Kindred Transitional Care and Rehabilitation – Forestview

Kindred Forestview Transitional Care and Rehab

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Kindred Transitional Care and Rehabilitation – Forestview? Our lawyers can help.

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About Kindred Transitional Care and Rehabilitation – Forestview

Kindred Forestview Transitional Care and RehabKindred Transitional Care and Rehabilitation – Forestview is a for profit, 175-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Wareham, Bourne, Carver, Sandwich, Fairhaven, Acushnet, Lakeville, Plymouth, New Bedford, Mashpee, Falmouth, Kingston, Duxbury, Bridgewater, Somerset, Taunton, and the other towns in and surrounding Plymouth County, Massachusetts.

Kindred Transitional Care and Rehabilitation – Forestview focuses on 24 hour care, respite care, hospice care and rehabilitation services whose legally registered business name is Forestview Nursing, L.L.C.

Kindred Transitional Care and Rehabilitation – Forestview
50 Indian Neck Road
Wareham, MA 02571

Phone: 508-295-6264
Website: http://www.forestviewwareham.com/

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, Kindred Transitional Care and Rehabilitation – Forestview in Wareham Massachusetts received a rating of 1 out of 5 stars.

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

Fines Against Kindred Transitional Care and Rehabilitation – Forestview

The Federal Government fined Kindred Transitional Care and Rehabilitation – Forestview for health and safety violations as follows:

  • $17,550 on 06/14/2016
  • $7,543 on 04/27/2017

Fines and Penalties

Our Nursing Home Injury Attorneys inspected government records and discovered Kindred Transitional Care and Rehabilitation – Forestview committed the following offenses:

The nursing home failed to give the resident's representative the ability to exercise the resident's rights.

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

Based on record review and staff interviews, the Facility failed to ensure that a Roger’s treatment plan was extended and in place for one Resident (#5) who was prescribed an antipsychotic medication out of total sample of 24 Residents.

Findings include:

Resident #5 was admitted to the Facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment with an assessment reference date of [DATE], indicated that the Resident required extensive care with all ADLs (Activities of Daily Living). The BIMS (Brief Interview for Mental Status) was determined to be not appropriate due to the Resident’s mental status. The staff assessment of Resident’s cognition indicated severe impairment. The MDS indicated the Resident had a Guardian in place for health care decisions. Review of the Guardianship documentation indicated that a Rogers authority was obtained by the use of antipsychotic medication on [DATE].

Review of Resident #5’s clinical record indicated that the Resident had a physician’s orders [REDACTED]. Review of the clinical record included a Treatment Plan from the Commonwealth of Massachusetts Probate and Family Court dated [DATE]. The form indicated that Resident #5 was approved to receive between 0.0 milligrams (mg) – 20 mg of [MEDICATION NAME] (antipsychotic medication) per day. The Treatment Plan indicated that the plan would be reviewed on or before [DATE] and, if not sooner extended, would expire on [DATE].

Review of the clinical record indicated that there was no further documentation from the court for a treatment plan since the treatment plan had expired on [DATE]. The Social Worker (SW) was interviewed on [DATE] at 10:40 A.M. The SW said that she faxed information to the court in [DATE] and at that time, they were waiting for medical certification to proceed. At 11:30 A.M. on [DATE], the SW provided the survey team with a letter from the law office representing the Resident and Facility in court. The letter indicated that they were waiting for information from the Rogers monitor. The SW said she was aware that the Resident’s Rogers Guardianship had expired in ,[DATE] and said, I don’t know how it fell through the cracks

The nursing home failed to resolve each resident's complaints quickly.

Based on Resident group meeting/interview, policy review, review of grievance logs and staff interviews, the facility failed to ensure that grievances were thoroughly investigated according to facility policy, and efforts were promptly made to effectively resolve concerns identified by the Facility’s Resident Council and 25 sampled grievances relative to a.) missing money/personal property, b.) resident rights, and c.) quality of care and quality of life/allegation of mistreatment by staff.

Findings include:

Review of the facility’s Complaints/Grievance Policy indicated that individuals may voice complaints/concerns without discrimination or reprisal. The policy indicated the procedure was for the Executive Director or designee is responsible for the grievance process, receiving, tracking and overseeing their conclusion. The policy indicated the complaint/grievances could be received verbally, written, social media, brought individual and/or from a group.

According to the facility policy, the staff are to date the grievance once received, summarize the grievance and take steps to investigate, summarize the pertinent findings, indicate if whether the grievance was confirmed or not confirmed, document any corrective action and date the written decision issued. In addition, the facility is to report any alleged violations involving neglect, abuse and misappropriation.

The Resident Group interview/meeting was held on 9/22/17 at 1:00 P.M. with 15 Residents in attendance. The Residents said that they were aware of the grievance process, but did not feel that it was effective. They said that if you let someone know about a problem, such as slow response to call bells, the issue does not get resolved and remains a long standing problem. The Residents said unless the grievance is a lost item, which is found they were not provided a response from the Facility. The group attending the meeting said that they generally did not file grievances because the Facility response was based on blaming them and not looking into the concern voiced.

In addition, the Residents said that the Facility responded poorly to the Resident Council meetings ideas and concerns. They said that the Facility either derailed or ignored their voiced concerns or put a band-aid on it and the problems resurfaced. The areas the Residents said were not addressed after reporting their concerns during the Resident Council meetings included the following: low staffing (not enough), no night time snacks offered, general cleanliness of facility and especially the shower rooms are dirty, soiled linens left on floors for long periods of time, medications not administered as ordered (administered either early or late), frequent changes and/or cancellation of scheduled activities without being notified, reported shortage of staff, problems with agency staff care, laundry, infection control, cold meals, long distance phone access and privacy, poor response of ideas to ensure there were more male oriented activities and ideas for additional activities and programs of interest, long waits for assistance to call lights, no staff consistency and the residents said they were not informed of who was assigned to them for care.

Review of Resident Council (RC) minutes dated 1/10/17, 2/9/17, 3/9/17, 4/13/17, 5/11/17, 6/8/17, 7/6/17, 8/3/17 and 9/6/17 indicated the RC members consistently reported their concerns about call lights, housekeeping concerns and activity suggestions and problems with cancellation of scheduled activities.

The Facility’s investigation was a general education of unnamed staff and/or statements that they addressed their issues without supportive substance and effective monitoring. See F 244. 2. Review of a sampling of 25 grievances filed from individuals from 1/6/17 through 8/30/17 indicated the following:

a.) 8 grievances indicated missing money/personal property. Of these grievances, 1 of the 8 was reported to the Department of Public Health for alleged misappropriation, however, further review indicated that 8 out of 8 were not thoroughly investigated, and/or did not include evidence that the Resident received follow up and resolution to the grievance according to facility policy. The Facility’s emphasis was focused on the Resident for not locking their draw or their cognitive status (confused). One Resident said he/she had not received a response from the Facility about his/her grievance for months (missing t-shirts). The facility indicated they would replace a t-shirt, although the grievance indicated more than one was lost. The grievance did not include an investigation and did not indicate why there had been a delay in addressing the grievance.

b.) 7 grievances were filed in regards to resident right issues. All, according to the grievance were resolved. The emphasis was on the Residents and there was no indication what was done other then take statements. Of these grievances, 7 were not thoroughly investigated, and/or did not include evidence that the Resident received follow up and resolution to the grievance according to facility policy.

c.) 10 grievances were filed in regards to quality of care and or life. One grievance indicated the staff took money from a resident (a gift of $50.00 for more than one staff). There was no conclusion and no indication that staff were educated to not take money from residents. Other grievances included 3 that the social service staff treated the 3 residents inappropriately. One alleged the Resident was accused of smoking marijuana, another grievance indicated that the resident was threatened if he/she complained to the administrator, and that the social worker told the Resident to give up his/her home rather than support their concerns about losing his/her house. In addition, resident to resident incidents were documented with little investigation and/or corrective action and poor care and/or rough care was handled with resident being viewed as asking for care that he/she is (according to the form) capable of doing. Infrequently, the grievance form indicated that staff were educated, but without supportive evidence of who was educated and what was done to ensure the Resident’s grievance was addressed.

Surveyor #1 interviewed the Social Worker (SW) at 4:00 P.M. on 8/22/2017 and on 8/24/17 at 2:00 P.M. The SW stated that she controlled the Grievance log. The SW stated that she would assist in writing out grievances and ensure that once a grievance was made that the department or staff responsible for the complaint area received a copy of the grievance. She stated that once the grievance was given to the discipline responsible for the area of the complaint they were expected to investigate and complete the necessary process to resolve it. She stated that new grievances were discussed daily at the morning meeting until they were resolved. She stated that the other disciplines provided copies of their investigations and she placed them into the grievance book.

The SW stated she did not review the grievances for completion as she was more a keeper of the information and assumed that they had been completed by the staff assigned to the grievance. The Surveyor reviewed the Grievance process with the Administrator on 9/26/17 at 11:00 A.M., the Administrator said little and made no comments that supported the Facility’s involvement in ensuring the grievances that included individual and the Resident Council concerns and ideas were acted upon. The Administration staff indicated that they educated staff when they were notified of a problem. The Surveyor reviewed that 3 of the 25 grievances identified the social service staff as displaying behavior that was determined offensive by the reporter and that one of the grievances indicated the social worker would apologize. The grievance failed to fully investigate or indicate action (other then an apology), or if the apology was effective. The Administrator acknowledged the 3 complaints and said he agreed that there should not be grievances (more than 1) filed against the social service staff. The Surveyor asked for any and all additional information regarding the grievances that may not have been contained in the notebook. No additional information was provided by the Facility.

The nursing home failed to develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property.

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

Based on interview and record review, the Facility staff failed to follow their abuse prevention policies and procedures. The Facility staff failed to thoroughly investigate an incident of abuse for one Resident (#18) in a total sample of 24 Residents. Additionally,  the Facility failed to demonstrate that they screened 5 out of 5 newly hired employees through the Certified Nurse Aide Registry prior to employment in accordance with the Facility abuse prevention policy.

Findings include:

Review of the Facility Abuse policy included key components screening, training, prevention, identification, investigation, and protection.

1. For Resident #18, the Facility failed to investigate if abuse prevention procedures were followed during a resident to resident altercation. Resident #18 was admitted to the Facility in 07/2012 with a [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) completed on 02/09/17 indicated Resident #18 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating a severe cognitive impairment. The MDS also indicated Resident #18 was an assist for transferring from surface to surface, was unable to ambulate and required staff assistance with all ADL (Activities of Daily Living) care. An investigation for a resident to resident altercation involving Resident #18 and Resident #11 on 04/28/17 was reviewed.

The investigation indicated that at 11:05 P.M. Resident #11 initiated his/her call light and asked the Certified Nursing Assistant (CNA #3) if Resident #18 could be medicated for restlessness and making noises. At 11:10 P.M., Resident #11 was observed by CNA #3 to be standing over the bed of Resident #18, yelling shut up and shaking his/her shoulders. The investigation included statements from the two CNAs who were working from 11:00 P.M. to 7:00 A.M. and from two of the three nurses who were on the unit at that time.

The statement from CNA #3 indicated she heard Resident #18 saying stop it. Upon coming to the room she saw Resident #11 with his/her hands on Resident #18. The CNA entered the room, asked what Resident #18 was doing and yelled for the nurse. The statement from Nurse #2 indicated CNA #3 came to the nurses station to notify the nurses that she heard Resident #11 saying shut up leaning over Resident #18 with hands on his/her arm. The statement from Nurse #3 indicated that CNA #3 approached the nurses station stating she had seen Resident #11 standing over Resident #18 yelling shut-up and shaking him/her.

The Director of Nurses (DON) was interviewed on 09/26/17 at 9:55 A.M. The DON said she investigated the incident and reported it to the Department. The Surveyor asked if the investigation included the conflict in statements regarding CNA #3 leaving Resident #11 with Resident #18. The DON said she went by the statement of the CNA and did not see the statements from the other staff indicating the CNA came to to the desk to notify them of the incident. The DON said there was no education conducted with staff about abuse prevention practices following the incident. The DON had no additional information to be included in the investigation.

2. The Facility staff failed to follow their policy to screen 5 out of 5 new hire employees through the Nurse Aide Registry.

A. Employee #1 was hired as a CNA on 08/02/17. Upon review of the employee file, verification from the Department of a Nurse Aide Registry check was unable to be located.

B. Employee #2 was hired as a CNA on 06/06/17. Upon review of the employee file, verification from the Department of a Nurse Aide Registry check was unable to be located. Review of education documentation indicated Employee #2 was not provided with education regarding abuse prevention policies and procedures until 08/03/17.

C. Employee #3 was hired as a CNA on 08/26/17. Upon review of the employee file, verification from the Department of a Nurse Aide Registry check was unable to be located.

D. Employee #4 was hired as a nurse on 09/20/17. Upon review of the employee file, verification of a Certified Nurse Aide Registry check was unable to be located.

E. Employee #5 was hired as a nurse on 06/27/17. Upon review of the employee file, verification from the Department of a Nurse Aide Registry check, verification from the Board of Nursing and verification of a CORI were unable to be located. Review of the education documentation indicated Employee #5 was not provided with education regarding abuse prevention policies and procedures as of 09/27/17.

The Surveyor met with the Administrator on 09/25/17 at 11:20 A.M. The Surveyor requested the verification of Nurse Aide Registry check for each employee.

The Assistant Director of Nurses (ADON) was interviewed on 09/27/17 at 11:00 A.M. The ADON said the employee background checks were conducted by an outside company and the Facility received computer generated documents that the Nurse Aide Registry checks were complete. The ADON said the Facility did not have the verification from the Department.

The nursing home was in disrepair and failed to provide housekeeping and maintenance services.

Based on observations and staff interviews, the facility failed to maintain safe environment by not maintaining the structural integrity of the resident’s windows and the buildings exterior facing the inner courtyard had multiple areas covered in black mold-like discoloration.

Findings include:

On 9/27/17 at 10:00 A.M., the Surveyors observed 3 Residents smoking in the inner courtyard of the facility. The surveyors asked the Executive Director (ED) to come to the courtyard area and observed the following: – When walking into the courtyard there was a strong odor of dampness.

– The facility’s white siding had multiple areas on the 4 sides that faced the inner courtyard, starting at the ground level climbing up in a pyramid shape that reached the bottom of some windows. The areas were blackened with clusters of spots spreading up from the ground.

– The ED touched the vinyl siding and he said it looks like it had been painted in the past but felt rough.

– Each resident window facing the courtyard had wood surrounding the windows that was unpainted, soft (the surveyor could easily slide a pen through the wood which was loose and easily could fall off), the ED said he had never seen this and said every window needs repairs.

– Multiple windows had missing wood and the spaces had green soft vegetation filling in where wood had once been.

– The tops of the windows had multiple areas rotted away and missing some wood.

The ED was asked if the resident rooms had water leakage and he said no, not that he knows of. At the end of the tour, the Executive Director was surprised by the condition of the building and added he was never told about the siding and windows and would contact the corporate office. The ED said he had only been the Director since May 2017 and had no information of how long the building had been like this.

The nursing home 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 record review and staff interview, the facility failed to complete a significant change Minimum Data Set (MDS) assessment for one Resident (#4) who had a decline in his/her activities of daily living, cognitive status and incontinence bowel and bladder pattern The total sample included 24 residents.

Findings include:

Resident #4 was admitted to the facility in 2/2017 with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] indicated Resident #4 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicated the Resident had no cognitive impairment and could understand and communicate his/her needs, but was inattentive and disorganized at times. The Admission MDS indicated the Resident was capable of independently transferring self, ambulating, eating and required assistance of 1 in his/her dressing and hygiene. The MDS indicated the Resident was continent of bowel and bladder.

Review of the subsequent quarterly MDS, dated [DATE] indicated a change in the Resident #4’s BIMS score. The score changed from 14 out of 15 to 6 out of 15, which indicated severe cognitive impairment. The Resident’s overall status showed no other changes of his/her activities of daily living and bowel patterns. Review of the most recent MDS (quarterly) dated 7/25/17, indicated a BIMS of 4 (a decline), symptoms of psychosocial symptoms that included a decline in mood, verbal behaviors and rejection of care. In addition, the MDS indicated a decline in his/her ability to transfer (from independent to limited assist from 2 staff), ambulate (from independent to an assist from 1 staff), dress (from limited assistance from 1 staff to an extensive assistance from 1 staff, participate in hygiene (a change of limited assistance to extensive assistance) and incontinence pattern of his/her bowel and bladder (from continent to occasional incontinence).

Further review of the clinical record indicated that following the quarterly MDS assessment dated [DATE], a physician’s telephone order dated 8/1/17 was obtained for a referral for hospice services. Although, the record indicated the Hospice assessment indicated the Resident did not meet the requirement, the Social Service progress note dated 8/1/17 indicated an overall decline in the Resident’s cognition and function. During interview on 9/25/17 at 10:00 A.M., the MDS Coordinator was interviewed. The MDS Coordinator stated that the Staff had discussed a significant change for the Resident, but that it had not been pursued at the time and therefore a significant change MDS was never completed.

The facility failed to ensure each resident receives an accurate assessment by a qualified health professional.

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

Based on record review and staff interviews, the facility failed to ensure that all sections of the Resident’s Minimum Data Set (MDS) assessments, were comprehensive and complete to accurately reflect the Resident’s status for 3 residents (#3, #10 and #19,) of 24 sampled Residents.

Findings include:

1. For Resident #3, the facility failed to accurately complete the Significant change MDS assessment with a reference date of 8/24/17 for antipsychotic medication. Resident #3 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED].

Review of the medical record indicated during the time period of the significant change MDS assessment the Resident had conflicting information in regards to the administration of an antipsychotic medication.

Review of the section of the MDS for antipsychotic medications administered, the MDS indicated if the Resident had received the antipsychotic medication, the assessment indicated no he/she had not received the medication.

During interview on 9/27/17 at 10:00 A.M., the MDS Coordinator said that she checked and that the coding was incorrect for the antipsychotic medication and would correct it. The Resident was receiving antipsychotic medication.

2. Resident #10 was admitted to the facility in 8/2013 with [DIAGNOSES REDACTED]. Review of the medical record indicated during the time period of the annual MDS assessment the assessment indicated conflicting information about the administration of antipsychotic medication.

Review of the section of the MDS for antipsychotic medications administered indicated the Resident was not being administered an antipsychotic medication (section N), but under the section the Resident had received antipsychotic medications (section S) the MDS indicated the Resident had been receiving the medications.

During interview on 9/27/17 at 10:00 A.M., the MDS Coordinator said that she checked and that the coding was incorrect for the antipsychotic medication and would correct it. The Resident was not being administered antipsychotic medications.

3. For Resident #19 the facility failed to complete Section C (Residents cognitive status) and Section D (Residents mood) on the Admission MDS. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS with a reference assessment date (ARD) of 6/30/17 indicated that Section C and Section D were marked as not assessed both for the Resident’s participation and the facility’s participation (One section is the Residents participation and the if the Resident is not able to participate the facility would complete the assessment). The Clinical Record indicated that the Resident was alert and oriented to person, place and time.

On 9/27/17 at 8:30 A.M. MDS Nurse #1 said that the above 2 sections were to be completed by the Social Worker, and that she would send her into talk to the Surveyor.

On 9/27/17 at 8:45 A.M. the Director of Social Service said that the reason that she did not complete the above sections of the MDS was that each time she went to visit the Resident, Resident # 19 was either sleeping, just too busy, out of the room or out of the building. When asked by Surveyor why she then did not complete the facility’s assessment of the Resident she stated she probably should have done the assessment for the facility.

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

Based on record review and staff interview, the facility failed to provided services in accordance with professional standards of quality for 1 Resident (#6) in a total sample of 24 Residents.

Findings include:

For Resident #6 the facility failed to ensure that clinical staff followed the plan of care (based on current nursing standards of practice) following the Resident’s witnessed [MEDICAL CONDITION]. Resident #6 was admitted to the facility in 5/2017 with the following pertinent Diagnoses: [REDACTED].

Resident #6 is receiving an anticonvulsant medication. Review of the Resident’s Plan of Care for [MEDICAL CONDITION] Disorder related to [MEDICAL CONDITION] indicates the following interventions which were not included in the nurse’s note:

-allow [MEDICAL CONDITION] to run its course and observe progression noting type of body movement and duration

-assess frequency, duration and type of [MEDICAL CONDITION] activity -conduct a head-to-toe assessment to determine if there was any trauma related to the [MEDICAL CONDITION] activity

-after [MEDICAL CONDITION], take vital signs and conduct neuro check-monitor for [MEDICAL CONDITION], headache, altered level of consciousness, paralysis, weakness or pupillary changes.

Review of a Nursing Progress Note dated 9/25/17 indicated that Resident #6 had a [MEDICAL CONDITION] with focal staring up and to the right with rapid left arm movements. The Resident received [MEDICATION NAME] 5 mg. via [DEVICE] with good effect. There was no duration of time or neurological evaluation documented.

The facility failed to provide care by qualified persons according to each resident's written plan of care.

Based on record review, observation and interview, the facility failed to follow the plan of care (based on assessed needs) for transfers and for bed mobility assistance, for one Resident (#6) in a sample of 24 Residents.

Findings include:

Resident #6 was admitted to the facility in 5/2017 with the following pertinent Diagnoses: [REDACTED]. Review of the most recent Nursing Summary dated 9/19/17, indicated that Resident #6 was assessed as an assist of 2 for bed mobility and transfer. Review of the Admission and Quarterly Minimum Data Set (MDS) for (5/25/17 & 8/28/17) indicates that Resident #6 is total dependence on staff for bed mobility and transfers (includes to or from bed and wheelchair).

Review of the Resident’s Care Plan indicates that the Resident requires total assistance with transfers.

Review of the Resident Status Sheet for the heading of Locomotion indicates a check off for lift to chair and with 2 assist. The Surveyor interviewed the CNA (CNA #1) who usually cares for the Resident. CNA #1 said that she turns the Resident in bed herself and transfers the Resident herself to the chair, which is not according to the Plan of Care for 2 person physical assist (the Resident is completely dependent on staff).

The Surveyor observed CNA #1 provide morning care on 9/26/17 at 12:15 P.M. CNA #1 used a draw sheet to turn the Resident in bed, but with difficulty (due to the HOB being at 30 degrees while tube feeding was continuously running) and rolled back so that the CNA needed to put her hands on the Resident to hold him/her in place. The Resident was also observed to be unable to assist with bed mobility.

The Surveyor interviewed the Resident’s spouse and invoked health care proxy (HCP) on 9/22/17 at 11:20 A.M. and throughout the survey. The HCP said that he/she has seen the CNAs transferring Resident #6 incorrectly with only 1 person. The HCP said that the Resident is dead weight and he/she is worried that the staff will injure the Resident during a transfer, but he/she said that the facility is understaffed and CNAs do it by themselves because other CNAs are busy.

The nursing home failed to assist residents who need total help with eating/drinking, grooming and personal and oral hygiene.

Based on observations, interviews and electronic medical record review, the facility failed to provide appropriate treatment for [REDACTED].#6), from a total sample of 24 Residents.

Findings include:

Resident #6 was admitted to the facility in 5/2017 with the following pertinent Diagnoses: [REDACTED].

Review of the Admission and Quarterly Minimum Data Set (MDS) for (5/25/17 & 8/28/17) indicates that Resident #6 is completely dependent on staff for personal hygiene (including washing/combing hair and brushing teeth), has impairment on one side of both upper and lower extremities is non-ambulatory and staff believe that Resident is capable of increased independence in at least some Activities for Daily Living (section G0900-B).

Review of the Physical Therapy Discharge Summary (7/28/17) indicates: Discharge from therapy services to continue long term care at this facility. Recommend patient to get up out of bed daily to high back wheelchair daily and frequent repositioning when in bed to minimize loss of joint ROM/maintain skin integrity.

Review of the Occupational Therapy Discharge Summary indicates: Staff to provide passive range of motion (PROM) to right upper extremity in preparation for positioning.

Review of the Care Plan for ADL Self Care Deficit (initiated 5/19/17) indicated a Goal as: will maintain current level of functioning in bed mobility, transfers, eating (Resident #6 is NPO or nothing by mouth with a gastrostomy tube), dressing, toilet use (Resident #6 is incontinent and utilizes a brief) and personal hygiene. Interventions: honor choices and preferences whenever possible and assistance with cleaning self, bed mobility, personal hygiene and oral care.

On 9/21/17 at 10:00 A.M. during the initial tour the Surveyor observed the Resident to have greasy hair with dry cracked lips and a white film over teeth.

On 9/22/17 at 11:20 A.M. the Resident’s spouse and invoked HCP (health care proxy) said that the Resident’s mouth is often full of white crud and that oral health is not addressed. He/she also said that the Resident’s hair is often greasy and this is so not like the Resident as he/she was always meticulous about his/her appearance. The HCP said that this was brought to the staff’s attention many times, but that staff told him/her that they can only wash hair on shower day. The HCP brings in his/her own personal products hoping that staff will use them, however he/she said I think his/her hair has been washed one time since admission (4 months ago).

On 9/26/17 at 12:15 P.M. the Surveyor observed ADL care with CNA #1. The CNA washed the Resident’s face and provided incontinence care, but did not provide oral hygiene care or range of motion to extremities. The Surveyor observed the Resident’s mouth to be covered with a white film over the tongue and teeth and the Resident’s hair remained greasy.

Review of the Resident Status Sheet indicates that Resident #6 should receive a shower on Fridays 3:00 P.M.-11:00 P.M., and is total care under the mouth care heading and indicates a completely blank section under the Restorative/ROM heading. Review of the CNA (point of care) flow sheets for Bathing (with a 30 day look back) indicates that Resident #6 was provided with a shower on the evening shift of 9/14/17, but did not receive the scheduled shower of 9/21/17 and review of the month of 8/2017, indicates that the Resident did not receive a shower.

On 9/26/17 after observation of ADL care with CNA #1, the Surveyor interviewed the Unit Manager and Nurse Practitioner (NP). The UM said that the facility did not provide a restorative program. The NP wrote an order to encourage ROM every shift and provide mouth care before and after every breathing treatment.

The nursing home failed to give the right treatment and services to residents who have mental or psychosocial problems adjusting.

Based on record review and staff interviews, the facility failed to develop a behavioral treatment plan for one sampled Resident #9, that resulted in multiple Section 12 (temporary involuntary hospitalization ) hospital admissions. The total sample was 24 residents.

Findings include:

For Resident #9, the facility and the psychiatric service had not developed a behavioral treatment plan for ongoing behaviors of refusing care, treatments and elopement. The Resident for 2017 had 6 Section 12 hospital admissions related to behaviors. The Resident was placed in a secured unit due to risk of elopement and denied any alternatives for smoking.

Resident #9 was a long term care resident with a [DIAGNOSES REDACTED]. The medical record indicated the Resident had a guardianship in place with his/her children as the decision maker for the Resident and was followed by the psychiatric service at the facility. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had no cognitive issues and scored a 15 out of 15 score for the BIMS (Brief Interview for Mental Status) and assessed as having no mood or behavioral issues. The assessment noted the Resident received scheduled and as needed pain medications and had no falls. The next MDS was a significant change in status assessment, dated 8/20/17 and again the Resident had no cognitive issues and scored a 15 out of 15 for the BIMS. The assessment noted no mood issues but exhibited verbal behaviors and needed an increase in assistance for activities of daily living.

During the initial tour of Unit (4) on 09/21/17 at 9:15 A.M., Resident #9 was observed in his/her room. The Resident was seated in a wheelchair with a bed table in front of him/her. The Resident was observed talking with 2 Certified Nursing Assistants (CNA), who left the Resident’s room, however he/she continue to ask the staff (as they left the room) for something to drink. After about 5 minutes after the Resident had asked for a drink and who was continuing to ask for staff assistance, no drink was provided.

The Unit Manager (UM #4), who was providing the tour, said the Resident had dementia, a legal guardian and often refused care. The Manager said the Resident had sustained a fracture of unknown origin and had to be Section 12 (a Section 12 is a transport order to a hospital), because he/she refused assessment of his/her fractured leg. The Unit Manager indicated this had occurred on 9/11/17. In addition, the Resident was described to have pain and that he/she was being evaluated for hospice care.

The Manager said the Resident was alert and oriented and able to communicate his/her needs. No other information was provided. During the tour, the Surveyor introduced self to the Resident and he/she responded pleasantly and coherently. The Resident asked for a drink and said that he/she was very thirsty. The Resident said he/she had broken his/her leg, but had not fallen. The Resident asked that the Surveyor could ask an identified (named) CNA to get him/her something to drink. The Surveyor sought out staff to assist the Resident and the name provided to the Surveyor was correct.

The Surveyor inquired with UM #4 about the Resident’s cognition and she said the Resident was alert and oriented. Subsequent to the initial observation, the Surveyor was observing Unit 4 on 9/21/17 at 11:00 A.M. Resident #4 was observed in room and being assisted by to Emergency Medical staff assisting him/her into a wheelchair. The Resident was talking with the Emergency Medical Staff, was smiling and not in any visible distress. The Facility staff did not indicate to the survey team that the Resident was in distress. It was later determined that Resident #4 was sent out on a section 12 for involuntary hospitalization on [DATE] at 11:00 A.M. for further medical and psychiatric evaluation.

The Resident was not able to be observed (further) during the survey period (9/21/17-9/27/17). The plan of care initiated on 8/14/12 for the Resident behavior of resistive to care and revised 9/18/17 (problem/focus only), indicated the plan’s tasks/interventions had not been changed since 2016 for his/her ongoing behaviors and listed some of the following interventions:

– Allow resident to make decisions about treatment regime, to provide a sense of control. – Assess for pain management needs.

– Educate resident about possible outcomes for not complying with treatment or care.

– Educate on the risk of refusing care.

– Encourage as much participation/interaction as possible during care activities.

– Resident responds best to being involved in his/her decisions about care or having choices.

The plan of care for this Resident had no new behavioral interventions added to the plan for 2017.

Another plan of care initiated on 8/21/12 for verbally abusive behaviors and accusatory to staff only revised and changed the goal 1/18/17 that read the Resident will verbalize understanding of need to control verbally abusive behaviors and accusatory behaviors through the review date. The only changed intervention for 2017 was for two staff at all times in sight of each other at all times when with Resident due to accusatory behaviors. No other interventions had been changed and updated in 2017. The Resident was Sectioned 12, six times in 2017 as provided by Unit Nurse Manager #4: – 1/16/17 Section 12 for refusing post-op care of a left [MEDICAL CONDITION] and refusing transportation to the emergency room .

– 7/4/17 Section 12 for an elopement. The facility failed to develop any plan for the potential problem of elopement.

– 7/22/17 Section 12 for refusing medical care. – 9/7/17 Section 12 for refusing all medical treatments and exit seeking. No plan developed for elopement.

– 9/20/17 Section 12 for refusal of medical treatment and refusing to remove choking hazard from his/her mouth. – 9/21/17 Section 12 for further medical and psychiatric evaluation.

Additional concerns, deficiencies, and compliance requirements are contained in the original report.

The nursing home failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents

Based on Surveyor observations and staff interview the facility failed to ensure if a bed or side rail is used that they ensure correct installation, use, and maintenance of bed rails are conducted and failed to assess the resident for risk of entrapment from bed rails prior to installation. The total sample was 24 residents.

Findings include:

1. The Facility failed to ensure if a bed or side rail is used that they ensure correct installation, use, and maintenance of bed rails are conducted and failed to assess the resident for risk of entrapment from bed rails prior to installation. During facility observations of each resident room, during the survey from 9/21/17 through 9/27/17, most of the beds had side rails and numerous beds had a variety bed rails and mattress sizes. During interview on 9/26/17 at 1:00 P.M., with the Administrator, Director of Nurses (DON) and Assistant Director of Nurses (ADON), the Facility policy for bed safety was reviewed, as was the bed safety evaluation tool. The Surveyor asked the Administration staff if they were conducting an assessment of entrapment in their evaluations of bed rails. Initially, the ADON said they were evaluating for safety, but after review of the evaluation tool and the Facility policy the assessments failed to included the assessment for risk of entrapment from bed rails. See F 461.

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

Based on observations, staff interviews and facility policy review, the facility failed to ensure that 3 sampled Residents (#6, #8, #12 and #14) received the appropriate medical care and treatment for one gastrostomy feeding tube (#6) and 2 Tesio [MEDICAL TREATMENT] catheters (#8, #14), from a total sample of 24 Residents.

Findings include:

1. For Resident # 12 the facility failed to ensure that emergency measures’s were in place for the Resident in the event the [MEDICAL TREATMENT] catheter (Vascular Access Device-VAD)in the Residents chest began to bleed. Resident #12 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. A VAD catheters have two openings inside; one is a red (arterial) opening to draw blood from your vein and out of your body into the [MEDICAL TREATMENT] pathway and the other is a blue (venous) opening that allows cleaned blood to return to your body.

The Resident with a VAD catheter placed in the chest requires some type of clamp readily accessible, preferably taped to the wall at the head of the Resident bed, so that in the event of an emergency (bleeding from the catheter) the staff has the necessary equipment to stop the bleeding from the VAD catheter. This is a potential risk of a Resident with this type of catheter in place. Clinical record review indicated that the Resident was receiving [MEDICAL TREATMENT] and a VAD was in place in the Residents chest for the Resident to receive [MEDICAL TREATMENT].

Surveyors conducted a tour of the Resident room on 9/26/17 at 11:00 A.M. and found that there was no equipment readily available in the event the Resident began to bleed from the [MEDICAL TREATMENT] catheter. On 9/26/17 at 11:45 A.M. the Assistant Director of Nursing said that she found the Residents did have the equipment (a clamp) but it was not readily accessible in the event the Resident was bleeding from the [MEDICAL TREATMENT] catheter.

2. For Resident #6 the facility failed to: a.) ensure that nursing staff assessed for [DEVICE] placement and gastric residual prior to installing medication and flushes (according to policy and standard of practice): b.) initiate and monitor an intake and output record, according to the facility’s Intake and Output Policy (3/2/06), to ensure that the Resident received the correct amount of enteral formula during a 24 hour period, according to the physician’s orders [REDACTED].

Resident #6 was admitted to the facility in 5/2017 with a history of [MEDICAL CONDITION], right sided [MEDICAL CONDITION], dysphagia (difficulty swallowing) with recent placement of a gastrostomy tube ([DEVICE]) in 6/2017 (a [DEVICE] is a tube inserted through the abdomen that delivers nutrition directly to the stomach). The Resident was unable to tolerate bolus feedings due to episodes of vomiting (per 6/8/17 Registered Dietician note). The Resident was also diagnosed with [REDACTED].

Review of the physician’s orders [REDACTED].) per hour x 24 hours continuous with pump-flush 200 ml. every 6 hours and check feeding tube placement before initiation of formula, medication administration and flushes and head of bed at 30 degrees at all times. Review of the facility’s Enteral Nutrition with release date of 9/27/16 indicated: bullet #14- when the patient is fed by tube: a.) make sure the feeding tube is properly placed, b.) nursing staff is assigned to specific enteral feeding responsibilities, such as administration of the feeding, formula, amount, feeding intervals, flow rate, flushing with tap water at appropriate intervals, maintaining HOB at 30-45 degrees as appropriate.

Review of the facility’s Intake and Output Policy (dated 3/2/2006) indicates (bullet #4.) total the amount of po (by mouth) at the end of shift and give to nurse for documentation- the licensed nurse records fluids for other types of fluid intake (ie., IV, NG/GT, flush, h20 with medications). Review of the Resident’s Care Plan for [DEVICE] (initiated 5/2017) indicates: check for tube placement and gastric contents/residual volume per facility protocol and record. a.) On 9/21/17 at 5:00 P.M., Surveyor #2 observed a medication pass via the Resident’s [DEVICE] with Staff Nurse #1. The Nurse was observed to administer Trazadone (50 mg.) 1/2 tab for total dose of 25 mg. crushed via the [DEVICE]. The Nurse did not check for placement prior to administering the medication or flushing with water. The Nurse also did not check for residual gastric content.

The Surveyor asked the Nurse about the observation outside of the Resident’s room. The Nurse said that he had checked for placement earlier in the evening.

b.) On 9/21/17 at 10:00 A.M. during morning tour with the Unit Manager (UM), the Surveyor observed an empty 1500 ml. formula bottle hanging. The empty bottle was dated 9/19/17 with the time hung of 9:45 A.M. (48 hours prior). The Surveyor asked the UM where extra tube feeding formula was stored. The UM took the Surveyor to the medication room. The Surveyor observed an un-opened new case (6/ 1500 ml. bottles/case) of [MEDICATION NAME] 1.2 calories on the counter of the medication room. A new tube feeding bottle was hung at 10:30 A.M. on 9/21/17.

On 9/22/17 at 9:04 A.M. the Surveyor asked where the staff were documenting formula intake, flushes and residuals. At 9:30 A.M. the UM, Director of Nursing (DON) and Assistant (ADON) were observed going through the computer, but unable to locate any intake recordings since admission. The facility could not substantiate that the Resident was receiving the correct amount of formula in a 24 hour period, the correct amount of water flushes, flushes for medications or gastric residuals.

On 9/22/17 at 3:00 P.M. the Surveyor observed the tube feeding formula (formula bottle dated 9/21/17 at 10:30 A.M.) with 200 ml. remaining. The UM joined the Surveyor and said that the tube feeding formula should have been changed at 10:30 A.M. on 9/22/7 per the physician’s orders [REDACTED]. c.) On 9/26/17 at 9:30 A.M. the Surveyor interviewed the spouse/HCP again. He/she said that over the weekend he/she had observed the Resident lying flat with the tube feeding running. He/she said that the Resident was gurgling and had secretions all over his/her pajamas. He/she said that staff were unavailable and he/she asked a housekeeper to elevate the HOB. The HCP later notified the UM of the observation. On 9/26/17 at 12:15 P.M. the Surveyor observed morning care with Certified Nurse Aide #1 (CNA). The spouse requested that the Resident be weighed. CNA #2 came in to assist with the hoyer lift scale. CNA #2 immediately lowered the Resident’s head of bed while the tube feeding was running (continuous). The Surveyor intervened and the CNA #2 elevated the HOB to 30 degrees. (weight of 9/14/17 =115.6 pounds and weight of 9/26/17 =113.5 pounds for 2.1 pound total weight loss in 12 days). 3. For Resident #14 the facility failed to provide availability of a [MEDICAL TREATMENT] clamp in the case of an emergency.

Resident #14 was readmitted to the facility in 7/2017 with [MEDICAL CONDITION], diabetes mellitus and recent placement of a Tesio catheter (a tunneled catheter which can be used as an interim/bridge technique for emergency access to [MEDICAL TREATMENT] or while an AVF matures. On 9/26/17 at 11:20 A.M. the Resident returned from [MEDICAL TREATMENT]. The Surveyor observed the Resident’s room without emergency equipment in case of catheter bleeding.

The Surveyor asked Staff Nurse #3 what she would do if the catheter started to ooze. The Staff Nurse looked around the room and said there should be a clamp at the bedside at all times. At 11:45 A.M. the Assistant Director of Nursing (ADON) said that Care Plan was updated to include the availability of a clamp at the bedside in case of a bleeding emergency.

Boston Nursing Home Neglect and Elder Abuse Lawyers

In additional to above, the facility was also cited for the following deficiencies:

  • Failed to kKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5 percent. Based on observations and staff interviews, the facility failed to ensure a medication administration error rate of 5% or less. A total of 25 observed opportunities with 3 errors calculated the medication error rate of 12 %.
  • Failed to prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.  Based on observation, interviews and test tray results, the facility failed to ensure that meals distributed by tray service to residents were acceptable and served at appetizing temperatures to residents.
  • Failed to reasonably accommodate the needs and preferences of each resident.  Based on interviews and record review the Facility staff failed to ensure a Resident (#8) who was a nutritional risk and on [MEDICAL TREATMENT] received a breakfast meal that accommodated the Resident’s individual needs. In a total sample of 24 Residents.
  • Failed to have a program that investigates, controls and keeps infection from spreading.  Based on observation, record review and staff interview, the facility failed to follow proper infection control practices to prevent the spread of infection for 2 sampled Residents and 1 Non-Sampled Resident (#12, #14 and NS #1) in a total sample of 24: and the facility failed to implement an effective infection control program by not having an ongoing, systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risks. The surveillance data was incomplete for the resolution of infections after treatment and the infection control data was not analyzed and not presented to the Quality Assessment and Performance Improvement (QAPI) committee as outlined in the facility’s infection control program policy.
  • Failed to make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident’s needs; or 5) adequate closet space.  Based on observation and staff interview, the facility failed to follow the manufacturer’s recommendations and specifications for installing and maintaining bed rails.
  • Failed to make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.  Based on policy review, observations and interviews, the Facility’s alleges the Facility is a smoke free or Tobacco Free Environment, and that no residents, staff, contractors, visitors and/or healthcare providers were allowed to smoke at the facility or on the premises. However, observation and through interview residents and staff were observed smoking on the Facility premises without safe receptacles for disposal of cigarette ashes, butts and without providing a safe area for residents and others who were observed smoking on the Facility premises.
  • Failed to listen to the resident or family groups or act on their complaints or suggestions.  Based on documentation review, staff, individual and Resident group interviews, the facility failed to ensure the Resident Council was an effective group that addressed regularly voiced needs and concerns and have input into the activities, policies issues affecting the lives in the facility.
  • Failed to provide activities to meet the interests and needs of each resident. Based on observations, interviews and record review the Facility staff failed to provide individualized activities to meet the needs and interests of 3 Residents (Resident #6, #10, and #20 ) in a total sample of 24 Residents. In addition, the Facility staff failed to ensure there were adequate and ongoing programs of activities designed to meet the needs of all the residents.

Kindred Transitional Care and Rehabilitation – Forestview, 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: December 20, 2017

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