Some health-care practices at the Vista Grande nursing home failed to meet federal care requirements during an unannounced inspection last month by Colorado Department of Health and Human Services.

According to the department’s recently released report on the long-term-care facility, inspectors found seven deficiencies involving medical-care practices and policies. Six violations were considered to be Level D, which means they involved individual cases with the potential for more than minimal harm to the resident.

The other received a Level E rating, meaning the problem has a more widespread pattern affecting multiple residents that could also lead to patient harm.

The scale runs from A to L, with A being no deficiencies and L meaning the resident is in imminent danger.

Vista Grande’s interim director, Terrylea Entsminger, said yesterday that the 76-bed long-term-care facility is in compliance with the federal standards, and that some of the deficiencies will be challenged during a follow-up process with the health department. Vista Grande has until Aug. 17 to respond to each violation listed under a plan of correction.

An inspection in September 1999 at Vista Grande found eight violations, six of which were Level D, along with one F and one G. The G involved a resident with repeated skin tears on her legs because of protrusions from her wheelchair.

The worst offense in the recent report, the Level E, involved the home’s alleged lack of adequate comprehensive care plans for patients. Surveyors investigated the care plans for 15 residents, finding that Vista Grande failed to "address the specific physical, psychosocial and behavioral needs" for four of those residents.

In one case a resident with a rotator-cuff tear was required to be fitted with a leg brace and tennis shoes for activities outside the room, including meals. Inspectors observed the resident without the shoes and brace in the dining hall, and noted that the items were left in the resident’s room, on the bed with a sign above stating, "Please put on tennis shoes for all transfers and to meals."

The person’s care plan revealed that the brace was to be worn on the right leg, but did not indicate for how long, under what circumstances, or who should put it on. Unless a care plan was initiated that clarified the brace-wearing schedule, the patient’s condition could be compromised, the report says, leading to a worsening of the rotator-cuff tear.

In another case, a resident’s tendency to fall while attempting to reach the bathroom or get out of bed was not adequately addressed in the individual’s care plan, according to the report. Medical records show that the resident fell four times in a five-month period, but during an interview with the nursing director, it was revealed that there was no care plan for the woman that addressed the problem of her falling.

"This failure (to develop a comprehensive care plan) created the potential for her to have additional falls, and to not reach her highest practical physical well-being," the report states.

A third resident complained of "fear and anxiety" at night caused by unresolved personal issues that kept her up. The problem was logged into medical records but no plan is in place to specifically address them, nor had staff members tried to discuss the issues with her, according to the resident, as reported by the health inspector.

The fourth case cited under the Level E violation was a resident diagnosed with depression and health problems who often refused to eat and became combative when caretakers tried to clean her. She likewise had no care plan to address "interventions for dressing, hygiene, or bathing," the report said.

Problems with medication disbursement and use, plus whether patients had the mental capacity to self-administer drugs, were also cited as being in violation of federal regulations. Increased sleeping-pill use by one patient needed to be better controlled, according to the report. For that patient, the report said, Vista Grande was deficient in establishing a drug regimen that federal guidelines say must be "free from unnecessary drugs" which involves excess dose or use.

In that case the resident was ordered 5 mg of Sonata (a sleeping pill) as needed. Staff reported that there was no evaluation for the continued use of the sleeping aid despite records of increased use — from three times in 10 days when first prescribed, to 11 doses in just as many days some two months later. In an interview with the resident following two months of Sonata use, she reported she was still staying up at night because of personal issues, and that before being admitted to the home she would sleep all night.

Interviews revealed that no gradual dose reduction was planned, leading to the charge that she was receiving an unnecessary drug.

Other problems outlined in the report included: One patient’s unscheduled weight loss of more than 5 percent in 30 days, considered significant under Medicare standards; the staff’s alleged failure to administer drugs with enough time before meals; and alleged failure to act upon a pharmacist’s report of drug-regimen irregularities for one of 15 residents.

In the latter case, a patient diagnosed with third-degree heart block and using a pacemaker was not given the recommended dose of the drug Ambien, a sedative hypnotic used for sleeplessness.

A pharmacist’s recommendation states that the dosage should be reduced because of "decreased effectiveness." No documentation could be found showing the reduction, the report said.

In July, nurses had just begun to review pharmacy recommendations to see if they were being responded to, according to the report, and no one had been doing this previously.

Referring to the survey results, Entsminger said that she does not agree with the health department’s crticisms, arguing that federal regulations are often interpreted differently.