Masconomet Healthcare Center

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Masconomet Healthcare Center? Our lawyers can help.

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

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.

About Masconomet Healthcare Center

Masconomet Healthcare Center is a for non-profit, 123-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Topsfield, Middleton, Ipswich, Danvers, Beverly, North Reading, Andover, Peabody, North Andover, Lynnfield, Haverhill, and the other towns in and surrounding Essex County, Massachusetts.

Masconomet Healthcare Center
123 High St
Topsfield, MA 01983

Phone: (978) 887-7002
Website: http://www.whittierhealth.com/nursing_homes/masconomet.html

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 2018, Masconomet Healthcare Center in Topsfield, Massachusetts received a rating of 4 out of 5 stars.

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

 

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Masconomet Healthcare Center committed the following offenses:

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a comprehensive care plan for dysphagia (swallowing difficulty) integrating the facilities Speech Language Pathologist’s evaluation, treatment and recommendations for one resident (#19) in a total sample of 22 residents.

Findings include:

Resident #19 was admitted to the facility in 1/16 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated that Resident #19 had moderate cognitive impairment, required limited assistance from one person for bathing, dressing and supervision for eating.

Review of the medical record on 1/4/17 indicated that Resident #19 had a choking incident on 10/3/16. Review of the facility occurrence report indicated that Resident #19 had choked in the main dining room on 10/3/16 and the Certified Nurse Assistant performed the [MEDICATION NAME] Maneuver successfully. The occurrence report indicated that nursing requested a screen/evaluation from the Speech/Language Pathologist. Review of the document labeled Speech Language Pathologist (SLP) physician’s orders [REDACTED]. The physician’s orders [REDACTED].

Review of the Speech Language therapy evaluation and plan of treatment dated 10/4/16, indicated precautions were recommended due to a recent choking episode on 10/3/16. The document indicated based on the Resident’s impulsive rate of intake, it was recommended that the Resident eat in the Capen Unit dining room to be able to encourage safe swallowing strategies. The document noted that the SLP consulted with the charge nurse regarding the SLP plan of care.

Review of the Speech Therapy Discharge summary dated 10/18/16 indicated that the Resident required minimum/close supervision for swallowing abilities. New diet recommendations included:

*Solids – Mechanical soft/Ground textures.
*liquids: thin liquids.
*Swallow strategies/position: upright 90 degrees for all intake, small bolus (small amount of food), reduced rate of intake, alternate textures, intermittent liquid wash, place utensils down on table to facilitate pacing.
*Supervision for oral intake: distant supervision.

During interview with CNA #2 on 1/4/16 at approximately 8:45 A.M., she said that Resident #19 ate his/her breakfast in his/her room. CNA #2 said she assisted the Resident in sitting on the side of the bed, set up the items on the tray and said the Resident was independent with eating and did pretty well. The CNA did not state any of the recommendation/interventions indicated by the SLP.

During interview with Charge nurse #3 at 10:53 A.M. on 1/4/16, she said Resident #19 now eats lunch and dinner in the main dining room which has staff presence, but recently refused to eat breakfast in the on-unit dining room which was the Resident’s right. Surveyor #1 asked Charge Nurse #3 to clarify what distant supervision meant the Charge Nurse #3 said that this means she, the charge Nurse, is near the outside of the Resident’s room during the meal.

During interview with the Director of Nursing (DON) on 1/4/16 at 1:24 P.M., Surveyor #1 asked what distant supervision required. The DON said that there is no distant supervision – it is either supervised or not supervised – it is black or white. The Certified Nursing Assistant assignment card was reviewed with the DON. The assignment card indicated that the resident was independent with eating with set up, required to be supervised to cue to eat slowly, chew and swallow and have sips of liquids.

During interview with the DON at 1:49 P.M., she said that Resident #19 should have been supervised during meals. Review of the medical record on 1/4/16 failed to have the presence of a comprehensive care plan with measured objective, timeframes and interventions that addressed Resident #19’s dysphagia.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide professional standards of practice as evidenced by failure to complete 3 day bowel and bladder patterns to determine feasibility of continence retraining, failure to complete incontinence and elopement assessments per facility policy, and failure to complete resident care plans, which affected 7 residents, (#1, #9, #10, #13, #16, #8, and #12), out of a total sample of 22 residents.

Findings include:

1. For Resident #1, the facility failed to complete a 3 day bowel and bladder pattern as indicated on his/her incontinence evaluation. Resident #1 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of Resident #1’s incontinence evaluation dated 8/29/16 indicated that he/she was frequently incontinent of bladder and that a 3 day bladder and bowel program was to be initiated to determine feasibility of continence retraining. No bowel or bladder program could be located in the resident record. After multiple requests to facility staff to locate the bowel and bladder program form, the facility was unable to provide evidence that a 3 day bowel and bladder program was implemented for Resident #1.

2. For Resident #3, the facility failed to complete elopement assessments and an incontinence evaluation per facility policy. Resident #3 was admitted to the facility in 2/2015 with [DIAGNOSES REDACTED]. Review of Resident #3’s clinical record revealed that he/she had a significant change in 2/2016 after being discharged from hospice services.

Review of the facility’s bowel and bladder program policy indicated that all residents are to be assessed for the presence of urinary or bowel incontinence upon a change of status. During interview with the MDS Coordinator on 12/30/16 at approximately 1:45 P.M., she said that due to the significant change, a bowel and bladder incontinence evaluation should have been completed per facility policy. No updated incontinence evaluation could be located in the resident record. After multiple requests to facility staff to locate the incontinence evaluation form, the facility was unable to provide evidence that an incontinence evaluation was completed for Resident #3 per facility policy.

Further review of Resident #3’s clinical record indicated that he/she had not been assessed for elopement risk since 2015. During interview with the on 12/30/16 at approximately 2:36 P.M., Director of Nursing, DON, they said that it was facility policy to assess all residents for elopement quarterly.

3. For Resident #10, the facility failed to complete a 3 day bowel and bladder pattern as indicated on his/her incontinence evaluation. Resident #10 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. Review of Resident #10’s incontinence evaluation indicated that he/she is occasionally incontinent of bladder and that a 3 day bowel and bladder pattern was to be initiated. Further review of his/her clinical record indicated that only 2 entries were made documenting Resident #10’s bowel and bladder patterns for 12/28/16, 1 entry for 12/29/16, and no entries for 12/30/16. During interview with the DON and the Administrator on 1/3/17 at approximately 10:30 A.M., they agreed that Resident #10’s bowel and bladder program was not completed as required.

4. For Resident #13, the facility failed to complete a 3 day bowel and bladder pattern as indicated on his/her incontinence evalution and failed to complete quarterly elopement assessments per facility policy. Resident #13 was admitted in 3/2016 with [DIAGNOSES REDACTED]. Review of Resident #13’s incontinence evaluation dated 3/4/16 indicated that he/she was occasionally incontinent of bladder and that a 3 day bladder and bowel program was to be initiated to determine feasibility of continence retraining. No bowel or bladder program could be located in the resident record. After multiple requests from facility staff to locate the bowel and bladder program form, the facility was unable to provide evidence that a 3 day bowel and bladder program was implemented for Resident #13. Further review of Resident #13’s record indicated that his/her last elopement assessment was completed on 3/4/16 with no other quarterly entries documented. During interview with the on 12/30/16 at approximately 2:36 P.M., the DON said that it was facility policy to assess all residents for elopement quarterly.

5. For Resident #16, the facility failed to complete a 3 day bowel and bladder pattern as indicated on his/her incontinence evaluation. Resident #16 was readmitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Review of Resident #16’s incontinence evaluation dated 10/5/16 indicated that he/she was frequently incontinent of bowel and bladder and that a 3 day bladder and bowel program was to be initiated to determine feasibility of continence retraining. No bowel or bladder program could be located in the resident record. After multiple requests to facility staff to locate the bowel and bladder program form, the facility was unable to provide evidence that a 3 day bowel and bladder program was implemented for Resident #16.

6. For Resident #8, the facility failed to complete a 3 day bowel and bladder pattern as indicated on his/her incontinence evaluation. Resident #8 was admitted to the facility in 6/2016 with [DIAGNOSES REDACTED]. Review of Resident #8’s incontinence evaluation dated 6/3/16 indicated that he/she was occasionally incontinent of bladder, with causative factors that include physical disability, cognitive impairment and that a 3 day bladder and bowel program was to be initiated to determine feasibility of continence retraining. No 3 day bowel or bladder record could be located in the resident record. After multiple requests to facility staff to locate the bowel and bladder program form, the facility was unable to provide evidence that a 3 day bowel and bladder record was implemented for Resident #8.

7. For Resident #12, the facility failed to complete his/her the incontinence evaluation and implement a 3 day bowel and bladder pattern as indicated on his/her incontinence evaluation. Resident #12 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Review of Resident #12’s incontinence evaluation dated 10/19/16 indicated that he/she was frequently incontinent of bladder. Page 2 of the incontinence evaluation was left blank under evaluation of urinary incontinence. Under recommendations it indicated that a 3 day bowel and bladder was to be initiated to determine feasibility of continence retraining. The 3 day bowel or bladder record could be located in the resident record. After multiple requests to facility staff to locate the 3 day bowel and bladder program record, the facility was unable to provide evidence that a 3 day bowel and bladder record was implemented for Resident #12.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to provide services in accordance with the Speech Language Pathologist’s evaluation, plan of treatment and discharge recommendations for 1 Resident (#19) in a total sample of 22 Residents.

Findings include:

Resident #19 was admitted to the facility in 1/16 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated that Resident #19 had moderate cognitive impairment, required limited assistance from one person for bathing, dressing and supervision for eating.

Review of the medical record on 1/4/17 indicated that Resident #19 had a choking incident on 10/3/16. Review of the facility occurrence report indicated that Resident #19 had choked in the main dining room on 10/3/16 and the Certified Nurse Assistant performed the [MEDICATION NAME] Maneuver successfully. The occurrence report indicated that nursing requested a screen/evaluation from the Speech/Language Pathologist.

On 1/4/16 at 8:00 A.M., Surveyor #1 observed Resident #19 lying in his/her bed with eyes closed. His/her breakfast tray was present on the bedside table and partially consumed. During interview with CNA #2 on 1/4/16 at 8:45 A.M., she said that Resident #19 ate his/her breakfast in his/her room. CNA #2 said she assisted the Resident in sitting on the side of the bed, set up the items on the tray and said the Resident did pretty well with eating.

Review of the document labeled, Speech Language Pathologist (SLP) physician’s orders [REDACTED]. The physician’s orders [REDACTED]. Review of the Speech Language therapy evaluation and plan of treatment dated 10/4/16, indicated precautions were recommended due to a recent choking episode on 10/3/16. The document indicated based on the Resident’s impulsive rate of intake, it was recommended that the Resident eat in the on unit dining room with staff support. The document noted that the SLP consulted with the charge nurse regarding the SLP plan of care. Review of the Speech Therapy Discharge summary dated 10/18/16 indicated that the Resident required minimum/close supervision for swallowing abilities. New diet recommendations included:

*Solids – Mechanical soft/Ground textures.
*Liquids: thin liquids.
*Swallow strategies/position: upright 90 degrees for all intake, small bolus (small amount of food), reduced rate of intake, alternate textures, intermittent liquid wash, place utensils down on table to facilitate pacing.
*Supervision for oral intake: distant supervision.

During interview with Charge Nurse #3 at 10:53 A.M. on 1/4/16, she said Resident #19 now eats lunch and dinner in the main dining room which has staff presence, but recently refused to eat breakfast in the on unit dining room which was the Resident’s right. Surveyor #1 asked Charge Nurse #3 to clarify what distant supervision meant. The Charge Nurse #3 said that this means she is near the outside of the Resident’s room during the meal.

During interview with the Director on Nursing (DON) on 1/4/16 at 1:24 P.M., Surveyor #1 asked what distant supervision required. The DON said that there is no distant supervision – it is either supervised or not supervised – it is black or white. The Certified Nursing Assistant assignment card was reviewed with the DON. The assignment card indicated that resident was independent with eating along with set up, required to be supervised to cue to eat slowly, chew and swallow and have sips of liquids.

During interview with the DON at 1:49 P.M., she said that Resident #19 should have been supervised during meals and a Speech Language Pathologist screen has been requested and that Resident #19 will be supervised with all meals even if he/she chooses to eat in his/her room.

Despite being able to return to the main dining room for meals there was no indication in the medical record that Resident #19 would be safe eating in her room.

Failed to keep all essential equipment working safely.

Based on observations and interviews, the facility failed to ensure that all nursing staff were properly in-serviced in the use and set up of emergency equipment on 2 of 3 nursing units.

Findings include:

1. On 1/3/17 at at 12:50 P.M., Surveyor reviewed the emergency equipment/crash cart on the Baker Unit with Nurse #1. Surveyor asked Nurse #1 to demonstrate that the suction machine was operational. Nurse #1 failed to connect the tubing from the suction machine to the suction canister. Surveyor questioned Nurse #1 three times if he/she was sure the suction machine would operate correctly in that condition. On the third attempt, Nurse #1 saw what the Surveyor was looking at and connected the tubing from the suction machine to the suction canister.

2. On 1/3/17 at 1:30 P.M. the Surveyor reviewed the emergency equipment /crash cart on the Capen Unit with Nurse #3. Surveyor asked Nurse #3 for the location of the defibrillator. Nurse #3 said that the defibrillator was located on 1 of the 2 units located on the second floor, but he/she was not sure which one.

Surveyor asked Nurse #3 to demonstrate that the oxygen tank was operational. Nurse #3 attempted to operate the oxygen tank multiple times, but was unable to do so. Nurse #3 said he/she needed to asked another nurse for help. Charge Nurse #3 then approached and showed Nurse #3 how to operate the oxygen tank.

The Director of Staff Development was interviewed on 1/4/17 at 10:40 A.M She said that use of the oxygen equipment and suction machine was not currently part of the annual nursing competency. The facility failed to ensure that all nursing staff had received proper instruction in the use of emergency equipment.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview the facility failed to maintain complete, accurate and readily available medication administration records for 1 resident (#14) in a total sample of 22 residents.

Findings include:

Review of the policy titled Medication Administration General Guidelines, dated 8/1/03 and reviewed on 3/3/09 was received from the Director of Nurses (DON) on 1/3/17 at 4:30 P.M The policy indicated that medications are administered as prescribed and in accordance with good nursing principles and practices.

Resident #14 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] indicated that the resident requires assistance from staff with activities of daily living including bathing, dressing and grooming. Review of the Medication Administration Record (MAR) for December 2016 and January 2017 indicated that Resident #14 had a physician order [REDACTED].M., and 9:00 P.M There were no blood pressures or pulse rates documented on either the December 2016 or January 2017 MARs.

On 1/3/17 at 2:25 P.M., Nurse #2 said that if a medication order says to hold the medication for a systolic blood pressure less than 100 or an apical pulse less than 60, those vital signs would usually be documented on the MAR, but, if they were not documented on the MAR they could be documented in a nurses note. He/she further said that he/she had administered the [MEDICATION NAME] that morning, but was not able to state what the blood pressure or pulse had been. He/she reviewed their shift report sheet and although vital signs were documented for other residents, he/she was not able to locate a blood pressure or pulse for Resident #14.

Review of nurses notes from 12/1/16 to 1/3/17 indicated that there was no documentation of a blood pressure or pulse at 9:00 A.M. for 27 of 34 [MEDICATION NAME] administrations. There was no documentation of a blood pressure or pulse at 9:00 P.M. for 5 of 34 [MEDICATION NAME] administrations. Without the documentation, there was no way to determine if the medication was administered in accordance with the physician ordered parameters.

On 1/3/17 at 2:20 P.M., the Director of Staff Development said that vital signs taken for medication parameters should be documented on the MAR. On 1/3/17 at 4:30 P.M., the Director of Nursing said that vital signs taken for medication parameters should be documented on the MAR.

Masconomet Healthcare Center, Nursing Home Neglect and Elder Abuse Lawyers

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

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

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

Boston Personal Injury Lawyers for Elder Abuse Cases

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


Sources:

Medicare Nursing Home Profiles and Reports – Masconomet Healthcare Center

Inspection Report for Masconomet Healthcare Center – 01/04/2017

Page Last Updated: May 6, 2018

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