Agawam Healthcare

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Agawam HealthCare? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About Agawam HealthCare

Agawam HealthCare is a for profit, 176-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Westfield,  Southwick, West Springfield, Chicopee, Holyoke, Springfield, Easthampton, Longmeadow, South Hadley, and the other towns in and surrounding Hampden County, Massachusetts.

Agawam Healthcare focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Agawam HealthCare
1200 Suffield St,
Agawam, MA 01001

Phone: (413) 789-2200

CMS Star Quality Rating

The Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2017, Agawam Healthcare in Agawam, Massachusetts received a rating of 2 out of 5 stars.

Performance Area Rating
Overall Rating 2 out of 5 (Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 3 out of 5 (Average)
Quality Measures 5 out of 5 (Much Above Average)

 

Fines and Penalties

Our Nursing Home Attorneys inspected government records and discovered Agawam Healthcare committed the following offenses:

Failed to make sure each resident receives an accurate assessment by a qualified health professional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the facility failed to assure the accuracy of the assessment for 2 residents (#8 and #12) regarding the resident’s cognitive patterns and [MEDICAL CONDITION], mood, and potential indicators of [MEDICAL CONDITION], out of a total sample of 24 residents.

Findings include:

1. Resident #8 was admitted to the facility in 7/2016 with a [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) Assessment completed on 3/27/17, indicated that the entire Section (C) Cognitive Patterns and [MEDICAL CONDITION], was coded with dashes (-) and not completed. Section (D) Mood Section was also coded with (-) and not completed. Section (E0100) Potential indicators of [MEDICAL CONDITION] was also coded with (-) and not completed. During an interview with the MDS Coordinator on 5/2/17 at 3:00 P.M., she said that it was time for the MDS to be signed and put through the system to stay in compliance with her schedule. The MDS Coordinator said the Sections should have been completed by the Social Worker. During an interview with the Director of Nursing (DON) and the MDS Coordinator on 5/2/17 at 3:10 P.M., the DON said that she would look into why the Sections of the MDS were not completed timely.

2. For Resident #12 the facility staff failed to complete Sections C, D, E and Q of the Quarterly Minimum Data Set (MDS) Assessment, dated 3/27/17. Resident #12 was admitted to the Facility in 12/2011 with a [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated, 3/27/17, indicated that Sections C (Cognitive Patterns), D (Mood), E (Behavior), and Q (Discharge Plan), contained dashes in every box indicating the sections were not completed. During an interview with the MDS Coordinator on 5/4/17 at 10:45 A.M., she said that Sections C, D, E, and Q of the the Quarterly MDS, dated [DATE], should have been completed.

Failed to provide care by qualified persons according to each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, observations and staff interviews, the facility failed to follow the resident’s plan of care relative to fall interventions for 1 resident (#10), out of a total sample of 24 residents.

Findings include:

For Resident #10, the facility failed to follow the resident’s falls care plan relative to the following: eye glasses were not being utilized, alarmed floor mat was not in place next to the resident’s bed, bed alarm was off and did not activate, non-skid socks were not utilized and the call bell was not within the resident’s reach, as planned. Resident #10 was admitted to the facility in 6/2013 and readmitted in 1/2016. Review of the Progress Note of 3/6/16 indicated the resident experienced an unwitnessed fall, with no injury. The falls care plan was updated to include: call bell within reach, utilize rolling walker, bed and laser alarms and utilize shoes or non-skid socks. Review of the PT (Physical Therapy) screen of 3/8/16 indicated the resident required supervision for transfers and to continue utilizing the chair alarm.

Review of the quarterly Minimum Data Set (MDS) Assessment of 3/7/16 indicated that the resident required eye glasses.

Review of a Physicians Order of 3/11/16 indicated that the laser alarm was discontinued and a pressure alarmed floor mat was initiated when the resident was in bed. Review of the Progress Note of 3/12/16 indicated the resident experienced an unwitnessed fall, with no injury. During review of the falls investigation with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the resident did not have his/her eyeglasses on, at the time of the fall, as planned. The falls care plan was updated to include: add non-skid strips to the back of the floor mat.

A care plan meeting was held on 3/21/16 to review the resident’s care plans and the following fall interventions remained in place: call bell within reach, utilize rolling walker, bed and chair alarms, utilize non-skid socks and/or shoes, pressure alarmed floor mat with non-skid strips adhered to the back of the mat, bed in low position and non-skid strips on the floor. Review of the Progress Note of 4/10/16 indicated the resident reported he/she experienced an unwitnessed fall, with no injury. During review of the falls investigation with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the resident’s floor mat was not in place, at the time of the fall, as planned. On 4/10/16, the Nurse on duty, at the time of the fall, secured a physician’s orders [REDACTED].

Review of the Progress Note of 4/25/16 indicated the resident reported he/she experienced an unwitnessed fall, sustaining a skin tear/abrasion/bruise. During review of the falls investigation with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the following: a. the resident did not have his/her eye glasses on, at the time of the fall, as planned, and b. at the time of the fall, the alarm was turned off and did not activate, as planned (UM #1 said the alarm box should have been under the resident’s bed and not within the resident’s reach). Review of the Annual MDS Assessment of 5/30/16 indicated that the resident did not use eye glasses for the assessment. UM #1 (on 5/3/17 at 2:55 P.M.) said the resident has poor eyesight and typically did utilize eye glasses. The care plan was reviewed on 6/9/16 and remained unchanged. Review of the quarterly MDS Assessment of 8/22/16 indicated that the resident did not use eye glasses.

Review of the Progress Note of 8/28/16 indicated the resident experienced an unwitnessed fall and was transferred to the local hospital emergency department. The cause of the fall, per the facility investigation, was that the resident was wearing socks and not slippers or non-skid socks, as planned. During interview with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the resident also did not have his/her eye glasses on, at the time of the fall, as planned. Review of the hospital Transfer Summary (received by the facility on the resident’s return from the hospital on [DATE] according to the Director of Nursing (DON) on 5/4/17 at 11:05 A.M.) indicated that the resident had sustained a fractured pelvis. Review of the Progress Note of 9/3/16 indicated the resident experienced an unwitnessed fall, with no injury. During review of the falls investigation with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the resident did not have his/her eye glasses on, at the time of the fall, as planned, and that the resident’s call bell was not within reach, as planned. Review of the quarterly MDS Assessment of 11/14/16 indicated that the resident did not use eye glasses for the assessment. The care plan was reviewed on 11/22/16 and remained unchanged. Review of the Progress Note of 12/26/16 indicated the resident experienced an unwitnessed fall, with no injury. During review of the falls investigation with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the resident did not have his/her eyeglasses on or non-skid socks on, at the time of the fall, as planned. The falls care plan was updated to include a winged mattress to the bed.

Review of the quarterly MDS Assessment of 2/13/17 indicated that the resident did not use eye glasses for the assessment. The falls care plan was reviewed on 2/21/17 and remained unchanged. On 5/2/17 at 7:50 A.M., the surveyor observed the resident lying in bed, with a throw blanket partially covering the resident. The resident did not have non-skid socks on, as planned, as the resident was observed being barefoot. The surveyor further observed the resident’s call light was clipped to the night stand lampshade and was not within reach, as planned. At 9:35 A.M., the surveyor observed the resident transferring into his/her bed with regular socks on. Both UM #1 and a CNA (Certified Nursing Assistant) heard the resident’s alarm sound and went into the resident’s room to assist him/her. After assisting the resident, UM #1 and the CNA left the resident’s room, however, the surveyor continued to observe the resident in regular socks and not in non-skid socks, as planned, and the resident’s call light remained on the lampshade and not within the resident’s reach, as planned. At 2:55 P.M., the surveyor observed the resident lying in bed, under the covers, and the call light was clipped to the night stand lampshade and was not within reach, as planned.

During an interview with CNA #1 on 5/2/17 at 3:00 P.M., she said that the resident does need to wear either slipper socks or shoes, he/she doesn’t wear eye glasses and that the call light should be either clipped to the bed sheet or railing. During observation of the resident with CNA #1 at 3:05 P.M., the resident’s call light was observed to be clipped to the night stand lampshade and not within the resident’s reach, as planned. CNA #1 said .I’ve been in there all day and didn’t notice the call bell on the shade CNA #1 immediately placed the call light within reach. On 5/2/17 at 3:20 P.M., the surveyor queried UM #1 regarding the whereabouts of the resident’s alarmed floor mat because the resident remained lying in bed. UM #1 said, after observing the resident in bed, that the floor mat was under the resident’s bed and not next to the bed, as planned. At 4:05 P.M., the surveyor and UM #1 observed the resident partially covered by a throw blanket, in bed, and the resident had regular socks on and not non-skid socks on, as planned. On 5/4/17 at 6:55 A.M., the surveyor observed the resident lying in bed and the alarmed floor mat was under the resident’s bed and not next to the bed, as planned. During interview with UM #1 (on 5/3/17 at 2:55 P.M.), a discussion was held regarding the facility failing to follow the resident’s falls care plan and as a result the resident sustained [REDACTED].

Failed to provide necessary care and services to maintain the highest well being of each resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review and interview, the facility failed to provide the necessary care and services for 1 resident receiving [MEDICAL TREATMENT] (#21) in a total sample of 24.

Findings include:

Resident #21 was admitted to the agency in 12/2016, with [DIAGNOSES REDACTED]. Review of the 3/7/17 quarterly Minimum Data Set assessment indicated that the resident had an intact mental status, was independent with activities of daily living and received [MEDICAL TREATMENT]. Record review indicated that there was no documentation regarding what type of [MEDICAL TREATMENT] access device the resident had or where the access device was located. Review of the 5/2017 physician’s monthly orders indicated that the resident received [MEDICAL TREATMENT] on Monday, Wednesday and Friday. The physician’s orders included: check bruit and thrill every shift (new order of 2/27/17), but the order was inaccurate as the resident did not have an arterial/venous shunt, so bruit and thrill could not be checked.

On 5/4/17 at 10:00 A.M., Resident #21 was observed sitting in a wheelchair next to his/her bed. Resident #21 showed the surveyor his/her right chest central line catheter. The central line was covered with a gauze square. Resident #21 said that the dressing was changed at [MEDICAL TREATMENT]. Resident #21 said that the central line was not monitored by the nurses at the facility. Review of the 5/2017 treatment record and Medication Administration Record [REDACTED]. During an interview, on 5/4/17 at 10:30 A.M., LPN (licensed practical nurse) #3 said that there was no physician’s order to monitor the right chest central line catheter. During an interview, on 5/4/17 at 11:00 A.M., Unit Manager #2 said that she was new to the unit and did not know what type of access device Resident #21 used for [MEDICAL TREATMENT].

Failed to make sure that residents receive proper treatment and assistive devices to maintain their vision and hearing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, observation, and staff interviews, the facility failed to ensure that 1 sampled resident (#10), out of a total sample of 24 residents, utilized assistive devices to maintain vision abilities.

Findings include:

Resident # 10, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) Assessment of 3/7/16 indicated that the resident required eye glasses. Review of the Annual MDS Assessment of 5/30/16 indicated that the resident did not use eye glasses for the assessment. During interview with Unit Manager (UM) #1 (on 5/3/17 at 2:55 P.M.), UM #1 said that the resident has poor eyesight and that typically he/she did utilize eye glasses.

Review of the quarterly MDS Assessment of 8/22/16 and 11/14/16 indicated that the resident did not use eye glasses for the assessments. Review of the Progress Note of 12/26/16 indicated the resident experienced an unwitnessed fall, with no injury. During review of the falls investigation with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the resident did not have his/her eyeglasses on, at the time of the fall, as planned.

Review of the quarterly MDS Assessment of 2/13/17 indicated that the resident did not use eye glasses for the assessment. On 5/2/17 at 2:20 P.M., the surveyor observed the resident sitting in his/her wheelchair, in the hallway, without his/her eye glasses on, as planned. During an interview with CNA (Certified Nursing Assistant) #2 on 5/2/17 at 3:00 P.M., she said that the resident doesn’t wear eye glasses. During an interview with Unit Manager (UM) #1, on 5/3/17 at 2:55 P.M., UM #1 said that the resident had poor eye sight and that he/she did wear eye glasses.

On 5/3/17 at 4:00 P.M., UM #1 and the surveyor went into the resident’s room and UM #1 asked the resident where his/her eye glasses were. The resident replied that they were in a basket, on the over the bed table, however, said he/she was unable to use them. The resident informed UM #1 that one of the eye glass lenses had popped out of the frame and that he/she has not been able to wear them for at least 6 months. UM #1 then located the eye glasses, in the basket, and found that one lens was in fact missing. She proceeded to search the resident’s night stand drawer and was unable to locate the missing lens for the eye glasses. However, UM #1 did find a second pair of eye glasses in the drawer, however, the second pair also had a lens popped out of the frame. Upon searching further, UM #1 did find the lens for the second pair of eye glasses and placed the lens back into the frame. UM #1 gave the second pair of eye glasses to the resident who then put the eye glasses on. When he/she put the eye glasses on, he/she said . these are good, I can see UM #1 informed the resident that she would make arrangements for the resident to see an optometrist. The resident was in agreement with an appointment.

Failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, observation and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 1 of 11 applicable residents (#10), in a total sample of 24 residents. The facility also failed to ensure that the environment remained as free of accident hazards, as possible, in order to decrease the potential to cause injury or illness to the residents on 2 of the 4 units.

Findings include:

1. For Resident #10, the facility failed to provide adequate supervision and effective interventions to prevent 8 falls, with one fall resulting in a fractured pelvis. Resident #10, with [DIAGNOSES REDACTED]. Review of the Progress Note of 3/6/16 indicated the resident experienced an unwitnessed fall (in bedroom), with no injury. During review of the falls investigation with Unit Manager (UM) #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the resident did not have his/her eyeglasses on, at the time of the fall, as he/she should have and that a referral to PT (Physical Therapy) was made after the fall. The falls care plan was updated to include: call bell within reach and encourage to utilize for transfer assistance, utilize rolling walker, bed and laser alarms and utilize shoes or non-skid socks. Review of the PT screen of 3/8/16 indicated the resident required supervision for transfers and to continue utilizing the chair alarm.

Review of the quarterly Minimum Data Set (MDS) Assessment of 3/7/16 indicated that the resident required eye glasses; was severely cognitively impaired; required assistance with ambulating; exhibited an unsteady balance and had a history of [REDACTED]. Review of a Physicians Order of 3/11/16 indicated that the laser alarm was discontinued and a pressure alarmed floor mat was initiated when the resident was in bed. Review of the Progress Note of 3/12/16 indicated the resident experienced an unwitnessed fall (in bedroom), with no injury. During review of the falls investigation with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the resident did not have his/her eyeglasses on, at the time of the fall, as planned, and that the resident’s floor mat slipped as he/she was transferring out of the bed. The falls care plan was updated to include: add non-skid strips to the back of the floor mat and a medical work-up would be conducted. A care plan meeting was held on 3/21/16 to review the resident’s care plans and the following fall interventions remained in place: call bell within reach and encourage resident to utilize for assistance with transfers, utilize rolling walker, bed and chair alarms, utilize non-skid socks and/or shoes, pressure alarmed floor mat with non-skid strips adhered to the back of the mat, bed in low position and non-skid strips on the floor.

Review of the Progress Note of 4/10/16 indicated the resident reported he/she experienced an unwitnessed fall (in bedroom), with no injury. During review of the falls investigation with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the resident’s floor mat was not in place, at the time of the fall, as planned. The staff were in-serviced to ensure that the resident’ floor mat was in place next to the bed. On 4/10/16, the Nurse on duty, at the time of the fall, secured a physician’s orders [REDACTED].

Review of the Progress Note of 4/25/16 indicated the resident reported he/she experienced an unwitnessed fall (in bedroom), sustaining a skin tear/abrasion/bruise. During review of the falls investigation with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the following: a. the resident was able to get him/her self off of the floor; b. the resident did not have his/her eye glasses on, at the time of the fall, as planned; c. the resident had been known to shut off his/her alarms and at the time of the fall, the alarm was turned off (UM #1 said the alarm box should have been under the resident’s bed and not within the resident’s reach), and d. the investigation indicated that the cause of the fall was the resident’s non-compliance using the call bell. UM #1 said the resident was not capable of being compliant due to his/her memory impairment. The care plan was updated to include: instruct resident not to shut off alarms and to utilize call bell for assist with transfers.

Review of the Annual MDS Assessment of 5/30/16 remained essentially unchanged except to indicate that the resident had not ambulated in his/her room during the 7 day assessment look back period and that the resident did not use eye glasses for the assessment. UM #1 (on 5/3/17 at 2:55 P.M.) said the resident has poor eyesight and typically did utilize eye glasses.

The care plan was reviewed on 6/9/16 and remained unchanged. Review of the quarterly MDS Assessment of 8/22/16 indicated the resident was now moderately cognitively impaired; required assistance with transfers and ambulation and had not experienced any falls since the previous assessment.

Review of the Progress Note of 8/28/16 indicated the resident experienced an unwitnessed fall (in bedroom) and was transferred to the local hospital emergency department. The investigation indicated that the resident was reaching to throw trash away while leaning on a chair, the chair gave way and the resident’s feet slipped. The cause of the fall, per the facility investigation, was that the resident was wearing socks and not slippers or non-skid socks, as planned. During interview with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the resident also did not have his/her eye glasses on, at the time of the fall, as planned. Review of the hospital Transfer Summary (received by the facility on the resident’s return from the hospital on [DATE] according to the Director of Nursing (DON) on 5/4/17 at 11:05 A.M.) indicated that the resident had sustained a fractured pelvis. Review of the Progress Note of 9/2/16 indicated that a therapy screen was sent to the rehab. (rehabilitation) department due to the resident’s increased weakness and hip pain. Review of the Progress Note of 9/3/16 indicated the resident experienced an unwitnessed fall (in bedroom), with no injury. During review of the falls investigation with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the resident did not have his/her eye glasses on, at the time of the fall, as planned, and that the resident’s call bell was not within reach, as planned. The staff were in-serviced and the care plan was updated to ensure that the resident’s call bell was within reach (although previously in care plan). Review of the quarterly MDS Assessment of 11/14/16 remained essentially unchanged. The care plan was reviewed on 11/22/16 and remained unchanged. Review of the Progress Note of 12/26/16 indicated the resident experienced an unwitnessed fall (in bedroom), with no injury. During review of the falls investigation with UM #1 (on 5/3/17 at 2:55 P.M.), UM #1 said the resident did not have his/her eyeglasses on, at the time of the fall, as planned, and that the resident had regular socks on and not non-skid socks on, as planned. The falls care plan was updated to include a winged mattress to the bed.

Review of the quarterly MDS Assessment of 2/13/17 remained essentially unchanged except to indicate that the resident had fallen since the previous assessment. The falls care plan was reviewed on 2/21/17 and remained unchanged. Review of the Progress Note of 3/3/17 indicated the resident reported he/she had experienced an unwitnessed fall (in bedroom/last night), with no injury (although expressed pain in upper arm and shoulder).

On 5/2/17 at 7:50 A.M., the surveyor observed the resident lying in bed, with a throw blanket partially covering the resident. The resident did not have non-skid socks on, as planned, as the resident was observed being barefoot. The surveyor further observed the resident’s call light was clipped to the night stand lampshade and was not within reach, as planned. At 9:35 A.M., the surveyor observed the resident transferring into his/her bed with regular socks on. Both UM #1 and a CNA (Certified Nursing Assistant) heard the resident’s alarm sound and went into the resident’s room to assist him/her. After assisting the resident, UM #1 and the CNA left the resident’s room, however, the surveyor continued to observe the resident in regular socks and not in non-skid socks, as planned, and the resident’s call light remained on the lampshade and not within the resident’s reach, as planned. At 2:55 P.M., the surveyor observed the resident lying in bed, under the covers, and the call light was clipped to the night stand lampshade and was not within reach, as planned.

During an interview with CNA #1 on 5/2/17 at 3:00 P.M., she said that the resident requires assistance when transferring and walking around, is confused at times, that the staff need to check on (him/her) often because he/she tries to get up alone and is not safe, he/she does need to wear either slipper socks or shoes, he/she doesn’t wear eye glasses and the call light should be either clipped to the bed sheet or railing. During observation of the resident with CNA #1 at 3:05 P.M., the resident’s call light was observed to be clipped to the night stand lampshade and not within the resident’s reach, as planned. CNA #1 said .I’ve been in there all day and didn’t notice the call bell on the shade CNA #1 immediately placed the call light within reach.

On 5/2/17 at 3:20 P.M., the surveyor queried UM #1 regarding the whereabouts of the resident’s alarmed floor mat because the resident remained lying in bed. UM #1 said, after observing the resident in bed, that the floor mat was under the resident’s bed and not next to the bed, as planned. At 4:05 P.M., the surveyor and UM #1 observed the resident partially covered by a throw blanket, in bed, and the resident had regular socks on and not non-skid socks on, as planned. During an interview with UM #1, on 5/3/17 at 2:55 P.M., she said the resident is confused, has poor eyesight, did wear eye glasses and that he/she requires assist with transfers and ambulation.

On 5/4/17 at 6:55 A.M., the surveyor observed the resident lying in bed and the alarmed floor mat was under the resident’s bed and not next to the bed, as planned. The surveyor brought this to UM #1’s attention and after going into the resident’s room, UM #1 returned to the Nurse’s Station and said to the 11:00 P.M. to 7:00 A.M. Charge that the resident’s floor mat slid under the bed again. The facility failed to provide effective interventions and adequate supervision to prevent continued falls.

2. The facility failed to ensure that the environment remained as free of accident hazards, as possible, in order to decrease the potential to cause injury or illness to the residents on 2 of the 4 units.

On 5/2/17 at 4:10 P.M., the surveyor observed Non-Sampled (NS) #1 sitting in a wheelchair, next to an unlocked med. (medication) cart (on East 1). The top drawer was observed to be opened up. NS #1 was observed attempting to take out medication cards (containing medications) from the med. cart. The resident was then observed to close the top drawer of the med. cart and open up the bottom drawer. NS #1 then started to pull out 3 medication cards when the Activity Director was observed ambulating down the hall, toward the resident and surveyor. Upon her observing the resident, she started to run down the hallway yelling out to the resident No No (resident’s name), No No. She approached the resident and pushed his/her wheelchair away from the unlocked med. cart. The surveyor asked the Activity Director where the Medication Nurse was. As the surveyor asked about the Nurse’s whereabouts, Nurse # 4 (Medication Nurse) came out of a resident’s room (2 doors down from the unlocked med. cart). As Nurse #4 approached the Activity Director, the surveyor, and the med. cart, the Activity Director informed Nurse #4 of the resident getting into the med. cart and attempting to pull out the medication cards from the bottom drawer due to the med. cart being unlocked. Nurse #4 said to the surveyor and Activity Director I don’t usually leave the cart unlocked. The surveyor observed the Activity Director go immediately into the Director of Nurse’s (DON) office and report her observations of the unlocked med. cart (as the surveyor had followed her into the DON’s office). During an interview on 5/3/17 at 9:45 A.M., with the DON and the facility Administrator, the Administrator said that they had had a discussion with Nurse #4 immediately following the incident regarding the Surveyor and Activity Director’s observations of the unlocked med. cart and the potential accident hazard which was exposed to NS #1, as well as to other residents. The facility failed to ensure that the environment remained as free of accident hazards, as possible.

3. The surveyor conducted a medication pass on 5/2/17 at 4:05 P.M. on the West 1 Unit with Nurse #1, for Resident #19. Nurse #1 poured 2 tablets of Acetaminophen 325 milligrams (mg), 1 tablet of Calcium Carbonate 500 mg, 1 capsule of Docusate Sodium 100 mg, 3 capsules of Potassium Chloride Extended Release (ER) 10 milliequivalents (mEq’s), and 1 capsule of Eye Health & Lutein.

Nurse #1 placed the cup of the dispensed pills in the top drawer of the medication cart, then left the medication cart without locking the cart. Nurse #1 walked two doors down the hallway from the medication cart into the residents room. Nurse #1 returned a minute later. There was a resident in a wheelchair in front of the medication cart. Nurse #1 then locked the medication cart. During interview with Nurse #1 at 4:10 P.M., she said that she should have locked the medication cart before leaving it unattended and out of her sight in the West hallway.

Failed to have a program that investigates, controls and keeps infection from spreading.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation and interview, the facility failed to provide a sanitary environment to prevent infection for 2 residents (#7 and #11) out of a total sample of 24 resident.

Findings include:

1. For Resident #7 the facility staff failed to ensure that the catheter was in a privacy bag and the tubing did not touch the floor. Resident #7 was admitted to the facility in 3/2008, with a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 4/4/17, indicated that the resident was moderately cognitively impaired as evidenced by a score of a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS), and was frequently incontinent of urine. Review of the nurse’s note, dated 4/21/17, indicated that the resident returned from the hospital with a suprapubic catheter. During an observation on 5/4/17 at 11:45 A.M., the surveyor observed the resident propelling himself/herself in the hallway in the wheelchair. The catheter bag was not in a privacy bag and both the catheter bag and the tubing were dragging on the floor. During an observation on 5/4/17 at 11:55 A.M., the surveyor observed the resident sitting in his/her room in the wheelchair. The catheter bag was not in a privacy bag and both the catheter bag and the tubing were dragging on the floor. During an observations on 5/4/17 at 2:15 P.M. and 2:30 P.M. the surveyor observed the resident sitting in the therapy room in the wheelchair. The catheter bag was not in a privacy bag and both the catheter bag and the tubing were resting on the floor. During an interview with Unit Manger #2, 5/4/17 at 2:35 P.M., she said that the catheter bag should be in a privacy bag and the tubing is on the floor and the tubing should not be on the floor.

2. For Resident #11, the nurse failed to wash her hands or use hand sanitizer after removing a soiled dressing during a treatment procedure to the pressure ulcer on the resident’s right buttock. Resident #11 was admitted to the facility in 4/2009 with [DIAGNOSES REDACTED]. Review of the May 2017 Treatment Records indicated that the resident had a physician’s orders [REDACTED]. During observation of the treatment on 5/2/17 at 11:35 A.M., Nurse #2 donned clean gloves, removed the old dressing which contained a moderate amount of yellow drainage, which was discarded into the trash bag along with the dirty gloves. Nurse #2 then donned clean gloves, without using hand sanitizer or washing her hands, and began to cleanse the wound with 4 x 4 gauze pads dampened with normal saline. The Therahoney was applied to the pressure ulcer with a 4 x 4 gauze pad and the ulcer was covered with an [MEDICATION NAME] dressing. On 5/2/17 at 11:45 A.M., during interview with Nurse #2, she said that she should have washed her hands and/or used hand sanitizer after removing the dirty dressing before cleaning the wound.

Failed to keep accurate, complete and organized clinical records on each resident that meet professional standards

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility staff failed to ensure the resident’s clinical record was complete and accurately documented, for 3 residents (# 5, #18, and #21), out of a total sample of 24 residents.

Findings include:

1. For Resident #5 the facility staff failed to ensure that the Salonpas Pain Relief Patch administration times were correctly documented on the Medication Administration Record (MAR). Resident #5 was admitted to the facility 3/2009 with a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set Assessment (MDS), dated [DATE], indicated that the resident was alert and oriented and triggered for pain. Review of the physician’s orders [REDACTED]. Remove at 9:00 A.M. and remove per schedule. Review of the MARs, dated 3/2017 and 2/2017, indicated that the patch was applied at 9:00 P.M. and removed at 8:59 P.M. the following day, 24 hours later. During an interview with Nurse #5 on 5/3/17 at 10:21 A.M. she said that the Salonpas patch was originally ordered for the daytime but the resident requested to utilize the patch at night. She stated that the patch was placed on the resident at 9:00 P.M. and removed at 9:00 A.M. and was not left on for 24 hours, as indicated on the MAR. During an interview with Resident #5 on 5/4/17 at 1:30 P.M. he/she stated that the Salonpas patch was applied in the evening and removed in the morning.

2. For Resident #18, the facility staff failed to accurately code the correct dosage of [MEDICATION NAME] on the MAR. Resident #18 was admitted to the facility in 4/2014 with a [DIAGNOSES REDACTED]. Review MARs, dated 2/2016 – 4/2017, indicated that the resident had a physician’s orders [REDACTED]. Per the Nursing 2015 Drug Handbook, the maximum dose should be no more than 4 grams, in one day. Further review of the MARs indicated that the resident received the [MEDICATION NAME] on 4/30/16 at 11:00 A.M., 5/20/17 at 7:57 P.M., 8/15/16 at 8:58 P.M., 8/30/16 at 4:44 A.M., 1/14/17 at 12:10 A.M., and 2/24/17 at 12:09 A.M. During an interview with Unit Manager #2 on 5/4/17 at 9:55 A.M. she said that the dosage of [MEDICATION NAME] should have read 1000 milligrams and not 1000 grams but the correct dosages were administered. During an interview with Nurse #3 on 5/4/17 at 10:35 A.M., he said the correct dose should have read 1000 milligrams and immediately clarified the order with the physician.

3. For Resident #21, the facility failed to ensure that the physician’s orders [REDACTED]. Resident #21 was admitted to the agency in 12/2016, with [DIAGNOSES REDACTED]. Review of the 3/7/17 quarterly Minimum Data Set assessment indicated that the resident had an intact mental status, was independent with activities of daily living and received [MEDICAL TREATMENT].

A. Review of the 5/2017 physician’s monthly orders indicated that the resident received [MEDICAL TREATMENT] on Monday, Wednesday and Friday. The physician’s orders [REDACTED]. B. Review of nurses’ notes indicated that, on 1/6/17 at 4:00 P.M., the right arm PICC (peripheral inserted central line catheter) was removed per physician’s orders [REDACTED].>Review of the 2/2017, 3/2017 and 4/2017 physician’s orders [REDACTED]. The nurses continued to document weekly that the right arm PICC dressing was changed even though it was removed (on 1/6/17).

C. Review of the 5/2017 physician’s orders [REDACTED]. Review of the 5/2017 treatment record and medication administration record indicated that there was no documentation that the right chest central line was monitored by the facility nurses to ensure that the line was intact, free from signs and symptoms of infection, such as drainage, pain, and redness to the surrounding skin, and failed to ensure that the dressing was dry and intact. During an interview, on 5/4/17 at 10:30 A.M., LPN (licensed practical nurse) #3 said, I don’t know what to say.

Failed to tell the resident completely about his or her health status, care and treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for 3 of 3 sampled residents (Resident #1, Resident #2, and Resident #3), the facility failed to obtain consent to administer [MEDICATION NAME] and [MEDICATION NAME] (medications used to treat anxiety) for Resident #1, Trazadone (a medication used to treat depression) for Resident #2, and [MEDICATION NAME] and [MEDICATION NAME] (medications used to treat depression) for Resident #3 prior to administration.

Findings include:

The Policy titled, Psychoactive Drug Use, dated 8/31/12, indicated the patient’s attending physician is responsible for disclosing the information necessary to make a decision to accept or refuse the use of an antipsychotic medication or psychoactive medication and obtains informed consent for their use. 1. The Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 had a [DIAGNOSES REDACTED].

The Order Summary Report, dated 3/1/17, indicated an order for [REDACTED]. The Order Summary Report, dated 3/1/17 through 3/31/17, indicated an order for [REDACTED]. The Medication Administration Record, [REDACTED]. The Medication Administration Record, [REDACTED]. The Medication Administration Record, [REDACTED]#1. The Medication Administration Record, [REDACTED]#1.

The Surveyor interviewed Unit Manager #1 at 3:30 P.M. on 7/19/17. Unit Manager #1 said there was no documentation that consent for the medication [MEDICATION NAME] or [MEDICATION NAME] for Resident #1 was obtained. The Surveyor interviewed the Director of Nurses (DON) at 1:31 P.M. on 7/20/17. The DON said there was no documentation that consent for the medication [MEDICATION NAME] or [MEDICATION NAME] for Resident #1 was obtained. There was no documentation in Resident #1’s clinical record that consent was obtained to administer the medications [MEDICATION NAME] or [MEDICATION NAME].

2. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #2 had a [DIAGNOSES REDACTED]. The Order Summery Report, dated 7/1/17, indicated an order for [REDACTED]. The Medication Administration Record, [REDACTED]. The Medication Administration Record, [REDACTED]. The Surveyor interviewed Unit Manager #1 at 3:30 P.M. on 7/19/17. Unit Manager #1 said there was no documentation that consent for the medication Trazadone for Resident #2 was obtained. The Surveyor interviewed the Director of Nurses (DON) at 1:31 P.M. on 7/20/17. The DON said there was no documentation that consent for the medication Trazadone for Resident #2 was obtained. There was no documentation in Resident #2’s clinical record that consent was obtained to administer the medications Trazadone.

3. The 14 day Minimum Data Set (MDS), dated [DATE], indicated Resident #3 had a [DIAGNOSES REDACTED]. The Order Summery Report, dated 7/1/17, indicated an order for [REDACTED]. A physician’s orders [REDACTED]. The Medication Administration Record, [REDACTED]. The Medication Administration Record, [REDACTED]. The Medication Administration Record, [REDACTED].

The Surveyor interviewed Unit Manager #2 at 3:35 P.M. on 7/19/17. Unit Manager #2 said there was no documentation that consent for the medication [MEDICATION NAME] or [MEDICATION NAME] for Resident #3 was obtained. The Surveyor interviewed the Director of Nurses (DON) at 1:31 P.M. on 7/20/17. The DON said there was no documentation that consent for the medication [MEDICATION NAME] or [MEDICATION NAME] for Resident #3 was obtained. There was no documentation in Resident #3’s clinical record that consent was obtained to administer the medications [MEDICATION NAME] or [MEDICATION NAME].

Failed to immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the facility failed to notify Resident #1’s responsible person after Resident #1 had a fall that resulted in Resident #1 to sustain a laceration above his/her right eye, bruising to his/her face and his/her right eye to be swollen shut.

Findings include:

The Policy titled, Condition Change of a Patient, release date of 5/28/15, indicated a change of condition may include but not limited to new or increasing confusion, behavior changes, and falls and to notify the family member/responsible party of patient’s condition. The Policy titled, NCD Fall Response and Management, release date of 2/14/16, indicated if a patient falls to notify the family.

1. The Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 had a [DIAGNOSES REDACTED]. The Resident Event Report Worksheet, dated 4/1/17, indicated Resident #1 had a fall with significant injury at 4:45 A.M. on 4/1/17 that resulted in a right eye hematoma (a solid swelling of clotted blood within the tissue), a right temple laceration, and a skin tear on the left side of his/her back. The Report indicated the Family/POA was not notified until 9:00 A.M. on 4/1/17, greater than 4 hours after the fall.

A Progress Note, dated 4/1/17, indicated Resident #1 was found at 4:45 A.M. on the floor, and was noted to have a swollen right eye, a 2 centimeter wide cut to the right temple near the right eye, and two skin tears on his/her left side of the back. The Note indicated that Resident #1 was agitated and was placed on 1:1 observation until his/her confusion subsided. The Note indicated Resident #1’s spouse was updated and was unhappy about the delay of being informed of Resident #1’s status. The Surveyor interviewed Nurse #1 at 1:06 P.M. on 7/19/17. Nurse #1 said Resident #1 had a fall at 4:45 A.M. on 4/1/17 and was restless and very confused at the time, and said Resident #1 was usually alert and oriented. Nurse #1 said Resident #1 had sustained a cut to his/her temple and later developed bruising and swelling to her eye. Nurse #1 said she did not notify Resident #1’s spouse until about 8:30 A.M. on 4/1/17. The Surveyor interviewed the Director of Nurses (DON) at 5:11 P.M. on 7/19/17. The DON said that she would have expected Nurse #1 to notify Resident #1’s responsible person/spouse sooner that she had.

On 07/19/17, the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by:

A. Nurse #1 was no longer involved in resident care at the Facility.
B. Licensed staff re-education on the Facility’s Condition Change of a Patient policy was completed by 04/12/17 by the Facility Educator.
C. Licensed staff re-education on the NCD Event Reporting policy was completed by 04/12/17 by the Facility Educator. D. An audit tool was developed to conduct random weekly audits by the DON/or designee on incidents within the building to ensure timely notification to family/responsible party on 4/3/17.
E. The results of the audit are reviewed by DON/or designee monthly at the QAPI committee on 5/25/17.
F. The DON said she was responsible for ensuring compliance.

Failed to develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property.

Based on records reviewed and interviews for 1 of 3 employee sampled records, (Certified Nursing Assistant (CNA) #13), the facility failed to conduct the Professional Reference Check, prior to hire.

Findings include:

The Facility Policy, titled NCD Preventing Abuse, original date 5/15/03, indicated the Facility will investigate into the past histories of a potential employee including inquiry of previous and current employers.

CNA #13’s personnel file indicated a hire date of 1/7/16. The Professional Reference Check was not conducted prior to hire. The Surveyor interviewed the Administrator at 4:55 P.M. on 3/23/17. The Administrator said that the Professional Reference Check for CNA #13 was not conducted prior to hire and it should have been done.

Agawam Healthcare, Nursing Home Neglect and Elder Abuse Lawyers

If someone you love has suffered neglect or elder abuse by a senior caregiver, nursing home, or other care facility, our lawyers may be able to help. Regardless of whether or not criminal charges are filed against an alleged abuser, you may still be able to pursue compensation in a civil claim. Compensation in elder abuse cases may be awarded if someone in the care of another suffers harm due to intentional or negligent actions (including failure to take action).

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Sources:

Medicare Nursing Home Profile for Agawam Healthcare

Nursing Home Safety, Health and Inspection Report for Agawam Healthcare 05/04/2017

Nursing Home Safety, Health and Inspection Report for Agawam Healthcare 07/19/2017

Nursing Home Safety, Health and Inspection Report for Agawam Healthcare 03/23/2017

Page Last Updated: February 16, 2017