An investigation into the reported maltreatment of an 81-year-old who was once a resident at Crystal Health and Rehab Center was recently verified in a report by the Florida Department of Children and Families.
It’s the second report to come out by a state agency that confirms maltreatment by the facility in Tavernier. The first report came out last fall by the state Agency for Health Care Administration, which sustained complaints that daughter Stephanie Matlock Fouts brought over the care of her mom, Nancy.
Within the DCF report, the investigator assigned to the case concluded there was inadequate supervision of Nancy after she fell out of her bed twice last August. No injuries were sustained in the first fall. The second incident, however, led to a pelvic fracture.
“There is enough evidence to support the allegations that the facility failed to take sufficient measures to ensure the (vulnerable adult’s) care and protection,” the report states.
In addition, the investigator concluded maltreatment for inadequate supply of food. According to the report, the facility failed to provide Nancy with the needed nutrition as requested by her dietitian.
The dietitian recommended she receive no-sugar shakes twice daily for an additional 400 calories and 14 grams of protein. Records show, however, that the no-sugar shakes were never ordered by facility staff. And records state that the facility’s director of nursing said the communication system between the dietitian and nursing staff was broken.
Further, the nursing director said she and her staff were not reading the emails sent by the dietitian, leading to a delay in the ordering of the shakes.
It wasn’t until a Facetime call Matlock Fouts had with her mother in late August that she started noticing her mother’s deteriorating health. Matlock Fouts questioned staff, who assured her she was fine and in good health. By late September, Matlock Fouts noticed some serious problems over her mom’s appearance.
That night, Matlock Fouts was informed her mother was vomiting. She asked the nurse how much she weighed and was told 123 pounds. Months before, Matlock Fouts said, she weighed around 140 pounds.
On Sept. 29, 2020, Nancy was transported to the emergency room at Baptist Hospital in Homestead after she was found to have gastrointestinal bleeding. It wasn’t the only issue Nancy had, as Matlock Fouts said her mom’s liver enzymes and kidney enzymes were elevated. She had renal failure, and her weight was around 100 pounds. Matlock Fouts said her mother also had a stage 2 pressure injury, which is an open ulcer, or bedsore, to the sacrum. She also has deep tissue injuries to her heels and elbows.
In response to the reports, the nursing facility said licensed and registered nurses were re-educated on completing weekly weighing when recommended by the registered dietitian. The facility, within its corrective action plan, also said that nurses were re-educated on the importance of appropriate interventions in place to prevent resident falls and injury.
“Licensed/registered nurses will receive ongoing quarterly education, ensuring appropriate interventions are completed and documented in clinical record,” the facility states.
Matlock Fouts said her mom is now residing in a different nursing facility in Florida.
