A South Florida assisted living facility is facing $16,500 in fines after officials say improper care by staff led to the death of one resident, the attempted suicide of another and at least three runaways that resulted in serious injury, state records show.
In a 33-page final order issued by the Agency for Health Care Administration, officials detail how workers at New Era Community Health Center in Homestead failed to provide adequate care to several residents in 2017 and 2018.
The three class II violations were bundled up in one final order, totaling $16,500 in fines — $5,000 per violation plus fees. Class I violations carry fines of $10,000 each.
Brian Lee, a former long-term care ombudsman who now works for an advocacy group, told the Miami Herald the penalty was “laughable.”
“It’s pretty alarming and confusing that AHCA has sanctioned them in this matter, by rolling up all these very serious violations into one larger sanction,” Lee said. “$16,500 for these series of deficiencies? I don’t know if this is the wake-up call that this place needs to start providing better care. For a 200-bed facility like that? That could be the cost of just doing business; it could only be a slap on the wrist for them, like slapping them with a wet noodle.”
“The agency didn’t find the residents to be in imminent danger at the time of the survey,” AHCA spokeswoman Shelisha Coleman said. “We will continue to monitor this facility closely.”
In one case, a woman died after having a seizure, falling and then going into an “unsurvivable” coma.
According to the final order, the facility failed to secure a neurologist for an epileptic woman who had come back home from a hospital stay. The ALF stated ”she only had Medicaid and none of them wanted to see her.”
Shortly after, on Aug. 28, 2017, the woman had a seizure and fell, records show.
“Nobody saw the resident fall. She was found on the floor but nobody saw her fall,” facility administrators said, according to the final order.
However, hospital records say otherwise. According to AHCA’s report, one witness did see the fall, which resulted in a fractured humerus, nose, neck and skull fracture, as well as two fractured ribs, forehead contusion and a hematoma. The woman died at the hospital.
In a second charge, ACHA details how three resident runaways in late 2017 resulted in injuries, including fractures, and dehydration. The report tells of a resident who tried to walk more than 25 miles to the mall to get some air conditioning and teriyaki.
In that case, the resident was found by police unconscious and severely dehydrated on the front lawn of a private home. Owners of the home bought the man water and called 911. He was then taken to the hospital, where he was diagnosed with rhabdomyolysis (a serious muscle injury syndrome) and a damaged kidney.
Records show another runaway was found unresponsive at a park in Hialeah with multiple fractures after his aunt called the ALF to say he might be there. Another resident went to a nearby clinic.
All three residents, some of whom took off more than once, were known flight risks, records show. None of them were wearing required identification bracelets and ALF workers didn’t immediately call police after noticing the residents were nowhere to be found, records show.
In a third violation, AHCA said New Era Community Health Center housed a suicidal patient on a second floor despite knowing about a previous suicide attempt.
“After several months of inadequately addressing addiction and mental health issues, [a woman] attempted suicide by jumping off a second-story balcony,” the June 2018 report said, noting that the 10-foot-fall resulted in a broken pelvis and other shattered bones.
According to hospital records, the 53-year-old, who battled drug and alcohol disorders, had relapsed on cocaine just a few months before jumping from the balcony.
The woman told investigators she jumped because she had pain radiating down her leg and vagina, was constipated and vomiting. She also said she used her Social Security money to buy crack from a nearby drug dealer.
“I don’t want to wake up,” she said, according to the report. “I want to go to sleep and die. The pain does not want to go away.”
New Era Community Health Center told the Miami Herald that the facility, which opened in early 2017, has since worked with state officials to implement “correction plans.”
“We learned our lesson. We now have a person at the door, security guards on the property, and identification wrist bands on all residents,” said owner Jorge Musa. “The patients mentioned in the final order came from the state hospital; we are not getting them anymore. Patients like that should stay there. It’s not easy taking care of patients that are that mentally ill.”