Federal Records Show Serious Patient Care Concerns at Local Nursing Home

HAGERSTOWN, MD News (6/2/2024) – Hagerstown Healthcare Center, a nursing home in Hagerstown, MD, has come under significant scrutiny from government regulators due to persistent quality and safety issues. According to data from a report recently released on CMS.gov, the facility has been a candidate for the Centers for Medicare & Medicaid Services (CMS) Special Focus Facility (SFF) Program for 50 consecutive months due to ongoing issues at the facility. Furthermore, Medicare reports show that the facility has been issued Federal fines totaling $158,148 over the past 3 years. Overall, Medicare.gov gives Hagerstown Healthcare Center a 1 out of 5 star rating, with equally low ratings for health inspections, staffing, and quality measures.

The SFF program identifies nursing homes with a history of serious quality issues and aims to stimulate improvements. Inclusion in the SFF program is based on the number and severity of deficiencies found during inspections, as well as the persistence of these issues. Notably, Hagerstown Healthcare Center is the only nursing home in Washington County to hold this concerning status. Other facilities in Maryland also on the SFF candidate list include Autumn Lake Healthcare at Pikesville in Pikesville, Elkton Nursing and Rehabilitation Center in Elkton, Manokin Nursing and Rehab in Princess Anne, and Pines Nursing and Rehab in Easton. Meanwhile, the only active nursing home in Maryland currently enrolled in the SFF program is Westminster Healthcare Center, located in Westminster, MD. Westminister Healthcare Center and Hagerstown Healthcare Center are both affiliated with CommuniCare, headquartered in Cincinnati, Ohio.

The most recent data from Medicare.gov reveal several critical deficiencies at Hagerstown Healthcare Center. The facility has been cited for 29 health violations, significantly higher than the national average of 9.4 and the Maryland average of 16.4. Recent inspections on December 22, 2023, and August 21, 2023, identified numerous deficiencies, highlighting the facility’s failure to maintain compliance with health and safety regulations.

Over the past three years, Hagerstown Healthcare Center has incurred federal fines totaling $158,148. These fines were issued on three separate occasions for various regulatory violations. On August 21, 2023, the facility was fined $8,190. Earlier in the same year, a more substantial fine of $140,208 was imposed on January 13, 2023. Additionally, Hagerstown Healthcare Center faced a $9,750 fine on November 3, 2021.

Complaint inspections have also revealed troubling patterns. Over the past three years, 28 complaints resulted in citations, and 23 citations arose from facility-reported issues. These figures suggest systemic problems with complaint handling and internal incident management.

One of the most serious complaints took place in early 2023. In one case a resident, only identified as Resident #73, diagnosed with dementia and psychosis, exhibited aggressive behavior on January 1, 2023. Initial preventive measures included monitoring by staff and closing other residents’ doors to prevent wandering. Despite these efforts, Resident #73 was involved in two physical altercations with other residents that day, resulting in injuries. The Director of Nursing (DON) later acknowledged that Resident #73 should have been placed on one-to-one supervision after the first incident.

Subsequent reviews indicated that a second resident, identified as Resident #88, sustained visible injuries, including a bruised forehead and nosebleed, from the altercations. Due to escalating aggression, Resident #73 was transferred to Meritus Hospital for evaluation, suspected to be influenced by an infection such as a UTI. The facility’s investigation confirmed Resident #73 as the aggressor in both incidents, highlighting the failure to protect Resident #88 from harm.

Interviews with staff and reviews of medical records revealed a lack of immediate and appropriate responses to the aggressive behavior and inadequate training on managing such incidents. The facility acknowledged the need for better training and one-to-one supervision protocols to prevent future occurrences of resident-to-resident abuse.

Further complaints show that Hagerstown Healthcare Center has faced significant issues regarding the competencies of its nursing staff, particularly those employed through agencies. A detailed review of medical records, staffing sheets, assignment sheets, policies, observations, and interviews revealed systemic problems in ensuring staff were adequately trained and supervised to maximize residents’ well-being. This issue was evident in five out of 26 residents reviewed during complaint investigations, but it has the potential to affect all residents.

Specific findings included incidents where agency nurses were unable to provide essential historical information during emergencies due to insufficient orientation. In one case, an agency nurse unfamiliar with the resident could not assist EMTs during a medical emergency. Additionally, staff members, including licensed practical nurses (LPNs) and geriatric nursing assistants (GNAs), often did not recall key details about residents’ care needs, indicating a lack of continuity and familiarity.

The facility was found to be relying heavily on agency staff, sometimes constituting over 50% of the workforce, without ensuring these staff members were adequately oriented or supervised. This resulted in medication administration errors, insufficient response to changes in residents’ conditions, and overall lapses in resident care. Interviews revealed that the facility did not consistently assign agency staff to the same residents or units, further contributing to the lack of continuity in care.

Despite efforts to implement orientation checklists and training packets for agency staff, these measures were only recently introduced and had not been uniformly applied. The administration acknowledged the need for improved oversight and consistent training to ensure all staff, particularly those from agencies, could meet the residents’ needs effectively. This lack of an effective system to ensure agency staff competency and supervision posed a risk to the safety and well-being of all residents at Hagerstown Healthcare Center.

Infection control is another critical area of concern. The center received 31 citations related to infection control over the past three years.

Staffing levels and turnover rates are crucial indicators of a nursing home’s quality of care. Hagerstown Healthcare Center has been rated much below average in this category. The facility provides 3 hours and 26 minutes of nursing care per resident per day, below both the national and state averages of 3 hours and 47 minutes. Residents receive 39 minutes of registered nurse (RN) care per day, which aligns with the national average but falls short of the Maryland average of 49 minutes. On weekends, RN hours drop to 21 minutes, significantly lower than the national average of 27 minutes and Maryland’s average of 35 minutes.

The total nursing staff turnover rate is 70.6%, markedly higher than the national average of 52% and Maryland’s 49%. RN turnover is even more concerning at 76.2%, indicating high staff instability, which can adversely affect the continuity and quality of care provided to residents.

The quality of care provided to both short-stay and long-stay residents is another area where Hagerstown Healthcare Center falls short. For short-stay residents, the facility performs below average in multiple metrics, including the percentage of residents re-hospitalized (27.6%) and those who had outpatient emergency department visits (12.8%). The percentage of short-stay residents who improved in their ability to move around on their own is 68.4%, below the national average of 76.7%.

For long-stay residents, the center has troubling statistics, including a high rate of hospitalizations (3.16 per 1,000 resident days) compared to the national average of 1.92 and the Maryland average of 1.37. The number of outpatient emergency department visits per 1,000 long-stay resident days is 2.66, significantly higher than the national average of 1.23 and the Maryland average of 0.86. Other concerning metrics include the percentage of long-stay residents experiencing worsened mobility (34.4%) and those with a urinary tract infection (3.7%).

The most recent fire safety inspection, conducted on December 13, 2023, identified eight deficiencies, exceeding both state and national averages. These deficiencies range from emergency preparedness to the maintenance of fire doors and medical gas storage areas. The presence of such deficiencies suggests potential risks to resident safety in the event of an emergency.

Beyond government reports, the facility’s reputation among residents and their families is also concerning. Hagerstown Healthcare Center currently holds a 1.8-star rating on Google as of June 2, 2024. Reviews frequently mention issues such as poor staff responsiveness, inadequate care, and unsanitary conditions. Former employees have expressed concerns about being overworked and underpaid, while some residents and their families have reported severe neglect and poor treatment outcomes.

Full information regarding Medicare’s assessment of Hagerstown Healthcare Center can be found on the Medicare website.

Potential residents and their families are advised to exercise caution when examining any nursing home option. It is crucial to review detailed inspection reports, speak directly with staff, and consult with local health agencies before making decisions regarding long-term care at this or any other facility.

Story by multiple RFHC contributors.

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