# Appendix — O'Bannon v. Town Court Nursing Center > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/brief%3Amicro_IA40385006_0067%3A02 ## Record - **Collection:** Supreme Court brief - **Document type:** Appendix - **Published:** January 1, 1980 - **Citation:** 447 U.S. 773 ## Text or Court, a 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. A Nta det, ethos eden) sn Kets eae een ered ee ne a ADM AP 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 ee ee ee 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. ATTACHMENT 1 aig ee Cutsem ne ee penne Smee wo cs ‘ ~ 2 .? ee | ros ‘Thera se “ve ‘oer . thy 29 IS. 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AOWIOY JLVLS AS GI12%640) 39 OL tne Seber ee , : gH yl gies. hy, IWLUVISNVUL ONY NONLVSISILUaS : ° VIAHNN BICIACN le : m “ = ee ’ : sac des toe ee ae eas he ‘ 7 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 Medica [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/brief%3Amicro_IA40385006_0067%3A02. Public record. Not legal advice.