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Was a Florida Nursing Home Tragedy Avoidable?


Too many patients and not enough nurses, CNA’s or other care givers to properly treat them.

Patients crying for assistance from too few staff.

Tragically, patients die or are critically ill because someone wanted to maximize the profit line.

That happened while one the nation’s most powerful hurricanes was barreling toward a nursing home, Rehabilitation Center at Hollywood Hills, in Hollywood, Florida. Reports indicate they lost power and the air conditioning.

Many people and places lost power and air conditioning, but most were not caring for as many as 152 elderly, ill patients as the Rehabilitation Center at Hollywood Hills had committed to doing.

Across the street from Rehabilitation Center at Hollywood Hills is  a high level hospital facility, Memorial Regional Hospital. Never, not once, did the management of Rehabilitation Center at Hollywood Hills call the hospital for help. They also did not express grave problems for the patients when they called emergency services. Never did they seek to evacuate patients to the hospital.

And at least eight died.

An Office of Inspector General’s (OIG) report we previously reported on cited to preventable problems:

“Medical record review determined that 69 percent of these patient-harm events could have been prevented had the SNF provided better care,” according to the alert. “Over half of the residents harmed during their SNF stays required hospital care to treat the adverse event.”

Our experience demonstrates a few facts leading to nursing home injuries and deaths. One of those is under staffing. Many nursing homes, particularly corporate based, intentionally under staff their facilities to save on the bottom line and maximize profits. After all, personnel is a high overhead item, but one that the owners of the nursing homes think they can control. But, minimizing staff does not allow the level of care necessary for elderly, sick and severely injured patients.

Rehabilitation Center at Hollywood Hills is a “limited liability corporation” (LLC); so they are operating in an entity that helps to shield investors and partners from liability. Dr. Jack Michel is shown in corporate records as the manager of the LLC. Dr. Jack Michel is also Chairman of the Board at Larkin Community Hospital in Hialeah, Florida.  Reportedly both the nursing home and Larkin Hospital have a history of regulatory issues with state healthcare officials. Larkin was fined over $15 million by the U.S. Justice Department in a settlement of a civil fraud complaint.

The Agency for Healthcare Administration and other agencies have cited Rehabilitation Center at Hollywood Hills many times over the years. As recent as March of 2017, deficiencies were found. In February of 2016, a 94-page list of deficiencies were found. Amongst them included:

  • The facility must promote care for residents in a manner and in an environment, that maintains or enhances each resident’s dignity and respect ln fun recognition of his or her individuality.
  • Failures in the “Quality of Life – Dignity” policies.
  • Failing to provide visual and audio stimulation to patients.
  • Allowing patients to remain, confined in a wheel chair, for long periods of time without moving them or providing them with activities.
  • Failing to care for patient hygiene, including hair, facial hair and nail care. Also, failing to attend to patients’ visual (glasses) and hearing impairment needs.
  • During meal time, staff members referred to patients as “feeders” and by room number, rather than their names.
  • Poor building and room maintenance.
  • Failing to provide a level of care to avoid development of decubitus ulcers and wound infection.
  • Failing to maintain appropriate pest control. There were flying insects noted around serving and food preparation areas.
  • Failing to conduct background and reference checks on employees.

The above deficiencies are simply a sampling of the 94-page report.

What does it tell us? This report and others in the AHCA file demonstrate a facility that is maintaining a minimal staffing level; performing the base essentials of services; and is maintaining its facility at only the very basic level.

All of these things can be signs of a facility more interested in profits than in patient care.

And, so eight people died and dozens are ill. Many more were placed at risk and unnecessarily in harm’s way.

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