CMS Report Cites Care Problems at Lanterman Developmental Center
A CMS inspection of the Lanterman Developmental Center, which has 600 residents with developmental disabilities, found "serious lapses in oversight" that placed residents in "immediate jeopardy" of harm, the Los Angeles Times reports. The 72-page report, based on an August visit to the facility, cited 55 resident injuries that were not adequately investigated and three incidents that "met the definition of abuse or neglect, including a client death." The report found that:
- A man died in March after a staff member improperly reinserted his feeding tube and he did not receive medical care in time to prevent an infection from the incident;
- Staff members did not properly supervise a resident who place placed in a "time out room," allowing the resident to injure herself by banging her head on the door;
- A woman waited nearly seven months to undergo a mammogram after a lump in her breast was detected;
- Staff members did not adequately monitor a resident who had a history of sexually aggressive behavior; and
- Staff members used unsafe restraints on residents and did not monitor residents' whereabouts adequately.
Because of the seriousness of the findings, the facility was immediately required to correct the issues to avoid the loss of federal funding; federal officials said they were satisfied with Lanterman's response. However, CMS last week issued a 365-page report detailing "additional, less serious" violations, the Times reports. The report will not be made public until Lanterman officials have a chance to respond to it.
Sherry Kohler, acting executive director of Lanterman, said the report's findings were "very unusual and ... disturbing," adding that inspectors may have evaluated the facility at a "much higher standard" than others. However, Steven Chickering, regional manager of CMS' hospital and community care branch in San Francisco, said the "requirements are the same" for all of the seven developmental disability facilities in the state. Kohler said Lanterman officials had addressed "all of the inspectors' concerns," according to the Times (Ornstein, Los Angeles Times, 10/9). The latest report comes after the Department of Health Services in July issued a $25,000 fine to the facility for not sufficiently protecting a developmentally disabled resident who was beaten to death in August 2002 (California Healthline, 7/7).
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