Hunt Nursing and Rehabilitation Center

Hunt Nursing and Rehabilitation Center

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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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About Hunt Nursing and Rehabilitation Center

Hunt Nursing and Rehabilitation CenterHunt Nursing and Rehabilitation Center is a non-profit, 120-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Danvers, Peabody, Middleton, Beverly, Salem, Lynnfield, North Reading, Marblehead, Swampscott, Lynn, Wakefield, Reading, Saugus, Ipswich, Melrose, and the other towns in and surrounding Essex County, Massachusetts.

Hunt Nursing & Rehab Center focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Hunt Nursing and Rehabilitation Center
90 Lindall Street
Danvers, MA 01923

Phone: (978) 777-3740
Website: https://huntnursinghome.org/

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, Hunt Nursing and Rehabilitation Center in Danvers 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 and Penalties

Our Nursing Home Accident Attorneys inspected government records and discovered Hunt Nursing & Rehab Center committed the following offenses:

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

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

Based on record review and interview, the facility failed to notify the Physician about a recommended treatment for 1 Resident (#9) with a pressure sore out of 4 sampled residents with pressure sores in a total sample of 24.

Findings include:

For Resident #9, the facility failed to notify the Physician regarding a treatment recommendation by the Wound Care Specialist. Resident #9 was admitted to the facility in 8/2012, with [DIAGNOSES REDACTED]. Review of the annual MDS (minimum data set) completed 6/28/16 and the CAAs (care area assessments) dated 6/29/16, indicated the resident was at high risk for pressure ulcers due to bowel incontinence and dependence on staff for repositioning. Further record review indicated that the resident was seen by a Wound Care Specialist weekly.

A 9/8/16 Wound Care Specialist Evaluation indicated the resident has an unstageable DTI (deep tissue injury) of the left heel, a shear wound of the right posterior thigh and a shear wound of the sacrum. The Wound Care Specialist noted improvement in these areas. However, the Wound Care Specialist made the following recommendation for the sacrum area which included: add: Foam– once daily and prn (as needed) please use large shaped border foam; change dressing if soiled. Under coordination of care, the Wound Care Specialist indicated the resident’s care was discussed with the facility’s nursing staff.

A 9/14/16 Wound Care Specialist Evaluation indicated the resident has an unstagable DTI of the left heel, a shear wound of the right posterior thigh and a shear wound of the sacrum and noted increased granulation in these areas. The Wound Care Specialist documented an initial evaluation of a shear wound of the right medial buttock. The Wound Care Specialist made the following recommendation for the right medial buttock: add: Foam– once daily and prn (as needed) please use large shaped border foam; change dressing if soiled. Under coordination of care, the Wound Care Specialist indicated the resident’s care was discussed with the facility’s nursing staff. During an interview on 9/20/16 at 2:00 P.M., Unit Manager #1 said that the Physician was not notified about the treatment recommendations made by the Wound Care Specialist on 9/8/16 and 9/14/16.

Failed to conduct initial and periodic assessments of each resident's functional capacity.

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

Based on record review, staff interview and observation, the facility failed to ensure that a comprehensive assessment was completed for 2 of 6 sampled residents with seatbelts (Resident #2 and Resident #9 ) out of a total sample of 24 residents.

Findings include:

For Resident #2, the facility failed to complete a comprehensive reassessment for the use of a velcro alarmed seatbelt since 2/12/16. Review of the resident’s clinical record on 9/14/16, indicated the resident was admitted to the facility in 10/2015, with [DIAGNOSES REDACTED]. On 2 of 5 days (9/14/16 at 8:30 A.M .and 9:00 A.M. and 9/15/16 at 10 :30 A.M.) of survey, Resident #2 was observed seated in a wheelchair with a velcro alarmed seatbelt across their lap.

The resident’s most recent quarterly Minimum Data Set ((MDS) dated [DATE], indicated the resident was coded as a 2 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment, required extensive assistance with activities of daily living and was always incontinent of bladder and bowel. The facility identified the resident as a high risk for falls. Further record review indicated the resident had a physician’s order dated 2/12/16, for a velcro alarm seatbelt in wheelchair, check function and placement every shift, assess resident’s ability to self release velcro alarm seatbelt weekly.

According to the facility’s physical restraint assessment form dated 2/12/16, the resident utilized no restraints, but used the velcro alarm seatbelt as an auditory reminder to request help and increase awareness of proximity of the edge of the wheelchair. There were no other assessments completed after the 2/12/16 assessment to determine if the velcro seatbelt was the least restrictive device for this resident. As of 9/14/16, which was 7 months after the application of the velcro seatbelt, the facility had not reassessed the resident for the continued use of the velcro alarm seatbelt.

During an interview with Unit Manager (UM) #3 on 9/16/16 at 2:00 P.M., Unit Manager #3 said the resident utilized a velcro alarm seatbelt as a reminder and the resident could release the velcro seatbelt if asked. UM #3 was not aware that the last comprehensive assessment completed for the use of the velcro alarm seatbelt was 2/12/16.

For Resident #9, the facility failed to obtain a physician’s order, conduct a complete assessment and provide ongoing evaluation for the use of a clip seatbelt in the wheelchair.

Resident #9 was admitted to the facility in 8/2012 with [DIAGNOSES REDACTED]. On 9/19/16 and 9/20/16, Resident #9 was observed in his/her wheelchair at various times of the day with a clip seatbelt applied.

Review of the Annual Minimum Data Set (MDS) assessment, dated 6/28/16, indicated the resident was cognitively intact (BIMS = 14) and had bilateral impairment of the upper extremities both sides (shoulder, elbow, wrist, hand). Restraint use was not identified. Review of Resident #9’s medical record indicated there was no physician’s order for the use of [REDACTED]. Review of the current care plan reviewed 7/2016, indicated no interventions for the use of a clip seatbelt in the wheelchair.

On 9/19/16 at approximately 1:30 P.M. Surveyor #2 observed Resident #9 sitting outside in his/her wheelchair with a clipped seatbelt applied across the waist. Resident #9 unclipped the seatbelt with difficulty and reported that it was getting harder to do this. The Resident indicated that when he/she is in the bedroom at night, he/she requires assistance to release the seatbelt.

During an interview with Unit Manager (UM) #1 on 9/20/16 at 9:30 A.M., Surveyor #4 inquired about Resident #9’s use of the seatbelt. UM #1 said that she believed the seatbelt had been in use since the resident had the chair (date unknown). UM #1 said that she was not aware of any assessment that had been done by O.T. (occupational therapy) for the use of a seatbelt.

Failed to develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.

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

Based on record review and staff interview, the facility failed to develop a comprehensive care plan to monitor a pacemaker for 1 applicable resident (Resident #8) and also failed to develop a comprehensive care plan to monitor an implanted cardioverter-defibrillator for 1 applicable resident (Resident #1), in a total sample of 24 residents.

Findings include:

For Resident #8, who was admitted to the facility in 3/2016, with [DIAGNOSES REDACTED].

Review of the clinical record on 9/15/16, indicated that there was no information on the type of pacemaker nor any documentation that pacemaker checks were to be completed. Review of the physician’s orders [REDACTED]. The physician’s progress notes did not contain documentation pertaining to when the pacemaker should be checked. During an interview with Unit Manager #3 on 9/15/16 at 10:00 A.M., Unit Manager #3 said the resident had a pacemaker and should have a care plan developed that identifies the make, model and serial number of the device. The care plan should include what the device is pacing at and how often the device should be checked.

For Resident #1, who was admitted to the facility in 12/2015, with [DIAGNOSES REDACTED].

Review of the clinical record on 9/20/16, indicated the Resident had an automatic implant cardiac defibrillator. The 12/3/15 nursing admission assessment checked that the Resident had a pacemaker and an automatic implant cardiac defibrillator. The 12/5/15 physician progress notes [REDACTED]. Further record review of the 2/27/16 and 6/25/16 physician progress notes [REDACTED]. Review of the physician’s orders [REDACTED]. Individuals with implantable cardioverter-defibrillator devices require regular clinical and technical assessment of their devices.

During an interview on 9/20/16 at 11:50 A.M., Unit Manager #1 said monitoring of the implanted cardiac device had been done a few months ago when a remote service was put into place. At 1:00 P.M., UM #1 provided documentation of remote monitoring of the device done in 4/2016.

UM #1 acknowledged that the care plan did not identify that the resident has an implanted cardiac defibrillator including the type of device, the model and how the device is monitored.

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

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

Based on record review and staff interview, the facility failed to ensure that services being provided met professional nursing standards of quality for 2 sampled residents (Resident #1 and Resident #20) in a total sample of 24 residents and for 1 Non-sampled resident (NS #1). The facility failed to ensure that physician orders [REDACTED].

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.

For Non-Sampled Resident #1, the facility failed to accurately transcribe a physician’s orders [REDACTED]. As a result, the 9/2016 Medication Administration Record [REDACTED]. Review of the clinical record on 9/14/16, indicated that the resident’s physician’s orders [REDACTED]. and 8 P.M The order was not signed by a physician or nurse practitioner. Review of the physician’s orders [REDACTED]. The order for Senna 8.6 mg tablet, give one tablet twice a day PRN was signed by the Resident’s physician. The original physician’s orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. During the medication pass on 9/14/16, at 11:09 A.M., Surveyor #2 observed Nurse #5 prepare medications for NS Resident #1. Nurse #5 poured one tablet of the medication Senna 8.6 mg and documented her initials on the Medication Administration Record [REDACTED].M. Nurse #5 then administered the medication to NS Resident #1. The nurse did not determine if the Resident was having difficulty moving his/her bowels.

During interview on 9/14/16, at 11:59 A.M., Unit Manager #2 reviewed the physician’s orders [REDACTED].#2. Unit Manager #2 said she was unable to locate the original order for the medication in the Resident’s clinical record. She also said that she was unable to locate a physician’s orders [REDACTED]. Unit Manager #2 said that the signed physician’s orders [REDACTED]. She said that she thought the error was due to an error in editing from the previous month. Unit Manager #2 then placed a phone call to the physician to report the error.

For Resident #20, the facility failed to accurately transcribe a physician’s orders [REDACTED]. As a result, the 9/2016 Medication Administration Record [REDACTED]. Review of the clinical record on 9/20/16 at 10:45 A.M., indicated that Resident #20 was admitted to the facility during 2/2012, with a [DIAGNOSES REDACTED]. The resident had a physician’s orders [REDACTED]. According to the 8/2016 Medication Administration Record [REDACTED]. However, review of the 9/2016 MAR indicated [REDACTED]. (From 9/1/16 to 9/11/16 on the 9/2016 MAR indicated [REDACTED].

On 9/20/16 at 12:10 P.M., Unit Manager (UM) #3 said the resident received the wrong dose of [MEDICATION NAME] and was suppose to receive [MEDICATION NAME] 7.5 mg by mouth at bedtime and not 3.75 mg. According to UM #3, the nurse who received and wrote the original physician’s orders [REDACTED]. to equal 7.5 mg. As a result, when the the pharmacy received and printed the new orders for 9/2016, the physician’s orders [REDACTED]. 3. For Resident #1, the facility failed to ensure that Resident #1 received the correct amount of a nutritional supplement as recommended by the Dietitian and ordered by the physician to address weight loss.

Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was observed at breakfast on 9/15/16 and lunch on 9/19/16 and was observed to eat more than 75% of the meals.

Review of the quarterly MDS (minimum data set) completed 8/29/16, indicated the resident had a significant weight loss of 6.7% in the last month. Further record review indicated a nutrition progress note dated 6/3/16, that indicated an 11% weight loss in the past 3 months. At that time, the resident had been receiving a frappe with lunch and dinner. On 6/16/16 the dietitian recommended 8 oz Boost Very High Calorie (VHC) TID (three times per day).

Review of the physician orders [REDACTED]. From 8/2/16 to 8/12/16 the resident was hospitalized for [REDACTED]. On readmission on 8/12/16, the physician’s orders [REDACTED]. Review of the 8/2016 MAR (medication administration record) from 8/12/16 to 8/31/16 (for 19 days) and the 9/2016 MAR, from 9/1/16 to 9/18/16 (for 18 days) indicated that the 8 oz Boost Very High Calorie (VHC) was offered only twice per day at 10:00 A.M. and 2:00 P.M. and not three times per day, as per the medical plan of care.

Failed to provide care by qualified persons according to each resident's written plan of care.

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

Based on observation, staff interview and record review, the facility staff failed to follow the physician’s orders for 3 Residents (#2, #19 and #21) out of a total sample of 24 residents.

Findings include:

For Resident #19, the facility failed to remove a bed alarm that had been discontinued by the physician. Review of the clinical record on 9/19/2016, at 8:30 A.M., indicated that Resident #19 had a physician’s order dated 9/14/2016, to discontinue the bed alarm. On 9/19/2016 at 9:00 A.M., and on 9/20/2016, at 7:30 A.M. and 9:20 A.M., Surveyor #2 observed Resident #19 in bed with a bed alarm on him/her. During an interview on 9/20/2016, at 10:40 A.M., CNA #1 said he was assigned to Resident #19 for the 7 A.M.-3 P.M. shift. He said he was unaware that the alarm had been discontinued. CNA #1 said that he had noticed the day before that the pads on the floor next to the Resident’s bed were not in place and had asked the charge nurse where they were and she said they had been discontinued, but that she never told him the Resident’s alarms had been discontinued. CNA #1 said he would immediately remove the bed alarm from the Resident.

For Resident #21 the facility failed to follow the medical plan of care by not documenting the assessment of the resident’s ability to self release the velcro alarm seatbelt weekly. Review of the clinical record on 9/19/2016, indicated that a physician order dated 9/3/2015, directed the nurse to assess the resident’s ability to self release the velcro seatbelt intentionally weekly on Tuesday on the 7 A.M.-3 P.M. shift. Further review indicated that for the month of 8/2016, and the first 2 weeks of 9/2016, the nurse signed the treatment administration record but failed to indicate the results of the assessment. During an interview on 9/19/2016, at 11:30 A.M., Unit Manager #3 said that the assessment should be documented on the back of the treatment administration record, otherwise no one would know if the resident could release the seatbelt restraint or not. She said that would make the difference between the seatbelt being considered a restraint or not and it was important to know.

For Resident #2, the facility failed to implement the medical plan of care by not assessing the resident’s ability to self release velcro alarm seatbelt weekly. Review of the resident’s clinical record on 9/14/16, indicated the resident was admitted to the facility in 10/2015, with [DIAGNOSES REDACTED]. On 2 of 5 days (9/14/16 at 8:30 A.M. and 9:00 A.M. and 9/15/16 at 10 :30 A.M.) of survey, Resident #2 was observed seated in a wheelchair with a velcro alarmed seatbelt across their lap.

The resident’s most recent quarterly Minimum Data Set ((MDS) dated [DATE], indicated the resident was coded as a 2 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment, required extensive assistance with activities of daily living and was always incontinent of bladder and bowel. The facility identified the resident as a high risk for falls.

Further record review indicated the resident had a physician’s order dated 2/12/16, for a velcro alarm seatbelt in wheelchair, check function and placement every shift, assess resident’s ability to self release velcro alarm seatbelt weekly. The physician’s order appeared on the 2/2016 and 3/2016 Treatment Records and indicated that the facility assessed the resident for the ability to self release the velcro alarm seatbelt by nursing as indicated by nursing writing their initials weekly on Mondays on the 3:00 P.M. to 11:00 P.M. shift. There was no other documentation in the resident’s clinical record or on the back of the 2/2016 and 3/2016 Treatment Records to indicate nursing assessed the resident, as per the medical plan of care.

The physician’s order dated 2/12/16, to assess the resident’s ability to self release the velcro alarm seatbelt weekly did not appear on the Treatment Records for 4/2016, 6/2016, 7/2016, 8/2016 and 9/2016. There was no other documentation that the facility implemented the 2/12/16 physician’s order and for 5 months nursing did not assess the resident’s ability to self release the velcro alarm seatbelt on a weekly basis, as per the medical plan of care.

During an interview with Unit Manager (UM) #3 on 9/16/16 at 2:00 P.M., Unit Manager #3 said she was unaware that the 2/12/16 physician’s order did not appear on the 5 Treatment Records. UM #3 said nursing staff should have assessed the resident on a weekly basis to determine if the resident could self release the velcro alarm seatbelt, as per the medical plan of care. UM #3 also said that the results of the weekly assessments would be documented on the back of the treatment records.

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

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

Based on record review and staff interview, the facility failed to follow protocol in providing the appropriate care and treatment of [REDACTED].#11 ) in a total sample of 24 Residents.

Findings include:

For Resident #11, the facility failed to change the catheter site dressing and document the measurement of the external catheter length and upper arm circumference with each dressing change, and as needed, per the physician’s orders [REDACTED]. Resident #11 was admitted to the facility in 6/2016, with [DIAGNOSES REDACTED]. Resident #11 had a PICC line in place for antibiotic administration to treat an infection of the left knee.

Review of the Facility’s policy dated 12/1/13, titled Central Venous Catheter: Dressing Change, General Guidelines, Section 2 indicated that for PICCs, measurements shall be performed upon admission, with each dressing change and with complications. Section 2 (e). external catheter length. (f). upper arm circumference (3 inches or 10 cm above catheter insertion site). The section titled Documentation indicated that Point 1. the date, time and type of dressing which was changed. Measurements recorded for PICCs. Review of the physician’s orders [REDACTED].

Review of the physician’s orders [REDACTED]. Change catheter site dressing every week and PRN with transparent dressing. Review of the Medication Administration Record (MAR) for 7/2016, indicated that the dressing was changed and the measurements were obtained as ordered for 7/24/16, but not on 7/31/16, one week later, as ordered.

Review of the MAR for 8/2016 indicated that the dressing was changed and the measurements were obtained as ordered for 8/8/16, but not on 8/15/16, one week later, as ordered, or on 8/29/16. Review of the MAR for 9/2016 indicated that the dressing was changed and the measurements were obtained as ordered for 9/5/16, but not on 9/12/16, one week later, as ordered, and on 9/19/16 and 9/26/16. Unit Manager #1 was interviewed on 9/14/16 at 2:10 P.M. Unit Manager #1 reviewed all the PICC line documentation in Resident #11’s medical record and MAR and said that nursing staff did not follow the physician’s orders [REDACTED].

Failed to keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.

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

Based on record review and observation, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. Two of six licensed nurses made errors while administering medications on 2 of 3 units. There were 2 errors which affected 1 sampled resident (Resident #17) and 1 Non-Sampled (NS #1) out of 9 residents with 26 opportunities. The facility had an error rate of 7.70%.

Findings include:

For Non-Sampled (NS) Resident #1, the facility failed to ensure that the medication Senna (a laxative) was administered without a physician’s orders [REDACTED].>Review of the clinical record on 9/14/16, indicated that the resident’s physician’s orders [REDACTED]. and 8:00 P.M. The order was not signed by a physician or nurse practitioner. Review of the physician’s orders [REDACTED]. The order for Senna 8.6 mg tablet, give one tablet twice a day PRN was signed by the Resident’s physician. The original physician’s orders [REDACTED]. During the medication pass on 9/14/16, at 11:09 A.M., Surveyor #2 observed Nurse #5 prepare medications for NS Resident #1. Nurse #5 poured one tablet of the medication Senna 8.6 mg and documented her initials on the Medication Administration Record [REDACTED].M. Nurse #5 then administered the medication to NS Resident #1.

During interview on 9/14/16, at 11:59 A.M., Unit Manager #2 reviewed the physician’s orders [REDACTED].#2. Unit Manager #2 said she was unable to locate the original order for the medication in the Resident’s clinical record. She also said that she was unable to locate a physician’s orders [REDACTED]. Unit Manager #2 said that the signed physician’s orders [REDACTED]. She said that she thought the error was due to an error in editing from the previous month. Unit Manager #2 then placed a phone call to the physician to report the error.

For Resident #17, the facility failed to ensure that the medication Dietary Aid ([MEDICATION NAME] Fast Act) was administered at the correct dose. Review of the clinical record indicated that the Resident had a physician’s orders [REDACTED].M., 12:00 P.M. and 5:00 P.M. During the medication pass on 9/19/16 at 4:17 P.M., Surveyor #2 observed Nurse #6 prepare medications for Resident #17. The nurse poured one tablet of the medication Dietary Aid. The nurse then proceeded to administer the medication to Resident #17. Review of the Dietary Aid medication bottle indicated that the serving size was three tablets which equaled 9000 iu. Therefore, each tablet contained 3000 iu. During an interview on 9/20/16 at 8:30 A.M., Unit Manager #3 reviewed the physician’s orders [REDACTED].#2. Unit Manager #3 said that the bottle indicated that each tablet contained 3000 iu and not 9000 iu. She said that the physicians order did not reflect the dosage available to the facility and that the order would have to be changed to reflect the correct number of tablets to dispense.

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

Based on observations and staff interview, the facility failed to ensure that out of date medications were removed from use and discarded on 1 of 3 nursing units, failed to date multidose vials of medications when opened for use on 2 of 3 nursing units, failed to ensure that liquid ativan (a controlled substance that is required to be stored under a double lock) was stored as required on 1 of 3 nursing units and failed to ensure that no items other than medications/vaccinations were stored in the medication refrigerator on 1 of 3 nursing units.

Findings include:

During an inspection of the first floor medication room on 9/15/16 at 1:30 P.M., with Unit Manager #1, the following was observed:

  • 1 bag of Cubicin 820 milligrams (mg) per 100 milliliters (ml) with an expiration date of 8/23/2016.
  • 1 bag of Cubicin 820 milligrams (mg) per 100 milliliters (ml) with an expiration date of 8/29/2016.
  • 6 bags of Cubicin 820 milligrams (mg) per 100 milliliters (ml) with an expiration date of 9/5/2016.
  • Glucagon with an expiration date of 7/20/2016.
  • 1 bottle of Vitamin D3 with an expiration date of 3/2016.
  • 1 bottle of Senokot S with an expiration date of 8/2016.
  • 1 bottle of Aspirin 325 mg with an expiration date of 8/2016.
  • 1 bottle of Vitamin B1 with an expiration date of 8/2016.
  • A plastic bag containing 10 cherries with a fuzzy green substance on them and dated 7/30/16.

During an interview on 9/15/16 at 1:35 P.M., Unit Manager #1 said that no food items were supposed to be kept in the medication refrigerators. She also said that the expired medications should have been disposed of and not available for use.

During an inspection of the second floor medication room on 9/15/2016, at 12:55 P.M. with Unit Manager #3, the following was observed:  1 bottle of Novolin N insulin, opened and without a date of when it was opened. During an interview on 9/15/2016, at 1:00 P.M., Unit Manager #2 said that the insulin should have been dated.

During an inspection of the third floor medication room on 9/15/16, at 1:15 P.M., with Unit Manager #2 the following was observed: 1 bottle of Latanoprost eye drops opened and without a date of when it was opened. 1 open bottle of Lorazepam and 2 unopened bottles of Lorazepam not locked inside the refrigerator.

During an interview on 9/15/2016, at 1:25 P.M., Unit Manager #3 said that all controlled substance medications are required to be locked inside the refrigerator to ensure they are double locked at all times. She also said that all medications are supposed to be dated when opened because they expire 28 days after being opened.

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

Based on observation, staff interviews and record review, the Facility failed to maintain an Infection Control program designed to prevent the development and transmission of disease and infection during meal pass, between residents after providing care and during housekeeping services.

Findings include:

On 9/14/2016, at 8:15 A.M., Certified Nurses Aid (CNA) #4 was observed to exit a resident’s room and walk down the hallway on the First Floor Unit wearing a glove.

On 9/19/2016, at 3:50 P.M. CNA #3 was observed to walk down the Third Floor Unit’s hallway carrying dirty linen with gloves on. She then entered the dirty laundry room and disposed of the linen and exited the room without washing her hands. CNA #3 then went to the clean linen cart, removed clean linen and brought it into another resident’s room.

On 9/20/16, at 7:45 A.M. CNA #2 was observed walking down the First Floor Unit’s hallway wearing gloves on both her hands.

On 9/20/2016 at 7:45 A.M. a housekeeper was observed to enter a resident’s room on the First Floor Unit and exit wearing gloves. She then was observed to walk down the hall, get a plastic trash bag, walk back down the hall with the gloves on, re-enter the resident’s room and exit 30 seconds later still wearing the same pair of gloves. The housekeeper then entered another resident’s room, checked the trash can and exited the room still wearing the same pair of gloves. She then repeated this action again, entering another resident’s room with the same pair of gloves on worn in all 4 rooms.

On 9/20/2016, at 5:00 P.M. Surveyor #2 observed a resident on the Third Floor Unit to open the food delivery truck and pick a spoon, a cup and a piece of bread up from another resident’s tray and replace them. A CNA observed what the resident had done and redirected him/her into the dining room, closing the food delivery truck door behind her. Another CNA opened the food delivery truck, took the tray that had been contaminated by the resident and served the food and utensils on the tray to another resident in the dining room. On 9/20/2016, at 12:10 P.M. the Infection Control nurse said that it is our policy not to wear gloves in the hallway. She also said that wearing gloves in the hallway increased the risk of spreading infection.

On 9/20/2016, at 2:30 P.M. the Director of Nursing said the expectation is that staff do not wear gloves in the hallway and all gloves are to be removed before exiting the resident’s rooms.

Failed to 1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compensation.

Based on review of personnel files and staff interview, the facility failed to complete a Certified Nursing Assistant (CNA) Registry check in another state where 1 of 3 newly hired CNAs (CNA #2) previously lived or worked prior to hire, as required.

Findings include:

For one newly hired Certified Nurses Assistant (CNA #2), the facility failed to conduct an out of state Nurse Aide Registry Check. CNA#2 was hired on 5/23/16. Review of CNA #2’s personnel file indicated she worked as a CNA in Florida. Further review indicated that as of 9/19/16, a Nurse Aide Registry Check was not conducted in Florida. During an interview with the Human Resource Manager on 9/19/16 at 1:00 P.M., she said she was not aware that this out of state Nurse Aide Registry Check was not done prior to hire, as required.

Failure 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 record review and staff interview, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 sampled resident (Resident #2) in a total sample of 24.

Findings include:

For Resident #2, the facility failed to ensure that the 9/2016 physician’s orders and Treatment Records were accurate and complete.

Review of the resident’s clinical record on 9/14/16, indicated the resident was admitted to the facility in 10/2015, with [DIAGNOSES REDACTED].

a. The resident had a physician’s order dated 10/9/15, to invoke Health Care Proxy. The physician’s order did not appear on the monthly physician’s orders for 9 months (1/2016, 2/2016, 3/2016, 4/2016, 5/2016, 6/2016, 7/2016, 8/2016 and 9/2016). There was no documentation to indicate the the physician’s order had been discontinued. During an interview with Unit Manager (UM) #3 on 9/141:30 P.M., Um #3 said the physician’s order dated, 10/9/15, to invoke the Health Care Proxy had not been discontinued and should have appeared on the current physician’s orders.

b. Further record review indicated the resident had a physician’s order dated 2/12/16, for a velcro alarm seatbelt in wheelchair, check function and placement every shift, assess resident’s ability to self release velcro alarm seatbelt weekly. The physician’s order to assess the resident’s ability to self release velcro alarm seatbelt weekly appeared on the 2/2016 and 3/2016 Treatment Records, but did not appear on the Treatment Records for 4/2016, 6/2016, 7/2016, 8/2016 and 9/2016. The physician’s order had not been discontinued.

During an interview with Unit Manager (UM) #3 on 9/16/16 at 2:00 P.M., Unit Manager #3 said she was unaware that the 2/12/16 physician’s order did not appear on the 5 Treatment Records and the current Treatment Record were not accurate and complete.

Failed to keep clinical record information safe, so that it will not be lost, destroyed or used by the wrong person.

Based on record review, observation and staff interviews, the facility failed to safeguard resident medical record information, as evidenced by not securing the medical information in a manner that would prevent the information from loss, destruction and/or unauthorized use. 19 Residents (including 6 sampled Residents: #7, #8, #16, #17, #18 and #20) medication information as documented in the September 2016, Medication Administration Record [REDACTED]. As of 9/20/16, the MAR binder was not located.

Findings include:

On 9/15/16 at approximately 12:10 P.M., Surveyor #3 asked Nurse #2 why the September MAR indicated [REDACTED]. Nurse #2 said that over the weekend (9/11/16 to 9/12/16), the MAR indicated [REDACTED]. A search was conducted and the MAR indicated [REDACTED] The Administrator and Director of Nursing (DON) were interviewed on 9/15/16 at 1:23 P.M. The Administrator and DON were asked about the incident. The DON said that she was off on 9/12/16 and 9/13/16 and was just learning about the event. The DON said that the entire Third Floor Unit West Side three ring binder which contained the MARs for 19 residents on that side was missing sometime after the change of shift report at 11:00 P.M. on 9/11/16. According to review of a telephone interview obtained by the Unit Manager (UM#3) on 9/12/16 with the Nurse who reported the binder missing (Nurse#1), Nurse #1 said that he came upstairs to the Third Floor Unit to count out and relieve the 3:00 -11:00 P.M. staff because he was working a double that night. Nurse #1 worked an evening shift on the First Floor Unit on 9/11/16 and then was scheduled to work the night shift (11:00 P.M. – 7:00 A.M.) on the Third Floor Unit on 9/11/16 – 9/12/16. Review of documentation by UM#3 indicated that Nurse #1 said he went down to the First Floor Unit where he had worked the previous shift to finish his work. When Nurse #1 returned to the Third Floor Unit, he could not locate the West Side MAR Binder.

According to review of the statement written by Nurse #1 on 9/12/16, he said that he worked the 11:00 P.M. to 7:00 A.M. shift. Nurse #1 said that within the first 15 minutes of the beginning of the shift, he put all the books I needed to sign on the West Side on top of the nurse’s desk. I discovered that the West MAR indicated [REDACTED]. I did not find it. I searched the unit assisted by the Certified Nurse Assistants (CNAs). We did not find the MAR. I became concern (sic) and reported it to the 7-3 staff. Review of the written statement by UM#3 on 9/13/16, indicated that she arrived at the Facility on 9/12/16 at 11:00 A.M. UM#3 was informed that the MAR for the Third Floor Unit MAR indicated [REDACTED]. Review of further documentation indicated the Pharmacy Supplier was contacted for temporary MAR indicated [REDACTED].

Review of the Facility’s policy titled Breach Notification Requirements, Section on Definition of Breach indicated that a breach is an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of the protected health information.

As of 9/20/16, the facility had not located the missing the Third Floor Unit, West Side’s MAR Binder. According to the Administrator, the Facility determined that this was a violation of resident’s protected health information and the Facility will implement their policy for Breach Notification Requirements.

Hunt 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.


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Page Last Updated: October 3, 2017

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