State Report Finds Booker Failures

DAYTON - A state inspection of Booker Rest Home this spring turned up plenty of issues and potential problems that must be addressed, but none of them posed actual harm or were "life threatening" to residents.

"There are some issues the facility needs to work on, that's quite obvious," said Shirlee Steiner, a regional administrator for Residential Care Services under the state Department of Social and Health Services, the agency that conducted the inspection.

The survey of Booker Rest Home took place over a six-day period in mid-April and a 29-page report was completed April 20.

Steiner said officials at the Columbia County Hospital District, which includes Booker Annex, submitted a state-required plan of correction to the regional RCS office on May 10. The plan, she added, was not entirely adequate.

"They need to fix some things and resubmit it," Steiner said.

The plan details what has already been done and what will be done in the future to resolve violations of state and federal guidelines for nursing homes that were identified in the state survey report. It also describes systems that will be put in place to prevent a reoccurrence of the same problems and identifies the employees responsible for overseeing the corrections.

"We have work to do," Charlie Button, CEO of Columbia County Health Systems, said in reference to the report's findings of which he learned a month ago. "(The report) is not as good as I would have hoped."

The four-member state inspection team, all nurses, used a relatively new computerized survey system that tends to be "highly prescriptive" but is more comprehensive and tends to eliminate inconsistencies due to personal judgments, Steiner said.

But she said the team still chose random residents (23 out of a total of 32) to follow and observe. "None of these reports are positive," she added. "They don't write down the good stuff."

Each issue raised received a "grade," or level of severity, that tells whether incidents are isolated, involve a pattern, or are widespread, and whether there is no potential for harm, potential for harm, actual harm or threatens health and safety of residents. Almost all problems involved isolated incidents that posed a potential for harm, according to the report.

"If I had a five-page report with actual harm, I'd be more concerned," Steiner said.

Still, Dr. Heidi Shields, who will be the new medical director to Booker Rest Home starting this month, said she would like to see all problems resolved no matter their severity.

"I will do everything in my power to make sure we correct these deficiencies and provide a good place for the residents," she said.

Here is what the state survey team found.

- Failure to notify a physician in a timely manner of multiple bruises and skin tears on one resident and sore skin areas on another.

- Failure to ensure personal privacy and risk embarrassment for two residents.

- Failure to post the location of the most recent state survey results for residents and visitors.

- Failure to consistently conduct thorough investigations following allegations of mistreatment by a nursing assistant and following the discovery of a bruise, and failure to protect residents from the possibility of further abuse, mistreatment or neglect in situations involving two residents.

- Failure to develop written policies and procedures relative to abuse prohibition.

- Failure to ensure a homelike environment, resulting in an "institutional-like atmosphere."

- Failure to ensure a medication error rate of less than 5 percent. "Seven timing errors occurred for 3 of 17 residents hellip; with a resulting medication error rate of 12 percent."

- Failure to maintain an infection control program and practices that prevent and/ or control actual or potential infections.