Woman Wants Better Oversight Of Nursing Homes

A Mineral Point woman said she wants the state to make sure policy changes are made and followed at nursing homes following an incident involving her mother.

Sitting on the couch of her Mineral Point home, it seems clear that Sue Kostohrys is the kind of woman who doesn’t anger easily. Yet the heat in her voice is unmistakable when she recalls what happened to her now-92-year-old mother last September.

“I said, ‘Mom, what are you experiencing?’ and she choked out, ‘I can’t breathe, can’t breathe,'” said Kostohrys about the first moments of a visit at the Mineral Point Care Center.

“So, I told the little (Certified Nursing Assistant), ‘Call 911. Run down the hall and call 911,'” said Kostohrys. “And she said, ‘I’m not allowed to call 911.'”

That’s what makes Kostohrys incredulous. She said she was confused why the CNA told her she wasn’t allowed to call 911.

It was just the first of five times Kostohrys and her husband, Jim, who was also visiting that day, said they asked for 911 to be called. They believed Kostohrys’s mom, Barbara McGrath, was having a heart attack.

“The nurse said, ‘I’m going to call her doctor.’ And I said, ‘No, call 911 now,'” she said.

As a part-time law enforcement officer, Jim Kostohrys had been trained to know seconds count. He ran outside to wait for an ambulance. When he didn’t hear sirens or see one arrive, he ran back to the nurses’ station, where he said he saw a nurse still trying to call McGrath’s doctor. Minutes had passed.

“I said, ‘You call 911 right now, and if you don’t I’m going to leap over the counter and I’m going to dial 911 myself,'” he said.

A brief Iowa County 911 call obtained by WISC-TV includes a brief request for an ambulance to take a resident with chest pains to a hospital emergency room.

Five minutes after the 911 call was made, an ambulance did arrive. By the time McGrath arrived at the ER, records from a state investigation into the incident indicate her pulse was in the 30s. But the failure to call 911 is just the first of several flaws WISC-TV found noted in the documents.

By law, care staff must report a change in condition to a physician, but in this case, that didn’t happen, WISC-TV reported. If nurses had reported McGrath’s shortness of breath to a doctor when they first noticed it hours earlier, a drug interaction that records note possibly caused her emergency might have been discovered.

In other cases, residents of the Mineral Point Care Center were given medication that hadn’t been ordered by a doctor. In another case, a resident’s lab test was not completed, according to state documents. And, state investigators noted the facility’s clinical records were poorly maintained and not up to accepted professional standards.

As a result, the Mineral Point Care Center received five federal citations, but no fine. The only requirement was that the facility submit a corrective action plan.

“I think it sends a message that you don’t have to change your attitude, you don’t have to change your policy, you don’t have to do anything different than you did before,” said Jim Kostohrys, adding that he believes the penalty wasn’t enough.

From the state’s perspective, the violations found don’t meet the level of “immediate jeopardy” that would trigger severe penalties, including hefty fines.

“For this level of violation, they have what’s called an opportunity to correct, because there’s no harm, no immediate jeopardy,” said Otis Woods, the administrator for the Division of Quality Assurance, which is the part of Wisconsin’s Department of Health Services that oversees nursing homes.

Each year, Woods’ staff conducts more than 1,000 complaint-based investigations, or surveys, in the state’s more than 400 nursing homes.

Approximately 40 percent of those complaints are substantiated. About 60 last year were deemed to be in the most severe category, “immediate jeopardy.”

Woods told WISC-TV that his staff did not conduct an on-site followup at the Mineral Point Care Center to make sure its corrective plan was implemented.

WISC-TV showed him parts of his staff’s own investigation, which found after the incident no staff members were interviewed by management and no internal followup was done.

WISC-TV asked Woods if a facility that operates in that way could be trusted to truly make changes.

“You make a good point, and upon re-review, it does look like we should have done more. It’s something I’ll have to look into. It’s a good point,” Woods replied. “Maybe there’s a change in practice or policy that should be looked into.”

That kind of look is what Sue Kostohrys said she hopes for, after she looked into her mother’s eyes and thought she’d seen the worst.

“I saw the look on her face and I thought, ‘This is it,'” she said. “Some people never have visitors ever, and what’s happening to them? That’s the concern.”

The Mineral Point Care Center opted not to comment to WISC-TV for this story, citing confidentiality. As part of its corrective action plan, it promised to re-educate and re-test nursing staff, conduct internal audits of records, and make sure doctors’ orders are properly followed.

The state does go back and randomly audit some of its own surveys to see if the right outcome was reached, and this case will likely get a second look.

Beginning in April, the state plans to expand the kind of records available online for families looking to research long-term care facilities.