Kathleen Daniel Nursing and Rehabilitation

Kathleen Daniel Nursing and Rehabilitation

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About Kathleen Daniel Nursing and Rehabilitation

Kathleen Daniel Nursing and Rehabilitation is a for profit, 124-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Ashland, Natick, Holliston, Southborough,  Wayland, Wellesley, Hopkinton, Sudbury, Marlborough, Weston, Medfield, Needham, Medway, Westborough, Westwood, and the other towns in and surrounding Middlesex County, Massachusetts.

Kathleen Daniel Nursing
485 Franklin St,
Framingham, MA 01702

Phone: (508) 872-8801
Website: http://www.kathleendaniel-health.com/

CMS Star Quality Rating

Kathleen Daniel Nursing and RehabilitationThe 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 July 2018, Kathleen Daniel Nursing and Rehabilitation in Framingham, Massachusetts received a rating of 2 out of 5 stars.

Performance Area Rating
Overall Rating 2 out of 5 (Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 2 out of 5 (Below Average)

Fines Against Kathleen Daniel Nursing and Rehabilitation

The Federal Government fined Kathleen Daniel Nursing and Rehabilitation $27,346 on 01/13/2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Kathleen Daniel Nursing and Rehabilitation  committed the following offenses:

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility staff failed to notify the physician and/or resident representative, relative to a change in medical condition, for 2 sampled residents ( #15 and #16), in a total of 20 sampled residents.

Findings include:

1. For Resident #16, the facility staff failed to notify the Guardian, when a prescribed medication was not administered, as ordered. Resident #16 was admitted to the facility in 10/2015, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/6/17, indicated that Resident #16 was rarely/never understood/understands, exhibited severe cognitive impairment, was totally dependent with Activities of Daily Living (ADLs), and had a Guardian in place. Review of the nurses notes, dated 4/11/17, indicated that the resident was observed by the nurse to have his/her Gastrointestinal tube ([DEVICE]), embedded in his/her abdomen, with a dressing that was saturated with thick yellow/green drainage, and his/her abdomen was red and hot. The Nurse Practioner (NP) was updated, and the [DEVICE] was removed, a temperature of 103.5 degrees Fahrenheit (F) was obtained, and the resident was sent to the emergency room for evaluation. Review of the Tufts Medical Center Fax form, dated 4/18/17 at 2:44 P.M., indicated that the resident was scheduled to be readmitted to the facility between 4:00 P.M. and 5:00 P.M.

Review of the Physician’s Telephone Orders, dated 4/18/17, indicated that the resident was readmitted to the facility on this date, with an order to administer Piperacil Tazobac ([MEDICATION NAME], an antibiotic) 3.375 gram/50 milliliter (ml), via PICC (peripherally inserted central catheter) line every 8 hours, infuse at 12.5 ml/hour (hr) over 4 hrs. Review of the Medication Administration Record [REDACTED]. Review of the Nurse’s notes, dated 4/19/17, indicated the re-admission orders [REDACTED]. The Nurse’s note further indicated that the PICC line was located in the resident’s lateral upper arm, was patent, and flushed without difficulty. The Nurse’s note indicated that the [MEDICATION NAME] was not available, and that the pharmacy was notified to send the medication. Further review of the Nurse’s notes, dated 4/19/17, indicated that the [MEDICATION NAME] was not administered as facility was awaiting X-ray results pending placement of the PICC line.

Review of the Fax Cover sheet, dated 4/19/17 at 11:33 A.M., indicated that the facility faxed the hospital requesting X-ray results to show PICC line placement. Review of the MAR, dated 4/2017, indicated that the resident received his/her first dose of [MEDICATION NAME], on 4/20/17 at 2:00 P.M. Review of the clinical record, did not indicate that the Guardian was updated regarding the [MEDICATION NAME] not being administered, as ordered. On 4/25/17 at 2:40 P.M., the surveyor observed Resident #16, seated in a Broda (a type of geriatric chair) chair in his/her room. The resident was dressed in a johnny, was wearing non-skid socks, and had a blanket covering him/her.

During an interview, on 4/25/17 at 3:45 P.M., the Director of Nurses (DON) said that the resident returned to the facility on [DATE] around 6:00 P.M. She further said that there was no nursing update received from the hospital upon readmission regarding proof of placement of the PICC line, and that the information was received from the hospital on [DATE]. The DON said there was information in the discharge paperwork from the hospital that indicated orders for IV (intravenous) medications, but that there was no verification of the PICC line included in the discharge paperwork. She said that the resident missed four doses of the scheduled [MEDICATION NAME], and the Guardian was not updated regarding the missed doses of the antibiotic.

2. For Resident #15, the facility staff failed to notify the Physician and the Guardian when a prescribed medication was not administered as ordered. Resident #15 was admitted to the facility in 7/2012, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, with an ARD of 3/10/17, indicated the resident exhibited intact cognitive function, had no mood/behaviors identified, received 7 days of antipsychotic medications, and had a Guardian in place, during the assessment period. Review of the MAR, dated 4/2017, indicated an order for [REDACTED]. Review of the nurses notes, dated 4/4/17, indicated that [MEDICATION NAME] 50 mg was unavailable.

Review of the nurses notes, dated 4/6/17, indicated that the [MEDICATION NAME] was administered at 11:50 P.M. On 4/25/17 at 9:35 A.M., the surveyor observed the resident lying in bed with his/her johnny on. The resident was wearing sunglasses and non-skid socks. During an interview, on 4/25/17 at 4:00 P.M., Unit Manager (UM) #2 said that [MEDICATION NAME] injections are kept in the refrigerator in the medication room, and that the agency nurse that was working on 4/4/17 did not know this and did not give the medication. She further said that there is no indication that the Physician or Guardian were updated about the medication not being administered as ordered.

Failed to keep each resident's personal and medical records private and confidential.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility staff failed to provide privacy during personal care for 1 sampled Resident, (#16) in a total of 20 sampled residents.

Findings include:

Resident #16 was admitted to the facility in 10/2015, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/6/17, indicated that Resident #16 was rarely/never understood/understands, exhibited severe cognitive impairment, was totally dependent with Activities of Daily Living (ADLs), and had a Guardian in place.

On 4/19/17, at approximately 9:00 A.M. during the initial tour with Nurse #1, the surveyor observed Resident #16 lying in bed, with Certified Nurse Aide (CNA) #1 present at the bedside. The surveyor observed that the bathroom door in front of the bed of Resident #16, was open. The privacy curtain was not drawn around Resident #16’s bed. The surveyor observed CNA #1 provide care to Resident #16, by taking off his/her johnny exposing his/her bare body and incontinence brief. The surveyor observed the roommate of Resident #16, exit the bathroom in his/her wheelchair, and propel him/herself to the other side of the room. The surveyor observed that CNA #1 and Nurse #1 did not close the privacy curtain around the bed of Resident #16, during this time.

During an interview, on 4/26/17 at 10:10 A.M., MDS Coordinator #1 said that staff will need to be educated on providing resident privacy.

Failed to provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility staff failed to provide a resident environment that promoted dignity and privacy for 1 sampled resident, (#9), in a total of 20 sampled residents.

Findings include:

Resident #9 was admitted to the facility in 11/2016, with [DIAGNOSES REDACTED]. Review of the Significant Change in Status MDS, with an ARD of 4/7/17, documented a Brief Interview of Mental Status (BIMS) score of 2 out of 15 (severe cognitive impairment) Review of Section K of the Significant Change in Status MDS, indicated that the resident had a feeding tube and received 51% or more of portion of total calories through the tube feeding.

During an observation, on 4/20/17 at 9:00 A.M., the resident was in his/her room. The resident was lying in bed and his/her feeding tube and dressing around the feeding tube was exposed, and in full view. There was no privacy curtain drawn around the bed. The top sheet cover was placed on the resident, below the feeding tube and dressing. During an observation, on 4/20/17 at 2:00 P.M., the resident was sitting in a Broda (a type of geriatric chair) chair, in his/her room and the resident’s feeding tube and dressing around the tube was exposed, and within full view. During an observation, on 4/20/17 at 2:20 P.M., the resident was in his/her room, sitting in a Broda chair, and his/her feeding tube and dressing around the tube was exposed, and within full view.

During an interview, on 4/20/17 at 2:25 P.M., the Nursing Supervisor said that the feeding tube and dressing around the feeding tube should not be exposed and within full view. She covered the feeding tube and dressing with the resident’s shirt.

Failed to provide housekeeping and maintenance services.

Based on observation,environmental tours and staff interview the facility staff failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, homelike and comfortable interior on 3 of 3 resident units.

Findings include:

Environmental tours on 4/25/17 at 10:30 A.M., 2:25 P.M. and 3:00 P.M. with the Maintenance Director the following observations were made: unit #1-

– Windows in resident rooms, 117, 118, 119 and the day/sitting room had a white film producing a cloudy/unclear view through window

-Room 103 resident bathroom sink had rust spots by the drain, missing faucet plate and the base of the faucet was tarnished/corroded and white in color unit #2-

– Windows in resident rooms, 201, 202, 206, 211, 216, 217 and 218 had a white film producing a cloudy/unclear view through window

-Faucet plates were missing in resident bathrooms, 204, 205 and 208

-The base of the faucets were tarnished/corroded and white in color in resident’s bathrooms 204 and 208

-Resident bathroom room 205 had areas of chipped paint on the heater, door and door frame

-Resident room 210 had areas of chipped paint around the heater

-Resident room 219 had scuff marks on the bottom of the door and area of chipped paint on the door frame

unit #3-

-Windows in resident rooms, 301, 302, 304, 311, 316, 317, 318 319 320, the day/sitting room and the resident library room had a white film producing a cloudy/unclear view through window

-The base of the faucets were tarnished/corroded and white in color in resident’s bathrooms 304, 314 and 317

-Faucet plates were missing in resident bathrooms, 310, 315 and 317 -Resident room 311 had scuff marks on the window wall and the door frame had areas of chipped paint

-Resident room 315 had a metal box loosely secured to the lower wall with sharp edges

-Resident room 310 had areas of chipped paint around the heater and there was a round hole at the bottom of the bathroom door approximately 2 inches in circumference

-Resident room 317 had areas of chipped paint on the window wall and bathroom heater

During interview, on 4/25/1 at 2:45 P.M. and 3:30 P.M., the facility Maintenance Director said it was difficult to clearly see outside due to the white film. He further said that the areas of concern needed to be addressed.

Failed to review or revise the resident's care plan after any major change in a resident's physical or mental health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, the facility staff failed to complete Significant Change Minimum Data Set (MDS) Assessments for 2 sampled Residents (#4 and #7), out of 20 sampled residents.

Findings include:

1. For Resident #4, the facility failed to complete a Significant Change MDS when the resident declined in multiple areas of Activities of Daily Living (ADL) and mobility. Resident #4 was admitted to the facility 11/2016, hospitalized for [REDACTED]. Review of the Admission MDS assessment dated [DATE] indicated the resident was independent with ADLs and mobility. Review of the Quarterly MDS Assessment, dated 2/14/17, indicated the resident had declined from independent to extensive assist in the following mobility and ADL areas: transfers, bed mobility, toileting, bathing, hygiene and dressing. During an interview, on 4/20/17 at 3:20 P.M., with the MDS Coordinator #2, she said that the resident had triggered for a Significant Change MDS and it had not been completed.

2. For Resident #7, the facility staff failed to complete a Significant Change in Status Assessment, when the resident displayed a decline in bed mobility. transfer status, ambulation, Activity of Daily Living (ADLs) and continence status. Resident #7 was admitted to the facility in 2/2015, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, with an Assessment Reference Date (ARD) of 5/14/16, indicated the resident required supervision for bed mobility and transfers, was independent for ambulation, and required extensive assistance of 1 staff for ADLs. The MDS further indicated that the resident was occasionally incontinent of bladder, and was always continent of bowel.

Review of the Quarterly MDS Assessment, with an ARD of 8/5/16, indicated that the resident now required extensive assistance of 2 staff for bed mobility and transfers, was not ambulatory, required extensive assistance of 1 to 2 staff for ADLs, and was always incontinent of bladder and bowel. On 4/20/17 at 1:50 P.M., the surveyor observed Resident #7 seated in a wheelchair in his/her room. The resident had a wheelchair cushion and anti-tippers in place, was dressed and had on shoes. During an interview, on 4/25/17 at 1:30 P.M., MDS Coordinator #1 said that a Significant Change in Status MDS should have been completed in August.

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 observations, interviews and record reviews, the facility staff failed to provide accurate coding on the Minimum Data Set (MDS) Assessments for 3 sampled residents (#2, #5, and #7), in a total of 20 sampled residents.

Findings include:

1. For Resident #2, the facility staff failed to accurately code the resident’s code status on the Quarterly MDS Assessment. Resident #2 was admitted to the facility in 8/2016, with [DIAGNOSES REDACTED]. Review of the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), dated 9/9/16, indicated the resident was a Do Not Resuscitate (DNR), Do Not Intubate and Ventilate (DNI), and transfer to the hospital.

Review of the Care Plan Conference Summary, dated 10/3/16, indicated the resident was a DNR/DNI status. Review of the Quarterly MDS Assessment, with an Assessment Reference Date (ARD) of 2/17/17, indicated that the resident was a Full Code status. On 4/19/17 at 2:00 P.M., the surveyor observed Resident #2 seated in a high back chair near the nurses station. The resident was dressed, had on shoes, and had a wheelchair cushion in place.

During an interview, on 4/20/17 at 2:50 P.M., MDS Coordinator #1 said that the MDS for 2/17/17 was mis-coded regarding the resident’s code status, and a modification would be completed to correct the error.

2. For Resident #5, the facility staff failed to accurately code that IV (intravenous) fluids were administered during the assessment period.

Resident #5 was admitted to the facility in 11/2015, with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED].

Review of the Nurse’s notes, dated 3/17/17 at 12:14 A.M., indicated that the resident was receiving normal saline at 77 cubic centimeters (cc)/hour (hr). Review of the Admission MDS Assessment, with an ARD of 3/17/17, indicated under Section K (Swallowing/Nutritional Status), that the resident was not receiving Parental/IV feeding during the assessment period.

On 4/20/17 at 3:45 P.M., the surveyor observed Resident #5 seated in a wheel chair in his/her room. The resident had bilateral leg rests on and was wearing bilateral foot booties. During an interview, on 4/25/17 at 1:45 P.M., MDS Coordinator #1 said that she spoke with the Dietitian about mis-coding the IV fluids under Section K. MDS Coordinator #1 said that a modification would be completed to reflect the IV fluids given to the resident during the assessment period.

3. For Resident #7, the facility staff failed to accurately code that a significant weight loss had occurred during the assessment period. Resident #7 was admitted to the facility in 2/2015, with [DIAGNOSES REDACTED]. Review of the Nutritional Review, dated 5/17/16, indicated that Resident #7 was 283.6 pounds (lbs). Review of the Quarterly MDS Assessment, with an ARD of 5/14/16, indicated under Section K (Swallowing/Nutritional Status), that the resident weighed 284 lbs, and did not experience significant weight changes (gain/loss) of 5% or more during the last month, or 10% or more during the last 6 months. Review of the Nutritional Review, dated 11/4/16, indicated that Resident #7 weight was 255 lbs.

Review of the Annual MDS Assessment, with an ARD of 11/4/16, indicated under Section K, that the resident weight was 255 lbs, and did not experience significant weight changes (gain/loss) of 5% or more during the last month, or 10% or more during the last 6 months. On 4/25/16 at 9:35 A.M., the surveyor observed Resident #7 seated in a wheelchair in his/her room. The resident was dressed and was listening to news on his/her radio. During an interview, on 4/25/17 at 2:00 P.M., MDS Coordinator #1 said that the resident should have been coded for a significant weight loss in the 11/4/16 MDS Assessment, and that a modification would be completed.

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, observation and interview, the facility staff failed to initiate a comprehensive person-centered care plan for Activities of Daily Living (ADL) for one sampled resident (#17), out of a total of 20 sampled residents.

Findings include:

Resident #17 was admitted to the facility in 2/2017, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 3/6/17, indicated the resident was severely impaired for cognitive skills for daily decision making. Further review of the MDS, indicated that the resident required extensive assist for transfers, dressing, eating, personal hygiene and bathing. During an observation, on 4/25/17 at 10:30 A.M., the resident was sitting in a wheelchair, in the unit Day Room, next to an Activity Aide, as a program was being held. The resident was non-verbal and unable to answer any questions when asked by the surveyor. Review of the medical record indicated there was no ADL Care Plan put in place for this resident. During an interview, on 4/25/17 at 10:45 A.M., the Assistant Director of Nurses (ADON) said there was no ADL Care Plan in place for the resident.

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 observations, interviews and record reviews, the facility staff failed to provide services in accordance with nursing standards of practice, related to the administration of injectable medications, for 4 sampled residents (#5, #11, #14 and #17), in a total of 20 sampled residents.

Findings include:

a. Review of the Nursing (YEAR) Drug Handbook, indicated the following for Insulin (an anti-diabetic medication used to treat Diabetes Mellitus) administration: Give injection in the abdominal region, buttocks, thigh or upper arm. Rotate injections within the same region to reduce risk of [DIAGNOSES REDACTED] (condition characterized by abnormal or [MEDICAL CONDITION] conditions of the body’s fatty tissue). A general rule is to not administer within 1 inch (2.5 centimeters) of the same site for 1 month.

b. Review of the Nursing (YEAR) Drug Handbook, indicated the following for [MEDICATION NAME] (an anticoagulation medication used to prevent blood clots) administration: give low-dose injections sequentially between iliac crests in the lower abdomen, deep into the subcutaneous fat. Inject drug subcutaneously slowly into the fat pad. Alternate sites every 12 hours, and record the location of the injection.

c. Review of the facility’s policy entitled: Medication Administration General Guidelines, dated 12/12, indicated that medications are administered as prescribed in accordance with manufacturers’ specifications, good nursing principles and practices.

d. Review of the facility’s policy entitled: Medication Administration Subcutaneous Insulin, dated 9/10, indicated to check the last site of injection, select a new appropriate site for injection, and document the injection on the MAR (Medication Administration Record), along with the injection site.

1. For Resident #5, the facility staff failed to rotate the injection sites for insulin administration. Resident #5 was readmitted to the facility in 3/2017, with [DIAGNOSES REDACTED]. Review of the physician’s orders [REDACTED].

if (blood sugar reading)
201-250 = 2 units
251-300 =4 units
301-350 =6 units
350-400 =8 units
401 or greater = call Nurse

Practitioner for further orders Review of the Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 3/17/17, indicated that the resident had an active [DIAGNOSES REDACTED]. Review of the physician’s orders [REDACTED].

Review of the MAR, dated 3/2017, indicated that the Humalog Insulin was administered a total of 49 times, and for 8 injections, the injection sites were not rotated. Further review of the MAR, indicated that the Insulin [MEDICATION NAME] 100 units/ml, was administered 43 times, and for 22 injections, the injection sites were not rotated. On 4/21/17 at 8:05 A.M., the surveyor observed Resident #5 seated in a wheelchair in his/her room.

The resident had a blanket on his/her lap and bilateral legs rests were applied to the wheelchair. During an interview, on 4/26/17 at 10:30 A.M., MDS Coordinator #1 said that insulin injection sites should be rotated with each administration. She said that the injections sites documented for Resident #5 did not indicate that the rotation of sites was occurring with each injection administered.

2. For Resident #14, the facility staff failed to rotate the injection sites for Insulin administration. Resident #14 was admitted to the facility in 5/2014, with a multiple [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, with an ARD of 4/21/17, indicated that the resident had a [DIAGNOSES REDACTED]. Review of the MAR, dated 4/2017, indicated orders for: -[MEDICATION NAME] (long acting Insulin) 100 unit/ml, inject 45 units subcutaneously at bedtime,

-Humalog Mix 75/25 Suspension (a combination of intermediate and rapid acting Insulin) 100 units/ml, inject 18 units subcutaneously before meals, -Humalog Solution 100 units/ml, inject as per sliding scale before meals:

if (blood sugar)
201-250 = 2 units
251-300 = 4 units
301-350 = 6 units
351-400 = 8 units
401-450 = 10 units
If blood sugar is 200 or below = no coverage
If blood sugar is greater than 451, give 12 units and notify the physician/nurse practitioner

Further review of the MAR, dated 4/2017, indicated that [MEDICATION NAME] 100 units/ml, was administered a total of 24 times, and for 7 injections of the medication, the injection sites were not rotated. Review of the MAR, dated 4/2017, indicated that Humalog Mix 75/25 Suspension 100 units/ml, was administered for a total of 76 times, and for 29 injections of the medication, the injections sites were not rotated. Further review of the MAR, dated 4/2017, indicated that Humalog Solution 100 units/ml, was administered a total of 54 times, and for 15 injections of the medication, the injections sites were not rotated. On 4/25/17 at 11:00 A.M., the surveyor observed Resident #14, seated in a wheelchair, in the day room area. The resident was wearing glasses and had a book in his/her hand. During an interview, on 4/26/17 at 10:40 A.M., MDS Coordinator #1 said that the Insulin injection sites were not rotated.

3. For Resident #11, the facility staff failed to rotate injection sites during the administration of [MEDICATION NAME] N and [MEDICATION NAME] Insulins and [MEDICATION NAME]. Resident #11 was initially admitted to the facility in 2/2017, with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, with an ARD of 3/1/17, indicated that the resident had an active [DIAGNOSES REDACTED]. During an observation, on 4/19/17 at 8:00 A.M., the resident was sitting in his/her wheelchair, in his/her room. The resident was alert and conversant with the surveyor.

a. Review of the Medication Review Report, dated (MONTH) 1, (YEAR), indicated an order for [REDACTED]. Review of the Location of Administration Report, dated (MONTH) 24, (YEAR), indicated the [MEDICATION NAME] N Insulin was administered 31 times in April, and on 17 occasions, the insulin injection sites were not rotated.

b. Review of the Medication Review Report, dated (MONTH) 1, (YEAR), indicated an order for [REDACTED]. Review of the Location of Administration Report, dated (MONTH) 24, (YEAR), indicated the [MEDICATION NAME] Insulin was administered 47 times in April, and on 31 occasions, the insulin injection sites were not rotated.

c. Review of the Medication Review Report, dated (MONTH) 1, (YEAR), indicated an order for [REDACTED].

Review of the Location of Administration Report, dated (MONTH) 24, (YEAR), indicated that the [MEDICATION NAME] Sodium was administered 44 times in April, and on 13 occasions, the [MEDICATION NAME] injection sites were not rotated. During an interview, on 4/25/17 at 1:40 P.M., Unit Manager (UM) #2 said the injection sites for the administration of [MEDICATION NAME] N and [MEDICATION NAME] Insulins, and [MEDICATION NAME] Sodium, were not always rotated.

4. For Resident #17, the facility staff failed to rotate injection sites during the administration of [MEDICATION NAME] Sodium. Resident #17 was initially admitted to the facility in 2/2017, with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, with an ARD of 3/6/17, indicated that the resident received anticoagulant injections for 7 days during the assessment period. Review of the MAR, dated (MONTH) (YEAR), indicated an order for [REDACTED]. Review of the Location of Administration Report, dated (MONTH) 25, (YEAR), indicated that the [MEDICATION NAME] Sodium was administered 48 times in April, and on 13 occasions, the [MEDICATION NAME] injection sites were not rotated. During an observation, on 4/25/17 at 10:30 A.M., the resident was sitting in a wheelchair, next to an Activity Aide, as a program was being held in the unit day room. The resident was non-verbal and was neatly dressed. During an interview, on 4/26/17 at 10:30 A.M., the Assistant Director of Nurses (ADON) said the injection sites for the administration of [MEDICATION NAME] Sodium, were not always rotated.

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 observations, interviews and record review, the facility staff failed to ensure that 1 sampled Resident (#3) receive appropriate care and services relative to pain management, in a total of 20 sampled residents.

Findings include:

Resident #3, was admitted to the facility in 8/2016, with [DIAGNOSES REDACTED]. Review of the Occupational Therapy (OT) Plan of Care, dated 1/19/17, indicated that the resident was readmitted to the facility from the hospital, and was referred to OT to address a decline in independence with activity of daily living (ADL) care due to muscle weakness. Further review of the OT notes, indicated that the resident declined participation in OT services secondary to ongoing 10 out of 10 pain in his/her left hip and bilateral lower extremities.

Review of the Nurse’s Notes, dated 2/1/17, indicated that the resident was out to the pain clinic, and that the pain clinic was waiting for the resident’s medical record. Review of the Quarterly MDS Assessment, with an ARD of 2/10/17, indicated that Resident #3 had a BIMS score of 15 out of 15 (indicating cognitively intact), received scheduled and as needed (PRN) pain medication, and frequently experienced pain that was 6 out 10 intensity, during the assessment period.

Review of the medical record, indicated that there was no documentation in the chart from the pain clinic regarding the appointment held on 2/1/17. During an interview, on 4/20/17 at 8:30 A.M., Resident #3 said that pain keeps him/her awake at night. During an interview, on 4/21/17 at 12:15 P.M., Certified Nurse Aide (CNA) #4 said that Resident #3 is repositioned onto his/her back when incontinent care is being done, other than that, the resident remains on his/her stomach. CNA #4 further said that the resident is not scheduled to be out of bed at certain times, but she does ask Resident #3 if he/she would like to get out of bed when she works. CNA #4 said that the resident had mentioned to her previously that he/she does not want to get out of bed because it takes too long to have staff hoyer him/her back to bed when he/she is uncomfortable.

During an interview, on 4/21/17 at 12:25 P.M., Unit Manager (UM) #1 said that there was a progress note entered on the day of the appointment, but there was no information from the appointment on 2/1/17, in the resident’s record.

During a follow up interview, on 4/25/17 at 9:45 A.M., UM #1 said that after surveyor inquiry the consultation note from the pain clinic visit of 2/1/17, was faxed over to the facility on [DATE], and it was now in the resident’s clinical record. She further said that an appointment was made at the pain clinic for a follow up, and that the resident had agreed to be re-evaluated.

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 observations, interviews and record reviews the facility staff failed to effectively implement interventions to prevent accidents and falls for 3 sampled residents (#8, #9 and #11) in a total sample of 20 residents.

Findings include:

1. For Resident #8, the facility staff failed to transfer the resident safely from the bed to the chair using a hoyer lift (mechanical lift). Resident #8 was admitted to the facility 6/8/16, with multiple [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set Assessment, dated 3/19/17, indicated the resident was totally dependent for bed mobility and transfers. Section C coded the resident’s cognitive patterns Brief Interview for Mental Status (BIMS) score to be 15 out of 15, which indicates the resident is cognitively intact. Review of the facility incident report, dated 3/30/17, indicated the resident was getting out of bed with a Hoyer lift, and upon finishing the transfer, the Resident’s foot was noted to be bleeding. The report described the assessment of the left foot as appearing to be scraped by the Hoyer,and that there was an overlapping flap of skin on the top of the knuckles of the second, third and fourth digits of the Resident’s left foot. The report further included the Resident’s description of the incident as that must have been from the lift.

On 4/21/17 at 9:20 A.M., the surveyor, the facility Wound Doctor and Wound Nurse, observed Resident #8’s second, third and fourth toes of the left foot. The toes were each wrapped with a Band-Aid, the Wound Nurse removed the Band-Aid, and on the top of each of the three toes, there was a black/scabbed area approximately 1 centimeter (cm) in length. During an interview with Unit Manager #1, on 4/21/17 at 10:25 A.M., she said that there is to be two people when using the Hoyer lift to transfer a resident. She further said that one person is to operate the lift, while the other is to guide the resident into the chair. Unit Manager #1 said that f the resident is not positioned with legs on one or on the other side of the Hoyer lift, the feet would hit the pole on the Hoyer. She further said that someone is supposed to be guiding the resident’s feet to ensure that the feet do not hit the Hoyer during the transfer. Unit Manager #1 said that staff education was completed because although there were two people completing the transfer with Resident #8 on 3/30/17, the resident’s feet were not being guided and they should have been.

2. For Resident #9, the facility staff failed to ensure that bed /chair alarms were in place and functioning properly as care planned. The resident experienced two falls with no injury, and one fall resulting with a laceration to the head. Resident #9 was admitted to the facility in 11/2016, with [DIAGNOSES REDACTED]. Review of the Falls/Fall Risk Care Plan, dated 2/1/17, indicated to apply bed and chair alarms at all times, and to check every shift for function and placement. Review of the Fall Risk Evaluation, dated 2/27/17, indicated that the resident was at risk for falls, and had a score of 15 (total score of 10 or above deems resident at risk). Review of the Significant Change in Status MDS Assessment, with an Assessment Reference Date (ARD) of 4/7/17, indicated that the resident had a BIMS score of 2 out of 15 (severe cognitive impairment). The MDS further indicated that the resident was dependent for transfers, dressing, eating, bathing and personal hygiene. In addition, the resident had impairment in upper and lower extremities on one side. The MDS Assessment also indicated in Section J1900, that the resident had experienced two or more falls since the prior assessment. During an observation, on 4/20/17 at 9:00 A.M., the resident was lying in bed. Seizure pads were noted on the upper side rails. A bed alarm was attached to the bed. During an observation, on 4/20/17 at 2:00 P.M., the resident was sitting in a Broda (a type of geriatric chair). An alarm was attached to the Broda chair.

a. Review of the Risk Management Form, dated 3/20/17, indicated that the resident sustained [REDACTED].M The resident was transferring him/herself from the bed to the wheelchair. No injuries were observed at the time of the fall. There was no indication on this form, if a functioning bed alarm was in place at the time of the fall. The Nurse Tech Information Kardex, undated, indicated that the resident utilized a bed and chair alarm. During an interview, on 4/20/17 at 12:45 P.M., the Assistant Director of Nurses (ADON) said there was no documentation to indicate an alarm was in place or sounding during the fall, as care planned.

b. Review of the Risk Management Form, dated 3/24/17, indicated that the resident sustained [REDACTED].M The resident was found lying on his/her back, on the floor between the two beds. No injuries were observed at the time of the fall. Further review of the Risk Management Form, indicated that the alarm was in place, but did not sound during the fall. The batteries were changed, and the alarm was tested after the fall, to ensure it was functioning properly. During an interview, on 4/20/17 at 12:45 P.M., the ADON said there was no process in place to ensure checking function and placement of alarms. She said she put a process in place in (3/2017), where all residents’ bed/chair alarms would have batteries replaced on the 15th of every month. She said this process would be listed on the resident’s monthly Treatment Administration Record (TAR).

c. Review of the Risk Management Form, dated 4/17/17, indicated that the resident had an unwitnessed fall at 3:15 P.M., in the unit dining room. The resident was found laying on the floor in between his/her wheelchair and the dining room table. The resident sustained [REDACTED]. The laceration measured approximately 4.2 cm (centimeters) in length. The wound edges were approximated and 7 steri-strips were placed on the wound site. Further review of the Risk Management Form, did not indicate an alarm had sounded to alert staff of the fall. During an interview, on 4/20/17 at 12:45 PM., the ADON said there was no documentation to indicate an alarm had sounded to alert staff of the fall, as care planned.

3. For Resident # 11, the facility staff failed to implement new interventions after he/she sustained 3 falls. Review of the facility Falls Management Policy, dated 3/20/16, indicated that the interdisciplinary team adjust/add interventions on the Plan of Care-Fall Risk Reduction, after each fall. Resident #11 was initially admitted to the facility in 9/2016, with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, with an ARD of 3/12/17, indicated a BIMS score of 14 out of 15 (cognitively intact). Further review of the MDS Assessment, indicated that the resident had an upper and lower extremity impairment on one side.

a. Review of the Occurrence Report Form, dated 10/7/16, indicated that the resident sustained [REDACTED].M There was no injury documented with this fall. Further review of the Occurrence Report Form, did not indicate any new interventions were put in place after the fall. During an interview, on 4/25/17 at 1:40 P.M., Unit Manager (UM) #2 said there was no intervention put in place, after the fall.

b. Review of the Risk Management Form, dated 3/3/17, indicated that the resident sustained [REDACTED].M The resident was found on the floor, next to his/her bed. The resident sustained [REDACTED]. Due to the resident’s erratic behavior, the resident was sent out to the hospital and returned to the facility on [DATE]. There was no documented post fall interventions noted after this fall. During an interview, on 4/25/17 at 1:40 P.M., UM #2 said if there were any new interventions, they would have been documented on the At Risk for Fall Care Plan.

c. Review of the Risk Management Form, dated 3/17/17, indicated that the resident sustained [REDACTED].M

The resident stated to staff, that he/she was trying to get into the wheelchair by him/herself, and lost his/her balance and fell . The resident complained of back pain and an x-ray was ordered. The resident was medicated for complaints of pain. Further review of the Occurrence Report Form, did not indicate that any intervention was put in place, after the fall. During an interview, on 4/25/17 at 1:40 P.M., UM #2 said that if there were any interventions put in place, they would be documented on the At Risk For Fall Care Plan. Review of the At Risk For Falls/Injury Care Plan, did not indicate any new interventions since the Care Plan was initiated on (2/24/17).

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, facility policies and staff interview, the facility failed to provide proper care and treatment for [REDACTED].#8) from a total sample of 20 Residents.

Findings include:

Review of the facility Infusion Therapy policy for IV Site Care and Maintenance Dressing Change for Vascular Access Devices, dated 10/11, included the following: -Transparent membrane dressings are changed every 7 days and as needed (PRN)

-Assess the site for [DIAGNOSES REDACTED], induration, swelling, drainage sutures and external length of catheter. Resident #8 was admitted to the facility 6/8/16, with multiple [DIAGNOSES REDACTED].

Review of the current 4/2017 Physician orders, indicated the resident was to receive [MEDICATION NAME] (antibiotic)1 gram (GM) intravenously (IV) every 12 hours, for osteo[DIAGNOSES REDACTED], and [MEDICATION NAME] (antibiotic) 3.375 GM IV every 6 hours for osteo[DIAGNOSES REDACTED]. The Physician orders indicated the following:

-change the IV dressing every 7 days and as needed (PRN)
-change the injection cap every 7 days and after each blood draw
-change IV administration set every 24 hours
-document the IV site appearance every shift (QS)

The Physician orders did not indicate the type of IV that was in place. Review of the Peripherally Inserted Central Catheter (PICC) insertion flow sheet, dated 3/24/17, indicated a PICC line had been inserted; gauge 44 french (F), length (internal) 44 cm (centimeters), external 0 and arm circumference 34 cm.

Review of the (MONTH) Medication Administration Record [REDACTED]. The entry was documented every shift from 4/1/17 through 4/25/17 with the nurses initials and a checkmark. Further review of the MAR, indicated that the appearance key was not utilized and no further documentation of the QS description of the IV site was found. During an observation of Resident #8, on 4/26/17 at 8:10 A.M., the resident was in bed, and the IV catheter was observed in his/her right upper arm, and was covered with a transparent dressing.

Further record review, indicated no documentation that the external IV catheter length had been measured since 3/24/17, at the time of insertion. During an interview with Unit Manager #1, on 4/26/17 at 7:50 A.M., she said that she had changed the IV dressing earlier, and that the resident had a single lumen PICC line in his/her right upper arm. She further said that no external catheter length measurement or arm circumference had been completed with the dressing change. A review of the nurses notes and MAR indicated [REDACTED]. During an interview with the DON and ADON, on 4/26/17 at 12:35 P.M., they said that the expectation is that nurses document what the IV site looks like, arm circumference and length of external catheter. They further said that the nurses should be documenting with each dressing change.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility staff failed to ensure that residents did not receive unnecessary doses of medication, for 2 sampled residents (#2 and #5), in a total of 20 sampled residents.

Findings include:

1. For Resident #2, the facility staff failed to ensure that [MEDICATION NAME] (an anticoagulant medication used to thin the blood), was not administered after the Physician discontinued the medication. Resident #2 was admitted to the facility in 8/2016, with [DIAGNOSES REDACTED]. Review of the Physician’s Telephone Order, dated 11/3/16 at 7:00 A.M., indicated an order to discontinue [MEDICATION NAME]. Review of the MAR, dated 11/2016, indicated that [MEDICATION NAME] 5000 units, was administered on 11/3/16 at 9:00 A.M., on 11/4/16 at 5:00 P.M., and on 11/5/16 at 9:00 A.M.

On 4/21/17 at 9:55 A.M., the surveyor observed Resident #2 seated in a high back wheelchair, near the nurses station. The resident was dressed and had on shoes. During an interview, on 4/21/17 at 2:45 P.M., the Assistant Director of Nurses (ADON) said that the [MEDICATION NAME] should not have been given on 11/4/16 and 11/5/16.

2. For Resident #5, the facility staff failed to ensure that [MEDICATION NAME] (an iron supplement) was administered as ordered by the Physician. Resident #5 was readmitted to the facility in 3/2017, with [DIAGNOSES REDACTED]. Review of the Physician’s Telephone Orders, dated 3/13/17, indicated an order for [REDACTED]. Review of the Medication Administration Record [REDACTED].M., the entry was initialed as administered 3/14/17 through 3/31/17. Review of the Physician’s Telephone Orders, dated 3/30/17, indicated an order for [REDACTED].>Review of the MAR, dated 3/2017, indicated an entry for the resident to receive [MEDICATION NAME] Tablet 325 mg by mouth once daily at 8:00 A.M. with breakfast, the entry was initialed as administered on 3/31/17. Review of the Physicians Orders, dated 4/2017, indicated two separate active orders for [MEDICATION NAME] Tablet 325 mg one time a day for [MEDICAL CONDITION]. Review of the MAR, dated 4/2017, indicated two different entries for the resident to receive [MEDICATION NAME] Tablet 325 mg by mouth once daily one entry was for 8:00 A.M. and the second entry was for 9:00 A.M., both of the entries were signed as administered daily from 4/1/17 through 4/21/17.

On 4/21/17 at 8:05 A.M., the surveyor observed Resident #5 seated in a wheel chair in the doorway to his/her room. The resident had bilateral leg rests in place, and had a blanket on his/her lap. During an interview, on 4/21/17 at 9:42 A.M., Nurse #2 said that Resident #5 receives iron supplementation once in the morning. Upon reviewing the MAR indicated [REDACTED]. Nurse #2 said that when she works, she only administers one dose of the medication, even though there is an order for [REDACTED].#2 was observed to contact the Nurse Practitioner (NP) at this time, and informed the surveyor that the one of the orders for iron was discontinued by the NP.

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 observations, record review and and staff interview, the Facility failed to ensure that its Medication Error Rate was not 5 % or greater as required. The medication pass observations were conducted on 4/19/17 and 4/20/17, and included observations of three nurses on three resident units. Two medication errors were observed for one non-sampled (NS) resident (NS #1), out of 28 medication opportunities, resulting in a 7.1% medication error rate.

Findings include:

During the morning medication pass observation, on 4/20/17 at 8:40 A.M., Nurse #5 was observed to prepare and administer multiple medications to NS #1. Upon reconciliation of the medications observed and administered, and the Physician orders, the following two errors were identified:

-Nurse # 5 administered the medication [MEDICATION NAME] 20 milligrams (mg) in error as it was scheduled to be administered at 8:00 P.M.
-Nurse #5 did not administer the medication [MEDICATION NAME] 20mg, which was scheduled to be administered at 9:00 A.M.

During an interview with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON), on 4/20/17 at 4:45 P.M., the DON said the Physician would be notified of the above information.

Failed to provide or obtain dental services for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure routine dental care for 1 sampled resident (#15), in a total of 20 sampled residents.

Findings include:

Resident #15 was admitted to the facility in 1/2007, with [DIAGNOSES REDACTED]. Review of the Authorization Form for Ancillary Medical Services, dated and signed by the resident’s Guardian on 7/6/12, indicated that the resident wanted to receive dental care. Review of the Dental Notes, dated 8/13/15, indicated that the resident refused care secondary to not feeling well.

Review of the Dental Notes, dated 9/28/15, indicated that the resident refused care secondary to not feeling well, and that the resident was on his/her way to the hospital. There were no further Dental Notes in the medical record. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 3/10/17, indicated that the resident had intact cognitive function and had [DIAGNOSES REDACTED].

On 4/25/17 at 9:35 A.M., the surveyor observed Resident #15 lying in bed with a johnny on. The resident was wearing sunglasses, had non-skid socks in place, and was observed to have numerous missing teeth. During an interview, on 4/26/17 at 11:30 A.M., Unit Manager (UM) #2 said that consents for ancillary services are obtained on admission or/and when changes occur with the resident. UM #2 further said that Resident #15 has not been evaluated by dental services since (YEAR) and she should have been.

Failed to safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed to ensure medications were available for 1 sampled Resident (#8) and 1 non-sampled (NS) Resident (NS #2) resident, in a total of 20 sampled residents and 3 Non-Sampled Residents.

Findings include:

1. For Resident #8, the facility failed to have the medication Vancomycin (antibiotic) for the treatment of [REDACTED]. Review of the 4/2017 Medication Administration Record [REDACTED]. Further review of the MAR, indicated that on 4/12/17, the 9:00 P.M. dose was initialed and noted as not available.

Review of a Nurse’s note, dated 4/12/17 at 10:22 P.M., indicated that there was no Vancomycin available, and that a Physician was notified, the pharmacy was aware, and would send the medication STAT(right away). During interview with Unit Manager #1, on 4/21/17 at 10:55 A.M., she said the resident’s Vancomycin dose due on 4/12/17 at 9:00 P.M. was not available for administration. The Physician was notified and a one time order was obtained to administer the Vancomycin dose to the resident when it arrived from the pharmacy. The resident received the Vancomycin at 1:24 A.M. on 4/13/17 when it was delivered by the pharmacy.

2. During observation of NS #2 ,during the morning medication pass on 4/20/17 at 9:20 A.M., Nurse #1 was observed to prepare and administer multiple medications to the resident. The resident was to receive the medication Torsemide (diuretic) 100 milligrams, and the medication was not available to administer to the resident, as required. During an interview with Nurse #1 on 4/20/17 at 11:00 A.M., she said the medication Torsemide was not available to administer to the resident. She further said that the pharmacy and the Physician were notified about the unavailability of the resident’s medication. Review of a Nurse’s note, dated 4/20/17 at 11:36 P.M., indicated the 9:00 A.M. dose of Torsemide was not available to administer to the resident. The pharmacy was called to deliver the medication. The Physician was notified and gave an order to hold the morning dose of the medication once, and to monitor the resident.

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

Based on observation 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 2 medication rooms.

Findings include:

During an inspection of medication storage in the second floor medication room, with Unit Manager (UM) # 2 on 4/20/17 at 9:50 A.M., indicated the following expired medications: [REDACTED]

-1 opened bottle of multivitamins that had an expiration date of 8/2016 -2 bottles of Ferrous Gluconate that had an expiration date of 11/2016 During interview with UM #2 on 4/20/17 at 9:50 A.M., she said that the above medications had expired and should not be in the stock medications.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, and staff interviews, the facility staff failed to follow proper infection control practices to prevent infections when completing a dressing change and treatment provision, for 1 sampled resident (#1), out of a total sample of 20 residents.

Findings include:

Resident #1 was admitted to the facility 8/2016, with multiple [DIAGNOSES REDACTED]. Review of the facility policy titled Non-Sterile Dressing Change, dated 8/16, included the following:

-Prepare a clean, dry work area at bedside. Use disinfectant solution to prepare work surface.
-Place trash bag at the end of the bed or within easy reach of working area
-wash hands apply gloves -prepare/open dressing items on table.
-Remove soiled dressing; place it in the trash bag.
-Remove gloves, wash hands, apply new gloves.
-Clean wound with normal saline or prescribed cleaner past the tissue surrounding the wound, dry with a 4×4 (gauze)
-Remove gloves, wash hands, apply new gloves
-Apply wound dressing
-Discard gloves and all used supplies in the trash bag. Remove equipment
-Wash hands
-Discard trash bag in bio-hazardous waste receptacle as indicated

During an observation, on 4/19/17 at 2:35 P.M., Resident #1 was lying on top of the bed on his/her left side. He/she said that he/she had two wounds, and was waiting for the nurse to come in to change the dressings. He/she further said that it was alright if the surveyor observed the dressings being changed. On 4/19/17 at 2:45 P.M. Nurse #1 was observed to do the following:

-enter the room with dressing supplies packaged gauze pads, individual normal saline containers placing the supplies onto the resident’s bed next to the resident.
-Washed hands with alcohol wash and put on gloves
-removed both dressings from the right and left ischium
-threw used dressings away and washed hands in the resident’s bathroom -put on gloves
-with gloved hands, removed gauze from packages by ripping across the top of the packaging and placing the gauze on top of the outside of the packaging, on the resident’s bed, overlapping onto the bed linens
-with gloved hands, took two pieces of gauze and folded them, placing them above each wound on the left and right ischium, under the gluteal fold
-with the same gloved hands,

Nurse #1 used her right hand to squirt normal saline onto the left gauze and cleaned the left wound, and then she squirted normal saline onto the right gauze and cleaned the right wound, placing the used gauze pads onto the resident’s bed. She then took a dry gauze pad and patted the left wound dry. There was no other gauze pads utilized, and she did not pat dry the right wound. -with her same gloved hands, she applied the dry protective dressings to the right and left ischium wounds

-with the same gloved hands, she opened the resident’s bathroom door and threw the gauze pads and used dressing/treatment materials away in the bathroom trash, removed her soiled gloves and was observed to not wash her hands prior to exiting the bathroom
-she came out to the resident, and with ungloved hands, picked up a used brief, brought it into the bathroom, and threw it away. She then washed her hands before exiting the bathroom.

Nurse #1 failed to follow the policy and prepare a clean work at the bedside for treatment/dressing supplies and failed to place a trash bag within easy reach of the working area. She failed to change her gloves, wash her hands, and apply new gloves between cleaning wounds, and applying the clean dressings. Nurse #1 failed to remove the dirty gloves prior to touching the doorknob, and entering the bathroom. Nurse #1 failed to wash her hands after disposing of the used treatment materials, and prior to exiting the bathroom.

During an interview with Nurse #1, on 4/19/17 at 3:00 P.M., the surveyor reviewed observations of the treatment and dressing changes. Nurse #1 said she should have washed her hands, and should not have used the dirty gloves to open the bathroom door.

Kathleen Daniel Health and Rehabilitation, Nursing Home Neglect and Elder Abuse Lawyers

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

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

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

Boston Personal Injury Lawyers for Elder Abuse Cases

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Sources:

Medicare Nursing Home Profiles and Reports – Kathleen Daniel Nursing and Rehabilitation

Inspection Report for Kathleen Daniel Nursing and Rehabilitation  – 04/26/2017

Page Last Updated: August 1, 2018