A Tulsa nursing home where a disabled resident burned to death in his wheelchair recently has been repeatedly cited by the state for failure to protect residents from accidents, records show.
The resident was smoking in a courtyard outside of Parks Edge nursing home on Aug. 5 when the fire occurred. The state medical examiner’s office identified the man as 68-year-old Roger McNerney.
Tulsa Police Officer Leland Ashley told The Frontier that another resident, also in a wheelchair, was outside smoking with McNerney at the home, 5115 S. Yale Ave., before the fire.
“She asked if he was coming and she noticed he was not moving. He said, ‘I’ve set myself on fire,’” Ashley said.
The woman was unable to put out the flames and went to a nearby door to get the staff’s attention.
“About the same time, a lady entered the courtyard and ran to the building to alert the staff,” Ashley said. “She and her husband were driving by when they saw the victim on fire in the courtyard. Her husband called 911.”
A staff member used a fire extinguisher to put out the flames but McNerney was dead, Ashley said.
Parks Edge is a 126-bed skilled nursing facility that accepts residents on Medicare as well as Medicaid. An employee who answered the phone at the home last week declined to comment for this story, which was reported by The Frontier and our media partner, NewsOn6.
Though it appears likely the fire was sparked by McNerney’s smoking, the Tulsa Fire Department’s report lists the cause of the blaze as unknown.
Funeral services for McNerney were held Friday. His obituary on the funeral home’s website says he enjoyed writing poetry, reading, watching movies and singing.
Survivors include his sister, who was his guardian, and two brothers.
“Roger loved the Lord and he loved every person he met,” his obituary states. “He once said in an interview, ‘If I can make someone laugh or someone smile, then, and only then is my life worthwhile.’ “
The wife of McNerney’s roommate in the nursing home wrote on the funeral home’s website about the friendship between the two men.
“Roger was such a sweet roommate to my husband,” the woman wrote. “When the two of them wore their cowboy hats, they called each other ‘Pardner.’ Now they can be ‘Pardners’ in Heaven. Roger was a good man. He recited poetry to me almost every time I saw him.”
Resident left outside for eight hours
The Oklahoma State Department of Health, which oversees long-term care facilities, will investigate McNerney’s death. The review will likely include how long it took staff members to respond to the fire and what measures the home took to supervise and protect residents in the courtyard.
The state has cited Parks Edge twice in the past year for failure to prevent accidents and placing residents in immediate jeopardy, the most serious level of violation a nursing home can receive. One of those incidents involved a resident who went outside to smoke, fell and remained on the ground for more than eight hours.
That report states that on the evening of Oct. 4, 2015, a female resident in a wheelchair went out to the nursing home’s courtyard to smoke.
At about 7 a.m., a staff member found the woman “laying on the ground in the courtyard visibly shaking with her body color purple 8 hours and 30 minutes after the last time she had been seen by staff,” the report states.
The woman was admitted to the hospital’s intensive care unit with hypothermia, the report states.
Nursing home records showed that about one week before the accident, staff members were reminded during training “to make rounds every hour” and check on residents.
Though the nursing home’s staff on duty at that time met minimum state requirements, “the staff who were present failed to supervise a resident which resulted in the resident experiencing an adverse event,” the report states.
The state substantiated a complaint of failure to provide sufficient staff to prevent accidents.
A nurse and nurse aide assigned to check on McNerney during the night had signed forms indicating they had done so. However they told inspectors they were unsure whether they actually saw him during the night.
The home fired both employees as a result of the incident, records show.
Home cited for bed rail dangers
An inspection report dated May 26 states that Parks Edge placed residents in immediate jeopardy when it failed to ensure that bed rails were not an accident hazard. The home improperly used bed rails, which are classified as restraints, on six out of six sampled residents, it states.
Bed rails can be an accident hazard and have resulted in serious injuries and fatalities in some nursing homes when residents try to climb over them or become trapped between the rails and the mattress. Before installing bed rails, nursing homes are required to obtain a doctor’s order for them, a consent form signed by the resident or the resident’s family family and must assess the resident to ensure the bed rails are not a hazard.
The OSDH states that 94 residents had bed rails but Parks Edge had not obtained consent forms or completed assessments for them.
The home’s assistant director of nursing “was asked how she determined if the use of a bed rail was a safety hazard for a resident. She stated, ‘I don’t know.’”
In the months leading up to the May inspection, staff members found several Parks Edge residents on the floor or hanging off their bed with limbs trapped in the bed rail, according to the inspection report.
In January, a male resident “had been found on the floor next to his bed face down with his head pointed toward the bathroom door. The left foot was on the floor and the right foot was caught between the bed rail and the bed. There was bruising noted to the bridge of the resident’s nose and chin.”
In April, a female resident “had been found hanging halfway out of bed with her head resting on the floor. The resident’s legs and feet were between the bed rail on the bed and the mattress. The facility continued to use the bed rails after the resident had become entrapped in the bed rail.”
Parks Edge was also cited with a fire safety deficiency in the report.
“The facility failed to maintain smoke resistant ceiling and walls in a manner that would retard the spread of smoke to adjacent areas in the event of fire. This practice could affect 51 of 51 residents who currently resided in the facility as identified by the administrator on 05/25/16.”
In June, the federal Centers for Medicare and Medicaid Services imposed a $9,100 fine against Parks Edge. It also threatened termination of the home’s ability to participate in the Medicare and Medicaid programs.
A complaint filed against the home prompted an inspection this month that resulted in no citations. The state inspected Parks Edge Aug. 1 after receiving allegations residents were not receiving proper medical care or being groomed and changed frequently enough.
“Residents were observed in their rooms, in the hallways, in the dining rooms, and in the lobby areas. Staff members were observed attending to the resident’s needs. Residents were observed to be clean and well groomed,” the report states.
“Eight residents were asked if the staff assisted them to toilet or change them timely if they had an incontinent episode. All of the residents stated yes. The residents were asked if they were receiving their baths/showers as scheduled. All of the residents stated yes.”