Blaire House of Worcester

Blaire House Worcester

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Blaire House of Worcester? 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 Blaire House of Worcester

Blaire House of Worcesteris a for profit, 75-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Worcester, Millbury, Shrewsbury,  Grafton, Sutton, Leicester, Westborough, Northborough, Holden, Northbridge, Oxford, Spencer, Clinton, Hopkinton,  Marlborough, and the other towns in and surrounding Middlesex County, Massachusetts.

Blaire House of Worcester
116 Houghton St
Worcester, MA 01604

Phone: 844.322.3648
Website: http://www.elderservices.com/blairehouseofworcester/

CMS Star Quality Rating

Blaire House WorcesterThe 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 July 2018, Blaire House in Worcester, Massachusetts received a rating of 4 out of 5 stars.

Performance Area Rating
Overall Rating 4 out of 5 (Above Average)
State Health Inspections 2 out of 5 (Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 5 out of 5 (Much Above Average)

Fines Against Blaire House of Worcester

The Federal Government has not fined Blaire House of Worcester in the last 3 years.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Blaire House of Worcester committed the following offenses:

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and facility policy review, 3 staff members failed to acknowledge the correct procedure in how to intervene in situations involving abuse. In addition, the facility staff failed to thoroughly investigate and report to the Department of Health (DPH), occurrences of bruising of unknown origin as per their policy, for 2 sampled residents (#3, #7), out of a total sample of 15 sampled residents.

Findings include:

Review of the facility Abuse Prevention Policies and Procedures, with revision date of 3/2017, indicated in Section E: Investigation, that upon observation of potential/alleged resident abuse, the observing staff is required to intervene, stop the potential/alleged abuse, and report to the supervisor.

1. During an interview, on 4/7/17 at 7:10 A.M., Certified Nurse Aide (CNA) #1 said he would report to a supervisor first, if he witnessed or overheard any suspected occurrence of abuse. When questioned further by the surveyor, he said he would not intervene immediately, as he would not want the alleged accuser to know it was he, who reported the occurrence.

2. During an interview, on 4/7/17 at 11:00 A.M., the Maintenance Assistant said he would report to a supervisor first, if he witnessed or overheard any suspected occurrence of abuse. He did not indicate that he would intervene first, to ensure resident’s safety, as per policy.

3. During an interview, on 4/7/17 at 7:10 A.M., the Activity Aide said she would report to a supervisor first, if she witnessed, or overheard any suspected occurrence of abuse. She did not indicate that she would intervene first, to ensure resident’s safety as per policy.

4. Resident #7 was admitted to the facility in 10/2014, with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Progress Notes, dated 6/21/2016, indicated that at about 4 :00 P.M., the resident was found to have purplish discoloration to his/her left eye lid region. Further review of the notes, indicated an entry was made to address the discoloration to the left eye on 6/23/16, 6/27/16 and 6/29/16. On 6/29/16 at 17:24, the progress note described the discoloration as a black eye to the left eye. Review of the facility Injury of Unknown Origin Investigation form, dated 6/21/16, indicated no outcome or intervention for the incident of the discoloration of the left eye.

Review of the facility Injury Of Unknown Origin Policy, with a revision date of 3/2017, indicated that Case Management will review the investigation documents to determine whether the injury may be associated with abuse, neglect or mistreatment. If so, the event must be reported to the Department of Public Health, Division of Health Care Quality via the online reporting system.

Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/24/17, indicated that the resident was severely impaired for cognitive skilled for daily decision making.

During an interview, on 4/12/17 at 2:20 P.M., the Director of Nursing Services (DNS) said that she did not complete the Injury of Investigation Form. She said she did not feel this bruise of unknown origin was the result of abuse. She said the resident did not complain of pain to the left eye, nor was there any swelling. She also said there was no change in the resident’s demeanor. She said maybe the resident rubbed his/her eye. She also said if she had a gut feeling that abuse had occurred, then she would have reported it to DPH, but she did not have that feeling, and she did not report it to DPH.

5. For Resident #3, the facility staff failed to thoroughly investigate an injury of unknown origin, and report findings to DPH, for a bruise on the resident’s eye. Resident #3 was admitted to the facility in 7/2015, with [DIAGNOSES REDACTED]. Review of the facility Injury Of Unknown Origin Policy, with a revision date of 3/2017, indicated that Case Management will review the investigation documents to determine whether the injury may be associated with abuse, neglect or mistreatment. If so, the event must be reported to the Department of Public Health, Division of Health Care Quality via the online reporting system. Review of the Quarterly MDS Assessment, with an ARD of 2/14/17, indicated that the resident had severe cognitive impairment, was rarely able to understand others/make self understood, was totally dependent with assist of 2 staff for dressing/personal hygiene, and exhibited no behavioral symptoms including physical/verbal or other behavioral symptoms, during the assessment period.

Review of the Interdisciplinary Progress Notes, dated 4/6/17, indicated that on the 11:00 P.M.-7:00 A.M. shift, the resident was awake most of the night and was attempting to get out of his/her chair, was undressing, combative and difficult to redirect. The note further indicated that [MEDICATION NAME] was administered with poor effect. Review of the Interdisciplinary Progress Notes, dated 4/6/17, indicated that on the 7:00 A.M.-3:00 P.M. shift, the CNA noted a red area on the right eyelid and notified the nurse. Review of the facility Quality Assessment and Assurance Incident Report form, dated 4/06/17, indicated that an injury of unknown origin was identified by the CNA during care. The CNA noted a bruise on the resident’s right upper eye. The report indicated that the resident was disoriented, and indicated that the cause of the injury was unable to be determined. The intervention added to the plan of care at that time was to provide constant redirection.

Review of the Interdisciplinary Progress Notes, dated 4/8/17, indicated that there was no changes to the resident’s right eyelid bruise. On 4/11/17 at 11:00 A.M., the surveyor observed Resident #3 seated in a scoot chair, in the hallway. The resident had on compression stockings, and had a clip belt positioned around his/her abdomen. The resident was observed pulling him/herself in the scoot chair, down the hallway. During an interview, on 4/12/17 at 12:30 P.M., the DNS said that the resident was resistive to care and strikes out at staff. She further said that the determination was that the area was self inflicted, but this determination was not part of the investigation or medical record. The DNS said that if abuse was suspected, she would have obtained statements from multiple shifts to determine the cause of the incident. The DNS said that she did not obtain statements from multiple shifts because it was determined that the area was self inflicted, as the resident is resistive to care, and may require the assistance of 2-3 staff to get dressed. During a follow up interview, on 4/12/17 at 2:20 P.M., the DNS said she did not feel this bruise of unknown origin was the result of abuse. She also said if she had a gut feeling that abuse had occurred, then she would have reported it to DPH, but she did not have that feeling, and she did not report it to DPH.

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 observation, interviews and record review, the facility staff failed to accurately code resident information relative to presence of infection and falls, in the Minimum Data Set (MDS) Assessment, for 2 sampled residents (#1, #12), in a total of 15 sampled residents.

Findings include:

1. For Resident #1, the facility staff failed to accurately code a fall in the MDS Assessment. Resident #1 was admitted to the facility in 4/2016, with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Progress Notes, dated 4/28/16, indicated that the resident experienced a fall, out of his/her geriatric chair in the hallway, with injury. The progress note further indicated that the resident was able to move all extremities and that neuro-check assessment was initiated.

Review of the 30 day MDS assessment, with an ARD of 5/11/16, indicated that the resident did not experience any falls since the last assessment period of 4/25/16. On 4/12/17 at 9:15 A.M., the surveyor observed Resident #1 ambulating in the hallway. The resident was wearing non-skid socks, a gait belt and was assisted by 3 staff members. During an interview, on 4/12/17 at 1:15 P.M., the MDS Coordinator said that the resident had a fall on 4/28/16, and that the fall was not coded on the 5/11/16 MDS, and it should have been.

4. For Resident #12, the facility staff failed to ensure correct MDS coding for infections. Resident #12 was admitted to the facility in 8/2016, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, with an ARD of 11/18/16, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 (severe cognitive impairment). Review of the Progress Notes, dated 11/4/16, indicated the resident was pale and soaked in sweat. The resident’s blood pressure was 157/63, his/her pulse was 95-144, temperature was 96.7 and oxygen saturation on room air was 92%. A call was placed to the Nurse Practioner, and orders were received to do lab work and a chest x-ray. Review of the Radiology Report for a Chest X-(NAME) done 11/4/16, indicated a right perihilar infiltrate (an abnormal substance in the hila region of the lung) and effusion (fluid).

Review of the Hematology report, dated 11/4/16, indicated the white blood cell count to be 18.6 (normal range is 4.8.-10.8). Review of the Physician’s Interim/Telephone Orders, dated 11/4/16, indicated the Doctor ordered [MEDICATION NAME] (an antibiotic) 500 mg (milligrams), to be given daily for 7 days. Review of the Progress Notes, dated 11/5/16, 11/7/16 and 11/8/16, indicated that the resident was receiving antibiotic therapy for pneumonia. Review of the Quarterly MDS, with an ARD of 11/8/16, indicated in Section I2000 that the resident did not have an active [DIAGNOSES REDACTED]. During an observation, on 3:00 P.M., the 4/12/17 at 12:20 P.M., the resident was sitting at a table, in the unit dining room, with 3 other residents, and was eating lunch. The resident smiled when he/she made eye contact with the surveyor. The resident was dressed neatly and was wearing shoes. During an interview, on 4/12/17 at 3:00 PM., the MDS Coordinator said she did not code Pneumonia on the 11/8/16 MDS, as she said the right perihilar infiltrate noted on the chest x-ray done on 11/4/16, could be a fluid or tissue growth.

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 observations, interviews and record reviews, the facility staff failed to follow the resident plan of care relative to preventing falls, providing a wheelchair cushion and multipodus boots, for 1 sampled residents 1 (#9), in a total of 15 sampled residents.

Findings include:

Resident #9 was admitted to the facility in 8/2016, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 8/22/16, indicated that Resident #9 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 (indicating severe cognitive impairment), required extensive assistance of 2 staff with bed mobility, transfers and toilet use, was frequently incontinent of bladder/bowel, and experienced no falls since admission or prior to admission.

Review of the Plan of Care for Falls, (initiated on 8/16/16), indicated the resident was at risk for falls relative to impaired cognition, impaired communication, impaired mobility, use of [MEDICAL CONDITION] medications, history of falls and incontinence. The following intervention was added on 8/31/16: Pressure alarm when resident is in the bed/chair.

Review of the Physician Orders, dated 9/2016, indicated an order (initiated 8/15/16) for the resident to have a pressure alarm while in the bed and in the chair. Review of the Quality Assessment and Assurance Incident Report, dated 9/22/16, indicated that Resident #9 experienced an unwitnessed fall, without injury, at 1:30 A.M. The report indicated that the resident was found on the floor, sitting on his/her buttocks, in the doorway to the bathroom. The resident was bare foot and stated he/she was going to the bathroom because his/her clothes were wet. The report indicated that a bed/personal alarm was not in use at the time of the fall, as ordered. The intervention added to prevent further falls included: slipper socks and a clip alarm.

Review of the Quality Assessment and Assurance Incident Report, dated 11/30/16, indicated that Resident #9 experienced an unwitnessed fall, without injury, at 5:00 A.M. The report indicated that the resident was awake in his/her wheelchair at 2:00 A.M., and was medicated with [MEDICATION NAME] 100 milligrams, (an antidepressant medication used to aid in sleep) at 3:00 A.M. The report further indicated, that at 5:00 A.M., the resident had fallen from his/her wheelchair, onto the floor, outside of the day room. The report indicated that the alarm was in place and ringing at the time of the fall, but that the resident had on socks, not slipper socks, as care planned.

On 4/6/17 at 8:30 A.M. during the initial tour, the surveyor observed Resident #9 lying in a low bed, with his/her eyes closed. The bed alarm was in place, and the call bell cord and push button was observed hanging over the call bell system box, attached to the wall, behind the resident’s bed, and was not accessible to the resident. During an interview, on 4/12/17 at 3:30 P.M., the Director of Nursing Services (DNS) said that the resident did not have the bed alarm on, as ordered, during the 9/22/16 fall. She further said that the intervention for adding non-skid/slipper socks after the 9/22/16 fall was not carried over to the resident’s plan of care, and that the resident did not have them on during the 11/30/16 fall.

Failed to keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility staff failed to ensure a medication pass error rate of less than 5 percent (%). The medication pass error rate was observed to be 26.9% for 1 Non-(NAME)pled (NS) resident, out of a total of 4 sampled residents, and 4 Non-(NAME)pled residents, in 26 opportunities.

Findings include:

Review of the facility policy, Medication Administration (NAME)es, with revision date of 5/1/2010, indicated that the facility should commence medication administration within 60 minutes before the designated times of administration, and should be completed by 60 minutes, after the designated time of administration.

NS #1 was admitted to the facility in 2/2016, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set Assessment, with an Assessment Reference Date (ARD) of 1/31/17, indicated a Brief Interview for Mental Status score of 13 out of 15 (cognitively intact).

Review of the Medication Administration Record [REDACTED].M

-[MEDICATION NAME] (medication to treat high blood pressure)12.5 mg (milligrams), one tablet by mouth

-[MEDICATION NAME] (medication used to treat anxiety) 15 mg, one tablet by mouth

-[MEDICATION NAME] Sprinkles (medication used as anticonvulsant) 125 mg, 4 capsules by mouth -Klonopin (medication used as an anticonvulsant) 0.5 mg, one tablet by mouth

-[MEDICATION NAME] (pain medication) 5/325 mg, one tablet by mouth

-[MEDICATION NAME] (stool softener) 100 mg, one tablet by mouth

-[MEDICATION NAME] (medication to treat nausea/vomiting) 25 mg, 3 capsules by mouth

During an observation of a medication pass, on 4/7/17 at 10:30 A.M., Nurse #1 was observed administering the following medications: [REDACTED] -[MEDICATION NAME] 12.5 mg, one tablet by mouth

-[MEDICATION NAME] 15 mg, one tablet by mouth

-[MEDICATION NAME] Sprinkles 125 mg, 4 capsules by mouth

-Klonopin 0.5 mg, one tablet by mouth

-[MEDICATION NAME] 5/325 mg, one tablet by mouth

-[MEDICATION NAME] 100 mg, one tablet by mouth

-[MEDICATION NAME] 25 mg, 3 capsules by mouth

During an interview, on 4/12/17 at 3:00 P.M., the Director of Nursing Services (DNS) said she was aware medications needed to be administered one hour prior to and one hour after the designated time of administration. She said that Nurse #1 was late in administering the medications to NS #1 on 4/7/17 at 10:30 A.M

Failed to maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Based on observation and interview, the facility staff failed to ensure that narcotic medications were stored in a separately locked, permanently affixed compartments, in the medication refrigerator.

Findings include:

During an observation, on 4/11/7 at 9:50 A.M., in the medication room, a small locked medication refrigerator contained a card of 20 tablets of (NAME)nol (a controlled medication used to treat nausea and vomiting), for a specific resident. In addition, one bottle of Ativan (a sedative) liquid, for a specific resident was noted in the refrigerator. Both medications were stored in this refrigerator in the open, and not in a separately locked, permanently affixed compartment, within the refrigerator.

During an interview, on 4/11/17 at 9:55 A.M., the Staff Development Coordinator said the (NAME)nol tablets and Ativan liquid medications were not stored in a separately locked, permanently affixed compartments.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record and policy review, the facility staff failed to provide infection control practices, relative to a Foley catheter (a type of tubing to allow the flow of urine) bag and/or Foley catheter tubing, for 1 sampled resident (#4), in total of 15 sampled residents.

Findings include:

Resident #4 was admitted to the facility in 9/2016, with [DIAGNOSES REDACTED]. Review of the Urinary Catheter Care Policy, (revised 10/2010), indicated under Infection Control, included the following: use standard precautions when handling or manipulating the drainage system, and be sure the catheter tubing and drainage bag are kept off of the floor.

Review of the Plan of Care, dated 1/4/17, indicated the resident had an alteration in elimination related to urinary retention, and required the use of an indwelling catheter. The interventions added to the plan of care included: keep all tubing off the floor and free of kinks. Review of the Significant (NAME)e in Status Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 3/24/17, indicated that the resident had severe cognitive impairment, required extensive assistance of 2 staff for toileting, and had an indwelling catheter in place.

Review of the Physicians Orders, dated 4/2017, indicated an order to connect the indwelling Foley catheter to a urinary drainage bag at all times. On 4/6/17 at 9:20 A.M., the surveyor observed the resident seated in a reclined geriatric (geri) chair, in his/her room, positioned in front of the door, facing the hallway. The resident had a Foley catheter bag that was lying sideways, on the floor, under the elevated leg rests. The Foley catheter bag was not observed in a privacy/dignity bag. On 4/6/17 at 2:30 P.M., the surveyor observed the resident lying in bed. The resident had bilateral floor mats in place, and the bed was in the low position. The surveyor observed that the Foley catheter bag was positioned within a privacy bag, but the bag was noted to be on the floor at the end of the resident’s bed. The catheter tubing was observed on the floor mat, that was positioned next to the bed.

On 4/7/17 at 12:00 P.M., the surveyor observed the resident seated in a geri-chair in the dining room. The resident had a Certified Nurse Aide (CNA) seated next to him/her. The surveyor observed the resident’s Foley catheter tubing to be on the floor.

On 4/12/17 at 11:30 A.M., the surveyor observed the resident seated in a geri-chair, in his/her room, with a rehabilitation staff member. The resident’s leg rests were positioned down, and the Foley catheter tubing was observed to be on the ground, with the resident’s shoes on top of the tubing.

During an interview, on 4/12/17 at 11:30 A.M., CNA #2 said that the Foley catheter tubing should be kept off the ground to prevent infection. During an interview, on 4/12/17 at 11:35 A.M., Unit Manager (UM) #1 said that the Foley catheter bag and tubing should be kept off the floor. She further said that she will look into the positioning of the Foley catheter tubing when the resident is in bed.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility staff failed to ensure medical record accuracy for 5 sampled residents (#1, #3, #4, #7, #14 and #15), out of 15 sampled residents, and for 1 non-sampled residents (NS #2), out of a total of 2 non-sampled residents.

Findings include:

1. Resident #7 was admitted to the facility in 10/2014, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/24/17, indicated that the resident was severely impaired for cognitive daily decision making skills. Review of the ADL (Activities of Daily Living) Care Plan, with an effective date of 2/9/17, indicated that the resident was to utilize a right arm bolster in the geriatric (geri) chair.

Review of the Physician Orders, dated 4/01/2017, indicated an order for [REDACTED]. During an observation, on 4/11/17 at 8:50 A.M., the resident was sitting in a Broda (type of reclining wheelchair) chair, in the dining room, and was being fed breakfast. The resident did not have a right arm bolster on the wheelchair. During an observation, on 4/11/17 at 9:30 A.M., the resident was sitting in a Broda chair, in his/her room. There was no right arm bolster observed on the chair. During an observation, on 4/11/17 at 10:00 A.M., the resident was in his/her room, sitting in the Broda chair, and there was no right arm bolster observed on the chair. During an interview, on 4/11/17 at 1:00 PM., the Staff Development Coordinator (SDC) said that the care plan was incorrect in stating that the resident required a right arm bolster when in the geri-chair. She said that since the resident was given a Broda chair, a right arm bolster was not needed. She said the ADL Care Plan had not been updated to reflect the current plan of care.

2. Resident #14 was admitted to the facility in 1/2017, with [DIAGNOSES REDACTED]. Review of the Physician Orders, dated 2/2/17, indicated an order to discharge to another nursing facility. Review of the Facility Discharge List form, indicated that the resident was discharged on [DATE]. Review of the Interdisciplinary Progress Notes, in the medical record, did not indicate when the resident was discharged , or any information regarding discharge from the facility. During an interview, on 4/12/17 at 3:45 P.M., the facility Regional Nurse said that the expectation is that a nurse should document on events occurring with a resident. She said a discharge is an event that would require documentation in the Interdisciplinary Progress Notes.

3. NS #2 was admitted to the facility in 3/2016, with [DIAGNOSES REDACTED]. Review of the (NAME)ual MDS Assessment, with an ARD of 2/7/17, indicated that the resident was severely impaired for cognitive skills for daily decision making. Review of the 2/2017 Physician Orders, indicated an order for [REDACTED]. Review of the 2/2017 Medication Administration Record [REDACTED].M. During an interview, on 4/7/17 at 4:00 P.M., the Director of Nursing Services (DNS) said the [MEDICATION NAME] order is incorrect, and [MEDICATION NAME] is administered once at 1:00 P.M.

4. For Resident #1, the facility staff failed to accurately document the date of a fall in the Interdisciplinary Progress Notes.

Resident #1 was admitted to the facility in 4/2016, with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Progress Notes, dated 4/23/16, indicated that the resident experienced a fall, with no injuries.

Review of the Admission MDS Assessment, with an ARD of 4/25/16, indicated that the resident exhibited severe cognitive impairment, required assist of 2 staff for transfers and ambulation, was unsteady and required staff assistance to stabilize when ambulating, turning around, moving from seated to standing position, and experienced 1 fall, with no injury, during the assessment period.

Review of the Interdisciplinary Progress Notes, dated 4/29/16, indicated that the resident was discussed in Medicare meeting on 4/28/16. The progress note further indicated that the resident experienced a fall on 4/24/16, with no injury. On 4/12/17 at 9:15 A.M., the surveyor observed Resident #1 ambulating in the hallway. The resident was wearing non-skid socks, a gait belt and was assisted by 3 staff members. During an interview, on 4/12/17 at 1:15 P.M., the MDS Coordinator said that the resident had a fall on 4/23/16 and the progress note on 4/29/16 was incorrect.

5. For Resident #3, the facility staff failed to accurately document the resident’s Advanced Directives in the Physician orders, Treatment Orders and the Plan of Care. Resident #3 was admitted to the facility in 7/2015, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, with an ARD of 2/14/17, indicated the resident had severe cognitive impairment, and had an Advanced Directives that included: Do Not Resuscitate (DNR= indicating do not perform cardiopulmonary resuscitation), Do Not Hospitalize (DNH), Do Not Intubate (DNI), and that the Health Care Proxy (HCP) was in place/invoked.

Review of the Physician Orders, dated 4/2017, indicated an order (dated 10/7/15) for DNR, DNI. Further review of the Physician Orders, indicated under Advanced Directives, that the resident was documented as a Full Code status (indicating to perform cardiopulmonary resuscitation). Review of the Treatment Record, dated 4/2017, indicated under Advanced Directives that the resident was a Full Code status.

Review of the current Plan of Care form, indicated the resident’s code status as DNR, DNI, DNH, no [MEDICAL TREATMENT], no artificial nutrition and no artificial hydration. Further review of the form, indicated under Advanced Directives that the resident was a Full Code. On 4/11/17 at 1:30 P.M. the surveyor observed Resident #3 sitting in a scoot chair, in the hallway. The resident was wearing bilateral TEDS (compression stockings), and non-skid socks, had a clip belt fastened around his/her abdomen. The resident was observed to be pulling him/herself in the chair, holding onto the wall railings. During an interview, on 4/12/17 at 11:50 A.M., Unit Manager (UM) #1 said that Resident #3 should be a DNR/DNI, not a Full Code status. She said the Full Code status listed under Advanced Directives was a computer entry error.

6. For Resident #4, the facility staff failed to accurately document the resident’s Advanced Directives in the Physician orders, Treatment orders and the Plan of Care. Resident #4 was admitted to the facility in 9/2016, with [DIAGNOSES REDACTED]. Review of the Significant (NAME)e in Status MDS Assessment, with an ARD of 3/24/17, indicated the resident had severe cognitive impairment and had Advanced Directives that included: DNR, DNH, DNI, and that the HCP was invoked. Review of the Physician Orders, dated 4/2017, indicated an order (dated 2/22/17) for DNR, DNI, DNH, no [MEDICAL TREATMENT], no artificial nutrition. Further review of the Physician Orders, indicated that under Advanced Directives, the resident was listed as a Full Code status, DNI.

Review of the Treatment Record, dated 4/2017, indicated under Advanced Directives that the resident was a Full Code status, DNI. Review of the current Plan of Care form, indicated the resident’s code status as DNR, DNI, DNH, no [MEDICAL TREATMENT], no artificial nutrition and no artificial hydration. Further review of the form, indicated under Advanced Directives that the resident was a Full Code, DNI.

On 4/6/17 at 1:00 P.M., the surveyor observed Resident #4, lying in a geriatric (geri) chair, that was reclined backwards in an almost supine (flat) position, with his/her eyes open. The resident’s leg rests were up, and a seat belt was fastened around his/her abdomen. During an interview, on 4/12/17 at 11:50 A.M., UM #1 said that Resident #3 should be a DNR/DNI, not a Full Code status. She said the Full Code status listed under Advanced Directives was a computer entry error.

7. For Resident #15, the the facility staff failed accurately document the resident’s Advanced Directives in the Physician orders. Resident #15 was admitted to the facility in 11/2015, with [DIAGNOSES REDACTED]. Review of the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, signed by the Physician on 8/3/16, indicated an order for [REDACTED]. Review of the Quarterly MDS Assessment, with an ARD of 12/13/16, indicated the resident had severe cognitive impairment, and had Advanced Directives that included: DNR, DNH, DNI, and the HCP was invoked.

Review of the Physician Orders, dated 2/2017, indicated an order (dated 8/3/1916) for DNR, DNI, DNH, no [MEDICAL TREATMENT], no artificial nutrition, no artificial nutrition. Further review of the Physician Orders, indicated that under Advanced Directives, the resident was listed as a Full Code status. During an interview, on 4/12/17 at 3:20 P.M., the Director of Nursing Services (DNS) said that she was made aware of the conflicting information in the resident records regarding code status, and that the resident was a DNR, DNI, DNH, not a full code. The DNS further said that the order date for the DNR order for Resident#15 was incorrect.

Blaire House of Worcester, 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 – Blaire House of Worcester

Inspection Report for Blaire House of Worcester – 04/12/2017

Page Last Updated: July 14, 2018

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