Nurses at Woodbriar Health Center put a resident back to bed Feb. 8 after a fall. They were supposed to be regularly checking overnight for complications but the next morning, the resident was discovered dead in bed.
A month earlier, staff members at the troubled Wilmington nursing home had received special training to spot problems in exactly this sort of case. Those retraining sessions were prompted by an earlier death: A resident was accidentally dropped from a mechanical lift on Christmas Day and died two days later.
The training sessions were revealed publicly in a plan the nursing home filed last month with state regulators that described strategies for preventing such episodes.
The documents, made public last week, state that staffers also reviewed the records of all patients who had fallen in the three months before the December accident and who received an X-ray. The review was to determine whether the X-rays were accurately interpreted and shared with families.
Regulators last week blamed the February death on deficient care — care that was given even after the retraining. The state now ranks Woodbriar in the bottom 6 percent of all Massachusetts nursing homes, based on repeated health and safety problems. The owners of the nursing home issued a statement Tuesday saying they disagreed with the state’s findings in the February death.
Investigators discovered issues surrounding the February death when they visited Woodbriar to determine whether the nursing home had corrected problems uncovered after the December accident.
In the more recent incident, nursing home workers put the resident back to bed after concluding the resident appeared to have no injuries. A physician ordered them to check the resident every two hours for signs of medical problems until the next morning, and then check every four hours, according to state documents.
But the resident was found dead by 5:30 the next morning, with no record the checks were done as required, according to the documents.
The state Department of Public Health last week declared residents in the 142-bed nursing home in “immediate jeopardy.” The department ordered Woodbriar to stop accepting patients, threatened to remove it from government programs that cover most residents’ bills, and recommended fines as high as $10,000 a day until safety is restored.
Woodbriar is part of a problem-plagued chain of 11 nursing homes owned by Synergy Health Centers, a New Jersey company that has faced mounting citations for substandard care since buying its first Massachusetts facility in 2012.
Synergy is appealing the state’s actions. The company also said the latest death was not related to the resident’s fall the night before.
“The procedures established by the Plan of Correction were followed in this case,” the statement said. “Our staff was properly trained, they performed their duties according to that training, and we stand by their actions.”
The state’s investigation found a widespread breakdown in communications and care at Woodbriar following the December death. Investigators concluded three shifts of nurses learned that 83-year-old Mary Meuse broke her legs in the Christmas fall but failed for 24 hours to let her, or her family, know the results. Meuse died two days later.
Synergy tacked a caveat to the front of its Plan of Correction submitted to state regulators regarding Meuse’s death.
“Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies,” it said. “The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.”
This language has recently become common in such documents, particularly by large out-of-state nursing home companies, said David Hoey, a North Reading attorney who has successfully sued other nursing homes and who represents Meuse’s family.
“This is supposed to be a promise to the Department of Public Health that you have identified a problem and are required by law to fix it,” Hoey said.
State and federal regulators said they are still investigating Woodbriar and have not determined penalties. The nursing home could face termination from Medicaid and Medicare, the government health programs that pay many of its bills, if conditions do not substantially improve by April 14.