Report: Nursing home failed to give resident HIV medication for 3 weeks, documented administering it anyway

HENRICO COUNTY, Va. — After CBS 6's reporting into the state's delayed and backlogged efforts to inspect and investigate Virginia's nursing homes, the health department completed a complaint investigation that was heavily anticipated by the people who prompted it.

“I wished it could be more, but at least they did something," Heather Tyler, one of the complainants, said.

In September, Tyler told CBS 6 she was frustrated that the Virginia Department of Health had not taken action in response to the complaint she submitted against her husband's Henrico nursing home, Westport Rehabilitation and Nursing Center.

WTVR

“Ironically, the day after we aired that story, I got a call from the health department saying that they were at Westport at that time investigating my complaint," Tyler said.

In January 2024, she filed claims with VDH alleging poor conditions at Westport, that her husband was left to sit in his urine for hours, and that he suffered unexplained injuries and marks on his body.

However, the understaffed health department has failed to meet its regulatory oversight requirements, according to federal data and a new state report which revealed significant inefficiencies and mismanagement within VDH.

“It took them nine months to walk in that door, and I thought this was a pretty serious complaint," Tyler said.

Nonetheless, VDH completed its survey of Westport on September 30 and provided the findings to Tyler.

The inspection report showed her complaint, along with a few others that were investigated during the same inspection, was "substantiated with deficiencies."

However, Tyler said neither she nor her husband were interviewed as part of the investigation and she did not know whether the pictures she documented were reviewed by health inspectors.

“So, what do the bruises and the pictures of the cuts and the trip to the emergency room, what does that all count for?” Tyler asked.

VDH's Director of Licensure and Certification Kimberly Beazley confirmed the agency does use pictures to supplement investigations; however, they cannot cite a violation solely based on a photo. When asked whether VDH interviews the complainant, Beazley said the complainant is "contacted by the investigator on the day that the investigation starts."

Here's what VDH's investigation did uncover, according to a survey sample of current residents and closed records:

• Westport failed to provide a resident with requested medical records after being discharged.
  
• Westport failed to provide a summary of a care plan for a resident, which Tyler identified as her husband.
  
• Westport failed to meet food and nutrition standards, with residents describing meals as "cold" and "hard as a brick."
  
• Westport failed to provide a resident medication to treat advanced HIV for three weeks, resulting in "significant medication errors."
  

The report showed the resident missed multiple doses of HIV medication from August 23 to September 14, 2024.

The medication was not available at the facility's pharmacy, but staff did not notify the provider so that new orders could be given, according to the inspection.

A nursing director told the inspector that "the process to obtain the medication was not followed" and that both the pharmacy and facility staff "dropped the ball."

Despite not having the medication on hand, investigators found staff "inaccurately documented" in clinical records that the medication was administered to the resident when it was not, a violation of professional nursing standards.

In total, about a dozen violations were cited during VDH's investigation. Many of them pertained to HIV medication issues, including a more serious deficiency cited when a nursing home's medication error rate exceeds 5%.

In response to the deficiencies, Westport submitted a corrective action plan that included educating staff and doing regular internal audits. Westport did not respond to CBS 6's request for comment.

Tyler questioned whether the corrective action plan would be enough to fix the violations and whether any penalties would be assessed.

Beazley said the Centers for Medicare and Medicaid Services (CMS) would be responsible for deciding whether to apply any enforcement actions. VDH is the state agency that conducts the investigation on behalf of CMS and is not involved in determining penalties.

Tyler believed the findings underscored the need for robust oversight of Virginia's nursing homes.

“We're all getting old. We all are going to need help at some point in time, whether it's in-home care or hospital care or nursing home care, and if they don't have an efficient system in place, then what just happens to us?” Tyler said.

Kimberly Beazley provided the following information about VDH's process for investigating complaints:

The [Office of Licensure and Certification] (OLC), through a contract with the Centers for Medicare and Medicaid Services (CMS), serves as the State Agency (SA). In this role, the OLC conducts state licensing inspections, federal certification surveys, and complaint investigations of nursing homes.

A complaint is an allegation of noncompliance with Federal and/or State requirements. If the SA determines that the allegation(s) falls within the authority of the SA, the SA determines the severity and urgency of the allegations, so that appropriate and timely action can be pursued. When a complaint is received, the SA must review all complaint allegations and conduct a standard or an abbreviated standard survey to investigate complaints of violations of the requirements. All onsite complaint investigations are conducted unannounced.

The SA must review the allegation(s) for all requirements that apply and should be investigated. A surveyor or survey team then investigates each of those areas of concern. 

The complaint process consists of several tasks to include offsite survey preparation, entrance conference/onsite preparation, information gathering, information analysis, and exit conference. The order and manner in which information is gathered depends on the type of complaint that is being investigated. Surveyors perform information gathering in order of priorities, obtaining the most critical information first. Based on this critical information about the incident, they will determine what other information to obtain in the investigation. Observations, record review and interviews are also conducted and can be done in any order necessary. Surveyors also observe the physical environment, situations, procedures, patterns of care, delivery of services to residents, and interactions related to the complaint. Also, if necessary, observations of other residents with the same or similar care need may be conducted.

Following the complaint investigation, the SA conducts a supervisory review and records any findings on Form CMS-2567, Statement of Deficiencies. The facility will then receive a copy of the CMS-2567. The facility must submit an acceptable plan of correction for any deficiencies cited.

CBS 6 is committed to sharing community voices on this important topic. Email your thoughts to the CBS 6 Newsroom.

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