An Open Letter to the Greene County Community
To our community stakeholders in Greene County:
As a not-for-profit organization dedicated to improving the human condition, Laughlin Healthcare Center has a very important role in our community, with our residents and their families. And as a part of Ballad Health, we are part of an organization with a culture of doing what is right. Today, communicating with you about recent events at Laughlin Healthcare Center is warranted and the right thing to do if we are to continue to earn your trust.
Let me start by addressing that our facility is staffed with good people who work hard every day to make the lives of our residents fulfilled and healthy. And we do invest in making sure we have good staff. But that does not mean we are not capable of falling short. And in a case that occurred last month, we did fall short. In a review of that case, we have identified opportunities to improve our processes, and we have moved swiftly to make the appropriate changes. Ballad Health’s policy is that when any of its affiliated facilities fall short, we acknowledge it, own it, fix it and make it better.
On July 3rd, a patient left the dedicated patient care area at the nursing home for a period of a few minutes, but did not leave the facility property. This is referred to as an “elopement.” Because any elopement may constitute a threat to the safety of the patient, we voluntarily self-reported this event to the state on the same day. By regulation, this type of event triggers a review from the Tennessee Department of Health and the U.S. Centers for Medicare and Medicaid Services (CMS). If there are findings by these surveyors, the rules require written corrective plans from the facility. The findings by the surveyors constituted a potential risk for patients who are at risk of elopement, so in order to ensure best practices are in place, the ability of our facility to admit new patients under the Medicare program has been suspended by both state and federal authorities until actions are documented to mitigate such risk. The corrective actions have been submitted to both state and federal officials, and have been accepted by federal regulators. Based on the acceptance of our corrective plan by federal authorities, we anticipate the state will follow suit soon, and the suspension of admissions will be lifted.
Our actions have been focused on improving our procedures related to security and monitoring of patients who are at risk of elopement.
- Our elopement policy was revised on July 21, 2018, and includes provisions for proper response to alarms and proper placement of transmitters so that if a patient at risk of elopement attempts to leave the facility, our staff is alerted and can respond appropriately.
- All facility staff, volunteers, and contract service providers have been educated on our updated elopement policy. Education was provided verbally and in writing on the supervision of residents at risk for elopement and how to appropriately respond to alarm soundings. This education was completed on July 29, 2018. Going forward, all new staff will be educated prior to their first day on the job.
- As of July 26, 2018, all wander guards in use (a safety monitor used for disoriented residents or patients) were placed on the residents’ ankles in accordance with appropriate practice.
- Elopement drills have been conducted for all team members.
- Updated care plans and resident assessments have been documented and established for all residents who are at risk for elopement.
- By July 30, 2018, elopement assessments were updated and completed for all residents.
It is important for me to point out that the surveyors from the state and Medicare found NO substantiation that staffing levels were too low. In fact, Medicare publishes information about nursing home staffing, and Laughlin Healthcare Center ranks above average. Any claim that Laughlin Healthcare Center is understaffed is not substantiated by the state and federal reviews. We take this very seriously, and are pleased that surveyors independently concluded there were no staffing issues.
I am grateful for the work our team members, volunteers and affiliates do each day to improve the lives of our residents. We try to care for each resident as if they were our own family. Part of being entrusted with this tremendous task is to make sure we earn your trust each day. To do this, we owe it to you to be honest about what happened, and transparent with what we are doing about it.
We love our community, and truly, we love our residents. We dedicate ourselves to their safety, and where we may have fallen short, you have our sincerest commitment we will learn from it so we hopefully will not repeat it.
Thank you for your continued trust,
Frederick Souder, Administrator
Laughlin Healthcare Center