Inspection finds new deficiencies at state veterans home

A recent inspection found that deficiencies and regulatory problems continue at the Nevada State Veterans Home in Boulder City, which is under scrutiny by the Nevada attorney general’s office.

The facility was issued 11 citations during a Medicare recertification inspection by the state in late December. One of the citations was for failing to monitor a patient who needed frequent supervision, the same issue related to the death of former Nevada legislator Robert Robinson last summer.

Robinson, who was a resident at the facility, suffered second-degree burns on his legs and other body parts when he was left outside in extreme heat for an extended period of time without supervision. He died three weeks later of sepsis, cellulitis, cutaneous burns and prolonged environmental heat exposure.

“The facility failed to ensure one of 26 sampled residents was supervised in 30-minute intervals according to the ‘Frequent Resident Observation’ for safety,” according to December state inspection documents.

The veterans home has been under investigation by the attorney general’s office since Robinson’s death. State investigations found several problems at the facility last year.

The attorney general’s office couldn’t comment on the specifics of the ongoing investigation, according to spokeswoman Beatriz Aguirre.

Other problems found during the December inspection included a medication error rate of 15.5 percent, clinical records being incomplete and services not meeting professional standards.

Also, a Medicare complaint investigation on Jan. 30 found the facility not meeting regulation with its policy for reserving beds for patients being transferred to other facilities for short-term medical care.

The complaint involved a patient who was transferred to a hospital and who had a bed-hold notification agreement documented on his medical records. But the resident was later told that “per administrator’s instructions,” staff members were not able to have a bed hold for him because he didn’t meet the eligibility requirements.

“The resident had been admitted prior to verification of the resident’s military service,” documents showed, administrator Frank Bellinger said during the investigation interview. “That was a mistake.”

Bellinger told investigators that when a resident doesn’t meet the requirements, the resident shouldn’t be admitted and that the facility may be fined.

Bellinger didn’t return calls seeking comment this week.

The state last week posted documents on the December inspection and the January complaint investigation at the veterans home on a public website after the Review-Journal requested the documents. Only some of the documents were available on a different state website, which visitors have to search for. Under the law, all documents should be posted and available for public view.

Kat Miller, director of the Nevada Department of Veterans Services, said last week that action to address the problems discovered during the December inspection have taken place already.

“We take immediate action on any citation and will continue to do everything in our power to make the Nevada State Veterans Home a place where every veteran receives the finest care available,” she said in a statement.

Miller said she wasn’t able to provide any other information because the veterans home is still under investigation.

Gov. Brian Sandoval’s staff said last week that the governor was receiving regular updates on the issues at the veterans home and would take additional action if necessary. But the governor’s office requested a copy of the December inspection from the Review-Journal.

“New policies and procedures are in place and disciplinary actions have occurred,” Sandoval spokeswoman Mary-Sarah Kinner later said in a statement.

According to documents from the December inspection, the veterans home corrected the citations in early January. But a plan of correction from the facility was just posted this week on a state website. It shows that a licensed practical nurse is no longer employed at the veterans home, and all licensed staff received training last month and were placed on quarterly skills assessments, which will be conducted by managers. Also, a new audit for medication administration was implemented.