Golden Living Center – Garden Place

Elder Abuse Lawyers - Complaints, Reviews, Raitings - Golden Living Center - Garden Gate Attleboro MA

 Attleboro Elder Abuse and Nursing Home Neglect Attorneys Serving the South Shore

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Golden Living Center – Garden Place? Our lawyers can help.

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

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Elder Abuse Lawyers - Complaints, Reviews, Raitings - Golden Living Center - Garden Gate Attleboro MAAbout Golden Living Center – Garden Place

Golden Living Center – Garden Place is a for profit, 133-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Attleboro, Norton, Rehoboth, Easton, Foxborough, Taunton, Wrentham, Mansfield, Seekonk, Providence, and Raynham, and other surrounding towns in and near Bristol County, Massachusetts.

Golden Living Center – Garden Place focuses on 24 hour care, respite care, hospice care, and rehabilitation services.

Golden Living Center – Garden Place is legally registered under the business name GGNSC Attleboro Pleasant Manor LLC.

Golden Living Center – Garden Place
193-195 Pleasant Street
Attleboro, MA

Phone: (506) 222-4950
Website: http://www.goldenlivingcenters.com/gardenplace

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, Golden Living Center – Garden Place in Attleboro, Massachusetts received a rating of 2 out of 5 stars (a below average rating.)

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

Fines Against Golden Living Center – Garden Place

The Federal Government fined Golden Living Center – Garden Place $31,546 on 07/22/2016 for health and safety violations.

Fines and Penalties

Our Nursing Home Abuse Attorneys inspected government records and discovered Golden Living Center – Garden Place committed the following offenses:

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

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

Based on records reviewed and interviews, for 2 of 3 sampled residents (Resident #1 and Resident #2), the Facility failed to ensure that all alleged violations involving abuse, neglect or mistreatment were immediately reported to the Supervisor, Executive Director or Director of Nurses, were thoroughly investigated and were reported within two hours to the Department of Public Health.

CNA #1 said she witnessed CNA #2 tell Resident #1 and Resident #2 to shut up or shut the [***] up on two occasions during September 2016. CNA #1 did not immediately report the alleged incident to the Administrator, an immediate internal investigation was not initiated in accordance with the Facility Abuse Policy, CNA #2 was not suspended in accordance with the Facility Abuse Policy and the allegations were not reported to the Department of Public Health for 17 days.

Findings include:

The Facility’s Policy and Procedure on Reporting and Investigation of Alleged Violations Involving Abuse, dated 9/7/16, indicated it is the policy of the Company to take appropriate steps to prevent the occurrence of abuse and the responsibility of each employee to immediately report all allegations of abuse to the supervisor, Executive Director or Director of Nurses.

Immediately is defined as soon as possible but not to exceed 24 hours. The Facility Policy indicated that the Facility takes appropriate steps to prevent the occurrence of abuse which includes using disparaging and derogatory terms to residents.

The Surveyor was unable to interview Resident #1 due to Resident #1’s impaired cognition.

The Surveyor was unable to interview Resident #2 due to Resident #2’s impaired cognition.

A Department of Public Health Incident Report Form, dated 09/27/16, indicated that on 09/10/16, CNA #1 witnessed CNA #2 yell – Shut up- at Resident #1 and on 09/16/16, CNA #1 witnessed CNA #2 yell at Resident #2 – Shut the [***] up- and kept yelling at Resident #2.

Although CNA #1 said she could not specify the date of the alleged incidents, employee punch detail forms for CNA #2 indicated she punched into the Facility at 2:48 P.M. and punched out at 9:03 P.M. on 9/10/16, into the Facility at 4:38 P.M. and punched out at 11:03 P.M. on 9/16/16 and punched into the Facility at 3:01 P.M. and punched out at 10:59 P.M. on 9/17/16.

The Surveyor interviewed the interim Director of Nurses and interim Executive Director at 5:20 P.M. on 3/6/17. The interim Director of Nurses and interim Executive Director said although it was the Facility policy for all staff to immediately report all allegations of abuse, CNA #1 did not immediately report the alleged incidents and, as a result, the Facility failed to immediately report the two allegations of verbal abuse to the Department of Public Health and failed to initiate an investigation for 17 days. Although the first incident was witnessed on 9/10/16, CNA #2 was not suspended until 9/19/16. Despite the Facility policy which indicated staff members accused of abuse should be suspended, CNA #2 continued to work for a period of 9 days and was in direct contact with Resident’s, placing them at risk for possible verbal / physical abuse.

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

Based on record review and staff interview, the Facility failed to ensure that for two Residents (#3 and #10), of a total sample of 24, that the physician requesting to be notified of changes, was not notified of changes in the Resident’s clinical status, specifically changes in weight for Residents on daily weights.

Findings include:

The record showed the Resident #10, a long-term care patient was receiving diuretic treatment for a medical condition.  Resident #10 was supposed to be weighed twice weekly per written medical instructions.  The doctor wrote in his order that he should be notified if Resident’s weight climbed more than 2 lbs.

The facility failed to report weight gain to Resident #10s physician in a timely manner and failed to weight Resident twice weekly.

In review of the weights that were recorded for 7/2016, fluctuations of as many as 9 to 16 pounds were noted over the course of the month, which could be indicative of a fluid and/or electrolyte imbalance requiring physician notification and intervention. There was no evidence in the record to indicate that the physician had been notified of the fluctuations in the Resident’s weights.

The IDON (Interim Director of Nursing) was interviewed on 7/22/16 at 12:00 P.M. No further information was provided as to the reason the Residents’ daily weights were not done as ordered. The IDON acknowledged the significance of these important clinical parameters to address and evaluate the health status of Residents with diabetes, [MEDICAL CONDITION],  and fluid and electrolyte issues. The IDON said that it is the Facility’s policy to notify the physician of any abnormal findings in Residents.

The nursing home used inappropriate physical restraints.

The nursing home failed to keep each resident free from physical restraints, unless needed for medical treatment.

Based on record review and staff interview, the facility failed to complete a physical restraint assessment for 1 Resident (#18) in a total sample of 24 Residents and for two non-sampled residents.

Findings include:

For Resident #18, the facility failed to perform a quarterly interdisciplinary team restraint assessment to determine if the device (alarmed velcro seat belt) was the least restrictive.

Resident #18 was admitted in 3/2012 with a [DIAGNOSES REDACTED].   Review of the most recent quarterly MDS (Minimum Data Set) dated 6/09/16, indicated Resident #18 scored a 0 out of 15 on the Brief Interview of Mental Status, indicating significant cognitive impairment and that the resident was in need of assistance with activities of daily living including transfers, ambulation, dressing, hygiene, and bathing.

Record review indicated that a velcro seatbelt was initiated on 3/31/16 with an order and an updated care plan. There was no documentation in the clinical record to indicate why the velcro seatbelt was initiated. Review of the progress notes show no indication for a need for a velcro seatbelt (no recent falls or attempts to get out of a wheelchair). There was no documentation within the clinical record that the interdisciplinary team met to discuss the alarmed velcro seat belt and determined if this device was the least restrictive.

On 7/21/16 at 2:25 P.M., Resident #18 was observed to be in bed, the wheelchair was in the room, with a velcro seatbelt attached.

During an observation on the B Wing on 7/21/16 at 2:25 P.M., non sampled resident (NSR) #1 was self propelling in a wheelchair around the nurses station, speaking to his/her self. NSR #1 was noted to have a velcro seatbelt on and was unable to release the seatbelt when asked by the surveyor, the resident looked at the belt, smiled and spoke indistinguishably to the surveyor.

An interview was conducted with the DON on 7/21/16 at 2:35 P.M. The DON stated she met with the MDS Nurse who said there were no restraints in the building. The DON had requested a house audit at that time.

On 7/22/16 at 7:20 A. M. during an interview with the DON, she said that there were a total of 5 residents in the building with seatbelts on their wheelchairs, at that time, 2 were able to self-release the seatbelts on command, 1 was not, and 2 still needed to be evaluated.

On 7/22/16 at 9:30AM. the DON and surveyor observed Nurse#3 ask Resident #18 to release the seatbelt, Resident #18 replied you have a good day too. Resident #18 was unable to self release the seatbelt, indicating that this device was a restraint for the resident.

During an interview with the DON on 7/22/16 at 10:00 A.M. the DON stated there are 3 out of 5 residents who were unable to self-release their seatbelts, indicating the seatbelts were restraints. Through investigation the DON was unable to determine why a seatbelt was initiated for Resident #18.

The nursing home failed to ensure services provided by the nursing facility meet professional standards of quality.

Based on record review and interviews the facility staff failed to follow physician orders for three Residents with diabetes (#3, #10 and #17), out of a total sample of 24 Residents.  Failures included not performing blood sugar finger sticks, and failure to record insulin that was administered to patients.

Findings include:

Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care.

Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively.

The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice.

1. Resident #10 was a long term care resident admitted to the facility in 3/2015 with [DIAGNOSES REDACTED]. 

Record Review of the eMAR for July indicated Resident #10 was a diabetic receiving units of insulin based on the fingerstick blood sugars (FSBS) checked four times during the day per the physician orders. The Resident had the following sliding scale schedule for insulin for July:

  • BS: 0-150= no coverage
  • BS: 151-200= 2 units
  • BS: 201-250= 4 units
  • BS: 251-300 = 6 units
  • BS: 301-350 = 8 units
  • BS: 351-400 = 10 units

Record review revealed that on 7/06/16 at 4:30 P.M., the nurse documented a FSBS of 217
with no documentation of the amount of units of insulin administered and on 7/14/16 at
4:30 P.M. the nurse documented a FSBS of 396 with no documentation of the amount of units
of insulin administered.

2. Resident #17 was a long term care resident admitted in 8/2013 and had [DIAGNOSES
REDACTED].

A. Record review indicated Resident #17 had an order for [REDACTED].)

B. Record review of the eMAR for July indicated Resident #17 was a diabetic receiving units of insulin based on the bloods sugars (BS) checked three times during the day per the physicians orders. The Resident had the following sliding scale schedule for insulin for July:

  • FSBS: 65-150= no coverage
  • FSBS: 151-200= 3 units
  • FSBS: 201-250= 6 units
  • FSBS: 251-300=8 units
  • FSBS: 301-350= 10 units
  • FSBS: 351-400= 12 units

Record review revealed that on 7/11/16 at 2:00 P.M. the nurse documented that the BS was 225 with no documentation of the amount of units of insulin administered. On 7/13/16 at 2:00 P.M. there was no documentation that the Resident’s blood sugar was checked.

3. Resident #3 was admitted in 1/2014 with [DIAGNOSES REDACTED].

Record review on 7/19/16, revealed that the Resident’s physician had ordered FSBSs (fingerstick blood sugars) twice daily before breakfast and supper with the following Sliding Scale Insulin schedule, using a [MEDICATION NAME], subcutaneously:

  • FSBS: 70-150= no insulin
  • FSBS: 151-200= 4 units
  • FSBS: 201-250= 6 units
  • FSBS: 251-300= 8 units
  • FSBS: 301-350= 10 units

Review of the eMAR for the month of June/2016, revealed that 6 out of 30 FSBS were not recorded as being done at 6:30 A.M. (before breakfast).

Review of the eMAR for the month of July/2016, revealed that 1 FSBS (as of the time of record review on 7/19) had not been recorded at 6:30 A.M.

The IDON (Interim Director of Nursing) was interviewed on 7/22/16 at 12:00. No further information  was provided as to the reason for the Residents’ FSBSs not being done as ordered. The IDON also acknowledged the significance of these important clinical parameters to evaluate the health status of  Residents with diabetes.

The nursing home failed to give some residents proper treatment to prevent new bed (pressure) sores or heal existing
bed sores.

Based on record review, interview and observation, the Facility failed to ensure for two out of a total sample of 24 residents (#5 and #11) that assessment of pressure sores was implemented. Resident #5 developed osteomyelitis in a Facility acquired pressure sore.

Findings include:

1. Resident #5 was admitted to the Facility in 8/2015, and his/her [DIAGNOSES REDACTED].

Review of the Wound clinic notes, dated 11/18/15 and 1/6/16, indicated that Resident #5 had 2 pressure sores upon admission to the Facility, one stage 4 pressure sore (full thickness loss with exposed bone, tendon and muscle) to the coccyx (A) and one stage 3 (full thickness loss without exposed bone or tendon and may have slough) to the right ischium (B).

The Surveyor requested the weekly skin assessments for Resident #5’s pressure sores since his/her admission. The Interim Director of Nurses (DON) was unable to provide any evidence that Resident #5’s pressure sores were assessed until 3/2016, although the staff provided treatments to the pressure sores. Review of the skin assessments provided indicated the documentation was incomplete, and did not identify the stage of the wounds, any drainage or interventions, and the name of the nurse who documented the findings.

Review of the Facility skin integrity guideline, (no date) indicated that evaluation and observation is to be completed within the first 24 hours of admission/quarterly/significant change of condition using the weekly skin review. The skin integrity guideline indicated that care of a pressure sore included weekly documentation that is accurate and thoroughly completed for each wound and the DON or designee observed the wounds on a weekly basis. The skin integrity guideline indicated that each facility must create a manual tracking system to monitor completion of the weekly skin evaluation. In addition nutritional assessment determines need for nutritional interventions. Review of the nurse’s note, dated 1/12/16, indicated that Resident #5 developed a new pressure area, a superficial area to the left buttocks (C) that measured 1.3 centimeters (cm) by 1.2 cm.

The nurses’ notes, dated 2/4/16, 2/11/6, 2/22/16, 3/2/16, and 3/16/16 identified different staff nurses assessed Resident #5’s pressure sores but no staff nurse identified the actual stage of the pressure sores.

Review of the Wound clinic notes, dated 2/17/16, indicated that Resident #5 had a new left buttock pressure sore (C), stage 3 that measured 1.2 cm by 1 cm by 0.5 cm. with moderate serosanguinous drainage.

There was no weekly skin assessment provided to the Surveyor for Resident #5’s left buttock pressure sore (C) until the 3/16/16 assessment. The 3/16/16 to 7/12/16 assessments were incomplete, did not identify any stages and drainage until 7/12/16, until the left buttock/ischium pressure sore was now a stage 4 pressure sore with moderate drainage.

Review of the nurse’s note dated 5/25/16, indicated new pressures sores had developed. Review of the weekly skin assessment, dated 6/1/16 indicated Resident #5’s left buttock wound (C) was now 3.5 cm by 3.5 cm by 0.5 cm, and there was no documentation that the wound had worsened and was larger than before Review of the Wound Clinic note, dated 6/3/16, indicated that Resident #5’s left buttock pressure sore (C) was deteriorating, measured 4.0 cm by 3.2 cm by 0.9 cm and had moderate yellow drainage.

Review of the Wound Clinic note, dated 6/17/16, indicated that the left buttock pressure sore (C) had worsened, the pressure ulcer had a strong odor and the left lateral leg (D) had worsened. The Wound Clinic note indicated that a protein supplement was needed for wound healing. There was no indication through the nurse’s notes that the Physician was notified of the worsening wounds.

Review of the Wound Clinic notes, dated 7/8/16, indicated that Resident #5 now presented as having possible osteo[DIAGNOSES REDACTED].

The Surveyor observed the ADON on 7/18/16 when he provided wound care. The Surveyor observed that Resident #5 dressings were saturated with bloody drainage and the old dressings had a strong odor from the drainage.

The Surveyor observed Resident #5 on a low air loss mattress but staff were unable to identify when the mattress was initiated, whether the settings were correct and the type of pressure relieving mattress.

The Surveyor interviewed the Physician on 7/19/16, at 11:30 A.M. The Physician said that he received a recent telephone call from the Wound Clinic Physician within the last week, regarding Resident #5’s deteriorating pressure sores. The Physician said that the Wound Clinic Physician was worried that Resident #5 had osteo[DIAGNOSES REDACTED]. The Physician said that is how he found out about the deteriorating wounds. The Physician said he ordered an MRI (magnetic resonance imaging) and results were pending regarding the next course of treatment for [REDACTED].

Review of the MRI results faxed to the Surveyor on 7/25/16, indicated that Resident #5 had bone marrow [MEDICAL CONDITION] involving the left ischium extending to the base of the left ischial spine, consistent with left ischial osteo[DIAGNOSES REDACTED]. 2. For Resident #11, the Facility failed to identify and assess his/her pressure sore upon admission to the Facility.

Resident #11 was admitted to the Facility in 7/2016 and his/her [DIAGNOSES REDACTED].

Review of the initial nursing assessment, dated 7/12/16, indicated that Resident #11 had two open areas of skin breakdown on his/her coccyx and lower left leg. The initial assessment indicated that if a skin condition was present, the nursing staff was to initiate a weekly skin report.

Review of the admission nursing note, dated 7/12/16, indicated Resident #11 had an open area on his/her coccyx, 1 inch by 1 inch and an open area on the left gluteal fold 3 cm by 2 cm.

The Surveyor requested the initial weekly skin assessment from Unit Manager #1 on 7/20/16. Unit Manager #1 said she was unaware that Resident #11 had any open areas on his/her coccyx and gluteal area so weekly skin assessments were not completed.

The nursing home failed to make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function.
Based on record review and staff interview, the Facility failed to ensure that for 1 Resident (#15), of a total sample of 24, received the necessary care, treatment, and services, in accordance with the medical plan of care and physician’s orders [REDACTED].

Findings include:

Resident #15 was admitted in 3/2016 with [DIAGNOSES REDACTED].

According to the last MDS (minimum data set), signed as being completed on 6/23/16, the Resident experienced short and long-term memory deficits with moderately impaired cognitive skills for daily decision making, required assistance with ADLs (activities of daily living), had an indwelling catheter for urinary drainage, and had not experienced a urinary tract infection.

Upon admission to the facility in 3/2016, a covering physician gave a telephone order for the S/P catheter to be changed at the Facility every 4-5 weeks. That order was given by the physician on 3/25/16.

The order to change the S/P tube was listed on the eMAR (electronic medical record) as: May change S/P tube here in nursing home every 4-5 weeks, every evening shift, every 1 month (s) starting on the 25th.

The April eMAR clearly indicated that the catheter was not changed in April.

Further review of the eMAR revealed that the S/P catheter was not changed until May 25th, (nearly two months following admission) which was the first time the S/P tube had been changed since the Resident was admitted in 3/2016.

On 7/19/16, Surveyor #2 observed the Resident’s spouse talking in a loud, angry voice, to one of the nurses on the C Wing. The Resident’s spouse was upset when he/she suspected that the Resident’s S/P tube had not been changed in nearly two months.

Record review from 7/19/16 to 7/21/16, revealed that the S/P tube had not been changed in the month of June, and was not changed from 5/25/16 until 7/19/16, nearly 2 months from when it was last changed. Additionally, upon further record review, and during interview with the IDON (Interim Director of Nursing) on 7/19/16, it was confirmed that the Resident was running a fever of 100 degrees Fahrenheit and was being worked up for a urinary tract infection by the physician.

Further interview with the IDON on 7/22/16 at 11:30 A.M., said that the Resident’s S/P tube was not changed every 4-5 weeks as ordered, should have been changed a month from 3/25/16, on 4/25/16, and was not. Additionally, the IDON confirmed that the S/P tube was changed on 5/25/16, however it was not changed on June 25th. The S/P catheter was only changed when the Resident’s spouse suspected on 7/19/16 that the S/P catheter was long overdue to be changed and questioned the nurses.

The IDON said during interview, that nursing staff’s failure on two occasions to change the Resident’s S/P tube was unacceptable, and she would be investigating the matter further to determine the cause for the omission of the S/P tube being changed.

The facility failed to properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.

Based on record review, interview and observation, the Facility failed to ensure that
proper treatment and care was provided for 1 out of a total sample of 24 residents( #11)
during care of the peripherally inserted central catheter (PICC) line.

Findings include:

Resident #11 was admitted to the Facility in 7/2016, and his/her [DIAGNOSES REDACTED].

Review of the Hospital discharge summary, dated 7/12/16, indicated that Resident #11 had an amputated left toe that was infected with [MEDICAL CONDITION](MRSA) and the treatment plan was for intravenous antibiotics ([MEDICATION NAME]) at the Facility.

On 7/20/16, The Interim Director of Nursing (DON) and the Surveyor reviewed the Facility policy, dated 4/2008, for care of vascular access devices.  Review of the policy indicated that measurement of the upper arm circumference should be taken at baseline and routinely after placement. Measurement of the length of the catheter should be taken at baseline and routinely after placement. The Interim DON said it was not clear how often the measurement should be taken but there were no baseline measurements for Resident #11’s PICC line. Review of the treatment record, dated 7/13/16, indicated a staff Nurse changed Resident #11’s PICC line dressing, but staff were unable to provide, and nurses’ notes did not indicate that any measurements of catheter migration or arm circumference were obtained at the time of the PICC line dressing change.

The Interim DON said that there were no baseline measurements taken either at admission or during Resident #11’s dressing change on 7/13/16.

The nursing home failed to ensure and adhere to an infection control program that investigates, controls and keeps infection from spreading.

Based on record review, observation and interview, the Facility failed to ensure that infection control practices were maintained during a dressing change for 1 resident (#5).

The facility failed to ensure that contact precautions and general infection control practices were followed for 4 sampled residents (#4, #5, #11, and #20), of a total sample of 24, in accordance with the Facility’s Infection Program. The facility failed to ensure that medications were poured according to acceptable infection control practices.

Findings include:

1. Resident #5 was admitted to the Facility in 8/2015 and his/her [DIAGNOSES REDACTED].

Review of the Wound clinic notes, dated 11/18/15 and 1/6/16, indicated that Resident #5 had 2 pressure sores upon admission to the Facility, one stage 4 pressure sore (full thickness loss with exposed bone, tendon and muscle) to the coccyx (A) and one stage 3 (full thickness loss without exposed bone or tendon and may have slough) to the right ischium (B).

Review of the nurse’s note, dated 1/12/16, indicated that Resident #5 developed a superficial area to the left buttocks (C) that measured 1.3 centimeters (cm) by 1.2 cm. Review of the Wound clinic notes, dated 2/17/16, indicated that Resident #5 had a new left buttock pressure sore (C), stage 3 that measured 1.2 cm by 1 cm by 0.5 cm. with moderate serosanguinous drainage.

Review of the nurse’s note dated 5/25/16, indicated new pressures sores had developed, Resident #5’s left malleolus and left lateral leg (D) were identified as pink, moist and red.

Review of the physician’s order, dated 7/12/16 included the following pressure sore treatments:

  • clean left leg with normal saline apply calcium alginate and [MEDICATION NAME] every other day;
  • clean left ankle with normal saline and apply calcium alginate and [MEDICATION NAME] every other day;
  • clean left buttock area with normal saline and apply Santyl and Allevyn dressing daily; clean right buttock with normal saline and apply Allevyn dressing daily.

The Surveyor observed the Assistant Director of Nurses (ADON) on 7/18/16 when he changed Resident #5’s dressings. The Surveyor observed the following during the wound care:

  • The ADON washed his hands and donned gloves after he set up his dressing supplies.
  • The ADON removed the old dressing from the right buttock, the Surveyor observed the dressing to be saturated with bloody drainage and there was a foul odor noted.
  • The ADON changed his gloves and did not wash his hands, The Surveyor intervened and questioned the ADON, who removed his gloves and washed his hands and donned new gloves.
  • The ADON then provided care to the right buttock pressure sore, the left buttock pressure sore, and the left leg and ankle pressure sore according to infection control protocols.

Review of the Facility policy for dressing changes, dated 2006, indicated that the following steps should occur during a dressing change:

  • perform hand hygiene and donn a pair of gloves;
  • remove soiled dressing and discard in plastic bagl
  • perform hand hygiene;
  • put on a second pair of gloves;
  • cleanse wound and apply medication as ordered;
  • remove gloves and discard;
  • perform hand hygiene.

Review of the Lippincott Manual of Nursing Practice, dated 2014, indicated that hand hygiene is the single most recommended measure to reduce the risks of transmitting organisms. Hand hygiene should be performed before donning and after removing gloves for infection control.

The ADON said he should have washed his hands after removing the soiled dressing and before he donned new gloves.

2. The Facility failed to implement their policy for contact precautions for Resident #11, on 7/15/16 and 7/18/16 when staff failed to ensure proper contact protocols.

Resident #11 was admitted to the Facility 7/2016, and his/her [DIAGNOSES REDACTED].

Review of the Hospital discharge summary, dated 7/12/16, indicated that Resident #11 had an amputated left toe that was infected with Methicillin Resistant Staphylococcus  Aureus (MRSA) and the treatment plan was for intravenous antibiotics ([MEDICATION NAME]) at the Facility.

The Surveyor noted that there was a precaution sign on Resident #11’s door and the staff told the Surveyor that Resident #11 was on contact precautions.

The Surveyor and the Interim Director of Nursing (IDON) reviewed the Facility policy for contact precautions. According to the Facility policy, residents known to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the environment should be on contact precautions. The Facility policy indicated that gloves should be worn upon entering the room, removed before leaving and hand hygiene performed. Also in addition according to Facility policy, gowns should be used upon entering the room and removed prior to leaving the room, along with hand hygiene. The policy indicated that examples of infections requiring contact precautions included heavily draining wounds with non contained drainage.

On 7/15/16 at 10:00 A.M., The Surveyor observed the Medication Nurse administer the intravenous medication [MEDICATION NAME] via Resident #11’s peripherally inserted central catheter (PICC) line. Although the Medication Nurse wore a gown and gloves prior to entering the room, he removed the gown and gloves and failed to perform hand hygiene before leaving the room.

On 7/18/16 at 10:30 A.M. the Dietician was observed in Resident #11’s room without any gowns or gloves, per Facility policy. The Surveyor questioned the Dietician about the precautions and the Dietician said she did not touch anything in Resident #11’s room and was told that she did not need a gown or gloves. The Dietician failed to follow the Facility policy for contact precautions.

The Surveyor observed the Assistant Director of Nurses (ADON) on 7/18/16 when he changed Resident #5’s dressings. The Surveyor observed the following during the wound care: The ADON removed the old dressing from the right buttock, the Surveyor observed the dressing to be saturated with bloody drainage and there was a foul odor noted. The Surveyor observed the ADON remove dressings from the left buttock, left leg and left ankle. The Surveyor noted that all of the dressings were saturated with bloody drainage. Neither the ADON, or the Staff Nurse Assisting him wore gowns and according to the Facility policy, infections requiring contact precautions included heavily draining wounds with non contained drainage.

3. For Resident #20 the facility staff failed to assess for the removal of contact
precautions following an infection.

Resident #20 was a long term care resident admitted to the facility in 2006.

During initial observation of the residents’ room on 07/14/16 at 9:25 A.M., there was a sign on the door alerting staff and visitors to see nurse prior to entering, the MDS Nurse (Minimum Data Set) was unsure of which resident had an infection or what the precautions were.

During an interview with MDS Nurse on 07/14/16 at 1:00 P.M., she stated Resident #20 had ESBL in the urine as of 08/11/2015, was on an antibiotic for 10 days and there was no additional follow-up information regarding the residents’ infectious status.

An interview was conducted with CNA #2 and CNA #3 on 07/20/16 at 2:15 P.M. CNA #2 and CNA #3 stated that Resident #20 was previously using a commode, until he/she was cleared from precautions. They stated the resident was an assist of one for transfers and had been using a commode in the bedroom.

Record review on 07/20/16 indicated that the physician was contacted on 07/14/16 regarding precautions status with a new order to obtain a urinalysis. The lab results came back negative on 07/17/16 and contact precautions were discontinued, including the commode. During an interview with the IDON on 07/20/16 at 2:30 P.M., she was unsure why this resident remained on contact precautions after the completion of antibiotic treatment.

4. On 07/15/16 at 9:58 A.M., the surveyor observed Nurse#2 at the medication cart. Nurse#2 punched 1 pill out of the medication card and into her hand, she then punched 2 pills from a different medication card into her hand and then signed the narcotic book.

During an interview with Nurse#2 following this observation, Nurse#2 stated it was just one pill and now I do this (demonstrating holding the medication card with one hand and popping the medication into a cup). Nurse#2 stated she always does that with a narcotic so that she does not drop it on the floor.

5. On 7/14/16 at 11:30 A.M., during the initial tour of the Facility’s C Wing, a CNA wearing blue scrubs was observed walking down the hall wearing contaminated, disposable gloves while carrying a plastic bag that contained soiled garments.

The CNA carried the soiled bag down the C Wing corridor and was observed headed in the direction of the soiled utility room to dispose of the soiled items. Interview with the MDS Nurse at that time, confirmed that the CNA was not following the facility’s infection control policy by removing her gloves in the room and performing hand hygiene during her handling of the soiled items.

6. On 7/21/16 at 8:50 A.M., the ST (Speech Therapist) was observed in Resident #4’s room (a precaution room).

The Resident was positive for the MDRO (multidrug resistant organism) MRSA (methicillin resistant staphyloccus aureus). According to the facility’s Infection Control Policy, gown and gloves are required by any person entering the room of a resident positive for MRSA.

The ST did not have a gown or gloves on, and was observed sitting at the foot of the Resident’s bed with a laptop computer resting on the Resident’s overbed table. The ST was interviewed at the C-Wing nurse’s station about Surveyor #1’s observation. The ST said she did not see the sign on the door that indicated to see the nurse before entering the room. The ST said she was sorry and said that she understood the concern of spreading disease from Resident to Resident by not following infection control policy. The C Wing Unit manager was interviewed on 7/21/16 at 8:55 A.M. She said that the facility’s Infection Control Policy requires any person entering a room of someone on precautions for MRSA to wear a gown and gloves prior to entering the Resident’s room.

Golden Living Center – Garden Place, Nursing Home Neglect and Elder Abuse Lawyers

If someone you love has suffered neglect or elder abuse by a senior caregiver, nursing home, or other care facility, our lawyers may be able to help. Regardless of whether or not criminal charges are filed against an alleged abuser, you may still be able to pursue compensation in a civil claim. Compensation in elder abuse cases may be awarded if someone in the care of another suffers harm due to intentional or negligent actions (including failure to take action).

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation. Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

Oftentimes, victims of abuse either cannot or will not speak up for themselves out of fear. If you notice any warning signs or symptoms of neglect of abuse an an elderly person, it is important you contact an elder abuse lawyer immediately. Not only are there statute of limitations on filing a claim, but the sooner we start helping you, the easier it will be to collect evidence and talk to any witnesses before important details are lost, hidden, or forgotten.

 

Boston Personal Injury Lawyers for Elder Abuse Cases

We offer a free, no-obligation legal consultation to help you understand your rights and the value of your case. Our personal injury law firm takes cases involving elder abuse and neglect. We offer legal service to clients in Massachusetts, Rhode Island and New Hampshire.


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Page Last Updated: November 14, 2017

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