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Last updated 1:19AM ET
March 3, 2021
VA Home Health Report Revised
(APR - Alabama Public Radio ) - The state health department has modified its earlier report on a Bay Minette veteran's home and now says deficiencies there did not cause the deaths of two residents who suffered falls.

The department had found that deficient practices at William F. Green State Veterans Home "resulted in a fatal outcome" for the residents, but an updated report released Monday softened the findings, saying the failures caused a "significant change in status" for the men.

Robert Graham, a regional director for HMR Governmental Services, Inc., said the new report supports what the South Carolina-based company maintained from the start the falls did not cause or contribute to the deaths.

"We do take our residents' health serious and there's nothing that we don't take serious about it," said Graham, who oversees management operations for HMR. "We have made some changes in policies to correct the issues that were found."

Bureau of Health Provider Standards director Rick Harris said the modified report is just as serious as the original.

"The facility had written us and expressed some concerns and we took a look at those, but that should not be read as an indication that this is anything less than a serious set of problems that needs to be quickly corrected by the facility," he said.

The Alabama Department of Veterans Affairs operates two other Alabama nursing homes in Huntsville and Alexander City and pays HMR Governmental Services, Inc. to run them.

Inspectors had also found that verbal abuse occurred when a nurse refused to straighten a patient in his wheelchair and commented within earshot that he was responsible for her shoulder problems.

The new report removes the finding of abuse, but cited staff for not thoroughly investigating an allegation of potential verbal/mental abuse.

Health department surveyors issued a 74-page statement of deficiencies at the Bay Minette home after an August inspection. The center has filed a plan of correction that has been approved.

The August report cited numerous problems at the home, most seriously that staff failed to follow proper procedures after patients fell.

The state report said nurses checked the vital signs only once on a patient who fell at noon on March 8 and they performed no neurological checks. The patient was found dead in his bed at 10:30 that night 10 hours and 30 minutes after the unwitnessed fall.

Staff also failed to do neurological checks on a resident who fell on May 3 at 12:45 a.m. The patient's family wasn't notified until 2:15 a.m. and the doctor wasn't informed of the resident's fall and low oxygen level until 2:35 a.m. and the resident died on the way to the hospital at 3:58 a.m.

"The problem with saying (the failings) resulted in death was we don't have a medical examiner reaching that conclusion," Harris said. "But I think you can look at the situation and say that given those residents' conditions, the facility did not respond to those falls as it should have."

State health department surveyors had also reported staff members taking too long to inform family members about their loved ones' conditions, water temperatures exceeding 110 degrees Fahrenheit and ant infestation in patient rooms.

None of those findings were changed in the updated report.

Both Graham and Kimberly Justice, Veterans Home Coordinator for the state VA department, pointed out that there's a very broad definition for falls which even includes rolling over from a floor mattress onto a mat.

Graham said the home has gone from having falls in the high 30s per month down to 15 to 20 a month now.

Justice said the department doesn't anticipate the home's license being downgraded. The state's three homes each have a 150-bed capacity and there are plans for a fourth location that will have 180 nursing home beds and 80 assisted living beds.

There are currently 250 veterans on a waiting list for placement which is a good sign that the services are wanted and needed, Justice said.

"The overwhelming majority of veterans and their families are pleased," she said. "There are some family members that are very unsatisfied right now at William F. Green and we will continue to address any concerns that are brought to our attention."

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