Benjamin Health Care

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Benjamin Health Care? 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.

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About Benjamin Health Care

Benjamin Health Care is a non-profit, 205-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Brookline, Boston, Cambridge, Somerville, Watertown, Chelsea, Everett, Newton, Milton, Medford, and the other towns in and surrounding Suffolk County, Massachusetts.

Benjamin Health Care
120 Fisher Ave,
Roxbury Crossing, MA 02120

Phone: (617) 738-1500
Website: http://www.epbhc.org/

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, Benjamin Health Care in Roxbury Crossing, 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 Against Benjamin Health Care

The Federal Government fined Benjamin Health Care $18,423 on June 20th ,2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Injury Law Firm inspected government records and discovered Benjaming Health Care committed the following offenses:

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 staff interview the facility failed to notify the physician and legal guardian at the time of a fall for 1 Resident (#3) in a total sample of 25 Residents.

Findings include:

Resident #3 was admitted to the facility in 5/1999. [DIAGNOSES REDACTED]. Review of an incident report submitted to the Department of Public Health’s Health Care Facility Reporting System on 1/11/17 indicated that Resident #3 had a fall on 1/9/17 at approximately 3:00 P.M. The report indicated that the 7:00 A.M. to 3:00 P.M. nurse (nurse #1) was aware of the fall at the time, but did not report the incident to staff nurses and did not document the fall in the Resident’s medical record. The incident report form indicated that Resident #3 had an x-ray on 1/10/17 with a result of a left femur fracture. The facility’s Incident/Accident report dated 1/10/17 indicated that the Unit Manager (U.M.) #1 was made aware on 1/10/17 at around 10:00 A.M. of the fall that occurred on 1/9/17 by Certified Nursing Assistants (CNA #1) and CNA #2 (over 19 hours after the fall occurred).

On 6/28/17 at 3:37 P.M., during interview with Nurse #1 she stated she was made aware around 3:00 P.M. on 1/9/17 by CNA #1 that Resident #3 was on the floor. Nurse #1 reported that she asked the Resident what happened and he/she said that he/she had rolled out of bed to the floor. The Nurse said that she did assess the Resident’s vital signs including blood pressure, temperature, pulse, and that the Resident could move his/her extremities as usual and denied pain. She said she did not document this information. Nurse #1 said she should have initiated an incident report which would have included notifying the physician, completing a falls assessment, pain assessment, updating the care plan and doing 10-15 minute checks, as the fall was unwitnessed. She said that after she left the facility she traveled that night out of the country for the next three and a half weeks, and it was not until she returned that she learned that Resident #3 had fractured his/her left femur.

On 6/28/17 at 4:20 P.M., during interview with UM #1, she said she was approached by CNA #1 and was asked if she was aware that Resident #3 fell the day before. UM #1 said that she was not aware and went to Resident #3 to do an assessment and Resident #3 reported to her I fell yesterday, you know and I have pain in my leg. UM#1 said at that time that she notified the physician, who gave orders for a portable x-ray. Review of the facility’s incident/accident report dated 1/10/17 indicated that the physician was notified at 10:00 A.M. on 1/10/17, 19 hours after Resident #3 had fallen. In addition, the incident/accident report indicated that the legal guardian’s office was notified of the fall at 10:15 A.M., 19 hours after the fall.

Failed to provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a dignified dining experience for residents on the 2nd floor unit and failed to respect resident room privacy.

Findings include:

1. The facility failed to provide a dignified dining experience for residents on the 2nd floor dining unit. During observations of the 2nd floor dining room on 6/28/17 the following was observed: At 11:59 A.M., 34 residents were seated in the dining area. 5 CNA’s were standing or seated in the far left corner of the room not interacting with the residents. 2 Activity Volunteer’s were moving tables and engaging with the residents saying that the activity was over and that lunch would be served shortly. An activity volunteer began to wheel a resident over to the left corner of the room and asked the CNA’s if the resident sat in that area during lunch. 1 CNA turned to say that the resident does sit there and told the Activity Volunteer to leave him/her right there and we’ll move him/her, or words to that effect, and then turned her back to the resident to continue to converse with the other aides.

At 12:02 P.M., 2 nurses entered the dining area and began to engage with some of the residents. The 5 CNA’s continued to stay in the corner of the room.

At 12:05 P.M., the 1st food truck arrived and 3 CNA’s remained in the corner of the room while 8 staff passed trays. At 12:10 P.M., the 2nd food truck arrived. A staff person pointed to the two trays left on the 1st truck and told another staff person those trays were for feeders. 3 CNA’s were in the corner of the room conversing and not passing out trays.

At 12:13 P.M., 40 residents were in the dining area, 16 trays had been delivered and 4 aides were in the corner of the room. The staff who were passing out trays did not engage with or speak with the residents. Some residents watched their tablemate’s eat while waiting for their food.

At 12:18 P.M., a CNA was observed standing while feeding a resident. The CNA did not speak with, or engage with the resident while assisting him/her. 2 other CNA’s were speaking to each other loudly and at a far distance discussing a resident and one said, who will feed him/her.

At 12:21 P.M., another CNA was observed standing while assisting a resident one bite of their meal, and then went to find a chair. She did not speak with or engage the resident she was assisting

. At 12:23 P.M., 2 residents stood and left the room as they had finished their meals. 2 Residents continued to wait for their meals to be delivered. Staff reported that those residents require assistance with their meals.

At 12:30 P.M., a CNA began to assist one of the last residents with his/her meal. The resident was seated in a reclining wheelchair and had his/her eyes closed. The CNA did not speak with the resident at any point, and began to feed the resident while his/her eyes were still closed.

At 12:34 P.M., the surveyor inquired with staff regarding the remaining resident who had been sitting and waiting for his/her meal while their tablemate’s eat their meal. Staff said that that resident’s tray had been delivered to another person by mistake and that they were waiting for the CNA to return from the kitchen with the tray.

At 12:40 P.M., the last tray was delivered to the last resident who had been waiting for 40 minutes for this/her meal while every other resident in the dining area had been served or assisted, including his/her tablemate’s. Additionally, the staff person who sat to assist the resident did not speak with or engage with the resident.

On 6/28/17 the following was observed during the evening meal: At 4:55 P.M., The Surveyor observed approximately 17 Residents seated at various table in the second floor dining room. Two CNAs were standing in the back corner leaning against the wall. A third CNA was observed standing behind a Resident glancing at her cell phone. The dining room was quiet. There was no observed interaction between staff and Residents. At 5:05 P.M., 20 Residents were seated in the dining room. Two CNAs remained in the corner. A third CNA was walking with her arms folded, and a third CNA was walking a Resident into the room. No observation of interaction or any engagement with Residents observed.

At 5:20 P.M., Three CNAs were observed leaning against the back of the room talking with each other. Again the room was quiet and no observation of interaction or engagement with Residents observed.

At 5: 23 P.M., the meal truck arrived and staff gathered at the truck to pass trays. During an interview with Administrator on 6/29/17 the above dining room observations were shared. He said that he had also made observations of the lack of engagement between staff and Residents.

2. Staff on the 2 West Unit failed to respect resident room privacy. During observations of the 2 West Unit on 6/29/17 the following was observed: At 9:03 A.M., a CNA was observed standing in room [ROOM NUMBER]. The CNA was observed watching the television belonging to the A bed resident who was not in the room and the B bed resident was observed sleeping in his/her chair.

3. Staff on the 1 East Unit failed to respect resident room privacy. During observations on the 1 East Unit on 6/30/17, the following was observed: At 10:04 A.M., two CNA’s were observed in room [ROOM NUMBER]. No residents were observed in the room. One CNA was standing and leaning against A bed’s bureau and another aide was seated in B bed’s chair. The CNA’s were having a private conversation in hushed tones. At 10:06 A.M., the CNA who was seated, left the room. The CNA who was standing then sat in A bed’s chair.

At 10:08 A.M., the CNA who left the room observed the Surveyor in the hallways and then called for the CNA who was still in the room for assistance. During interview with the Unit Manager at 10:20 A.M., she said that no staff at that time were on break. The Surveyor alerted her of the above observations and she said that it was inappropriate for staff to be in resident rooms unless they are providing care, supervision or assistance.

Failed to make sure services provided by the nursing facility meet professional standards of quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure for 1 sampled Resident (#3), nursing services met standards of quality of care by failing to report and investigate a fall with fracture for 19 hours, resulting in delay in treatment.

Findings include:

Resident #3 was admitted to the facility in 5/1999. [DIAGNOSES REDACTED]. Review of the significant Minimum Data Set (MDS) with a completion date of 12/31/16, indicated that Resident #3 had a Brief interview of Mental Status score of 13 out of 15 which indicated Resident #3 was cognitively intact. The MDS indicated that Resident #3 required extensive assistance of 2 people for bed mobility, extensive assistance of one person for transfers and dressing, and was totally dependent on staff for bathing. The MDS indicated that Resident #3 required a wheelchair for mobility. Additionally the MDS indicated that Resident #3 received schedule pain medication regimen and was pain free in the previous five days from 12/31/17. Review of the fall risk assessment dated [DATE] indicated a fall score of 16. The falls risk assessment indicated that a total score of 10 or above represents High risk. Review of the facility’s policy on Accidents and Incidents indicated that all accidents or incidents involving resident, employees, visitors, vendors etc., occurring on the facility premises shall be investigated and reported to the Administrator.

The policy further indicated that the Nurse Supervisor/Charge Nurse and /or the department director or supervisor shall promptly initiate and document the investigation of the accident or incident. The policy indicated that the following data , as applicable, shall be included on the Report of Incident/Accident form:

a. The date and time the accident or incident took place
b. The nature of the injury/illness ( e.g , bruise, fall, nausea, etc., );
c. The circumstances surrounding the accident or incident;
d. Where the accident or incident took place;
e. The name(s) of witnesses and their accounts of the accident or incident;
f. The injured person’s account of the accident or incident;
g. The time the injured person’s attending physician was notified, as well as the time the physician responded and his or her instructions;
h. The date/time the injured person’s family was notified and by whom;
J The disposition of the injured ( i.e., transferred to the hospital, put to bed, sent home, returned to work, etc.,);
k. Any corrective action taken;
l. Follow up information m. Other pertinent date as necessary or required; and
n. The signature and title of the person completing the report

Review of an incident report submitted to the Department of Public Health’s Health Care Facility Reporting System on 1/11/17 indicated that Resident #3 had a fall on 1/9/17. The Incident report form indicated that Resident #3 had a fall on 1/9/17 at approximately 3:00 P.M. The report indicated that the 7:00 A.M. to 3:00 P.M. nurse (Nurse #1) was aware of the fall at the time, but did not report the incident to other staff nurses and did not document the fall in the Resident’s medical record. The incident report form indicated that Resident #3 had an x-ray on 1/10/17 with a result of a left femur fracture. The facility’s Incident/Accident report dated 1/10/17 indicated that the Unit Manager (U.M.) #1 was made aware on 1/10/17 at around 10:00 A.M. of the fall that occurred on 1/9/17 by Certified Nursing Assistants (CNA #1) and CNA #2 (over 19 hours after the fall occurred). Review of the hospital discharge summary dated 1/13/17 indicated that Resident #3 had a non displaced femoral neck fracture and that on 1/11/17 underwent a successful closed reduction percutaneous pinning. Resident #3 was discharged back to the facility on [DATE]. On 6/28/17 at 3:37 P.M., during interview with Nurse #1 she stated she was made aware around 3:00 P.M. on 1/9/17 by CNA #1 that Resident #3 was on the floor. Nurse #1 reported that she asked the Resident what happened and he/she said that he/she had rolled out of bed to the floor. Nurse #1 said that she did assess the Resident’s vital signs including blood pressure, temperature, pulse, and that the Resident could move his/her extremities as usual and denied pain. She said she did not document this information. She said the Resident insisted on getting to up off the floor. Nurse #1 said CNA #1 and CNA #2 assisted her to get Resident #3 into bed. Nurse #1 said she should have initiated an incident report which would have included notifying the physician, completing a falls assessment, pain assessment, updating the care plan and doing 10-15 minute checks, as the fall was unwitnessed. She said that after she left the facility she traveled that night out of the country for the next three and a half weeks, and it was not until she returned that she learned that Resident #3 had fractured his/her left femur.

During interview with CNA #1 on 6/29/17 at 9:36 A.M., she said she answered a call light in Resident #3’s room and found him/her on the floor. She said she could not recall if the bed alarm was sounding or if he/she had a bed alarm in use. CNA #1 said Nurse #1 and CNA #2 came in the room and that Resident #3 was saying get me up, get me up. CNA #1 said that she and Nurse #1 and CNA #2 got Resident #3 back into bed. CNA #1 said she did not report the fall to anyone as as she figured Nurse #1 would have done an incident report. CNA #1 said that the next morning CNA #2 was caring for Resident #3 and got a report the Resident had pain. CNA #1 said that she and CNA #2 then told the Unit Manager that Resident #3 had a fall the previous day around shift change (3:00 P.M.) During interview with CNA #2 on 6/29/17 at 10:14 A.M., she said she was in the dining room when a co-worker told her that Resident #3 was on the floor in his/her room. She said she went to the room and Nurse #1 checked him/her out and then she along with CNA #1 and Nurse #1 assisted the Resident off the floor. She said at this point it was time to leave and Nurse #1 stayed behind with Resident #3. CNA #2 said the following morning (1/10/17) she did not receive any report that Resident #3 had a fall. CNA #2 said when she went to Resident #3 and he/she complained of left hip pain and she became worried. CNA #2 said she went to CNA #1 and together they went to the Unit Manager to report that Resident #3 had a fall the previous day.

On 7/5/17 at 4:39 P.M., during interview via phone with Nurse #2 he said he was the 3:00 P.M. through 11:00 P.M. nurse that cared for Resident #3 on 1/9/17. He said he did not get any report from the previous shift nurse that Resident #3 had a fall. He said that he gave Resident #3 his/her evening medications and did not notice or have any suspicion that Resident #3 had any condition change. Review of a the nurses progress note, dated 1/10/17 with a time of 0628 (6:30 A.M.), indicated that Resident #3 slept on and off throughout the night, he/she complained of pain on his/her left leg 4 out of 10 on the pain scale, scheduled [MEDICATION NAME] 5 milligrams given with good effect, fluid encouraged as needed. vital signs; blood pressure 141/78, pulse 93, oxygen saturation 98 percent, temperature 98.8. Safety precautions maintained, no fall.

During interview on 6/29/17 at 9:07 A.M., via telephone, with Nurse #3, who had written the above nurses progress note, said she worked on the 11:00 P.M. -7:00 A.M., shift on 1/9/17-1/10/17. She said that she did not receive any report from the previous shift nurse that Resident #3 had a fall. She said she did take Resident #3’s vital signs in the morning and gave him/her scheduled pain medication. She said he/she indicated a pain score of 4 out of 10 which she said was unusual for him/her. She said that Resident #3 said his/her leg hurt but he/she did not say anything about a fall. During interview via telephone with CNA #3 on 6/29/17 at 9:28 P.M., he said that he worked a double shift from 3:00 P.M. through 7:00 A.M., and that he was assigned to care for Resident #3. CNA #3 said he was not given any report from nursing staff that Resident #3 had a fall. CNA #3 said that when he went to assist Resident #3 to get up for supper, Resident #3 complained of pain. CNA said he reported the complaint of pain to Nurse #2 and Nurse #2 said that he was aware and that Resident #3 could stay in bed for supper. CNA #3 said it was unusual for Resident #3 to stay in bed for supper, that he/she typically is up in his/her wheelchair. CNA #3 said he assisted Resident #3 in washing up in bed and Resident #3 remained on his/her back. At 11:30 P.M., CNA #3 said Resident #3 complained of pain. CNA #3 said he reported the pain to the nurse but he was not sure what was done about the pain. CNA #3 said that Resident #3 did not get up out of bed since he came on shift at 3:00 P.M.

On 6/28/17 at 4:20 P.M., during interview with UM #1, she said she was approached by CNA #1 and was asked if she was aware that Resident #3 fell the day before. UM #1 said that she was not aware and went to Resident #3 to do an assessment and Resident #3 reported to her I fell yesterday, you know and I have pain in my leg. UM#1 said at that time that she notified the physician, who gave orders for a portable x-ray. During interview with Resident #3 on 6/29/17 at 8:40 A.M., he/she was asked about what he/she recalled about the fall on 1/9/17. He/she said that he/she stepped on the floor and then landed on the floor. He/she said the nurses came and picked me up and put me into bed. The Resident was asked if he/she had any pain and he/she said he/she had hip pain but the nurses knew about it and I went to the hospital (on 1/10/17). Resident #3 said prior to the fall he/she would stay up in his/her wheelchair and watch television. When asked if he/she got up again the night of the fall he/she responded no.

Review of the nurses note dated 1/10/17 at 22:34 (10:34 P.M.), indicated the following; Numerous calls received (times 5) from Boston Medical center between a nurse and doctor, inquiring how the resident fell . Writer not able to answer questions. Resident admitted ( to the hospital). (The facility did not have a report or investigation initiated at the time of the fall to give to Boston Medical Center the information they needed on the investigation of Resident’s # 3’s fall.) During interview with the Director Of Nurses on 6/28/17 at 3:53 P.M. she said the facility did not fail the policy of incident reporting and investigation but that an individual staff person (Nurse #1) did not follow the policy. She said she attempted both by phone and email to reach nurse #1 about Resident #3’s fall but was unable to reach her as she was out of the country. For a period of 19 hours Resident #3 did not have any Licensed Nursing Staff or Certified Nursing Aid staff aware that he/she had a fall with a resulting injury. As per facility policy a prompt Incident/Accident report and investigation was not initiated at the time of the occurrence resulting in a delay in Resident #3 in getting necessary care and treatment of [REDACTED].

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 observations and interviews, the facility failed to provide adequate supervision in the facility designated smoking area to two sampled residents, (#29 and #30) out of a total of 32 sampled residents, and to a group of non-sampled residents who smoke.

Findings include:

Review of the facility’s smoking policy, dated 1/1/2015, indicated that smoking is only permitted under the supervision of a staff member in the facility’s designated somking area. On 8/18/17 at 10:40 A.M., the Surveyor observed a resident attempting to go outside to the smoking area.

There was no Security Guard in the area. The resident was in a wheelchair, holding open the heavy door with his/her arm as the automatic door opening mechanism had timed out. The resident continued to struggle and there were no staff in the area. Other residents were observed smoking outside.

On 8/18/17 at 12:58 P.M., the Surveyor observed 12 people outside in the smoking area. Including Resident #8, Resident #29 and Resident #30.

Resident #29’s annual smoking assessment dated [DATE], indicated that he/she requires supervision while smoking. Resident #29 was observed wearing a smoking apron. Resident #30’s annual smoking assessment, dated 9/13/16, indicated that he/she requires supervision while smoking due to hand tremors.

At 12:58 P.M., the Surveyor observed that no Security Guard was in the area to supervise the residents who were smoking. Resident #8 was attempting to manuver his/her electric wheelchair into the building but was struggling as Resident #30’s walker was obstructing the path. Resident #8 repeatedly asked Resident #30 to move his/her walker, and then became frustrated and drove his wheelchair into the walker, causing it to jerk and hit Resident #30 in the legs. The Surveyor alerted a rehab staff person to assist. The Surveyor then spoke with Resident #30 who denied that his/her walker had hit his/her legs. At 1:05 P.M., the Security Guard returned to the area.

During interview with the Administrator at 1:37 P.M., he said it was not acceptable that the Security Guard left the area and that the expectation is for the Security Guard to remain at his post to supervise residents as they smoke. He said that the Security Guard had been trained on this.

Failed to prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.

Based on interview and test trays, the facility failed to serve food that was palatable and at approrpriate temperatures. During the Resident Group Interview on 6/27/17 at 3:00 P.M., multiple participants from various units reported they had concerns with the food regarding taste and temperature. Participants reported that meals are served cold and do not taste good.

Findings include:

On 6/28/17 at 8:08 A. M., the surveyor observed the breakfast meal service in the main dining room. The meal consisted of scrambled and hard-boiled eggs, bacon, toast, grits, oatmeal, coffee and milk. The meal was being served out of a steam table and the coffee was being served out of a water pitcher that was not insulated. At 8:16 A.M., they surveyor obtained a sample meal of scrambled eggs, bacon, oatmeal, coffee and milk. The scrambled eggs were cool and registered at 146 degrees Fahrenheit. The oatmeal was cool, tasteless and paste-like and registered at 135 degrees Fahrenheit. The toast was soggy and cold, and the bacon was flavorful but cold. The coffee with milk registered at 124 degrees Fahrenheit and was cool. The cook said that he does not take the temperature of the meal prior to serving it out of the steam tray and goes by the temperatures that were registered when the temperatures are taken in the kitchen.

On 6/28/17 at 11:59 A.M., the surveyor observed the lunch meal service in the 2nd floor dining area which services residents from both the 2 East and 2 West units. The meal consisted of meatloaf, baked potato, carrots, ice-cream and milk. The meals were delivered via trays on food trucks. The first truck was delivered at 12:04 P.M., and the last tray was delivered to at 12:40 P.M. The Surveyor obtained a test tray. The meatloaf was cold and with a paste like consistency and registered at 104 degrees Fahrenheit. The baked potato was luke warm at 120 degrees temperature and taste. The following were the results:

*Carrots registered at 90 degrees Fahrenheit and were warm, not hot to taste.
*Meatloaf with gravy on top registered at 105 degrees Fahrenheit and tasted warm, not hot and the gravy was salty.
*White rice registered at 105 degrees and tasted warm, not hot.
*apple juice registered at 59 degrees Fahrenheit and tasted cool.
* orange jello registered at 58 degrees Fahrenheit and tasted cool not cold.
* Hot water for tea, registered 120 degrees which tasted warm, not hot. The test tray did not present as having hot food hot and cold foods cold.

Failed to store, cook, and serve food in a safe and clean way

The facility failed to maintain an appropriate temperature level for food items in the main walk in refrigerator in the kitchen.

Findings include:

During the initial kitchen walk through on 6/27/17 at 7:15 A.M., the surveyor observed that the walk in refrigerator door was propped open. They surveyor observed the thermometers inside of the refrigerator as reading at 50 degrees Fahrenheit (safe temperature levels for refrigerated food items is 40 degrees Fahrenheit). The Surveyor alerted a dietary aide that the door to the refrigerator was opened and he closed it and said that the staff had left it open as they were preparing the milk and forgot to close it.

Failed to keep all essential equipment working safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the Facility failed to ensure that the Automatic External Defibrillator (AED- a device that can identify an abnormal heart rhythm that needs a shock, which increases the chance of survival) were in working condition with current [MEDICATION NAME] pads readily available for immediate usage.

Findings include:

During an initial report of the 2 East nursing unit, on 8/18/17 at 8:00 A.M., Nurse #1 indicated that Resident #31 had a recent incident which required the use of the facility AED. Review of nurses notes for Resident #31 indicated that on 7/2/17 at 8:55 A.M. there was a code blue (an emergency situation announced in a health care facility requiring nursing providers to rush to a specific location and begin immediate resuscitative efforts). The AED was activated four times. 911 was called and Resident #31 was transferred to the hospital.

Observation of the AED on 8/18/17 at 8:45 A.M. revealed that there were [MEDICATION NAME] pads connected to the AED that had expired 1/17/17. In addition there were 3 other sets of [MEDICATION NAME] pads next to the AED that were opened and expired 1/18/16, 12/6/16, 3/17/17. The AED checklist sheet for August 2017 indicated a daily check is to be completed including checking of the [MEDICATION NAME] pad expiration dates.

During an interview with Nurse #2 on 8/18/17 at 9:00 A.M., she confirmed that the pads were expired and should have been checked. She also said that the AED was the only one in the facility and there are residents in the facility that are a full code (wants resuscitation measures taken). During an interview with the Director of Nurses on 8/18/17 at 9:30 A.M., she said that the ambulance company is responsible for the AED [MEDICATION NAME] pads.

Based on observation and staff interview, the Facility failed to ensure that the Automatic External Defibrillator (AED- a device that can identify an abnormal heart rhythm that needs a shock, which increases the chance of survival) were in working condition with current [MEDICATION NAME] pads readily available for immediate usage.

During an initial report of the 2 East nursing unit, on 8/18/17 at 8:00 A.M., Nurse #1 indicated that Resident #31 had a recent incident which required the use of the facility AED.

Review of nurses notes for Resident #31 indicated that on 7/2/17 at 8:55 A.M. there was a code blue (an emergency situation announced in a health care facility requiring nursing providers to rush to a specific location and begin immediate resuscitative efforts). The AED was activated four times. 911 was called and Resident #31 was transferred to the hospital.

Observation of the AED on 8/18/17 at 8:45 A.M. revealed that there were [MEDICATION NAME] pads connected to the AED that had expired 1/17/17. In addition there were 3 other sets of [MEDICATION NAME] pads next to the AED that were opened and expired 1/18/16, 12/6/16, 3/17/17.

The AED checklist sheet for August 2017 indicated a daily check is to be completed including checking of the [MEDICATION NAME] pad expiration dates. During an interview with Nurse #2 on 8/18/17 at 9:00 A.M., she confirmed that the pads were expired and should have been checked. She also said that the AED was the only one in the facility and there are residents in the facility that are a full code (wants resuscitation measures taken).

During an interview with the Director of Nurses on 8/18/17 at 9:30 A.M., she said that the ambulance company is responsible for the AED [MEDICATION NAME] pads.

Failed to make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

The facility failed to maintain and follow an effective pest control program in the kitchen and on resident units regarding mice and flies.

Findings include:

During initial observations in the facility kitchen on 6/27/17 at 7:15 A.M., the surveyor observed multiple flies in various areas of the kitchen. During interview with the Food Service Director, (FSD), on 6/27/17 at 11:29 A.M., he said that the flies in the kitchen had been an ongoing issue and that pest control services had been involved. Flies were also observed in the kitchen on 6/28/17.

During the group interview on 6/27/17 at 3:00 P.M., 8 of 20 participants vocalized seeing mice on resident units. Review of the facility’s pest control service logs indicated that their pest control services have been visiting weekly and had made the following recommendations: 5/5/17 for door to the loading dock near the kitchen to the outside dumpster to be kept closed. The notes indicated that observations from the pest control service on 5/5/17, 5/17/17 and 6/21/17 indicated that the door on the loading dock is left open or ajar. 5/12/17 recommendations were made for the kitchen to have screens around the entrance doors and windows.

6/14/17 and 6/21/17 recommendations were made for the kitchen staff to no longer store wet mop heads in the kitchen chemical closet. Further review of the pest control logs indicated that mice were continued to be reported in resident rooms and units during various visits throughout 5/2017 and 6/2017. On 6/28/17 at 9:11 A.M., the Surveyor noted that loading dock door near the dumpster was propped open. The Surveyor also observed multiple flies in the kitchen chemical closet and wet mop heads were stored in the closet as well, which conflicted with the reccomendations made by the pest control services. No screens were observed at the kitchen doors or windows.

On 6/28/17 at 9:47 A.M., the Surveyor observed that the loading dock door was still open. Upon further inspection, the Surveyor observed that the door latch was broken and did not shut automatically and instead, someone would need to pull the door shut after entering the building. The FSD then arrived and the Surveyor alerted him that the door was broken. He said that maintenance was responsible for monitoring the door. Despite having weekly pest control visits, the facility failed to follow the pest control recommendations resulting in a continuance of flies and reports of mice in the facility.

Benjamin Health Care, 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 Profile for Benjamin Health Care

Nursing Home Safety, Health and Inspection Report for Benjamin Health Care 06/30/2017

Page Last Updated: March 2, 2018

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