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Worcester nursing home fined $140K after fatal fall

Telegram & Gazette - 2/9/2018

Feb. 08--WORCESTER -- Holy Trinity Nursing and Rehabilitation Center, where 87-year-old Walter E. Haddad suffered a fatal fall in August, has been fined $140,000.

Meanwhile, the nurse who did not report Mr. Haddad's fall, and failed to follow procedures that family members believe would have prevented Mr. Haddad's death, still has an active license to practice.

The civil fine imposed by the federal Centers for Medicare & Medicaid Services was reduced by 35 percent after Holy Trinity agreed to waive its appeal rights. The nursing home paid the final fine of $91,104 electronically Jan. 31. Holy Trinity has achieved substantial compliance after approved corrective measures, according to CMS.

In determining the amount of the fine, one of the things that CMS considered was Holy Trinity's history of noncompliance, including repeated deficiencies and its financial condition. The federal agency also prohibited Holy Trinity from conducting another Nurse Aide Training and Competency Evaluation program until Aug. 29, 2019.

But the nursing home has not operated the program since at least Oct. 22, 2015, when it had to pay CMS a fine in the amount of $15,372.50. Since that date, Holy Trinity has paid CMS close to $200,000 in reduced fines stemming from four separate investigations.

Gerald E. Shaffer, the nursing home's executive director, on Tuesday said the fines come out of the operating budget. He said he "hopes and expects" that Holy Trinity will be reimbursed for the latest fine by Omni Healthcare Staffing Inc. at 390 Main St., which employed the nurse who was working at Holy Trinity when Mr. Haddad fell.

"It is quite a hit and it comes out of the operational budget," Mr. Shaffer said of the $91,104 fine. He said the facility will not cut back on services to make up for the fine.

"We have to look for ways to be better managing money. We're still full speed ahead in terms of proving quality services," he said.

Steve Fotos, president of Eastern Orthodox Management Corp., the nonprofit that owns Holy Trinity, said budgets are constantly being tweaked. He said there was some expectation that a fine would be coming.

"What happened in the past is very unfortunate. We don't want anything like that to happen again," he said.

CNA fired

Mr. Shaffer said a certified nursing assistant was fired and that he has not used nurses from Omni since Mr. Haddad's fall on Aug. 7. Mr. Haddad, a retired accountant who had helped found Holy Trinity, had moved into the nursing home in 2016 after Parkinson's disease left him prone to falls.

Omni owner Edwin G. Githiaca of West Boylston did not return phone calls seeking comments.

The Centers for Medicare & Medicaid Services report on the circumstances leading to Mr. Haddad's death said that after hearing a loud thud, a certified nursing assistant and a licensed practical nurse found Mr. Haddad lying on the floor and they took him to use the restroom, then helped him back into bed.

The CNA told investigators that he did not report the fall as required, and that the LPN had asked him not to. The LPN, later identified as 41-year-old Johnson W. Wangati of Leicester, initially would not come to the nursing home to be interviewed about what had happened. He later told investigators, on Sept. 12 in a telephone interview, that he had no recollection of Mr. Haddad or anyone falling during his shift from 11 p.m.Aug. 5 to 7 a.m.Aug. 6.

"Nothing unusual occurred during the night. Nothing was reported to me by either CNA. I had a quiet night except I could not use the" computer, the report said Mr. Wangati told investigators.

The two men not only failed to complete an incident report and forward it to nursing administration as required, they also did not follow the facility's procedure for when a patient falls, investigators determined. The policy said it is imperative that a resident who has fallen not be removed from the floor until an assessment has ruled out serious injury. The policy also requires that the resident's family and physician be notified.

Mr. Wangati, who was working his first shift at Holy Trinity to fill in for an absent staff member, signed orientation paperwork that included information about procedures to follow if a patient falls.

The staff's failure to notify Mr. Haddad's family and physician of his fall "resulted in a delay of transfer to the hospital for evaluation of possible injury," the report said. Even when Mr. Haddad told staff after breakfast six hours later that he had fallen and hit his head on the side of his nightstand around 4 a.m., his physician still was not notified.

An hour later, he was given Tylenol when his family, who had come to visit, noticed that his speech was slurred and he complained of neck pain. But a physician was not called until nearly an hour after that, when his mental status continued to decline.

It took more than another hour for him to be taken to a hospital for evaluation, after a physician made that order. At the hospital he was diagnosed with a traumatic subdural hemorrhage.

Surgery too risky

Because of his "advanced age and progressive neurological decline, surgical intervention was deemed too risky," and Mr. Haddad died the next morning, the report said.

Investigators also noted that Mr. Haddad's condition was "exacerbated by the Plavix," an antiplatelet agent that he was given along with his other prescribed morning medications a few hours after the fall. He was taking the medicine because of his history of subdural hematoma secondary to falls and coronary artery disease. One of the side effects of the medicine is an increased risk of severe bleeding, which can be fatal.

Mr. Johnson had signed the facility's fall prevention policy, indicating that he had read it.

When serious injury is not suspected, the charge nurse is supposed to be called to take the resident's vital signs while still on the floor. For all falls, staff is required to notify the resident's family and physician and complete an incident report, which is to be forwarded to nursing administration.

After a public records request, a spokesperson for the Department of Public Health said that Mr. Wangati's LPN license is active. He was still working a month after Mr. Haddad's death, according to a woman who answered the telephone at Omni at the time. This paragraph has been updated to include the source of Mr. Wangati's work status.

DPH spokeswoman Ann Scales said in an email that the Board of Registration in Nursing "voted for discipline and it is in process. The license remains active until discipline is finalized."

Mr. Haddad's daughter, Lorna Haddad, was upset to learn that Mr. Wangati still has a license to practice.

"I think it's ridiculous. The AG (attorney general) should get involved," she said Tuesday. "There is something wrong if he still has his license. There's definitely something wrong with the system."

Holy Trinity's overall rating from from Medicaid is below average.

Marcia Gazoorian of Worcester reached an out-of-court monetary settlement with Holy Trinity in 2013, after her 102-year-old mother, Maritza Gazoorian, died as a result of a fall.

According to a wrongful death lawsuit filed in Worcester Superior Court, the elderly woman had dementia and had five falls before the fatal one on Jan. 5, 2009. When she fell, a motion sensor required by a personal care plan was not in place, according to the lawsuit. She died of blunt head injury with subdural hematoma eight days later.

Ms. Gazoorian said the legal action was never about money, but rather acknowledgement of the nursing home's wrongdoing. She said no one in administration ever apologized for her mother's death.


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