The Arizona State Veteran Home violated 10 state and federal licensing standards when its staff discharged a patient who could not care for himself, ignored resident complaints, rigged a woman's call light so it wouldn't work and prevented residents from leaving the grounds without an escort, state health inspectors have ruled.
In a complaint investigation released Monday, the state Department of Health Services also cited the beleaguered state-run nursing home for being so short-staffed that practical nurses were put in charge in violation of state licensing and nursing board rules.
The findings were part of a weeklong investigation launched late last month after surveyors declared the facility's residents in immediate jeopardy, the second time in just over a year that the Phoenix nursing home has received the worst possible designation.
A companion federal survey has not yet been released, but the home for military veterans will be cited with 10 federal violations and could lose its ability to admit new Medicare patients. That restriction has been imposed three times in the past 18 months.
The nursing home has 10 days to respond with a plan to correct the problems or dispute any findings.
Dave Hampton, a spokesman for the state Department of Veterans' Services, which oversees the home, said the agency will appeal some of the citations, including claims that licensed practical nurses were overstepping their authority and circumstances surrounding the discharge of a disoriented, diabetic man without medication or home health services.
"There are some things we do not agree with on the discharge," Hampton said.
But state health officials say the facility's chronic problems - even after a legislative task force, a gubernatorial inquiry, top-level firings and resignations, and more than $3 million in additional state funds - could lead the federal Centers for Medicare and Medicaid Services to terminate the home's contract or bring in temporary management.
Hoping to avoid those sanctions, Gov. Janet Napolitano's office has put together a coalition of state and federal agency officials to figure out what's wrong at the veterans home and fix it.
"There are certainly enough serious issues that keep coming up," said Sylvia Balistreri, program manager for long-term care licensing. "That's why we've set up this task force."
At the same time, a key state lawmaker is gathering information to determine whether to reopen legislative hearings.
Rep. John Nelson, R-Phoenix, led hearings in March 2007 after a scathing survey that included allegations of resident abuse and neglect.
"It bothers the living daylights out of me. ... To me it looks like we're almost going back to what we had a year ago," said Nelson, a veteran.
"The commitments that were made are not being fulfilled," he said. "I'm going to watch this thing very closely."
After the 2007 inspection, the home was hit with more than $20,000 in state and federal fines. Lawmakers gave the department $6.1 million over two years to make improvements.
But problems persisted, and inspectors responding to a complaint last fall found improper care for bedsores and poor supervision for residents at risk of falls that led to a broken hip and other injuries.
Federal health officials pulled the 200-bed home's ability to accept new patients for about three weeks, until inspectors declared the facility in compliance in mid-January.
Then in March the facility received 24 citations, including neglect, after a resident in an electric wheelchair sheared off three of his toes. That led to another denial of new admissions for two weeks in May and a federal fine of $3,250.
The latest survey followed the May 15 discharge of a veteran who was eager to go home but, according to the report, was unable to care for himself and was described by staff as "disoriented" and "confused" the day he was driven home.
The physician who approved his discharge did not include orders for medication or home health care services, even though the man was taking medicine for four separate conditions, including diabetes, high blood pressure and anxiety. Staff members said he wouldn't have know how or when to take them.
In addition to diabetes and a brain injury, the man suffered from post-traumatic stress disorder and was a heavy drinker, the report said.
Two home health care agencies refused to care for him, but a social worker sent him home anyway. She then called the state's Adult Protective Services to check on the man, and they in turn notified state health inspectors.
The social worker has been fired, but no other disciplinary action has been taken, Hampton said.
The home has also been cited for violating residents' rights by banning them from going outside without an escort. The policy followed the incident with the man in the electric wheelchair.
"One resident described it as making him feel like a facility 'POW,' and others likened it to being 'in jail,' " the report said.
"It's not the right thing to be punishing the residents," Balistreri said. "I think what they did was they overreacted."
The report also cited the home for ignoring complaints brought by the residents' council regarding call lights not being answered at night and for not immediately reporting a call light that was "purposefully rigged" not to work.