Major sanctions at Darby nursing home after neglect found

The Pennsylvania Department of Health revoked the regular license of St. Francis Center for Rehabilitation & Healthcare last month and installed a temporary manager at the Darby nursing home after an August inspection found that a patient had developed "wounds that went down to the bone with exposed tendon."

The 273-bed facility, one of five sold in 2014 by the Archdiocese of Philadelphia to Center Management Group of New York, appealed the decision and remains open under a temporary manager installed by the health department. The revocation was the first in Pennsylvania since at least the beginning of 2014.

"The secretary doesn't take this action lightly and felt as if the severity of this issue and the survey reports and things like that did require significant action," April Hutcheson, spokeswoman for acting health secretary Rachel Levine, said this week. "Our goal is to make sure the patients are safe."

The order revoking the Delaware County nursing home's regular license was issued Sept. 1 to owner Charles-Edouard Gros after an inspection completed Aug. 23.

The inspection, prompted by five complaints, found patterns of harm involving severely deficient wound care, failure to respond to residents who suffered significant weight loss because they were not eating, inadequate response to acute change in medical condition, and other problems.

"There was a time when they would do that more often," Diane Menio, executive director of the Center for Advocacy for the Rights & Interests of the Elderly, in Center City, said of regulators revoking a license.

An appeal filed Sept. 6 halted the loss of the license, pending the outcome. Surveys are not public until at least 41 days have passed since the completion date.

St. Francis said it has since revamped management, hiring a new administrator and director of nursing, as well as dietary and wound-care experts. "We're using this opportunity to optimize both our services and operations," Vincenzo Manzella, Center Management's regional administrator for St. Francis, said in a statement.

A Sept. 19 order set conditions on the continued operation of St. Francis, including the use of more rigorous care standards, the hiring of two wound-care nurses, and regular reporting to the health department. If the terms were met after 30 days, the ban on new admissions could be lifted. That ban remained in effect Thursday, Hutcheson said.

On Aug. 18, during the inspection, St. Francis had 258 residents. That number was slightly more than 200 this week, a St. Francis spokeswoman said.

Given his brother's experience during more than six months at St. Francis last year, Joe Devlin was not surprised to learn of St. Francis' troubles with state regulators. Devlin said Thursday his brother, who had soft-palate cancer, was forced to go eight to 16 hours in at least a dozen instances without any pain medicine because the facility ran out. "That's being conservative," Devlin said.

Devlin's complaint with the Department of Health went nowhere, and had plenty of company. In the year before St. Francis' license was revoked, state inspectors visited the facility 17 times in response to 37 complaints, including three times in July, when no deficiencies were found. Department of Health reports do not disclose specific complaints.

But the August inspection found neglect in the care of 11 of 28 patients reviewed and significant problems in the care of nine of those 28 patients.

The 164-page report goes into detail on a man admitted in April. His son found him unresponsive, but it took an hour and 15 minutes to get the resident to the hospital next door.

A review of the patient's records, described in the report, found that he had developed four new wounds by July 20.

Nevertheless, in an Aug. 23 interview, the wound-care physician, employed by a contractor, said he "had not seen and/or examined" the patient's wounds and confirmed "that the resident had wounds that went down to the bone with exposed tendon."