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Forest View patients were in "immediate jeopardy"

Durham nursing home closes after state investigation 

Forest View patients were in "immediate jeopardy"

click to enlarge Forest View Rehabilitation Center closed in November after a state investigation found many critical health and safety violations that endangered patients. The building is being sold. - PHOTO BY MATT SALDAÑA
  • Photo by Matt Saldaña
  • Forest View Rehabilitation Center closed in November after a state investigation found many critical health and safety violations that endangered patients. The building is being sold.

In the official investigation reports, to protect their privacy they are referred to only by number: Resident No. 2, No. 6, No. 8 and so on. But they are people, once patients at Forest View Rehabilitation Center in Durham. They are people who were not given even Tylenol to alleviate the pain from deep, penetrating bed sores. They are people sexually assaulted by fellow patients. They are people who, unsupervised by nursing home staff, repeatedly fell; another person was bitten by fire ants. They are people who contracted urinary tract infections from dirty catheters—at least one of which was washed with the same cloth used to wipe feces from a person’s rectum.

Forest View Rehabilitation Center, a 138-bed, for-profit nursing home on Mt Sinai Road near the Durham/ Orange county line, quietly closed last month. The 100 or so residents, which included the elderly, sick and those with mental and physical disabilities ranging from multiple sclerosis to kidney failure to Alzheimer’s, were transferred to other facilities.

Documents obtained by the Indy from the N.C. Department of Health and Human Services detail the Aug. 8 and Sept. 12 investigations, conducted after state regulators received complaints about care at Forest View. In more than 100 pages, investigators noted serious, even critical hygiene, health and safety violations at Forest View.

Fire ants invaded one resident’s room and bit him, causing 8-inch welts from his arm pit to his waist. A nurse’s aide stated “approximately 150 fire ants” were crawling on the person’s body and “he was lying in bed mumbling.”

The fire ants had built a mound outside by the dumpster; there was an ant trail leading from the dumpster, past a smoking area and to the person’s room. The areas were treated to eliminate the ants.

At least two people, both mentally impaired, were sexually assaulted by other “alert and oriented” residents, one of whom had a sexually transmitted disease, documents show. After Forest View staff discovered the people in their respective rooms having sex, they called police. The victims were sent to the emergency room and later returned to Forest View.

One of the residents who was sexual aggressor was transferred to another facility. In another instance, Forest View staff and a doctor disagreed whether the sex was consensual. The doctor, whose patient was the sexual aggressor, wrote “Because he is a danger to an incompetent female resident and other patients we can no longer safely care for him in a safe environment for all of our residents.” He was later discharged.

Yet, the Forest View administrator contradicted the doctor’s evaluation, saying the alleged victim, who had been diagnosed with psychosis and other mental disabilities and often acted out sexually, initiated the sex.

While many of the incidents happened because nursing staff, including assistants, didn’t follow procedure, the failures, as the documents detail, started at the top. Forest View’s Director of Nursing, who is not named, stated she “was unaware” of many of the major violations occurring at the facility. For example, she told investigators she didn’t know that several residents had no doctor’s orders for catheters. After investigators learned there was no registered nurse on duty for more than a day—the law requires an RN be on duty for at least eight consecutive hours daily—the Director of Nursing is quoted as saying “she did not think about registered nurse coverage for the day.”

The only documented instance of disciplinary action is a van driver who was suspended and formally disciplined—and the facility’s transport van service, discontinued—after a resident tilted over in his power wheelchair and was lodged against the window while the van was moving; the wheelchair had not been properly strapped down.

On Sept. 17, the state deemed that patients were in “immediate jeopardy” at Forest View and declared the quality of care “substandard.” Yet according to a letter from federal regulators, by Sept. 30, the conditions at Forest View had not improved; the state again notified the facility that patients remained in “immediate jeopardy.”

In a letter dated Oct. 3, the Centers for Medicare & Medicaid Services in Atlanta notified Forest View that it was out of compliance with state and federal laws. Regulators stripped the facility of its certification to receive Medicare and Medicaid reimbursements effective Oct. 5.

There was a 30-day grace period for residents admitted to Forest View before Oct. 5, to allow federal reimbursement payments to continue while other living arrangements were made.

No one answered the phone Dec. 23 at Forest View, where John Walder is listed on federal and state documents as the administrator.

Matt Stanley, Epic Group spokesperson, would not elaborate on the report. He told the Indy that it is “impossible to respond” to the problems and complaints at Forest View, citing privacy concerns. “The care and rights of people are our primary concerns,” he said.

Stanley said the building is being sold.

As with many nursing homes, Forest View’s ownership sprawls through several health care companies in different states. The center is owned by Durham Manor LLC. In turn, Durham Manor is managed by Epic Group, whose principal address is in Myrtle Beach, S.C., but also lists a P.O. Box in Kernersville, N.C. Epic’s owner, W. Stewart Swain, lists his address in South Carolina. Over the last 13 years, Swain has been listed as a key person in at least a half-dozen health care organizations, including managing member of Tampa Health Investors, treasurer and secretary of Atlantic Healthcare Consulting, and president and director of Vsjg Healthcare. All of these groups are listed in Debary, Fla., northeast of Orlando.

Index to investigation documents:

  • Part 1: improper administration of pain medicine, improper catheter use and cleanliness, an accident involving a wheelchair that had not been adequately strapped down in a transport van, repeated falls, fire ant invasion; physical assault. (download: Report #1)
  • Part 2: sexual assault, no registered nurse on duty for several days. (download: Report #2)
  • Part 3: a resident’s hair was matted and dirty; a resident was sent to the hospital emergency room without medical or family information. (download: Report #3)
  • Part 4: improper care of a skin graft wound, repeated falls (download: Report #4)
  • Part 5: failure to notify family of a resident’s broken left hand, bedpans not labeled with residents’ names and stored improperly (download: Report #5)
  • Involuntary Termination Notice: Revokes Forest View’s federal Medicaid and Medicare reimbursements (download: Involuntary Termination Notice)

Look for a followup story in the Jan. 7 edition of the Indy.

  • Forest View patients were in "immediate jeopardy"

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