Nursing home gave “poor patient care,” officials say, after dementia patient discharged to empty, locked home

A nursing home and rehabilitation facility in Charlotte was fined, and could lose its Medicare provider agreement after at least two elderly residents received “poor patient care,” federal officials said, following an inquiry that stemmed from a FOX 46 investigation.

An official with the Centers for Medicare and Medicaid Services (CMS) say the agency is treating the findings of its investigation into the Mecklenburg Health and Rehabilitation Center “seriously.” Last month, FOX 46 discovered the nursing home let a 71-year-old dementia patient, Alexander Rose, sign his own discharge papers put him in a taxi to his son’s locked and empty home.

He was found disoriented and lost wandering around the neighborhood, Rose said.

“You can’t do an elder like that,” said Alexander’s son, Tarance. “You can’t just put them in a cab, incompetent, not knowing where to go and not know what to do.”

A court deemed Alexander incompetent this year and awarded guardianship to Rose, who says he was caught off guard when he received a voicemail that his dad was discharging. He says, by law, he should have signed off on his father’s release, which he said stemmed over a payment dispute.

“Like a relief off my shoulders of joy that the state and federal [officials] went in and found information saying this facility was doing wrong things to the elders,” said Rose.

CMS found Alexander’s discharge to be improper, noting there was no post-care plans in place.
Rose plans to sue.


“We are looking into it very seriously,” said his attorney Charles Hands. “And we mean business when it comes to making sure that this is wrong is rectified.”

They are seeking unspecified damages for emotional distress, negligence and breach of standard of care.

Disciplinary Actions Taken

Mecklenburg Health and Rehabilitation Center was fined $10, 210 for its handling of the Rose case, which FOX 46 first uncovered, and for another situation where a resident was now allowed to return after a four hour therapeutic leave.

The facility now faces a “mandatory termination” of its Medicare provider agreement, if it does not come up with a corrective plan of action by March 19, 2020. CMS will begin denying new Medicare and Medicaid claims after Dec. 19 of this year, if the facility is not in compliance.

“Most facilities work to correct deficiencies and come into compliance prior to termination of their provider agreements,” a CMS spokesperson said.

The facility also may no longer offer state-approved nurse aide training to its employees, according to a CMS letter sent to the facility.

“CMS is taking this complaint and the incidents cited in the report seriously demonstrated by the civil money penalty and notice of potential termination of its provider agreement if the facility fails to correct the deficiencies that lead to poor patient care,” a spokesperson said. “We are working with the State Survey Agency to protect the health and welfare of the residents served by this facility.”


“Our first priority is to protect the health and safety of the patients,” the spokesperson added.

The facility’s administrator Cassandra Dority, who previously dismissed Rose’s concerns as “inaccurate,” said she could not comment because she was “still bound by patient privacy laws” and said she stands by a previous statement sent to FOX 46.

“As a trusted healthcare provider, we arrange safe and appropriate discharges according to the guidance of an interdisciplinary team of physicians and other trained clinicians, and federal and state regulations. When a patient is competent and capable of returning to his or her prior home setting, we have a responsibility to honor his or her wishes,” Dority said on Sept. 10. “To accommodate the patient’s wishes, we help arrange appropriate transport and provide the family with ample notice to plan accordingly.”

Rose disputes that and says he found out, by voicemail, when he was three hours away in South Carolina. He says a friend found his father wandering, lost, with difficulty breathing. 

“They shouldn’t have did me like that,” said Alexander, who said he was frightened. “I could have had a heart attack.”

Voicemails from Alexander to his son indicate he did not know where he was going before he got into a taxi or where he was, the day he signed his discharge papers.

“I’m in the courtroom,” he said in one voicemail from inside the Mecklenburg Health and Rehabilitation Center. “I’m in Brooklyn.”

“Although privacy laws prohibit us from commenting about particular patients without their permission, we can say that a family member’s opinion and healthcare provider’s assessment may differ in regards to a patient. We remain committed to our patients and take great pride in the care that we provide.”