State issues rare severe citation to Nesconset nursing home after resident's death

A Nesconset nursing home's resident with a history of gastrointestinal issues became septic and died after nurses failed to address her severe constipation for at least a week, according to a Sept. 8 inspection report issued by the state Department of Health.

Health inspectors issued a rare Level 4 violation to The Hamlet Rehabilitation and Healthcare Center, citing “immediate jeopardy to resident health or safety" — the most severe infraction issued by the department, records show. An "immediate jeopardy" citation indicates urgent action is necessary to address an incident that caused "serious injury, harm, impairment or death." 

"The facility is required to provide a written plan of correction," said health department spokeswoman Erin Clary. "The department cannot comment further as the survey is still open at this time."

Records show a monetary fine has not yet been issued. The maximum amount a nursing home can be fined for a single citation under state law is $10,000.

In a statement, The Hamlet, a 240-bed, for-profit nursing home, said it's challenging the "immediate jeopardy" designation with the Centers for Medicare and Medicaid Services, which has federal oversight of nursing home standards.

"The patient in question was admitted to The Hamlet with multiple co-morbidities, including those from which the resident ultimately passed," the facility said. "All relevant protocols were in place and implemented during the patient's reside."

A CMS spokesman said the agency "would likely" have a comment on the situation Wednesday.

After the citation was issued, The Hamlet was resurveyed by health department inspectors and "found to be in compliance," the facility's statement said.

The Hamlet has received fewer citations of any severity than the state average, records show.

The Hamlet is owned by CareRite Centers, which operates five Long Island nursing homes, including Water’s Edge Rehab and Nursing Center at Port Jefferson, which made headlines this year when a woman pronounced dead there was found later to be breathing at a funeral home. 

Details outlined in the inspection report point to several failed opportunities to provide treatment for the unidentified Hamlet resident.

The resident, who was admitted to The Hamlet with multiple rib fractures, a collapsed lung, incontinence issues and a common reflux ailment, required extensive assistance from two nurses transferring to and from the toilet, records show.

Nurses are responsible for documenting bowel movements and administering over-the-counter constipation treatment and other medication, inspectors found. 

But there is "no documented evidence" that the resident's physician or nurse practitioner implemented the facility's correct protocol, even after the patient had been constipated for at least a week straight, the report states.

Nursing records show the resident "had no bowel movements or the bowel movement section [on Hamlet forms] was left blank on 15 days" although it's unclear if those days are consecutive, inspectors wrote.

When the resident complained of abdominal pain and lethargy, a nurse ordered X-rays and lab tests, which showed a large fecal impaction in the rectum, the report states. While an enema was ordered in the facility's computer system, nurses told health inspectors one was not administered, the report found.

The resident later developed an infection that was treated with antibiotics, with the primary physician suggesting possible pneumonia, inspectors said.

She was eventually taken to a hospital in septic shock related to stercoral with perforation — a condition in which chronic constipation leads to fecal impaction, causing holes in the colon wall — along with multi-organ failure, the report states. The resident died at 1 p.m.

In New York, "immediate jeopardy" violations are exceedingly rare, representing less than 2% of all department citations, according to data calculated by Richard Mollot, executive director of the Manhattan-based Long Term Care Community Coalition, an advocacy group for nursing home residents.

New York ranks 49th in the country — out of 50 states, Puerto Rico and the District of Columbia — in issuing "immediate jeopardy" citations to nursing homes, the data shows.

The Hamlet, Mollot said, failed to provide even the minimum-care standards to the deceased resident.

"Not only was it catastrophic for the resident … it was also the result of numerous failures by various staff over a long period of time," he said. "It is hard to imagine the prolonged, avoidable pain that this resident suffered."

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