Fairview Commons Nursing and Rehabilitation Center

FAIRVIEW COMMONS NURSING

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About Fairview Commons Nursing and Rehabilitation Center

Fairview Commons Nursing and Rehabilitation Center is a for non-profit, 180-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Pittsfield, North Adams, Westfield,  Southwick, Easthampton, Northampton, Holyoke, Chicopee, and the other towns in and surrounding Berkshire County, Massachusetts.

Fairview Commons Nursing and Rehabilitation Center
151 Christian Hill Rd,
Great Barrington, MA 01230

Phone: (413) 528-4560
Website: https://fairviewcommons.org/

CMS Star Quality Rating

FAIRVIEW COMMONS NURSINGThe 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, Fairview Commons Nursing and Rehabilitation Center in Great Barrington, 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 3 out of 5 (Average)
Quality Measures 5 out of 5 (Much Above Average)

Fines Against Fairview Commons Nursing and Rehabilitation Center

The Federal Government fined Fairview Commons Nursing and Rehabilitation Center $10,238 on June 4th, 2015  and $3,746 on January 20th, 2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Fairview Commons Nursing and Rehabilitation Center committed the following offenses:

Failed to assess the resident when the resident enters the nursing home, in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interview, the facility staff failed to complete Comprehensive Minimum Data Set ( MDS) Assessments within the required time frame for 2 Residents (#10 and #12) in a total sample of 24 residents.

Findings include:

Admission MDS Assessments:

-The admission MDS assessment is a comprehensive assessment for a new resident that must be completed by the end of day 14, counting the day of admission as day 1.

-Federal statute and regulations require that residents are assessed promptly upon admission (but no later than day 14) and the results are used in planning and providing appropriate care to attain or maintain practicable well being. -The MDS completion date (Item Z0500B) must be no later than day 14.

1. For Resident #10, the facility staff failed to complete an Admission MDS Assessment in the required timeframe. Record review indicated Resident #10 was admitted to the facility on [DATE]. The Admission MDS was dated as completed (Item Z0500B) on 9/25/17, 20 days after admission and not 14 days as required.

2. For Resident #12, the facility staff failed to complete an Admission MDS Assessment in the required timeframe.

Record review indicated Resident #12 was admitted to the facility on [DATE]. The Admission MDS was dated as completed (Item Z0500B) on 9/4/17, 29 days after admission and not 14 days as required.

During an interview on 10/10/13/17 at 12:00 P.M., the Clinical Reimbursement Coordinator (CRC) said the Admission MDS Assessments for Residents #10 and #12 were completed late and not in the required timeframe.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility staff failed to ensure the accuracy of assessments for 3 residents (#9, #11 and #16), in a total sample of 24 residents.

Findings include:

1. Resident #9 was admitted to the facility in 8/2006 with [DIAGNOSES REDACTED]. Review of the Weekly Wound Measurement Form of 7/13/17 indicated that the resident had a venous ulcer of the left heel that measured 3.5 centimeters (cm) in length by 4.0 cm in width by 0.5 cm in depth.

Review of the Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 7/31/17, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 (cognitively intact). Section M1030 – Number of Venous and Arterial Ulcers was incorrectly coded as 0.

Observation on 10/16/17 at 2:30 P.M., found Resident #9 sitting in an electric wheelchair in his/her bedroom. During a treatment observation, Nurse #1 removed the dressing from Resident #9’s left foot exposing a venous ulcer.

During an interview on 10/16/17 at 11:30 A.M., the MDS Coordinator said that the venous ulcer should have been coded on the MDS assessment.

2. Resident #16 was admitted to the facility in 4/2015 with [DIAGNOSES REDACTED]. Review of the Significant Change in Status MDS Assessment, with an ARD of 9/29/17, indicated that the resident had clear speech, was able to make self understood and had the ability to understand others. Section C0100. – Should Brief Interview for Mental Status be conducted was incorrectly coded as 0 (no, resident is rarely/never understood). Section D0100. – Should Resident Mood Interview be Conducted was incorrectly coded as 0 (no, resident is rarely/never understood). Section J0200. – Should Pain Assessment Interview be Conducted was incorrectly coded as 0 (no, resident is rarely/never understood). During an interview on 10/17/17 at 12:30 P.M., the MDS Coordinator said the MDS assessment was incorrectly coded for Section C0100, D0100 and J0200.

3. For Resident #11, the facility staff failed to ensure the accuracy of 2 Annual MDS Assessments relative to reflecting the [DIAGNOSES REDACTED]. Review of the 10/19/16 and 10/11/17 Annual MDS Assessment’s indicated that although the resident had a [DIAGNOSES REDACTED]. During an interview on 10/17/17 at 3:10 P.M., the MDS Nurse said the resident’s [DIAGNOSES REDACTED].

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 record reviews, observations, and staff interviews, the facility failed to follow residents’ plans of care regarding fall interventions for 3 residents with falls (#1,#3, and #21) in a total sample of 24 residents.

Findings include:

1. For Resident #1, the facility failed to follow the resident’s falls care plan regarding the following: pressure bed and chair alarms did not activate; chair alarm was not placed in chair; bolsters were not on bed as planned and bed in low position. Resident #1 was admitted /readmitted to the facility in 10/2016. Review of the 11/2016 falls care plan indicated the resident required a bed and chair alarm due to frequent falls (10/20/16 with no injury).

On 3/5/17, the resident was found on the floor next to the bed. The alarm was sounding, but was ineffective because staff did not hear the alarm due to the resident’s door being closed.

On 3/22/17, the resident was found on the floor and had hit his/her head requiring Steristrips above the left eye and also on the left elbow. The bed with the bumper mattress was not in low position as per care plan.

On 3/25/17, Resident #1 had an unwitnessed fall from a reclining chair that was in the hallway. The investigation indicated there was no chair alarm on the chair at the time of the fall as per care plan.

On 3/28/17, Resident #1 had a witnessed fall from from a chair in the hallway. The resident complained of left hip pain and was sent to the ER. There were no apparent injuries. There was no chair alarm on the chair at the time of the fall as per care plan.

On 10/6/17, the resident had an unwitnessed fall in the bedroom, the bed alarm did not sound and bolsters were not in place on the bed at the time of the fall as per care plan. During an interview on 10/16/17 at 3:00 P.M., the Director of Nurses (DON) said that she was aware that there has been issues with staff ensuring the alarms are functioning properly.

2. For Resident #3, the facility staff failed to follow the resident’s falls care plan relative to ensuring resident was wearing slipper socks and bed alarm was functioning. The resident sustained [REDACTED].

Resident #3 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Review of the 8/30/17 Quarterly Minimum Data Set (MDS) Assessment indicated the resident was moderately cognitively impaired as evidenced by a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS). The resident required extensive assist of one person for dressing, transfers and hygiene.

Review of the Falls Risk Care Plan indicated the resident was to wear slipper socks and have a bed and chair alarm.

a. Review of the 8/30/17 Incident/Accident Report indicated the resident had a fall with no injury. A bed alarm sounded and the resident was found between his/her bed and bathroom. The resident was wearing regular socks.

b. Review of the POS [REDACTED]. The bed alarm did not sound and the resident had bare feet.

During an observation on 10/13/17 at 9:05 A.M., the resident was sitting in a wheelchair in the unit dining room. The resident was wearing slipper socks and an alarm was noted on the wheelchair.

During an interview on 10/13/17 at 3:00 P.M., the DON said the resident was not wearing slipper socks when he/she fell on [DATE] and 9/29/17, as care planned. The DON said the resident’s bed alarm should have sounded during the 9/29/17 fall, as care planned, but it did not.

3. For Resident #21, the facility failed to follow the plan of care for non-skid floor strips.

Resident #21 was admitted to the facility in 6/2017 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, with an ARD of 8/30/17, indicated a BIMS score of 15 out of 15 (cognitively intact). The resident was independent with transfer and ambulation, required assist with toilet use and had 2 falls since admission. Review of Progress Notes indicated that after a fall on 9/5/17, the plan of care for fall risk was updated to include: Non-skid strips on floor from bedside to bathroom. Review of Progress Notes of 10/11/17 indicated that Resident #21 was transferred from room [ROOM NUMBER]A to room [ROOM NUMBER]A.

Observation, on 10/17/17 at 9:45 A.M., found Resident #21 sitting in a wheelchair in the hallway. At 9:50 A.M., observation of room [ROOM NUMBER]A, indicated that there were no non-skid strips on the floor, from Resident #21’s bed to the bathroom, as per plan of care.

During an interview, on 10/17/17 at 2:30 P.M., UM #2 said that she had requested the maintenance department to install non-skid strips on the floor of room [ROOM NUMBER] next to bed A. UM #2 said that she was not aware that the non-skid strips were not in place.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide the necessary care and services for 1 resident (#8), in a total sample of 24 residents.

Findings include:

Resident #8 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set Assessment, with an Assessment Reference Date of 3/15/17, indicated a Brief Interview for Mental Status score of 6 out of 15 (severe cognitive impairment). Resident #8 required assist of one with bed mobility, transfer, toilet use and ambulation, was frequently incontinent of bowel and bladder and had no pain.

Review of the Physician’s Progress Notes of 5/2/17 indicated that the resident had a history of [REDACTED]. Recent flair up and voicing suicidal ideation. Surgeon in Albany felt resident’s surgical risk was too high. A local surgical consult would be obtained as resident’s quality of life was significantly and negatively impacted by recurrent rectal prolapse, such that surgical consideration was reasonable despite medical risks. Review of the Physician’s Progress Notes of 7/20/17 indicated that the surgical consult was pending. Pain was reasonably well controlled.

Review of the Colon and Rectal Surgery consult of 7/24/17 indicated that the resident’s Health Care Proxy (HCP) was very concerned because the resident spent most of his/her days occupied by the rectal prolapse, and she had seen a deterioration in the resident. While in the office, the resident kept moaning and straining. The HCP believed that a [MEDICAL CONDITION] would improve the resident’s quality of life. Trial of conservative treatment by adding [MEDICATION NAME] daily. If that doesn’t help, the surgeon recommended a full medical evaluation to determine fitness for surgery and general anesthesia. Follow-up in office in 2 months for reevaluation of symptoms on fiber. Review of physician’s orders [REDACTED].

Review of the Physician’s Progress Notes of 9/28/17 indicated that the rectal prolapse was no longer highly symptomatic.

Review of Progress Notes of 9/29/17 indicated that the resident’s HCP told the nurse that the surgeons office was supposed to send a report from the rectal prolapse consult (of 7/24/17) to the facility via facsimile.

Observation, on 10/12/17 at 7:35 A.M. and 8:00 A.M., found Resident #8 in the bathroom, moaning loudly.

During an interview, on 10/16/17 at 12:15 P.M., Nurse #1 said that the physician asked about the surgical consult report. Nurse #1 said that prior to the physician asking about the surgical consult report, she was unaware of the appointment. Nurse #1 said there was no documentation in the Progress Notes regarding the surgical consult appointment. Nurse #1 said she spoke with the HCP, and the HCP told her about the previous surgical consult. Nurse #1 said that she called the surgeon’s office to request a copy of the surgical consult (over 2 months later). Nurse #1 said that she received the consult via facsimile (on 9/29/17). Nurse #1 said that Resident #8 was transferred from Unit 1 to Unit 2, so that might have had something to do with the confusion. Nurse #1 said she scheduled a follow-up appointment on 11/30/17 (over 4 months after the first appointment).

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 observation, record review and interview, the facility staff failed to ensure that 2 of 11 residents with falls (#1 and #3), received adequate supervision and assistive devices to prevent accidents and review the risks and benefits of side rail use and obtain informed consent for 8 residents (#3, #8, #9, #12, #13, #14, #15, and #20), in a total sample of 24 residents.

Findings include:

1. For Resident #1, facility staff failed to ensure that effective interventions were implemented to keep the patient from falling. Resident #1 was admitted to the facility in 11/2015 and readmitted in 10/2016 with a history of falls, hypertension, dementia and Chronic Obstructive Pulmonary Disease (COPD). Review of the Change of Status Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/1/16, indicated the resident was able to communicate with staff and make needs known. Had a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment; required extensive assistance from staff for all activities of daily living and had a history of [REDACTED].

Review of the Plan of Care addressing Falls was developed in 12/2015. Risk factors included:

– history of falls
– unstable balance
– confused/forgetful
– exhibits unsafe behavior

Care plan interventions included:

– Fall risk assessment upon admission, re-admission, significant change in condition, quarterly and if a fall occurs;
– Educate resident/family on fall prevention strategies;
– Provide well lit, uncluttered environment
– Place items resident uses frequently in reach to prevent bending or reaching;
– Encourage participation in diversional activities
– Individualize care plan to meet resident’s assessed needs.
– bed/chair alarms (initiated 11/22/16)
– Floor mats on both sides of bed (initiated 3/6/17)
– Bumper Mattress and bed in lowest position (no initiation date, but was supposed to be in place prior to 3/22/17 per Fall Investigation)
Review of the Fall Assessments through 10/2016 indicated the resident was at high risk for falls.

Review of the Fall Investigation dated 3/5/17 indicated Resident #1 was found sitting on the floor in the bedroom at 9:00 P.M. The report indicated the resident was incontinent of bladder and lost his/her balance while attempting to ambulate to the bathroom unattended (no toileting schedule in place). The investigation indicated that two half side rails were up and the alarm was sounding, however, the bedroom door was closed and staff were unable to hear the alarm (making the alarm an ineffective intervention). There were no apparent injuries and staff were adding floor mats on both sides of the bed and making sure the bedroom door stayed open as new interventions.

Review of a Fall Investigation of 3/22/17 indicated the resident was found lying on the floor in the bedroom at 10:50 P.M. next to the closet. The report indicated the resident’s two half rails were up and when the resident fell from bed, he/she sustained lacerations above the left eye and left elbow requiring Steristrips, and had bruising on the left knee as well. The resident hit head on the oxygen concentrator and the left elbow on the night stand. The report indicated that the bed was not in low position at the time of the fall and there was no indication that the floor mats were in use.

Review of the Fall Investigation of 3/25/17 indicated the resident had an unwitnessed fall from a recliner in the hallway next to the Nurses’ Station at 9:30 P.M. The report indicated there was no chair alarm in use at the time of fall as per care plan. There were no apparent injuries. Staff education was to be provided regarding use of alarms. Review of the Fall Investigation of 3/28/17 indicated that a Certified Nursing Assistant (CNA) saw Resident #1 get out of a chair in the hallway and walk toward a wheelchair. The CNA said the resident stumbled over his/her own feet and fell to the floor at 5:45 P.M. The report indicated there was no chair alarm in place at the time of the fall. The resident complained of left hip pain after the fall and was sent to the ER for an evaluation. The resident returned to the facility with a [DIAGNOSES REDACTED]. Review of the Fall Investigation of 4/4/17, indicated the resident was sitting in the hallway in the wheelchair. When the resident stood up, the chair moved backwards and he/she fell on the floor. The alarm was sounding and there were no apparent injuries. Anti-tipping devices were applied to the wheelchair.

Review of the Fall Investigation of 10/6/17 indicated that Resident #1 was found on the floor next to the bed at 6:40 A.M. (unwitnessed fall). The report indicated the resident was alert and confused, a bed alarm was on the bed, but did not sound; two half bed rails were in use, and the resident lost his/her balance while ambulating in the bedroom. The report also indicated the resident complained of pain after the fall, however, there were no apparent injuries. The report indicated that the Bed Bolsters were not applied to the bed at the time of the fall. The facility was waiting for a new concave mattress to arrive.

On 10/12/17 at 10:30 A.M., the Surveyor observed the resident sitting in a recliner in the dining room. There was a staff member sitting with the resident. An alarm was on the chair. During interview on 10/16/17 at 1:30 P.M., the newly appointed Unit Manager (UM)#3 (was previously a staff nurse on the unit) said that she was aware the resident has had numerous falls. During interview on 10/16/17 at 3:00 P.M., the Director of Nurses(DON) said that she was aware that staff were not using the alarms per plan when most of the falls occurred.

2 a. For Resident #3, facility staff failed to ensure interventions put in place after 3 falls were effective to prevent accidents. Review of the facility Falls Risk Reduction Policy, dated 12/22/16, indicated those determined to have risk factors will receive individualized interventions based on the risk factors in order to reduce risks for falls and minimize the actual occurrence of falls.

Resident #3 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 8/30/17, indicated the resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status score of 12 out of 15. Further review of the MDS indicated the resident was legally blind and required extensive assist for transfer, hygiene and dressing.

Review of the medical record indicated the resident had an unwitnessed fall on 6/3/17 at 10:50 P.M. The staff responded to an alarm and found the resident on the floor in his/her room. The resident had bare feet and there was urine on the floor. The intervention put in place after the fall was for resident to have slipper socks and alarmed floor mat.

Review of the Incident/Accident Report dated 8/30/17 indicated the resident had a fall at 3:15 P.M. in his /her room. The staff responded to a bed alarm and found the resident on the floor. The resident stated he/she was trying to go to the bathroom and slipped. The resident was wearing regular socks. The intervention put in place after the fall was to make sure the resident was wearing slipper socks and toilet after meals. Review of the Incident/Accident Report dated 9/29/17 indicated the resident yelled out for help at 9:10 P.M Upon entering the resident’s room, he/she was found on their knees on the floor. The resident had bare feet and the bed alarm did not sound during the event. The new intervention put in place after the fall was to provide the resident with a new alarm and toilet every 2 hours as tolerated by the resident. Review of the undated Resident Profile indicated the resident would have slipper socks on in bed, and chair and floor alarm in place.

During an observation on 10/13/17 at 9:05 A.M., the resident was sitting in the unit dining room in an alarmed wheelchair. During an interview on 10/13/17 at 3:00 P.M., the DON said that the resident should have had slipper socks on when resident fell on [DATE] and 9/29/17. She also said the bed alarm should have sounded when the resident fell on [DATE] and it did not. b. For Resident #3, the facility staff failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to use.

During an observation on 10/13/17 at 11:00 A.M., the resident was lying in bed with eyes closed and 2 bed side rails in the up position. Record review indicated no informed consent obtained or review of risks and benefits of bed rails use completed as required. During an interview on 10/17/17 at 1:15 P.M., the DON said that there was no informed consent for the use of side rails obtained prior to use or risks and benefits reviewed with the resident or resident representative.

3. For Resident #12, the facility staff failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to use. During an observation on 10/13/17 AT 9:00 A.M., the resident was in bed with eyes closed and 2 bed side rails were in the up position. Record review indicated no informed consent obtained or review of risks and benefits of bed rails use completed as required. During an interview on 10/17/17 at 1:15 P.M., the DON said that there was no informed consent for the use of side rails obtained prior to use or risks and benefits reviewed with the resident and/or resident representative.

4. For Resident #13, the facility staff failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to use. During an observation on 10/11/17 at 9:00 A.M., the resident was awake and lying in bed. 2 bed side rails were in the up position. Record review indicated no informed consent obtained or review of risks and benefits of bed rails use completed as required. During an interview on 10/17/17 at 1:15 P.M., the DON said that there was no informed consent for the use of side rails obtained prior to use or risks and benefits reviewed with the resident and/or resident representative.

5. For Resident #20, the facility staff failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to use. During an observation on 10/11/17 at 9:00 A.M., the resident was awake and lying in bed. 2 bed side rails were in the up position.

Record review indicated no informed consent obtained or review of risks and benefits of bed rails use completed as required.

During an interview on 10/17/17 at 1:15 P.M., the DON said that there was no informed consent for the use of side rails obtained prior to use or risks and benefits reviewed with the resident and/or resident representative.

6. For Resident #15, the facility staff failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to use. Resident #15 was admitted to the facility 1/2017 with multiple [DIAGNOSES REDACTED]. Record review indicated no informed consent including the risks and benefits had been completed as required. Resident #15 was observed on 10/12/17 at 11:35 A.M., in bed with his/her eyes close, the bed was in low position and 2 half siderails were up. During an interview with UM #1 on 10/17/17 at 10:55 A.M., she said that there is no consent for the use of side rails obtained prior to use.

7. For Resident #8, the facility failed to ensure that staff reviewed the risks and benefits of side rail use and failed to obtain consent from the resident and/or responsible party.

Resident #8 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. Review of the 3/8/17 Side Rail Utilization Assessment indicated that Resident #8 used bilateral 1/4 side rails for weakness to promote mobility. Review of the Quarterly MDS Assessment, with an ARD of 9/6/17, indicated a BIMS score of 6 out of 15 (severe cognitive impairment). Resident #8 required assist of one with bed mobility, transfer and ambulation.

Observation on 10/12/17 at 9:45 A.M., found Resident #8 lying in bed, with bilateral 1/4 side rails in place.

Record review indicated that there was no documentation that the risks and benefits of side rail use were reviewed with the resident and/or responsible party, and there was no documentation that consent for side rail use was obtained. During an interview, on 10/12/17 at 10:10 A.M., Nurse #1 said that the facility did not review the risks and benefits of side rail use or obtain consent from the resident and/or responsible party.

8. For Resident #9, the facility failed to ensure that staff reviewed the risks and benefits of side rail use with the resident. Resident #9 was admitted to the facility in 8/2006 with [DIAGNOSES REDACTED]. Review of the 7/26/17 Side Rail Utilization Assessment indicated that Resident #9 used bilateral 1/2 side rails for right hemiparesis, right below the knee amputation, demonstrates poor bed mobility and unable to come to a sitting position at bedside. Review of the admission MDS assessment, with an ARD of 7/31/17, indicated a BIMS score of 13 out of 15 (intact cognitive status). Resident #9 required supervision with bed mobility and transfer.

Observation, on 10/16/17 at 8:00 A.M., found Resident #9 lying in bed, with bilateral 1/2 side rails in place. Record review indicated that there was no documentation that the risks and benefits of side rail use were reviewed with the resident. During an interview, on 10/16/17 at 11:10 A.M., UM #2 said that the facility did not review the risks and benefits of side rail use with Resident #9.

9. For Resident #14, the facility failed to ensure that staff reviewed the risks and benefits of side rail use with the resident.

Resident #14 was admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. Review of the 8/22/17 Side Rail Utilization Assessment indicated that Resident #14 used side rails for positioning due to difficulty with balance and trunk control. Review of the admission MDS assessment, with an ARD of 8/29/17, indicated a BIMS score of 15 out of 15 (intact cognitive status). Resident #14 required assist of 2 with bed mobility, transfer and toilet use.

Observation, on 10/12/17 at 7:30 A.M., found Resident #14 lying in bed, with bilateral 1/2 side rails in place. Record review indicated that there was no documentation that the risks and benefits of side rail use were reviewed with the resident. During an interview, on 10/16/17 at 11:10 A.M., UM #2 said that the facility did not review the risks and benefits of side rail use with Resident #14.

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, policy review and staff interview, the facility failed to ensure that medications and biologicals were of current date to provide reliability of strength and accuracy of dosage in 1 of 3 medication rooms.

Findings include:

Review of the facility policy for Preparation and General Guidelines IIA3: Vials and Ampules of Injectable Medications, dated 1-1-13, indicated the following:

-The date opened and the initials of the first person to use the vial are recorded on multidose vials (on the vial label or an accessory label affixed for that purpose).

-Medications in multidose vials may be used (until manufacturer’s expiration date/for the length of time allowed by the state law/according to facility policy/for 28 days) if inspection reveals no problem during that time.

During observation of medication storage in the Unit #1 medication room, with Unit Manager (UM) # 1, on 10/13/17 at 11:50 A.M.,the surveyor observed one multidose open vial of Tubersol (Tuberculin purified protein derivative used in a skin test to help diagnose [DIAGNOSES REDACTED]) that was not dated as to when it was opened.

During an interview with UM #1 on 10/13/17 at 11:50 A.M., she said that the Tubersol should have been dated when it was opened and it was not, therefore, it will need to be discarded.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility staff failed to ensure complete and accurate medical records for 4 residents (#3, #8, #12 and #20), in a total of 24 sampled residents.

Findings include:

1. For Resident #12, the facility staff failed to document the air mattress setting on the Treatment Administration Record (TAR) to ensure the setting was accurate.

Review of the facility Air Mattress Pressure Reducing Policy, dated 5/02/05, indicated to check air mattress routinely to ensure that it is working properly.

Resident #12 was admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. During an observation on 10/12/17 at 1:30 P.M., the resident was resting in bed with eyes closed. The call light was within reach. The resident was lying on an air mattress that was set at #3.

Review of the 10/2017 TAR did not indicate the use of an air mattress. During an interview on 10/13/17 at 4:00 P.M., the DON said that use of air mattresses and settings are documented on the Treatment Administration Record (TAR) and nurses check the settings each shift for accuracy. During an interview on 10/17/17 at 2:30 P.M., Nurse #3 said the 10/2017 TAR did not indicate the use of an air mattress and it should have.

2. For Resident #20, the facility staff failed to document the air mattress setting on the Treatment Administration Record (TAR) to ensure the setting was accurate. Resident #20 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. During the initial unit tour observation on 10/11/17 at 9:00 A.M., the resident was lying on an air mattress set at #3. The call light was within reach. Review of the 10/2017 TAR did not indicate the use of an air mattress. During an interview on 10/17/17 at 9:35 A.M., Nurse #4 said the 10/2017 TAR did not indicate the use of an air mattress and it should have.

3. For Resident #3, the facility staff failed to complete a Urinary Incontinence Questionnaire/Assessment to determine type of incontinence. Review of the facility Urinary Incontinence Management Policy, dated 12/22/16, indicated urinary incontinence management includes completion of the Urinary Incontinence Questionnaire/Assessment, the Bladder Pattern Assessment if indicated and development of an individualized plan of care to assure optimal function and dignity. Resident #3 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Review of the Admission Bowel and Bladder Elimination Assessment, dated 5/31/17, indicated the resident was continent of bladder and bowel.

Review of the Admission Minimum Data Set (MDS) Assessment, dated 6/7/17, indicated the resident was frequently incontinent of urine.

Review of the Bladder Pattern Assessment completed 6/21/17 thru 6/23/17 indicated the resident had episodes of incontinence.

The undated Urinary Incontinence Questionnaire Assessment was blank and there was no documentation to indicate the type of incontinence the resident was experiencing. During an observation on 10/13/17 at 9:05 A.M., the resident was sitting in a wheelchair in the unit dining room, dressed neatly, wearing slippers and was very conversant. During an interview on 10/17/17 at 2:00 P.M., Unit Manager (UM) #2 said the Bladder Pattern Assessment indicated episodes of incontinence and the Urinary Incontinence Questionnaire Assessment was blank and it should have been completed.

4. For Resident #8, the facility failed to document that the resident had a surgical consult regarding a rectal prolapse and required a follow up appointment. Resident #8 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. Review of the physician’s Progress Notes of 5/2/17 indicated that the resident had a history of [REDACTED]. Recent flair up and voicing suicidal ideation. Surgeon in Albany felt resident’s surgical risk was too high. A local surgical consult would be obtained as resident’s quality of life was significantly and negatively impacted by recurrent rectal prolapse, such that surgical consideration was reasonable despite medical risks. Review of the Colon and Rectal Surgery consult of 7/24/17 indicated that a trial of conservative treatment by adding [MEDICATION NAME] daily would be attempted. If that doesn’t help, the surgeon recommended a full medical evaluation to determine fitness for surgery and general anesthesia. Follow-up in office in 2 months for reevaluation of symptoms on fiber.

Review of Progress Notes of 9/29/17 indicated that the resident’s HCP told the nurse that the surgeons office was supposed to send a report from the rectal prolapse consult (of 7/24/17) to the facility via facsimile.

Observation, on 10/12/17 at 7:35 A.M. and 8:00 A.M., found Resident #8 in the bathroom, moaning loudly.

During an interview, on 10/16/17 at 12:15 P.M., Nurse #1 said that the physician asked about the surgical consult report. Nurse #1 said that prior to the physician asking about the surgical consult report, she was unaware of the appointment. Nurse #1 said there was no documentation in the Progress Notes regarding the surgical consult appointment. Nurse #1 said she spoke with the HCP, and the HCP told her about the previous surgical consult. Nurse #1 said that she called the surgeon’s office to request a copy of the surgical consult (over 2 months later). Nurse #1 said that she received the consult via facsimile (on 9/29/17). Nurse #1 said that Resident #8 was transferred from Unit 1 to Unit 2, so that might have had something to do with the confusion. Nurse #1 said she scheduled a follow-up appointment on 11/30/17 (over 4 months after the first appointment).

Fairview Commons Nursing and Rehabilitation 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 – Fairview Commons Nursing and Rehabilitation Center

Inspection Report for Fairview Commons Nursing and Rehabilitation Center – 10/17/2017

Page Last Updated: April 15, 2018

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