State to investigate alleged mistreatment at Huntsville VA retirement home

State to investigate alleged mistreatment at Huntsville VA retirement home

HUNTSVILLE, AL (WAFF) - Two former employees of the Floyd E. “Tut” Fann State Veterans home said they have seen gross mistreatment of veterans and bed bugs at the facility.

They claim to have seen evidence of staff negligence, disinterest in feeding the veterans properly, and an inadequate response to a Scabies outbreak.

Both individuals reached out to WAFF 48 News independently. They requested to remain anonymous, citing concerns over future job prospects.

WAFF 48 News agreed to keep their identities private after the individuals were able to prove their employment at the veterans’ home. They provided documents and identification only employees of the facility would possess.

WAFF 48 investigated their claims by looking at the home’s violation history. Years of state records support some of their claims.

The Alabama Department of Veterans Affairs Commissioner Kent Davis vowed to investigate the claims after speaking with WAFF 48 News.

Employee 1: Former housekeeper

The first former employee said she did laundry and common area work from December 2016 to December 2018, but operated primarily in the G-Wing of the facility.

She described the G-Wing as the living area for veterans suffering from dementia.

The individual said she saw mistreatment, negligence and poor living conditions.

During a G-Wing shift in fall 2018, the former employee said she heard a veteran fall out his bed. When she came to help, she found the veteran with bed sores and blood on the floor from the fall.

The housekeeper said the man had not been receiving the care and attention needed to prevent bed sores.

The Mayo Clinic describes bed sores as ulcers caused from prolonged pressure.

She said she did not report the incident, citing an administrative culture of inaction on similar issues.

In the fall of 2018, she said she saw a veteran suffering from Scabies, a condition where mites burrow into the skin of a host.

The CDC describes Scabies as “very contagious to other persons and can spread the infestation easily both by direct skin-to-skin contact and by contamination of items such as their clothing, bedding, and furniture.”

For the sake of privacy, WAFF will refer to the veteran with Scabies as “Mr. James.”

She said Mr. James often moved between the C-Wing, F-Wing, E-Wing and lobby of the facility. She said the administration took no action to limit his movements when she raised that concern with administrators.

In December 2018, she said she saw a G-Wing co-worker suffering from bed bug bites.

She said the bed bugs were present in the C-Wing, D-Wing and laundry room.

The former employee said she informed the home’s administrators, but they did not attempt to clean or quarantine the areas infected.

She said she avoided the wings that were infected, and was ultimately fired for “wing abandonment.”

Employee 2: Former dietary cook

The second employee said she worked as a cook at the facility from December 2018 to January 2019.

The cook said she interacted with “Mr. James” on a daily basis in the facility dining room. She confirmed Mr. James moved freely throughout the facility, despite what she described as a visible case of Scabies.

She said administrators told her to wear gloves whenever interacting with “Mr. James," but did not know whether he was being treated for Scabies.

She said the facility misled veterans and their families about its dietary offerings, and veterans were fed food that ran counter to their dietary restrictions.

The former cook said she raised this concern with her kitchen supervisor, but was told “I don’t care.”

She said she left the facility because the treatment of the veterans was “unconscionable.”

Corporate response to the claims

Tut Fann is part of the Alabama Department of Veterans Affairs system. The Alabama VA owns and governs the home, but currently contracts its operations to HMR Veterans Services (headquartered in South Carolina).

HMR Veterans Services has run Tut Fann’s day-to-day operations since July 2004.

HMR’s Vice President Scott Hurst oversees the company’s Alabama operations.

Hurst declined and later did not respond to multiple interview requests for this story.

The day of this story’s publication, HMR’s public relations firm Direct Communications sent the following statement on his behalf:

“Nothing is more important to us than providing the highest quality of care possible to our veterans. We work closely with state and federal agencies and follow important guidelines and procedures in providing care. For example, a recent independent survey named Tut Fann in the top 15% in the country which included nursing service, dining service, food quality, communication, cleanliness, activities, and dignity and respect for veterans. The most recent federal compliance survey from the Veterans Administration found the facility to be in compliance with all requirements. This is a great compliment to our loyal employees as well as state and federal officials who work with us on a day to day basis.“

The above-cited independent survey awarded Tut Fann for “communication.”

Hurst did say state and federal law prevented him from discussing healthcare matters at the nursing home.

He said he could not corroborate any reports or comments made by the former employees given their anonymity, but did forward WAFF 48 News an email with a link for concerned individuals to reach out.

A mixed past of violations and awards

Both employees said they’ve been told by former coworkers the mistreatment of veterans goes back years.

Alabama Department of Public Health records support that claim.

The department performs inspections of nursing homes roughly once a year and visits them upon the receipt of a complaint, publishing its findings on its website.

An ADPH survey of Tut Fann in January 2019 only found issues with the sprinkler system and kitchen appliance disorganization.

Sources point to the most recent federal VA inspection being positive as well.

Federal VA spokesman Jeffrey Hester, Alabama Department of Veterans Affairs Commissioner Kent Davis, and an Alabama Nursing Home Association announcement from August 2018 all state the facility was found “deficiency free” in that federal report from July.

WAFF 48 News requested the inspection from the federal VA, but was unable to obtain it in time for this publication.

The announcement stated the home earned the distinction by meeting all the standards set forth by the veterans administration.

In 2016, the facility won the American Health Care Association’s Bronze-Commitment to quality award for its ability “to implement a performance improvement system.”

Despite those accolades, the facility does have a history of violations.

The ADPH’s records of those violations include but are not limited to the following.

The dates in bold are the days the departments surveys were completed, and the surveys are linked accordingly.

9/28/2017: “The facility failed to ensure RI (Resident Identifier) #7′s bathroom floor was free of a brown substance. This was observed three of three days of the survey."

  • The facility’s director of environmental services later said it was related to water damage issues, and the “brown substance” had been there a month.

9/28/2017: “The facility failed to ensure Resident Identifier (RI) #5 was care planned for refusal of the Ensure supplement at meal times.”

  • The ‘Ensure’ supplement was part of the resident′s diet per physician’s orders.
  • An licensed practical nurse later said the nurses responsible for RI #5′s supplements failed to provide it to him, due to his refusal.
  • The licensed practical nurse said she did not make “anyone aware of the resident’s refusing ensure," and said to the surveyor “I don’t know what to tell you.”
  • Other food related violations included not taking milk temperature, bagged food with no use-by date, and a failure to provide assistive utensils ordered by a physician for a veteran.

9/28/2017: “The facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) #6, did not touch the water faucet handles with soiled gloves while performing colostomy care.”

4/23/2015: “The facility failed to ensure Resident Identifier (RI) #12′s care plan was implemented. On 4/22/15, RI #12 was not provided incontinency care every two hours as planned.”

  • The certified nursing assistant assigned to the resident did not provide incontinence care for two hours and 40 minutes.
  • The veteran’s care plan stated they were “at risk for impaired skin integrity due to fragile skin.”
  • The CNA later admitted failing to provide the care could result in “skin breakdown.”

9/26/2014: “The facility failed to ensure the code status of Resident Identifier (RI) #3 was accurately documented in the resident’s medical record."

  • The resident had indicated they wanted to be “Full Code” (i.e. resuscitated in the event of no pulse).
  • Facility records had the veteran’s code as “Do Not Resuscitate (DNR)."

9/26/2014: An employee found “a Full Code resident, cold, without a pulse and not breathing on 2/19/14 and failed to initiate Cardiopulmonary Resuscitation (CPR). Instead of initiating CPR, EI #12, a Licensed Practical Nurse (LPN) who was certified in CPR, left the room to call the cell phone of a Registered Nurse (RN) Supervisor for help.”

  • First responders arrived and later pronounced the veteran dead.
  • Tut Fann failed to report the incident to the Alabama Board of Nursing.
  • The first nurse on the scene (who made the call) later stated “I did not look at the chart, I really didn’t know what to do but get some help. There was no training on what to do in a code. I had never been through a code before."
  • The nurse walked out of the room, telling another the nurse the resident had died.
  • The C-Wing of the building was not stocked with adequate emergency gear at the time.

9/26/2014: The department found undocumented tube feeding of a veteran, with no information on when the feeding began, how much the veteran had received, or who began the feeding.

9/26/2014: “The facility failed to ensure Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) washed her hands and changed gloves after cleaning stool from Resident Identifier (RI) #2 and before touching the lift machine.”

6/13/2013: “The facility staff failed to follow the Physician’s Orders to remove Resident Identifier (RI) #1′s Exelon 4.6 mg (milligram) patch daily, prior to applying a new patch.”

  • Upon the resident’s admittance to the ER for “respiratory distress," he was found with four patches on his body.
  • An ER nurse later said there “were concerns related to him having 4 Elexon patches on his body."

Once a violation is published, nursing homes are required to submit a “plan of correction” to the department.

The severity of the violation could potentially downgrade the facility to probational status or lead to the revocation of its license.

On Feb. 21, 2019, WAFF emailed the ADPH’s State Program Director Mia Sadler about how the corrective action plans were missing from the above-mentioned surveys.

By Feb. 25, 2019, three of the four surveys (with the exception of the 6/13/2013 survey) were re-published with their respective corrective action plans.

The plans from 2017 and 2015 begin with the statement: “Preparation and/or execution of this plan of correction does not constitute admission or agreement by the principles of the truth of the facts alleged or conclusions set forth in the statement of deficiencies.”

The three plans of correction include the “re-education” of employees, the implementation of audits, increased administration supervision and the introduction of social services in response to the 9/26/2014 violations.

Sadler said in an email, “If the plan of correction appropriately addresses the deficient practice cited, we accept the plan of correction. We then look for corrections to the prior violations, as well as for any new violations during the next scheduled survey.”

The department approved all three plans.

Sadler said the facility was under probation in the late 1990′s, but has not been on probation since 2001.

She said the department is no longer in possession of the survey which laid out the violations that led to the probation.

The contractor that oversaw Tut Fann’s operations during the 1990’s probational period filed for bankruptcy in 1998.

Sadler also said in an email: “...Deficient practices are fairly common. Our surveyors are focused on finding out whether or not facilities are in compliance with state and federal regulations. Unless the deficient practices are totally egregious, they would not stand out to the Department.”

Tut Fann has been sued for abuse

Huntsville attorney Tommy Siniard said he has represented clients against the veterans home “three or four” times in his 26-year career practicing nursing home cases.

This includes a 2007 case where a WAFF article from the time states the victim’s son secretly videotaped his fathers mistreatment for 60 days.

Siniard said at the time, “Over the course of his treatment (the patient) has suffered an excess of 20 falls, several of which had been serious (including) broken 2 jaw, he’s been, we allege struck by employees.”

“During the course of that filming he saw that his father would go 8, 10, 12 hours without a person coming in his room."

The son removed his father from the facility.

In February, Siniard said he could not speak to the specifics of that case other than it had been settled.

Speaking in general terms, he said nursing home mistreatment is an “epidemic.”

“What we see is, sadly, is not huge, complicated medical mistakes. It’s people that fail to get properly watered, have water, fed, turned in their bed so they don’t get pressure sores or bed sores, falls, where they’re inappropriately assisted to the restroom or to their wheelchair,” he said.

He said a lot of the issues he’s seen involve nursing homes being inadequately staffed.

The Alabama Department of Veterans Affairs Commissioner says he’ll investigate

The Alabama Department of Veterans Affairs Commissioner Kent Davis said he will personally visit Tut Fann in March and investigate the claims made by the former employees.

“Our utmost concern is the care of veterans, that’s why we exist as a department. That’s what we’re about here. We take very seriously any allegation of neglect or mistreatment,” he said.

“I can tell you this, I did not know the specific allegations until you showed up today. I can personally look into those..."

Davis said he had read some of the above-cited ADPH surveys, and his understanding “is all those issues have been followed up on.”

He also said he welcomes and encourages anyone with concerns about any VA nursing home to reach out to his office.

Davis said the Alabama VA is represented at the home by its facility director, but the care of the veterans predominantly falls to HMR employees.

That VA facility director, Charlotte Eason, did not respond to multiple requests for an interview.

What can be done?

If a loved one is suffering from mistreatment at any nursing home, the ADPH can be contacted through the following means:

  • The complaint hotline (1-800-356-9596)
  • By mail (P.O. Box 303017, Montgomery, AL 36130-3017)
  • Or its website

Sadler said in an email:

“It is very helpful for the complainant to provide detailed and specific information about the allegation (who, what, where, how and why). ADPH staff will obtain as much information about the allegations as possible.

A determination will then be made as to whether or not there is a potential violation of the rules for nursing homes. It is helpful in the intake process and the investigation if the complainant can leave contact information in case further information is needed.

We take every precaution not to reveal the source of the complaint to the facility. If a potential regulatory violation exists, an unannounced complaint investigation will be conducted.”

The Alabama Department of Veterans Affairs can be contacted via:

  • It’s Montgomery Office (334-242-5077)
  • It’s Madison County Office (256-532-1662)
  • Or its website

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