04/05/09 — Three O'Berry staffers fired following death

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Three O'Berry staffers fired following death

By Matthew Whittle
Published in News on April 5, 2009 2:00 AM

The state Department of Health and Human Services announced Friday that three employees have been fired following the "unusual" March 11 death of a female patient at O'Berry Neuro-Medical Treatment Center.

Additionally, officials said, the Center has until April 15 to implement its plan of correction and have those steps approved by the federal Centers for Medicare and Medicaid or else risk losing approximately $4.7 million in funding per month.

According to the Center's plan of correction, the facility was placed in immediate jeopardy status because of findings of patient neglect.

Specifically, the report states that the patient, who was sitting in a standard wheelchair, was placed in her room in group home 5-5 at 5:40 p.m. by a staff member who was then called into a meeting with her administrator.

Upon leaving the meeting at 6:45 p.m., the report reads, that staff member was informed that the patient had not yet eaten dinner. It then continues to read that when the staff member walked into the room she found the patient slumped in her wheelchair with the seat belt around her neck, her eyes open and lips pale.

After beginning CPR with the help of another staff member, the rescue squad was called and the patient was taken to Wayne Memorial Hospital where she was pronounced dead at 7:43 p.m.

However, state spokesman Brad Deen noted, there has not been an official cause of death given yet.

"The state medical examiner is still looking into that," he said.

That report is not expected until mid-June -- 90 days from when the incident occurred.

But, the report said, the patient, who was known to slide down in her wheelchair -- though not that much, staff members testified -- should have been monitored at least every 15 minutes, according to directions given to staff during an in-service held just days before the incident.

Additionally, facility director Dr. Frank Farrell described the patients living in group home 5-5 as "non-ambulatory and severely handicapped."

As such, CMS found that the patient "was not provided adequate supervision," and identified the situation as immediate jeopardy to patients in the group home because of "a lack of sufficient process to adequately supervise the (patients) ... therefore putting them at increased risk."

Among the actions now in place to correct that problem are updated staff training, documented 15-minute monitoring and the placement of a "continuously floating" supervisor in the home at all times.

Deen explained that the plan was actually created and given approval by CMS before surveyors had even completed their initial inspection, and that they do not anticipate the facility losing its federal funding.

"We're very confident," he said. "It is a good plan. We have a lot of confidence in the administration of the facility to make sure something like this does not happen again."

And, Farrell believes that this was an isolated incident.

"I've been here since '75 and I'm not aware of us ever having an immediate jeopardy situation," he said. "I'm confident that this was an isolated incident.

"We're working hard to implement our plan of correction and to get this thing resolved."

Neither Farrell or Deen would discuss specific reasons for the firing of the three employees -- two supervisors and one health care technician -- only saying that those decisions were made as a result of the incident.

"This is one more indication that (DHHS) Secretary (Lanier) Cansler and Gov. (Beverly) Perdue's zero-tolerance policy is in full effect and that when people jeopardize the health and welfare of those under their care, we will take appropriate measures."

The fourth employee who was placed on investigator leave has been retained by the facility.