Cape Heritage Rehabilitation and Health Care Center

Cape Heritage Rehabilitation

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About Cape Heritage Rehabilitation & Health Care Center

Cape Heritage Rehabilitation & Health Care Center is a for profit, 123-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Bourne, Mashpee, Wareham, Yarmouth, Dennis, Falmouth, Carver, Plymouth, South Yarmouth, Kingston, Brewster, Duxbury, Acushnet, Harwich, Fairhaven, and the other towns in and surrounding Barnstable County, Massachusetts.

Cape Heritage Rehabilitation & Health Care Center
37 Route 6A
Sandwich, MA 02563

Phone: (508) 888-8222

CMS Star Quality Rating

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

As of 2018, Cape Heritage Rehabilitation & Health Care Center in Sandwich, Massachusetts received a rating of 2 out of 5 stars.

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

Fines Against Cape Heritage Rehabilitation & Health Care Center

The Federal Government fined Cape Heritage Rehabilitation & Health Care Center $3,900 on 03/18/2016 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Cape Heritage Rehabilitation & Health Care Center committed the following offenses:

Failed to give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for.

Based on observation and interview, the facility failed to post all requirements including pertinent information about accessing Medicare.

Findings include:

During the survey visit 6/15/17 – 6/22/17, the survey team observed no postings on contacting or accessing information related to Medicare. During interview on 6/22/17 at approximately 10:40 A.M., the Administrator was not aware that there was no posted information in the facility for Medicare as required.

Failed to allow residents to easily view the results of the nursing home's most recent survey.

Based on observations and staff interview, the facility failed to post notice of and make readily available and accessible reports with respect to any surveys, certifications, and complaint investigations made during the three preceding years, in areas of the facility that were prominent and accessible to the public.

Findings include:

For all days of the survey 6/15/17 to 6/22/17: Observations throughout the facility including the lobby area, lower level, and all three Resident units, failed to include required postings. There was no evidence of postings for the current survey and a notice informing Residents, family members, and legal representatives of Residents of the availability of survey results for the preceding three years.

During interview on 6/22/17 at approximately 10:40 A.M., the Surveyor asked the Administrator if she was aware of the changes that occurred in 11/2016 for regulatory compliance with required survey postings and the Administrator said she was unaware of any new requirements or changes. The facility failed to ensure that the current survey (2016) was visibly posted for viewing and that the availability of any survey, certifications, and complaint investigations conducted during the three preceding years, and any plans of correction in effect with respect to this facility must be posted prominently and be accessible to the public.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) accurately reflects the Resident’s status for 5 (#4, #6, #7, #12 and #16) sampled Residents, from a total sample of 20 Residents.

Findings include:

1. For Resident #7, the facility failed to ensure that the Resident’s admission MDS was accurate and reflected the Resident’s status.

Resident #7 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Review of the clinical record on 6/16/17 indicated that the Resident’s health care proxy had been activated on 4/25/17, had a therapeutic diet (diabetic diet) and had a gastrostomy feeding tube which was flushed daily with water. The admission MDS with a completion date of 5/12/17, did not identify that the Resident had a gastrostomy feeding tube, or a therapeutic diet or that his/her health care proxy had been invoked. The MDS Coordinator was interviewed on 6/20/17 at 10:00 A.M The Surveyor identified the inaccuracies to the coordinator who then submitted a modification for all the inaccuracies on the admission assessment.

2. For Resident #6, the facility failed to ensure that the Resident’s quarterly MDS was accurate and reflected the Resident’s status. Resident #6 was admitted to the facility in 7/4/11 with [DIAGNOSES REDACTED]. The quarterly MDS signed as completed on 6/14/17, indicated that the Resident received PRN pain medication and non medication pain interventions as well as having shortness of breath. Review of the clinical record indicated that none of these areas accurately reflected Resident #6. On 6/22/17 at 1:30 P.M., the Surveyor notified the MDS Coordinator who said she would look into it. At 2:45 P.M. the Surveyor received a modified MDS reflecting that the Resident did not use PRN pain medications or was short of breath. The MDS Coordinator left in that the staff used non mediation pain interventions but did not comment to the Surveyor why.

3. For Resident #16, the facility failed to ensure that the Resident’s quarterly MDS was accurate and reflected the Resident’s status. Resident #16 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of the clinical record on 6/16/17 indicated that the Resident had a temporary guardian with a court date to convert to a permanent guardianship. The quarterly MDS, signed and completed on 4/19/17 did not reflect that the Resident had a guardian. On 6/22/17 at 1:30 P.M. the Surveyor notified the MDS Coordinator who said she would look into it. At 2:45 P.M. the Surveyor received a modified MDS reflecting that Resident #16 had a guardian.

4. For Resident #4, the facility failed to complete the most recent quarterly Minimum Data Set (MDS) assessment that accurately reflected the Resident’s advance directive status. Resident #4 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Record review indicated the Resident’s health care proxy was invoked on 1/5/17. The completed MOLST (medical orders for life sustaining treatment) dated 1/2/17, indicated health care decisions for do not resuscitate, do not intubate, do not hospitalize, no [MEDICAL TREATMENT], no feeding tube, and no intravenous. Review of the Admission Minimum Data Set ((MDS) dated [DATE], indicated the Resident had cognitive deficits and required assistance with activities of daily living. For Section S, advance directive information identified a health care proxy, and that the proxy was invoked. Advanced directive wishes included do not resuscitate, do not intubate, do not hospitalize, feeding restrictions, and other restrictions. Review of the quarterly MDS dated [DATE], for assessment Section S the advance directives indicated a health care proxy and that the proxy was invoked. The advance directive wishes were all blank and did not accurately reflect the advance directive choices in effect. The MDS assessment information was discussed with Unit Manager #3 on 6/20/17 and Director of Nurses on 6/22/17.

5. For Resident #12, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the Resident’s advance directive for a health care agent. Resident #12 was admitted in 5/2017 for rehabilitation following a hospitalization for [MEDICAL CONDITION], rib fractures, metabolic [MEDICAL CONDITIONS] and diabetes. Record review indicated a health care proxy form was completed on 5/16/17 and identified a health care agent and alternate agent. Medical progress note dated 5/24/17, indicated advanced directive information was reviewed with the Resident and included full code status and use all interventions.

Review of the Admission Minimum Data Set ((MDS) dated [DATE], indicated the Resident was alert and oriented and required assistance with activities of daily living. For Section S, there were no advance directives noted. The assessment did not reflect that the Resident had a health care agent in place. Information was reviewed with the Director of Nurses on 6/22/17.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the Facility failed to meet professional nursing standards of practice of documentation for 1 Resident (#10) out of a total sample of 20 Residents.

Findings include:

Standard reference: Standard of Practice Reference: 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. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice.

Each nurse licensed by the Board and engaged in the practice of nursing shall have knowledge and understanding of the Standards of Conduct for Nurses set forth in 244 CMR 9.00, all state laws and Board regulations governing the practice of nursing, and all other state and federal laws and regulations related to such practice. A nurse licensed by the Board shall not knowingly falsify, or attempt to falsify, any documentation or information related to any aspect of licensure as a nurse, the practice of nursing, and the delivery of nursing services.

The Centers for Medicare and Medicaid (CMS) transmittal letter 442 titled Update for Amendments, Corrections and Delayed Entries in Medical Documentation issued on 12/7/12 stated: Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, and ZPICs containing amendments, corrections or addenda must: 1. Clearly and permanently identify any amendment, correction or delayed entry as such, and 2. Clearly indicate the date and author of any amendment, correction or delayed entry, and 3. Not delete but instead clearly identify all original content.

For Resident #10, the facility presented Medication Administration Records (MAR) to the survey team that had been completed after Surveyor #4 had reviewed the records 48 hours prior and found them to be incomplete and lacking information that indicated that the respiratory status assessments had not been done as the Physician ordered. Resident #10 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. Review of Admission Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident had severe memory impairment and was unable to communicate. Resident was not able to walk and required total assistance for all activities of daily living. Resident #10 has a [DEVICE] for all nutrition and hydration due to high risk of aspiration (inhalation of food/liquids into the lungs).

A review of the medical record indicated that on 4/16/17, the Resident was transferred from the Facility to the acute care hospital due to respiratory distress. The Resident was hospitalized from [DATE]- 4/28/17 and diagnosed with [REDACTED].[MEDICAL CONDITION] is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs (JAMA. (YEAR) [DATE];315(8): 801-810) Review of the medical record indicated the Resident was re-admitted to the facility on [DATE] and the Physician ordered the following:

1. Evaluate respiratory status each shift
2. Lung sounds each shift
3. Respiratory rate each shift
4. Oxygen saturation levels each shift
5. [MEDICATION NAME] (a steroid inhaler that helps open airway) .5-3 mg 1- unit dose via nebulizer every 4 hours as needed for wheeze/shortness of breath
6. Document post assessment when nebulizer is administered:
A. Respiratory rate after treatment
B. Oxygen saturation level after treatment
C. Sputum
B= Bloody
C= Clear
G= Green
W= White
Y= Yellow
N= None
D. Outcome/Response
I= Improved
W= Worsened
NC= No Change

The (MONTH) (YEAR) MAR (6/1-6/15/17) was reviewed on 6/15/17, 6/16/17 and 6/20/17. The day shift (7:00 A.M. to 3:00 P.M. ) failed to document: Respiratory status for 14 of 15 days . Lung sounds for 14 of 15 days. Respiratory rate for 14 of 15 days. Oxygen saturation levels for 14 of 15 days. The evening shift (3:00 P.M. to 11:00 P.M.), failed to document: Respiratory status for 8 of 10 days. Lung sounds for 8 of 15 days. Respiratory rate for 8 of 15 days. Oxygen saturation levels for 8 of 15 days.

The night shift (11:00 P.M. to 7:00 A.M.), failed to document: Respiratory status for 6/15 days. Lung sounds for 6/15 days. Respiratory rate for 6/15 days. Oxygen saturation levels for 6/15 days. Nurse #4 was interviewed on 6/16/17 at 7:45 A.M. and was asked how she assesses the Resident’s respiratory status and she said I know by looking at him/her, his/her body language and lung sounds. I can also pick up on how he/she is based on his/her cough. When asked if respiratory assessment is to be completed and documented every shift, she responded yes. When asked where the information is documented, she said On the MAR indicated [REDACTED]

On 6/20/17 at approximately 1:30 P.M. the DON was interviewed. This surveyor reviewed the physician orders [REDACTED]. The DON was notified by this Surveyor that respiratory assessments were not documented in the MAR indicated [REDACTED]. The DON said she was not aware that the respiratory assessments were not being documented every shift as ordered. On 6/22/17 at 10:45 A.M., the DON provided the Surveyor with documentation that she described as additional information for Resident #10. Upon review of the documentation, the Surveyor discovered they were the MARS previously reviewed by this Surveyor on 6/16/17 and 6/20/17 with the missing information now filled in including nurses initials to attest that assessments were complete, description of lung sounds, respiratory rates and oxygen saturation numbers. When the DON was asked why the information was now filled in, she said that she started re-educating the nurses on the unit and they must have gone back and filled in the missing information. The Surveyor asked the DON to investigate the matter and report back with her findings.

On 6/22/17, the DON reported to the survey team that the nurses had gone back and filled in missing information going back to the beginning of the month. The DON provided written statements from the nurses. The day shift nurse wrote that she filled in missing information for 15 shifts spanning from 6/1/17 to 6/16/17. The evening shift nurse wrote that she filled in missing information for 9 shifts and a missed [MEDICATION NAME] (inhaled steroid that helps open airways) treatment. The DON spoke to the night nurse by phone who also indicated that she filled in missing information. The DON said that all of the nurses were re-educated on the proper procedure for completing late entry nursing notes.

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 observation, record review and staff interview, the facility failed to ensure that for 2 Residents (#4 and #10) out of 20 Sampled Residents, that the medical plan of care was followed.

Findings include:

1. For 2 of 3 meal observations, the facility failed to implement Resident #4’s nutritional plan of care to provide milk ([MEDICATION NAME] free) at meal times to increase protein, calories and fluid intake as planned.

Resident #4 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE], indicated the Resident had cognitive deficits and required extensive assistance for dressing, bathing, hygiene needs and supervised for ambulation and eating. The assessment noted the Resident’s weight status at 169 pounds, and 70 inches tall.

Record review indicated the Resident had a choking episode on 1/20/17, was evaluated for ENT (ear nose throat) and seen by speech therapy for dysphasia. Recommendations included supervision at meals and a puree texture diet with thin liquids. Further record review indicated a nurses note dated 4/11/17, that Resident #4 was diagnosed with [REDACTED]. The quarterly assessment and nutritional progress note dated 4/18/17, indicated the Resident’s meal intake had declined and nursing had reported digestive (dairy) dietary intolerance after meals and the weight status now at 148 to 150 pounds. The dietician’s recommendation included a nutritional supplement (Ensure Clear 200 milliliters) two times a day and to provide Lactose free milk, [MEDICATION NAME] tablets prior to meals and supervise/assist with meals.

According to physician’s orders [REDACTED].#4’s diet order included dysphasia I (puree texture) diet with thin liquids, milk ([MEDICATION NAME]) at meals and a nutritional supplement Ensure clear twice a day. Review of weight documentation indicated Resident #4’s weight status had shows a gradual monthly (3/9/17 to 6/13/17) decline from 150.4 to 143.4 pounds, a total loss of 7 pounds. During meal observations Resident #4 was served only a juice beverage at meal times as follows:

On 6/16/17 at the noon meal, Resident #4 was set up in the unit day room at the table to eat. A meal tray was provided that included a puree meal, cranberry juice beverage and dessert item. Staff provided cues for the Resident to feed him/herself as he/she voiced uncertainty on what to do. The Resident consumed all the juice beverage before finishing the entree and staff offered another glass of juice. The lactose free milk was not served to the resident. For the supper meal on 6/16/17 at 6:06 P.M., the Surveyor observed Resident #4 sitting in the unit day/dining room with a puree meal served that contained an 8 ounce cranberry juice. Review of the Resident’s tray card included [MEDICATION NAME] (a lactose free milk beverage). Although nursing staff had checked the meal tray for accuracy and provide the hot and cold beverages from the food cart, Resident #4 did not receive the (lactose free) milk beverage according to the nutritional plan. On 6/16/17 at 6:08 P.M., during interview, Unit Manager #3 was unaware that Resident #4 had not been receiving the (lactose free) milk as planned.

2. For Resident #10, the Facility failed to follow the physician’s orders [REDACTED]. Resident #10 was admitted to the Facility in 4/2017 with [DIAGNOSES REDACTED]. Review of Admission Minimal Data Set (MDS) assessment dated [DATE], indicated that the Resident has severe memory impairment and is unable to communicate. The assessment noted the Resident is not able to walk and is totally dependent on staff for all activities of daily living. The Resident has a [DEVICE] for all nutrition due to high risk of aspiration (inhalation of food/liquids into the lungs). The Medical Record was reviewed on 6/15/17, 6/16/17 and 6/20/17. A review of the medical record indicated that on 4/16/17, the Resident was transferred from the Facility to the acute care hospital due to respiratory distress. The nurses’ note dated 4/16/17 indicated the Resident had labored breathing and congestion with a productive cough. According to the nurses’ note, the staff attempted to suction him/her 4 times but the Resident was resistant and clenched his/her jaw. The Resident was hospitalized from [DATE]- 4/28/17 and diagnosed with [REDACTED].[MEDICAL CONDITION] is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs (JAMA. (YEAR) [DATE];315(8): 801-810)

Review of the medical record indicated the Resident was re-admitted to the facility on [DATE] and the Physician ordered the following:

1. Evaluate respiratory status each shift
2. Lung sounds each shift
3. Respiratory rate each shift
4. Oxygen saturation levels each shift
5. [MEDICATION NAME] (a steroid inhaler that helps open airway) .5-3 mg 1- unit dose via nebulizer every 4 hours as needed for wheeze/shortness of breath
6. Document post assessment when nebulizer is administered:

A. Respiratory rate after treatment
B. Oxygen saturation level after treatment
C. Sputum
B= Bloody C= Clear G= Green W= White Y= Yellow N= None D. Outcome/Response I= Improved W= Worsened NC= No Change

The Medication Administration Record [REDACTED]. Of the 19 days reviewed, the day shift (7:00 A.M. to 3:00 P.M. ) failed to document: Respiratory status for 19 of 19 days . Lung sounds for 17 of 19 days. Respiratory rate for 17 of 19 days. Oxygen saturation levels for 17 of 19 days. The evening shift (3:00 P.M. to 11:00 P.M.), failed to document: Respiratory status for 5 of 19 days. Lung sounds for 6 of 19 days. Respiratory rate for 5 of 19 days. Oxygen saturation levels for 4 of 19 days. The night shift (11:00 P.M. to 7:00 A.M.), failed to document: Respiratory status for 5 of 19 days. Lung sounds for 5 of 19 days. Respiratory rate for 4 of 19 days. Oxygen saturation levels for 3 of 19 days.

The Nursing Progress Notes were reviewed. The Facility failed to document respiratory assessment in the nursing progress notes for 17 of the 19 days on the day shift, 4 of the 19 days on the evening shift and 3 of the 19 days on the night shift. There were no nursing progress notes in the record from 5/13/17 to 5/19/17. A review of the 5/19/17 nursing progress note indicated that the Resident had an elevated temperature of 99.9 Fahrenheit (F) and the Physician Assistant (PA) ordered stat labs, a chest x-ray and urine culture. The chest x-ray showed small bilateral lower lob infiltrates (pneumonia) and the Nurse Practitioner (NP) ordered a dose of [MEDICATION NAME] (an antibiotic) IM (intramuscular) and [MEDICATION NAME] (an antibiotic) to be administered for 7 days via midline (IV). Review of the MAR indicated [REDACTED]. The MAR from 5/20/17- 6/4/17 when he/she received IV antibiotics indicated the following: Of the 15 days reviewed, the day shift (7:00 A.M. to 3:00 P.M. ) failed to document: Respiratory status for 15 of 15 days . Lung sounds for 15 of 15 days.

Respiratory rate for 15 of 15 days.
Oxygen saturation levels for 15 of 15 days.
The evening shift (3:00 P.M. to 11:00 P.M.), failed to document:
Respiratory status for 12 of 15 days. Lung sounds for 12 of 15 days.
Respiratory rate for 12 of 15 days.
Oxygen saturation levels for 12 of 15 days.
The night shift (11:00 P.M. to 7:00 A.M.), failed to document:
Respiratory status for 7 of 15 days.
Lung sounds for 8 of 15 days.
Respiratory rate for 8 of 15 days.
Oxygen saturation levels for 7 of 15 days.
The Nursing Progress Notes were then reviewed.
The Facility failed to document respiratory assessment in the nursing progress notes for 14 of /15 days on the day shift, 9 of /15 days on the evening shift and 8 of 15 days on the night shift.

There were no nursing progress notes in the record from 5/28-6/4/17. A review of the 6/4/17 nursing note indicated that Resident #6 had coughing, mucus discharge and a fever of 100.4 F.

Resident was suctioned and a nebulizer treatment was given. The physician’s service ordered stat labs and a chest x-ray. The chest x-ray showed slight right lower lobe infiltrate (pneumonia) and [MEDICATION NAME] (an antibiotic) was ordered for 7 days. Review of the MAR indicated [REDACTED]. The MAR from 6/5/17- 6/15/17 was reviewed. Of the 10 days reviewed, the day shift (7:00 A.M. to 3:00 P.M. ) failed to document: Respiratory status for 9 of 10 days . Lung sounds for 9 of 10 days. Respiratory rate for 9 of 10 days Oxygen saturation levels for 9 of 10 days The evening shift (3:00 P.M. to 11:00 P.M.), failed to document: Respiratory status for 5 of 10 days. Lung sounds for 5 of 10 days. Respiratory rate for 5 of 10 days Oxygen saturation levels for 5 of 10 days The night shift (11:00 P.M. to 7:00 A.M.), failed to document: Respiratory status for 5 of 10 days. Lung sounds for 3 of 10 days. Respiratory rate for 2 of 10 days Oxygen saturation levels for 2 of 10 days

The Nursing Progress Notes were then reviewed. The Facility failed to document respiratory assessment in the nursing progress notes for 8 of the 10 days on the day shift, 4 of the 10 days on the evening shift and 7 of the 10 days on the night shift. There were no nursing progress notes in the record for 6/13/17 and 6/14/17. Resident #10 had a standing order to respiratory assessment to be completed every shift beginning on 4/28/17 due to his/her hospitalization for pneumonia [MEDICAL CONDITION]. Resident was treated for [REDACTED]. Throughout this time, the Facility failed to assess and document the respiratory status for Resident #10. During interview on 6/16/17 at 7:45 A.M., Nurse #4 said that Resident #10 has had persistent pneumonia. She reported that Resident is not able to swallow his/her saliva and secretions and is unable to take deep full breaths. She said that Resident has excess mucus that he/she has a very hard time clearing because of very weak cough reflex. When

asked how she assesses the Resident, she said I know by looking at him/her, his/her body language and lung sounds. I can also pick up on how he/she is based on his/her cough. This surveyor asked what the physician had ordered for respiratory assessment and Nurse #4 said monitor oxygen saturations and lung sounds. When asked if respiratory assessment is to be completed and documented every shift, she responded yes. Resident #10 was observed on 6/16/17 at 4:30 P.M. and exhibited shallow breathing and gurgling noises with breaths. He/she did not spontaneously cough to clear secretions in the throat and was observed to expel a small amount of frothy white sputum and breathing then continued to be gurgling and labored and Surveyor #4 notified nursing. The Physician was in the Facility and assessed the Resident with this surveyor present. He reported that Resident had upper airway congestion present. He stated it is difficult to assess lung sounds as Resident is unable to take deep breaths, however the Resident’s lungs seemed clear. He stated he would order a follow up chest x-ray to monitor Resident’s condition. During interview on 6/20/17 at 1:30 P.M., the Director of Nurses (DON) reviewed the Physician orders [REDACTED].

Failed to give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure, for 1 Resident (#6) who was assessed to be at high risk for skin breakdown, the prevention of a pressure injury in a sample of 20 Residents.

Findings include:

Resident #6 was a long term care Resident admitted in 7/2011 with [DIAGNOSES REDACTED]. During the initial tour of the Tupper Unit on 6/15/16 at 9:30 A.M., Unit Manager #3 informed Surveyor # 4 that Resident #6 had an open area on the left heel and was treated for [REDACTED]. She also said the resident had a history of [REDACTED].

A review of the annual Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident rarely made self understood and rarely had the ability to understand others. The Resident was assessed to have short and long term memory deficit and was severely impaired for decision making and exhibited no behaviors and no indicators of [MEDICAL CONDITION]. The assessment indicated the Resident was totally dependent on staff for all activities of daily living. The MDS indicated the Resident was at risk for developing pressure ulcers. Review of the Norton Plus Skin Assessment, dated 3/15/17 and 6/7/17, indicated the Resident was at high risk for skin breakdown.

Review of the Resident’s Care Plans identified that the Resident was a risk of skin breakdown, initiated 5/2014, and the goal was for the skin to remain intact. Review of the multiple interventions indicated that the facility would conduct weekly skin checks. Review of the weekly skin audits completed on 5/4/17 and 5/11/17 indicated the Resident’s skin was intact. There were no skin checks completed on 5/18/17 and 5/25/17 to indicate the condition of the Resident’s skin and no nursing progress notes to review of any skin changes from 1/19/17-6/1/17. Review of the Monthly Nurse Summary for (MONTH) (YEAR), indicated no behaviors and no skin breakdown. The nursing summary noted the Resident was heavy and helpless and needed special attention due to immobility-2 or more people to bathe, ambulate, transfer or position.

Review of the clinical record indicated that there were no nursing progress notes written for 5/29/17, 5/30/17, 5/31/17 and 6/1/17. The nursing note dated 6/2/17, indicated the Resident had an open area on the left heel and the Physician was contacted and ordered a Xeroform dressing and to wear a Prevalon boot. The nurses’ note further indicated the Resident was started on [MEDICATION NAME] ([MEDICAL CONDITION] medication), 1 GM three times a day for 7 days, for shingles. The physician also ordered to increase the Resident’s [MEDICATION NAME] (antidepressant) order to 50 mg every day at hour of sleep related to restlessness moving feet constantly in bed. The restlessness of the Resident’s feet had not been documented in the nursing progress notes, behavioral records, psychiatry assessments, treatment records or the MDS assessments.

The primary care Physician documented on 6/8/17 about the rash on the Resident’s neck and treatment for [REDACTED]. The Physician noted the sore on his/her left heel is likely due to restless leg from his/her generalized discomfort from Shingles that has produced a friction sore on the left heel and is wearing boots on both heels. The nursing documentation had no written notes of the Resident exhibiting this restlessness and/or kicking behavior of the left leg in bed. The facility acquired wound was documented as a Stage 2 (loss of epidermis) and measured 0.7 cm x 0.5 cm with a 0.1 cm depth. The Clinical Coordinator documented on 6/2/17 that the left heel wound was unavoidable due to the medication reduction and resulted in increased restlessness which may have contributed to skin breakdown. During interview on 6/16/17 from 1:10 P.M. – 1:22 P.M., the primary care Physician/Medical Director and the Director of Nurses came to discuss the Resident’s pressure injury. The Medical Director said the Resident developed an an area on the heel from leg movement. The Medical Director was asked with a [DIAGNOSES REDACTED]. The MD said the heel was only a chafing and the Director of Nurses said no it is a pressure area.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure there was a current written plan of care that includes both services between the facility and the hospice that assured effective communication according to the written agreement with this Hospice agency for 1 of 5 sampled Residents (#5) receiving services from a total of 20 Sampled Residents.

Findings include:

For Resident #5, the facility failed to have an integrated plan of care that collaborated the services between the facility and the hospice services. Record review failed to include documentation from hospice team members whom had provided services to the Resident, and failed to have a current physician recertification outlining the terminal illness and plan of care. Facility staff were not aware of hospice services for Resident #5.

The Hospice Service Agreement signed and dated 7/15/2011 with the facility indicated the following responsibilities:

– Hospice shall identify care and services needed and the scope and frequency of such services and by which provider, Hospice or Nursing Facility, to be responsible for performing which functions according to a plan of care.

– Hospice shall maintain a Hospice plan of care that is integrated with the facility documentation.
– Hospice team members providing services to the Hospice patient in the nursing facility will provide documentation of all services provided in the patient’s facility record. During the facility tour on 6/15/17, Unit Manager #3 identified that Resident #5 was readmitted and now receiving Hospice but was unfamiliar with the services. Upon completion of the unit tour, unit manager asked the clinical coordinator for further information.

The clinical coordinator provided a list dated 6/12/17 of the hospice health aide schedule which identified the Resident name, the date and time services are to be provided to the residents. Resident #5 was not on the list and the Unit Manager #3 was uncertain what the hospice plan was. The clinical coordinator was unable to provide additional information at that time.

Resident #5 was admitted for long term care in 3/2016 with [DIAGNOSES REDACTED]. The Resident’s MDS assessment dated [DATE] indicated cognitive impairment with invoked health care proxy. For activities of daily living, the Resident was independent in ambulation and eating; requiring extensive assistance for dressing, hygiene and bathing needs.

Record review indicated the Resident had a change in status and was sent to the hospital for evaluation 5/20/17 and returned. A significant change assessment was initiated on 6/13/17.

Review of readmission physician orders [REDACTED]. The Hospice service agreement with the facility indicated the Hospice agreed to coordinate and provide the above information. Review on 6/16/17 and 6/20/17, the Resident’s plan of care failed to identify services or interventions from the Hospice agency.

The Resident Care Card, dated 6/12/17 for nurse aide use also failed to identify that Resident #5 was on Hospice services. Facility staff were not aware of when services were provided to Resident #5.

During interview with Unit Manager #3 on 6/20/17 at 10:20 A.M., Resident #5 was readmitted on Hospice services 6/10/17, and then changed Hospice providers on 6/13/17. Interview on 6/20/17 during the afternoon, Hospice case manager was asked why there was no documentation regarding the hospice services provided for Resident #5, and the case manager explained that they were working on their medical record system. The case manager was not aware that facility staff were unfamiliar with the schedule and that there was no documentation in the facility for the services that started a week ago.

Interview on 6/22/17 at 9:30 A.M. the facility certified nurse aide (cna) #1 assigned to care for Resident #5 was unaware when the hospice aide would care for Resident #5 or on what day of the week. The cna #1 was preparing to ready Resident #5 for a shower as scheduled.

Interview with the hospice health aide on 6/22/17 at 9:35 A.M., said that although the home health aide schedule lists who will be seen it is not always accurate. At times, there will several residents, that are scheduled at the same time, so it is flexible. The hospice home aide also said that they do not provide any direct care. The services include things like taking the resident outside, sitting with them, taking to activities, etc.

Cape Heritage Rehabilitation & Health Care 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

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 – Cape Heritage Rehabilitation & Health Care Center

Inspection Report for Cape Heritage Rehabilitation & Health Care Center – 06/22/2017

Page Last Updated: August 8, 2018