Troubled Central New York nursing home slammed for not reporting suicide attempt

Oswego, N.Y. — The state has faulted Pontiac Nursing Home for failing to report a suicide attempt and an employee who broke rules by borrowing money from a resident.

The violations are the latest in a litany of problems which landed Pontiac on the federal government’s list of the nation’s worst nursing homes in March. Pontiac is the only Central New York facility on the list of 86 nursing homes. Facilities on that list can lose federal funding unless they improve care.

State law requires nursing homes to report all cases of alleged abuse, neglect, exploitation and mistreatment to the state Health Department. But an April 22 state Health Department inspection found staff at the troubled Oswego nursing home did not do that.

Pontiac’s director of nursing, the person responsible for reporting these cases to the health department, did not know which types of incidents had to be reported, according to the inspection posted on the Health Department’s website July 1. Pontiac’s administrator told an inspector the nursing home was not using the health department’s incident reporting manual.

Pontiac was cited for a similar violation last year. An Oct. 19 inspection found the nursing home didn’t notify police as required after a registered sex offender living in the facility repeatedly sexually abused a female resident suffering from dementia.

The April 22 inspection was the first in-depth inspection of the 80-bed nursing home conducted since Pontiac was placed on a list of the nation’s worst nursing homes. Facilities on the list are inspected at least twice a year. Nursing homes are typically inspected once a year.

Pontiac has a lengthy history of problems endangering residents’ health and safety. The home has been cited for failing to protect residents from sexual abuse, not sending gravely ill residents to the hospital for emergency care and letting water from a leaky roof drip into residents’ rooms for years.

The latest inspection cited Pontiac for 11 violations that have the potential to cause “more than minimal harm.”

Pontiac said in a state-approved plan of correction it has educated all nursing staff on what constitutes a reportable incident.

Nursing homes are required to report all cases of alleged abuse, mistreatment and neglect so the state can investigate and determine if the allegations are true, said state Health Department spokesman Jeffrey Hammond.

“The department will continue to hold Pontiac and all other providers accountable for the quality of care they provide or lack thereof,” Hammond said.

Langston McFadden, Pontiac’s lawyer, did not respond to phone and email inquiries from syracuse.com | The Post-Standard.

Here are the unreported incidents uncovered during the most recent inspection.

Suicide attempt: A resident was threatening suicide and trying to wrap sheets and cords around their neck. The sheets and cords were removed from the person’s room. The resident was placed under one-to-one supervision, then sent to a hospital for evaluation and treatment. The nursing home did not conduct an internal investigation of the incident. The nursing home administrator told the inspector the incident was not reported to the health department, but should have been.

Aide borrows resident’s money: The nursing home’s employees are not supposed to accept money or gifts from residents. A resident, however, loaned $200 to an aide who agreed to repay the money in monthly installments. When the aide missed a payment, the resident complained to staff and demanded to be repaid. The resident was not coerced into lending the money, according to the inspection report. Pontiac repaid the resident and deducted the money from the aide’s paychecks. The aide was given a written warning and directed to review the employee handbook. The resident was told not to loan any more money to employees. The nursing home administrator told the inspector the facility did not report the “misappropriation” of the resident’s money because it was not following the state’s incident reporting manual.

Physical abuse among residents: One resident hit another resident with a closed fist on the face and was “whipping” another resident with a call bell. Residents also slapped and pushed each other. When interviewed about the incidents, the nursing director told the inspector employees were unfamiliar with the health department’s nursing home incident reporting manual.

The inspection also faulted Pontiac for not providing enough supervision and assistance to prevent accidents among residents.

A legally blind resident was given a cup of hot cocoa to drink while “slouched down” in bed. The resident spilled the cocoa, getting a superficial first-degree burn, the inspection report said.

An investigation by the nursing home determined the accident resulted “from an error of judgment but the incident was avoidable.”

A few days later the inspector observed the same resident sitting unattended in a lounge area with a meal tray on a table. The resident took a bite of a grilled cheese sandwich, set it down and the sandwich slid down the blanket onto the resident’s chest. A dietician told the inspector the visually impaired resident needed help from staff during meals.

In its plan of correction, Pontiac denied that the resident was burned by the cocoa. To avoid other accidental spills, staff members were directed to give the resident a specialty cup with a lid for hot drinks.

Oswego Mayor William Barlow threatened to shut down Pontiac two weeks ago after an inspection by city officials found temperatures inside the facility exceeded 80 degrees. A nursing home representative denied the mayor’s allegations and said city officials recorded temperatures incorrectly.

James T. Mulder covers health and higher education. Have a news tip? Contact him at (315) 470-2245 or jmulder@syracuse.com