice, filed.
14 August—29 Deft. Joseph Califano, Jr.’s motion to
dismiss, memorandum of law, and certificate of
service, filed.
15 September—2 Plaintiffs’ Memorandum of Law in
Opposition to defendants’ motion to dismiss,
filed.
16 September—12 Plfts’ motion for extension & re-
newal of preliminary injunction, and memo-
randum of law, filed.
17 September—15 Transcript of preliminary hearing
on July 26, 27, 1977, filed.
18 September—15 Order that plfts’ motion for ex-
tending the duration of preliminary injunction,
Denied and the preliminary injunction entered
is Dissolved: provided, however, that defts.
shall not withhold payments from services ac-
tually provided to patients, filed, JPF, J.
9/16/77 Entered and copies mailed.
19 September—15 Order, that this Court’s Order dis-
solving preliminary injunction entered is Stayed
for a period of 10 days from date hereof, to per-
mit pltfs to file notice of appeal, etc., plft’s. re-
quest for a longer stay from this court is Denied,
filed. JPF 9/16/77 enter and copies mailed.
eee ee
Pn OE, teal RE i Bret ate te UI a WS aha
a es
Docket Entries 5a
20 September—-15 Hearing re: plfts’. motion to ex-
tend preliminary injunction is Denied Without
Prejudice, filed.
21 September—15 Brief of Federal deft. in opposition
to plft’s. motion to extend preliminary injunc-
tion, and Certification, filed.
22 September—19 Transcript of trial testimony held
9/15/77, filed.
23 September—16 Notice of appeal of Emma Cooper,
et al. received 9/16/77 at 4 PM, filed. (Appeal
77-2222) 9/20/77 enter2d & copies to Nathan
L. Posner, Robert deLuca, M. Faith Angell.
24 September—16 Copy of Clerk’s notice to US.
Court of Appeals, filed.
—September—16 Bond for costs on Appeal in the
sum of $250 with Fidelity & Deposit Co. of
Maryland as surety, filed.
25 September—16 Notice of Appeal of Town Court
Nursing Center, Inc., received 9/ 16 at 4: 05 PM,
filed. 9/20/77 entered & copies to William F.
Coyle, Esq., Robert deLuca, M. Faith Angell.
; k ice to US.
26 September—16 Copy of Clerk’s notice
Court of Appeals, filed. (Appeal No. 77-222).
—Se —16 Bond for costs on Appeal in the
pg 356 with Fidelity & Deposit Co. of
Maryland as surety, filed.
27 September—26 Certified copy of Order US. Court
of Appeals Granting appellants motion for in-
junction pending appeal, etc., filed.
6a Docket Entries Complaint 7a
—September—26 Sum of $100.00 deposited into
Registry of Court.
IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF
PENNSYLVANIA
—October—11 Original record transmitted to U.S.-
C.A. (except paper No. 4)
Civil Action No. 77-2474
Class Action
TOWN COURT NURSING CENTER, INC.
and
EMMA COOPER
and
MARY CRAWFORD
and
q HAZEL KEMP
and
s
7
i
4
4
:
j
é
;
‘Kare Pe a ae AF
ARNOLD L. PHILLIPS
eg Se ee -.
and
DELPHINE TADDEI
and
NANCY TRUITT, individually and on behalf of the
class of patients, eligible for Pennsylvania Medical
atin
8a Complaint
Assistance Program benefits at Town Court Nursing
Center, Inc.,
Plaintiffs,
v.
FRANK S. BEAL, individually and in his capacity
as Secretary of Public Welfare of the Commonwealth
of Pennsylvania,
and
JOSEPH A. CALIFANO, JjR., individually and in his
capacity as Secretary of the United States Department
of Health, Education and Welfare,
Defendants.
II.
VERIFIED COMPLAINT
1. Plaintiff Town Court Nursing Center, Inc.:
(hereinafter referred to as ‘Town Court’’) is a cor-
poration organized under the laws of the Common-
wealth of Pennsylvania with his offices at 1526 Lom-
bard Street, Philadelphia, Pennsylvania, where it Op-
erates Town Court Nursing Center; a skilled care fa-
cility.
2. Plaintiffs Emma Cooper, Mary Crawford,
Hazel Kemp, Arnold L. Phillips, Delphine Teddei
and Nancy Truitt are individuals who have been pa-
tients, at and residents of Town Court Nursing Center
since at least February 28, 1977 and who are quali-
fied as medically indigent under the Pennsylvania
Medical Assistance Program, 62 P.S. §441.1 et seq.
(more commonly known as “‘Medicaid”) .
ative
Complaint 9a
3. Defendant Frank S. Beal is Secretary of Public
Welfare of the Commonwealth of Pennsylvania. He
is sued both in his individual and his official capaci-
ties.
4. Defendant Joseph A. Califano, Jr. is Secretary
of the United States Department of Health, Educa-
tion and Welfare. He is sued both in his individual
and his official capacities.
5. Jurisdiction is founded upon 28 U.S.C. §§13-
31(a) and 1361. The amount in controversy exceeds
$10,000, exclusive of interest and costs.
COUNT I
(Town Court v. Beal)
6. On or about May 20, 1977 defendant Beal,
through his deputy, Glenn Johnson, Director, Bureau
of Medical Assistance, Department of Public Welfare,
notified Town Court that, effective June 18, 1977,
it would ‘“‘no longer receive payments under the Med-
ical Assistance Program for skilled nursing care or
for services provided to Medical Assistance patients.”
7., Therefore, effective June 18, 1977, defendant
Beal terminated the Skilled Nursing Home Care
Agreement entered into by and between the Pennsyl-
vania Departzient of Public Welfare and Town Court
on September 4, 1975 as extended.
8. Pursuant to Federal regulation, Town Court
continued to be eligible to receive Medicaid payments
until July 18, 1977 when, despite denial of all charges
and written appeal and a demand for a hearing, eligi-
bility for such payments ceased. —
10a Complaint
9. The aforesaid action by defendant Beal violates
Town Court’s constitutional right to due process un-
der the Fifth and Fourteenth Amendments to the
United States Constitution.
10. Approximately 180 of the 198 patients at
Town Court are qualified under the Medicaid pro-
gram which program pays their charges for use of
the facilities at Town Court.
11. In the absence of reimbursement for the ser-
vices provided these patients, Town Court will be un-
able to maintain operations and will be forced to
close to avert an overwhelming and irreparable fi-
nancial loss to its owner, Geriatric and Medical Ser-
vices, Inc., a public company.
12. There is no adequate remedy at law.
COUNT II
(Emma Cooper, et al. v. Beal) ~
13. Paragraphs 1 through 8, inclusive, and 11 and
12 above, are incorporated by reference as though
set forth herein in full.
14. The individual plaintiffs are in chronic need
of the services provided by Town Court which ser-
vices are not presently available at other skilled care
facilities in Philadelphia.
15. The following sets forth the most recent date
of admission to Town Court for each of the named
individual plaintiffs:
Emma Cooper—July 16, 1976
Mary Crawford—September 23, 1975
Hazel Kemp—Ociober 18, 1973
-
Reet ei eal
ee EO Oe ee Te eee ST Te |
athe ts BOI aS MNO IF PO I aN
eee eats
Complaint lla
Arnold L. Phillips—October 18, 1973
Delphine Taddei—October 16, 1976
Nancy Truitt—February 28, 1977
CLASS ACTION ALLEGATIONS
16. The individual plaintiffs are six of the one
hundred eighty patients at Town Court eligible to re-
ceive Medical Assistance program benefits.
17. Each of these patients will suffer and is suf-
fering a loss of benefits of the aforesaid program
without the benefit of a hearing under 45 C.F.R.
§205.10 and in violation of their constitutional rights
to due process under the Fifth and Fourteenth
Amendments to the United States Constitution.
18. This action is designated a class action pur-
suant to Rules 23(a) and 23(b) (2) of the Federal
Rules of Civil Procedure.
19. If Town Court is compelled to close or other-
wise cease providing skilled c~~e services to the mem-
bers of the plaintiff class, they will suffer immediate
and irreparable psychological and physical harm.
COUNT III
(Town Court v. Califano)
20. Paragraphs 1 through 8, inclusive, and 11 and
12 above, are incorporated by reference as though
set forth in full herein.
21. By letter dated May 17, 1977, defendant
Califano, by his agent, Mr. Robert J. Taylor, Director
of Long Term Care, Standards Enforcement, Depart-
ment of Health, Education and Welfare, notified
12a Complaint
Town Court that, effective June 18, 1977, its certifi-
cation as a skilled care facility provider under the
Medicare program, pursuant to an agreement dated
July 19, 1976, was terminated.
22. Inconformity with Federal regulations, Town
Court thereupon requested a reconsideration which
reconsideration was denied by defendant Califano by
his failure to respond to that request as of July 18,
1977, ;
23. Although Town Court has denied all charges
and has requested but not yet received a hearing on
the merits, defendant Califano has nevertheless ter-
minated Town Court’s participation in the Medicare
program.
24. The aforesaid action by defendant Califano
violates Town Court’s constitutional right to due
process under the Fifth Amendment to the United
States Constitution.
WHEREFORE, plaintiffs request that this Honor-
able Court enter the following preliminary and per-
manent relief against the defendants herein:
1. Enjoin defendants Beal and Califano,
their agents, attorneys, deputies, employees and
successors from, prior to a final determination
of all appeals by Town Court Nursing Center,
Inc. from the termination of its Medicare and
Medicaid certifications:
a. terminating the Medicare and Medicaid
certifications of plaintiff Town Court Nursing
Center, Inc.;
Complaint 13a
b. removing patients who are eligible for
Medicare and Medicaid from Town Court Nurs-
ing Center, Inc.’s skilled care facility at 1526
Lombard Street, PhiJadelphia, Pennsylvania;
c. discontinuing or withholding payments to
plaintiff Town Court Nursing Center, Inc. for
the care of Medicare and Medicaid beneficiaries;
d.- prohibiting placement of other Medicare
and Medicaid patients with plaintiff Town Court
Nursing Center, Inc.;
2. Awarding plaintiff Town Court Nursing
Center, Inc. the amount, with interest, of any
payments heretofore withheld by either of the
defendants on account of their respective de-
certifications; and
3. Awarding plaintiffs their attorneys fees
and costs.
(s) Jeffrey B. Albert
(s) Nathan L. Posner
Jeffrey B. Albert
1401 Walnut Street, 10th
Floor
Philadelphia, PA 19102
(215) LO8-5700
Of Counsel:
Fox, Rothschild, O’Brien & Frankel
Commonwealth of Pennsylvania
County of Philadelphia, ss:
DANIEL VELORIC, being duly sworn according
to law, deposes and says that he is the president of
the plaintiff in the within action, that he is authorized
14a Complaint
to and does take this affidavit on behalf of the plain-
tiffs in this action and that the averments contained
in the within complaint are true and correct to the
best of his knowledge, information and belief.
(s) Daniel Veloric
Daniel Veloric
Sworn to and Subscribed Before me this 19th day
of July, 1977.
(Illegible)
Notary Public
No.ary Public, Phila., Philadelphia Co.
My Commission Expires December 16, 1980
Sie Gale ki nSh ty an neon. gf tt cba niet ee dab
*™
Motions for Restraining Order 15a
IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF
PENNSYLVANIA
Civil Action No. 77-2474.
TOWN COURT NURSING CENTER, INC., et al.
Plaintiffs
V.
JOSEPH CALIFANO, JR., Secretary of Health,
Education and Welfare,
and
FRANK S. BEAL, Secretary of Public Welfare,
Commonwealth of Pennsylvania,
Defendants
III.
MOTIONS FOR TEMPORARY RESTRAINING
ORDER AND PRELIMINARY INJUNCTION
Plaintiffs, Town Court Nursing Center, Inc., et al.,
by their attorneys, Nathan L. Posner and Jeffrey B.
Albert, Esquires, move this Honorable Court for a
temporary restraining order in the form attached here-
to restraining defendants as set forth therein pending
hearing and determination of plaintiffs’ motion for a
preliminary injunction, on the ground that immediate
16a Motions for Restraining Order
and irreparable injury, loss and damage will result to
plaintiffs before such hearing can be held and that
notice of the filing of this motion has been given as
set forth in the affidavit attached hereto, and plain-
tiffs further move this Honorable Court for a pre-
liminary injunction granting all preliminary relief
prayed for in the Complaint filed in this action.
(s) Jeffrey Albert
Nathan L. Posner
(s) Jeffrey Albert
Attorneys for Plaintiffs
Of Counsel:
Fox, Rothschild, O’Brien & Frankel
Commonwealth of Pennsylvania
County of Philadelphia, ss:
I, Maurice E. Linden, being duly sworn, do here-
by state and aver as follows:
1. I am a practicing physician duly licensed: in
the Commonwealth of Pennsylvania. I maintain of-
fices at 7100 Germantown Avenue, in the City of
Philadelphia.
2. Iam familiar with Town Court Nursing Cen-
ter, 1526 Lombard Street, Philadelphia, Pennsylvania
and the type of patients who reside there.
3. Town Court is a skilled care facility which has
a substantial number of elderly and chronically ill
patients. &
4. Transfer from such a facility may cause these
patients to suffer substantial psychological and phys-
SS Ce ER cs eR Fd oS a WE
BPO eS tnd s SA - ae L
Ce Raed ee eee
a ag ce eee Ee ere ee
Motions for Restraining Order 17a
ical harm and, in certain circumstances, could in-
crease the possibility of serious illness and even death.
5. Unless an individual patient is clearly shown
to be able to withstand the trauma of being moved to
another facility, I would not favor such a transfer
from Town Court.
Maurice E. Linden M.D.
Sworn to and Subscribed before me this 19th day
of July, 1977.
(Illegible)
Notary Public
Notary Public, Phila., Philadelphia Co.
My Commission Expires December 16, 1980
Commonwealth of Pennsylvania
County of Philadelphia, ss:
AFFIDAVIT OF DANIEL VELORIC
I, DANIEL VELORIC, being duly sworn, do here-
by state and aver as follows:
1. I am the president of Town Court Nursing
Center, Inc. which operates a 198-bed skilled nursing
facility, at 1526 Lombard Street, Philadelphia, Penn-
sylvania.
2. Among the patients presently occupying beds
at Town Court approximately 180 have been deter-
mined to be eligible under Pennsylvania’s Medical
18a Motions for Restraining Order
Assistance Program (commonly known as Medicaid) ,
i.e. indigent persons as defined by 62 P.S. §441.1 et
seq. |
3. Asa provider of nursing home services to these
patients, Town Court may be reimbursed for its ser-
vices to these patients by the Commonwealth of Penn-
sylvania if and only if Town Court is certified for
participation in the Medicaid program. 62 PS.
§443.1(3).
4. That certification is obtained pursuant to an
agreement entered into between the Commonwealth
and Town Court with respect to Town Court’s status
as a provider.
5. On September 4, 1975 such an agreement was
entered into between the Commonwealth and Town
Court.
6. By letter dated May 17, 1977 Mr. Robert
Taylor, Director, Office of Long Term Care, Stan-
dards Enforcement, United States Department of
Health, Education and Welfare, terminated Town
Court’s certification as a provider under the Medi-
care program by failing to renew the then existing
provider agreement dated July 19, 1976 between
Town Court and the United States Department of
Health, Education and Welfare with respect to that
program.
7. By letter dated May 20, 1977 Mr. Glenn John-
son, Director, Bureau of Medical Assistance, Depart-
ment of Public Welfare, Commonwealth of Pennsyl-
vania, terminated Town Court’s participation in the
Medicaid program ‘“‘due solely to the fact that HEW
has notified us of your Title XVIII termination’’.
at gi i in ta
Motions for Restraining Order 19a
8. No means of review of the determination is
provided by the Commonwealth of Pennsylvania as to
the merits of the termination, the review being lim-
ited to whether ‘“‘HEW has not decided to terminate
your facility from participation in the Medicare pro-
gram....”
9. No means of review of the termination, by the
Federa! Government is provided as to the merits
prior to termination except that Town Court did file
a request for reconsideration which request has been
ignored.
10. As a result of the aforesaid terminations of
Town Court from participation both under the Medi-
care and Medicaid programs, Town Court is no longer
receiving, as of July 19, 1977 any financial reimburse-
ment from any source for the provision of nursing
home and related services to any of the individual
patients and its other patients, present and prospec-
tive, who are or will be entitled to benefits under
either of these programs. :
11. Town Court will, if no immediate relief is
granted it in the instant litigation and insofar as beds
are available elsewhere, begin removing plaintiffs
from Town Court to other facilities certified for par-
ticipation in these programs.
12. However, at present there are no known
available beds in such facilities and, in fact, there is a
tremendous shortage of such beds in the Philadelphia
area.
13. Further, Town Court is the largest skilled
nursing and intermediate care facility in Philadelphia.
20a Motions for Restraining Order
It is constantly being asked by local hospitals and
other institutions to admit additional Medicare and
Medicaid patients for which Town Court has no
room.
14. Therefore, unless immediate relief is granted,
Town Court is to be left with the unenviable alterna-
tive of treating patients for no compensation whatso-
ever, or literally dumping these ill elderly on the side-
walks of Lombard Street.
15. Further, even were beds available elsewhere,
these patients are likely to suffer what has been de-
scribed as transfer trauma:
“The damage which may result from such
transfers is irreparable in the true sense of the
word. Changes in surroundings and movements
— of long distances of senior citizens who are suf-
fering from physical and psychological infirmi-
ties are likely to aggravate their condition and
increase the likelihood of death.”
Burchette v. Dumpson, 387 F. Supp. 812, 819 (E.D.
N.Y. 1974). See also HEW Technical Assistance
Memorandum A.A-TA-75-1 (Feb. 19, 1975).
“There is a genuine hazard in the relocation
of infirm aging persons from one facility to an-
other. Dramatic increases in mortality far in ex-
cess of what would normally be expected have
been documented.”
Quoted in Klein v. Mathews, 430 F. Supp. 1005 (D.
N.J. 1977), and Hathaway. v. Mathews, 546 F.2d
227,231 (7th Cir. 1976).
a ee
ee ee ee eee mae ee Seeee yin SS
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Motions for Restraining Order 21a
16. But for the Federal and State termination of
Town Court, Town Court would have continued to
be and desires to continue as a provider under both
the Medicare and Medicaid programs.
(s) Daniel Veloric Pres.
Daniel Veloric
- Sworn to and Subscribed before me this 19th day
of July, 1977. .
(s) Francis M. Killian
Notary Public
Notary Public, Phila., Philadelphia Co.
My Commission Expires December 16, 1980
22a Order Dated July 21, 1977
IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF
PENNSYLVANIA
TOWN COURT NURSING CENTER, INC., et al.
Plaintiffs
Vv.
JOSEPH CALIFANO, JR., Secretary of Health,
Education and Welfare,
and
FRANK S. BEAL, Secretary of Public Welfare,
Commonwealth of Pennsylvania,
Defendants
IV.
ORDER
AND NOW, this 21st day of July, 1977, upon con-
sideration of the Verified Complaint, the affidavits
submitted therewith, plaintiffs’ memorandum of law,
the affidavit of plaintiffs’ counsel as to the giving of
notice to counsel for the defendants herein, and plain-
tiffs’ motions for temporary restraining order and pre-
liminary injunction,
IT.IS HEREBY ORDERED AND DECREED that,
pursuant to Rule 65 of the Federal Rules of Civil Pro-
cedure, the defendants, Frank S. Beal and Joseph A.
ee ee em ews
Order Dated July 21, 1977 23a
Califano, Jr., each of them, their agents, attorneys,
deputies, employees and successors, shall be enjoined
and restrained until 2:00 P.M., Tuesday, July 26,
1977, from: .
a. discontinuing or withholding payments to
plaintiff Town Court Nursing Center, Inc. for the
care of Medicare and Medicaid beneficaries.
Plaintiffs shall file with this Court security in form
satisfactory to the Clerk of the Court in the amount of
$100.00.
IT IS FURTHER ORDERED that plaintiffs’ mo-
tion for preliminary injunction shall be heard by this
Court on the day of Tuesday, July 26, 1977 at 2:00
P.M. in Courtroom at the United States Courthouse,
6th & Market Street, Philadelphia, Pennsylvania.
IT IS FURTHER ORDERED that a true copy of
~ this Order together with the Summons, Complaint,
Affidavits and Memorandum of Law be served with-
in three (3) days of the date hereof upon each of
the Defendants. Service and the return of service
may be made by any competent persons eighteen
(18) years of age or older.
(s) John P. Fullam
United States District Judge
i -
24a Defendant Beal’s Motion To Dismiss
IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF
PENNSYLVANIA
Civil Action No. 77-2474
TOWN COURT NURSING CENTER, INC., et al.
Plaintiffs
Vv.
JOSEPH CALIFANO, JR., Secretary of Health,
Education and Welfare
and
FRANK S. BEAL, Secretary of Public Welfare,
Commonwealth of Pennsylvania,
Defendants
V.
DEFENDANT’S MOTION TO DISMISS
The defendant Secretary Frank S. Beal, by his at-
torney, M. Faith Angell, Deputy Attorney General
for Eastern Pennsylvania, reserving the right to file
an answer on the merits if the same is required, here-
by moves the Court to dismiss plaintiffs’ Complaint
under Federal Rule of Civil Procedure 12(b) for the
following reasons:
Meine satin ha tippy St
“s
Defendant Beal’s Motion To Dismiss 25a
1. The Complaint fails to state a claim against
Defendant Beal upon which relief can be granted.
2. The Court lacks subject matter jurisdiction.
3. The absence of a pre-termination hearing fails
to rise to a due process constitutional violation.
This Motion is based on the accompanying Memo-
randum of Law.
Respectfully submitted,
(s) M. Faith Angell
Deputy Attorney General
Michael von Moschzisker
Deputy Attorney Generai,
Easiern Regional Director
Robert P. Kane
Attorney General
206 Siate Office Building
Philadelphia, Pa. 19130
Telephone: (215) 238-6661
26a Defendant Califano’s Motion To Dismiss
IN THE UNITED STATES DISTRICT COURT.
FOR THE EASTERN DISTRICT OF PENNSYL-
VANIA
Civil Action No. 77-2474
Town Court Nursing Center, Inc. et al.
Plaintiffs
V.
Joseph A. Califano, Jr., Secretary of Health, Educa-
tion & Welfare
and
Frank S Beal, Secretary of Public Welfare, Common-
wealth of Pennsylvania,
Defendants
VI.
MOTION TO DISMISS
Defendant, JOSEPH A. CALIFANO, JR., Secre-
tary of Health, Education and Welfare, moves this
Honorable Court pursuant to Federal Rule of Civil
Procedure 12(b) to dismiss the complaint against
him for the reason that this Court lacks jurisdiction
ST PT Dee
Defendant Califano’s Motion To Dismiss 27a
over the subject matter, and that the plaintiffs have
failed to establish entitlement to injunctive relief.
Respectfully submitted,
/s/ David W. Marston
United States Attorney
/s/ Robert N. deLuca
Assistant United States
Attorney
Chief, Civil Division
Dated: 29 August 1977
28a Motion for Extension
. VIL.
IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF PENNSYL-
VANIA
PLAINTIFFS’ MOTION FOR EXTENSION AND
RENEWAL OF PRELIMINARY INJUNCTION
[Caption Omitted]
1. On July 27, 1977 this Honorable Court issued
an order granting plaintiffs certain preliminary in-
junctive relief until such time as the United States
Department of Health, Education and Welfare gave
the parties five (5) days notice of its decision with
respect to the request by plaintiff, Town Court Nurs-
ing Center, Inc., for reconsideration of HEW’s de-
cision to terminate Town Court’s status as a Medi-
care provider.
2. On September 9, 1977, by hand delivery, Town
Court, but neither its counsel nor counsel for the in-
dividual plaintiffs, received notice that HEW had de-
nied Town Court’s request for reconsideration on Au-
gust 4, 1977, and that such decision would become
effective on September 14, 1977.
3, Since the State inspection on June 24, 1977,
there has been no Federal or State inspection of Town
Court.
4. During the period prior to the reconsideration
decision, as well as thereafter, to best of plaintiffs’
knowledge, information and belief, no efforts have
been made by defendants to gain knowledge of the
then existing conditions at Town Court.
5. During the period prior to the reconsideration
decision, as well as thereafter, Town Court has not
Motion for Extension 29a
been requested by either defendant to change or cor-
rect any condition then existing at Town Court.
6. Town Court continues to provide the excellent
quality of care and physical environment testified to
by plaintiffs’ witnesses at the hearing held on July
26 and 27, 1977, which testimony is incorporated
herein, by reference.
7. The parties-plaintiff will suffer immediate and
irreparable harm if the preliminary injunctive relief
granted them on July 27, 1977 is not continued until
such time as Town Court’s rights to participation in
the Medicare and Medicaid programs are fully and
finally adjudicated after hearing and judicial review,
if necessary.
8. There is no adequate remedy at law.
WHEREFORE, plaintiffs respectfully request this
Honorable Court to extend and renew the preliminary
injunction issued on July 27, 1977 until such time as
plaintiffs have exhausted their rights to seek review
of defendants’ efforts to terminate Town Court Nurs-
ing Center, Inc. as a Medicare and Medicaid pro-
vider.
(s) Nathan L. Posner
Nathan L. Posner
Jeffrey B. Albert
Attorneys for Town Court
Nursing Center, Inc.
(s) William F. Coyle
William F. Coyle
Attorney for Emma Cooper
et al.
Of Counsel:
Fox, Rothschild, O’Brien & Frankel
4
30a Opposing Affidavit of C. B. Campbell
) VII.
IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF PENNSYL-
VANIA
AFFIDAVIT OF CLAUDETTE V. CAMPBELL
[Caption Omitted]
State of Pennsylvania
County of Philadelphia ss
CLAUDETTE V. CAMPBELL, being duly sworn,
deposes and says as follows:
I am Claudette V. Campbell, a registerec’ nurse
with a Bachelor of Science degree in Nursing and a.
Master of Public Health degree. I am a Commissioned
Officer in the United States Public Health Service,
holding the rank of Senior Nurse Officer. In 1974,
I received an appointment as Program Officer/Nurse
Consultant to the Office of Long Term Care Stan-
dards Enforcement. This agency was incorporated in-
to the Health Standards and Quality Bureau, Health
Care Financing Adminisiration, Region III, United
States Department of Health, Education and Welfare
on June 19, 1977. '
One of my functions as the Regional Office Long
Term Care Nurse Consultant is to review provider
files prepared for termination from participation in
the Medicare/Medicaid program. The purpose of
my review is to ensure that Federal health standards
have been applied and documented substantially in
accordance with Federal regulations. The other criti-
cal determination that is made is an evaluation of the
effect of non-compliance with the Conditions of Par-
Opposing Affidavit of C. V. Campbell 31a
ticipation on the health and safety of patients in the
facility under review. My findings are a result of a
thorough review of all documentation submitted by
the State agency and a review of the provider file.
After the above review is completed, I recommend
either concurrence or non-concurrence with the ad-
verse action to the Director, Office of Long Term
Care Standards Enforcement.
The following statement summarizes the develop-
ments culminating in my decision on May 12, 1977 to
recommend to the Director of the Office of Long
Term Care Standards Enforcement acceptance of the
State survey agency’s recommendation of non-renewal
of Town Court Nursing Center’s provider agreement,
which had expired April 30, 1977.
1. On January 1, 1967, the facility received con-
ditional approval for participation in the Medicare
program based on the State agency’s finding of a
serious nurse staffing deficiency. Other deficiencies
related to the requirement that oral orders should
only be given to a licensed nurse, and reduced im-
mediately to writing, and physicians should be ad-
vised of stop order policies and contacted for renewal
of orders. |
2. On May 9, 1968, a supplement to the initial
agreement was issued to the facility based on substan-
tial progress in correcting deficiencies outlined above.
However, remaining deficiencies noted included
pharmaceutical services: ail medications administered
to patients were not ordered in writing by the patient’s
physician, oral orders were not given only to a licensed
nurse, and were not immediately reduced to writing.
32a _ Opposing Affidavit of C. V. Campbell
3. A State survey agency visit on September 8-9,
1971 resulted in deficiencies being noted, including
the following: physicians orders were not being re-
vised every 30 days, and maintenance of sanitary con-
ditions in the entire kitchen area including store
rooms and staff dining room areas was “deplorable”.
4. The State survey agency made a special visit to
the facility on January 28, 1972 and found deficien-
cies previously listed corrected, but an additional de-
ficiency noted was in Nursing Service in that there
was no night supervising nurse for the three weeks
prior to the survey.
5. On April 10, 1972, a supplemental agreement
was issued as a result of the facility’s substantial com-
pliance, with correctible deficiencies. The deficien-
cies noted include incorrect storage of medication and
poor housekeeping.
6. A survey performed by the State agency on
October 23, 1973 revealed deficiencies including nurs-
ing staff shortages, an unlicensed nurse as shift super-
visor, medications not properly recorded, labeled, or
stored, narcotic records not properly maintained, pa-
tient call bells removed, and inadequate housekeeping.
7. A special unannounced survey visit on March
19-20, 1974 by the State agency revealed numerous
serious deficiencies and the results were transmitted
to Office of Long Term Care Standards Enforcement
with a termination recommendation. (See Attach-
ment 1).
8. On March 28, 1974 the facility received an ex-
tention to their agreement to May 31, 1974 to deter-
Opposing Affidavit of C. V. Campbell 33a
mine whether compliance with the Conditions of Par-
ticipation had been achieved.
9. On May 9, 10 and 15, 1974, an unannounced
licensure visit was conducted and revealed continuing
major deficiencies. (See Attachment 2).
10. On May 22, 1974, the facility was notified
that it was being given a short term agreement, for a
period of 90 days, from June 1, 1974 to August 31,
1974, to correct the deficiencies that were found dur-
ing survey visits on March 19 and 20, 1974.
11. Based on the results of revisits by the State
survey agency on May 9, 10, 15, 1974 and June 3, 4,
5, 1974 (see Attachment 3), a recommendation of
non-renewal was made by the State survey agency.
12. On September 30, 1974, the facility was noti-
fied that its provider agreement would not be re-
newed and that its participation in the program was
terminated as of “ctober 31, 1974.
13. Survey results of April 14, 1976 revealed no
deficiencies, and the facility was readmitted to the
program effective that date.
14. The Office of Long Term Care Standards En-
forcement received a request from the District Attor-
ney’s Office, Philadelphia, Pennsylvania, Economic
Crime Unit, to investigate complaints of poor care at
the facility on July 8, 1976.
15. A Federal survey performed July 19-23, 1976
substantiated the above complaint. In addition, the
following Conditions of Participation were not met:
34a Opposing Affidavit of C. V. Campbell
Medical" Direction and Nursing Services. The Con-
ditions Participation for Physican Services and
Dietaty Services were only marginally met, and addi-
tional standards were found not met. (See Attach-
ment 4).
16. On November 22-24, 1976, an unannounced
survey was performed by the State survey agency.
An Office of Long Term Care Standards Enforcement
staff member participated in the survey on November
22, 1976. A physician from the State survey agency
also participated. The same and additional Condi-
tions of Participation and standards were found not
met. (See Attachment 5).
17. The facility filed a Plan of Correction dated
February 10, 1977 which was unacceptable to the
State survey agency based on omission of completion
dates for the correction of deficiencies. A new plan
of correction was submitted March 17, 1977 showing
completion dates.
18. On April 21, 1977, the Pennsylvania Depart-
ment of Health forwarded the November 1976 and
March 1977 survey results with a Certification and
Transmittal recommending non-renewal of the facil-
ity’s provider agreement.
Non-compliance with the Conditions of Participa-
tion impacts significantly on the health and safety of
the patients at Town Court and poses a threat to their
welfare. It is imperative that medical direction,
physician services, nursing services, and pharma-
ceutical services, k> provided in a safe and adequate
manner. The State survey findings reveals significant
omissions in these areas.
Opposing Affidavit of C. V. Campbell 35a
Of equal importance in my concurrence with the
recommendation of non-renewal was the pattern
demonstrated by the facility of having the same stan-~
dards not met on successive resurveys starting from
1974 through 1977. The facility has not performed
in a responsible matter with respect to maintenance
of health standards in order to ensure adequate and
safe services. The history on file clearly demonstrates
this central weakness in the facility. All of the above
can be substantiated by a careful review and analysis
of the actual reports.
(s) Claudette V. Campbell
Claudette V. Campbell
Sworn to and subscribed before me this 14th day
of September, 1977.
Kathleen Taylor
Notary Public
Philadelphia, Philadelphia
Co.
My commission expires October 31, 1977.
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Opposing Affidavit of C. V. Campbell 37a
March 27, 1974
Madeleine S. Bowen, R.N.
Field Representative
Standards and Licensure
Narrative Report
An unannounced visit was made to Town Court
Nursing Home, 1526 Lombard Street, Philadelphia,
Pennsylvania 19146 for the purpose of investigating
a complaint and documenting a post recertification
Medicare and Medicaid visit.
_ Mrs. Marjorie Steever, R.N. Survey Validation Of-
fice, Department of Health, Mr. Jack Slusser, R.N.
and Mrs. Madeleine Bowen, R.N., Field Representa-
tives from the Southeastern Regional Office, were ad-
mitted to the facility at 9:35 P.M. on March 19, 1974.
The visit was terminated at 2:45 A.M. on March 20,
1974.
This facility is a five (5) story brick and masonry
building in the densely populated area of Philadelphia.
The capacity is 138 beds. Patients are housed on the
second (2), third (3) and fourth (4) floors. The
census on the night of the visit was 134 patients.
Several patients had been sent to the hospital. Eighty-
seven (87) patients were on Medical Assistance and
13 were on Medicare.
A nurses aide admitted the representatives to the
home and then summoned Mrs. Walker, R.N., Super-
visor on the 3-11 tour of duty. The representatives
introduced themselves and Mrs. Bowen stated the
purpose of the visit. Mrs. Walker, R.N. was ad-
vised to notify the Administrator Mr. John Thomas
i ie]
ee
38a Opposing Affidavit of C. V. Campbell
of the presence of the representatives in the facility
and the purpose of the visit.
Mrs, Walker telephoned Mr. Thomas.
Mr. Thomas spoke with Mrs. Bowen on the tele-
phone. He offered to come into the home and be
available. He was informed that most of the neces-
sary data was readily available except the closed files
which were locked in his office. Upon questioning
by Mr. Thomas, Mrs. Bowen stated she hoped to com-
plete the visit in two (2) hours, but could not say for
certain how much time would be necessary since the
survey had not yet begun. Mr. Thomas related that
his traveling time was 40 minutes each way and there-
fore he would not come in for the visit.
_ Mr. Thomas is an unlicensed nursing home admin-
istrator and is planning to take the state licensure ex-
amination in April 1974. He had been advised by
Mrs. Bowen on January 14, 1974 to apply for a pro-
visional license but has failed to do so because of the
cost involved.
Mrs Walker, R.N. supervisor on the 3-11 tour of
duty was from an agency known as Medical Personnel
Pool and was not an employee of the home. She
stated she worked at Town Court an average of three
(3) evenings a week.
Mrs. Walker provided Mr. Slusser with the cur-
rent nursing time schedules for his review while Mrs.
Steever and Mrs. Bowen conducted a tour of the fifth
(5) floor.
Discrepancies were found in staffing of nursing
personnel. Mrs. Moise, R.N. 11-7 and Mrs. De-
|
, Opposing Affidavit of C. V. Campbell 39a
Vastey, R.N. 3-11 appeared on the nursing schedule
but it was learned that Mrs. Moise had not worked
for several weeks and Mrs. DeVastey had resigned.
The nurse on 11-7 tour of duty, Mrs. Bernard was a
foreign nurse not licensed in Pennsylvania. The
nursing schedule showed no 3-11 R.N. scheduled on
March 15, 16, 17, 1974. On the 7-3 tour of duty on
March 16, 17, 1974there was no scheduled relief for
the Director of Nurses. There were quantitative de-
ficiencies on the 7-3 tour of duty on March 16, 17,
on 3-11 on March 15, 16, 17, and on 11-7 on March
14, 16, 17th. There was a time clock and time cards
in the nurses station on second (2) floor but almost
all of the time cards were blank.
Mrs. Smith, a nurses aide on her first night of duty
had been assigned to another nurses aide for orienta-
tion. Nurses aides on the 11-7 tour of duty “thought”
they had inservice, but could not relate to the last
topic discussed.
Fifth Floor
Two (2) nursing personnel were on the 5th floor,
Mrs. Bush L.P.N. and an aide. Mrs. Bush, L.P.N.
was in charge of the fifth floor and accompanied the
representatives. The census on this ,floor) was 34
patients. Plastic bags of soiled linen were’ found in
the hallway and the alcove near the\refrigerator. The
refrigerator was soiled with spilled juice. In Rooms
511 and 516, foley catheter bags were observed lying
on the floor. There was no H:O glass or cup in room
513, water pitchers in rooms 512, 514, and 516 were
empty and one unit in 516 had no water pitcher. All
other pitchers were alfhost empty and only one pitcher
4
40a Opposing Affidavit of C. V. Campbell
was filled with water containing ice. In room 511,
two (2) soiled bedpans were cn the floor. The medi-
cation cardex showed many medications had not been
given; nursing care plans were incomplete and the
vital sign book had no recording since January.
A patient, Rabbi Sobol was awake and got out of
bed to talk to the representatives when they entered
his room. Initially his speech was very fast, garbled
and unintelligible. Mrs. Bush stated that he was dis-
oriented. After a few minutes Rabbi Sobol was able
to speak clearly and coherently. He was fully mobile
and moved and walked about freely and easily. He
appeared anxious and agitated as he told the repre-
sentatives that he was not allowed to go outside of
the home at all even though he was capable of doing
so. He also spoke about his house and was con-
cerned about the disposition of his property. He
complained about the food in the facility stating that
it was not to his taste. He insisted that Mrs. Bowen
write the repesentatives names on paper and where
they were from. He took this piece of paper and put
it in a book on his bedside table. He asked the
representatives to help hiin and his wife get out of
this home. His wife is a patient on the same floor
and according to the nurse is also capable of self care.
Rabbi Sobol followed the representatives out into the
hall pleading with them to help him get out of this
facility. Mrs. Bowen accompanied him back into his
room and listened to him for at least 10 minutes: He
was very reluctant to permit her to leave.
A review of Rabbi Sobol’s chart revealed the pres-
ence of an application to the Home for the Jewish
Aged. No social service notes were on the chart.
.
Opposing Affidavit of C. V. Campbell 4la
Rabbi Isiah Sobol’s clinical record revealed that
there was an order for a Kosher Diet and force fluids
which did not appear on the Nursing Care Plan. The
medication record indicatéd the patient did not re-
ceive Mellaril 15 mg. T i d on March 6, 9, through
March 13, 15,16, 17,1974. The’ order was clfanged
to Mellari! 25 mg. T i rch 17, There.was no
indication on the record whether it was’ obtained or
given. Although the physicians order was for “force
fluids-water and juices” there was no current intake
and output record on the chart. Nupies notes stated
that Rabbi Sobol frequently requested fruit juice for
constipation but that fruit juice was not available.
In Room 512, Mrs. Gerard, a 64-year old patient
was observed lying in bed clad only in underpants.
The bedclothes were in disarray and one bedside rail
was down. Mrs. Bowen spoke with Mrs. Gerard
who was unable to respond to questions such as “how
are you?”’, and “do you know where you are?” Mrs.
Gerard responded by spelling her first name which
is Elodie. This patient appeared very sluggish and
drowsy. There was not water on her bedside table.
Mrs. Bush put a gown on the patient, explaining that
Mrs. Gerard frequently disrobed.
Mrs. Gerard’s clinical record revealed that she was
admitted to Town Court Nursing Home on May 3,
1973 from Albert Einstein Medical Center Psychi-
atric Unit. Her diagnosis at Albert Einstein was
Depression. The initial physical examination done
at Town Court stated a diagnosis of Cerebral Arterio-
sclerosis. The discharge summary from Albert Ein-
stein stated that this patient was an Alcoholic and
42a Opposing Affidavit of C. V. Campbell
had had a previous admission to their Psychiatric
Unit.
Upon questioning, Mrs. Bush, L.P.N., stated that
Mrs. Gerard was usually a lively interested indi-
vidual who participated in many activities in the home
and was very well-ti y the other patients. She
stated thatin the past month Mrs. Gerard had “failed”
and was withdrawn, disorierited, frequently disrobed
and attempted to climb out of bed, and that her food
and fluid intake was poor. She sometimes wandered
around the 5th floor at night.
A review of the clinical record revealed that Mrs.
Gerard had been under the care of Dr. Gottlieb. On
February 27, 1974 she was seen by Dr. Schwartz be-
cause she apparently had an upper respiratory infec-
tion. Doctor’s progress notes indicate her tempera-
ture was 101 degrees and her pulse was 120 at that
time. No respiratory rate was recorded. The only
temperature recorded on the record was in May 1973.
Dr. Schwartz wrote an order for Robitussin and an
order to take all vital signs 4 times daily for 4 days.
No record of any vital signs was found on the clinical
record or the vital sign book. However, the order
had been transcribed onto the medication sheet and
initialed in the appropriate spaces by a nurse. On
February 28, 1974, a verbal order was written on
the Doctors order sheet to transfer Mrs. Gerard to
the service of Dr. Kramer. The Verbal order had
not been co-signed by Dr. Gottlieb. On March 1,
1974, progress notes written by Dr. Storey stated the
patient had a Upper Respiratory Infection, Tracheo
bronchitis, Dehydration, and possible Electrolyte Im-
balance. He ordered Tetracycline, force fluids, water
Opposing Affidavit of C. V. Campbell 43a
and juices, discontinue Lasix and discontinue Mellaril.
Nurses notes on March 1 stated only that fluids were
forced and patient slept all day. No intake or output
record was kept. On March 2, 3rd, Tetracycline
was charted as given intramuscularly; it had been or-
dered by mouth. On March 3, 1974 the patient was
sent to Graduate Hespital of ‘the University of Penn-
sylvania because of her upper respiratory infection.
A note from the hospital signed by Dr. Freedman
stated that Mrs. Gerard had Laryngitis, Bronchitis,
and moderate dehydration. A prescription for Pen
VK was returned to Town Court with the patient the
same evening. No nurses notes were written from
the time the patient was sent to the hospital until
March 7, 4 days later, on the 11-7 and 3-11 tour of
duty.
On March 4, Dr. Adelman discontinued the Pen
VK which had never been given, and ordered Tetra-
cycline continued which was not recorded as given.
He ordered fluids pushed to 2000 cc per day. No
record of any intake was available on the clinical rec-
ord. On March 17, Thorazine was ordered by Dr.
Kramer.
The Nursing Care Plan for this patient stated only
that the patient’s status was stationary; the block
marked “withdrawn” had not been checked. No
other information was on the nursing care plan.
Nursing summaries were incomplete and lacked
any information indicating the patient’s real condition
mentally, physically or emotionally. One nurse’s
notation on the night tour of duty stated that the
patient had been restless and walking around request-
ing food and drink, but no food or juice was avail-
ee tl
44a Opposing Affidavit of C. V. Campbell
able. No nursing assessment\ had been recorded.
Doctor’s progress notes dated September, October,
November and January were illegible.
Fourth Floor—Census 39
3-11 Charge nurse Mrs. Clark—Aides
11-7 Charge nurse Mrs. Williams—L.P.N.
(W)
Mr. Slusser conducted a tour of the 4th floor.
There was a notable odor of urine upon entering the
lounge area from the elevator. Mrs. Williams, L.P.N.
(W) was in charge of the 4th and 3rd floors on the
11-7 tour of duty. She accompanied the representa-
tive on complete rounds, and was very knowledgable
of all the patients on these areas.
Mrs. Bernard, supervising nurse on 11-7 tour of
duty frequently consulted Mrs. Williams in regard to
extra procedures and routines, i.e., she asked Mrs.
Williams to leave her areas of duty and come to the
second floor to identify the proper key to the emer-
gency drug kit.
Medication records on fourth floor revealed that
some patients did not receive medications on the fol-
lowing dates, February 11, 12, 13, 14, 18, 20, 25,
27th, March 6, 10, 12, 16, 18, and 19th.
Mrs. Edna Kirkoff was Medicare patient in room
412. She had been admitted to Town Court Nursing
Home on February 15, 1974 from Graduate Hospital
with a diagnosis of Right Cerebral Vascular Accident,
Diabetic, Ulcer of left leg, and Arteriosclerosis Obli-
terans. The patient had a nasogastric tube in-place
at the time of admission. On February 24, and March
I>
Opposing Affidavit of C. V. Campbell 45a
1, 1974 Mrs. Kirkoff was sent to Graduate Hospital
for reinsertion of the nasogastric tube after she had
pulled it out. Nurses notes on March 1st indicate
that after the tube was reinserted at the hospital dur-
ing the day tour of duty, and the patient again pulled
it out on the 3-11 tour of duty. No nurses notes were
written until March 3, 1974 when “tube feeding”
was noted.
There was no report of a chest x-ray or urinalysis
on the record. The patient did not receive her
Mandelamine on March 2, at 6 and 10 P.M. nor her
Lanoxin on March 12, 1974. No tube feeding was
recorded on the medication sheet on March 1, 2, 6,
at 6 and 10 P.M. and on March 12 at 10 and 2 P.M.
Betadine was ordered to the ulcer of left leg 2 times
a day, however it was recorded on the medication
record only 4 times for March.
A nursing care plan for Mrs. Kirkoff was for-
warded to Town Court from the hospital. The nurs-
ing care plan was as follows:
Stimulate patient by talking to her
Mouth care
Catheter care
Good skin care
Ulcer care
Bath oil, dry skin
OOB b.i.d., try diversion
Posey mitt to hands, remove T.i.d.
Naso-gastric Tube
Watch for impaction, sit up hi—fowlers for
feeding.
s
46a Opposing Affidavit of C. V. Campbell
The nursing care plan at Town Court read as fol-
lows:
“Return to A D L, Needs full nursing care,
needs to be oriented.”
a
‘Jennie Bradley was a medicare patient in room
412. She is 79 years old and was admitted on Janu-
ay 25, 1974 from St. Agnes Hospital. The nursing
care plan from the hospital read as follows:
Encourage to feed using extremities assist
ambulating due to vision and balance, wear neck
brace OOB, cervical collar in bed
soft diet
ROM Therapy
commode after breakfast
watch for decubiti after brace is removed
There was no nursing care plan for this patient at
Town Court. Nurses notes stated “routine care.”
There was no discharge summary on the record. The
patient’s temperature had not been taken since ad-
mission on January 25, 1974.
Third Floor—Census 39
3-11 Mrs. Booker, LPN—charge nurse—aides
11-7 Mrs. Williams—2 aides
A tour of third floor was made by Mrs. Bowen ac-
companied by Mrs. Booker, LPN. In rooms 214,
317, and 320 there were no drinking cups; there was
also a strong odor of urine. Soiled bedpans were on
the floor in patients rooms. In room 320 a Foley
Catheter drainage bag was lying on the floor. In
room 307, two (2) bedside units lacked water
pitchers. Water pitchers were almost empty and
Opposing Affidavit of C.V. Campbell 47a
none contained any ice. External drugs i.e., eye drops
and 10se drops were unlocked at the nurses station.
Nursing Care Plans were either not done at all or
incomplete. Medication sheets dated October and
November 1973 were loosely piled on the desk at the
nurses station.
A review of the medication records revealed that
on March 12 and 17, 1974, no medications had been
given on the 3-11 tour of duty. There was no record
that Insulin had been given to Joshua Williams on
March 10, 11, 1974. Valison ointment and Benadryl
otdered for Mrs. Helen Davis on March 14, were not
started until March 17. No medications were re-
corded as given to Dora Vashen on March 6, 1974,
or to Thomas Butler on February 27.
The tour was concluded with a visit to the Dietary
Department by Mrs. Steever, Mrs. Bowen and Mr.
Slusser accompanied by Mrs. Bernard supervising
nurse. A large bowl of eggs was found unrefrigerated.
Since there was no juice available on any patient
floors, Mr. Slusser advised Mrs. Bernard to take a
can of orange juice which was stored in the break-
fast cart. Mrs. Bernard picked an opened can of
juice, but Mr. Slusser urged her to take a full un-
opened can, which she did with some reluctance.
Sanitation in the kitchen was satisfactory. Food
stores were locked and could not be surveyed. 7
A special visit was made to this facility by Mrs. ,
Madeleine Bowen, R.N. Field Representative and
Mr. Jack Slusser, R.N. Assistant Supervisor Stan-
dards and Licensure, Department of Public Welfare
and Mrs. Marjorie R. Steever, R.N. Survey Valida-
tion Officer, Division of Licensure and Certification,
48a Opposing Affidavit of C. V. Campbell
Department of Health on the night of March 19, 1974,
and by Mrs. Phoebe Somma, R.N., and Mrs. Mary P.
Berman, R. N.; Field Representatives, Department of
Public Welfare Division of Standards and Licensure
on the morning of March 20, 1974.
The purpose of the visit was to investigate regard-
ing a patient care complaint and follow-up on the
2567 (B) corrective action taken. As indicated in
the attached summary this facility has had on numer-
ous survey visits patient care deficiencies which repre-
sents a hazard to the health and safety of the patients
within the facility. A post-certification revisit report
and certification and transmittal is attached for the
March 19, and 20, visits.
A recommendation for termination of the provider
agreement is being made.
March 18, 1974
Subject: Town Court Nursing Home
To: File
From: Madeleine S. Bowen, R.N.
Field Representative
Standards and Licensure
Mrs. Philomena Shewcheck a complainant was
telephoned on March 15, 1974 and asked to write her
complaint and be more specific as to the charges of
negligence, inadequate care, inhuman and degrading
treatment.
Mrs. Shewcheck replied she is very burdened at
home at present. with an ill husband and father-in-
-
Vw
‘Opposing Affidavit of C.V.Campbell 49a
law and will try in the near future to write to the
Department of Standards and Licensure specifically
stating her complaints.
Mrs. Shewcheck said she did not want to become
involved today. She stated that the patient Wanda
Nefka, had died after being transferred from Town
Court to a hospital where she laid 7 1/2 hours before
being identified. She said that another patient at
Town Court was refused water because she was in-
continent.
Mrs. Shewcheck concluded the conversation by
saying she would write to this office in a week or two.
March 22, 1974
Subject: Town Court Nursing Center
To: File
From: (Mrs.) Phoebe Somma, R.N.
(Mrs.) Mary Berman, R.N.
Field Representatives
Standards and Licensure
A special unannounced visit was made March 20,
1974 to Town Court Nursing Center by Field Repre-
sentatives Mary Berman and Phoebe Somma; follow-
ing the unannounced night visit of March 19, 1974.
Mr. Thomas, acting administrator accompanied
Field Representatives and Mrs. Gross, R.N. Director
of Nursing Services joined the surveyors during the
tour of patient care areas.
50a Opposing Affidavit of C. V. Campbell
Fifth (5) Floor
Census 34—staffed by one (1) L.P.N.
(waiver) and two (2) nurses aides.
Mrs. Adelman, a patient in Room 509 was of seri-
ous concern to surveyors; this concern was also evi-
denced during the special undnnounced visit made
the previous night (see previous report). Review of
her clinical record on March 20, 1974 revealed the
medication, ampicillin, had been secured from the
Pharmacy. Although the medication label was dated
March 19, 1974 there was no documentation that the
prescribed dose of ampicillin (ten (10) cc every six
(6) hours) was given until 12 noon on March 20,
1974. The L.P.N. on duty stated she did not know
why the medication was not given as ordered. Pa-
tient’s temperature recorded as (104) (R) at 8:00
A.M.—100 (R) at noon. Intake and output was re-
corded from 8:00 A.M. until time of visit (12:30
P.M.)
Mrs. E. Pennington, patient in Room 501, ad-
mitted March 15, 1974, verbalized complaints in-
volving rough handling and verbal abuse by staff
members; no particular personnel named. Clinical
record reviewed to ascertain prescribed medications
and treatments. Verbal physician’s orders revealed
an order for insulin, Colase and a sitz bath treatments.
Insulin and colase were charted as being given but
no record of sitz bath treatment. While conversing
with patient, her daughter brought in two bottles of
medications, which the patient had been receiving at
home on a daily basis (Dilantin and Urecholine).
These were given to Mrs. Gross, R.N. by the patient’s
Opposing Affidavit of C. V. Campbell 5la
daughter. Neither of these medications appeared on
physician’s order sheet.
Fourth (4) Floor
Census 39—staffed by one (1) L.P.N.
(waiver) , four (4) nurses aides.
Very offensive odor of urine permeated the
entire floor.
Clinical record of Amaza Smith revealed
medication had not been
Third (3) Floor
Census 39—staffed by one (1) L.P.N. (ex-
amination) and four (4) nurses aides.
Viola Thomas in Room 309 was observed to be
having difficulty eating her lunch. Upon investiga-
tion the patient stated she was partially blind and her
fingers were observed to be severely deformed by an
arthritic-like condition. She stated she does require
assistance with her meals but does not receive it. She
further stated the nurses yell and curse at her when
she requests help.
Clinical record of Hermin Garfinkle revealed his
medications had not been charted as given since
March 19, 1974.
Clinical record of Mabel Watson revealed medica-
tions had not been charted as given since March 1,
1974.
Second (2) Floor
Census 24— staffed by one (1) R.N. three (3)
nurses aides.
Random selection of clinical reccrds revealed no
major discrepancies in charting.
A
52a Opposing Affidavit of C. V. Campbell
Review of closed clinical records in administrator
office.
Charles Alexander admitted March 15, 1974 ex-
pired March 19, 1974. Physical examination on ad-
mission, stated Nutrition was poor, admitting diag-
nosis Heart failure. Nurses notes were not written at
time of admission, nor in chronological order there-
after.
One medication (Lasix 40 mgm O.D.) ordered by
physician on admission, was not recorded as being
given during the patient’s stay. Verbal orders of
March 17, 1974 were not signed by physicians. No
discharge progress note by physician.
Celia Diamond discharged to Graduate Hospital on
March 18, 1974.
March 13, 1974 nurses notes stated patient fell
hitting the back of her head resulting in a laceration.
She was sent to Graduate Hospital for X-rays and
sutures. The next entry in nurses notes on March 18,
1974 stated patient appears very pale and lethargic,
slurred speech, temperature 102, and vomiting and
bile colored fluid. Transferred to Graduate Hospital
with all her belongings.
In reference to a complaint received in Regional
Office on March 15, 1974, Wanda Meks’s clinical
record was reviewed, patient was admitted January
3, 1974 with a diagnosis of arteriosclerotic, cardio-
vascular disease, chronic heart failure, and diabetes.
No significant nurses notes until January 17, 1974,
at which time note stated patient looks poor: vital
signs: no pulse, respirations 43. B/P 120/60. Dr.
Nathanson notified instructed nurses to give Lasi 40
mgm i.m.
Opposing Affidavit of C. V. Campbell 53a
Next entry stated—patient transferred to Presby-
terian Hospital where according to complainant she
expired. No progress notes by physician except one
entry which states “see P.E.”. No intake or output
recorded despite diagnosis and diuretic medication
order. ;
Following this visit and reviewing the above facts
it is the opinion of the surveyors that the care ren-
dered to the patients in this facility is jeopardizing
their health and safety.
PS: MB/ig
(s) Mary P. Berman, R.N.
(s) Phoebe Somma, R.N.
Town Court Nursing Home
Maich 20, 1974
A special visit was made to this facility by Mrs.
Madeleine Bowen, 'R.N. Field Representative and Mr.
Jack Slusser, R.N. Assistant Supervisor Standards and
Licensure, Department of Public Welfare and Mrs.
Marjorie R. Steever, R.N. Survey Validation Officer,
Division of Licensure and Certification, Department
of Health on the night of March 19, 1974, and by
Mrs. Phoebe Somma, R,N., and Mrs. Mary P. Berman,
R.N., Field Representatives, Department of Public
Welfare Division of Standards and Licensure on the
morning of March 20, 1974.
The purpose of the visit was to investigate regard-
ing a patient care complaint and follow-up on the
2567 (B) corrective action taken. As indicated in
the attached summary this facility has had on numer-
,e4
54a Opposing Affidavit of C. V. Campbell
ous survey visits patient care deficiencies which rep-
resents a hazard to the health and safety of the pa-
tients within the facility. A post-certification revisit
report and certification and transmittal is attached
for the March 19, and 20, visits.
A recommendation for termination of the provider
agreement is being made.
ATTACHMENT 2
Subject: Town Court Nursing Home
To: File
From: (Mrs.) Madeleine S. Bowen, R.N.
. Standards and Licensure
Field Representative
Summary: .
An unannounced licensure visit was made at Town
Court Nursing Home on May 9, 10, and 15, 1974.
Mr. Jack Slusser, R.N., Mrs. Mary Berman, R.N. and
Mrs. Madeleine Bowen, R.N. conducted the survey.
Mr. Thomas, Administrator, Mrs. Moody, Assistant
Administrator, and Mrs. Gross, Director of Nursing,
accompanied and assisted the surveyors.
On April 3, 1974.this facility received a certified
registered letter citing 26 deficiencies found at the
time of an unannounced night visit on March 19,
1974. A thirty (30) day period was allotted to the
facility to provide time for those corrections needed
in order to meet full compliance with the State regu-
lations.
Opposing Affidavit of C. V. Campbell 55a
The survey revealed that some deficiencies had been
corrected. Mr. Thomas had a temporary administra-
tors license and had taken the administrators exam-
ination. Disaster Plans had been posted, linen sup-
plies were increased, call bells were available many
more medications were being charted and more nurs-
ing care plans were available.
Major deficiencies continued to exist in staffing,
nursing care, medications, clinical records, physicians
orders and in the dietary department. The census
remains at 138 and in the past 5 1/2 months 65
patients had been transferred to hospital, 19 had ex-
pired, and 26 had been sent home or to other nursing
homes. Because of the unusually high number of
hospital admission, 26 closed records were reviewed
and it was revealed that only 2 of 20 patients were
transferred or discharged with a physician’s order.
Two (2) bodies had been removed:from the facility
before pronouncement of death by the physician.
One (1) clinical record contained no pronouncement
of death.
It was also discovered that on April 28 telephone
verbal orders were received and signed “Carol Fertig,
RN.” although Miss Fertig did not work on that day.
The writing appeared to be that of F. Lohier a regis-
tered nurse currently unlicensed in Pennsylvania.
Ms. Lohier’s name did not appear on any time’ sched-
ule.
The problem of poor nursing care suggests that
daily rounds by Registered Nurses are not being done
and therefore no professional nursing assissments are
made. This ultimately results in the practice of cor-
rective rather than preventative medical and nursing
56a Opposing Affidavit of C. V. Campbell
care inadequate supervision and direction of nursing
personnel. Such problems as dehydration and fecal
impactions are preventable by careful nursing ob-
servation and nursing intervention, neither of which
is in evidence in this home.
Changes in patients conditions are not noted until
those changes have resulted in some acute condition
necessitating medical intervention.
In addition to the poor quality of professional
nursing supervision the nursing staff is deficient in
quantity therefore compounding the problem. It is
the contention of the Director of Nursing that the
patients are showered and kept clean. That alone is
not the only goal of geriatric care. The number of
males needing shaves scems to be a result of inade-
quate staffing.
Nursing personnel other than R.N.’s are oriented
by their peers. They were not aware of the meaning
of an ADA diet or the significance of “double” on a
patient’s tray.
The dietary department had glaring deficiencies
particularly in the area of therapeutic diets. Of
eleven (11) patients on fifth (5) floor ordered to
receive therapeutic diets, only five (5) were receiv-
ing them. On May 9th the luncheon entree of “sloppy
joes” was insufficient in quantity to serve all the
patients and other substitutions had to be made. A
tube feeding was being prepared with the syrup from
canned fruit, milk, and eggs.
Complaints received in the Regional Office.about
cold food and hungry patients were substantiated.
Opposing Affidavit of C.V.Campbell 57a
Observation of lunch being served revealed that food
stands on carts from 5 to 25 minutes while nurses
aides pour coffee and milk and put condiments on
trays. No heating devices are available to maintain
warmth.
Upon questioning several patients stated they were
often hungry but additional food was never available.
Almost every bedside cabinet had supplies of cookies,
crackers and candy supplied by families. One (1)
male patient refused to offer any comments about the
home stating ‘“‘I’d be a fool if I complained”’.
Water pitchers were dirty, water was not fresh
there was no ice in any pitchers; some patients had
no water pitchers or drinking glasses.
Mrs. Baur, a patient on third (3) floor complained
to a surveyor about the inhuman treatment and verbal
abuse. Several telephone and written complaints
have been received in the regional office concerning
thé treatment of patients in this facility.
The exit interview was conducted with Mr. Thom-
as, Mrs. Moody and Mrs. Gross. The numerous prob-
lems werd discussed and the problem of staffing was
reviewed.\ Mr. Thomas and Mrs. Gross stated that
obtaining ahd keeping staff was difficult. Upon ques-
tioning Mr. Thomas revealed that he felt petsonnel
policies for nursing staff were poor and felt his own
benefits were inadequate. He stated that requests to
the corporate office for increased- benefits have been
denied. ;
Licensure was not recommended at this time. Mr.
Slusser stated that the report of the survey would be
turned over to the legal department for action. Both
58a Opposing Affidavit of C. V. Campbell
Mr. Thomas and Mrs. Moody were of the opinion
that most of the deficiencies had been corrected prior
to the survey. It was the findings of the survey how-
ever, that not only .new areas of deficiencies but
continuing serious deficiencies in nursing. Mr. Slusser
pointed out that no request for consultation had been
forthcoming from the facility although it had been
offered in the letter of April 2.
Mr. Thomas said he would #end a formal request
for consulation to Mrs. Poppert.
Jun 18 1974
ATTACHMENT 3
June 28, 1974
Summary: Town Court Nursing Center
Survey of June 3, 4,5, 1974
Provider Number
39-5129
An unannounced survey for the purpose of Licen-
sure, Medicare and Medicaid, was done at Town Court
Nursing Center on June 3, 4, 5, 1974. Participating
surveyors were Mrs. Barbara Faillace, R. N., Mrs.
Madeleine Bowen, R.N., Mrs. Phoebe Somma, R.N.,
and Mrs Mary Berman, R.N., Mrs. Marjorie-Steever,
Medicare Validation Officer, qneriaQung also par-
ticipated in the visit.
The license for this facility expired on March 22,
1974, and no recommendation for licensure has been
made ‘by the Regional Office of the Department of
Welfare.
Opposing Affidavit of C. V. Campbell 59a
Several extensions of time have been granted to
Town Court in order to provide this facility the op-
portunity to come into compliance with state regu-
lations.
On April 2nd, 1974, Mr. Thomas, Administrator
received a letter and a list of violations by certified
mail. A thirty (30) day period ending May 4, 1974,
was granted to correct existing deficiencies. An
offer to provide consultation was included in the
~letter but was not acted upon by Mr. Thomas. Notice
was given that the next survey would be unannounced.
On May 9, 10, 15th, an unannounced licensure
survey was done and because substantial improve-
ment had not been made in the quality of patient care,
no recommendation for a license was made.
On May 24th, 1974, a meeting was held in the
Regional Office at the request of Mr. Al Casper of
Regional Health Planning. He was accompanied by
Mr. Daniel Veloric, President of Geriatric and Medi-
cal Centers, Inc., and Mr. John Thomas, Administra-
tor of Town Court. Representing the Department of
Welfare were Mrs. Dorothy Poppert, Regional Super-
visor, Mr. Cecil Maidman, Attorney for the Depart-
ment, and Mrs. Ruby Buckler, Miss Roseanne Mar-
sicanno, Mr. Jack Slusser, Mrs. Barbara Faillace, Mrs.
Madeleine Bowen, and Mrs. Marjorie Steever, Valida-
tion Officer, from Harrisburg.
Mr. Casper and Mr. Veloric wished to ceroaltiiione
term plans for Town Court as the corporation has
been authorized by Regional Health Planning to be-
gin new construction for the addition of sixty (60)
beds. The position was taken by the Department of
a ae
60a Opposing Affidavit of C. V. Campbell
Welfare that the immediate needs of Town Court
were a priority and demanded immediate correction
because patients health and welfare were jeopardized.
Jul 5 1974
Mr. Veloric and Mr. Thomas then requested that
one (1) week be granted to bring the facility into
compliance.
Therefore on June 3, 4, 5th, 1974, another survey
was done. Major deficiencies continued to exist in
Dietary, Nursing, Housekeeping, and Administration.
The Director of Nurses had resigned and Mrs. Carol
Fertig Leonard was Acting Director. She was un-
qualified to carry out the responsibilities of that posi-
tion. Staffing was deficient qualitatively and quanti-
tatively Improvement had been made in the chart-
ing of medications. Overall quality of nursing care
was unacceptable. It was noted that Mrs. Fertig
Leonard had written a nurses note stating that a
physician had pronounced death at 8:30 P.M. on
May 21, 1974. Time cards revealed that Mrs. Fertig
Leonard was not in the facility at that time. The
death certificate gave the date of death as May 21,
1974; the physician dated his signature on April 22,
1974.
Dietary services were grossly inadequate with food
in short supply, cold food, diet-errors, and therapeutic
diets not being served.
Observation of a fire drill revealed negligence on
the part of Mr. Thomas who did not seem aware of
how to conduct a fire drill. After five (5) minutes
he delegated this responsibility to Mrs. Moody, Ad-
ministrator. Surveyors posted on all floors noted that
Opposing Affidavit of C.V.Campbell 6la
there was absolutely no response at all to the an-
nounced drill on 2, 3, and 4th floors. Fifth (5) floor
personnel responded inappropriately. Documentation
of monthly fire drills was provided by Mr. Thomas.
In conclusion then, from April 2nd to June 5th,
1974, conditions at Town Court have not significantly
improved, and these conditions adversely affect the
health, welfare, and safety of patients.
It was noted at the time of the June survey that
construction of the new addition had begun.
MSB/jct
ATTACHMENT 4
DEPARTMENT OF HEALTH, EDUCATION AND
_ WELFARE
Region III
3535 Market Street
Philadelphia, Pennsylvania 19101
September 20, 1976
Office of the
Regional Director
Mailing Address
es P. O. Box 13170
Philadelphia,
Pennsylvania 19101
3133
Our Reference: OLTC (1) ew
Mr. Richard Zarin
Acting Director
62a Opposing Affidavit of C. V. Campbell
Division of Licensure and Certification
State Department of Health
Health and Welfare Building
Harrisburg, Pennsylvania 17120
Re: Town Court Skilled’ Nursing Facility
1526 Lombard Street
Philadelphia, Pennsylvania 19146
Medicare No. 39-5337
Medicaid No. 04-00357
Dear Mr. Zarin:
Our office received a request to investigate a com-
plaint of poor nursing/patient care and improper
billing procedures with respect to Medicare patients
at the above listed skilled nursing facility.
During the week of July 19 through the 23, 1976,
a federal team investigated the alleged complaint and
at the same time conducted a complete federal survey
of all the health conditions of participation governing
skilled nursing facilities.
The findings of the survey substantiate the allega-
tion of poor nursing/patient care. In reference to
billing procedures there appears to be some concern
and our office will request the Bureau of Health In-
surance Integrity Branch to conduct a complete in-
vestigation.
The Federal Survey findings are significant in that
the following conditions of participation are not met:
405.1122 Medical Direction
405.1124 Skilled Nursing Services
Opposing Affidavit of C. V. Campbell 63a
The Conditions of Participation for Physician Ser-
vices and Dietary Services are marginally met. In ad-
dition, the federal findings reveal that many stan-
dards and elements throughout the health standards
are not met. Moreover, a further investigation needs
to be undertaken with respect to medical care ren-
dered at this facility.
The results of the federal survey of July 19-23,
1976, compared with the state survey of April 14,
1976, indicates serious and significant differences be-
tween the two surveys. The state survey found all
conditions, standards and elements met. See the at-
tached federal survey narrative findings.
In accordance with Section 942 of the State Agency
Long Term Care Manual, you are requested to con-
duct a complete resurvey of the Town Court Skilled
Nursing Facility immediately. Forward a completely
documented survey report form and the appropriate
accompanying documents.
Sincerely yours,
(s) legible
Robert J. Taylor, Director
Office of Long Term Care
Standards Enforcement
Enclosure
SUBJECT:
Federal Survey Findings
Town Court Skilled Nursing Facility
1526 Lombard Street
Philadelphia, Pennsylvania 19146
64a Opposing Affidavit of C. V. Campbell
Medicare No. 39-5337
Medicaid No. 04-00357
Total Number of skilled beds certified—198
Federal Survey Performed
July 19 through the 23, 1976
Prepared by the Office of Long Term Care, Stan-
dards Enforcement, DHEW, Region III.
Narrative Findings
Standards and elements not met including the
standards and elements found not met under the Con-
ditions of Participation.
Medical Direction: Coordination of medical care
standard (a) F94, F95. There is no evidence that
the medical director is involved in the coordination
of medical care in the facility. The administrator
apparently has attempted to provide some coordina-
tion as evidenced by a physicians’ staff meeting dated
2/23/75 with four physicians attending and the
Medical Director not present. According to the ad-
ministrator, he initiated the meeting. A memo from
the administrator, dated 2/25/76, definitions were
established for common terms for patients’ condi-
tions such as good, fair, serious and critical, so that
when inquiries are made these terms could be used
by all; there was no evidence of approval by the
Medical Director. The Medical Director has not de-
veloped by-laws, regulations, or outlined the re-
sponsibilities of the attending physicians. There
were no policies/directives with respect to physician
services and the provision of services.
Standard (b) Responsibilities to the facility F98,
F99, The administrator and nursing staff assume the
Opposing Affidavit of C.V.Campbell 65a
responsibility for surveillance of the health status of
the facility’s employees.
With respect to incidents/accidents, there were 106
incident/accident reports reviewed by the Medical
Director, with the exception of nineteen. Accord-
ing to the records, the nineteen were dated from
6/7/76 to 7/21/76. The 106 incidents/accidents
occurred from the period January 1, 1976.
The situation described above indicates an im-
mediate need to reinforce policies, procedures and to
monitor staff and patients in order to provide a safe
environment for the patients. At the present time,
the facility is revising the incident/accident form and
the assistant director of nursing has implemented an
on-going study in reference to this problem.
In addition to the above, there is no evidence that
the administrator is given appropriate information to
help ensure a safe and sanitary environment for pa-
tients and personnel.
According to the records of meetings maintained
by the facility, the medical director attends the utiliza-
tion review and the patient care policy review meet-
ings. However, his attendance at the Pharmaceuti-
cal and infectiqa, Control Committee meetings raises
some concern.
The administrator indicates that the Pharmaceuti-
cal Committee meets monthly. The Federal Regula-
tions require at least quarterly meetings. The Medi-
cal Director did not attend the Pharmaceutical Com-
mittee meetings dated: June 1975, September 1975,
February 1976, March 1976, April 1976, May 1976
or June 1976.
66a Opposing Affidavit of C. V. Campbell
With respect to infection control, the administra-
tor stated that the committee meets quarterly; how-
ever, the policy of the facility outlines annual meet-
ings. The Medical Director was in attendance on
March 3rd and 3ist, 1976. There were no other
committee minutes.
Recommendation
The medical direction functions need to be imple-
mented immediately specifically with reference to co-
ordination of medical care rendered to patients, to
prevention of patient accidents, i.e., protection from
injury and to provide assurance for a safe and sani-
tary environment for patients and personnel. The
medical direction functions need to be fully coordi-
nated with all other service areas: Nursing, pharmacy,
infection control, dietary, specialized rehabilitation,
laboratory, etc. The medical director along with the
administrator need to review contracts with all the
participating hospitals that have entered into trans-
fer arrangements. Temple University, Graduate Hos-
pital, Center City Hospital. Careful policies and pro-
cedures must be developed in order to protect both
the patient and the facility as it pertains to providing
services to patients. There are gross omissions with
respect to information from the transferring facility
that have the potentia! for creating a hazardous situa-
tion as it pertains to patient care.
Standard (b) is not met. Deficiencies are noted
in F 107 and F 109. The following charts have
omissions with respect to this standard.
Chart No. 1394, Medicaid admission of June 19,
1976. Old CVA, dehydrated with right sided
Opposing Affidavit of C.V.Campbell 67a
paralysis. This patient has an extensive decubitus on
the sacrum and coccyx area that has deteriorated and
increased in size significantly since admission. The
patient is on 24 hours hypodermoclysis solution con-
taining Wydase (medication). Transfer information
as of July 23, 1976 has not been received by Town
Court. The patient was transferred from German-
town Hospital. Nursing staff members report only
a “piece of paper came with patient,” (they cannot
locate the information for the federal surveyor). The
only laboratory results is dated July 21, 1976 of the
results of the culture and sensitivity of laboratory
specimen from the decubitus ulcer—Proteus micro-
bilas. As of July 23, 1976, there is no history or
physical examination. There is a medical care plan
dated June 24, 1976. However, this contains only
diagnosis, discharge plans, etc.
Chart No. 1181 Medicaid admission September 12,
1975, The physical examination was dated Novem-
ber 15, 1975.
Chart No. 998 Medicaid admission. There was
no physical examination on the patient’s record ex-
cept one dated 10/24/74.
Chart No. 1160 Medicaid. CVA with hemiplegia.
The last physical examination was dated July 21,
1975. The laboratory report of February 13, 1976
showed RBC 3.47 (4.6N), Hb 9.9 (14-18), HCT
32.2 (40-54). There are no additional laboratory
reports.
Chart No. 1341 Medicaid. CVA with right
hemiparesis, pneumonia. The laboratory report dated
February 27, 1976, showed Hb 11.6 (14-18) RBC
4.30 (4.6).
68a Opposing Affidavit of C. V. Campbell
Chart No. 1077 Medicare admission of February
6, 1976. Old myocardial infarction—senile. The
last physical examination was dated February 7, 1975.
The laboratory report dated December 23, 1975—
RBC 3.80 (4.6-6.2) Hb 10.2 (14-18) HCT 30.9 (40-
54) no follow-up laboratory report.
Chart No. 1161 Admission July 17, 1975, Right
Hemiparesis—old craniostomy. Medication order of
June 17, 1976:
—Darvocet N 100 mgm q 6 hours prn for pain
— Diazide cap 1 daily
— Tylenol tab 11 g 6 hours
— P.O. Di 100 mgm t.i.d.
—- Haldol’S mgm B.i.d.
— Vitron C tab 1 daily
— Dalmane 30 mgm at HS prn
— Phenobarb 30 mgm in a.m. daily
— Phenobarb gr 1/2 h.s. prn.
— Surfax 240 mgm at h.s.
— Surbex tab 1 6 p.m. if oral medicines refused,
sparine 75 mgm, thorazine 50 mgm at HS.
On June 24, 1976, the physician’s progress report
read, patient is over-medicated. Heart shows tachy-
cardia, Lungs clear. Slight ankle edema. On 6/24/76,
the following medications were discontinued: Thora-
zine H.S., Haldol b.i.d., Phenobarb H.S. The labora-
tory findings not within the normal range lacked
follow-up reports. A review of the patient’s drug
regimen might have prevented over medication.
There were ten (10) patients ordered restraints
prn., three of these did not indicate the type of re-
straint to be applied.
Opposing Affidavit of C.V.Campbell 69a
Federal regulations require that the physician pre-
scribe a planned regimen of total patient care based
on a medical evaluation of the patient’s immediate
and long-term needs. The medical evaluation of the
patient is based on a physical examination done with-
in forty-eight hours of admission unless such exam-
ination was performed within five days prior to ad-
mission. In spite of the fact the facility’s physicians
are reviewing the patient every thirty days, there are
omissions as outlined in the charts reviewed and cross
referenced with the nursing services. Better coordi-
nation with physician services should be implemented.
Recommendations
The condition of participation in reference to
physician services is marginally met. Moreover, the
requirements under Medical Direction have a direct
relationship to the problems encountered under physi-
cian services.
The facility needs to implement immediately the
requirements outlined under medical direction. Closer
monitoring of physician services, accident prevention
and surveillance of employee health status needs to
be significantly improved.
Analysis of Nursing Care—See attachment
A full direct Federal survey was performed at the
Town Court Skilled Nursing Facility during the en-
tire week of July 19-23, 1976. The purpose of the
survey was to investigate a complaint in reference to
nursing and general patient care. Sixty-six (66) rec-
ords were reviewed in conjunction with direct obser-
vations and interviews with patients.. Twenty-seven
(27) of the Sixty-six (66) charts reviewed, and nurs-
ing observations made, raise concern with respect to
70a Opposing Affidavit of C. V. Campbell
some aspect of nursing/patient care. This represents
Forty (40) percent of the sample size of Sixty-six
(66).
Twenty-three (23) Medicaid—Four (4) Medi-
care (1.¢., the twenty-seven that have areas of
concern)
The direct Federal survey reveals the following in
reference to nursing and patient care:
Of the Twenty-seven (27) records reviewed, there
were six (6) incidents of patient falls, one patient
experienced two (2) falls (Chart No. 1272). This
patient fell on 1/6/76 at 3:30 P.M. (a gash on the
top head). This patient fell while going to the
bathroom. He was transferred to Presbyterian Hos-
pital and returned at 10:30 PM. On 7/20/76, at
twelve midnight, patient fell while getting out of bed.
Patient was semi-conscious at the time. Orange juice
was given. The Rescue Squad came and administered
IV 50cc of Dextrose. Patient responded at once.
(No record of vital signs indicated.) On 7/21/76,
at 4:30 AM vital signs T 98.6, P-76, -24 and B/P
140/70. A nursing note indicates patient did not
eat. The attending physician was notified. 10:30
A.M. physician’s note, “abrasions of head, forehead
and nose. Quiet respirations. Comfortable. Bed-
side blood sugar low.” One of the six incidents re-
sulted in a patient sustaining a fracture of the left
distal radius as noted by the referring physician at
Graduate Hospital on 7/15/76. The patient was .
transferred to Graduate Hospital because of bruising
and swelling of the left lower arm. (Chart No. 402.)
In addition to the above concern for patient safety,
the review of the Twenty-seven (27) records dis-
Opposing Affidavit of C.V. Campbell 71a
closes a pattern of a lack of (1) thoroughness in
charting pertinent observations, particularly with re-
spect to observation and healing status of decubitus
ulcers. The majority of nurses’ notes only indicate
if a treatment was done, more seriously observations
reveal that (2) nursing assistants are primarily re-
sponsible for the special treatments to decubitus, 1:€.,
cleaning, application of topical medications and for
foley catheter irrigations including the introduction
of medicated irrigating solutions and other special
treatments. One particular observation of an aide
reveals improper aseptic technique was employed in
doing the decubitus care and foley irrigation. More-
over, the aide did not follow the facility’s procedure
and informed the surveyor that she observed another
aide as opposed to receiving instructions and demon-
stration and supervision from the licensed nursing
staff. (See attachment), (3) In certain instances,
where it is appropriate, there are omissions in refer-
ence to total and types of food tolerated and con-
sumed by some of the diabetic patients and for the
one patient who has a large non-healing decubitus.
This patient is on IV hypodermoclysis with Wydase
added.
All of the above results in a pattern of poor nurs-
ing care as it relates to monitoring patients, prevent-
ing accidents, careful follow-through of nursing care,
lack of direct supervision of aides, assignment to aides
of procedures that should be pertormed by the li-
censed staff. This pattern of nursing care delivery,
particularly the concerns raised in the 27 records, has
a potential to jeopardize the health and safet of
patients.
7 7 ; oq)
aoe
¥:
72a Opposing Affidavit of C. V. Campbell
An additional occurrence of July 23, 1976 raises
further concern,*although the charge nurse indicated
that it was a very unusual situation. The laboratory
technician was late arriving to the floor to obtain the
Fasting Blood Sugars from approximately eight (8)
diabetic patients. The breakfast trays were on hold.
Hot foods, i.e., scrambled eggs and toast were luke-
warm to cold when Federal surveyor observed the
delay. These trays were not contained in warmers.
Patients finally started to receive trays between 9:15
and 9:30 A.M. The laboratory technician completed
her activitics at 10:10 A.M.
One patient complained later she did not receive
a tray.
Based on the above (See narrative attachment)
standard (c) of 405.1124 is not met. It is the pat-
tern of nursing care observed as revealed in the 27
records that renders the condition of Participation
405.1124 not met.
Patient Identification No.
1. No.402—Medicaid
Admission 5/2/72
Primary Diagnosis: left fracture—neck of left
femur (?) ASHD
Current physical dated 11/9/75
On initial day of survey, Federal surveyor ob-
served an elderly female neatly dressed in a colorful
nightgown lying in bed. The patient’s left lower arm
was bruised and an ace bandage was applied: The
left hand was swollen. The patient’s arm rested to
the side There was no suport, i., a sling. The
charge nurse iidicated the swelling was essentially as
it had been on previous days. She indicated the
Opposing Affidavit of C.V.Campoell 73a
patient received special soaks and would be followed
at Graduate Hospital. On 7/20/76, another Fed-
eral Surveyor observed swelling of the patient’s left
hand. The 3-11 supervisor visited the patient. Jndi-
cated the ace bandage was tight. The physician’s
note of the day also indicated ace bandage was tight.
The evening supervisor indicated ace bandage would
be adjusted and a sling applied. Next A.M. (ap-
proximately 9 A.M.), Federal surveyor saw patient.
Patient indicated she bathed self with assistance from
the aide, this A.M. Stated she did not eat breakfast,
only orange juice. Her complaint was, toast is al-
ways a little burnt. Charge nurse observed ace band-
age, still applied incorrectly, no splint applied. Aide
assigned to soaks. Federal surveyor observed aide
and interviewed her in reference to the treatment.
The patient indicated aide was doing a good job.
Patient was out of bed. On return to facility, at ap-
proximately 1:40 P.M., Federal surveyor notified that
the patient expired suddenly. The physician indi-
cated as an immediate cause of death, “myocardial
failure (heart failure) 5-10 minutes and arterioscler-
osis 2-3 years.” He also ordered an autopsy. The
evening supervisor informed the Federal surveyor
that an autopsy is not performed when natural cause
of death is listed. The attending physician was not
available: however, a message was given regarding
this.
Review of record.reveals the following:
7/11/76 ae
Patient’s left hand is edematous. Physician’s an-
swering service called. Physician ordered hand soaks
in Epson solution.
74a Opposing Affidavit of C. V. Campbell
7/11/76
Verbal order taken by RN and signed by the physi-
cian. Soak left hand in 2 tsp. of Epsom salts to one
pint of water three times a day. Keep hand elevated.
7/12/76—Physician’s note:
“Patient presumably fell one week ago and injured
left hand, no tenderness—no chills—fever. Soaks
ordered” (NOTE: some words in this notation can-
not be discerned by the Federal surveyor) .
7/12/76—Nurse’s note:
7-3 shift, left hand swollen, soaks to left hand done,
visited by physician.
3-11 shift, left (hand) soaked, as ordered, with
normal saline solution. (On 7/12/76, physician or-
dered normal saline solution soaks.)
7/13/76
7-3 shift, left hand still swollen, soaks, hand ele-
vated in sling.
7/15/76—Physician’s note:
Hand swollen, but less. Sling ordered. Burrow’s
solution.
7/15/76—4:30 P.M. Nurse’s note:
Message left at relative to inform them of fracture.
3-11 Patient returned from Graduate Hospital
7/15/76 written on prescription sheets. Not signed
by referring physician. Physician’s name was con-
tained in content of order, i.e., in reference to who
to notify if there are problems.
7/15/76—Nurse’s note:
“Patient transferred to Graduate Hospital via
cabulance at 3:15 P.M. Returned at 5:25 P.M. No
apparent distress.”
Opposing Affidavit of C.V.Campbell 75a
Prescription sheets (2) state:
(1) distal radius fracture non-displaced
(1) encourage finger motion
(2) Check neuro vascular status regularly left
hand
(3) remove ace bandage daily to care for skin on
dorsum of forearm
(4) call Dr. Kimbin? if any questions
(5) to be seen in 2 weeks
7 /16/76—Nurse’s note:
“Patient’s arm still swollen, denies pain. Bruising
throughout forearm to the elbow. Encouraged to
move fingers. Ace bandage removed and rewrapped.
Patient’s fingers checked, feels pain, color good, warm
to touch, nail beds, appears normal,” etc.
Treatment to lower left arm not recorded by Nurs-
ing Service on 7/16/76
7 /18/76—Physician’s order:
Sling to left hand
x-ray, D/C Saline soaks
Use Burrow’s solution
7/20/76—Physician’s note:
“Splint seems to suffice . . . swelling—wrist, ace
bandage too tight”
7 /20/76—Nurse’s note:
Patient’s arm swollen, (better) no complaint of
pain.
7/21/76
Federal surveyor saw patient in A.M. Wrist
swollen but less than 7/20/76. As noted in after-
noon, ace bandage not applied correctly. House
supervisor removed and asked aide to bathe and apply
76a Opposing Affidavit of C. V. Campbell
treatment. Federal surveyor briefly observed patient
receiving treatments this morning.
7/21/76—No time listed—Nurse’s note:
Patient found lying down—unresponsive VS P(0),
R(0),B/P (0), Temp. 94, Dr. notified
7/21/76—1:30 P.M. Physician’s note:
Patient expired 1:30 P.M.
Autopsy ordered
Death Certificate signed
Immediate cause of death Myocardial failure 5-10
min.
Arteriosclerosis 2-3 years’
Federal surveyor notified by 3-11 supervisor that
State does not perform an autopsy when natural
causes are given for death.
Incident form dated 6/24/76
The appropriate blocks in reference to notification
of physician not checked. Vital signs, 98T, P-70, R-
no record. Description of incident, laceration on
arm, 2nd bruised spot on left knee. Treatment, ice
pack given; placed on left knee and left arm, dressing
after cleansing with hydrogen peroxide. Question
on form: How to prevent accident. Response from
aide: “We cannot because patients are subject to
falls,” signed by floor nurse and Director of Nursing,
not by Medical Director.
2. No. 13 17—Medicaid
Admission 2/13/76
Chief Complaint—Chronic UTI
Primary Diagnosis: CVA, Chronic Brain Syndrone
* Poor mouth care
* Good care plan
Opposing Affidavit of C. V. Campbell 77a
3. No. 1408—Medicaid
Admission 7/15/76
Chief Complaint—Recurrent GI bleeding, lower
abdominal cramps, severe anemia
Physician’s note: Severe anemia 2° GI bleeding
aggravating a known refractory anemia due to bone
marrow failure. H & H stabilized at 8-9.
7/20/76—Nurse’s note: . . . “Patient sustained fall
to the floor, no evidence physician notified
Lab results 7/20/76
RBC 3.37 L
Hg 9.7 L
Het 29.5 L
Doctor notified of results 7/22/76”
In bed when Federal surveyor went with charge
nurse to observe patient.
Good Care Plan
4. No. 1064—Medicaid
Admission 1/7/74
Note 7/15—Patient fell from wheelchair, T 98, P-
60, R. 18, B/P 130/70. Supervisor notified. No
documentation in reference to notifying physician.
5. No. 1352—Medicaid
Referred from home
Date of Admission 3/24/76
Diagnosis: Diabetes, CVA
Review Lab results:
7/3/76 Glucose 82
4/9/76 Glucose 63
7/16/76 Glucose 170 High
On a 1500 ADA diet
=
re aeipes
78a Opposing Affidavit of C. V. Campbell
There are notations in reference to feeding and
assisting with meals, no description of diet tolerance
or consumption. -
6. No. 1135—Medicaid
Admitted 5/20/75
Admission physical examination 11/5/75
Diagnosis: Diabetes Mellitus
Nurse’s notes reveal:
6/8/76
Patient took milk and crackers—urine negative
with trace of acetone, still feels weak—encouraged to
take fluids.
6/8/76 patient feeling much better, ate entire
serving of diet supper, would like to have soup at
supper, notation for dietitian.
6/8/76—4:30 P.M. insulin held because of com-
plaint of weakness and dizziness.
6/26/76—1600 ADA 1/5, 2/5 including 3 P.M:
snack, 2/5 including hs snack
6/30/76—Complaint of weak and dizzy. Patient
got up from chair, attempted to get to bed, slipped
and fell to floor.. No visible injuries. No complaint
of pain. Vital signs B/P 180/90, T-98, P-76, R-20
awaiting for physician to return call.
9:20 P.M. telephone call from physician, stop all
medication, will see patient tomorrow.
No apparent distress.
7/1/76—Patient weak, dizzy
Doctor examined patient, to remain in bed today,
all meals stopped.
Opposing Affidavit of C. V. Campbell 79a
7/1/76—Patient lethargic and pale, B/P 160/80-
80-20
Doctor notified. Additional insulin dosage given.
7/5/76—FBS 156, physician notified
7/8/76—insulin changed per assessment and visit
by physician.
7/12/76—physician notified of increase in Blood
sugar, insulin increased by physician.
7/19/76—FBS 152
7/21/76—insulin reaction noted, VS 166/120-98-
20 OJ and sugar P.O. time not noted by: licensed
nurse
7/21/76—3-11
“Patient appears drowzy, lying in bed most of shift.
Ate good dinner. Statement of patient (patient feels
better) insulin given by supervisor this evening.”
Chromology of Lab studies: —
6/25/76 Fasting Glucose 162
7/ 2/76 Fasting Glucose 156
7/ 9/76 Fasting Glucose 204
7/16/76 Fasting Glucose 152
No Registered Dietitian’s notation on chart in
reference to diet tolerance or consumption or if any
problems discerned.
Patient apparently unstable with respect to Diabe-
tes.
‘On Patient Care Plan there is a notation in refer-
ence to nursing approach to Diabetes.
“Patient to give own insulin—reinforce technique
in class.”
There is no current physician’s order regarding this
although there was an update of plan, July 2, 1976.
al
-
80a Opposing Affidavit of C. V. Campbell
7. No. 952 Type 2
Admission 5/20/75
Current Hx and physical examination 5/21/76
From current information: Diagnosis: Bilateral
A/K amputation, Glaucoma, Diabetes Millitus
* Nurse’s note:
7/16/76 by RN “Patient has not had an eye ex-
amination 2 years. Federal surveyor questioned nurse
regarding this.
Eye appointment has been scheduled for August
- 13, 1976.
8. No. 1402 Medicaid
Admission 6/20/76
Diagnosis: Congestive heart failure
Diabetes
Has decubitus on admission
Location: Left hip, 1 cm in diameter—approxi-
mately inch, healing.
Aides responsible for treatment to the decubitus
and left stump area.
Treatment to decubitus: Paint on left hip with
3% mercurochrome, allow to dry. Apply BFI pow-
der bid.
Aide applying topical medications. Indicated she
received no instruction with respect to treatment.
Aide used H:O: solution used for other patients.
Poor technique, held bottle opening close to decubitus
while pouring solution to clean skin area. nt
When aide turned patient, sheets very ruffled,
crumbs in bed, spoon under patient, coffee cup dirty
with deep staining. Aide indicates she usually checks
Opposing Affidavit of C.V.Campbell 81a
cups before serving, but forgot this one. Indicates
kitchen sends cups up like this one frequently.
On physician’s order sheet there is an order be-
tween dates of 7/7/76 and an order of 7/21/76 for
weekly FBS unless otherwise ordered. 7/2/76 FBS
140 high. There are no other FBS results on record.
There is an R.D. notation 7/20/76—1500 cal.
ADA pureed diet, must be fed, appetite fair.
9. No. 1394—Medicaid
Admission 6/19/76 from Germantown Hospital.
No transfer information received.
Admission note by LGPN 6/19/76—‘Received
patient this PM from Germantown Hospital via
ambulance. Dehydrated OLD CVA with right pa-
ralysis, vital signs taken.
Decubitus on Sacrum/Coccyx, left heel.
House supervision indicates decubitus twice size
since admission. A heel cushion is applied.
Description of Decubitus on Sacrum/Coccyx low
spine.
Approximately 2 inches in diameter and 1% inch
deep. No signs of healing, outside tissue red, inside
decubitus tissue has grayish/whitish appearance.
Result of recent C & S of decubitus Lab report
verbal, 7/21/76. Proteus Mirobilas S-Senitive Kana-
mycin and Ampicillin. Physician ordered Ampicillin
500 mg. q 60. vr
There is no complete Hx, PE on record. The only
lab report is the above listed report of 7/21/76, it
was ordered 7/17/76. Patient previously on Keflin
1.5 gm. Im q 60 as of 7/17/76. I/O is recorded
82a Opposing Affidavit of C. V. Campbell
and food consumption is described in terms, appetite
fair. Nothing recorded by RD about diet intake as
it pertains to protein consumption. Nothing recorded
in reference to type of foods consumed. Nurse’s
notes do not contain a good description of status and
degree of deterioration of the decubitus. The decu-
bitus is not healing. Patient receives over 24 hour
daily hypodermocylsis solution. Federal surveyor
observed the aide perform the treatment for this A.M.
‘Decubitus care applying topical medications, and
the Foley catheter irrigation, consists of Neosporin
Solution. Aide indicated no licensed staff demon-
strated treatment, that she observed another aide.
Poor technique observed, especially with respect to
prevention of cross contamination. Aide used thin
plastic glove, cleaning feces continuously, changed to’
do care to decubitus; however, aide proceeded to
irrigate foley with same gloves after decubitus care.
(See attached.) Technique not in accordance with
facility’s policy/procedure.
Federal surveyor suggested she wash hands, aide
complied with request, poor technique in reference to
Foley irrigation as it relates to promoting asepsis.
Tube draped over thigh, thus not effecting good
gravity for return of irrigating solution. Using. medi-
cated solution to irrigate Foley, Neosporin.
No assessment by RD since admission Hypo der-
mocylsis: 2.5% in ¥% PSS with 150u Wydase. On
a soft to bland as tolerated.
* Cardex diagnosis bladder infection listed—Fed-
eral surveyor cannot discern this in physician’s nota-
tion.
Opposing Affidavit of C. V. Campbell 83a
Nothing in Care Plan in reference to problems and
approaches to decubitus care. Statement on Nurse's
notes indicate only decubitus care as ordered.
Additional notes:
7/11/76—Nurse’s notes:
9:15 P.M. Patient perspiring freely, pain where
hypodermocylsis inserted, vital signs; T-102(R), P-
100, R-36, B/P 118/60
10:00 P.M., T-103(R) 10:55 P.M. physician re-
turned call.
Tylenol gr x q.i.d. ordered.
7/12/76—Visited by physician in A.M.
7/17/76—Physician’s note:
“Sacral decubitus is quit large and odorous.
Irrigate decubitus with clorox solution, diluted 1
pint to 9 pints water tid. Keflin 1.5 gm q 60 IM re-
store hypodermoclysis to thigh, add wydase amp. to
each IV.” a
Nurse’s notes do not reflect description of urinary
irrigations. Federal surveyor cannot discern any C
& S on a urine specimen.
See attached in reference to Foley irrigation proce-
dure.
10. No. 1183—Mediciad
Admission 9/12/75
Diagnosis: Benign Prostatic with Hypertrophy
Bladder Calculus
C.C. Incontinence
Has Foley catheter
Teeth on P & E very poor condition, mostly gone,
few remaining—bad condition.
* No additional dental follow-up
a5e*" x
NES
Ss
84a Opposing Affidavit of C. V. Campbell
During week 7/19-7/23/76, patient having prob-
lem with catheter.
. Physician in and changed catheter, and placed pa-
tient on I/O during afternoon of 7/22/76. Charge
nurse for day initiated order; however, it was not
implemented.
Federal surveyor brought order to attention of
charge nurse on 7/23/76 at 10:30 A.M: She imme-
diately checked the situation and .mplemented order
written by physician, approximately 18 hours after.
* There is nothing on Patient Care’ Plan in refer-
ence to urinary problems.
* There is a physician’s order for Valium 10 mg
IM prn, | hour prior to obtaining blood for lab work
Transcription omits route of administration, i.e., IM
11. 1181—Medicaid
Diagnosis: Diabetes Mellitus, anemia,
Paranoid Schizophrenia
Admission 9/12/75
; Physicial examination not done 48 hours of admis-
sion or within 5 days previous to admission. P & E
performed 11/15/75.
' Omission in transcribing a medication order:
Thorazine concentrate 30 mg. PO bid
“i Sparine 50 mg. if refuses Thorazine
Sparine 50 mg. IM q 120 prn
12. No. 1272—Medicaid
Admission 11/19/75
Diagnosis: Obstructive Emphyzema, ASHD
? diabetes, pyelitis
Opposing Affidavit of C. V. Campbell 85a -
Federal surveyor observed a very thin W/M lying
in bed. Very weak during tour of survey.
Several accidents have occurred:
7/5/76—3:30 P.M.
“Fell while going to bathroom with gnash on top
of head.
Condition of patient lethargic. Medical Director
called.
Patient sent to Presbyterian Hospital and returned
at 10:30 P.M. that evening.”
7/20/76—During 11-7 shift:
12 P.M. “Patient was apparently getting out of
bed, had accidentally lost his balance and fell down
with his face down to the floor. Was semi-conscious
at that time. OJ given. Rescue squad came and
administered IV 50cc of Dextrose. Patient responded
at once.” (No report of vital signs)
7/21/76—7:30 A.M.
VS; T-98.6, P-76, R-24, B/P 140/70
Alert and cooperative
No signs of difficulty this A.M.
Skin warm and dry, color good
Denies pain or discomfort, confused.
Two inch laceration scalp—closed
Bruise—forehead
Took a small glass of orange juice
Dr. Hand notified
10:30 A.M.—Physician’s note:
Abrasion of head, forehead, nose
Quiet respiration, comfortable,
Bed side sugar low
Note last FBS dd 3/18/76 (88)
86a Opposing Affidavit of C. V. Campbell
11:30 P.M.—Same day, nurse’s note:
Charge nurse suspects hypoglycemic reaction. Dr.
Hand notified. RD has not been in to assess patient.
13. No. 1327—Medicaid °
Admission 2/19/76
Diagnosis—CVA, Aphasia
Per physician’s note 2/19/76 “patient quite debil-
itated, will start on physical therapy. Decubitus RT
hip, left hip and left buttock. Not ascertained if
decubitus were present on admission. S
Physician was informed by nursing that decubitus
not healing. C & S ordered. RT hip. No report as
yet. .
Ordered 7/20/76.
Physician’s note of 7/19/76:
“Called to see patient because of non-healing of
decubitus, physical shows decubitus not as clean as
it should be, cultures taken, and *nursing instructed
about the cleaning of decubitus.
From 7/11/76-7/19/76, there is no accurate nurs-
ing description of status of this decubitus. Aide ap-
plying treatment—ointment. Right hip decubitus—
diameter of a “25 cent piece” Left hip—approxi-
mately 1 inch in diameter—skin breakdown. Aide
assigned to decubitus care.
Patient on 1/O—chart—Doctor’s order 1500 to
2000 cc/d omitted on 7-3 shift.
Care Plan needs update—contains notation has a
foley—patient does not have a foley catheter. Pa-
tient receives PT,
Nurse’s notes omit any notation re ROM exercises.
Opposing Affidavit of C. V. Campbell 87a
Foley during initial time of admission—April, May,
1976—
Federal surveyor could discern no order.
14. Chart No. 1322—Medicaid
* Federal surveyor spoke with patient on 7/ 20/76.
He shared fact he fell out of bed, sustained a large
black and blue bruise on back, approximately 3
inches in diameter, size of large grapefruit. Federal
surveyor brought this to the attention of 3-11 charge
nurse. She°observed it immediately, indicated pa-
tient fell on 7/19/76, but he did not tell anyone.
Federal surveyor feels this should be detected dur-
ing routine back care of this patient. k
Physician to the patient 7/23/76. Physician had
been in to see patient on 7/21/76 and patient did
not inform him.
* Physician ordered Elixir Terpin Hydrate drams
1 q 3 hours with codeine 7/21/76. Not transcribed
by charge nurse on day tour.
Federal surveyor shared this with charge nurse on
evening.
Order noted immediately.
15. No. 1388—Medicare
Admission 5/28/76
Diagnosis: Parkinson’s Disease involving left ex-
tremity
eview of physical therapy notes reveals services
ae 6/22/16, 6/24/76, 6/25/76, 7/1/76,
7/6/76,. 7/6/76, 7/7/76, 7/12/76, 7/15/76,
7/20/76, 7/21/76.
Patient evaluation conducted 6/3/76.
“a
88a Opposing Affidavit of C. V. Campbell
No discrete progress notes recorded from 6/22-
7/21/76. Only date and RPT signature. Nurse’s
notes do not reflect any ROM exercises in conjunc-
tion with physical therapy.
16. No. 983—Medicaid
Current physician orders indicate PT and ST, no ST
is given.
Diagnosis: CVA, Anemia
A recap of orders done by licensed nursing staff and
physician signed “July recap.”
RPT notes 5/20/76, 7/9/76, 7//13/76, 7/20/76
contain date and signature, no status report.
17. Chart No. 11—Medicaid
Admission 9/7/72
4/1/76 current P & E & Hx
Diagnosis: ASHD, renal insufficiency
Dental
Physician has indicated lower loose tooth, poor
teeth condition, no dental follow-up. Patient has de-
cubitus—developed while in nursing home.
5 /20/76—Physician’s note:
Called by nurse about decubitus getting worse, de-
brided and dressed.
7/1/76—Progress note by physician:
Decubitus healing.
* Decubitus 14 inch deep—buttock area. Paiient
on B/B training. No nurses note re status. Decubitus
care rendered by aide.
18. No. 1343—Medicare
Admission 2/29/76
Referred from Graduate Hospital
Opposing Affidavit of C.V.Campbell 89a
Adm P & E & Hx dated 3/1/76
* Physician Services
Federal regulations require this to be done within
48 hours of admission or within 5 days of admission
from referring source.
2/19/76—Nurse’s note admission:
‘Patient admitted via stretcher from Graduate Hos-
pitel’at 3:00 P.M. Foley draining well. Vital signs
taken and noted.
No transfer information
CC Poor appetite
Neoplasm of head of Pancreas, MS
No decubitus on admission
Decubitus noted 5/25/76—-size of dime—reddened
area. Appears to be healing. There is no reference to
Hepatitis—No evidence special precaution. This may
be chronic due to diagnosis of CA of Pancreas?
On high protein and cheese
Patient has not been eating weil—only RD note
found—7/23/76 | “ :
New dietitian has been hired. She visited patient
this date.
19. Chart No. 122—Medicaid
Admission 6/2/70
5/1/75—current Hx and P & E due for 76 annual
P&E
Diagnosis—post fracture—shoulder ofhip ;
* 7/21/76
_.. “fell on floor, 9:45 P.M. Patient found lying on
floor on back. Physician not in to see patient. Li-
censed nurse gave Valium 2 mg.
90a Opposing Affidavit of C. V. Campbell
There is an order for this—Federal surveyor cannot
discern physician’s input after fall.
On 7/23/76
Approximately 8 diabetic patient’s had hold trays.
Many on insulin, which was also held.
Several patients complaining.
Lab work completed approximately 10:10 A.M.
Lab Technician started approximately 9:40 A.M.
All trays were cold—scrambled eggs, toast, coffee—
one patient indicated that she never received tray—
this was some time past 10:10 A.M.
* Federal surveyor observed no proportionate dif-
ference between 1500 and 1800 diabetic diets for
breakfast meal. Same amount of juice, milk, bread.
Nursing
No. 998 Medicaid—On 7/1/76, physician ordered
force fluids.
No evidence of fluids being forced except for a no-
tation 7/4/76 by the night nurse which stated fluid
forced. There was no indication of the amount.
* This patient was also sent to HMCH by mistake,
the note from HMCH, dated 7/8/76, so indicated.
No. 1360 3/31/76 Medicaid—CVA right side
Hemiplegia. This patient was observed with mittens
on both hands, had poor posture, restrained, and in
need of mouth care.
No. 1160 Medicaid 7/75—CVA—Hemiplegia.
On the day patient observed, generally not neat and
in need of shaving, skin dry, badly in need of mouth
care.
No. 1405—7/8/76—-ASHD Diabetic—1200 cal
Req—Decubiti observed on adm. The nurses notes
\
Opposing Affidavit of C.V.Campbell 9la
did not adequately describe decubitus areas. Areas
on both heels necrotic.
No. 1341 Medicaid—-CVA right Hemiparesis
On 7/17/76, intake and output ordered and fluids
to 1500 cc/day—no evidence of this order being car-
ried out. The patient also had foul breath odor
No. 857—Medicaid—Osteoarthritis of hands.
This patient had an order to force fluids, there was
no record of intake.
No. 1096—Medicaid—3/12/75—Abdominal Aor-
tic Anuresym
ASCVD order to be weighed daily, not recorded.
No. 1019 Medicaid 10/2/74—CVA c right Hemi-
paresis Epilepsy.
Treatment shows Foley irrigated weekly. There was
no order for this treatment. Elase to Decubitus, no re-
corded nursing observation of decubitus.
General observations:
Nursing Care Plan did not reflect accurately patient
needs. Revisions were not made as needed.
More registered nurse supervision is needed for em-
ployees providing care to patients on the third floor.
Once restraints are applied, there is no evidence of
monitoring restraints. There were no observations re-
corded « patients restrained except the notation that
the patient was restrained.
Attachment in reference to No. 1394
Foley irrigation procedure
Foley irrigation
Contents
Plastic Drainage Tray
Plastic Graduate
+ os
92a Opposing Affidavit of C. V. Campbell
Plastic Bulb Irrigating
Syrene 50 cc
Cotton Gauze 4” x 4”
Plastic Coated Towel
Graduate Cover
Syringe Tip Protector (omitted from procedure)
Procedure
1. Snap bag open and remove tray.
2. Position patient and place plastic bag on bed to
be used as a waste receptable.
Patient not positioned correctly to effect drainage
solution flow by gravity. Patient on left side, foley
tubing draped over thigh.
3. Remove tray cover, either by sliding tray out of
sleeve, or tearing sleeve at iear spot, depending on
technique. Place plastic backed paper towel, absor-
bent side up, under patient.
4. Grasp outside graduate w/lid, containing
syringe, remove and stand graduate upright to main-
tain sterility of inner surfaces. Remove syringe and
place in tray to protect sterility. Prepare irrigating
solution/MD’s order—Solution already prepared—
Neosporin Solution—Medication—
Irrigation by aide
5. Remove syringe protector and place on drain-
age tube connection to maintain tube’sterility during
procedure, before proceeding with procedure.
Not done, no tip protector, tubing end placed on
sheet.
Afde proceeded to go from decubitus care to cath-
eter irrigation. Federal surveyor suggested that she
wash hands before proceeding with procedure.
Opposing Affidavit of C.V.Campbell 93a
6. Place syringe in solution and slowly depress
bulb then release, to fill syringe. Proceed with irri-
gation, observe aseptic technique, collect irrigation,
observe aseptic technique, etc. |
Record findings in nurse’s notes. Aide did pro-
cedure, only initialed a special Rx sheet.
Standards, elements not met under nursing
Standard (b) Charge nurse. Elements 130 and 132
are not met.
The administrator, on occasion, has assigned the
Director of Nursing as charge nurse.
Federal regulations require that the charge nurse is
to be designated by the director of nursing services for
each tour of duty. Moreover, the director of nursing
cannot serve as a charge nurse in a facility with an
average daily total occupancy of 60 or more patients.
Standard (c) Twenty-four hour nursing service is
not met. Elements F 135, 136, 137 have deficiencies.
(See the narrative report)
Standard (d) Patient Care Plan is not met.
Thirty-two (plus) care plans were reviewed. Fif-
teen of the care plans lacked some items that are re-
quired by Federal regulations. The majority did not
indicate the coordination of other services, i.e., dietary,
physical therapy. The majority of care plans contained
only the nursing aspect of care. In a few instances,
care plans were not completely in accordance with
physician orders. The revisions did not indicate
changes in patient status. Omissions were observed in
the care plans of following chart numbers: No. 1402,
1064, 402, 1135, 952, 1394, 1183, 1272, 1327, 1388,
122, 1398, 115°, 1414, 1406. (Care plans of patients
on the fifth floor at Town Court.) In addition, the
4
94a Opposing Affidavit of C. V. Campbell
general observation with respect to care plans on the
fourth floor reveals nursing care plans did not reflect
accurately patient needs. Revisions were not made as
needed.
Standard (e) Rehabilitative nursing care is not met.
Deficiencies are noted in the following areas: Docu-
mentation is inadequate with respect to ROM exer-
cises performed by nursing as an extension of physical
therapy. In some instances, there is no documentation
with respect to patient progress in progressing in ac-
tivities of daily living. There are references to bowel
and bladder training.
Standard ({) Supervision of patient nutrition is not
met,
In reference to the diabetics and in other special in-
stances, nursing does not record adequate type of
foods consumed and notification to dietary with re-
spect to problems. The RD started documenting on
patients’ records on 7/20/76. Previous to this, the
Federal team could not observe dietary input. A new
dietitian was hired 7/23/76, thus some of the dietary
concerns may be resolved. On one record, the phy-
sician ordered an Intake and Output; however, the
charge nurse had riot transcribed the order until re-
ported by the Federal surveyor the next day. This was
uncovered by review of the patient’s chart. (Cross
reference with dietary services deficiency list.)
Element (F 190) under Standard (h) Conformance
with physicians’ drug orders. In certain instances,
medication orders were not transcribed correctly or
promptly. (See the nursing narrative.)
Element (F 206) under Standard (i) Storage of
drugs and biologicals.
Opposing Affidavit of C.V.Campbell 95a
The emergency drug box is not kept readily avail-
able. It is located in a locked closet on the second
floor exit stairwell. The supervisor on duty is to be
called if the emergency box is needed. The June 29,
1976 pharmacy report indicates separate emergency
drug boxes are to be housed and accessible on each
unit. “As of July 23, 1976, this had not been done. The
Director of Nursing informed the surveyor that this
would be completed during the week of July 26th.
The deficiency is cited to insure appropriate follow-up.
Opposing Affidavit of C.V. Campbell
96a
naan 24
Census 194 . .
Staffing, Nursing Hours Per Patient Per
Twenty-four Hours :
rk Week Begins Thurs. . ee
Ends Wed. ‘
Nursing No. of No. of 2
Hours/Patient/ Nursing Hours Asst.
Date Per 24 hours | Personnel | Per Day DON DON
1, 1976 (Thurs) 2.14 52 416 not included | included
2, 1976 (Pri) 2.18 53 424 not included | off
3, 1976 (Sat) 2.14 52 416 not included | off
4, 1976 (Sun) 2.18 53 424 off included
5, 1976 (Mon) 2.22 ~.54 432 off serves as DO?
not included
6, 1976 (Tues) 2.18 53 424 not included | included
7, 1976 (Wed) 2.35 S57 456 not included | included
8, 1976 | (Thurs) 2.26 55 440 not included |not included
9, 1976 (Fri) 2.30 56 448 not included |not included
10, 1976} (Sat) 2.18 53 424 off off
ll, 1976] (Sun) 2.22 54 432 not included icff
12, 1976} (Mon) 2.35 57 456 not included |not included |
13, 1976) (Tues) 2.14 52 416 off F132 deficier
included
charge on C-2
14, 1976] (Wed) 2.39 58 464 oft : Re
|
|
15, 1976] Thurs) 2.35 57 456 not included |included
16, 1976] (Fri) 2.38 59 472 not included [not included
17, 1976; (Sat) 2.47 60 480 off off
18, 1976} (Sun) 2.38 59 472 off « off
included
19, 1976; (Mon) 2.58 64 502 DON charge on/states she is
2 F132 DON today?
deficiency
y 20, 1976] (Tues) 2.88 65 560 not included jnot includea
21, 1976| (Wed) 2.88 65 560 not included jnot included
98
Opposing Affidavit of C.V.Campbell 97a
Recommendation—Nursing Services
1. Licensed nursing staff be assigned to the special
treatments, i.e., decubitus care that require topical
medications, foley catheter irrigations, other special
treatments.
2. Licensed nursing staff need to improve in de-
scribing the status, i.e., healing or deterioration of a
decubitus ulcer and not just a recording that a treat-
ment is done. On the majority of instances, on the day
tour, the aides performed these special treatments.
3. Licensed nursing staff need to closely supervise
aides to ensure proper care. This can be accomplished
- via direct supervision and increasing rounds on cer-
tain patients.
4. The facility should conduct a study in reference
to care of decubitus and prevention of decubitus.
The following is noted:
The administrator is attempting to address the prob-
lems in nursing. This is demonstrated in his hiring of
a new director of nursing and assistant director of
nursing, February, 1976. The facility is attempting
to recruit more licensed staff. The director of nursing
indicates there are eight (8) licensed staff vacancies:
2 RN’s and 6 LGPN’s. The administrator has initialed
the following:
Daily schedule of rounds:
Administrator/Direcior of Nursing—3rd floor
11 A.M. Mon.
Administrator/Director of Nursing—2nd floor
1 P.M. Tues. |
Administrator/Assistant Director of Nursing—5th
floor—2 P.M. Wed.
98a Opposing Affidavit of C. V. Campbell
Administrator/Assistant Director of Nursing—4th
floor—10 A.M. Thurs.
The facility has combined the recording of phy-
sician and nursing progress notes.
On March 19, 1976, a notation was made by the
Administrator, ‘“‘to date, there has been a poor amount
of follow-through in providing quality nursing care.
To be remedied today. Each of you (referring to the
Director of Nursing and Assistant Director of
Nursing) are expected to check each chart each week
on your respective floors to ensure accuracy, complete-
ness and that physician’s orders are carried out.”
Four months have passed and in the review of the 27
records, the problem of a “poor amount of follow-
through” continues. Particularly in those areas out-
lined in the proceeding paragraphs.
In addition, the Federal surveyor learned through
an interview with the Director of Nursing that both,
she and the Assistant Director of Nursing, report to
the administrator. This may create a problem in cen-
tral decision making in nursing. The facility should
review this and clearly appoint a Nursing Director
who has central authority.
This interview reveals that the administrator, on
occasion, has assigned the Director of Nursing to be
charge nurse on Floor C-2. Under the requirement for
charge nurse, F130 states in part: “...a registered
nurse, or a qualified licensed practical nurse (voca-
tional) nurse, is designated as charge nurse by the
Director of Nursing Services for each tour of duty.
The Assistant Director of Nursing would be more ap-
propriate to designate if the additional nurse were
Opposing Affidavit of C.V.Campbell 99a
needed. In addition, Federal regulations require that
the Director of Nursing does not serve as a charge
nurse in a facility with an average daily total occu-
pancy of 60 or more patients.
One of the surveyors provided some possible insight
regarding this. The Administrator is-evaluating the
current Director of Nursing as it pertains to her per-
formance as the Director of Nursing. This can be ac-
complished without ei her current responsi-
bilities, i.e., not assigningCharge nurse responsibilities.
Note, the Director of Nursing was assigned charge.
nurse on C-2, the initial day of the survey.
The facility had the Registered Dietitian review pa-
tients in reference to dietary. On 7/20/76, notations
were made. Federal surveyor could not discern any
previous notes on the current records. On 7/23/76, a
newly aired dietitian was observed making rounds.
The Administrator asked Federal surveyor for refer-
ence concerning nursing audits.
Dietary Services 405.1125
Standard (a) Staffing is not met.
Deficiences are noted in F210, F211 and F213. The
survey reveals that although the facility has contracts
with two ADA’s the frequency, of visits is not enough
for this facility. Moreover, considering the size of the
facility and the type of diets required, increased di-
etary personnel is necessary.
Please note that Federal surveyors observed the
dietitian documenting in patient records on July 20,
1976. Previous to this date, for the majority of pa-
tients on special diets who would need some follow-up,
there was no documentation or visitation by the con-
100a Opposing Affidavit of C. V. Campbell
sultant dietitian. The dietitian has been ill and the
facility hired a new dietitian on July 23, 1976. The
dietary consultative activities need monitoring to en-
sure that the dietary needs of patients are met.
Please see the nursing narrative with respect to the
current omissions of dietary. For example, a particular
situation occurred to an individaul patient: Chart
1313 Medicaid, admission 2/3/76. Diabetic—Hemi-
plegia, Left CVA. The physician ordered on June 17,
1976, “please have dietitian review patient.’”’ Progress
notes also indicate that a dietary request has been
made as of June 18, 1976.
A nursing progress note to the physician indicates
the administrator stated that “when he gets a dietitian,
the resident may have a conference with him.” On
June 30, 1976, the patient continued to complain of
being hungry all the time. The patient has gained
twenty pounds. On July 4, 1976, nursing progress
record showed that the patient is still complaining of
being hungry. Nursing service requested the dietitian
to speak with this patient, but as yet this had not been
accomplished. The notation indicates I am sorry that
the patient is hungry. On 7/13/76, patient is com-
plaining. On 7/23/76, this patient was seen by the
newly hired dietitian.
Standard (b) Menus and nutritional adequacy is not
met.
The survey reveals that although menus are planned
they are not implemented.
Standard (c) Therapeutic diets is not met.
Deficiencies are noted in elements F224 and F225,
the survey reveals that the diets indicated in dietary
and those on the floor do not agree.
Opposing Affidavit of C.V.Campbell 01a
2nd floor
Regular 17
Diabetic 2
Low Na. 4
24
3rd floor
Regular 31
Soft . 4
Puree 1
Diabetic 12
Low Na. 10
58
4th floor
Regular 37
Soft 3
M/S 2
Puree 3
Diabetic. 9
Low Na. 4
58
5th floor
Regular 25
Puree 2
Diabetic 16
Low Na. 9
52
The fifth floor staff nurses indicated nine diabetic
diets. A better system of transfer of information about
diets must be established.
102a Opposing Affidavit of C. V. Campbell
it ara (e) Preparation and service of food is not
et.
Deficiencies are noted in elements F238 and F239
The survey reveals due to the lack of well trained staff
food is prepared without consideration for attractive
looking meals, nor are substitutions made appropri-
ately. Work assignments are not implemented in this
department. —
Element under hygiene and staff (f) is not met
F242. Food handling techniques observed are poor
Element under senitary conditions (g) is not met
F247. The area for storage of waste was dirty and not
acceptable. Individual diet cards are dirty. Refriger-
ation in the storage area is dirty. The dietary condition
of participation is marginally met.
Specialized Rehabilitative Services
Element F258 under Standard (b), plan of care is
not met. The survey reveals that treatments are re-
corded regularly; however, patient progress is not re-
corded.
Pharmaceutical Services
_Element 268 of Standard (a) Supervision of ser-
vices is not met. The pharmacist indicates to the ad-
ministrator that he reviews each patients’ drug regi-
men. However, the notation made on each cardex is
not an acceptable signature. Some type of symbol is
made and it is not discernible. Moreover, many of the
medication and charge nurses did not recognize the
symbol.
Through OLTC, formerly ONHA (policy direc-
tive) , the monthly review of the patient’s drug regimen
is to be noted by the Registered Pharmacists on the
patient’s individual medical record. This can easily
*
Opposing Affidavit of C. V. Campbell 103a
be accomplished by noting in the margin of the phy-.
sician’s drug orders and a clear signature with the title
R Ph. Medical records standards require that a signa-
ture and title be given for licensed health practitioners
and also when non-licensed staff record observations,
etc., i.e., Mrs. Ann Jones, nursing assistant.
Element F281 under (d) Pharmaceutical services
committee is not met.
The survey reveals that the medical director does
not meet with the pharmaceutical committee at least
quarterly.
LLL ODE tt,
a ae
_ (a) Advisory Dentist
eS . 2 .
Not Met
Lab & X-ray 405.1128
(a) Provision for
Services Factor not
met
Dental 405.1129
Standard not met
(b) Arrangements for
outside services-
Factor not met
; . ; J
Social Services
405.1130
All standards. met
(b) Staffing
3
wm! Sogn ead ied °
‘The facilit. does have
- 7/24/76.
Opposing Affidavit of C. V. Campbell 104a
-
.
-
f=.
Findings
In one record of 23 re-
viewed,. 12 lab tests
were done and
charged to Medicare.
There were no doctor's
orders for these tests.
In another record of
23 reviewed, 8 lab test
were done with no
doctor's orders and,
likewise, billed to
Medicare.
Last in-service (Mouth
Care) was conducted
6/4/75. No indication
from staff or written
documentation that
advisory dentist
recommends oral hygiene
policies and practices
for the care of patients]
Name and phone numbers
of dentists was not
documented in patients’
medical records nor were
lists and phone numbers
of dentists available
at nurses’ stations.
an agreement with
Graduate for dental
services and this num-
ber is available at
nurses’ stations.
Agreement with qualified
social worker signed
7/23/76 by administra-
tor and social worker.
According to the ad-
ministrator, the social
worker will begin duty
104
“. op” Bee wy. “a
Recommendations
Policies and procedures
stating that services are
provided only on the orders
of the attendiiy physician
were available, but should
be enforced. The OLTCSE
should notify the inter-
mediary of these two cases
(Case Numbers 1306 and 126;
_
oe sen
‘~~.
In accordance with the
dental agreement and polici
the administrator and medic
director should assure that
-the dentist provides in-
service and recommends ora
hygiene policies and prac-
tises as appropriately
needed.
' $elf-explanatory
As with all health
deficiencies found on this
validation survey, OLTCSE |
should monitor carefully to
assure that the qualified
social worker provides
required services.
Opposing Affidavit of C.V. Campbell 105a
\V. Physical Environment 405.1134
Elements F384, F385, F388, F389 under Standard
(c) facilities for the physically handicapped are not
met.
The survey reveals that there are insufficient water
fountains and public telephones of average heights.
There is no provision for the blind to identify rooms,
facilities and hazardous areas. The facility does not
provide audible and visual warning signals.
The surveyor needs to determine if the latter re-
quirement is waiverable. All deficiencies are to be
corrected.
Infection Control 405.1135
Element F446 under Standard (d) linen is not met.
The survey reveals that ventilation in the soiled linen
room is not adequate.
Standard (e) Pest Control is not met.
Roaches were seen on the fourth floor and third
floor. The exterminating program in effect needs to
_be intensified.
Disaster preparedness 405.1136
Standard (b) Staff training and drills is not met.
A review of the fire drills showed evaluations by
the staff for the past three months except for 1975.
No drills were held January, February. The employees
rated the drills from fair to poor; therefore, additional
improvements in the training programs are needed.
Opposing Affidavit of C. V. Campbell
Not Met
Medical Records
405.1132
(c) Content
Standard not met
‘
(e) Completion of
records and
centralization
‘ ef reports.
Standard not met
“See standard (c)
-
Findings
In 16 discharge records
reviewed, discharge
summaries were not
completed and signed by
the attending physician.
In 4 of 13 current
records reviewed,
orders were not reviewed
and updated every 30
days by the attending
physician.
Dental notes were not
documented in medical
records for the only
three patients that
were referred for
dental treatment.
Dietary notes were not
documented in 27 of 29
records reviewed.
Discharge summaries
from referring
hospitals were not
available in 6 of 29
records reviewed.
Discharge summaries
not completed and
signed by the attending
physician and not
received from referring
facilities.
106
Recommendations
The facility hes appropriat,
policies and procedures
regarding the deficiencies
found. The administrator,”
medical director, and
medical record consultant
should collaborate in
enforcing these policies
and procedures. The medica
record consultant should
visit more frequently to.
assist in correcting these
deficiencies.
See ¢tandard (c)
‘
*
o- ©
Opposing Affidavit of C. V. Campbell
Not Met
Uv. R. 405.1137 5
(h) Discharge
planning
Standard not met
_ is initiated on ad-
Findings
The administrator has
not delegated re-
sponsibility for
Gischarge planning in
writing.
Written discharge
Planning procedures do
not state how the dis-
charge coordinator will
function, and his
authority and relation-
ships with the
facility's staff.
maximum time period
after which a re-
evaluation of each
patient's plan is made
indicates only that
patients’ plans will be
re-evaluated as often
as necessary. Dis-
charge summaries are not
complete with attending
physician's signature.
The
Documentation in medi-
cal records indicated
that discharge planning
mission only.
107
1064a
33
Recommendations
Administrator, medical
director and social worker
consultant should ®
collaborate in correcting
deficiencies. State surve}
agency should provide
special consultation and
technical assistance for
this deficient standard.
Opposing Affidavit of C.V. Campbell 107a
Other standards and elements found not met.
Element F43 under 405.1121 Standard (g) person-
nel policies and procedures. The survey reveals not all
personnel records are current. Evaluations and train-
ing orientation was missing.
Standard (h) Staff development is not met.
Deficiencies are noted in elements F49, F50, F51,
F52
Although documentation is available, there is no
active orientation or ongoing training in the facility
being given consistently nor does the program provide
for inservice in:
Patient confidentiality
Preservation of patient dignity
Protection of patient’s privacy
The documentation available is not specific nor
does it reflect a consistent program for all personnel.
Elements F55 and F75 under Standard (i) Use of
outside resources are not met.
The agreements must reflect objectives and finan-
cial arrangements as well as responsibilities. Although
agreements are available, they did not confirm the ac-
tive participation of the consultants in the facility.
Consultant reports are not consistent nor do they re-
flect recommendations for the facility to implement.
i.e., No consultant reports for social services. The last
medical records’ consultant report is dated 3/4/75.
Consultant reimbursements are not benefiting the
patients in this facility particularly in the area of di-
etary and social services. The facility needs to correct
this situation immediately so that individual needs of
patients will be met.
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ATTACHMENT 5
It appears that patients within the homes owned by
tionable.
the chain are transferred because of finances.
The survey reveals that the medical records and
minutes do not reflect that policies and procedures
are written as implemented.
Please note in reference to housekeeping and main-
tenance, the carpets throughout patient areas need
Element F85 under Standard (1) Patient Care
It should be noted that the facility has policies; how-
cleaning. Urine odor is retained in the carpets.
Opposing Affidavit of C. V. Campbell
Elements F65, F66, F67, F71 are not met under
Policies.
Standard (k) Patient Rights.
See notations under dietary services standards 405-
Standard (h) Standard kitchen and dietetic service
1125 (e), (f) F242 and (g) F247.
108a
This allegation needs further exploration by the state
agency.
ever,
areas not met.
Opposing Affidavit of C.V. Campbell 109a
SOUTHEASTERN REGION
LONG TERM CARE
Telephone Number
Area Code (215) 631-
Ext. 2325
January 20, 1977
Norristown State Hospital
Building No. 37
Norristown, Pennsylvania 19401
Mr. Daniel Veloric
President, Geriatric Medical Centers
c/o of Town Court Nursing Center
1526 Lombard Street
Philadelphia, Pennsylvania 19146
Dear Mr. Veloric:
An unannounced visit was made to Town Court
Nursing Center on November 22, 23, and 24, 1976, by
David Hawk, M.D., Kay Dodds, R.N., Carole Schneid-
er, R.N., and Nancy Burns, R.D., and me. The state
survey team was joined by Ms. Claudette Campbell,
R.N., HEW Long Term Care, on November 22, 1976.
The purpose of the visit was a follow-up survey
based on the findings of a federal violation survey con-
ducted July, 1976.
Patient care and physical environment observed on
the days of the survey and in patient care areas was
unacceptable. Significant deficiencies of a serious na-
ture were identified in these areas as well as dietary,
medical records, pharmacy, and infection control ser-
vices.
‘..
110a Opposing Affidavit of C. V. Campbell
These deficiencies were discussed in part with you
and in total with John Halbrook, NHA, and members
of the corporate administrative staff.
A follow-up visit to Towncourt on December 30,
1976, indicated that some inprovements in patient
care areas and dietary have been made since the No-
vember, 1976 survey.
Enclosed is form SSA 2567 which outline the de-
ficiencies. Please enter your plan of correction (in-
cluding target dates) opposite each deficiency and re-
mit to this office within ten (10) working days from
receipt of this letter. You may detach and retain the
provider copy for your files. °
If you have any questions regarding this letter or the
visits please do not hesitate to contact this office.
Very truly yours,
(Mrs.) Judith A. Passerin, R.N.
Field Representative
JAP/cef
Enclosures
January 3, 1977
Town Court Nursing Home
Jay E. Laff
Director, Division of Long Term Care
Judith A. Passerin, R.N.
Field Representative
Through: Dorothy H. Poppert, R.N.
Regional Supervisor
Enclosed please find the Summary of the visit to
Town Court conducted November 22, 23, 24, 1976.
Opposing Affidavit of C.V.Caninbell 111a
The full health survey report is currently being com-
pleted and will be forwarded as soon as possible.
JAP: ct
Town Court Nursing Home
1516 Lombard Street
'‘ Philadelphia, Pa. 19104
Kathleen Dodds, R.N.
Carole Schneider, R.N.
Judith Passerin, R.N.
Nancy Burns, R.D. -
Field Representatives
SUMMARY
An unannounced visit was made to the above men-
tioned facility on November 22, 23, 24, 1976, by Mrs.
K. Dodds, R.N., Miss Carole Schneider, R.N., Mrs.
Nancy Burns, R.D., David Hawk, M.D., and Mrs.
Judith Passerin, R.N. The surveyors were accom-
panied by Ms. Claudette Campbell, R.N., on the first
day of the visit.
In July, 1976, a Federal survey team conducted a
validation survey at this facility. Deficiencies were
identified in medical and nursing services. The pur-
pose of this visit was a full health survey to evaluate
health care delivery and services to patients resultant
to the report forwarded to this office by H.E.W.
The facility’s administrator, Mr. John Holbrook,
NHA, was apprised of the nature of the visit and the
findings of the validation teams survey at the outset.
A tour of the facility followed.
The patient care areas were toured by all members
of the team. .Serious patient care and environmental
deficiencies were identified.
112a Opposing Affidavit of C. V. Campbell
Patients were observed to be in need of assistance
with activities of daily living. Many patients were im-
properly attired; dirty and torn clothing, barefooted,
incontinent patients were soiled. Male and female pa-
tients were in need of showers, nail, mouth and hair
care.
Patients both in and out of bed were observed in
poor body alignment. Evidence of restorative nursing
measures were not seen. Adaptive equipment is not
utilized.
One patient with massive decubitus ulcers was
ordered to be placed in isolation on the first day of the
surveyor’s visit. The following morning, the isolation
technique and procedures were reviewed. This patient
had been placed in a private room that was fully car-
peted, even though tiled, private rooms were available.
The isolation gowns were of a disposable nature and
sleeveless. When the survey team questioned the de-
cision to utilize a carpeted room for isolation purposes,
the patient was moved to another room.
Nursing assistants were ‘ater observed caring for
this patient. They were not wearing gowns nor gloves.
The soiled laundry was being carried out of the pa-
tient’s room by a nurse’s aide. This aide did not bag
the laundry and was carrying it clutched to her body.
On all patient floors visited, patients were seated in
lounge areas in numbers from 11 to 16. No nursing
personnel were in attendance in these lounge areas.
Patients were observed restrained in chairs; the re-
straints were attached to the patients beds.
The physical environment in patient areas was poor.
Soiled and clean linens were observed piled together
on patients beds, bedside cabinets and chairs. Water
Opposing Affidavit of C.V.Campbell 113a
pitchers and cubicle curtains were observed soiled
with feces. Toilet brushes were observed stored with
water carafes and drinking cups. Roaches were ob-
served in the second and third floor pantry. A urine
odor was prevalent on the second and third floors.
Shower and tub rooms as well as the floors of patient
bedrooms were in need of cleaning. Soiled underpads
were observed in patients bedside cabinets, on the
floor and in bedside trash containers.
The dietary department was clean. Although a well
qualified dietician has been employed by the facility,
to-date she has not been able to function in her con-
sultant capacity. Menus prepared by the dietician
were rejected so that a menu utilized by another cor-
porate facility could be instituted.
Medical records were reviewed by all survey team
members. (See attached report by David Hawk,
M.D.)
Many of the records reviewed lack patient care
plans. Nursing care plans did not reflect the actual pa-
tient needs or goals. Verbal orders were not counter-
signed on a timely basis. Physicians’ orders were not
being executed promptly or correctly on eight records
reviewed. Nurses’ notes were not chronological or
consistent especially as relates to patients who become
ill or manifest unusual signs or symptoms. Medica-
tions were not being administered properly nor charted
correctly (e.g. tincture of benzoin was being applied
to a decubitus ulcer, tetrocycline was administered to
a patient receiving milk) .
The findings of the survey were discussed in detail
with the President, Mr. Daniel Veloric, and several of
his corporate and administrative staff members.
114a Opposing Affidavit of C. V. Campbell
Suggestions for improvement in the various areas
discussed were made.
The staff of this facility appeared receptive and con-
cerned.
Addendum:
On December 20, 1976, members of the Town
Court N.H. Staff were present in this office for con-
sultation at their request. Those present were Daniel
Veloric, President, John Holbrook, N.H.A., Bernadine
Sterner, R.N., D.O.N., and Charles Fagin, F.S.S.
Mr. Holbrook introduced Mrs. Sterner, as the newly
appointed directo
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