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DCF looks into Naples nursing home when deputies can't reach staff

Naples nursing home investigated by DCF
Posted at 4:23 PM, Jul 16, 2021
and last updated 2021-07-16 20:28:52-04

NAPLES, Fla. — The Department of Children and Families is looking into an incident reported at Naples Green Village on June 7, after one of the resident's family members called the Collier County Sheriff's Office.

According to the incident report, the daughter's mother, who has dementia, moved in earlier that day. When the daughter tried to contact staff to check in on her later that night, no one answered the phone. The report says the only call that was answered, was by a female resident who was in the lobby, after wandering out of her room. The report also state that deputies were also unable to contact staff. Once they were inside, deputies located an employee about three hours after they were first dispatched. The certified nurse's assistant told deputies that she was in the breakroom after her intial check of patients. The employee also said there's no phone in the breakroom so she was not alerted. The deputy adds, "Neither did any of the knocking, flashlights, or doorbells."

The daughter took her mother out of that memory care facility that night. DCF couldn't comment at this time, since it's considered an active investigation.

Concordis Senior Living, the owner of Naples Green Village emailed FOX 4 the following statement:

"Naples Green Village senior living community is grateful for our long-standing partnership with Collier County first responders.

We are thankful that during the events of June 7th, none of our residents were ever in distress, in any danger, or suffered any harm. Late at night the family of one of our residents called Naples Green Village. Although the community phone is forwarded to an overnight cell phone each night, so the lead team member can answer calls, the calls from the family were not answered. It is our understanding the family then came to Naples Green Village. Since the family could not enter the community, they called the Naples police for assistance. As cited in the police report, when police officers arrived, one of our residents was sitting calmly in the Living Room / Lobby area of the community, and the family was outside. For those not intimately familiar with senior living, it may have seemed strange that a resident was not in their apartment asleep so late at night. However, for residents of Naples Green Village, the entire community is their home, and they are allowed to utilize the common areas any time they wish.

To ensure the safety of our residents, Naples Green Village has interior and exterior surveillance cameras, secured access doors, emergency pull cords, emergency pendants, staff pagers, cellphones, door alarms, as well as fire alarm and fire suppression systems. In fact, the security of the community was validated the night of June 7th by the fact that the resident was not able to wander out of the community, and only the Naples Fire Department was able to gain access to the community without being granted access by one of our team members.

As would be expected during the night shift (10:00pm to 6:00am), most of our residents are sleeping throughout the shift. Therefore, nighttime staff conducts periodic rounds to ensure none of the residents are in need of assistance. The lead team member during the night shift carries the overnight phone to answer phone calls to the community. The onsite staff also monitor for any alerts to our separate emergency nurse call and fire alarm systems.

On the night of June 7th, staff failed to answer telephone calls to the community which were forwarded to the overnight phone. This failure to follow protocol has resulted in significant disciplinary action of the relevant staff. To ensure this lapse does not occur in the future, all Naples Green Village staff were re-trained on overnight care and telephone protocols.

Naples Green Village is committed to providing quality care to our residents and families, and will continue to use technology, compassionate care and manpower to ensure their safety and well-being. We would like to once again extend our sincere apologies to the resident and family who were impacted by the lack of response by our night staff on June 7th. We are thankful the resident was never in any danger and suffered no harm. We are confident the issue has been addressed and will not be repeated.

Regarding your unrelated questions from ACHA surveys/audits conducted in 2020, we hope that you will find the following helpful:

January of 2020 AHCA Survey/Audit

Since changing ownership, Naples Green Village has been very proactive in ensuring the safety and well- being of our residents and families. When the community was purchased by the current owners, the building did not have a nurse call system. Although nurse call systems are not required in assisted living facilities in Florida, Naples Green Village invested significant capital to install a state-of-the-art nurse call system. In January of 2020, ACHA conducted a survey/audit, during which it was noted that a document in the community’s admission package referenced nurse call system and the ability to “call for assistance.” At the time of this survey a nurse call system had not yet been installed as the community was undergoing a substantial renovation and the installation of the nurse call system requires construction to be complete as the wireless devices need to be installed on finished, painted surfaces, doors, etc. At the time of this survey, it was apparent to everyone at Naples Green Village that no nurse call system was in place. AHCA simply cited the discrepancy in an admission form, and the document was promptly modified to remove the reference to a nurse call system. In November of 2020, following completion of renovations, a state-of-the-art Notify nurse call system was installed. This nurse call system includes emergency pull cords, emergency pendants, door alarms, staff pagers and cellphones.

Emergency pull cords are installed in every resident apartment, and certain common area rooms. Upon request, residents can be issued an emergency call pendant.

We are always looking at how we can integrate technology and manpower to ensure the safety and well-being of our residents, families and staff. In addition to the nurse call system, a video surveillance system and secured access doors were installed throughout the community, as well as a standby generator powering the entire community.

August 31, 2020 AHCA Survey/Audit resulting in May 2021 Final Order

On August 31, 2020, AHCA conducted a routine survey/audit of the Naples Green Village. During the survey several deficiencies relating to human resource documentation were cited. None of the issues cited related to resident safety or care. As referenced in the report, the Vice President of Human Resources had visited Naples Green Village two weeks prior to the survey. Therefore, the discrepancies in documentation had already been noted by Naples Green Village management.

  • The Administrator on site at the time acknowledged that “we know we have discrepancies” relating specifically to TB tests that were missing the signature of a doctor. New TB tests had already been ordered, but AHCA came in for the survey the week before the TB tests were to be administered.
  • The Administrator at the time also acknowledged “we know we have problems” speaking specifically to the fact that reference checks relating to employees, including those hired in 2014 and 2017, under prior ownership, were missing from some employee files.
  • The Administrator at the time acknowledged “we know we have discrepancies” relating specifically to an employee hired on June 15, 2020, but the employee was not added to the community’s Clearinghouse Roster until August 15, 2020, instead of within 10 days of employment."

Previous surveys by the regulatory Agency for Health Care Administration or, AHCA, show other "deficiencies," the latest occurring in 2020. As a result, AHCA issued a FINAL ORDER in May of 2021, fining the facility $2000.