Patient care issues at Evergreen |

Patient care issues at Evergreen

by Susie Vasquez
Nevada Appeal photo Evergreen Health and Rehabilitation Center on Ormsby Boulevard.

A resident at Evergreen Health Care nursing home on Ormsby Boulevard since 1999, Harold Peterson died of a stroke Feb. 17.

He suffered from a number of illnesses including dementia, diabetes and severe acid reflux disease that required specific medication. His daughter, Tonya Vincent, alleges the struggle to keep her father comfortable and stable was even more difficult after the home was purchased by Evergreen in late 2002.

“When Carson Health Care owned the facility, my dad was getting very good care,” Vincent said. “Why weren’t they able to keep the doors open?”

In late December 2003, Vincent’s father was hospitalized several times for a urinary tract infection and gastrointestinal bleeding, the latter a problem that cropped up when he didn’t get the right medication for acid reflux. He was so severely dehydrated he was forced into renal failure, she said.

“It was unbelievable,” Vincent said. “If I had done any one of these things to my dad, they would have put me in jail.”

Doug McCoy, regional manager for Evergreen, said he was not aware of any concerns Vincent had with respect to her father’s care and wouldn’t comment on the allegations. A national chain, Evergreen Health Care owns two nursing homes in Carson City – Mountain View Health Care is on Koontz Lane and Evergreen Health Care on Ormsby Boulevard. Peterson was at the Ormsby site.

In Nevada, all nursing homes are subject to an annual inspection by Nevada’s Bureau of Licensure and Certification. Mountain View passed its most recent inspection last month after failing two times. The facility failed an October inspection by state health officials that revealed 29 deficiencies, followed by a second inspection in February.

Problems at the Mountain View facility were compounded by the deaths of six residents Dec. 9. Four of those allegedly died of upper-respiratory illness.

The outbreak received national attention because of the number of deaths, but efforts by the Centers for Disease Control and Prevention in Atlanta, together with state officials, did not pinpoint the exact cause.

One of the deficiencies described a patient’s struggle with an untreated urinary tract infection in the Feb. 11 report.

Nursing home records indicate signs of a urinary tract infection in a female patient on Dec. 5, but physician orders for the lab work were not done. The patient had a history of urinary tract infections, caused by a virulent, antibiotic-resistant bacteria.

She also has diabetes and dysphasia, a condition that makes swallowing difficult. She continued to show signs of a urinary tract infection when a nurse noted that the urine was cloudy on Jan. 11, but the lab work was still not done.

On Jan. 21, the patient was admitted to an acute-care facility with a urinary tract infection, blood infection, concurrent bowel obstruction and dehydration. The bowel obstruction was not detected and the patient started vomiting “brown, foul-smelling emesis,” the report states.

“The nursing staff failed to follow the physicians’ order, (and) failed to monitor the urine output as outlined in the nursing care plan,” the report said. “The patient did not receive a comprehensive assessment of a probable urinary tract infection in a timely manner, which may have contributed to an acute care hospitalization for early sepsis and a bowel obstruction.”

“I have a great deal of confidence in services the staff at Mountain View is providing,” McCoy said. “Whatever the issues were on the Feb. 11, survey, they’ve been resolved to the state’s satisfaction.”

Barred from taking both Medicare and Medicaid patients after failing its second inspection in February, Mountain View is now accepting both.

Diane Allen, supervisor for the Northern Nevada Bureau of Licensure and Certification, could offer no explanation as to why the Mountain View staff did not perform tests on the infected patient.

“The staff nurse acknowledged that the tests had not been done. That’s all we can publicly say,” Allen said. “That’s how the survey process works.”

The state’s investigation process was set up using federal guidelines. The facility was subjected to weekly unannounced visits as long as the center was failing its inspections, from October to March, Allen said.

“We saw significant improvement in the last survey and we anticipate they will stay in compliance,” Allen said. “That is their commitment.”

Kathy Givens worked as a hairdresser for three years at Mountain View, but quit recently because she couldn’t stand to watch the patients being compromised, she said.

“The last day I was at Evergreen, I entered the dining room looking for a customer. One gentleman was having trouble with his oxygen,” she said. “It looked serious. The man was blue, so I approached a nurse and told her the man needed oxygen.”

The nurse turned her back and did not help the patient, Givens said.

“I finally left the dining room and went to the director of nurses, to get him some help,” she said. “That sort of thing is unforgivable. I decided I couldn’t watch it any more and left.”

Givens said new nursing staff was hired in time for inspections, but they would be gone as soon as the inspection was over.

Allen agreed, and said it’s not unusual for centers to hire additional staff for inspections. The staffers are then let go or transferred to another facility.

“But we’ll be back in six to nine months for an annual survey, or anytime there are complaints,” Allen said.

According to the Web site,, the Ormsby Boulevard center is Medicare certified, which would mean it has passed its latest inspection. However, though the Web site was updated last month, it is missing the results of the 2003 and 2004 inspections at the Koontz Lane Center and the certification may not be current.

Vincent, concerned about the care her father received, said the system doesn’t go far enough.

“Someone has to stop this. It’s ludicrous. People are being abused and neglected daily. No one says anything and it’s like everyone is saying it’s OK,” Vincent said. “These elderly are like babies. They can’t defend themselves. If they were babies, everyone would be here, fighting for them.”