Records: SC nursing home repeatedly failed to investigate claims of abuse against veterans it serves

• State pays Anderson-based company nearly $36.5 million annually to operate two nursing homes for veterans
• The company, HMR Veterans Services, has failed to properly investigate injuries and claims of abuse, federal regulators say
• The company coached employees to be misleading in reports, regulators say
• Families considering the home see nothing about recent troubles on the federal government's website for comparison

Officials at a South Carolina nursing home for veterans have repeatedly failed to properly investigate injuries and claims of abuse, and they have used misleading language in their records to make serious incidents appear minor, inspectors found after looking into more than a dozen complaints.

Inspectors descended upon Veterans' Victory House in Walterboro in December and spent at least five days investigating complaints and documenting faults, according to records from the Centers for Medicare and Medicaid Services that were recently obtained by The Greenville News and the Independent Mail.

As inspectors studied records at the home, they found example after example of the pains of vulnerable residents not being thoroughly investigated by officials at the facility, records show. In one case, a frightened veteran alleged that his roommate had beaten him, but the staff never took the steps necessary to find out if he was telling the truth. In another case, a worker heard a resident yelling "help, help!" When the worker got to the resident's room, the worker found him cut and bloodied, with another resident standing over him. But that, too, wasn't properly investigated, inspectors found.

In other case cases, inspectors found multiple times that staff members at the facility had failed to do all they could to determine why veterans got unexplained injuries in the home, including eye wounds and hip and nose fractures. 

"Based on record review and interviews, the facility failed to implement their abuse policy on investigating and protecting residents from abuse or 16 of 16 facility reported Incidents of abuse/neglect and injury of unknown origin," inspectors wrote."

Things were so bad at the home in Walterboro that inspectors found the existence of "immediate jeopardy," a rare designation of danger that can result in residents being moved into another facility right away. 

"Immediate jeopardy represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death," according to regulations from the Centers for Medicare and Medicaid Services, or CMS. The agency, a part of the U.S. Department of Health and Human Services, oversees the quality of care in nursing homes that are certified to receive Medicare and Medicaid payments.

The home is a state-owned facility for honorably discharged veterans that is overseen by the South Carolina Department of Mental Health. It is operated by Anderson-based HMR Veterans Services Inc., which manages a total of 10 homes in four states. The company is paid nearly $36.5 million annually by the state of South Carolina to operate two of the state's three veterans' homes, including the Richard M. Campbell Veterans Nursing Home in Anderson County.

Heyward Hilliard, HMR's vice president of operations, did not respond to three phone calls and messages seeking comment for this story. 

The Independent Mail and The Greenville News first reported allegations of neglect and substandard care at the home about 50 miles west of Charleston in July 2018, when family members of several veterans spoke about perceived gaps in their care. Inspectors went into the home several months later and issued a blistering report.

One of those family members, 86-year-old Anne Harrell, went as far as calling the White House to seek a federal investigation into the care of her husband, James, an Air Force veteran who has Alzheimer's disease. Anne Harrell said her husband has had repeated infections, several hospitalizations and unexplained bumps and bruises since he arrived at the home in September 2015.

While "immediate jeopardy" no longer exists at the Walterboro home, the facility still is not in compliance with regulations, a spokesperson for CMS said Friday. Inspectors will make another unannounced visit to the home in the coming months. 

Federal website provided for comparison does not include most recent inspection reports

A family looking to compare the quality of Veterans' Victory House with that of another home would see no hint of the facility's recent troubles on Medicare.gov's official "Nursing Home Compare" website. As recently as Friday, the website showed the home in Walterboro rated overall as a five-star facility, "much above average." Documents on the website indicate the facility's most recent health inspection was in March 2018, and they do not include the most damning inspections conducted in recent months.

Inspectors from the state Department of Health and Environmental Control found continuing problems at the facility this year, including gaps in staff training and at least four instances in February when workers couldn't verify that a resident had received prescribed medical treatments. DHEC inspectors also found an ice and water dispenser in the facility to be "unsanitary with visible pink and black debris," according to state records.

Mark Binkley, the state Department of Mental Health's interim director, said his agency has been working for quite some time to put in place more oversight for the areas in which it contracts out work, including the operation of veterans' nursing homes. He said the "very serious" December findings at Veterans' Victory House sped up that process. Now, if there is an adverse incident at the home in Walterboro, "100 percent" of the paperwork about the incident gets sent to a team for review instead of just summaries of incidents, which his agency used to get, he said.

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Binkley said his agency has set up more formal meetings with representatives of HMR and that there is now a set of "formal expectations of information that needs to come on a regular basis from our on-site contract monitors."

DHEC, South Carolina's public health agency, has also levied fines against HMR because of the findings at Veterans' Victory House.

The state Department of Mental Health typically has terms in its contracts that would allow the agency to issue a warning to HMR after violations like those found at the Walterboro, Binkley said. The Department of Mental Health likely could have given the company a certain amount of time to correct those or face stiff consequences, including the loss of its contract, Binkley said. But the agency didn't take that step, he said.

"We've been monitoring the contractor very closely," he said.

In a July 2018 interview, HMR's Hilliard said the company was committed to quality care.

"We want to make the veterans' homes as nice a place as they can be," he said. "We serve a special group, and we serve it in a special way... They served us; now we serve them. We are serious about it."

Five months later, inspectors at the home in Walterboro found conditions at a "scope and severity of L," according to records. That rating, the worst available to a nursing home, means there is a widespread pattern of a particular deficiency and that residents' health and safety are in immediate jeopardy, according to documents from CMS.

Problems at Veterans' Victory House include insufficient investigations and misleading reports

A veteran told a nurse about being beaten up by a roommate, according to records from CMS. The veteran who reported the allegations didn't know the name of the person who was accused and was "scared to get anyone in trouble," according to records.

That was just one of more than a dozen reports of abuse, neglect or injuries since August 2018 that were not thoroughly investigated, according to federal records. Inspectors said that when the facility's staff investigated what happened, it failed to identify the certified nursing assistant assigned to the resident making the allegations or the staff member assigned to the roommate.

"In addition, the facility investigation failed to show time cards or staff assignments to show who had worked at the time of the alleged incident in order to determine if abuse actually (occurred)," inspectors wrote.

In another case, a nursing student reported that a certified nursing assistant was rude to a resident when the veteran did not show the student how to turn on a shower. When the veteran mumbled something, the nursing assistant responded by saying, "You keep on and I will get you in trouble and you will be out," according to records. Inspectors found that accusation was not properly investigated.

"Based on review of facility files and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident," according to inspectors' records from CMS.

Federal inspectors also found that in documenting what happened to residents at Veterans' Victory House, the nursing home's staff used language that was "misleading and unclear," failing to maintain complete and accurate medical records. Staff members at Veterans' Victory House were encouraged to use "soft" language, according to the findings of inspectors.

Of 18 medical records reviewed by inspectors, all of them were found to be lacking.

For example, the facility's records indicated the staff observed a resident "making contact" with another resident's neck with an "open hand" and "contact with" the chest with a "closed hand" which resulted in one veteran having red marks on the neck. In another case, the facility's records said a resident reported that a nursing assistant had "touched him or her with closed hands in his or her stomach." 

Words such as "punch" or "slap" weren't used, a staff member told inspectors, because those words are "subjective" and could "mislead" residents' families. 

An inspector reviewing a staff member's file found this notice about how the worker should keep notes at Veterans' Victory House: 

"Notes should not include hard words such as hit, punched, shoved, etc. They should include soft words such as touched or made contact with. Please understand that while your opinions and observations may be helpful in providing care to our residents and we would like to be made aware of your findings, the nurse's notes are not the appropriate place to communicate this type of information. Notification via phone call to the nursing supervisor or by listing it on the 24 hour report is sufficient."

Inspectors who reviewed the facility's records said the documents were insufficient.

"Physical contact was described in incidents as 'touched,' 'came in contact with,' 'open hand' or 'closed hand.' The investigation summaries and notes within the medical records do not contain an accurate representation of the actual experiences of the residents," inspectors wrote.

In other cases, Veterans' Victory House staff failed to investigate how veterans got certain injuries, including a fracture that affected a hip and another one that affected a resident's nose. 

Inspectors also noted three altercations involving residents in which the facility's investigation failed to determine the origins of residents' injuries or who initiated the fight. In another case, the facility's investigation of an incident involving residents did not include statements from at least five people who were working at the time.

An unannounced visit by inspectors from DHEC on Feb. 20 found continuing problems at the home, including multiple examples of veterans whose medication was either not properly documented or not given to them at all.

The inspectors also randomly pulled records of the facility's staff. From a sample of 10 records, inspectors found one person that had no records available to show when or if the employee had ever been trained in "aseptic techniques" meant to minimize contamination and the spread of infection. Another employee's record showed the worker hadn't been trained in things such as disinfecting, sterilizing, dressing wounds or proper scrubbing since October 2014.

'Be vigilant about your loved one's care,' veteran's family member says

Along with managing the care of South Carolina's aging veterans, HMR also oversees care for them in three other states, daily watching over more than 2,000 veterans. HMR manages a total of eight other nursing homes for veterans in Alabama, Maryland and Texas, according to the company's website.

The Independent Mail and The Greenville News are seeking additional records to determine the quality of care in those out-of-state homes.

In February, the Anderson City Council agreed to provide HMR with $100,000 in economic incentives over the next five years for moving its headquarters from a site off Liberty Highway and into a building downtown.

Pam Copeland, who lives near Charleston, is one of the people who has filed complaints with DHEC about Veterans' Victory House. She said Thursday that she doesn't know if her complaint was among those investigated by inspectors, but she hopes it was. 

Copeland's father, Keith Thompson, had Alzheimer's disease and moved into Veterans' Victory House in January 2017. She said his health took a turn in early December 2017. She said the doctor who oversees the residents' care at the nursing home took her father off the two drugs to manage his Alzheimer's.

When Copeland brought him baked goods shortly after the medicine was halted, she was surprised by what she found. 

"He couldn't even hold a cookie," she said. "I had to tell him to bite down on it."

Her family sought a second opinion about the medicine from her father's longtime physician outside the facility, Copeland said. 

By the time Thompson's medication was restored on Dec. 22, 2017, he was unable to swallow, she said. He was using a feeding tube and was unable to speak before he died last September. 

Even after her father's death, Copeland said she is keeping an eye on the Walterboro facility where he spent his final days.

"Our veterans deserve the very best care," she said. "We're born and raised to trust doctors and nurses, but they are human. Be vigilant in your loved one's care. Know to speak up. If there's any doubt about something that's happening, speak up."

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