A Spokane nursing home that has faced previous sanctions for unsafe conditions has been ordered to stop accepting new residents after the death of a resident last month.
State officials say staff at Franklin Hills Health and Rehabilitation Center provided poor care for Robert Coon, 63, who died after staff failed to provide him the level of fluids his physician recommended.
Coon was ill for several days before staff called 911. He was rushed to a hospital, where he died four hours later.
His June 5 death came less than two weeks after a complaint was filed in U.S. District Court alleging an 88-year-old Franklin Hills resident died in 2007 because of neglect by staff.
It also came in the midst of the facility’s annual inspection by the state Department of Social and Health Services. State surveyors noted strong odors of feces and urine throughout the facilities, as well as several problems with resident care, medication distribution, and family and doctor notification.
But it was Coon’s death that brought the most serious sanctions. State inspectors imposed a $3,000 fine and banned Franklin Hills from accepting new residents beginning June 17 as officials investigated how staff let Coon become so ill before seeking outside medical attention.
State records of previous investigations show Franklin Hills has a pattern of neglectful practices in the past year, including complaints about improper patient care and staff interaction.
In Coon’s case, staff failed to thoroughly assess and document his change of condition, and they failed to notify his family and physician of changes as required, state inspectors found.
But what the inspectors think killed Coon was the failure of Franklin Hills staff to monitor and document his fluids. Records show he received less than half the daily recommended amount.
Franklin Hills, located at 6021 N. Lidgerwood St., also was temporarily prohibited from accepting patients in 2006 because of ongoing problems.
No other facility in the Spokane area currently is barred from accepting residents.
Barring new residents at a facility is “a pretty strong action that we take when we feel there’s an issue that we need to have corrected,” said Shirlee Steiner, regional administrator for DSHS Residential Care Services in Region 1, which serves 11 Eastern Washington counties.
A nurse is visiting the facility at least once a week “to make sure residents are still safe and healthy,” Steiner said.
Administrators said this week that the facility should be back in compliance by Tuesday; surveyors will visit shortly after, Steiner said.
“At this point I can’t gauge whether or not they’ve improved. The real gauge will be when we go back in,” Steiner said.
She added, “They’re working on it. They’re not ignoring the issues.”
Franklin Hills Administrator Trent Cunningham declined to answer questions but released a statement saying the nursing home is cooperating with the investigation and recently submitted a corrective plan.
Staff members are being retrained on protocols and “an aggressive monitoring process” is in place to verify the staff follows procedures, Cunningham said in the statement.
“We incorporated the surveyor’s comments, as well as any comments by family members into our quality assurance program,” he said.
The facility has received eight citations in the past year, including one for failing to report changes in a resident’s condition in March.
Coon, who was diagnosed with mental illness and diabetes, became ill June 3, according to state records. When he showed signs of dehydration the next day, staff contacted his physician and received orders for administering fluid. Still, they didn’t notify the man’s family, who didn’t learn of his health problems until after staff called 911 on June 5.
State inspectors say Franklin Hills staff had failed to document Coon’s condition to ensure he was monitored during all work shifts.
“As a result, a period of almost 17 hours elapsed without any documented resident assessment,” according to a state report.
Coon was hospitalized with septic shock, pneumonia, kidney failure and respiratory failure before he died.
A federal wrongful-death lawsuit filed on behalf of the family of Ulysee A. Huguenin, of Chewelah, Wash., alleges Franklin Hills staff failed to properly care for Huguenin, leading to severe ulcers, dehydration and other complications that resulted in the 88-year-old’s death on Sept. 26, 2007.
A similar lawsuit filed against another facility owned by Franklin Hills’ parent company, the Gardens on University, 414 S. University Road in Spokane Valley, was dismissed. Both Franklin Hills and the Gardens are owned by Extendicare Health Services Inc., of Milwaukee. Extendicare also operates Cherrywood Place, 100 E. Dalke Ave.
Neither the Gardens nor Cherrywood Place are facing sanctions, though the Gardens has received six citations in the last year out of 47 complaints about the facility. Cherrywood was the target of two complaints, neither of which resulted in a citation.
Plans for a new facility on the South Hill have not proceeded. An Extendicare spokesperson did not return a phone call seeking comment on the plans.