Report: Cape Coral nursing home failed to prevent ulcers and promote healing

A 53-page report from the state of Florida calls out Cape Coral nursing home Gulf Coast Village for neglecting some of the most vulnerable in our community.

Things got so bad the report says at least two patients developed a preventable ulcer.

Nursing homes are supposed to be comforting places for people, but this 53-page report by the Department of Health and Human Services details how it’s nothing like that at Gulf Coast Village in Cape Coral. You can read the full report at the bottom of this story.

The report, done last November, says Gulf Coast Village “Failed to prevent the development and promote healing — of advanced stage pressure ulcers” for three patients.

“Historically, nursing homes have been small businesses. And so, people necessarily haven’t been given the training on what is proper practice, what is continuous improvement, what are proper management systems,” said Jim Jordan, healthcare professor at Carnegie Mellon University.

Jordan said a lack of training usually leads to violations like the one at Gulf Coast Village.

In this case, the director of nursing admitted fault because “The facility was using a lot of agency nurses, and she had not educated them.”

A CNA, or certified nursing assistant, who cared for one of the affected patients told investigators, “She had not received any orientation before starting to work,” and “She did not know what preventative measures needed to be place.”

“It’s sort of like when you get pulled over, and you say, ‘I didn’t know I broke the law, officer.’ But that doesn’t mean that you’re not responsible for the violation,” said Jordan.

The class one deficiency violation requires immediate corrective action.

Jordan said that corrective action starts with improved communication. “Simply having a 10 or 15-minute meeting before shifts and after shifts could make a world of difference. And that doesn’t cost money.”

I got this statement from a public relations firm representing Gulf Coast Village. It says in part, “After the identification of areas for correction and improvement. Immediate change took place. Gulf Coast Village reviewed its policies, procedures, and training for all staff. It’s hired an outside consulting firm to add a fresh perspective.”

Gulf Coast Village said it hired a director of nursing and a clinical administrator whose focus is to enhance patient and resident safety.

Since the report, the state has confirmed Gulf Coast Village is in full compliance.