Colonial Skilled Nursing Home & Rehabilitation

Colonial Skilled Nursing Home & Rehabilitation

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Colonial Skilled Nursing Home & Rehabilitation? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a Colonial Skilled Nursing Home & Rehabilitation 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 Colonial Skilled Nursing Home & Rehabilitation

Colonial Skilled Nursing Home & RehabilitationColonial Skilled Nursing Home & Rehabilitation is a for profit, 205-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Weymouth, Braintree, Quincy, Hingham, Holbrook, Randolph, Rockland, Milton, Hull, Abington, Norwell, Whitman, Brockton, Stoughton, Hanover, and the other towns in and surrounding The Greater Boston area, Massachusetts.

Colonial Skilled Nursing Home & Rehabilitation focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Colonial Skilled Nursing Home & Rehabilitation
125 Broad St,
Weymouth, MA 02188

Phone: (781) 337-3121
Website: https://www.banecare.com/Colonial-skilled-nursing-home-rehabilitation

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, Colonial Skilled Nursing Home & Rehabilitation, Massachusetts received a rating of 3 out of 5 stars.

Performance Area Rating
Overall Rating 3 out of 5 (Average)
State Health Inspections 2 out of 5 (Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 3 out of 5 (Average)

Fines Against Colonial Skilled Nursing Home & Rehabilitation

The Federal Government fined Colonial Skilled Nursing Home & Rehabilitation $1,625 on October 9th 2014, $15,015 on June 25th, 2015 and $45,555 on October 13th, 2016 for health and safety violations.

Fines and Penalties

Our Senior Abuse Lawyers inspected government records and discovered Colonial Skilled Nursing Home & Rehabilitation committed the following offenses:

Failed to provide doctors orders for the resident's immediate care, at the time the resident was admitted.

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

For Resident #18, the facility failed to reconcile medications in a timely manner following a hospital transfer to the facility. The on-call physician’s group failed to return 2 phone calls to the facility staff, which resulted in the Resident missing an anti-[MEDICAL CONDITION], anti-nausea and pain medications.

Resident #18 was admitted to the facility in 9/2016 with the following pertinent Diagnoses: [REDACTED]. The Resident developed [MEDICAL CONDITION] around the J-tube site requiring intravenous antibiotics at the hospital. The Resident was admitted to the facility for rehabilitation before transitioning to home. The Resident required that all medications be administered via his/her J-tube. Review of the Medication Reconciliation Policy (reviewed 5/2016 with no changes) indicated

Findings include:

Purpose: 1. To prevent or reduce medication errors which occur when residents transition from one healthcare setting to another.

Policy: 1. An attempt will be made to do an accurate medication reconciliation for all residents admitted , readmitted or returning to the facility from a medical leave of absence. (The policy does not provide a time frame for reconciliation.) Review of the Resident admission form indicates that the Resident was admitted to the facility at 7:25 P.M. on 9/28/16.

Review of the first Nursing Progress Note, following admission, indicated that the Resident complained of discomfort (to the 3:00-11:00 P.M. nurse who stayed until 1:00 A.M.). The physician was called on 2 separate occasions; once during the 3:00 P.M.-11:00 P.M. shift and once before the nurse left the facility at 12:55 A.M., to reconcile all medications. (5 hours after admission to the unit). The note further indicates that the physician did not return the calls.

Review of the Medication Administration Record [REDACTED].M. (2 days after hospital transfer to facility), [MEDICATION NAME] [MEDICATION]) was not administered as scheduled on 9/28/16 at 10:00 P.M. and [MEDICATION NAME] (pain medication every 6 hours as needed) was not administered until 10/3/16 (5 days after transfer to facility).

On 10/13/16 at 3:15 P.M. the Surveyor interviewed the Director of Nursing Services (DNS). The DNS said that the facility did not have a policy for physician response time to staff calls, but that the response time is based on the acuity level of the clinical issue/concern. The Surveyor asked about staffs’ concerns regarding a resident’s pain level. The DNS said that she would expect a physician to call back within a half hour for that situation.

The Surveyor interviewed the Medical Director (MD) on 10/17/16 at 9:29 A.M The MD said that medication reconciliation should take place at a minimum, within a few hours of admission, even though the time frame is not written in a policy. The MD also said that there are road blocks with getting certain medications from the in-town hospitals to the pharmacy, but that it does not happen on a regular basis. He said that it is something that needs to be discussed and that he would talk with the facility staff. Refer to F309

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

Based on observations, interviews and record reviews, the facility failed to maintain professional standards of practice for complete MEDICATION ORDERS FOR [REDACTED].

 

Findings include:

1. For Resident #18, the facility failed to reconcile medications in a timely manner following a hospital transfer to the facility. The on-call physician’s group failed to return 2 phone calls to the facility staff, which resulted in the Resident missing anti-[MEDICAL CONDITION], anti-nausea and pain medications.

Resident #18 was admitted to the facility in 9/2016 with the following pertinent Diagnoses: [REDACTED]. The Resident developed [MEDICAL CONDITION] (an infection) around the J-tube site requiring intravenous antibiotics at the hospital. The Resident was admitted to the facility for rehabilitation before transitioning to home. The Resident required that all medications be administered via his/her J-tube. Review of the Medication Reconciliation Policy (reviewed 5/2016 with no changes) indicated the following:

Purpose: 1. To prevent or reduce medication errors which occur when residents transition from one healthcare setting to another.

Policy: 1. An attempt will be made to do an accurate medication reconciliation for all residents admitted , readmitted or returning to the facility from a medical leave of absence. (The policy does not provide a time frame for reconciliation.) Review of the Resident admission form indicates that the Resident was admitted to the facility at 7:25 P.M. on 9/28/16.

Review of the first Nursing Progress Note following admission indicated that the Resident complained of discomfort and the physician was called x2 to reconcile all medications at 12:55 A.M., or 5 hours after admission to the unit. The note further indicates that the physician did not return the calls.

Review of the Medication Administration Record [REDACTED].M. (2 days after hospital transfer to facility), [MEDICATION NAME] [MEDICATION]) was not administered as scheduled on 9/28/16 at 10:00 P.M. and [MEDICATION NAME] (pain medication every 6 hours as needed) was not administered until 10/3/16 (5 days after transfer to facility). On 10/13/16 at 3:15 P.M. the Surveyor interviewed the Director of Nursing Services (DNS). The DNS said that the facility did not have a policy for physician response time to staff calls, but that the response time is based on the acuity level of the clinical issue/concern. The Surveyor asked about staffs’ concerns regarding a resident’s pain. The DNS said that she would expect a physician to call back within a half hour for that situation.

The Surveyor interviewed the Medical Director (MD) on 10/17/16 at 9:29 A.M The MD said that medication reconciliation should take place at a minimum, within a few hours of admission, even though the time frame is not written in a policy. The MD also said that there are road blocks with getting certain medications from the in-town hospitals to the pharmacy, but that it does not happen on a regular basis. He said that it is something that needs to be discussed and that he would talk with the facility staff. Refer to F309

2.) For Resident #19, the facility failed to follow their own policy for Neurological Assessment after an unwitnessed fall and while receiving anticoagulation therapy (blood thinners) and complaining of headache pain. Findings include: Resident #19 was admitted to the facility in 8/2016 with the following pertinent Diagnoses: [REDACTED]. Review of the Fall Incident Report packet on 10/12/16 at 12:30 P.M. indicated no attached neurological flow sheet.

On 10/11/16 at 11:00 A.M., the Surveyor asked to review the neurological assessment for Resident #19 (for the date of the unwitnessed fall). The UM said that the neuro exam is not entered into the computer, but kept as a paper document with the incident report and fall investigation. The UM could not locate the document. The Surveyor also requested the facility’s policy for neuro checks throughout the survey (3 days) from the facility staff and the corporate staff.

On 10/11/16 at 2:30 P.M. the Unit Manager (UM) was interviewed. The Surveyor asked for the incident report packets used by staff. The UM provided the Surveyor with a blank packet titled: Resident/Visitor Incident Report. The last page of the packet was titled Neurological Observations. The neurological assessment tool was dated 12/1997 and had the facility’s former corporate name, which was currently being used by staff. The tool had no specific guidelines for the frequency of neurological checks.

On 10/13/16 (last day of survey), the UM provided Resident #19’s neurological assessment to the Surveyor and said that it was filed incorrectly with other residents’ information. The neurological assessment indicated that the Resident was monitored one time each shift, upon return from the hospital. The assessments indicated the following: level of consciousness, nausea/vomiting, hand grips, extremity movement, pupils and a comment section for 8/31/16 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. for a total of 2 neurological assessments, 9/1/16 all 3 shifts for a total of 3 neurological assessments, 9/2/16 all 3 shifts for a total of 3 neurological assessments.

Review of the facility’s newly implemented Neurological Observation and Assessment Policy, provided one hour prior to exit conference at 4:00 P.M., indicated the following: After any unwitnessed fall or head injury, residents will have neurological and vital signs monitored every 15 minutes x4, every 30 minutes x2, followed by every 4 hours for 24 hours and then every shift x48 hours. Additional monitoring will be done as determined by resident condition or MD order.

The facility staff failed to follow their own policy for Neurological Assessment (after a fall with head injury) and failed to implement a policy that was consistent with the current standard of practice for neurological assessment, dated or signed by the Medical Director.

Failed to provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay.

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

Based on record review and interviews, the facility failed to complete for 1 Resident (#24), in a total of 24 sampled Residents, a physician discharge summary that included a recapitulation of the Resident’s stay and a final summary of the Resident’s status at the time of discharge.

Findings include:

Based on record review and interview, for Resident #24 the facility failed to have the physician complete a final discharge summary that included a recapitulation of the Resident’s stay, and a final summary of the Resident’s status in the facility at the time of discharge. Resident #24 was admitted in 7/2016 for short term rehabilitation following hospitalization for acute mental status change due to [MEDICAL CONDITION] and dementia. Record review indicated the Resident was admitted in 7/2016 and was discharged on [DATE]. Review of the Resident’s discharge documentation indicated that the physician failed to complete a discharge summary of the resident’s stay as required.

The Director of Nursing was interviewed on 10/13/16 at 11:00 A.M. and following review of the medical record with the surveyor said that the physician failed to complete a discharge summary of the Resident’s stay in the facility.

Nurse Practitioner (NP #2) was interviewed via the telephone on 10/13/16 at 1:55 P.M. NP #2 said that she picked up the Resident’s care from another NP when the resident was assigned to become long term care (could not recall the exact date.) The NP said that on 8/9/16 the facility nurse contacted her to report that paperwork needs to be completed for a discharge the following morning to an assisted living facility. The NP said that she did not see the Resident during his/her stay at the facility and did not complete a discharge summary.

Failed to develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home.

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

Based on closed record review and interviews, the facility failed for 1 Resident (#24) of 24 sampled residents, to initiate a post discharge plan of care that assessed the Resident’s continuing care needs and included a plan to ensure the Resident’s needs will be met following discharge.

Findings include:

For Resident #24, the facility failed to identify on discharge when the resident’s medications were last administered and failed to identify pertinent discharge information regarding the recent adjustment of an antipsychotic medication prior to discharge to a memory care assisted living facility.

Resident #24 was admitted in 7/2016 for short term rehabilitation following hospitalization for an acute mental status change due to [MEDICAL CONDITION] and dementia. Review of the clinical record indicated a 7/25/16 discharge summary completed by the Nurse Practitioner (NP) #1 indicated that the Resident was being discharged to an assisted living facility on 7/29/16 following successful completion of rehabilitation therapy services.

On 7/27/16 a Social Worker (SW) progress interim note indicated that the SW met with the Resident and family member to discuss transition to long term care and on 7/29/16 the Resident was transferred to another unit for long term care. There was no documented explanation regarding the status of the discharge planned by NP #1 on 7/25/16.

medication regimen and recommended to taper Resident #24 off the antipsychotic medication [MEDICATION NAME] that was and initiated by the physician on 8/4/16. On 8/8/16 the day shift nurse documented that a second Nurse Practitioner (NP #2) was updated of delusions resident was having over the weekend per the family while they were visiting. NP #2 gave a new order to increase the [MEDICATION NAME].

Review of an 8/9/16, NP #2 telephone progress note (who had increased the [MEDICATION NAME]), indicated that the facility nurse called to request for paperwork to be signed for discharge the following day. The NP indicated that the medical team was unaware of plans for Resident #24 to be discharged . The NP indicated that the nurse was made aware that the Resident would need to be seen before he/she is discharged to another facility. Review of the 8/10/16, 10:43 A.M. NP’s progress note indicated that she arrived to the facility and was informed that the Resident was discharged earlier that morning without being seen as planned on 8/9/16. The NP indicated that a covering physician who was in the building doing an admission the previous evening signed paper work needed by staff for discharge but did not give the discharge order. The NP indicated that she spoke with the Unit Manger about not communicating the discharge plan to the team and sending the Resident with no discharge order given.

The Director of Nursing (DON) was interviewed on 10/13/16 at 11:00 A.M. and following review of the medical record with the surveyor said that there was no documented evidence of a page 2 patient referral form which outlines the Resident’s care needs and should be completed by the nurse upon discharge as per facility policy. The DON said that that there was no documented evidence that the nurses communicated when the Resident’s medications were last administered prior to the Resident’s discharge. The DON reviewed the NP’s documentation of 8/9/16 and 8/10/16 and said she had no further information to provide. The DON was unable to provide a physician’s discharge order. The DON said that she would call the memory care assisted living facility to see what they received.

Following Surveyor inquiry on 10/13/16 at 1:00 P.M. the corporate information officer said that she contacted the assisted living facility for copies of information provided to them at discharge. A copy of the Resident’s face sheet and the current physician’s orders [REDACTED].M. were provided for surveyor review. These orders did not identify when the Resident’s medications were last administered. A physician order [REDACTED]. (following the Resident’s departure) remained unsigned.

NP #2 was interviewed via the telephone on 10/13/16 at 1:55 P.M. said that she picked up the Resident’s care from NP #1 when the resident was assigned to become long term care (could not recall the date.) The NP said that she was not familiar with Resident #24 when the nurse called on 8/8/16 indicating that the family was upset because the Resident’s [MEDICATION NAME] was lowered and wanted the Resident put back on the previous dose. The NP said that she told the nurse it was okay to do what the family asked and planned to visit to assess the Resident. The NP said the she was unaware of the Resident’s plan for discharge prior to increasing the [MEDICATION NAME]. The NP said that on 8/9/16 the facility nurse contacted her to report that paperwork needs to be completed for a discharge the following morning. The NP said she told the nurse on 8/9/16 that she and the medical team were unaware of the plan for discharge but that the Resident would need to be seen prior to discharge to another facility. The NP said that when she arrived at the facility on 8/10/16 the Resident had already been discharged without NP #2 having the opportunity to assess the Resident’s status. NP #2 was asked if the facility was aware of her concerns said yes, my team has spoken with the Director of Nurses (DON) . I wanted them to know that I was concerned that bumping up the [MEDICATION NAME] and discharging the Resident without being seen is a big deal.

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

Based on observation interview and record review, the facility failed to provide the necessary care and services to attain the highest physical, mental and psychosocial well-being, for 1 Resident (Resident #18), from a total sample of 24 residents.

Findings include:

For Resident #18, the facility failed to ensure that pain medication was available for administration for 5 days following a hospital transfer to the facility. Findings include: Resident #18 was admitted to the facility in 9/2016 with the following pertinent Diagnoses: [REDACTED]. The Resident developed [MEDICAL CONDITION] around the J-tube site which required intravenous antibiotics at the hospital. The Resident was transferred to the facility for rehabilitation before transitioning to home. The Resident required that all medications be administered via his/her J-tube.

The Whipple procedure is performed to remove a tumor in the head of the pancreas behind the stomach and above the small intestine. The duodenum, or the first part of the small intestine, the end of the common bile duct, and the gallbladder are removed. Sometimes, part of the stomach must be removed. The rest of the common bile duct and the remaining pancreas are attached to the jejunum, or middle part of the small intestine. The procedure can cause significant, episodic abdominal discomfort.(Whipple Procedure, Memorial Sloan Kettering Hospital https://www.mskcc.org/cancer-care/patient-education)

Review of the Comprehensive Pain Assessment (completed by Nurse #1 on the evening of admission with no date or time), indicated that the Resident’s acceptance level of pain/pain goal was no pain. The following sections were crossed out and blank: Quality of pain, Current Regime, Pain is improved with various options and the 5 day pain assessment screen (page 2), including indicators of pain, is also crossed out and not completed. Review of the initial Minimum Data Set (MDS) with a reference date of 10/5/16 indicated that the Resident was cognitively intact and showed no signs of [MEDICAL CONDITION]. The pain assessment interview (section J) indicated the following:

  • Presence of pain= yes (in last 5 days)
  • Pain frequency= frequently
  • Numeric rating scale in last 5 days= 5 (from 0-10 scale)

Review of the facility’s interim plan of care, dated 9/29/16 indicated a pain section which indicated: [MEDICATION NAME] 2.5-5.0 mg. listed under medications. There was no indication of acceptable level of pain, goals or non-drug interventions.

Review of the Care Plans indicated a Hydration/Nutrition care plan only. A care plan to address the potential for pain was not observed in the medical record.

Review of the hospital discharge medications (referral form) for pain relief (generated on 9/28/16 at 4:53 P.M.), included the following [MEDICATION NAME]:

  • [MEDICATION NAME] (Tylenol) 325 mg./10.15 ml solution (20.3 ml./650 mg. total) by J-tube every 4 hours as needed for mild pain.
  • [MEDICATION NAME] 5mg/5ml. oral solution 2.5-5mg. every 4 hours as necessary for moderate pain.

Review of Resident #18’s admission form indicates that the Resident was admitted to the facility at 7:25 P.M. on 9/28/16. Review of the first Nursing Progress Note by the 3:00-11:00 P.M shift, following admission indicated that the Resident complained of discomfort and the physician was called x2 to report the Resident’s pain and to reconcile all medications at 12:55 A.M., or 5 hours after admission to the unit. The note further indicates that the physician did not return the calls and that the oncoming 11:00 P.M.-7:00 A.M. nurse was notified to follow-up with the physician.

The Surveyor interviewed Nurse #1 on 10/13/16 at 1:15 P.M. by telephone. Nurse #1 said that he had received report from the hospital staff and without being able to reconcile the medications, took care of the Resident’s needs by continuing the tube feeding, according to the hospital report and referral form, but was not able to provide any medications, including pain medication. Nurse #1 said that he was planning on informing the physician that the Resident was experiencing pain and refused to have a dressing change done due to his/her pain. Nurse #1 said that he reported the information to the 11:00 P.M.-7:00 A.M. nurse. Nurse #1 did not notify a supervisor. Nurse #1 said that he was unable to reconcile the medications (including pain medications) that evening because the physician never returned his 2 phone calls, one from the evening shift and one just before he left at 1:30 A.M.

The Surveyor interviewed Nurse #2 on 10/13/16 at 1:30 P.M Nurse #2 said that she did not get a return call from a physician on the night of 9/29/16 and that she would remember if she had spoken with a physician on the night shift. Nurse #2 did remember that the Resident was very restless in bed that night, but could not remember the resident’s level of pain and did not document a nursing progress note.

The Surveyor interviewed the Unit Manager (UM) on 10/12/16 and throughout the survey from 10/6/16 to 10/13/16. The UM said that all medications should be reconciled as soon as possible and that a nurse practitioner or physician are always available from 8:00 A.M. to 7:00 P.M., but after that, calls are answered by a covering medical group. The UM said that medications cannot be administered until the orders are reconciled with the covering physician. The UM also said that the staff should have contacted the supervisor for assistance reaching the doctor, but did not. The UM said that residents are supposed to come with prescriptions from the hospital and medication can’t be dispensed until they are filled at the pharmacy.

Review of the facility physician’s orders [REDACTED].M. or 15 hours after admission), indicated the following pain medication orders [REDACTED] *Tylenol 325 mg tablet, give 2 tablets by J-tube every 4 hours as needed for pain *[MEDICATION NAME] 5 mg/5 ml oral solution, give 2.5 mg. by J-tube every 6 hours as needed for pain.

Review of the on-call physicians’ group, Improving Patient Care (IPC) Guidelines for Notification indicate the following: During the night (7:00 P.M.-8:00 A.M.): Direct issues pertaining to the list below to the physician on call:

  • New admissions (Resident #18 was a new admission at 7:30 P.M., therefore, the IPC group of physicians should have responded to the staff calls)
  • Transfer patient to ER
  • Critical change in medical status

Review of the Nursing Progress Notes from 9/28/16-10/3/16 indicated the following reports of pain without availability of pain medication:

  • 9/29/16 at 12:55 A.M.- (night of admission to facility): Patient refused dressing change due to complaint of discomfort.
  • 9/29/16 at 3:18 P.M.- complaining of nausea, vomiting x2 this morning
  • 9/30/16 at 9:36 P.M.- – Resident refused tube feeding most of the shift due to vomiting and discomfort. Nurse Practitioner aware- new order for [MEDICATION NAME] suppository 25 mg. per rectum (for nausea) administered with mild effect-vomited x2 during shift.
  • 10/1/16 at 8:38 A.M.- Resident alert, verbal and oriented with increased nausea and abdominal pain-needs script for prn [MEDICATION NAME] and @ 2:36 P.M.- nausea, vomiting x2- tube feeding held, medicated with [MEDICATION NAME] (another anti-nausea medicine) Call out to MD to update on condition.
  • 10/2/16 at 7:43 A.M.-Had as needed (prn) Tylenol at 4:50 A.M. for abdominal pain 4/10. Still needs script for [MEDICATION NAME].
  • 10/3/16 at 4:14 A.M.-Requested Tylenol at 3:05 A.M. for abdominal pain 4/10. Review of the Occupational Therapy Treatment Encounter Notes for 10/1/16 and 10/4/16 indicated the following:
  • 10/1/16: Reason for missed session: Pt. with 10/10 abdominal pain with nausea and vomiting throughout day. Nursing aware.
  • 10/4/16: Pt. reported not feeling well, but willing to get out of bed for therapy. Once up in gym, pt doubled over in pain and reported nausea. Tylenol provided by nursing with minimal effect. Pt. returned to bed. Unable to complete therapy.

On 10/13/16 at 2:30 P.M., the Surveyor interviewed the Occupational Therapist (OT). The OT said that she remembered the Resident bent over in excruciating pain. The OT said that she had to get a wheelchair to return the Resident to his/her bed. The OT also said that the Resident was experiencing a combination of nausea and pain and that nursing was always made aware.

On 10/13/16 at 12:00 P.M. the UM and Surveyor reviewed the narcotic log and emergency kit administration logs. The logs indicated that pain medication was first administered to the Resident on 10/3/16 (5 days after admission to the facility).

The UM contacted the Pharmacist on 10/13/16. The UM said that the orders were entered into the facility computer software program on 9/28/16 (admitted ), but that the prescription for pain medication was not received until 10/3/16. Once the prescription was received, it was dispensed within 2 hours. No other communication was documented. On 10/17/16 at 8:45 A.M. the Surveyor interviewed the Pharmacist. The Pharmacist said that the Resident’s medications were entered into the software program, but the [MEDICATION NAME] order was not transmitted and that it was being reviewed internally to figure out what happened.

On 10/13/16 at 3:15 P.M. the Surveyor interviewed the Director of Nursing Services (DNS). The DNS said that the facility did not have a policy for physician response time to staff calls, but that the response time is based on the acuity level of the issue/concern. The Surveyor asked about staff concerns regarding a resident’s pain. The DNS said that she would expect a physician to call back within a half hour for that situation. The Surveyor interviewed the Medical Director (MD) on 10/17/16 at 9:29 A.M. The MD said that medication reconciliation should take place within a few hours of admission. The MD also said that there are road blocks with getting certain medication prescriptions from the in-town hospitals to the pharmacy, but that it does not happen on a regular basis. He said that it would be discussed with the facility because it can be a problem.

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 record review, observation and interviews, the facility failed to ensure adequate supervision to prevent falls for 2 Residents (#16 and #19) in a total sample of 24 Residents.

Findings include:

1. Resident #16 was readmitted to the facility with [DIAGNOSES REDACTED]. Review of the Resident’s medical history referral information indicated the resident had required daily support of family who transported the resident to day care, shopped and provided meals. The resident’s [DIAGNOSES REDACTED]. The Resident was requiring a lot of one to one attention, had several recent falls, walked with a quad cane and preferred to sleep sitting up on the side of the bed with propped up pillows, and legs dangling over the side.

Review of the admission Minimum Data Set (MDS) assessment, completed 10/7/2016, indicated the resident required limited assistance of one for transfers and ambulation on the resident unit; unsteady but able to stabilize without staff assistance, and use of a cane device. The assessment indicated the resident exhibited indicators for delirium and had symptoms of physical and verbal behaviors towards others, with a BIMS (Brief Interview for Mental Status) score of 6/15 indicating severe cognitive impairment.

Review of the plan of care included admission physician orders [REDACTED]. The resident was at high risk for falls. Nursing progress notes (9/28/16-10/2/16) indicated the resident ambulated the entire hallway, in and out of other resident rooms, frequently looking for a family member and at times exit seeking. Redirection with snacks, activities and Trazodone medication (12.5 mg) were utilized as interventions.

This Resident was observed at 3:30 P.M. on 10/6/16 ambulating in the unit hallway from his/her room without a cane device, to the nursing desk and then back towards his/her room, holding his/her bowed head in his/her hand, asking if he/she could stay the night. A nurses note dated 10/6/16, indicated the resident’s wandering and exit seeking continued with increased aggressive behaviors of banging the window of the unit door with a cane, demanding to be let out. Redirection with snacks, activities and Trazodone medication were not consistently effective.

On 10/9/16, the 11:00 P.M.-7:00 A.M. shift nurses note indicated the resident continued to wander, was agitated, pushing on doorway and demanding to be let out. Although the resident was put into bed twice, he/she quickly got up and paced the unit. Restlessness continued, with increased agitation and intrusiveness. After administration of 12.5 mg of Trazodone medication the Resident rested for 2 hours and then the wandering resumed. Nursing (10/10/16) documentation indicated the resident had been up awake most of the night and refused an additional dose of Trazodone that morning. Behaviors included banging on the walls and window of unit door with a quad cane, at times threatening and combative towards staff with the cane, wandering room to room, and exhibiting delusional ideas that other residents were family members. The Physician was notified and ordered a one time medication dose of Neurontin (100 mg). The medication was administered. The resident was redirected to his/her room to lie down on the bed several times.

Although the Resident’s behaviors and sleeplessness had increased there had been no changes noted for the supervision of the resident during this time despite the resident’s increased risk of falls.

Review of incident documentation dated 10/10/16, indicated that Resident #16 had an unwitnessed fall with injury at approximately 1:20 P.M. The information indicated that the resident was found on the floor, lying on his/her left side, near the doorway of room 1. The resident’s eyeglasses had broken, and there was blood on the Resident’s forehead. The resident was sent to the emergency room after the fall and the hospital report indicated Resident #16 was treated for [REDACTED].

Review of the facility’s initial investigation of the resident’s fall failed to indicate that a bed alarm or personal alarm was in use when the resident was lying on the bed 10/10/16 prior to the fall as indicated in the admission plan of care. Review of the statements written by staff as part of the fall/incident investigative report indicated that no one reported hearing an alarm sound (from the use of an operating bed and/or chair alarm device). Staff were only alerted to the Resident’s fall from the noise (bang) of the resident falling. The fall took place in a room down the hall, on the opposite side of the corridor of resident #16’s room, and the resident had to walk out of his/her room, through the main corridor of the unit, pass the nurses station in order to reach Room One where the fall occurred.

During interview, on 10/13/16 at 10:30 A.M., Unit Nurse #1 said that the Resident had been up the previous evening, as noted in the shift report and had not slept much, and the Resident’s agitation escalated, waving his/her quad cane at staff and the door/window to exit. She attempted to have the Resident lie down in his/her room, but the Resident would not rest for very long and be up wandering again. The medication Trazodone and redirection were not always effective. Unit Nurse #1 said that she had been on the medication cart at the time of the fall, at the other end of the hall when she heard the noise. The nurse said that she entered the Resident’s room/bathroom but the Resident was not there, and had not seen the Resident leave his/her room.

Review of a written statement from 1 of 3 certified (CNA) nurse aides assigned to the unit on the 10/10/16 day shift indicated that the one CNA was on break and not on the unit at the time of the fall, the second CNA was in the day/dining room collecting meal trays. The investigation did not identify were the third CNA was at the time of the incident. The facility failed to adequately supervise Resident #16 and ensure the use of alarms was implemented as appropriate to identify that the Resident was in motion to avoid a fall/injury. The facility failed to attempt an alternative sleep/rest arrangement that the Resident was accustomed to in the community as per the admission referral from the community practitioner.

2. For Resident #19, the facility failed to provide supervision to prevent an avoidable fall while the Resident was receiving anticoagulation therapy (blood thinners). Review of the Fall Incident Report (incident occurred on 8/31/16 at 11:35 A.M.) indicated that the Resident was left unattended in the bathroom, fell and hit his/her head and was transported to the hospital emergency room for head and spine imaging.

The Centers for Disease Prevention (CDC) indicates that falls with head injury can be very serious, especially while on blood thinners. The elderly are predisposed to developing subdural hematomas from weakened blood vessels and a relatively minor head injury can cause a hematoma (bleeding in the space between the brain and the skull), which can cause swelling and put pressure on the brain. There are different types of hematomas and the symptoms may take days or weeks to present themselves after a head injury and therefore, close monitoring is warranted.

Resident #19 was admitted in 8/2016 with the following pertinent Diagnoses: [REDACTED]. Review of the facility’s Fall Prevention Guidelines (no creation date or professional references), indicated the following pertinent program components: investigation of each fall, interdisciplinary falls committee, communication of interventions to caregivers, education of all skilled nursing facility staff and continuous quality/performance improvement-tracking for trends.

Review of the Initial Nursing assessment dated [DATE] indicated that the Resident had impaired memory, poor safety awareness and was at risk for falls. Review of the Interim Plan of Care for falls, dated 8/24/16, indicated the following: orient to call light and keep in reach at all times, non-skid socks, instruct on safety, bed/chair alarms. The Care Plan was revised after the Resident’s fall to include: not to be left alone without staff while in the bathroom.

Review of the Certified Nursing Assistant (CNA) Kardex indicated the following care instructions: bed in low position, 2 alarms (chair/bed) and gait belt. The CNA Kardex was revised on 8/31/16 (date of fall) to include: do not leave alone in bathroom.

Review of the Physical Therapy Evaluation (8/25/16-9/23/16) indicated that the Resident required moderate assistance for toileting with 1 person, wheelchair and verbal and tactile cues for safety.

On 10/12/16 at 2:45 P.M., the Surveyor interviewed the Physical Therapist (PT). The PT said that moderate assist means that the staff do 75% of the effort while the resident does 25% and requires frequent cueing for safety.

Review of the Incident Report/Investigation (incident @ 11:35 A.M. on 8/31/16), indicated that the Resident was found on the floor of the bathroom with the raised toilet on top of his/her legs. The nurse on duty reported the following: CNA assisted resident to bathroom, then left unattended. Loud bang heard. Resident supine on floor, head facing out of the shared bathroom with feet remaining in bathroom and raised toilet laying on resident’s legs. Complaining of head pain.

The Resident was sent to the emergency room urgently for a CT scan of head and spine, which later indicated no evidence of injury. The investigative reports from staff are incomplete with 2 of the 3 staff statements not indicating a response to the following question: Was this resident assigned to you?. No Incident Analysis was included as part of the packet.

Review of the staff in-servicing record on 8/31/16 indicated 10 signatures of staff who attended the in-servicing. From the 10 listed signatures, the CNA, identified by the interim Director of Nursing Services (DNS), as the CNA assigned to the Resident on the day of the fall, was not on the list. The DNS could not explain why the CNA was not in-serviced. The length of time section and Presenter name on the Inservice Record were also left blank.

The interim (DNS) was interviewed about root cause analyses for falls on 10/12/16 at 4:00 P.M. The DNS said that after a fall, the unit manager and nurse are notified to do an assessment, an incident report is completed with witness statements, discussed at weekly meeting and tracked at risk meeting to discuss if interventions are working.

Failed to make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so.

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

Based on record review and interview the facility failed to follow physician orders [REDACTED].#12) of 24 sampled Residents.

Findings include:

For Resident #12, the facility failed to obtain a nutrition consult that assessed the Resident’s low protein and low [MEDICATION NAME] level.

Resident #12 was admitted in 8/2016 with [DIAGNOSES REDACTED].

Review of the 9/6/16 Admission Minimum Data Set (MDS) Assessment, indicated that Resident #12 was alert and oriented with a score 15 of 15 on the Brief Interview for Mental Status (BIMS), due to limited mobility the resident was in need of staff assistance with all activities of daily living except to eat; this resident weighed 147 pounds and required pain medication. The resident was admitted for rehabilitation services with plans to return to the community.

Review of the clinical record included a nutritional assessment dated [DATE] that indicated Resident #12 received a house diet. The assessment indicated the Resident’s estimated daily requirement needs included 2100 calories, 2100 milliliters of of fluid and 60 grams protein. The plan of care included to monitor weight, laboratory values and meal intake.

Review of physician progress notes [REDACTED]. The physician prescribed medication to treat the [MEDICAL CONDITION] and ordered (9/19/16) to increase fluids 250 ml three times a day.

Blood test results, dated 9/29/16, indicated low total protein (5.2) (normal range of 6-8.3 g/dL) and [MEDICATION NAME] (2.6) (normal range levels 3.5-5.5 g/dL) which can be indicators of protein deficiency/malnutrition; and an elevated BUN (blood urea nitrogen) (52) (normal range of 6-20 mg/dL) which can be indicative of [MEDICAL CONDITION], altered hydration status and other organ system failures.

A medical progress follow up note, dated 9/30/16, indicated Resident #12 had been treated with steroid (anti-[MEDICAL CONDITION]) medication for wrist pain (pseudogout). The resident’s pain had reportedly improved, and he/she continued to work with rehabilitation therapy with weight bearing as tolerated, wearing a left lower extremity cast. For the abnormal low [MEDICATION NAME] and total protein laboratory blood test, the physician ordered a dietary consult to address the protein status, and a nutritional supplement (60 ml) twice per day.

A dietary progress note dated 10/4/16 indicated Resident #12 was eating 75% of meals with weight at 150.8 pounds; no acute nutrition concerns. There was no evaluation of the Resident’s protein intake or mention of abnormal laboratory blood levels to comply with the physician’s orders [REDACTED].

During interview on 10/6/16, Resident #12 expressed concern regarding a problem with diarrhea and wishing to return home. Nurses notes (10/7/16-10/10/16) indicated the Resident continued with loose bowel movements; with on going testing for [MEDICAL CONDITION], KUB (kidney urine bladder) and guaic monitoring in process.

Documentation on 10/10/16 included a follow up dietary note reporting the resident’s weight as stable after cast removal, weighing 145 pounds. At that time, there was no further nutritional evaluation of Resident #12’s protein levels, laboratory results, bowel or hydration status.

During an interview on 10/12/16 at 1:20 P.M., the Dietitian said that she had not been aware that a consult to evaluate Resident #12 for protein deficiency was ordered by the physician and agreed may have been an oversight. The Dietitian said that she was not aware of a facility policy for communicating requests for nutrition consult, rehabilitation therapy services or other consultations. Interview on 10/12/16 at 2:25 P.M., the nurse that transcribed the 9/30/16 order for the dietary consult said that she recalled mentioning to the Dietician, when she saw her, that the physician ordered a consult and said that she was not aware if there was any other system of communicating orders for consults other than verbal.

Documentation indicated that tests for [MEDICAL CONDITION] and KUB were inconclusive, however Resident #12 was transported to the emergency roiagnom on [DATE] for acute evaluation with [MEDICAL CONDITION], vomiting and dehydration. The acting Director of Nurses said on 10/13/16 that she was not aware of any policy for communicating consultation orders/requests and that the facility would review the practice.

Failed to make sure that each resident's drug regimen is free from unnecessary drugs and each resident's entire drug/medication is managed and monitored to achieve highest well being.

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

Based on closed record review and interview, the facility failed for 1 (#24) of 24 sampled Residents to ensure that the drug regimen was free from unnecessary [MEDICAL CONDITION] medications to treat behaviors without an adequate indication for use.

Findings include:

For Resident #24, who was being tapered of the antipsychotic medication [MEDICATION NAME], the facility failed to ensure that there was adequate indication for increasing the [MEDICATION NAME] in the absence of behaviors.

Resident #24 was admitted ,[DATE] for short term rehabilitation following hospitalization for acute mental status change due to [MEDICAL CONDITION] and dementia. Review of the closed medical record indicated that the Admission Minimum Data Set (MDS) Assessment with a reference date of 7/25/16 indicated that the Resident was assessed as cognitively impaired and required staff assistance with activities of daily living. The Resident was assessed with [REDACTED].

Review of the nursing progress notes from 7/19 -8/3/16 consistently indicated that the Resident was alert, pleasantly confused and had no behaviors.

A 7/25/16 discharge summary completed by the Nurse Practitioner (#1) indicated that the Resident was alert with no [MEDICAL CONDITION] noted, with normal mood and affect and had no behavioral issues noted.

Review of the Psychiatric Nurse Practitioner (PNP) consultant evaluation of 8/3/16 indicated that the PNP was asked to assess the medication management (due to [MEDICATION NAME]). The PNP indicated that the Resident had no unusual or excessive anxiety or depressive symptoms and listed the prior psychiatric disorder as a history of dementia and [MEDICAL CONDITION]. The PNP recommended to taper Resident #24 off the [MEDICATION NAME] and use [MEDICATION NAME] (antidepressant) as needed for any intermittent symptoms of anxiety and to stop the taper if [MEDICAL CONDITION] is noted.

On 8/4/16 the physician gave new orders as recommended, to taper the [MEDICATION NAME] to 12.5 milligrams (previously 25 milligrams) twice daily for 7 days then to discontinue. Review of nurses notes on 8/7/16 indicated that the Resident continued with decrease of [MEDICATION NAME] and had no behaviors noted.

On 8/8/16 the day shift nurse documented that the Nurse Practitioner (NP #2) was updated of delusions resident was having over the weekend per the family while they were visiting. The NP gave a new order to increase the [MEDICATION NAME] to 25 milligrams twice daily which was initiated (on 8/8/16) by the evening shift nurse who indicated that there were no signs and symptoms of hallucinations noted.

Review of the 8/9/16, NP #2’s telephone progress note indicated that the facility nurse called to request for paperwork to be signed for discharge the following day. The NP indicated that the medical team was unaware of plans for Resident #24 to be discharged to an assisted living facility.

The NP indicated that the nurse was made aware that the Resident would need to be seen before he/she is discharged to another facility. According to the 8/10/16, 10:43 A.M. NP’s progress note indicated that she arrived to the facility and was informed that the Resident was discharged earlier that morning without being seen as discussed with the nurse on 8/9/16. The NP indicated she was concerned about the Resident’s discharge.

Review of the Medication Administration Record [REDACTED].M. The Director of Nurses (DON) was interviewed on 10/13/16 at 11:00 A.M and following review of the medical record with the surveyor said that review of physician’s orders [REDACTED].

The DON said that there was no documented evidence provided during survey that the Resident was exhibiting any behaviors other than the delusions that the family reported to the nurse on 8/8/16.

NP #2 was interviewed via the telephone on 10/13/16 at 1:55 P.M. NP #2 said that she picked up the Resident’s care from NP #1 when the resident was assigned to become long term care. The NP said that she was not familiar with Resident #24 when the nurse called on 8/8/16, indicating that the family was upset because the Resident’s [MEDICATION NAME] was lowered and wanted the Resident put back on the previous dose. The NP said that she told the nurse it was okay to do what the family asked and planned to visit to assess the Resident. The NP was asked what were the behaviors identified by the family said she could not recall. The NP was asked if the facility made her aware of any previous behaviors exhibited by the Resident and she said there were no issues. NP #2 said that on 8/9/16 the facility nurse contacted her to report that paperwork needs to be completed for a discharge the following morning. The NP said she told the nurse on 8/9/16 that the Resident would need to be seen prior to discharge to another facility. NP #2 said that when she arrived on 8/10/16 the Resident had already been discharged without the opportunity to assess the Resident’s status. NP #2 was asked if the facility was aware of her concerns said yes, my team has spoken with the Director of Nurses (DON) . I wanted them to know that I was concerned that bumping up the [MEDICATION NAME] and discharging the Resident without being seen is a big deal.

The facility failed to ensure that there was adequate indication for increasing the [MEDICATION NAME] in the absence of behaviors.

Failed to give or get quality lab services/tests in a timely manner to meet the needs of residents.

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

Based on record review and staff interview, the facility failed to ensure that physician ordered laboratory tests were performed as ordered for one Resident (#3) of 24 sampled Residents.

 

Findings include:

For Resident #3, the facility failed to perform laboratory test for [MEDICAL CONDITION] stimulating hormone and lipid panel as ordered.

Resident #3 was admitted to the facility with [DIAGNOSES REDACTED].

Review of the clinical record on 10/11/16 identified current physician orders [REDACTED]. Review of the laboratory test reports indicated that the April tests for the TSH and the fasting lipid profile were not available.

During interview on 10/12/16 at 4:30 P.M., Unit Manager (UM) #2 said she was uncertain why the laboratory test results were not available and would check the resident’s medical record overflow.

On follow-up on 10/13/16, the staff had no further information regarding whether the 4/2016 laboratory tests were obtained as ordered for Resident #3.

Colonial Skilled Nursing Home & Rehabilitation, 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.

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Sources:

Medicare Nursing Home Profiles and Reports – Colonial Skilled Nursing Home & Rehabilitation

Nursing Home Inspection, Safety and Deficiency Report Colonial Skilled Nursing Home & Rehabilitation – 10/13/2016

Page Last Updated: August 14, 2017

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