BILLINGS, MT - Parkview Care Center faces immediate jeopardy citations after staff repeatedly denied entry to a frail cancer patient who sat outside the facility for approximately four hours in 46-degree weather and rain, despite administrative orders to allow him inside.
The June 6, 2024 inspection revealed that facility staff turned away the vulnerable resident twice during one overnight shift on May 23, 2024, even after receiving clear instructions from administration at 1:14 a.m. to "let him rest at the facility for the night." The incident occurred when the resident returned from the hospital via taxi after leaving against medical advice.
Critical Breakdown in Communication and Judgment
The cascade of failures began when the resident left the hospital against medical advice around midnight on May 23, 2024. Hospital staff contacted Parkview Care Center to notify them that the resident was returning by taxi. When the cab arrived at approximately 12:15 a.m., night shift staff refused entry and instructed the driver to take the resident back to the hospital.
The facility had clear authority to readmit the resident. Medical records show the facility maintained a signed bed hold agreement dated May 21, 2024, and the resident's discharge was coded as "unplanned" with "return anticipated." Despite this documentation and explicit administrative permission to allow entry, staff continued to deny access.
The night supervisor explained her reasoning: "I didn't have any orders or anything, was to let him go back to the ER because that's where he needed to be because he was sick." However, this decision directly contradicted the administrative directive received 45 minutes later instructing staff to allow the resident inside.
Medical professionals emphasize that nursing facilities routinely manage residents with complex medical needs and are equipped to provide appropriate care while awaiting physician orders. The presence of a valid bed hold agreement specifically indicates the facility's commitment to maintain the resident's place and provide continued care.
Dangerous Exposure to Elements
Police body camera footage documented the resident's deteriorated condition after hours of exposure. The 46-degree temperature, combined with 93% humidity and rain, created particularly dangerous conditions for an elderly person with compromised health.
Officers observed the resident "wearing a lightweight button-up shirt with T-shirt underneath, and lightweight pants" while "in the rain and his clothes were wet." The footage showed him "attempting to protect his face and head from the rain and cold with his shirt collar" and "grimacing in obvious discomfort and was having difficulty breathing."
Extended exposure to cold, wet conditions poses severe risks for elderly individuals. Hypothermia can develop when body temperature drops even slightly below normal, and older adults are particularly vulnerable due to decreased ability to regulate body temperature. The combination of wet clothing, wind, and cool temperatures accelerates heat loss and increases the risk of respiratory complications.
The resident's weakened state made the exposure even more dangerous. A facility staff member later observed: "he just found out he had cancer and was so weak... I don't even know how he got into his truck, because he was that weak." This level of frailty, combined with environmental exposure, created conditions that could have resulted in serious medical complications or death.
Staff Indifference Despite Clear Identification
Perhaps most troubling was staff behavior after learning the person outside was their resident. When a newspaper delivery person approached staff around 4:15 a.m., requesting help for an elderly man on the facility's bench, staff initially claimed ignorance of his identity. However, multiple witnesses confirmed staff knew exactly who was outside.
One aide recalled: "The police showed up and it was a woman cop, and when she came in she said that [the resident] said he was a resident there and that his name was [resident name]. At that point, we were all shocked because we had believed that he was back at the hospital."
Police body camera footage revealed the extent of staff indifference. When officers confirmed the resident's identity and room number, no facility staff expressed concern for his health or well-being, and no staff member went outside to assess or assist him. Instead, staff continued to insist he "doesn't stay here so it's not our deal" and "we're not going to help him."
A police officer noted the staff's dismissive responses: "They were incredibly rude. Not even one person there was surprised or concerned at all about the resident after being told he was out there."
Industry Standards and Required Protocols
Nursing facilities are required to maintain 24-hour nursing coverage specifically to handle situations like emergency returns. Federal regulations mandate that facilities assess residents' immediate needs and provide appropriate care, regardless of the time of day or circumstances of return.
When residents return from hospitals, standard protocol requires nursing assessment of vital signs, current symptoms, and medication needs. Even without specific physician orders, facilities can provide basic comfort measures, monitoring, and safety while contacting on-call medical providers for additional instructions.
The facility's own bed hold policy demonstrated their obligation to readmit the resident. Bed hold agreements are specifically designed to maintain a resident's place during temporary hospitalizations and ensure seamless return to care.
Medical ethics and basic humanitarian principles also demanded intervention. Healthcare providers take oaths to "do no harm," which includes protecting vulnerable individuals from preventable dangers, regardless of administrative complications.
Administrative Failures and Cover-up Attempts
The facility's response to the incident raised additional concerns about transparency and accountability. When surveyors requested security footage from the front entrance, administrative staff reported the video was "being deleted due to space capacity as administrative staff were reviewing it" and would be unavailable for inspection.
The administrator admitted: "he probably should have reported the incident" but failed to conduct a thorough investigation or report the event to state authorities as required by federal regulations. This failure to report represented a separate violation of nursing home regulations requiring timely notification of significant incidents.
Additional Issues Identified
The inspection revealed systemic reporting failures affecting multiple residents. The facility failed to submit investigation findings to the State Survey Agency within required timeframes for 11 of 14 sampled residents. These delays ranged from 5 to 23 days beyond the mandatory five-day reporting deadline.
Incidents with delayed reporting included: - Falls with injuries (multiple cases with delays of 9-22 days) - Resident-to-resident abuse allegations (delays of 5-23 days) - Staff-to-resident abuse allegations (6-day delay) - Injuries of unknown origin (9-day delay)
The director of nursing acknowledged responsibility: "I dropped the ball, and it was my responsibility to report and investigate facility events when the administrator was absent."
The combination of immediate jeopardy violations and systemic reporting failures indicates broader problems with facility management and oversight. Federal regulators removed the immediate jeopardy status only after the facility implemented corrective measures, but the incident exposed dangerous gaps in staff training, administrative oversight, and emergency protocols that put vulnerable residents at risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkview Care Center from 2024-06-06 including all violations, facility responses, and corrective action plans.
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