Attleboro HealthCare

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Attleboro 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 Attleboro HealthCare

Attleboro HealthCare is a for profit, 120-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Attleboro, Valley Falls RI, Central Falls RI, Pawtucket RI, Norton, Cumberland RI, Rehoboth, Mansfield,  Wrentham, Foxborough, and the other towns in and surrounding Bristol County, Massachusetts.

Attleboro HealthCare
27 George St Attleboro,
MA 02703

Phone: (508) 226-1650

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 2018, Attleboro HealthCare in Massachusetts received a rating of 1 out of 5 stars.

Performance Area Rating
Overall Rating 1 out of 5 (Much Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 3 out of 5 (Average)
Quality Measures 4 out of 5 (Above Average)

Fines Against Attleboro HealthCare

The Federal Government fined Attleboro HealthCare $1,625 on March 10th, 2016 and $9,773 on April 26th, 2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Attleboro HealthCare committed the following offenses:

Failed to give the resident's representative the ability to exercise the resident's rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that an activated health care proxy was properly utilized for 4 Residents (#1, #9 #13, #14 ) in a total sample of 22 Residents.

Findings include:

1. For Resident #13 the facility failed to ensure that the Resident’s primary Health Care Proxy (HCP) made the health care decisions for the Resident and instead permitted the Resident’s family member (sister) to make the health care decisions for the Resident. Resident #13 was admitted to the facility in 10/2011 with [DIAGNOSES REDACTED]. Clinical Record review indicated that on 10/31/11 the Residents physician activated the Residents HCP. Review of the physician’s orders [REDACTED].

a). [MEDICATION NAME] 3.75 milligrams (mg) every hour of sleep (antipsychotic)
b). [MEDICATION NAME] 20 mg every day (antidepressant)
c), [MEDICATION NAME] 12.5 mg as needed for anxiety

Further clinical record review indicated that there was no documentation that the primary HCP and the 2nd alternate HCP had rescinded his/her role as the primary and secondary HCP delegating authority to the sister to make health care decisions. The consents were signed by the Residents sister, and not the primary or secondary HCP. On 1/24/17 at 8:35 A.M., the Social worker said that the facility failed to ensure that an activated health care proxy was properly utilized for the [MEDICAL CONDITION] consents and would have the delegated HCP sign the consents.

2. For Resident #9 the facility failed to ensure that the Resident’s primary Health Care Proxy (HCP) made the health care decisions for the Resident and instead permitted the Resident’s family member (daughter) and the 2nd alternate to make the health care decisions for the Resident. Resident #9 was admitted to the facility in 7/2016 with [DIAGNOSES REDACTED]. Clinical Record review indicated that on 7/14/16 the Residents physician documented that the Resident lacked the capacity to make or communicate health care decisions with the nature of the incapacity due to dementia and the extent being moderately to severely advanced. Review of the physician’s order [REDACTED].

a). [MEDICATION NAME] 5 mg twice a day (antipsychotic)
b). [MEDICATION NAME] 12 mg every day (antipsychotic)
c), [MEDICATION NAME] 40 mg every day (antidepressant)
d). [MEDICATION NAME] 22.5 mg every hour of sleep (antidepressant)
e). [MEDICATION NAME] .25 mg every day (antianxiety) and [MEDICATION NAME] 1 mg every 12 hours as needed for anxiety

Further clinical record review indicated that there was no documentation that the primary HCP had rescinded his/her role as the primary delegating authority to the 2nd HCP. The Massachusetts Health Care Proxy document did not have a 3rd alternate or indicate that the daughter could make health care decisions for the Resident. The consents were signed by the Residents daughter and the 2nd alternate, not. by the primary HCP. On 1/23/17 at 1:30 P.M., the Social worker said that the facility failed to ensure that an activated health care proxy was properly utilized for the [MEDICAL CONDITION] consents.

4. For Resident #1, the facility failed to ensure the Resident’s Guardian obtained prior authorization from the court before executing a Do Not Resuscitate (DNR). Resident #1 had been admitted to the facility in 5/2013 and had [DIAGNOSES REDACTED]. The medical record was reviewed on 1/23/17. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident had short and long term memory impairment and was unable to make decisions. The MDS indicated the Resident had a Guardian and a DNR (there was no evidence a Health Care Proxy had been executed prior to the Guardianship). Review of the Guardianship documentation indicated that it had been obtained for the use of antipsychotic medication on 6/14/13. The Guardian had obtained the appropriate authority through the court for the continued use of antipsychotic medication (expiration was 5/19/17). However, further review indicated the guardianship was limited to the use of the antipsychotic and did not include the authority to execute a DNR. According to the Massachusetts Uniform Probate Code allows the limited guardian to only have responsibilities and authority as outlined in the court order. A guardian must obtain prior authority from the court before executing a DNR. Review of the 1/2017 signed physician orders [REDACTED]. However, the medical record failed to indicate that the Guardian had obtained the prior authority from the court before executing the DNR. The only documents available in the medical record at the time of review had been the Massachusetts Department of Public Health/Office of Emergency Medical Services Comfort Care/DNR order verification form, signed by the Guardian on 1/4/13.

The Unit Manager (UM #3) was asked about the order on 1/23/17 at 10:45 A.M. UM #3 said that she the thought the DPH Comfort Care form was the consent by the Guardian. She said she was unaware of any other document consenting to the DNR. Following the discussion the Unit Manager provided 5 forms indicating consent for the DNR, however, none of the forms were obtained through the court and the dates were after the limited guardianship was obtained. In addition, there was no health care proxy During interview on 1/25/17 at 9:15 A.M., the Social Worker said that she would not admit the Resident to the facility without a Guardianship, because the Resident had been refusing his/her medications. She said she said she knew that a limited authority of Guardianship required the Guardian to go back to court to obtain the authority to execute the DNR, but had not done anything about it (even though she had assisted in the yearly update to continue with the court order for antipsychotic medication.

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 record review and staff interview, the facility failed to ensure Residents or their responsible person were fully informed in advance, and given information necessary to make health care decisions including the risks and benefits of [MEDICAL CONDITION] medications prior to administration for 3 Residents (#14, #16 and #18) in a total sample of 22.

Findings include:

1. For Resident #14, the facility failed to ensure that the Resident’s health care proxy was provided accurate information necessary to make a health care decision including information about the benefits and reasonable risks, and about reasonable available alternatives for the use of the antidepressant medication [MEDICATION NAME] SR prior to its administration. Review of the most recent annual Minimum Data Set (MDS) with a reference date of 12/16/16, indicated that Resident #14 had moderate cognitive impairment and had an activated health care proxy. The medical record was reviewed on 1/26/17 and 1/27/17. Resident #14 was admitted to the facility in 12/2014 with [DIAGNOSES REDACTED]. Review of January 2017 physician’s orders [REDACTED]. Further review of the medical record indicated an incomplete informed consent form for [MEDICAL CONDITION] medication. The incomplete consent failed to include the following required information:

-Date of discussion regarding the risks and benefits of the medication
-Facility representative’s name and title whom conducted the discussion
-Date of last medication review of the facility
-Purpose of the medication was listed as [MEDICAL CONDITION] -Medication risks -Medication benefits

During interview with Unit Manager #1 on 1/27/17 at 8:15 A.M., she reviewed the informed consent form for [MEDICATION NAME] SR and said that it was incomplete and inaccurate.

2. For Resident #16, the facility failed to ensure that a written consent forms were in place for the [MEDICAL CONDITION] medications Prozasin and [MEDICATION NAME], and that the Resident was provided accurate dosage information necessary to make a health care decisions for 2 additional [MEDICAL CONDITION] medications: [REDACTED] Review of the most recent annual Minimum Data Set (MDS) with a reference date of 12/23/16, indicated that Resident #16 was cognitively intact and was able to make his/her own healthcare decisions. The medical record was reviewed on 1/27/17. Resident #14 was admitted to the facility in 6/2014 with [DIAGNOSES REDACTED]. Review of the January 2017 physician’s orders [REDACTED]. Review of the medical record failed to indicate a written consent form for [MEDICATION NAME] and [MEDICATION NAME]. Further review indicated inaccurate dosage ranges for the following medications:

[REDACTED] -[MEDICATION NAME] 100 mg – 600 mg (Resident takes 700 mg daily)
-[MEDICATION NAME] 150 mg twice daily (Resident has an additional order for 25 mg, half tablet twice daily as needed)

During interviews with the assistant director of nursing (ADON) on 1/27/17 at 9:30 A.M., and the Director of Nursing (DON) and Administrator at 10:45 A.M., the Surveyor reviewed Resident #16’s consent forms for [MEDICAL CONDITION] medications. They said that the consent forms need to be in place for all [MEDICAL CONDITION] medications administered and they must be accurate to reflect the dosage the Resident is administered.

3. For Resident #18, the facility failed to ensure that the Resident was provided accurate dosage information necessary to make a health care decisions for 4 [MEDICAL CONDITION] medications: [REDACTED]. Resident #18 was admitted to the Facility in 5/2013 and had [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] and the significant change MDS dated [DATE], indicated the Resident was alert and oriented, capable of making own decisions and showed a change in staff assistance from supervised to an extensive assistance in his/her activities of daily living. The Resident did not have an invoked Health Care Proxy and was therefore making his/her own medical decisions The medical record was reviewed on 1/26/17. Review of the current physician (1/2017) orders included the following [MEDICAL CONDITION] medication regimen; [MEDICATION NAME] (antipsychotic) 125 mg at hour of sleep daily and 75 mg every morning, [MEDICATION NAME] (antidepressant) 100 mg at hour of sleep daily, and [MEDICATION NAME] (anti-anxiety) 0.5 mg, twice daily. Review of the medical record indicated that consent forms for [MEDICAL CONDITION] administration were signed by the Resident on 11/11/16, for the above medication. However, review indicated inaccurate dosage ranges for 2 of the medications, inaccurate purpose for 2 of the medications and no information indicating the Resident understood the risks and benefits for all 3 of the medications.

-[MEDICATION NAME] -150 mg (Resident takes 275 mg daily), the purpose for the medication was for depression and there was no indication the Resident was made aware of the risks and benefits of the medication.
-[MEDICATION NAME] – the purpose was for [MEDICAL CONDITION] and there was no indication the Resident was made aware of the risks and benefits.
-[MEDICATION NAME] – 0.5 mg (Resident takes 1 mg daily) and there was no indication of risks and benefits.

During interviews with the ADON on 1/27/17 at 9:30 A.M., and the DON and Administrator at 10:45 A.M., the Surveyor reviewed consent forms for [MEDICAL CONDITION] medications. They said that the consent forms need to be in place for all [MEDICAL CONDITION] medications administered and they must be accurate to reflect the dosage the Resident is administered.

Failed to let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the that medical plan of care including physician orders [REDACTED].#2) out of a total sample of 22 residents.

Findings include:

Resident #2 was admitted to the facility in 5/2015 and had [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 11/18/16, indicated that Resident #2 was cognitively impaired and unable to make decision. The MDS indicated the Resident had an activated Health Care Proxy (HCP) and was on hospice.

Review of the medical record indicated that Resident #2’s Health Care Agent met with the physician and completed a MOLST (Medical Orders for Life-Sustaining Treatment) form which included a Do Not Hospital (DNH) order which was signed on 7/28/16. Although, it was not included on the MOLST form the current physician orders [REDACTED]. On 8/13/16, the nurse’s note indicated the Resident had a change in condition and contacted the physician. The physician ordered the Resident be transferred to the hospital. The note indicated that the message was left for the Health Care agent. The nurse’s note indicated the Resident was sent to the hospital without evidence the Health Care agent agreed to the transfer. The Resident was readmitted on [DATE], and on 8/18/16, the NP indicated the Health Care Agent had contacted him/ her regarding the Resident’s status. The Health Care agent reaffirmed his/her decision for no treatment.

On 1/26/17 at 12:30 P.M., the Resident’s physician (who was the Medical Director for the facility) was interviewed. The Physician was asked about the advance directive to not hospitalized and she said she did not know if the Health Care Agent had chosen to transfer the Resident to the hospital after having consented to not hospitalized the Resident. The physician said she would check to see if she had any note clarifying the situation, but did not.

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 record review and interview, the facility failed to notify the physician and/or the Resident’s responsible person of changes and/or of recommendations from a consultant resulting in a delay of a treatment change and/or decisions to alter the treatment plan for 2 Resident (#2 and 4) in a sample of 22 Residents.

Findings include:

1. For Resident #2, the facility failed to notify the Health Care Agent of abnormal laboratory results to ensure that the Health Care agent could chose to treat the Resident based on the results. The medical record was reviewed on 1/25/17 and 1/26/17. Resident #2 was admitted to the facility in 5/2015 and had [DIAGNOSES REDACTED]. The medical record indicated that the Health Care Proxy had been invoked on 8/15/16. Review of the medical record indicated that the Resident’s [MEDICAL CONDITION]/cancer was no longer in remission and that the Health Care Agent had requested end of life care and consented to specific advance care directives (7/28/16). On 8/3/16, a CBC (complete blood count) was completed and the result included critical high and critical low results. The Resident’s WBC (white blood count) was 120.4 and the reference range was 4.8-10.8, the HGB (hemoglobin) was 7.4 and the reference range was 13.5-17.5 and the HCT (hematocrit) 24.2 – 40.0-50.0 (both consider critically low and the WBC extra high). The Nurse Practitioner (NP) requested the results be sent to the oncologist. On 8/10/16, the nurse’s progress note indicated that the Resident was seen by his/her oncologist and that the Health Care Agent decided not to pursue [MEDICAL CONDITION], but wanted laboratory tests to be completed so that he/she could decide the course of treatment. The nurse indicated that the laboratory test would include the hemoglobin (HGB) test and that the result would be discussed with the Health Care agent. The Agent wanted to decide if based on the result (7 or less) if he/she would decide if a blood transfusion would be done. The nurse indicated she would notify the physician. On 1/25/17, a CBC laboratory test was done and noted to have critical low abnormal reference ranges RBC, HCB,and HCT (red blood count, hemoglobin, hematocrit), in addition the WBC (white blood count) was extra high. The HGB was 3.6. The NP and Hospice were notified of the results, however there was documented evidence that the Resident’s Health Care agent was informed of results. On 1/26/17 at 12:30 P.M., the Resident’s physician (who was the Medical Director for the facility) was interviewed. The Physician was unaware of the laboratory results, but would look into it. Review of the physician’s note dated 1/27/17 indicated she reviewed the laboratory results, but failed to indicate that she notified the Health Care agent as he/she had requested.

2. For Resident #4, the facility failed to notify the Health Care Agent and physician of significant weight loss; and the facility failed to notify the Health Care Agent and the physician of the frequency of medication refusal, that included behaviors of hiding and spitting out medications and that included blood pressure and antipsychotic medications. The medical record was reviewed on 1/23/17, 1/24/17 and 1/25/17. Resident #4 was admitted to the facility in 10/2014 and had [DIAGNOSES REDACTED]. The medical record indicated that the Health Care Proxy had been invoked prior to the Resident’s admission on 9/23/14 and supported by the physician on admission in 10/2014. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had some memory loss (scoring an 11 out of 15 on his/her Brief Interview of Mental Status), did not exhibit mood or behavioral symptoms. The MDS indicated the Resident was 73 inches tall and weighed 167 lbs.

a) Review of the Resident’s weight history indicated that the Resident’s weight showed weight gain during 2015. On 9/8/15, the Resident weighed 185.2 lbs, 10/6/15 -189 lbs, 11/3/15 – 187 lbs. The Resident’s weight continued to increase and on 3/11/16 weighed 192 lbs. The monthly weights for April and May 2016 were 189.6 lbs and 189.8. On 6/10/16 – 184.4 lbs; 7/5/16 -175.2 lbs; 8/3/16 – 175.4 lbs, 8/16/16 -174.4 lbs; 8/21/16 -174 lbs; 10/10/16 -174.4 lbs; 10/25/16 – 170 lbs; 11/7/16 – 175.4 lbs, 12/5/16 170.6 lbs and 12/26/16 – 166.8 lbs. The dietician recognized the weight decline and documented on 7/18/16 that the weight of 175.2 lbs reflected a net loss of 11.8 lbs past 180 days and 9.2 lbs (5%) in the past 30 days. The dietician indicated that the Resident’s intake had not changed and that he/she received large portions fortified pudding at meals and at hour of sleep. The progress note indicated that the physician was aware of the weight loss, but does not indicate that the Health Care Agent was notified.

Review of the medical record failed to indicate that the physician was notified of the weight loss identified on 7/18/16. On 8/18/16, the dietician indicated the Resident had additional weight loss of 15.2 lbs or 8,7% in past 90 days and 17 lbs, or 9% in past 180 days. She documented the Resident’s intake is stable and receives house supplements, fortified foods twice daily. There is no indication that the physician and/or the Health Care Agent was notified of the weight loss.

On 10/18/16 and 1/17/17, the dietician documents a weight loss trend. The dietician indicated in both progress notes that the Resident said that he/she was refusing foods because the staff were putting medication into it (because he/she refused medication). The dietician reassured the Resident that staff were not doing this (although there was a physician order [REDACTED]. The weight loss in 1 year was over 20 lbs. There was no indication that the physician and Health Care Agent were notified of the weight loss or that his/her refusal was due to medications being put in his/her food. Further clinical record review indicated that there was no documentation by the facility dietician she had communication with the physician and/or Health Care Agent of the weight loss and verbalization that medications were being put in his/her food. On 1/25/17 at 12:00 P.M., the facility Dietician said she did not know if the physician or Health Care Agent had been notified of the Resident’s weight loss. The Dietician said she hoped the staff had notified them.

b) Review of the Medication Administration Records (MAR) from 5/2016 through 1/2017, and the medical record that included physician notes and nursing notes indicated that the Resident often refused medication and/or spit it out. The medications refused included [MEDICATION NAME] (medication for [MEDICAL CONDITION]), multivitamins, [MEDICATION NAME] (hypertensive medication), [MEDICATION NAME] (medication treats indigestion), [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (vitamin supplement) and [MEDICATION NAME] (hypertension medication). The record indicated that the refusals included all medications and for up to 11 days straight. Although, the record indicated the refusals had declined, the Resident stated he/she spit out medications on a regular bases because he/she did not need the medication.

The record had sporadic documentation that the Health Care Agent and physician had been notified of a refusal for 1 day, but there was no evidence that the physician and Health Care Agent were notified of the frequency and length of time of the refusals. Review of the 5/2016 MAR indicated [REDACTED]. The nurse’s notes indicated they were unsure if the Resident had swallowed his/her medications on 5/15/16, 5/16/16, 5/18/16, 5/19/16 and 5/24/16 (that medications were given in applesauce). Out of the 10 times the Resident refused his/her medications, the staff notified the physician and Health Care Agent twice of the refusal of medication on 5/28/16 and 5/29/16.

During 6/2016, the Resident refused his/her medication 17 times including refusal of his/her antipsychotic medication (2 times) and blood pressure medications multiple times. Documentation indicated that on 6/4/16 the physician was notified that the Resident refused his/her medication that day, but no evidence the Health Care Agent was notified. According to the MAR for 7/2016, the Resident refused his/her medications 18 times, which included refusal of the hypertensive medications 14 times which included refusal of the medications for 11 days in a row and the antipsychotic medication 4 times. The nursing staff indicated on 7/15/16 they notified the physician and health care agent that the Resident had refused his/her blood pressure medications on 7/15/16. On 7/17/17, the physician was notified of that days medication refusal, and on 7/20/16. There was no documentation in the nurses notes or physicians notes quantifying the amount of medication refused. According to the MAR for 8/2016, the Resident refused his/her medications 18 times, which included refusal of the hypertensive medications 17 times which included refusal of the medications for 7 days in a row and the antipsychotic medication 8 times. There was no evidence the Health Care Agent was notified and the nursing staff indicated on 8/17/16 and 8/27/16 they notified the physician the Resident had refused his/her medications on those days. The physician noted in his/her progress note that on 8/8/16 that the Resident was non-compliant with medications. The physician indicated the Resident asked to discontinue the medication and the physician said he educated the Resident of their importance. According to the MAR for 9/2016, the Resident refused his/her medications 10 times, which included refusal of the hypertensive medications 9 times which included refusal of the medications for 3 days in a row and the antipsychotic medication 3 times. There was no evidence the Health Care Agent was notified and the nursing staff indicated on 9/13/16 and 9/27/16 they notified the physician the Resident had refused his/her medications on those shifts.

According to the MAR for 10/2016, the Resident refused his/her medications 6 times/ The physician was notified twice and a message left one time, there was no indication the Health Care Agent was notified. For 11/2016, the Resident refused medications on 4 days and no evidence the physician and/or Health Care Proxy had been notified. For 12/2016 and 1/2017 there was no documentation the Resident was refusing medication or spitting out the medication. During interview with the Resident on 1/24/17 at 10:00 A.M., the Resident said that he/she did not take his/her medication, but that the staff thought he/she was taking them. The Resident said that he/she did not need the blood medication and or any of the others. The Resident said he/she never had high blood pressure before coming to the facility and did not want to take the medication. Resident #4 said he/she tried to talk with the physician several months ago, but got a lecture. The Resident said that staff used to make him/her drink water when taking the medications so that the medications were swallowed. Resident #4 said that staff also said the Resident would not be able to smoke if he/she did not take the medication and would also put it in his/her food. The Resident said he/she has learned how to not swallow the medication. Resident #4 laughed and said that the local bird population’s blood pressure was perfect.

During interview with the Director of Nurses and Social Worker on 1/25/17 at 9:30 A.M. they said they were aware that the Resident refused medications and that it had included spitting out medication, refusal and hiding medications. The Social Worker had stated that Residents who refused medications (antipsychotic) were required to have a Guardian with an antipsychotic authority. She said that she was aware of the significance of the Resident’s refusal, but had not pursued contacting the Health Care Agent because he/she was not that involved. The Director and Social Worker made little response to the Resident’s statement that he/she gave his/her medication to the birds. Subsequently, the Director of Nurses stated on 1/26/17 at 8:30 A.M., that she had contacted the Health Care Agent and arranged a meeting to review the Resident’s care; and that the physician was notified of the Resident’s statement of hiding medications (frequently) and decreased many of the hypertensive medications and ordered the staff to monitor his/her vital signs (vital signs had been reviewed during record review and blood pressure appeared at a normal range). During interview on 1/30/17 at 10:00 A.M., Nurse #3 was asked about notification and she said that when residents refused medications she would notify the physician. Nurse #3 did not say she would notify the Health Care Agent. The Surveyor inquired if she were aware of the Resident’s admission of hiding and throwing out his/her medication. The Nurse’s response was that medications had been found in his/her room.

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

Based on documentation review and staff interview during the Abuse Protocol Review, the facility failed to conduct a timely and complete screening for 5 out 5 (Staff A, B, C, D and E) newly hired employees.

Findings include:

For newly hired staff, the Facility failed to conduct a timely Nurse Aide Registry Check prior to hire as required for Staff A, Staff B, Staff C, Staff D and Staff E. According to the Facility’s policy titled Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident’s Property, last reviewed and/or revised on 9/7/16, indicated the Facility requires that prior to employment all potential new employees are subject to the following:

1. Reference checks with current and past employer.
2. Appropriate licensing board or registry check.
3. Drug testing per company policy.
4. Fingerprinting as required by state law.
5. Criminal background check pursuant to company policy and/or state law.

In addition, the policy indicated that during orientation (and annually), new employees shall be trained on the obligation to report alleged violations.

-Staff A was hired on 10/11/16. During review of of the pre-screening documentation on 1/27/17, the facility was not able to provide evidence that the Certified Nursing Assistant (CNA) registry check for in state and out of state registry check (as documentation indicated the Staff worked in another state) was obtained prior to hire. The registry check were completed on 12/27/16 for out of state and on 1/18/17 for in state.

-Staff B was hired on 10/17/16. During review of of the pre-screening documentation on 1/27/17, the facility had not completed that the Certified Nursing Assistant (CNA) registry check for out of state prior to hire (as documentation indicated the Staff worked in another state).

-Staff C was hired on 10/11/16. During review of of the pre-screening documentation on 1/27/17, the facility was not able to provide evidence that the Certified Nursing Assistant (CNA) registry check for in state and out of state registry check (as documentation indicated the Staff worked in another state) was obtained prior to hire. The registry check was not completed for out of state and the in state was completed 1/23/17.

-Staff D was hired on 9/26/16. During review of of the pre-screening documentation on 1/27/17, the facility was not able to provide evidence that the Certified Nursing Assistant (CNA) registry check for in state and no out of state registry check was done (as documentation indicated the Staff worked in another state) was obtained prior to hire. The in state registry check was competed on 11/10/16.

-Staff E was hired on 11/14/16. During review of of the pre-screening documentation on 1/27/17, the facility was not able to provide evidence that the Certified Nursing Assistant (CNA) registry check for in state and no out of state registry check was done (as documentation indicated the Staff worked in another state) was obtained prior to hire.

On 1/27/17 at 9:00 A.M., the Assistant Director of Nurses said that the Facility had not done them as outlined in their policy.

Failed to listen to the resident or family groups or act on their complaints or suggestions.

Based on documentation review, group Resident interview, individual Resident interviews and interviews with administrative staff, the facility failed to address concerns identified by the Resident Council. These concerns included the following: staff on all shifts not answering call bells in a timely manner, afternoon and nightly snacks were either not offered or not available (not available on the unit or eaten by staff) and there was no consistency when and if they were provided, staff speaking in other languages in Resident areas, staff using cell phones in Resident areas, food complaints, and multiple problems with staff care. The Residents said that the Resident Council group was not an effective vehicle for addressing their concerns.

Findings include:

During the group meeting with 11 residents on 1/24/17 at 2:00 P.M., the Residents were asked a series of question about their life and quality of care in the facility. The Residents were also asked about the Resident Council group and the facility’s response to concerns identified by the Resident Council. The Residents engaged easily in the group conversation and stated that they were frustrated with the Resident Council group and the Facility’s lack of response to the issues brought forward by the Resident Council. The Residents said that the reason there was no Resident Council President was because the same issues were brought up month after month and their issues were not addressed and they did not receive any feed back. The Residents said that the Activity Director assisted at the meetings and recorded their concerns, shared upcoming events, and informed them of their rights. However, the Residents said that even though this process was done monthly, nothing changed. All 11 Residents in attendance reported various concerns and the lack of facility response to these complaints. The Residents’ complaints included:

-No accommodation of choices. As an example, the majority of the Residents said that there was no choice about their morning routine. The Residents said they had to get up for breakfast or did not get it. The Resident said they could not sleep in and if they missed breakfast it was difficult to get a cup of coffee and/or a later breakfast. The Residents said this was a rule they did not like. The Residents were unaware that they could seek an alternate choice.

-Privacy – the majority of Residents reported an incident that included a problem with ensuring they had privacy. During the group interview, when the issue was brought up, the entire group of Residents laughed and said the minute you entered the building you lost your dignity and privacy. The Residents described individual incidents. Residents reported that staff failed to knock when entering their rooms, bathrooms and shower rooms. The Residents said that staff walk into their bathrooms and showers (while they are using them) without knocking and have no realization that they have intruded upon the Resident’s privacy.

-Grievance – Although, the Residents were aware of how to file a grievance, they were unaware that the Facility was responsible in ensuring they were notified of the outcome. The Residents said they often reported things, but unless it was a lost item that was found, they were unaware of any process by the facility to address the grievance.

-Care issues reported during the group included the majority of the Residents stating that the Facility Staff had poor attitude and did not seem to understand the needs of the Residents. The majority of Residents said that not only that they had individual problems with care, but that they had witnessed other Residents (roommates) not receiving care as they should have. The Residents said that there were long waits for the call bells to be answered (half hour and more) on all shifts, staff using cell phones and talking in other languages in Resident areas, and long waits to get their meals (as staff are talking amongst themselves) and snacks not given out. In addition, staff are short tempered and seem uncaring. The Residents said they live in the facility 24 hours, seven days a week and are frustrated with the staff’s attitude. The Residents’ said that the facility staff did not include anyone that advocated for them. The Residents’ said the Social Worker was too busy brown nosing the Administration staff and not available for them.

too busy brown nosing the Administration staff and not available for them. The Residents said that these issues and many other issues have been brought to the Resident Council group, but remained problematic and unresolved. The Residents said they were unaware of how the Facility had addressed their issues, but added if they had done anything, it had been ineffective. Review of Resident Council minutes from 1/2016 through 12/2017 identified a variety of issues which included: delayed response to call bells, snacks not being provided, cell phone use, staff speaking in other languages, staff not knocking on Residents doors and food complaints.

Review of the minutes of the Resident Council meetings dated 1/15/16, 2/19/16,3/29/16, 4/21/16, 8/25/16, 9/29/16, 10/25/16, 11/29/16 and 12/19/16 indicated the Residents consistently complained of long waits for the certified nursing assistants to answer call bells, staff not knocking and not providing privacy, cell phone use, snacks not being provided, late meals, poor food quality and staff speaking in other languages. The Residents’ complaints were documented onto a grievance form and assigned to the relevant discipline (i.e. nursing, dietary, maintenance ). The grievance form identified the issue, indicated what was done to address the issue and when it was resolved. Review of the grievance forms associated with the Residents’ repeated complaints identified during the Resident Council meetings since 01/15/16, indicated that the Facility educated staff.

Review of the staff education form was in the following format: type of meeting (i.e. training etc), method of training, subject covered, the reaction from participants, summary and conclusion, signature of staff in attendance. Review of education forms completed by the staff development coordinator identified the subject of the education and staff signatures. There was neither a date of when the education was provided, nor what method of training was utilized. Additionally, there was no information provided to identify how effective the education was. Interview with the Activity Director on 1/26/17 at 11:30 A.M., said she participated in the Resident Council and was responsible for the minutes. She documented the minutes on a Resident council meeting minutes form and transcribed issues onto a grievance form and gave this form to the department head responsible for the issue. The department head was to take corrective action and sign and date the form when completed. The Activity Director said she would review the outcome with the Resident at the next meeting. The Activity Director said she was aware that the same problems have come up month after month. She said that when she reports the repeated concerns to Administration, they sometimes tell her that they do not believe her.

During interview with the Director of Nurses (DON) and the Administrator on 1/27/17 at 12:00 P.M., the Surveyor shared the issues identified in the Resident group interview indicating that the Residents felt that the Resident Council was ineffective and that they were frustrated with the lack of resolution to issues they brought forward. The Director of Nurses said that every time a grievance was brought to her attention, staff was educated about the corresponding issue. She said that the education consisted of staff reading a statement on the education sheet, such as knock on all Resident’s doors or reading a policy on the computer. Staff then signed the education form indicating that they had completed it. There was no interaction with staff during this education process. The Administrative Staff said that other then this method of education, no other process had been implemented in an attempt to effectively address Resident concerns as identified in the Resident Council.

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 interviews, the facility failed to ensure that all sections of the Resident’s Minimum Data Set (MDS) assessments, were comprehensive and complete to accurately reflect the Resident’s status for 5 (#6, #10, #11, #12, #15) out of 22 sampled Residents.

Findings include:

1. For Resident #6, the facility failed to accurately complete the admission MDS assessment with a reference date of 1/11/17 for section G for functional limitation in range of motion. The medical record was reviewed on 1/24/17 and 1/25/17. Resident #6 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of section G (G0400) of the MDS for functional limitation in range of motion that interfered with daily functions or placed Resident at risk of injury, indicated that Resident #6 had an impairment on one side of his/her lower extremity. Review of medical record failed to show documented evidence that Resident #6 had any impairment of his/her lower extremity as indicated on the MDS assessment. During interview with Unit Manager #2 on 1/25/17 at 12:25 P.M., she said that Resident #6 does not have any limitations in range of motion on one side of his/her lower extremity and that the MDS was coded incorrectly.

2. For Resident #10, the facility failed to accurately complete the admission MDS assessment with a reference date of 1/15/17 for section S for health care proxy. The medical record was reviewed on 1/24/17. Resident #10 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of section S (S0171B) of the MDS for advance directives, indicated that Resident #10 had an activated health care proxy. Review of medical record failed to show documented evidence that Resident #10 had an activated health care proxy as indicated on the MDS assessment. During interview with the facility social worker on 1/24/17 at 11:00 A.M., she said that Resident #10 is alert and oriented and does not have an activated health care proxy and that the MDS was coded incorrectly.

3. For Resident #11, the facility failed to accurately complete the annual MDS assessment with a reference date of 1/13/17 for section S for advance directives. The medical record was reviewed on 1/24/17. Resident #11 was admitted to the facility in 1/2015 with [DIAGNOSES REDACTED]. Review of section S of the MDS for advance directives indicated that Resident #11 was a full code (initiate resuscitation measures when the heart stops beating) and wished to be intubated. Review of medical record indicated that Resident #11 had a signed advanced directive document (signed on 10/17/16) identifying his or her advance directive as a DNR (do not resuscitate), and DNI (do not intubate). During interview with the facility social worker on 1/24/17 at 11:00 A.M., she said that Resident #11 was a DNR, DNI and that the MDS was coded incorrectly.

4. For Resident #12, the facility failed to accurately complete the annual MDS assessment with a reference date of 1/13/17 for section J for fall history. The medical record was reviewed on 1/23/17. Resident #12 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of section J of the MDS for fall history indicated that Resident #11 had not had a fall any time in the last month prior to admission. Review of hospital documentation indicated that Resident #11 sustained a fall at home one week prior to admission to the hospital on [DATE] (approximately 2 1/2 weeks prior to admission to the facility). During interview with the assistant director of nursing (ADON) on 1/25/17 at 1:15 P.M., she said that after Surveyor inquiry, she reviewed the Resident’s medical record again, and both she and the MDS nurse saw that the Resident had fallen within the month prior to admission and that the MDS was coded incorrectly.

5. For Resident #15, the facility failed to accurately complete the quarterly MDS assessment with a reference date of 1/6/17 for section H for Bladder and Bowel Appliances. The medical record was reviewed on 1/26/17 and 1/27/17. Review of the most recent quarterly MDS with a reference date of 1/6/17 indicated that Resident #15 had moderate cognitive impairment and was always continent of bowel and bladder and had an ostomy appliance. Resident #15 was admitted to the facility in 7/2016 with [DIAGNOSES REDACTED]. Review of the medical record failed to indicate that Resident had an ostomy appliance as indicated on the above referenced MDS assessment. During interview on 1/26/17 at 12:15 P.M., Resident #15 said that he/she does not have an ostomy appliance. During interview with Unit Manager #2 on 1/26/17 at 1:40 P.M., she said that the Resident does not have an ostomy appliance.

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 and staff interview, the facility failed to consistently implement the medical plan of care for 2 Residents (#19 and #5) in a total sample of 24 Residents.

Findings include:

1. For Resident #5 the facility failed to ensure that a right air boot was applied and that the Residents bilateral heels were off loaded (not touching the mattress) as per the physician’s orders [REDACTED].>Resident #5 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. The Resident was also noted to have a blister on the right heel present on admission Clinical record review indicated a physician’s order [REDACTED]. Surveyor observation while the Resident was in bed on 1/25/17 at 8:55 A.M., 1/25/17 at 11:35 A.M., 1/26/17 at 8:05 A.M., and 1/30/17 at 8:55 A.M., indicated that the right air boot had not been applied and the Residents bilateral heels were not off loaded as per the physician’s orders [REDACTED].

On 1/30/17 at 8:35 A.M. Unit Manager #2 said that the Resident had refused to wear the right boot and that the nursing staff had not indicated the refusal in their documentation. Also that the Residents bilateral heels were not off loaded as per the physician’s orders [REDACTED].>2. For Resident #19, the facility failed to ensure that checking residuals and the placement of a Gastrostomy tube ([DEVICE]) were performed as ordered by the physician Resident #19 was admitted to the facility in 1/13/2017 with [DIAGNOSES REDACTED]. The Resident had a [DEVICE] placed in the hospital prior to admission. Clinical record review indicated a physician’s orders [REDACTED]. -Check [DEVICE] residual and placement every shift. If greater than 100 milliliters (ml) hold feeding for 1 hour and recheck. If resolved resume feeding. Further clinical record review indicated that the above order was incorrectly edited onto the Medication Administration Record [REDACTED]. This resulted in no documented residuals or placement checks every shift as per the physician’s order [REDACTED]. On 1/30/17 at 11:50 A.M. the Assistant Director of Nursing said that the facility had failed to ensure that the residuals and the placement of the [DEVICE] were performed every shift as ordered by the physician.

Failed to make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide therapeutic nutritional interventions for one sampled Resident (#4), identified at nutritional risk and unplanned weight loss, from a total sample of 22 residents.

Findings include:

For Resident #4, the facility identified a weight loss of 20.2 pounds in the past year (187 pounds down to 166.8 pounds) but failed to ensure interventions that had been recommended remained in place after a hospitalization and that new information was shared to maintain the Resident’s weight. The Dietician documented the Resident with weight loss 7/18/16, 8/18/16, 10/18/16 and 1/17/17, but failed to ensure that therapeutic interventions were in place and or altered. Resident #4 was admitted to the facility in 10/2014 and had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had some memory loss (scoring an 11 out of 15 on his/her Brief Interview of Mental Status), did not exhibit mood or behavioral symptoms. The MDS indicated the Resident was 73 inches tall and weighed 167 lbs, and that there was an invoked Health Care Proxy.

Review of the Resident’s weight history included the following weights and trends. On 9/8/15, the Resident weighed 185.2 lbs, 10/6/15 -189 lbs, 11/3/15 – 187 lbs. The Resident’s weight continued to increase and on 3/11/16 weighed 192 lbs. For April and May 2016 were 189.6 lbs and 189.8. On 6/10/16 – 184.4 lbs; 7/5/16 -175.2 lbs; 8/3/16 – 175.4 lbs, 8/16/16 -174.4 lbs; 8/21/16 -174 lbs; 10/10/16 -174.4 lbs; 10/25/16 – 170 lbs; 11/7/16 – 175.4 lbs, 12/5/16 170.6 lbs and 12/26/16 – 166.8 lbs. The Dietician recognized the weight decline and documented on 7/18/16 that the weight of 175.2 lbs reflected a net loss of 11.8 lbs in the past 180 days and 9.2 lbs (5%) in the past 30 days. The dietician indicated that the Resident’s intake had not changed and that he/she received large portions, house supplement daily,and fortified pudding at meals and at hour of sleep. The progress note indicated that the physician was aware of the weight loss, but does not indicate a change.

On 8/18/16, the Dietician’s progress note indicated the Resident had additional weight loss of 15.2 lbs or 8.7 % in past 90 days and 17 lbs, or 9 % in past 180 days. She indicates the Resident’s intake was stable and receives house supplements, fortified foods twice daily. There was no indication the plan of care was changed. On 8/27/16 through 9/8/16 the Resident was hospitalized for [REDACTED]. On 10/18/16, the Dietician documents a weight loss trend (14.6 pounds in one year). The Dietician indicated the Resident’s intake was stable and that the loss was not planed. The Dietician indicated that the Resident said that he/she was refusing foods because the staff were putting medication into it and he/she did not want to take the medication. The Dietician reassured the Resident that staff were not doing this (although there was a physician order [REDACTED]. The note indicated the Resident was receiving supplements fortified foods and large portions, however there were no orders for the supplements and added foods.

On 1/17/17, the Dietician documents a continued weight loss trend 5 % in 180 days and 10.8 % in year). The Dietician indicated that the Resident continues to think that staff are putting medicine in his/her food and she indicated she reassured the Resident this was not true. The Dietician indicated that the Resident has not been receiving the fortified foods and supplements and will not accept them. The Dietician indicates because of the medicine in the foods. There is no change to the plan of care which was standardized and had not included any changes except the foods the Resident had not been receiving since 9/2016. On 1/25/17 at 12:00 P.M., the facility Dietician was interviewed. She initially informed the Surveyor had been receiving supplements 6 times a day, then she said it was three times and then indicated that the supplements had included fortified foods. The Dietician also said that she had thought the Resident was taking all the foods and supplements provided, but later learned the Resident refused frequently during the past 6 to 9 months. The Dietician said that she had just recently become aware that the orders for the supplements and fortified foods had been discontinued in 9/2016. She said that the kitchen sent fortified foods (a pudding) three times daily, but could not quantify the amount of the pudding the Resident consumed. The Dietician was asked about the Resident’s comments about medication in his/her food. The Dietician dismissed the Resident’s statements and was surprised to be informed that staff had an order to put the Resident’s medications in his/her food and that the Resident exhibited significant behaviors associated with refusal of medication.

Failed to properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to ensure the proper care and treatment of [REDACTED].#12). The facility failed to ensure that residual checks were conducted for a Gastrostomy tube for 1 Resident (#9). The sample included 22 residents.

Findings include:

1. For Resident #12, the facility failed to notify the physician of a change in measurement of the external length of the catheter during a dressing change. Resident #12 was admitted to the facility in 1/2017 following a brief hospitalization for [MEDICAL CONDITION]. A midline catheter was inserted during the hospitalization to facilitate the administration of antibiotics for treatment of [REDACTED]. The medical record was reviewed on 1/23/17. Review of the procedure note for the vascular access device insertion indicated that the midline catheter was inserted on 1/3/17, had a total length of 15 cm (centimeters) with an external length of 0 cm.

Review of the January 2017 signed admission orders [REDACTED]. Review of the facility’s midline documentation form and infusion therapy Medication Administration Record [REDACTED]. The external length of the catheter was measured again on 1/15/17 with a dressing change and measured 7.5 cm.

Review of nursing progress note dated 1/15/17 indicated that the midline dressing was changed, and the external catheter length was measured at 7.5 cm (7 cm longer than upon admission), confirming the measurement documented on the infusion therapy medication administration record. There was no evidence that Resident #12’s physician was notified of the change in measurement. Despite the discrepancy, facility nurse continued to use the line for administration of intravenous antibiotics. Per the Infusion Nurses Society’s Infusion Nursing Standards of Practice 2016, infusion through a migrated (malpositioned) catheter should be withheld until proper tip position has been established. The nurse should notify the physician or appropriate delegate immediately of any signs or symptoms related to central venous access device malposition and obtain orders for diagnostic procedures. Procedures include, but are not limited to, chest radiograph and contrast injection through the catheter under fluoroscopy. During interview with Unit Manager #1 (UM#1) on 1/24/17 at approximately 10:00 A.M., she said that the external catheter measurement taken by staff nurse #1 on 1/15/17 must have been a mistake because it measured too long. UM#1 said that staff nurse #1 was not in the building because he is on vacation During interview with the assistant director of nursing (ADON) on 1/24/17 at approximately 3:00 P.M., she said that she reviews nursing documentation and had not picked up on the catheter length discrepancy. She also said that she had contacted staff nurse #1 on the telephone regarding the measurement discrepancy and said that the nurse did not measure the external length of the catheter correctly.

2. For Resident #9 the facility failed to ensure that the Resident had an order for [REDACTED]. Resident #9 was admitted to the facility in 7/2016 with [DIAGNOSES REDACTED]. The Resident had a [DEVICE] placed in the hospital prior to admission. The facility policy for Enteral Tube Medication Administration with respects to Residual checks is as follows: -Check gastric content for residual feeding. Return residual volumes to the stomach. Report any residual above 100 milliliter (ml). Clinical record review of the current physicians orders indicated that there was not a physician’s orders [REDACTED]. On 1/23/2017 at 1:20 P.M. UM #3 said that the facility failed to ensure that the physician’s orders [REDACTED]. contained Residual check orders.

Failed to make sure that each resident's drug regimen is free from unnecessary drugs; Each resident's entire drug/medication is managed and monitored to achieve highest well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure each resident’s drug regimen included a clinical rationale for receiving duplicate therapy; and/or failed to consider an attempt of a trial reduction of an antipsychotic drug, and/or identified behaviors that required increasing the antipsychotic medication, despite no continuing demonstration of the symptoms or behaviors for 1 resident (#3) out of a total sample of 22 residents.

Findings include:

1. For Resident #3, the facility failed to ensure that there was documented justification for the use of duplicative (three) anti-depressant medications and failed to consider and/or attempt a trial dose reduction of an antipsychotic drug despite no continuing demonstration of the symptoms or behaviors since 12/2015. Resident #3 was admitted to the facility in 8/2011, with [DIAGNOSES REDACTED]. Review of Resident #3’s Quarterly MDS assessment dated [DATE] and the Annual MDS assessment dated [DATE], indicated the Resident had cognitive impairment and was not capable of making his/her decisions. The Resident did not exhibit any mood indicators and had no behavioral symptoms identified. The assessment indicated the Resident required minimal supervision with activities of daily living with assistance for dressing. Medications included anti-depressant and anti-psychotic. Record review on 1/24/17 included current physician orders [REDACTED]. Current medications include the following:

-Anti-depressant medications included: [MEDICATION NAME] 20 milligram daily
[MEDICATION NAME] 37.5 mg daily
[MEDICATION NAME] 25 mg daily, and 50 mg at hour of sleep/as needed. -Anti-psychotic medications: [REDACTED] [MEDICATION NAME] 2.5 mg at hour of sleep.
-Mood Stabilizer: [MEDICATION NAME] 250 mg every morning, 125 mg every evening and 375 mg at hour of sleep. Clinical record documentation including nursing nurses notes, social service and physician notes from 9/2015 through survey indicated the Resident was stable and was followed by the consulting psychiatric service.

Documentation indicated that this resident was followed by the consulting psychiatric service for medication management with the last visit 5/12/16. Review of the 5/12/16 evaluation indicated the Resident was stable and did not recommend any changes in his/her medication.

Review of the behavior flow sheets for 9/2015. 10/2016, 11/2016, 12/2016 and 1/2017 identified paranoia, delusions and threatening towards others as problems, however, the flow sheets indicated that the behaviors had not occurred. Review of the pharmacy recommendation dated 1/5/17, recommended a dose reduction of the antidepressant as the Resident had been on it, at the same dose since 12/2015. The physician checked the form indicating the Resident was having good response to treatment and requires dose for stability. No change was made. There was no documentation addressing the three antidepressants and/or evidence that the staff were aware of what the medications were used for.

Review of the informed consent forms, dated 11/24/16, for [MEDICAL CONDITION] medications indicated the [MEDICATION NAME] was for depression and [MEDICAL CONDITION], the [MEDICATION NAME] for [MEDICAL CONDITION] and the [MEDICATION NAME] was for dementia and mood disorder. There were no consents for the [MEDICATION NAME] or [MEDICATION NAME]. The care plans included the Resident being an elopement risk, behaviors of shouting and getting agitated because he/she was inpatient and potential risk for [MEDICAL CONDITION] drug related complications related to prescribed anti-depressant (the care plan did not address the antipsychotic medication and was standardized monitor side effects, monthly pharmacy reviews).

Observation of the Resident were as follows; On 1/23/17 at 8:30 A.M., Resident was observed in the dining room. The Resident was pleasant and engaged easily. The Resident reported leg pain and described the pain as a 10.

On 1/24/17 at 11:45 P.M., the Resident was in room and in bed. The Surveyor knocked and the Resident responded appropriately, by inviting into the room and having general conversation. The Resident was alert to self and did not become agitated or anxious.

On 1/25/17 at 9:00 A.M. and at 11:00 A.M. and 2:00 P.M. and throughout the days of 1/26/17 and 1/30/17, During all observations the Resident was quiet, usually sitting and or in bed and was able to respond to questions without difficulty.

On 1/25/17 at 9:30 A.M., the Social Worker and the Director of Nurses were interviewed. The Social Worker said the Resident was on the medications because he/she had been threatening towards his/her spouse, but that the spouse had passed away over a year ago and the Resident had not displayed issues since.

On 1/25/17 at 11:45 A.M. CNA #3 was asked about caring for the Resident. CNA #3 said the Resident was a sweet heart and never was a problem providing care. During interview with the consulting psychiatric provider, on 1/25/17 at 12:00 P.M., the provider said that she had not reviewed the Resident’s record but would agree that the medications should be reviewed and supported with [DIAGNOSES REDACTED].

On 1/26/17 at 12:30 P.M., the Resident’s physician (who was the Medical Director for the facility) was interviewed. The Physician said that she was familiar with the criteria for the use of [MEDICAL CONDITION] medications in the elderly, but said she was prone to not change medications for fear that the behaviors would reoccur. The Physician said she rarely consider a trial gradual dose reduction (GDR) and had not considered differ ways a reduction could be trialed. The Physician said that Resident #3 was psychotic and that he/she had tried to run someone over with his/her car prior to admission. The admission documents were reviewed with the physician, which indicated the Resident had had changes in mental status and had been consuming alcohol. The Resident barricaded self in a room and was subsequently hospitalized . The hospital discharge record indicated the behavior had been associated to the alcohol and that he/she had never done this before or had ever been assaultive. The incident had occurred in 8/2011. The Physician said that she misspoke and said that she understood that documentation was needed to support the medication use and that she would speak with the facility and document more often her rational for the medication use.

On 1/26/17 at 2:00 P.M., the consultant pharmacist was interviewed. The consultant said that she followed the process as outlined by the pharmacy protocols to notify the physician and the facility of her reviews for recommended changes. She said that she notified the Facility of trial dose reduction, duplicate therapy and the need for supportive documentation and a need for a rationale for the use of [MEDICAL CONDITION] medications. She said that generally the physician did not agree with her recommendations, and therefore the medications and lack of documentation continued. The pharmacist said that she had attempted during quarterly Quality Assurance meetings to discuss excessive medication use and gradual dose reduction trials, but that there has been no change.

Failed to Give specialized rehabilitative services that are medically necessary by qualified personnel, when ordered by a doctor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to have a physicians order for psychiatric services for 2 Residents (#14 and 15) receiving psychiatric services, in a total sample of 22 Residents.

Findings include:

1. For Resident #14, the facility failed to ensure a physician’s order was in place for this Resident receiving one-to-one psychotherapy and psychopharmacological medication review. This Resident received this services on 6 occasions since 9/2016 with no documentation of a physician’s order for these services. The medical record was reviewed on 1/26/17 and 1/27/17. Review of the most recent annual Minimum Data Set (MDS) indicated that Resident #14 had moderate cognitive impairment, was administered [MEDICAL CONDITION] medication and had an activated health care proxy.

Resident #14 was admitted to the facility in 12/2014 with [DIAGNOSES REDACTED]. A review of signed physician’s orders for January 2017 indicated the Resident received the antidepressant medications [MEDICATION NAME] and [MEDICATION NAME] as well as Klonopin for anxiety. There was no physician’s order for psychiatric services Review of the interdisciplinary care plan indicated that the Resident received psychiatric services to address medication and behavior intervention recommendations. Review of the facility’s psychiatric consultant’s notes indicated that the Resident was seen by the psychotherapist for behavioral health consultations on 9/20/16, 9/22/16, 12/22/16, 1/19/17 and the psychiatric nurse practitioner (NP) to evaluate his/her [MEDICAL CONDITION] medication regime on 10/21/16 and 1/20/17. During interview with the facility’s psychotherapist consultant on 1/27/17 at 10:55 A.M., the Surveyor informed the clinician that Resident #15 did not have physician’s orders for psychiatric consultant services, and no evidence that an individualized treatment plan had been developed. The consultant said he was unaware there was no physician’s order and was unable to identify individualized, measurable goals of therapy for Resident #14.

During interview on 1/30/17 at 10 :30 A.M., the Surveyor informed the director of nursing (DON) and Administrator that Resident #14 did not have physician’s orders for psychiatric consultant services.

2. For Resident #15, the facility failed to ensure a physician’s order was in place for this Resident receiving one-to-one psychotherapy and psychopharmacological medication review. This Resident received this services on 9 occasions since 9/2016 with no documentation of a physician’s order for these services. The medical record was reviewed on 1/26/17 and 1/27/17. Review of the most recent quarterly MDS with a reference date of 1/6/17 indicated that Resident #15 had moderate cognitive impairment and was administered [MEDICAL CONDITION] medication. Resident #15 was admitted to the facility in 7/2016 with [DIAGNOSES REDACTED]. Review of January 2017 signed physician’s orders indicated the Resident received the antidepressant medication [MEDICATION NAME]. There was no physician’s order for psychiatric services Review of the medical record failed to indicate that a care plan was developed to address Resident #15’s psychosocial needs, [MEDICAL CONDITION] medication regime and psychiatric services. Review of the facility’s psychiatric consultant’s notes indicated that the Resident was seen by the psychotherapist for behavioral health consultations on 9/13/16, 10/13/16, 10/20/16, 11/3/16, 11/17/16, 11/29/16, 12/8/16, 12/22/16 and the psychiatric nurse practitioner (NP) on 11/25/16 to evaluate his/her [MEDICAL CONDITION] medication regime. Further review of the consultant’s progress notes indicated that Resident #15’s status was stable with no signs or symptoms of depression. Additionally, there was no evidence that a treatment plan had been developed with individualized, measurable goals of treatment. During interview with the facility’s psychotherapist consultant on 1/27/17 at 10:55 A.M., the Surveyor informed the clinician that Resident #15 did not have physician’s orders for psychiatric consultant services, and no evidence that an individualized treatment plan had been developed. The consultant said he was unaware there was no physician’s order and was unable to identify individualized, measurable goals of therapy for Resident #15. During interview on 1/30/17 at 10 :30 A.M., the Surveyor informed the director of nursing (DON) and Administrator that Resident #15 did not have physician’s orders for psychiatric consultant services.

Failed to make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.

Based on documentation review and staff interview, the facility failed to provide the required inservice training that included dementia training for newly hired employees.

Findings include:

During the Abuse Protocol Review and review of newly hired employees, the facility failed to provide dementia training as required for 5 (Staff A, B, C, D and E) out of the 5 employee files reviewed. On 1/27/17 at 9:00 A.M., the Assistant Director of Nurses said that the Facility had not provided the dementia training as outlined in their policy.

Failed to train all employees on what to do in an emergency, and carry out announced staff drills.

Based on observation and staff interview the facility failed to ensure that the proper equipment was set-up and available for use in the event of an emergency on one of three Resident care units.

Findings include:

On 1/25/17 at 1:25 P.M., Surveyor reviewed the emergency equipment/code cart on Unit # 1 with Unit Manager (UM) #1. Review of the Emergency Cart Check List, located on all of the code carts indicated, the equipment/code cart was checked daily and indicated that the suction machine was functional, however the check list did not indicate that the suction machine was set-up and ready for use in the event of an emergency. At 1:32 P.M. (after approximately 7 minutes) UM #1 was still unable to connect the tubing to the suction machine properly in order to demonstrate operation of the suction machine in the event of an emergency. This was due to the proper equipment for the set-up of the suction machine being unavailable on the Emergency Cart which prevented the proper set-up by UM#!.

On 1/25/17 at 1:40 P.M. the Assistant Director of Nursing (ADON) intervened and proceeded to try to locate the proper tubing. It was then identified that the tubing was not available. The ADON stated that the tubing should have been connected and the suction machine should have been ready to go in the event of an emergency.

Failed to arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews, the facility failed to ensure that for 2 residents (#2 and #18) that hospice service and the facility took an active role in end of life care, out of a total sample of 22 residents.

Findings include:

1. For Resident #2, the facility failed to ensure that end of life care and/or hospice services took an active role in developing, directing and implementing a plan of care related to the Resident’s condition and end of life. Resident #2 was admitted to the facility in 5/2015 and had [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 11/18/16, indicated that Resident #2 had short and long term memory loss, was unable to make his/her decisions and did not exhibit behaviors associated with mood and/or behaviors. The MDS indicated the Resident required staff assistance with his/her activities of daily living, had an activated health care proxy and was receiving hospice care.

Record review indicated that Resident #2 had a [DIAGNOSES REDACTED]. Review of the physician’s progress notes dated 6/1/16, 6/9/16 and 7/21/16 indicated that the Resident’s [MEDICAL CONDITION], had not achieved any type of remission and after reviewing laboratory results with abnormal reference ranges of his/her blood count, requested the Resident be evaluated by his/her oncologist.

The 6/1/16 laboratory results indicated abnormal laboratory results based on reference ranges as follows: CBC (complete blood count) indicated a normal range WBC (white blood count) – 8.5 out of a range of 4.8-10.8 K/uL, low RBC (red blood count) – 2.93 out of a range 4.20-5.70 K/uL, low HGB (hemoglobin) – 10.8 out of a range 13.5-17.5 g/dL.

On 6/9/16, the physician’s note indicated the Resident was evaluated by his/her oncologist who recommended palliative [MEDICAL CONDITION]. The physician indicated she was awaiting the full evaluation.

On 7/9/16, the Resident was hospitalized and readmitted on [DATE] with with [DIAGNOSES REDACTED].

On 7/18/16, the NP’s (Nurse Practitioner) progress note indicated that the Health Care Agent requested comfort measures, no [MEDICAL CONDITION] and requested a hospice consult.

On 7/21/16, the physician indicated that the Health Care Agent wanted comfort care/end of life care for the Resident.

On 7/28/16, the Health Care Agent met with the physician and consented to advance directives which included DNR (do not resuscitate), DNI (do not intubate), DNH (do not hospitalize/unless needed for comfort), no [MEDICAL TREATMENT], no artificial nutrition and use of hydration for short term care.

On 8/3/16, the laboratory results for a CBC included critical high and critical low results. The Resident’s WBC was significantly elevated at 120.4 with a reference range of 4.8-10.8, the HGB was identified as critically low at 7.4 with a reference range of 13.5-17.5 and the HCT was identified as critically low at 24.2 with a reference range of 40.0-50.0. The NP requested the results be sent to the oncologist.

On 8/10/16, the nurse’s progress note indicated that the Resident was seen by his/her oncologist and that the Health Care Agent decided not to pursue palliative [MEDICAL CONDITION]. The note indicated the Health Care Agent would allow laboratory tests to determine a choice for blood [MEDICAL CONDITION]. The Health Care Agent indicated that he/she requested notification of the hemoglobin (HGB) and based on the result (7 or less) he/she would make a decision for care. The nurse indicated she would notify the physician.

On 8/13/16 the Resident was transferred to the hospital for pneumonia and a questionable area noted on his/her lung and returned on 8/14/16. On 8/18/16, the NP indicated the Health Care Agent had contacted him/ her regarding the Resident’s status. The Health Care agent reaffirmed no treatment and asked for the Resident to be placed on hospice. The note did not indicate why the Resident had not already been place on hospice, as the medical record indicated that the Health Care Agent had made the decision for hospice care on 7/18/16.

On 8/18/16 hospice services met with the Resident and Health Care agent. An initial assessment and plan of care was developed and placed in a separate hospice binder on the unit. Review of the hospice binder indicated the Resident would be receiving end of life care and services which included nursing, home health care, social service, volunteer services and spiritual care. Review of the hospice binder indicated that the last hospice note was dated 10/19/16.

Review of the medical record indicated that facility staff (including social service, nursing, physician, recreation and dietary) referred to the Resident receiving hospice care in their documentation. However, the interdisciplinary notes contained no detailed information and failed to indicate what services hospice was providing. The notes included that a monthly hospice care meeting had been held.

Review of the interdisciplinary care plan included a standardized plan. The care plan indicated the focus was hospice care, the goal of comfort and the interventions were to coordinate plan of care with hospice, notify hospice of any changes and obtain physician orders. Review of the hospice binder indicated 2 communication notes written by the hospice nurse, one on 10/6/16 and the other on 1/25/17 since 8/18/16 and no updated progress and/or visit notes since 10/16/16). The 10/6/16 the communication note indicated the Resident had increased pain and increased paranoia. The recommendations included adding two laxatives (Senna and [MEDICATION NAME]), decreasing the gout medication [MEDICATION NAME], decreasing the medication [MEDICATION NAME] (muscle relaxant medication), discontinuing the pain medication ultra and adding [MEDICATION NAME] (a medication that decreases stomach acid), lacteals (ammonia reduce/laxative) and consider the anti-depressant medication [MEDICATION NAME].

The physician agreed to all the medications with the exception of the antidepressant medication [MEDICATION NAME], asking for the reason. Record review failed to indicate that hospice responded. The second communication note was dated 1/25/– (assuming 2017) and recommended a CBC (complete blood count) to have update for comparison. The laboratory test was done on 1/25/17 and noted to have critical low abnormal reference ranges RBC, HCB,and HCT (red blood count, hemoglobin, hematocrit and), in addition the WBC (white blood count) was extra high. The results were reported to the nurse practitioner who requested they be faxed to hospice on 1/25/27. As of 1/30/17, there was no evidence in the medical record that hospice had responded to the results. On 1/26/17 at 8:30 A.M., Unit Manager #2 was asked if there were additional hospice notes

available in the facility. After looking, the UM said there were no additional notes, but that the Facility had contacted the hospice agency to obtain them. The UM said that in the past, hospice would fax over the progress notes and that they would be added to the hospice binder. UM #2 said she had not been recently made aware that there were notes missing from the binder. The Surveyor inquired about the services and the hospice visit schedule. UM #2 said that there was no schedule and never knew when they would be in to see the Residents, but hospice would let her know if they had any recommendations. The Surveyor asked what services were being provided by hospice and the UM said she did not know and that there was little communication with them and the hospice staff came and went. The UM said that hospice staff would alert her if there was a change in the Resident’s status. She said that the only change she was recently aware of was the abnormal laboratory results for the CBC. She said that the hospice service had been requested the test so that they could use the results for the recertification. She said the results had been faxed on 1/25/16, but that they had not responded to the abnormal results.

On 1/26/17 at 12:30 P.M., the Resident’s physician (who was the Medical Director for the facility) was interviewed. The Physician was asked about hospice care for the Resident and the Surveyor shared that there was no evidence provided by the hospice service of their involvement since 10/2016 (with the exception of the lab test needed to recertify the Resident care). The Physician said that maybe hospice care had been discontinued and she would check into it. Following Surveyor inquiry, the Assistant Director of Nurses provided a stack of papers, that had been provided by the hospice agency on 1/27/17. Review of the papers indicated that hospice had visited the Resident, and the plan of care remained as outlined in the admission plan. The notes failed to indicate how the hospice service was directly involved and how it was integrated into the Resident’s end of life care. The documents were later observed in a binder on top of a shelf at the nurses station and was not identified as the Resident’s hospice plan of care.

The hospice Clinical Director (via telephone) and hospice liaison was interviewed on 1/27/17 at 10:30 A.M. They said that Residents whom receive hospice services have a purple binder which is kept at the nursing station on their unit. The hospice liaison said the binder contains the schedule of hospice staff as well as progress notes and care plans. The hospice liaison said that the CNA (certified nursing assistant) schedule is faxed to the facility every Monday morning. She went on to say that all hospice staff documentation is entered into an electronic device (tablet), downloaded at the hospice office and printed. The notes are then placed into a folder for hospice staff to bring to the facility within 2 or 3 days of the visit.

2. For Resident #18, who does not have an invoked Health Care Proxy and was therefore making his/her own medical decisions, and after learning of the complications related to his/her [MEDICAL CONDITION], informed the Facility that he/she wished comfort care through hospice services. After, making the decision the Facility contacted hospice, but following the initial visit, the Facility failed to ensure the resident received end of life care in coordination with hospice services. Resident #18 was admitted to the Facility in 5/2013 and had [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] and the significant change MDS dated [DATE], indicated the Resident was alert and oriented, capable of making own decisions and showed a change in staff assistance from supervised to an extensive assistance in his/her activities of daily living. The medical record was reviewed on 1/26/17.

Record review indicated that on 11/29/16, the physician discussed the Resident’s [MEDICAL CONDITION] with Resident #18. The physician note indicated the Resident was explained the significance of laboratory results that represented acute and severe [MEDICAL CONDITION]. The Resident stated clearly that he/she wanted to stay comfortable and signed a MOLST form (Medical Orders for Life-Sustaining Treatment) that directed no hospitalization , no resuscitation, no [MEDICAL TREATMENT], no intravenous and no artificial nutrition. Although, the Social Worker documented on 12/1/16, that she spoke with the Resident about hospice services; made a referral to the hospice provider; and entered a standardized care for hospice into the electronic record, there was no evidence that hospice met with the Resident and provided service Review of the interdisciplinary care plan indicated that the focus was hospice care, the goal of comfort and the interventions were to coordinate plan of care with hospice, notify hospice of any changes and changes in and/or obtain physician orders. Further review of the medical record failed to indicate hospice’s involvement in the Resident’s care.

During review on 1/26/17 at 3:30 P.M., the Surveyor asked the nursing staff if there was a hospice binder for Resident #18. The nursing staff looked for the binder and initially were unsuccessful, but during the observation found an binder with the Resident’s name on it.

Review of the binder failed to contain any documents indicating that hospice’s has had or had any involvement in the Resident’s end of life care. During interview on 1/26/17 at 3:45 P.M. Unit Manager #3 said that hospice did not send schedules anymore and that she was unsure if hospice was still involved with Resident #18. The Unit Manager said she would check to see if documents where available. The hospice Clinical Director (via telephone) and hospice liaison was interviewed on 1/27/17 at 10:30 A.M. They said that Residents whom receive hospice services have a purple binder which is kept at the nursing station on their unit. The hospice liaison said the binder contains the schedule of hospice staff as well as progress notes and care plans. The hospice liaison said that the CNA (certified nursing assistant) schedule is faxed to the facility every Monday morning. She went on to say that all hospice staff documentation is entered into an electronic device (tablet), downloaded at the hospice office and printed. The notes are then placed into a folder for hospice staff to bring to the facility within 2 or 3 days of the visit. Surveyor #1 and Surveyor #2 reviewed Resident #18’s hospice binder with the hospice liaison and UM #3. The binder contained no progress note, no hospice schedule and no care plans. The hospice liaison could not explain why there was no documentation in Resident #18’s binder. As of 1/30/17, no documents were provided indicating hospice/end of life care for Resident #18.

Attleboro 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).

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.

Oftentimes, victims of abuse either cannot or will not speak up for themselves out of fear. If you notice any warning signs or symptoms of neglect of abuse an an elderly person, it is important you contact an elder abuse lawyer immediately. Not only are there statute of limitations on filing a claim, but the sooner we start helping you, the easier it will be to collect evidence and talk to any witnesses before important details are lost, hidden, or forgotten.

Boston Personal Injury Lawyers for Elder Abuse Cases

We offer a free, no-obligation legal consultation to help you understand your rights and the value of your case. Our personal injury law firm takes cases involving elder abuse and neglect. We offer legal service to clients in Massachusetts, Rhode Island and New Hampshire.


Sources:

Medicare Nursing Home Profiles and Reports – Attleboro HealthCare

Inspection Report for Attleboro HealthCare – 01/30/2017

Page Last Updated: June 4, 2018