Veteran home woes resurface

Health inspectors declared residents at the state-run nursing home for military veterans to be in immediate jeopardy this week following allegations that staff members discharged a man who was too ill to care for himself, drove him home and left him there alone.

It’s the second time in 15 months that the Arizona State Veteran Home in Phoenix has received that designation — the worst possible for a nursing home — with conditions deemed so serious that inspectors won’t leave until the problems are fixed.

In this case, the veteran, a diabetic recovering after being hospitalized with a brain injury, was reported to have no medication when investigators from the state’s Adult Protective Services, responding to a complaint, checked on him at home. They reported their findings Thursday to state licensing officials.

“It came to our knowledge yesterday morning and we had people out there by noon,” Susan Gerard, director of the state Department of Health Services, which licenses nursing homes, said Friday. “I notified the governor’s office after we declared immediate jeopardy.”

The health department’s investigation is ongoing.

Jeanine L’Ecuyer, a spokeswoman for Gov. Janet Napolitano, said the veterans’ home disputes some allegations.

“There are differences between the two agencies as to what exactly happened,” she said. “We need to get clear on the facts of this situation.”

The home and Napolitano’s office came under fire in March 2007 after surveyors, responding to another complaint, found residents were neglected and abused. They reported cases of patients burning themselves with cigarettes, left in soiled clothes and bedding, and being ignored when calling for help.

As the story unfolded, including allegations of nepotism on the part of the home’s director and questions about what the governor knew and when she knew it, lawmakers created a task force to investigate the matter and Napolitano launched her own inquiry.

Napolitano’s then-co-chief of staff, Alan Stephens, took the brunt of the blame after Gerard testified that she called him the night she learned about problems at the home. Stephens told lawmakers he thought the matter had been taken care of, and Napolitano wasn’t notified until the day before the story broke.

Stephens and Pat Chorpenning, then-director of the state Department of Veterans’ Services, which oversees the home, resigned shortly thereafter.

The veterans’ home was hit with more than $20,000 in state and federal fines. A new administration was hired and the governor appointed retired National Guard Brig. Gen. Richard Maxon to lead the agency.

Lawmakers gave the department an additional $6.1 million to hire more than 40 new staff, raise nursing salaries, replace equipment and make other improvements.

But problems didn’t end there.

In the fall, inspectors responding to another complaint found improper care for bedsores and lax supervision for residents at risk of falls, leading to injuries that include a broken hip and cuts.

And during an annual inspection in March, state regulators cited the 200-bed facility for 24 deficiencies, including problems managing bedsores, improperly monitoring use of psychiatric medication and neglecting a man whose toes were sheared off while he was in his electric wheelchair.

Those citations could result in additional fines and sanctions.

Still, state licensing officials were defending the home earlier this month, saying that the latest survey showed it was, overall, a better-run facility than a year ago.

“We’re disappointed,” Gerard said. “We thought they were doing well.”

In the latest case, the veteran was reported to have been eager to be discharged and was released May 16. Staff members drove him home, but the door was locked and the man had lost his keys. A locksmith opened the door but apparently broke the lock so the door could no longer be secured.

After Adult Protective Services was notified and reported its findings to state licensing officials, their investigation led them to require immediate action by the nursing home to ensure there were adequate discharge policies.

The state then notified the health plan companies used by residents of the home, as well as federal health care officials who license the facility to accept Medicare and Medicaid patients. Last year, federal authorities temporarily suspended the nursing home’s authority to accept new patients until corrective plans were approved.

The discharged man was still at home Friday, and Adult Protective Services caseworkers were determining his eligibility for programs that would provide home health care. That’s typically a job done by social workers at hospitals and nursing homes before patients are discharged.