Scrutinizing Michigan nursing homes

KALAMAZOO, Mich. (WOOD) - Target 8 is looking deeper into Michigan nursing homes in an effort to help you find the safest place for your loved one.

Last month, Target 8 reported that Borgess Gardens near Kalamazoo was on a federal watch list of nursing homes of troubled nursing homes. 

When the Centers for Medicare and Medicaid Services (CMS) recognizes what it considers a pattern of serious problems, it puts facilities on its Special Focus Facility (SFF) list. Those facilities are then at risk of losing federal funding if they fail to improve.

State documents detail what landed the Borgess Gardens on the SFF list. The documents show a pattern of miscommunication and incompetency that led to injuries and even the death of one patient.
 
On July 29, 2010, a nurse gave medication to the wrong resident. That resident ended up in the Intensive Care Unit.
 
A month later, a 244-pound patient with a tracheostomy was supposed to have two people help clean or move her to make sure her breathing tube didn't get caught and dislodge. One night, only one nursing assistant came in to clean her. The breathing tube got caught and eventually came out.

The aide called for help. Nurses told investigators the patient started having "trouble breathing" and "looked fearful." That patient died after being rushed to the emergency room.
 
That nursing assistant later claimed she cared  for the resident by herself all the time.
 
The nurse called in to help with the tracheostomy told investigators that she'd only recently received her nursing license and hadn't worked on tracheostomies since nursing school.

The Detroit Free Press reported on Dec. 12 that the family of that woman is suing the facility for the wrongful death of their loved one.

But the nursing home's administrator insisted to Target 8 that the incidents were isolated.

"Borgess Gardens is a safe place. We are advocates for this vulnerable population," said Borgess Gardens administrator Beth Ann Brehm.
 
But, Brehm said, Borgess Gardens recognizes the seriousness of the incidents:
 
"These were serious incidents. Clearly they were," said Brehm.
 
When asked if the home was working on fixing the safety, concerns, Brehm said:
 
"We certainly are. These are issues related to competency."
 
There are more serious concerns dating back to 2008.
 
One investigation revealed that instead of using wheel chairs with foot rests, nurse aides would tell residents to 'lift their feet.'
 
In April of 2008, a patient with a history of falling out of her chair got her feet caught. She was propelled face first out of the wheelchair and suffered bruises and a cut on her face. That aide was later instructed to use the foot rests, which is now policy.
 
And just a few months ago, staff placed a container of skin cream next to a blind resident's meal. She thought it was peanut butter, put it on her toast, and ate it. She's all right, but staff now separates certain items, especially when a patient is blind.
 
A state advocacy group is pushing for tougher laws and stronger nursing home licensing requirements.
 
"The state has an obligation to protect you," said Elmer Cerano, the executive director of the Michigan Protection and Advocacy Service. "Honestly, I don't care if they have to send in the National Guard. Send in people to protect people and don't let this stuff happen again."
 
In the meantime, Borgess Gardens is taking steps to improve quality.
 
Brehm said Borgess Gardens now has a skills competency lab in which newly-hired employees have to demonstrate that they know how to do their job. Staff members also now have daily meetings, which they call 'huddles,' to go over safety concerns and improvements.
 
The nursing home has also hired more staff, including more registered nurses to ensure that more qualified people are working directly with patients.
 
Brehm insists that people can trust the Borgess Gardens staff. And there is some evidence that she's right. Borgess Gardens received a 5-star rating from Medicare just two years ago.
 
So Brehm is confident that Borgess Gardens will get off the watch list.
 
To make sure you're choosing a quality nursing home, don't rely solely on the star system. Visit the facility and gauge if residents are happy and satisfied.
 
State inspections of nursing homes are also public record and you available for review at each nursing home.

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Online:

The following links will take you to a list of links to reports from the specified nursing home.

In the case of Borgess Gardens, the list of links are broken down by year because of quantity.

You can click on the institution and then choose the report you're interested in looking at, which will open a pdf file .

Borgess Gardens reports 2008

Borgess Gardens reports 2009

Borgess Gardens reports 2010

Borgess Gardens reports 2011

Calhoun CMCF

Covenant Village

Hillcrest

Laurels of Galesburg

Magnumcare of Albion State

Riverview Manor