Pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997, the Civil Rights Division of the U.S. Department of Justice ("DOJ") conducted an investigation of conditions at the Claudette Box Nursing Home ("the Box Home"), a state-operated facility in Alabama. Residents who were admitted to the home had to be over 65 and diagnosed with a significant mental illness. The investigation resulted in a findings letter being sent to the state's governor on June 2, 2003. The letter observed that in November and December of 2002, DOJ and certain of its expert consultants toured the facility, interviewed residents and staff, and both reviewed documents and obtained documents for later review. The DOJ's investigation led it to conclude that conditions at the Box Home violated residents' federal constitutional and statutory rights. According to the DOJ, residents at the Box Home suffered harm or the risk of harm from deficiencies in the following areas: medication administration, clinical services, dietary services, resident rights protection, and quality assurance.
These DOJ findings were not the first legal problems the state faced due to conditions at the home. In 1986, the state and private plaintiffs entered into a consent decree regarding the conditions at Searcy, a settlement that included the Box Home. In 1998, the Box Home was released from the obligations of that consent decree. Then, on May 17, 2002, the United States Department of Health & Human Services Centers for Medicare & Medicaid Services ("CMS") notified the Box Home that its Grants to States for Medical Assistance Programs certification was being terminated retroactively, effective May 15, 2002. The decision to terminate was based on the facility's subjecting of residents to immediate jeopardy to their health and safety, by failing to adequately investigate allegations of physical and sexual abuse. On June 21, 2002, based on a finding by CMS that the jeopardy had been remedied, the Box Home was reinstated to the federal funding program. The DOJ's investigation leading to the findings letter occurred less than six months later, suggesting that improvements made to regain certification had been temporary.
The Box Home's deficiencies in medication administration included problems in provision of psychotropic medication (overuse and misuse), pain medication (under-use), and inadequate medication monitoring. DOJ found that the Box Home over-relied on bed rails alone as restraint devices, to residents' detriment, and failed to provide residents with appropriate clinical and needs assessments, with care planning and implementation, and with restorative care and activity services required to prevent physical and psychological harm. Substandard discharge evaluation and planning for eligible residents also characterized the Box Home's efforts. Furthermore, the DOJ found that the dietary services provided at the Box Home were inadequate and did not comply with generally accepted standards of care for residents in long-term care facilities. The home failed to provide adequate therapeutic diets or furnish proper nutrition and hydration; failed to include adequately its dietitian in clinical care decisions; and failed to provide proper feeding services to its residents.
The Box Home insufficiently respected residents' rights to dignity and self-determination, according to the DOJ's investigation. For example, few residents were allowed decision-making regarding basic functions of daily living or were provided information about medications administered to them and why. Residents were not invited to care conferences nor, for those cognitively unable to participate, were surrogate decision-makers. The facility had no policy defining the role of the resident in the treatment process nor did it sufficiently ensure that residents' wishes were accounted for in the case of a medical crisis. The investigation found that facility staff failed to make appropriate eye contact or use verbal cues with residents, relying instead on physical force, and sometimes spoke about residents, in their presence, in demeaning ways.
Finally, the Box Home failed to have a quality assurance program that (1) actively collected data relating to the quality of services, (2) assessed the data for trends, (3) initiated inquiries regarding problematic trends and possible deficiencies, (4) identified corrective action, and (5) monitored to ensure that appropriate remedies were achieved. The DOJ described such a program as standard practice in nursing homes.
The DOJ findings letter proposed remedial actions to remedy the deficiencies, invited the state to address the issues, and alerted the state to the possibility of a CRIPA lawsuit brought by the United States to compel remedial action.
We have no post-findings letter information about this matter.Mike Fagan - 06/19/2008