Care One at Peabody

Care One at Peabody

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Care One at Peabody? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About Care One at Peabody

Care One at PeabodyCare One at Peabody is a for profit, 150-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Peabody,  Danvers, Lynnfield, Salem,  Middleton, and the other towns in and surrounding Essex County, Massachusetts.

Care One at Peabody focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Care One at Peabody
199 Andover Street
Peabody, MA 01960

Phone: 978-531-0772
Website: http://ma.care-one.com/locations/careone-at-peabody/

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,One Care in Peabody Massachusetts received a rating of 1 out of 5 stars.

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

Fines and Penalties

Our Nursing Home Neglect Attorneys inspected government records and discovered Care One at Peabody committed the following offenses:

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

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

Based on staff interview and record review, the facility failed to notify the activated health care proxy (HCP) for a medication change and failed to notify the physician timely in regard to a resident’s change of condition for 1 resident (#7) from a total sample of 24 residents.

Findings include:

For Resident #7, the facility failed to notify the resident’s physician timely in regard to a change in condition. Review of a nurses note, dated 8/2/16, indicated that Resident #7 had multiple episodes of agitation on the 7-3 shift. In addition, the note indicated that the resident was yelling out derogatory names and abusing staff for 3 hours. The note indicated that nursing gave the resident [MEDICATION NAME] 12.5 milligrams (mg) by mouth at 11:00 A.M. without effect. The physician was not notified of the resident’s change in condition.

The physician was not notified until 8/3/16 at 3:00 A.M., for a change in condition in regard to the resident’s behavioral status, which began on 8/2/16 at 10:00 A.M.

Failed to determine if it is safe for the resident to self-administer drugs.

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

Based on observation, record review and interview, the facility failed to assess 1 resident (#12) for the ability to safely self administer medications in a total of 24 sampled residents.

Findings include:

During observation on 9/15/16 at 3:30 P.M., Resident #12 was on a stretcher at the nurse’s station waiting for the elevator to be taken to [MEDICAL TREATMENT]. At that time, Nurse #1 handed this Resident a pill packaged in a plastic bag. After this Resident left for [MEDICAL TREATMENT], surveyor asked Nurse #1 what did she hand to this Resident. Nurse #1 stated it was an [MEDICATION NAME] (which is [MEDICATION NAME]) 25 mg for this Resident to self-administer at [MEDICAL TREATMENT].

Failed to provide housekeeping and maintenance services.

Based on observation and staff interviews, the facility failed to maintain medication and treatment carts sanitary and in good repair.

Findings include:

On 9/15/16 at 1:00 P.M., the surveyor observed a first floor medication cart to be laden with dirt and built up debris. Dripped spills with caked debris was observed on all sides of the cart and debris along the bottom rails on all sides. The medication cart was actively being used for medication administration to residents at this time.

On 9/15/16 at 1:20 P.M., the surveyor observed a second floor medication cart to be laden with dirt and built up debris. Spills and built up debris was observed and this cart was actively being used for medication administration to residents.

On 9/15/16 at 1:45 P.M., the surveyor observed that the third floor medication and treatment carts were in the same condition as the first and second floor carts.

On 9/21/16, the 1st floor medication cart again was observed for cleanliness by the surveyor at 3:20 P.M. The cart remained laden with dirt and debris. Three of three medication carts were soiled. Two of two treatment carts were soiled. One of two treatment carts had broken corners that were taped to hold them together. Nurse #6 opened the drawers to the medication cart for the surveyor and the surveyor observed the drawers to have spills and debris all over the bottom. Nurse #1 said the nurses try to keep the carts clean as much as possible.

Failed to provide necessary care and services to maintain the highest well being of each resident

Based on observation, record review, and interview, the facility failed to provide the necessary care and services to attain or maintain his/her highest practicable level of physical, mental and psychological well-being to alleviate escalating behaviors for 1 resident (#7) in a total sample of 24 residents which resulted in the resident receiving the administration of [MEDICATION NAME] (antipsychotic medication) 5 MG Intramuscular (IM).

Findings include:

Resident #7 was admitted to the facility 4/16 from a hospital psychiatric unit with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set assessment (MDS), dated [DATE], indicated the Brief Interview for Mental Status (BIMS) (a cognitive assessment) score was 9 out of a possible 15 (indicating moderate cognitive impairment). The MDS indicated that the resident had verbal behavioral symptoms not directed towards others. The resident requires assistance with all activities of daily living, ambulates with a walker, is usually understood and usually understands others. The Health Care Proxy is activated.

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

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

Based on observation, record review and staff interview, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for one resident #12 who is given a controlled medication to take to dialysis out of a sample of 24.

Findings include:

During interview on 9/15/16 at 10:00 A.M., Resident #12 said that he/she goes to dialysis 3 times a week on Tues., Thurs., and Sat., but said that the chair at dialysis is very uncomfortable. (This Resident is gone from this facility approximately 3:30 P.M.- 9:30 P.M. which is during supper time on those days). Resident #12 said the Nurse on duty at this facility, gives the resident a Tramadol pill to take to dialysis and s/he self administers at dialysis. The Resident said, this had been going on for awhile. Tramadol is a narcotic to treat moderate to severe pain. It is a countable controlled medication.

Review of the dialysis communication book (which is a written communication tool used between the dialysis facility and this facility) reflected a dialysis communication progress note, dated 8/20/17, indicating Resident #12 was sent with Tramadol 25 milligrams (mg). There was documentation from the dialysis facility indicating Venofer medication was administered at dialysis. There was no indication this resident self administered the Tramadol while at dialysis.

Review of the narcotic book indicated Tramadol 25 mg was removed from count on 8/20/16 at 3:00 P.M. There was no indication this medication was given to the Resident to take at dialysis nor any indication this medication returned back to the facility. During observation on 9/15/16 at 3:30 P.M., Resident #12 was on a stretcher at the nurse’s station waiting for the elevator to be taken to dialysis. At that time, Nurse #1 handed this Resident a pill packaged in a plastic bag. After this Resident left for dialysis, the surveyor asked Nurse #1 what did she hand to this Resident. Nurse #1 stated it was an Ultram (which is Tramadol) 25 mg for this Resident to self-administer at dialysis.

Review of the Resident’s Medication Administration Record [REDACTED].M. on 9/3, 9/8, (resident did not go to dialysis on 9/8 as scheduled but the narcotic book indicated Tramadol 25 mg was removed from count), 9/10, 9/13, 9/15 and 9/17, (dialysis days) with a physician’s orders [REDACTED]. In addition this Resident has a current physician’s orders [REDACTED].*premedicate before dialysis but the MAR indicated [REDACTED].

Review of the narcotic book indicated the nurses removed Tramadol 25 mg on 9/3/16 at 3:00 P.M., 9/8/16 at 4:00 P.M., 9/9/16 at 4:00 P.M., ( this Resident was not scheduled to go to dialysis on 9/9/16, there was no documentation on the MAR indicated [REDACTED].M., 9/15/16 at 4:00 P.M. and 9/17/16 at 3:15 P.M. There was no documentation that on 9/10/16 when the Resident went to dialysis Tramadol was removed from count. There was no documentation that the Tramadol was removed from the narcotic count, re- packaged and given to this Resident to self administer at dialysis as observed on 9/15/16.

During interview on 9/22/16 at 10:40 A.M. the Medical Director said there needs to be a better system in place to address controlled medications given to Residents for self-administration.

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

Based on observation, staff interview and review of facility policy, the facility failed to ensure that facility staff followed proper infection control practices for the prevention and spread of infection for 3 of 4 Non-Sampled residents (NS #1, NS#3 and NS #4) and 1 (#17) out of a total sample of 24 while performing finger stick blood sugars and failing to perform hand hygiene.

Findings include:

1. For NS#3 and NS #4 the facility failed to ensure proper infection control practices were observed during a finger stick blood sugar procedure. Review of the facility’s policy entitled Blood Glucose Monitoring ,dated July 2012, indicated the following:

  • Disinfect the meter before and after each use , or when the monitor is visibly soiled.
  • Use Super Sani-Cloth germicidal disposable wipe to wipe down the meter using caution not to get liquid in the test strip and key code ports of the meter.
  • If the Super-Sani Cloth is unavailable, use a 1:10 sodium hypochlorite solution and soft cloth.

During observation of a finger stick blood sugar test on 09/15/16 at 3:40 P.M., Nurse #3 was observed using a blood glucose meter that is used for multiple residents, without using the appropriate disinfecting procedure which is part of the facility’s policy for cleaning and disinfecting blood glucose meters.

Nurse #3 was observed preparing to obtain a finger stick blood sugar reading for NS#3. The nurse took the blood glucose meter out of a box and applied gloves. He placed a new testing strip in the blood glucose meter and proceeded to perform the blood glucose test.

After obtaining this resident’s blood sugar, Nurse # 3 placed the contaminated lancet and testing strip into a sharps biohazard container, and removed his gloves. Without disinfecting the blood glucose meter, Nurse #3 prepared the meter with another strip and entered NS #4’s room. Nurse #3 applied gloves and performed the blood glucose test. Nurse #3 placed the contaminated lancet and testing strip into a sharps biohazard container, and removed his gloves. Without disinfecting the blood glucose meter, Nurse #3 proceeded to prepare the blood glucose meter for use for another resident. He placed the strip into the meter and walked away from the medication cart with the blood glucose meter in hand. The surveyor stopped Nurse #3 and asked him what the facility policy was for disinfecting the blood glucose meter. Nurse #3 said I think they do it at the end of every shift. During interview on 09/16/16 at 2:15 P.M., the Director of Nursing (DON) said the facility policy for blood glucose meter disinfection is to use the Super Sani-Cloths to disinfect the blood glucose meter before and after each patient use.

2. For Resident #17, NS #1 and NS #3, the facility failed to ensure staff performed hand hygiene during medication pass.

A. During a medication pass observation on 9/15/16 at 4:30 P.M., Nurse #3 was observed pouring medications for NS #3. The nurse entered the resident’s room and administered the medications. Nurse #3 left the room and without performing hand hygiene, began to review the medication administration record (MAR) for NS #1. Nurse #3 poured medications into a medication cup and brought the medication into NS #1’s room for administration. Nurse #3 left the residents room without performing hand hygiene. During interview on 9/15/16 at 5:00 P.M., Nurse #3 said he should have washed his hands before entering the room and once he finished giving each resident their medications. He said he just forgot.

B. During a medication pass observation on 9/16/16 at 9:20 A.M., Nurse #4 was observed pouring medications for Resident # 17. The nurse verified the resident and administered the medications. Nurse #3 left the area and without performing hand hygiene, began to review the MAR for the next resident. When asked by the surveyor in regard to hand washing, Nurse #4 said that she usually has hand sanitizer on her medication cart, but wasn’t sure where it was. Without performing hand hygiene, Nurse #4 continued to handle the MAR on the medication cart and pour medications for the next resident. The surveyor intervened and requested that she perform hand hygiene.

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

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

Based on observation, record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 sampled residents (#12) in a total sample of 24 residents. Resident #12 was admitted in 5/2016 with [DIAGNOSES REDACTED]. Resident #12 receives [MEDICAL TREATMENT] at a chronic care outpatient [MEDICAL TREATMENT] facility 3 times a week on Tuesdays, Thursdays and Saturdays. This Resident is gone from this facility approximately 3:30 P.M.- 9:30 P.M. which is during supper time on those days. Review of the clinical record on 9/15/16 at 3:00 P.M. for Resident #12, indicated the Resident had the following medication orders [REDACTED]. There was no order on the September’s 2016 Medication Administration Record [REDACTED].

  • [MEDICATION NAME] is a narcotic to treat moderate to severe pain. It is a countable controlled medication.
  • [MEDICATION NAME] is a [MEDICATION NAME] binder given to patients on [MEDICAL TREATMENT] to reduce serum phosphorous and it must be given with meals and/or snacks in order to receive good efficacy.

Findings include:

During observation on 9/15/16 at 3:30 P.M., Resident #12 was on a stretcher at the nurse’s station waiting for the elevator to be taken to [MEDICAL TREATMENT]. At that time, Nurse #1 handed this Resident a pill packaged in a plastic bag. After this Resident left for [MEDICAL TREATMENT], the surveyor asked Nurse #1 what did she hand to this Resident. Nurse #1 stated it was an [MEDICATION NAME] 25 mg for this Resident to self-administer at [MEDICAL TREATMENT].

During interview on 9/20/16 at 8:30 A.M., the Director of Nurses, (DNS) stated this Resident had a physician’s orders [REDACTED].o. 7/18 (indicated new order on 7/18) in the medications box, and in the hour section, hand-written FYI (for your information) This information was not on the copied MAR from 9/15/16. The DNS could not explain the discrepancy. Review of the narcotic book indicated from 9/1/16 -9/1716 the nurses removed [MEDICATION NAME] 25 mg on 9/3/16 at 3:00 P.M., 9/8/16 at 4:00 P.M., 9/9/16 at 4:00 P.M., 9/13/16 at 3:00 P.M., 9/15/16 at 4:00 P.M. and 9/17/16 at 3:15 P.M. (6 times) There was no documentation that the [MEDICATION NAME] was removed from the narcotic count, re- packaged and given to this Resident to self administer at [MEDICAL TREATMENT] as observed on 9/15/16.

Review of the [MEDICAL TREATMENT] communication book (which is a written communication tool used between the [MEDICAL TREATMENT] facility and this facility) from 9/1/16 – 9/17/16 lacked any indication this Resident was sent to [MEDICAL TREATMENT] with [MEDICATION NAME]. The Resident went to [MEDICAL TREATMENT] on 9/3, 9/10, 9/13, 9/15 and 9/17/16. (5 times)

Review of the Resident’s Medication Administration Record [REDACTED].M. on 9/3, 9/8, 9/10, 9/13, 9/15 and 9/17 (6 times) prior to [MEDICAL TREATMENT] but the resident did not go to [MEDICAL TREATMENT] on 9/8/16.

There was no further documentation as to why Resident #12 received [MEDICATION NAME] on 9/8/16 prior to [MEDICAL TREATMENT] when this Resident did not go to [MEDICAL TREATMENT] on that day.

There is no documentation in the Resident’s clinical record as to who, when, where or why [MEDICATION NAME] 25 mg was removed from the narcotic count on 9/9/16 at 4:00 P.M. There was no documentation in the narcotic book that a [MEDICATION NAME] 25 mg was removed from count even though the clinical record indicated this Resident received [MEDICATION NAME] prior to going to [MEDICAL TREATMENT] on 9/10/16.

In addition, the [MEDICATION NAME] was signed off in the MAR indicated [REDACTED]. on 9/3, 9/10, 9/13, 9/15 and 9/17 but the Resident was at [MEDICAL TREATMENT] on those days and therefore could not have received the [MEDICATION NAME] as documented. During interview on 9/22/16 at 10:40 A.M. the Medical Director stated there needs to be a better system in place to address controlled medications given to Residents for self-administration and will look into the administration of the [MEDICATION NAME].

Care One at Peabody, 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.


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Page Last Update: November 25, 2017

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