State Department of Health cites Doak Walker Care Center


— The Colorado Department of Health recently cited the Doak Walker Care Center for inappropriately medicating a resident and failing to notify the resident's family of changes in medication and behavior.

Care center officials said the facility has responded to the citation and corrected any deficiencies. A hospital spokesperson said the Doak Walker Care Center provided appropriate care to the resident and her family.

The Health Facilities Division of the Department of Health enforces state and federal regulations through unannounced annual surveys and investigations into complaints.

Medical personnel make the annual unannounced visits to every nursing home in Colorado. The Doak Walker Care Center earned a deficiency-free survey in January. Complaint investigations occur when the department receives a formal complaint from family members, staff, residents or friends.

Chet Cynoski told the state in March that he thought the Doak Walker Care Center was overmedicating his 87-year-old mother, Josephine Cynoski, who had been a resident there for three and a half years.

He complained the facility had not informed him or his wife Nancy Cynoski, a nurse about his mother's changing drug regimen and behavior.

The Doak Walker Care Center notified the Cynoskis in February that it would release Josephine Cynoski to another facility in 30 days because her behavior was too aggressive. She now is in another facility in Longmont.

Josephine Cynoski was earlier diagnosed with dementia, and the Cynoskis said they knew of her declining mental faculties. But they were unaware of any aggressive behavior, they said.

"We were amazingly ignorant," Nancy Cynoski said.

Carole Schaffer, director of the Doak Walker Care Center, said the discharge was warranted because staff could no longer meet the resident's needs.

The facility has an obligation to protect its residents, she said. Residents who demonstrate consistently inappropriate behavior are transferred to a facility that can better tend to their needs, Schaffer said.

"We do an excellent job of caring for our residents," she said. "We don't do (transfers) lightly. We do it with a great deal of thought."

As the Cynoskis looked for an appropriate nursing home, they researched medical records and nurse's notes to determine why it was the Doak Walker Care Center told them Josephine Cynoski needed to go.

Chet Cynoski said it was during that time they learned of his mother's behavioral changes and the number of different drugs she had been prescribed.

"It was shocking," he said.

Every time his mother's behavior worsened, he told the state, her medications were changed but her behavior was not assessed.

Josephine Cynoski was prescribed seven psychotropic medications during her stay at the Doak Walker Care Center to address her aggressive behavior, sleeplessness and depression. She wandered the halls, resisted care and physically and verbally abused staff and other residents.

The state determined in its survey that the Doak Walker Care Center had prescribed Josephine Cynoski an excessive dose of anti-psychotic medication, despite her adverse reactions to the drug.

Findings from the survey also concluded the facility had failed to notify the Cynoskis of changes in her condition and drug regimen.

The Doak Walker Care Center could not provide the state with any documentation of staff notifying Chet or Nancy Cynoski about medication or behavioral changes. No mention was found in nurse's notes, social services records, care plan records or "anywhere else in the medical record," according to the state survey.

Christine McKelvie, spokeswoman for Yampa Valley Medical Center, said the Doak Walker Care Center maintains close communication with family members. Regular care conferences provide staff a chance to share any concerns with family members, she said.

In the state survey findings, a social services staff member told Chet Cynoski he would have been informed of changes to his mother's drug regimen had he attended the care conferences. Chet Cynoski said he was never informed of anything that would have warranted him attending the meetings.

When the state hands out deficiencies, facilities must respond with a plan of correction.

The Doak Walker Care Center immediately presented its plans of correction, and the state accepted those plans, McKelvie said.

One plan calls for documentation of any notification to family members about significant behavior or medication changes.

A second plan involves monitoring of medication dosages.

McKelvie said the Doak Walker Care Center didn't have to implement its plans of correction because the facility was already following all of the guidelines laid out in the plan.

"It wasn't anything different from what we had done," McKelvie said.

The facility works with physicians to give residents medication that will give them the best quality of life, Schaffer said. But the care center cannot meet every need, she said.

"We feel like we did what we needed to do," Schaffer said.

The care center recognizes the one area it failed was in documenting its communications to the family about changes to the residents' drug regimen and changing behavior, McKelvie said.

"We continue to feel that our care and commitment to the family was appropriate in this specific situation," McKelvie said.

The Cynoskis said they have no grievance with the staff of the Doak Walker Care Center. They just hope things have been amended so the same problem never arises again.

"I would like to think appropriate changes have been made at the Doak so others could be treated fairly," Chet Cynoski said.


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