Brentwood Rehabilitation and Healthcare CTR

Brentwood Rehabilitation & Healthcare Center

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About The Brentwood Rehabilitation & Healthcare Center

Brentwood Rehabilitation & Healthcare CenterBrentwood Rehabilitation and Healthcare CTR is a for profit, 159-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Danvers, Peabody, Middleton, Beverly, Salem, Lynnfield, North Reading, Marblehead, Swampscott, Lynn, Wakefield, Reading, Saugus, Ipswich,  Melrose, and the other towns in and surrounding Essex County, Massachusetts.

Brentwood Rehabilitation and Healthcare CTR focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Brentwood Rehabilitation & Healthcare Center
56 Liberty St,
Danvers, MA 01923

Phone: (978) 777-2700
Website: http://thebrentwoodrehab.com/

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, Brentwood Rehabilitation & Healthcare Center in Danvers 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 4 out of 5 (Above Average)
Quality Measures 4 out of 5 (AboveAverage)

Fines Against Brentwood Rehabilitation & Healthcare Center

The Federal Government fined Brentwood Rehabilitation and Healthcare Center $2,500 on April 7th 2015,  $2,300 on August 24th 2015, and $33,031 on October 7th, 2016 for health and safety violations.

Fines and Penalties

Our Nursing Home Neglect Lawyers inspected government records and discovered Brentwood Rehabilitation and Healthcare CTR committed the following offenses:

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 interviews, the facility failed to notify a court appointed guardian of a Physician’s order in 1 (Resident # 21) of 24 sampled resident’s.

Findings include:

For Resident #21, the facility failed to inform the court appointed legal guardian of a Physician’s Order for change in condition and evaluation and admission to hospice services.

Resident #21 was admitted to the facility in 1/2015 with [DIAGNOSES REDACTED]. On 4/18/16 at 3:30 P.M., progress notes were reviewed and indicated that on 4/9/17 the resident was lethargic, difficult to arouse and unable to maintain eye contact. The Nurse Practitioner and family were notified of Resident #21’s change in condition. The Nurse Practitioner wrote an order for [REDACTED].

On 4/18/14 at 3:45 P.M., in an interview with the floating Unit Manager, she said she was unsure if the resident was on hospice benefits yet. When she checked the electronic medical record,she found the resident was not. She could not find a referral in the record either. On 4/18/17 at 4:00 P.M., a telephone interview with the court appointed guardian took place. She said that she had not been informed of the order for hospice evaluation and admit.

In an interview with the Director of Nursing on 4/18/17 at 4:23 P.M., the Director of Nursing said that the facility attempted to reach the guardian and hadn’t heard back from her yet. There was no documentation in the record of attempts to reach the guardian. Review of the medical record indicated that the Social Worker reached out to the court appointed guardian on 4/18/17 at 4:18 P.M., regarding the hospice order. This was nine days after the Nurse Practitioner’s order.

Failed out follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death.

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

Based on review of accounting records and interview, the facility failed to convey within 30 days the resident’s funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident’s estate for 1 resident (#22) in a total sample of 24 residents.

Findings include:

Resident #22 was admitted to the facility on ,[DATE]. The resident expired at the hospital on [DATE].

On [DATE] at 9:25 P.M record review of the discharged record indicated that Resident #22 had a $0.00 balance in the Personal Needs Account (PNA). Review of the account record indicated that Resident #22 had $29.61 in the PNA on [DATE], [DATE] and [DATE]. On [DATE] the PNA fund account indicated a debit in the amount of $29.61 was placed in a Care Cost Payment account. Leaving the PNA account with a $0.00 balance as of [DATE].

On [DATE] at 10:15 A.M., the Regional Consultant for the nursing home said that she didn’t know what the Care Cost Payment was and would ask the billing office. She returned to say that it must have been for Personal Paid Amount (PPA) owed to the account after the death of Resident #22.

During interview on [DATE] at 1:00 P.M., the Regional Consultant said that as of [DATE] the Personal Needs Account money had not been returned to the state as required. The billing department changed billing companies and there was an error in the debit of $29.61 going into the Care Cost Account ledger.

The money was to have been returned within 30 days after the death and had not been returned until 97 days (67 days late) after the resident expired.

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

Based on observation and Group interview, the facility failed to provide a dignified environment for residents, who indicated that staff speak foreign languages in front of residents and argue in front of residents making the residents feel uncomfortable. (7 non-sampled residents and 1 sampled resident #15.)

Findings include:

A Group Interview was held with the residents on 4/13/17 at 10:00 A.M. There were 8 Residents present at the group meeting. Non-Sampled (NS) #1 said that the staff doesn’t speak English. He then went on to say that we don’t understand them and they don’t understand us. The group unanimously agreed to this. NS #1 also said that the staff fight in front of the residents and it is uncomfortable.

Review of the 1/27/17 and 2/22/17 Resident Council minutes indicated that the Residents complained of staff speaking in foreign languages, the residents feel staff make fun of them in their foreign languages and that staff pretend not to speak English. The minutes also indicate that the Residents are uncomfortable when arguments break out among staff. The minutes further indicated that staff were inserviced on professional behaviors and the issues have, for the most part, been resolved.

On 4/13/17 at 12:35 P.M., Surveyor #2 observed 3 staff members in the hall and doorway to the 2 East dining/activity room. They were speaking in a loud tone amongst each other, in front of the group of Residents in the dining/activity room, arguing over whose turn it was to go on break and who had to stay in the dining/activity room.

On 4/18/17 at 10:56 A.M., Surveyor #2 observed 1 staff member, Certified Nurses Aide (CNA) #3 come into the 2 East dining/activity room from the 2 West dining/activity room and shout to Activity Assistant #2 in Spanish to speak with him. There were 19 Residents in the activity/dining room when this behavior occurred.

On 4/19/17 at 11:30 A.M., in an interview with the Director of Nursing, she said that she has done training with the staff on professional behavior and has been working to end this type of behavior.

Despite education regarding professional behavior provided to the staff members, observations were made, and residents continue to complain of staff speaking foreign languages and fighting in front of them.

Failed to provide activities to meet the interests and needs of each resident.

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

Based on observations, interviews and record review, the Facility staff failed to provide an ongoing program of activities designed to meet the needs of individual residents in accordance with the comprehensive assessment and interests for 4 of 24 sampled Residents (#5, #6 #9 and #16). In addition, the overall systems for the provision of meaningful activities was lacking on 3 of 4 nursing units (2 East, 2 West and 1 West).

Findings include:

1. For 2 East (2E) (long term care unit), the facility failed to provide an ongoing program of meaningful activities throughout Surveyor #2’s observations of the facility from 4/12/17-4/14/17 and from 4/18/17-4/19/17.

The activity calendar provided to the survey team indicated that Activity Centers would take place from 9:00 A.M. until 5:00 P.M. in this dining room on 2E every day of the week for the whole month of April., with no specific activity at any given time.

In an interview with the Activity Director on 4/14/17 at 2:13 P.M, she said that Activity Centers are 1 hour blocks of activities that Activity Assistants and Certified Nursing Aids lead. The Activity Centers include areas of health and fitness, life skills, education, discovery and arts and humanities. There are no specific Activity Center blocks mentioned on the calendar. The Acitvity Director said that the Activity Aides and Nurses Aides can pick whichever ones they chose to do at any given time of the day. They are set up to engage residents with a lower attention span. She said they are a kindergarten level of activity for the resident population that they serve.

On 4/12/17, during initial observations of the facility, the activity calendar on 2E was on a cork board outside of the activity/dining room and was covered by the Monthly Gazette so it was unable to be read by the residents.

On 4/13/17 from 9:30 A.M. – 10:00 A.M., Resident #16, 8 non sampled residents and Certified Nurses Aid (CNA)#1 were observed in the dining/activity room on 2E. CNA #1 was not interacting with any of the Residents in the dining/activity room and there was no meaningful activity being provided to any of the 9 Residents in the room. When Surveyor #2 asked CNA #1 if there was an activity going on, he pointed to the Daily Chronicle which was on the dining tables. There were no residents looking at this and no one was reviewing it with them. When asked what the Daily Chronicle was, he said it was the activity.

On 4/13/17 at 1:48 P.M., Resident #16, 12 non-sampled residents and Activity Assistant #2 were observed in the dining/activity room. Activity Assistant #2 was in the room, sitting in a chair, watching TV, not engaged with any residents. There was no meaningful activity being provided to any of the 13 residents in the room.

On 4/14/17 at 9:20 A.M., Resident #16, 16 non-sampled residents and CNA #2 were observed in the dining/activity room. CNA #2 was sitting in a chair next to 1 non-sampled resident providing 1:1 support. Resident #16 and 15 other residents were not engaged in any meaningful activity.

On 4/14/17 at 10:00 A.M., Resident #16, 16 non-sampled residents and CNA #2 were observed in the dining/activity room. CNA #2 was sitting in the room in a chair at a table. She was not interacting and engaging with the residents and there was no meaningful activity being provided to any of the 17 residents in the room.

When asked what her role is in the dining/activity room, she told Surveyor #2 she is in there to keep an eye on residents and make sure they don’t fall. She did not think she was in there to provide organized activities.

On 4/14/17 at 11:32 A.M., Surveyor #3 noted a large group of residents in the dining/activity room. One activity assistant was speaking Spanish and engaging with one Spanish speaking resident and a CNA was seated with another resident. When asked by Surveyor #3 if there was a scheduled or planned activity for the residents on the unit, she said that lunch would be arriving and they would be setting that up soon.

On 4/18/17 at 10:50 A.M., Resident #16, 18 non-sampled residents and Activity Assistant #2 were observed in the dining/activity room. Activity Assistant #2 was reading trivia questions aloud. Of the 19 residents in the room, 13 were sleeping, 5 were looking around the room and only 1 non sampled resident was answering the questions.

2. For 2 West (2W) (Secured Long Term Care Unit), the facility failed to provide an ongoing program of meaningful activities throughout Surveyor #2’s observations of the facility from 4/12 /17 – 4/14/17 and from 4/18/17-4/19/17.

The activity calendar provided to the survey team indicated that Activity Centers would take place from 9:00 A.M. until 5:00 P.M. in this dining room on 2E every day of the week for the whole month of April, with no specific activity at any given time.

On 4/12/17, during the initial tour of the facility there was no activity calendar on 2W in a common area or in any resident bedrooms.

On 4/13/17 at 12:10 P.M., the Activity Director was observed hanging the Activity Calendar on the wall outside of the 2W dining/activity room.

On 4/13/17 at 12:25 P.M., Resident #6 and other non-sampled residents were observed in the dining/activity room sitting at a table with no interaction with activity staff or nursing aides. There were no activities being provided at this time.

On 4/14/2017 Surveyor #3 made direct observations in the activity/dining room on the 2W unit from 9:33 A.M., to 10:28 A.M. During that time, 11-13 residents were in and out of the room with Activities Assistant #1 and the following was observed:

At 9:46 A. M., Activities Assistant #1 gave a resident a sheet of paper and markers to color and another resident a binder with pictures, leaving 8 remaining residents without activities. The eight remaining residents were either dozing, or looking around the room at others. The Resident who was given the piece of paper asked another resident if water colors were available and the resident who was given the binder was not interested in it, and did not look through it but instead, looked around the room with others.

At 9:52 A.M., Activities Assistant #1 placed cards in front of two residents seated at the table with her. They were not interested and did not touch the cards. At that time, Activities Assistant invited one resident to play the 2 person card game war with her.

At 10:02, Activities Assistant #1 continues to play cards with a resident and offered another resident something to color. When that resident declined, she gave the resident a magazine which he/she did not touch or look through and Activities Assistant #1 returned to playing cards with 1 resident.

At 10:12 A.M., Activities Assistant #1 passed out drinks to 4 of the 12 residents in the room and returned to playing cards with one resident. None of the 4 drank what was given to them. The resident who was coloring had stopped and was dozing off, while the resident who was given the binder of pictures had also dozed off. The resident who was given the magazine left the magazine untouched in front of him/her. 8 remaining residents had not been asked to participate in, or given a meaningful activity that they would like to or were able to engage in.

At 10:20 A.M., Activities Assistant #1 asked residents if they wanted to do morning exercises, and put the playing cards away as she began to set up the room.

At 10:28 AM., Activities Assistant #1 had grouped 6 residents in a circle in the center of the room and began a seated chair exercise routine, leaving the other 6 residents in the room disengaged from the group.

On 4/14/17 at 3:30 P.M., Resident #6 and other non-sampled residents were observed sitting in the dining room. There was an activity in the main dining room down stairs titled Rosary with Kay, in which the resident was not in attendance.

On 4/18/17 at 11:30 A.M., Resident #6 and other non-sampled residents were observed sitting in the dining room on 2W. There was no meaningful activity provided at this time.

On 4/19/17 at 11:00 A.M., Resident #6 was observed sitting in the dining room on 2W. There was a copy of the Daily Chronicle sitting in front of his/her and other non-sampled residents. There was no meaningful activity provided at this time.

3. For 1 West (1W) (short term and long term care unit), the facility failed to provide an ongoing program of meaningful activities throughout Surveyor #2’s observations of the facility from 4/12/17-4/19/17.

The activity calendar provided to the survey team indicated that Activity Centers would take place from 9:00 A.M. until 5:00 P.M. on 1W every day of the week for the whole month of April.

On 4/14/17 at 9:50 A.M., observation of the 1 W dining/activity room was made. There were 7 residents in the room and 1 facility staff member. The staff member was working on a puzzle with one resident and the other 6 residents were left unengaged without meaningful activity provided.

On 4/14/17 at 10:25 A.M. observation of the 1 W dining/activity room was made. There were 8 residents in the room and no staff members present. One resident was putting a puzzle together while the other 7 sat at 4 separate tables unengaged without any meaningful activity.

On 4/19/17 at 9:30 A.M. observation of the 1 W dining/activity room was made. There were 6 residents and 1 CNA. The CNA was sitting in a chair watching TV, not providing meaningful activities to the 6 residents.

4. For Resident #5, the facility failed to provide ongoing, individualized, meaningfulactivities to the resident.

Resident #5 was admitted to the facility in 2/2015 with [DIAGNOSES REDACTED].Review of the Quarterly Minimum (MDS) data set [DATE] indicated that the Resident wascognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15.

Review of the resident’s activity care plan indicated that Resident #5 was dependent on staff for activities and that when resident chooses to not attend organized activities, to turn on the television (TV) or offer puzzles to resident.

Observation of Resident #5’s bedroom on 4/13/17, 4/14/17, 4/18/17 or 4/19/17, revealed that the resident does not have a TV on or visibly present in the room and that there were no puzzles available to the resident in his/her room.

In an interview with Resident #5 on 4/19/18 at 11:00 A.M., the resident said that he/she does not watch TV and has not been offered puzzles. The resident informed Surveyor #2 that he/she likes puzzles and needle point and if puzzles or needle point were offered he/she would accept them, but they haven’t been offered.

5. For Resident #6, the facility failed to provide ongoing, individualized, meaningful activities to the resident.

Resident #6 was admitted to the facility in 1/2008 with [DIAGNOSES REDACTED]. Review of the Resident’s Annual MDS dated [DATE] indicated that the resident had severe cognitive impairment and was unable to answer the questions in the BIMS. The Resident was assessed by the staff as having short and long term severe memory impairment.

The MDS Staff Assessment of Daily and Activity Preferences indicated that the resident enjoys music, going outside and participating in favorite activities.

Review of the Activity assessment dated [DATE] indicated that the resident was a music teacher, and enjoys music, coloring and puzzles. It further indicated that Resident #6 was very religious and religion played an important role in his/her life prior to nursing home placement.

On 4/14/17 at 12:10 P.M., observation of Resident #6’s room revealed that there was no activity calendar posted in his/her room.

At no time during observations made by Surveyor #2 on 4/13/17, 4/14/17, 4/18/17 or 4/19/17 of Resident #6, was the resident engaged in a meaningful activity addressed in the care plans.

6. For Resident #9, the facility failed to provide ongoing, individualized, meaningful activities to the resident.

Resident #9 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] indicated that the resident had no speech, had severe cognitive impairment and was unable to answer the questions in the BIMS. The Resident was assessed by the staff as having short and long term severe memory impairment. Review of the the Admission MDS indicated the Staff Assessment of Daily and Activity Preferences was not completed.

Review of the medical record on 4/13/17 indicated that the resident would benefit from 1:1 activities and TV.

On 4/13/17 at 9:30 A.M., Resident #9 was observed in the bed with his/her head tilted back toward the right shoulder. The TV was on but could not be seen by the resident due to positioning of the resident’s head. There were no staff members in the bedroom.

On 4/14/17 at 10:20 A.M., Resident #9 was observed awake in bed. Head back and tilted to the right shoulder. TV was on but could not be seen by the resident due to positioning and could not be heard over the sound of medical devices in room. There were no staff members in the bedroom.

On 4/14/17 at 3:35 P.M., Resident #9 was observed awake in bed with his/her head tilted back toward the right shoulder. The TV was on but could not be seen by the resident due to positioning and could not be heard over the sound of the medical devices in the bedroom. There were no staff members in the bedroom.

On 4/19/17 at 8:25 A.M. Resident #9 was observed awake in bed and the TV was not on. At no time during observations made by surveyor #2 on 4/13/17, 4/14/17, 4/18/17 and 4/19/17 of Resident #9 were meaningful activities provided for the resident.

7. For Resident #16, the facility failed to provide ongoing, individualized, meaningful activities to the resident. Resident #16 was admitted to the facility in 2/2007 with [DIAGNOSES REDACTED]., depression and psychiatric disorder. Review of the Significant Change MDS dated [DATE] indicated that Resident #16 had no speech, had severe cognitive impairment and was unable to answer the questions in the BIMS. The Resident was assessed by the staff as having short and long term severe memory impairment and inattention.

Review of the Significant Change MDS Staff Assessment of Daily and Activity Preferences indicated that Resident #16 enjoyed music, animals, religion and being out in the fresh air.

Review of Resident #16’s Activity Care plan dated 4/8/2014 indicated that Resident #16 is dependent on staff for activities, cognitive stimulation, social interaction due to [MEDICAL CONDITION]. Resident #16 will enjoy hand massages, [MEDICATION NAME] touch, music and observe programs. Resident will listen to Willie Nelson CD and other music often. Resident will also enjoy sitting out in the sunshine. The interventions in place indicate that facility staff Assure that I receive hand massages and gentle touch. Please smile at me and call me by name.

At no time during observations of Resident #16 was a staff member interacting with the resident or following the individualized care plan while in the dining/activity room. An interview with the Activities Director and the DON took place with the survey team on 4/14/17 at 2:13 P.M. The Activities Director said that she recently revamped the facility activity program to create more individualized programming for all residents and that the activities staff and CNA staff were responsible for engaging with the residents in activities.

The DON said that the facility CNA staff had been given education regarding the responsibilities for activity programming. When asked about formal planning or guidance for staff to follow, the Activities Director said that she had grouped together categories of activities and the expectation was for the staff to perform one of the hourly activity sets from the five categories a day. The five activity sets include areas of health and fitness, life skills, education, discovery and arts and humanities, with no specific activity at any given time throughout the day.

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, observation and interviews, the facility failed to accurately code assessments for 4 residents (#6, #9, #11 and #17), out of a total sample of 24 residents.

Findings include:

1. For Resident #6, the facility failed to to accurately code the result of his/her fall/injury type.

Resident #6 was admitted to the facility in 1/2008 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] indicates that the resident had a fall since last review which resulted in minor injury.

Review of the fall investigation and the Health Care Facility Reporting System indicated that the resident had a fractured nose as a result of a fall on 12/29/16. This injury should have been coded as a major injury on the quarterly MDS. On 4/18/17 at 8:00 A.M. the Director of Nursing said that the resident did have a fall resulting in fracture and she didn’t know why it was not coded as a major injury on the MDS.

2. For Resident #9, the facility failed to accurately code the resident in the area of Range of Motion.

Resident #9 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] indicated that Resident #9 had impairment on both sides of the upper body in regard to range of motion and impairment of both sides of the lower body in regard to range of motion.

Review of the Quarterly MDS dated [DATE] indicated that Resident #9 had no impairment on either side of the upper body in regard to range of motion and no impairment on either side of the lower body in regard to range of motion.

Review of the resident’s medical record did not indicate that the resident was free of range of motion impairment of both the upper and lower body during the time of the assessment reference date of the Quarterly MDS.

In an interview with the Director of Nursing on 4/19/17 at 8:00 A.M., the Director of Nursing was not aware of the error.

3. For resident # 17, the facility failed to accurately code the Resident’s smoking status.

Resident #17 was admitted to the facility in 12/2015 with [DIAGNOSES REDACTED]. On 4/18/17, review of the Annual MDS indicated that the resident was not a smoker. Review of the medial record and care plan indicated that the resident was a smoker since admission in 12/2015. The resident was observed on 4/18/17 going outside to smoke in a supervised smoking area.

In and interview with the Director of Nursing on 4/18/17 at 8:00 A.M., she was not aware that the MDS had been documented in error.

4. For Resident #11, the facility failed to accurately code the Resident’s ambulation status.

Resident #11 was admitted to the facility in 8/2014 with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE], indicated that Resident #11 required limited assist of 1 to ambulate. Review of the Quarterly MDS dated [DATE] indicated the resident was no longer ambulating. The medical record and the care plans indicated that the resident continued to ambulate.

In an interview with the regional MDS coordinator, she said the Quarterly MDS was not coded correctly and a modification would be done.

Failed to develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.

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

Based on record review and staff interview, the facility failed to ensure that care plans were developed for 3 resident’s (Resident #2, #5, #7) in a total sample of 24 residents.

Findings include:

1. For Resident #5, the facility failed to develop a care plan for cognitive loss and [MEDICAL CONDITION].

Resident # 5 was admitted to the facility in 2/2015 with [DIAGNOSES REDACTED]. On 4/12/16, review of the resident’s Significant Change Minimum Data Set ((MDS) dated [DATE] indicated that the Resident had severe memory impairment with a Brief Interview for Mental Status (BIMS) score of 0. The review of the Care Area Assessment indicated that a care plans should be developed to address cognitive loss and [MEDICAL CONDITION] due to the memory impairment findings.

Review of the Resident’s Care Plans indicated that the care plans for cognitive loss and [MEDICAL CONDITION] were not developed. An interview with the Director of Nursing on 4/19/17 at 8:00 A.M. revealed that the care plans were not created and that she felt that the [MEDICAL CONDITION] care plan should not have been triggered as there was no sign of [MEDICAL CONDITION] in the MDS.

2. For Resident #5, the facility failed to develop a care plan addressing the Resident’s mood.

On 4/13/17, review of the Resident’s Annual MDS Care Area assessment dated [DATE] indicated that a care plan should be developed to address mood concerns. Review of Section D (Mood) in the Annual MDS indicated that the resident had a total severity score of 2 indicating minimal depression.

Review of the Resident’s care plans indicate that the care plan for mood was not developed. During interview on 4/19/17 at 10:00 A.M.,with the facility’s Regional Consultant, she was unsure why the mood care plan was not developed.

3. For Resident #2 the facility failed to develop a comprehensive care plan for activities of daily living (ADL’s). Resident #2 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED].

Review of the resident’s Annual Minimum Data Set ((MDS) dated [DATE] indicated that the Resident requires extensive assist for dressing, hygiene and grooming and he/she is dependent on staff for bathing. Review of the Care Area Assessment indicated that a care plan should be developed to address ADLs.

Review of the resident’s care plans indicated that the care plans for ADLs were not developed.

An interview with the Director of Nursing on 4/19/17 at 9:00 A.M., revealed that the care plan was not created.

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 observation, record and policy review the facility failed to ensure that proper care for a peripherally inserted central catheter (PICC) line was provided for 1 resident (#2) out of a total sample of 24 residents.

Findings include:

Resident #2 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. According to the Quarterly Minimum (MDS) data set [DATE] he/she needs extensive assistance with activities of daily living including bed mobility, dressing and grooming. Observation of the PICC line transparent dressing on 4/12/17 at 2:30 P.M., revealed a date of 4/5/17.

Review of the medical record on 4/12/17 indicated that a PICC line was inserted for the administration of double antibiotics [MEDICAL CONDITION], start date 4/2/17 at 1:00 A.M. Review of the Medication Administration Record (MAR) and the Treatment Administration record on 4/12/17 at 2:30 P.M., indicated no dressing changes to the PICC line dressing were done.

Review of the facility policy titled Central Venous Catheter Dressing Changes, dated 4/2016 and revised 10/2016 indicated that for a PICC line, dressing changes using a transparent dressing are performed 24 hours post insertion and every 5-7 days there after according to the physician’s order.

There was no documentation that the dressing was changed on 4/3/17, 24 hours after initial insertion as required. Observation of the PICC line transparent dressing on 4/14/17 at 2:00 P.M., indicated the transparent dressing change occurred on 4/13/17 1 day late. During an interview with the Unit Manager on 4/13/17, she said she was unaware the dressing needed to be changed and she would review the MAR and make corrections.

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

Based on observations and staff interviews, the facility staff failed to ensure that medications and biological’s were of current date to provide reliability of strength and accuracy, on 2 of 4 units observed.

Findings include:

1. During an inspection of the 2 East and 1 West nursing units on 4/14/17 and 4/19/17 the following observations were made.

A. One bottle of Loratadine 10 mg tabs with an expiration date of 1/20/2017.

B. One multi-dose vial of Humulin N insulin opened with expiration date of 4/13/17.

The Centers for Disease Control recommends that multi-dose vials should always be discarded when ever sterility is compromised or questionable. In addition, the United States Pharmacopoeia, (USP) General Chapter 797 recommends if a multi-dose vial has been opened or accessed (e.g., needle-punctured the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

During an interview with the medication nurse on 4/19/17 at 9:10 A.M., she said there should be no expired medications on the nursing units.

Failed to 1) hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

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

Based on records reviewed and interviews, for one of six sampled Residents (Resident #1) the Facility failed to report an alleged incident of abuse to the Department of Public Health (DPH) within two hours.

On 04/15/17, at approximately 1:15 P.M., Certified Nursing Assistant (CNA) #1 witnessed CNA #5 forcefully push Resident #1’s forehead in an aggressive manner using the palm of her hand, causing Resident #1’s head to be jerked backwards onto the bed and immediately reported the incident to Nurse #8. Nurse #8, however, failed to report the alleged incident of abuse to the Administrator or the designee, and the facility did not report the incident to DPH until 4/16/17.

Findings include:

The Policy titled, Abuse Investigation and Reporting, dated 05/2017, indicated the facility would ensure an incident or suspected abuse, neglect, exploitation, mistreatment, and any injury of unknown source be thoroughly investigated and reported to the Department of Public Health within two hours. The Policy indicated the investigation of the reported incident shall be conducted by the Administrator or their designee.

The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1’s medical [DIAGNOSES REDACTED]. The MDS indicated Resident #1’s Brief Interview of Mental Status (BIMS) score was 3 (score range 1-15, 0-7 indicates severe cognitive impairment.) The Facility’s Incident Report, dateless, indicated the date of the alleged abuse incident occurred at approximately 1:15 P.M. on 04/15/17. The Incident Report indicated CNA #1 reported CNA #5 pushed Resident #1 on the forehead in an aggressive manner at the end of a transfer back to bed. The Incident Report indicated it was submitted on 04/16/17 by the Director of Nursing.

The Healthcare Facility Reporting System (HCFRS) indicated the Facility reported the alleged incident of abuse of Resident #1 by CNA #5 at 10:01 P.M. on 04/16/17, which was more than thirty-three hours after the alleged incident occurred.

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

Based on records reviewed and interviews, for one of six sampled Residents (Resident #1) the Facility failed to ensure staff immediately reported an allegation of suspected resident abuse to the Administrator or their designee and did not follow its Policies and Procedures for Abuse Investigation and Reporting. -On 04/15/17, at approximately 1:15 P.M., Certified Nursing Assistant (CNA) #1 witnessed CNA #5 forcefully push Resident #1’s forehead in an aggressive manner using the palm of her hand, causing Resident #1’s head to be jerked backwards onto the bed and immediately reported the incident to Nurse #8. Nurse #8, however failed to follow facility policy and did not report the alleged incident of abuse to the Administrator or the designee that day or the following day. An investigation was not initialed by the facility until approximately thirty-three hours after the alleged incident occurred, when Director of Nurse’s #1, heard about the incident from another staff member.

Findings include:

The Policy tilted, Abuse Investigation and Reporting, dated 05/2017, indicated the facility would ensure an incident or suspected abuse, neglect, exploitation, mistreatment, and any injury of unknown source be thoroughly investigated and reported to the Department of Public Health (DPH) within two hours. The Policy indicated the investigation of the reported incident shall be conducted by the Administrator or their designee.

Surveyor #1 and Surveyor #2 interviewed CNA #1 at 2:50 P.M. on 06/14/17. CNA #1 said on 4/15/17 at approximately 1:15 P.M., she with the help of CNA #5 transferred Resident #1 into bed. CNA #1 said she was standing at the foot of the bed, placed Resident #1’s feet on the bed, then witnessed CNA #5, who was standing next to her at the head of the bed, using the palm of her right hand, forcefully and quickly hit Resident #1’s forehead causing his/her head to be jerked back onto the bed. CNA #1 said CNA #5 did not speak and left the room.

CNA #1 said she reported the incident immediately to Nurse #8, and said Nurse #8 responded back by saying it was not nice or words to that effect. CNA #1 said the following day she told CNA #4 (lead CNA) about the incident because she was not happy with the response she received from Nurse #8. CNA #1 said she was not asked to write a written statement until a few days after the incident occurred.

Surveyor #1 and Surveyor #2 interviewed CNA #5 at 2:42 PM. on 06/16/17. CNA #5 said she was standing at the foot of the bed, placed Resident #1’s feet on the bed, took off Resident #1’s shoes, and left the room. CNA #5 said she never touched Resident #1’s head at all, and said the transfer from chair to bed was uneventful.

Surveyor #2 interviewed Nurse #8 at 2:55 P.M. on 06/19/17. Nurse #8 said she remembered CNA #1 telling her on 04/15/17 about CNA #5 pushing Resident #1 with her fingers on his/her forehead. Nurse #8 said she did not report the allegation of abuse or complete an assessment on Resident #1.

Surveyor #1 and Surveyor #2 interviewed Director of Nurses (DON) #1 at 12:26 P.M. on 06/15/17. DON #1 said she received a telephone call on 4/16/17 from CNA # 7 in regards to another concern and said CNA #7 mentioned during the same telephone call that she overheard staff talking about CNA #5 having pushed Resident #1’s head back onto his/her pillow. DON #1 said it was late in the evening on 4/16/17 when she found out about the allegation of abuse that occurred the day before, on 04/15/17.

Failed to keep all essential equipment working safely.

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

Based on observations, records reviewed and interviews the Facility failed to ensure that emergency supplies and equipment on the Emergency Code Carts were available and functioning for three out of four resident units.

-At approximately 12:20 P.M. through 1:40 P.M. on 06/14/17, Surveyor #1 and Surveyor #2 observed that three out of four Emergency Code Carts were not adequately stocked with properly functioning suction equipment, respiratory equipment and supplies needed to respond to resident’s in cardiac or respiratory arrest. At the time of the survey 53 resident’s out of a total census of 136 resident’s were full codes (in event of cardiac or respiratory arrest, attempts at resuscitation will be made).

Findings include:

The Policy, titled, Emergency Equipment, dated 02/2015, indicated, emergency equipment would be kept in a clearly designated location, available to all staff members. The Policy indicated, the Facility would attach an emergency checklist form to the Emergency Code Cart.

The Facility’s Emergency Cart Checklist indicated all equipment and supplies, including oxygen tubing and masks, suction equipment, will be monitored daily during the 11:00 P.M. to 7:00 A.M. shift to ensure all items are accounted for and to test all equipment is functioning. The Emergency Cart Checklist indicated items removed from the cart must be replaced immediately.

On 06/14/17 at approximately 1:00 P.M., Surveyor #2 accompanied by the Assistant Director of Nursing (ADON), made observations of the Emergency Code Cart on Unit 1 West. Documentation indicated, that the Emergency Code Cart Checklist was signed as checked off by nursing daily from 06/01/17 through 06/14/17, indicating supplies were in working order and in place as readily available.

-Upon entering the clean utility room where the Emergency Code cart was stored, Surveyor #2 observed the Director of Maintenance looking at the suctioning machine on the Emergency Code Cart. The Director of Maintenance said he was checking to make sure all the connections on the suctioning machine were present and said it was nursing’s responsibility to check if the suctioning machine was functioning properly.

Surveyor #2 observed and confirmed by the ADON at 1:05 P.M. on 06/14/17, the following items were missing or found to be contaminated on the Emergency Code Cart on Unit 1 West;

  • Suctioning tubing/[MEDICATION NAME] on the canister was not in a protective sleeve
  • Three [MEDICATION NAME]’s (oral suctioning tool) missing
  • The blood pressure gauge was not working properly, unable to visualize a blood pressure reading
  • No connecting tubing (clear plastic tubing line that can be connected to medical devices),
  • Three sterile waters missing,
  • No oxygen tubing/masks,
  • A nebulizer mask with a resident’s name was in a plastic bag on the Emergency Code Cart.

This was not consistent with the documentation completed on the Emergency Code Cart Checklist, signed as last checked on 06/14/17, which indicated all supplies were in place and emergency equipment was functioning.

Director of Nurses (DON) #2 joined the ADON and Surveyor #2 to review the Emergency Code Cart and said he would ensure all the Emergency Code Carts were immediately stocked and all equipment working properly.

On 06/14/17 at approximately 12:20 P.M., Surveyor #2 accompanied by Unit Manger #4 made observations of the Emergency Code Cart on Unit 1 East. Documentation indicated, that the Emergency Code Cart Checklist was signed as checked off daily by nursing from 06/01/17 through 06/14/17, indicating supplies were in working order and in place as readily available.

Surveyor #2 observed and confirmed by the Unit Manager #4 at 12:20 P.M. on 06/14/17, the following items on the Emergency Code Cart 1 East Unit; the following items were found to be missing, contaminated or not functioning properly;

  • Suction machine was not set up correctly and an extra suction canister was missing
  • Suctioning tubing/[MEDICATION NAME] on the canister was not in a protective sleeve
  • The suctioning machine not functioning properly, would not start when turned on
  • There was no oxygen wrench (opens the oxygen tank)
  • The blood pressure bulb and value were missing from the blood pressure cuff
  • One adult oxygen mask was open and not in a protective package
  • Eight plastic cups were not in a protective package.

This was not consistent with the documentation completed on the Emergency Code Cart Checklist, signed as last checked on 06/14/17, which indicated all supplies were in place and emergency equipment was functioning.

Surveyor #1 observed and confirmed by DON #2 at 12:30 P.M. on 06/14/17, the following items on the Emergency Code Cart 2 West Unit; the following items were found to be missing or not functioning properly;

  • The suctioning machine not functioning properly, unable to provide suction when tested
  • Missing three bottles of sterile water.

This was not consistent with the documentation completed on the Emergency Code Cart Checklist, signed as last checked on 06/14/17, which indicated all supplies were in place and emergency equipment was functioning.

Surveyor #1 and Surveyor #2 interviewed DON #2 at 12:30 P.M. on 06/14/17 and throughout the survey. Don #2 said he was aware that the documentation requirements for the Emergency Code Cart Checklist were inconsistent from floor to floor throughout the facility.

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

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

Based on records review and interviews, for 1 of 3 sampled Residents (Resident #1), the facility failed to immediately notify the Physician and his/her Health Care Proxy (HCP) of increased complaints of pain and an x-ray result, which indicated Resident #1 had a distal femur fracture (lower part of thigh bone just above knee) of his/her left leg, following a fall on 9/5/16.

Findings include:

The Facility Policy titled Change in a Resident’s Condition or Status (Dated April 2016) indicated the Facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the Resident’s medical/mental condition and/or status and the Nurse Supervisor/Charge Nurse will notify the resident’s attending Physician or on-call Physician when there has been an accident or incident involving the resident. The Facility Policy titled Assessing Falls and Their Causes (Dated April 2016) indicated when a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone.

Resident #1’s Quarterly Minimum Data Set (MDS) assessment, dated 5/10/16, indicated Resident #1 was cognitively impaired, dependent on staff for assistance with transfers and mobility and he/she recieved Hospice services for care and comfort related to end stage demementia. An X-ray Report, dated 9/5/16 and electronically signed at 11:34 P.M., indicated Resident #1 had a distal femur fracture (lower part of thigh bone just above knee) of his/her left leg.

The Director of Nursing (DON) was interviewed on 9/27/16 at 8:42 A.M. The DON said on 9/7/16, during the course of the Facility’s internal investigation, Nurse #1 and Nurse #2 admitted Resident #1 fell on [DATE], they put him/her back into bed and Nurse #1, who was assigned to care for Resident #1, did not notify Resident #1’s Physician or Health Care Proxy about Resident #1’s fall at that time. This was not consistent with the Facility’s Policy titled Assessing Falls and Their Causes.

Nurse #4 was interviewed on 10/7/16 at 11:25 A.M. Nurse #4 said when she arrived on the Unit on 9/5/16 for her 11-7 shift, the x-ray technician was still at the Facility and had just finished taking Resident #1’s x-ray. Nurse #4 said although the x-rays were obtained at the beginning of her shift, she did not call to request Resident #1’s x-ray results because she didn’t know how long the process took. The DON said the Facility is typically notified of x-ray results by electronic fax and/or phone call and results are ready within 4 hours after the Facility first calls to schedule the x-ray.

The Director of Clinical Services for the imagining company (company that performed the x-ray) was interviewed on 10/6/16 at 4:00 P.M. The Director of Clinical Services said Resident #1’s x-ray results were electronically faxed to the Unit that Resident #1 resided on at 11:38 P.M. on 9/5/16.

The DON said if Nurse #4 did not receive Resident #1’s x-ray results by fax, she should have called to obtain the x-ray results. The DON said she called the imaging company the following morning to request the x-ray results which indicated Resident #1 had a fracture of his/her left leg.

The Unit Manager was interviewed on 10/7/16 at 9:58 A.M. The Unit Manager said on 9/6/16 at approximately 12:00 P.M. (approximately 24 hours since the time of fall), she informed Resident #1’s Nurse Practitioner that Resident #1 had a fracture of his/her left leg. The Unit Manager said Resident #1 was transferred to the hospital on [DATE] at approximately 2:30 P.M. (approximately 26 hours from the time of fall and 14 hours from the time his/her X-ray results were found positive for a distal femur [MEDICAL CONDITION] leg).

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 records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to perform and document a thorough clinical assessment after Resident #1 fell and failed to obtain treatment orders for Resident #1’s left distal femur fracture (lower part of thigh bone just above knee).

Findings include:

Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data.

The Facility Policy titled Assessing Falls and Their Causes, (dated April 2016), indicated the residents must be assessed in a timely manner for potential causes of falls and the nursing staff will; record vital signs, evaluate for injuries, notify the resident’s physician and family, observe for delayed complications, and document findings in the medical record.

The Facility Policy titled Pain-Clinical Protocol, (dated April 2016), indicated the nursing staff will assess each individual for pain when there is onset of new pain or worsening of existing pain, staff will identify any situation or interventions where an increase in a resident’s pain may be anticipated, and staff will reassess the individual’s pain at regular intervals.

The Facility Policy titled Change in a Resident’s Condition or Status, (dated April 2016), indicated prior to notifying the Physician the nurse will make detailed observations, gather relevant information and complete an SBAR (documentation within the electronic medical record what includes the change of status, background information about a resident, the nurse’s assessment findings, response to medications, and recommendations). An X-ray Report, dated 9/5/16 and electronically signed at 11:34 P.M., indicated Resident #1 had a distal femur fracture (lower part of thigh bone just above knee) of his/her left leg.

Nurse #1 was interviewed on 9/28/16 at 10:18 A.M. Nurse #1 said that on 9/5/16, she went into Resident #1’s room, sometime mid-morning, after hearing him/her yelling and observed Resident #1 on the floor beside his/her bed. Nurse #1 said she and Nurse #2 assisted Resident #1 off the floor and into bed. Nurse #1 said she assessed Resident #1 and he/she had no pain or signs of injury, however approximately 1 hour later Resident #1 complained of pain, but was unable to specify the location of the pain because of his/her impaired cognition. Nurse #1 said she medicated Resident #1 with Tylenol (an [MEDICATION NAME] medication) which seemed to be effective. Nurse #1 said she called the Physician to inform him that Resident #1 fell and had no injuries, but she didn’t remember who she spoke with or the time she placed the call.

There was no documentation to indicate Nurse #1 assessed Resident #1. Resident #1’s Medication Administration Record [REDACTED]. There was no documentation to indicate Nurse #1 called Resident #1’s Physician. This was not consistent with the Facility’s Policy or with Nurse #1’s statement.

Nurse #2 was interviewed on 9/28/16 at 10:45 A.M. Nurse #2 said on 9/5/16, some time mid-morning, Nurse #1 called her into Resident #1’s room to help get Resident #1 off the floor because he/she fell . Nurse #2 said when they assisted Resident #1 off the floor and into bed Resident #1 was yelling that his/her stomach hurt. Nurse #2 said, later in the shift, she was on the phone with the Nurse Practitioner and asked Nurse #1 if she wanted to notify the Nurse Practitioner about Resident #1’s fall and Nurse #1 said she didn’t want to speak with the Nurse Practitioner and would call her later.

The Nurse Practitioner who was on call on 9/5/16 was interviewed on 10/5/16 at 3:08 P.M. The Nurse Practitioner said she did not recall whether or not she was notified of Resident #1’s fall by Nurse #1.

The Director of Nursing (DON) was interviewed at 2:05 P.M. on 10/24/16. The DON said that during the course of the Facility’s Internal Investigation Nurse #1 and Nurse #2 said they did not notify the Physician when Resident #1 fell and admitted they lifted Resident #1 off the floor and into bed.

An Incident Report, dated 9/7/16 and timed at 10:44 P.M., indicated Resident #1 fell on [DATE]. The report indicated Resident #1 fell and there was no bed alarm in use as a preventative measure at the time of the fall.

Resident #1’s Treatment Administration Record, dated 9/5/16 and documented as signed by Nurse #1, indicated Nurse #1 checked Resident #1’s bed alarm for placement and function during the shift. However, when interviewed by the Surveyor on 9/28/16, Nurse #1 said Resident #1 did not have a bed alarm in use when she found Resident #1 on the floor on 9/5/16.

Nurse #3 was interviewed on 10/5/16 at 9:18 A.M. Nurse #3 said on 9/5/16 he obtained shift report from Nurse #1 at the beginning of his 3-11 shift and Nurse #1 did not mention that Resident #1 complained of pain or that he/she fell during the 7-3 shift. Nurse #3 said he heard Resident #1 call for help and when he went into Resident #1’s room, he/she complained of leg pain and Resident #1 expressed fear of never being able to walk again, or words to that effect.

Nurse #3 said when he moved Resident #1’s left leg he/she was in extreme pain. Nurse #3 said he called the Nurse Practitioner to obtain orders for an x-ray of Resident #1’s leg. There was no pain assessment or SBAR documented by Nurse #3 which was not consistent with Facility’s Policy.

Certified Nursing Assistant (CNA) #1 was interviewed on 10/11/16 at 4:20 P.M. CNA #1 said she worked during the evening shift on 9/5/16 and when she went into Resident #1’s room she observed him/her holding his/her thigh saying, I’m in pain, I’m in pain. or words to that effect. CNA #1 said Resident #1 was incontinent of urine at the time and because of his/her level of pain, CNA #1 didn’t want to touch him/her so she asked Nurse #3 for assistance. CNA #1 said resident #1 was complaining of pain and moaning while they changed and cleaned him/her. CNA #1 avoided moving Resident #1 for the remainder of the shift because he/she was in too much pain.

Nurse #4 was interviewed on 10/7/16 at 11:25 A.M. Nurse #4 said when she arrived on the Unit on 9/5/16 for her 11-7 shift, the x-ray technician was still at the Facility and had just finished taking Resident #1’s x-ray and Nurse #3 told her Resident #1 was in a lot of pain. Nurse #4 said when she went into Resident #1’s room, Resident #1 was yelling out, the pain, the pain, the pain, or words to that effect, and she medicated Resident #1 with Tylenol. Nurse #4 said she knew Resident #1 was in a lot of pain because he/she took the Tylenol right away and Resident #1 didn’t typically like to take medications.

There was no pain assessment or SBAR documented by Nurse #4 which was not consistent with the Facility’s Policy. Nurse #4 said although the x-rays were obtained at the beginning of her shift she did not call to request Resident #1’s x-ray results because she didn’t know how long the process took.

The Director of Clinical Services for the imagining company (company that performed the x-rays) was interviewed on 10/6/16 at 4:00 P.M. The Director of Clinical Services said Resident #1’s x-ray results were electronically faxed to the Unit, where Resident #1 resided, at 11:38 P.M. on 9/5/16.

The Director of Nurses (DON) was interviewed on 10/7/16 at 10:45 A.M. The DON said the Facility is typically notified of x-ray results by electronic fax and/or phone call and results are ready within 4 hours after the Facility first calls to schedule the x-ray. The DON said if Nurse #4 did not receive Resident #1’s x-ray results by faxed she should have called to obtain Resident #1’s x-ray results and notified the Physician of Resident #1’s of the fracture to obtain treatment orders.

The DON said she called the imagining company the following morning, on 9/6/16, to request Resident #1’s x-ray results which indicated Resident #1 fractured his/her left leg. The Unit Manager was interviewed on 10/7/16 at 9:58 A.M. The Unit Manager said she told the Nurse Practitioner about Resident #1’s fracture at approximately 12:00 P.M. on 9/6/16, approximately 24 hours from time of fall. The Unit Manager said Resident #1 was transferred to the hospital at approximately 2:30 P.M. on 9/6/16, approximately 26 hours from the time of fall and and 14 hours from the time his/her X-ray results were found positive for a distal femur [MEDICAL CONDITION] leg. A Nurse Progress Note, dated 9/6/16 and timed at 8:51 P.M., indicated Resident #1 returned to the Facility at 6:00 P.M. with his/her left leg immobilized due to a distal femur fracture of his/her left leg.

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 records review and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure Resident #1’s bed alarm was in place and functioning correctly, as ordered by the Physician and Resident #1 fell on [DATE] and sustained a distal femur fracture (lower part of thigh bone just above knee) of his/her left leg.

Findings include:

Resident #1’s Quarterly Minimum Data Set (MDS) assessment, dated 5/10/16, indicated Resident #1 was cognitively impaired, was dependent on staff for assistance with transfers and mobility, and he/she received Hospice services for care and comfort related to end stage dementia.

A Fall Risk assessment dated [DATE] indicated Resident #1 was a high risk for falls. A Plan of Care, dated as revised on 6/13/16, indicated Resident #1 was at risk for falls related to deconditioning and he/she required 2 person physical assistance with bed mobility and transfers.

The Director of Nursing (DON) was interviewed on 9/27/16 at 8:42 A.M. The DON said Resident #1 fell on [DATE], without injury, and the plan was to place an alarm on his/her bed to alert staff in the event he/she tried to get out of bed without assistance, or words to that effect. A physician’s orders [REDACTED].#1 was to have a bed alarm with checks for placement and function on every shift.

There was no documentation to indicated Resident #1’s Care Plan was updated to include the physician’s orders [REDACTED]. An Incident Report, dated 9/7/16 and timed at 10:44 P.M., indicated Resident #1 fell on [DATE]. The report indicated Resident #1 fell and there was no bed alarm in place as a preventative measure at the time of Resident #1’s fall.

Nurse #1 was interviewed on 9/28/16 at 10:18 A.M. Although documentation shows Resident #1’s Treatment Administration Record was documented as signed by Nurse #1 indicating Resident #1’s bed alarm was checked for placement and function during the 7:00 A.M. to 3:00 P.M. shift on 9/5/16, Nurse #1 said she went into Resident #1’s room, on 9/5/16, in response to hearing Resident #1 yelling and said Resident #1 did not have a bed alarm on his/her bed when she found Resident #1 on the floor. An X-ray Report, dated 9/5/16, indicated Resident #1 had a distal femur fracture (lower part of thigh bone just above knee) of his/her left leg.

The Unit Manager was interviewed on 10/7/16 at 9:58 A.M. The Unit Manager said Resident #1 was transferred to the hospital on [DATE] at approximately 2:30 P.M.

Brentwood Rehabilitation & Healthcare Center, 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

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Page Last Updated: November 18, 2017

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