Mount Saint Vincent Care Center

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Mount Saint Vincent Care 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 Mount Saint Vincent Care Center

Mount Saint Vincent Care Center is a for profit, 125-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of New Bedford, Fall River, Dartmouth, Westport and the other towns in and surrounding Bristol County, Massachusetts.

Mount Saint Vincent Care Centerfocuses on 24 hour care, respite care, hospice care and rehabilitation services.

Mount Saint Vincent Care Center
35 Holy Family Road
Holyoke, MA 01040

Phone: (413) 532-3246
Website: http://www.mercycares.com/mount-saint-vincent

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, Mount Saint Vincent Care Center in Holyoke, Massachusetts received a rating of 3 out of 5 stars.

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

Fines Against Mount Saint Vincent Care Center

The Federal Government fined Mount Saint Vincent Care Center $19,883 in  September 29th, 2016 for health and safety violations.

Fines and Penalties

Our Nursing Home Abuse Lawyers inspected government records and discovered Mount Saint Vincent Care Center committed the following offenses:

Failed to tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #2) the facility failed to provide Resident #2 or their responsible person the bed hold notice policy at the time of transfer to hospital.

Findings include:

The Admission Record, dated 6/26/17, indicated Resident #2’s [DIAGNOSES REDACTED]. The Record indicated Resident #2’s primary payer source was Medicaid. The Facility Policy titled Appendix E, Bed Hold Policy, dateless, indicated Federal Regulations require that a nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed hold policy under the Medicaid state plan during which the resident is permitted to return and resume residency in the facility. This notice must be provided well in advance of any transfer and at the time of any transfer.

A Physician’s Interim/Telephone Order, date illegible, indicated to send Resident #2 to the hospital for evaluation via section 12 (an involuntary transfer to the hospital) and that Resident #2 may not return to the facility until a psychiatric placement is made. A Progress Note, dated at 17:38 (5:38 P.M.) on 6/30/17, indicated Resident #2 was transferred to the hospital at 17:45 (5:45 P.M.). There is no documentation in Resident #2’s medical record that a bed hold notice was provided to Resident #2 and or his/her legal representative at the time of transfer to the hospital on [DATE].

The Notice of Intent to Transfer or Discharge Resident with Less than 30 Days’ Notice (Expedited Appeal), dated 7/24/17, 24 days after Resident #2 was transferred to the hospital, indicated Resident #2 was transferred to the hospital on [DATE]. The Surveyor interviewed Nurse #2 at 9:14 A.M. on 9/21/17. Nurse #2 said she did not provide a bed hold notice to Resident #2 or to his/her family member or legal representative at the time of transfer to the hospital on [DATE]. The Surveyor interviewed Social Worker #1 at 11:13 A.M. on 9/11/17. Social Worker #1 said she did not provide a bed hold notice to Resident #2 or to his/her family member or legal representative at the time or transfer to the hospital on [DATE].

The Surveyor interviewed the Director of Social Services at 11:33 A.M. and 2:47 P.M. on 9/11/17. The Director of Social Services said bed hold notices are sent to resident’s legal representative when she knows that a resident has been admitted to a hospital. The Director of Social Services said she does not send the bed hold notice with the resident at the time of transfer to the hospital. The Director of Social Services said Resident #2’s bed hold notice was not given to Resident #2 and or his/her legal representative. The Director of Social Services said the Notice of Intent to Transfer or Discharge Resident with Less than 30 Days’ Notice (Expedited Appeal) was not sent to Resident #2 and or his/her legal representative until 7/24/17, 24 days after Resident #2 was transferred to the hospital.

The Surveyor interviewed the Administrator at 2:27 P.M. on 9/11/17. The Administrator provided the Surveyor with Appendix E, Bed Hold Policy, and said this was the current facility policy for bed holds and that it is provided to Residents on admission. The Administrator said the 30-day notice is given to residents at the time of discharge or a few days after discharge.

Failed to keep each resident free from physical restraints, unless needed for medical treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to identify the presence of a specific medical symptom that would require the use of a restraint and failed to initiate a restraint reduction plan for one sampled resident (#3) out of four applicable residents, in a total sample of 24 residents.

Findings include:

Review of the facility’s Policy for Restraints, dated 5/2008, indicated the following: Purpose: .utilize the lease restrictive device for residents and only as a means to maintain or assist a resident in reaching his/her highest practicable level of well-being. Guidelines:
-Physical restraints are limited to circumstances where medical symptoms warrant their use. They are never used for discipline, convenience .
-Physical restraints are used only with the written order of the physician .the physician order [REDACTED].
-The interdisciplinary team identifies the least restrictive restraint for use and develops a gradual restraint reduction plan.

The following documentation must occur with the use of a restraint:
*Pre-Restraint Assessment-indicates types of measures that have been attempted prior to the restraint application.
*Completion of a therapy screen for use of alternate positioning devices.
*physician’s orders [REDACTED].
*A restraint reduction plan with restraint reduction documented at least quarterly.

Resident #3 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Review of the current care plan for falls indicated an intervention for an alarmed seatbelt in the wheelchair due to agitation and restlessness which was initiated on 10/15/16. Review of the physician’s orders [REDACTED]. Ask resident to release belt daily. Review of the Admission Minimum Data Set (MDS) assessment, dated 11/6/16, indicated the resident had severe cognitive impairment, physical behaviors 1-3 times per week, rejected care 4-6 times per week, required extensive assist of two staff for transfers, and had no restraints. Review of the current care plan for restraints/devices indicated an intervention, initiated on 12/14/16, to assess the resident’s ability to release the seatbelt every shift.

Review of the Progress Notes indicated the resident was unable to release the alarmed seatbelt when asked to do so on the following dates: 11/21/16, 11/26/16, 11/28/16, 11/29/16, 11/30/16, 12/12/16, and 12/14/16. Review of the Quarterly MDS assessment, dated 2/26/17, indicated the resident had impaired short and long term memory and severely impaired decision making ability, rejected care 1-3 times per week, was dependent on staff for transfers, was non-ambulatory, and had no restraints.

Review of the Restraint/Assistive Device Assessment, dated 7/18/17, indicated the resident used an alarmed seatbelt in the wheelchair due to impulsivity, restlessness, and agitation from [DIAGNOSES REDACTED]. The boxes for attempt re-education/change and reassess in were both left blank. Review of the Quarterly MDS assessment, dated 7/21/17, indicated the resident had impaired short and long term memory and severely impaired decision making ability, had physical behaviors 1-3 times per week, rejected care 1-3 times per week, required extensive assistance of two staff for transfers, was non-ambulatory, and had no restraints.

Review of the 9/2017 Medication Administration Record [REDACTED]. The nurses initialed as being completed, but there was no documentation of whether or not the resident was able to release the belt on command. Review of the clinical record did not indicate that a restraint reduction plan was initiated as is required.

During the initial tour of the facility on 9/19/17, the resident was up and dressed in the wheelchair with alarmed seatbelt attached as he/she was being fed breakfast. During an observation on 9/22/17 at 9:15 A.M., the resident was being fed breakfast in the Solarium with alarmed seatbelt attached. During an observation on 9/22/17 at 12:15 P.M., the resident was in the Solarium with Certified Nurses Aide #4 who told the surveyor the resident sometimes tried to get out of the chair. In the presence of the surveyor, CNA #4 asked the resident twice to release the alarmed seatbelt and the resident was unable to release it both times. During an interview on 9/22/17 at 1:30 P.M., Unit Manager (UM) #1 said she thought the seatbelt was used for positioning but she wasn’t sure and she didn’t know there needed to be a medical [DIAGNOSES REDACTED].

During an interview on 9/22/17 at 4:40 P.M., with two other surveyors present, the Director of Nurses (DON) said the staff checked daily to see if the resident was able to self release the seatbelt. She said the seatbelt should have been considered a restraint when the resident couldn’t take it off on command in November 2016. She said there was no medical [DIAGNOSES REDACTED].

Failed to protect each resident from all abuse, physical punishment, and being separated from others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interviews and record reviews, the facility staff failed to ensure that 1 sampled residents (#19) and 1 Non-Sampled Resident (NS #1), were free from abuse, in a total of 24 sampled residents and 1 Non-Sampled Resident.

Findings include:

1. For Resident #19, the facility staff failed to ensure the resident was protected during an active investigation, and failed to report the allegation of abuse to the Department of Public Health (DPH), as required.

Resident #19 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 3/16/17, indicated that Resident #19 had severe cognitive impairment, exhibited no behaviors, and required assistance of 1 staff for transfers, ambulation and toileting. Review of the Nursing Note, dated 4/23/17 at 10:54 A.M., indicated Resident #19 called Nurse #5 to his/her room in the morning to report Certified Nurse Aide (CNA) #6 had answered his/her call bell and when the resident asked for assistance to use the bathroom, CNA #6 told the resident to get up and go, I have more problems then you will ever have. Nurse #5 documented that Resident #19 was very upset and did not want CNA #6 to take care of him/her again. Nurse #5 indicated she had contacted the Unit Manager to report the incident.

Review of the Nurses Note, dated 4/23/17 at 1:13 P.M., indicated Nurse #5 contacted the DON by phone to inform her of the incident that occurred earlier including Resident #19’s accusations and the testimony of a CNA who was also in the room at the time of the incident and heard the interaction. The note indicated the DON will look into the allegation and instructed that CNA #6 is not to take care of Resident #19 for that night. Review of the facility investigation, dated 4/23/17, indicated Resident #19 reported to Nurse #5 that CNA #6 was mean to him/her. Nurse #5 indicated that Resident #19 stated he/she rang for staff assistance and CNA #6 entered and said in an angry tone what do you want?, and that CNA #6 put her forehead on the resident’s forehead and said . you think you’re sick, I’ve had more problems then you ever had. Nurse #5 written statement indicated the resident indicated CNA #6 pulled hard on his/her right arm and made him/her grab the bar, and that CNA #6 knocked over his/her puzzle. Nurse #5’s written statement indicated Resident #19 was crying and shaking, and another staff member (CNA #7) had witnessed this.

Review of CNA #6 written statement, dated 4/23/17, indicated at 6:45 A.M., Resident #19 rang for assistance asking to be toileted, and she told him/her to get up. When Resident #19 said he/she couldn’t do it, CNA #6 told him/her that he/she could and had done it before. CNA #6 indicated she went to assist another CNA (CNA #7) in the same room, and Resident #19 kept saying he/she could not get up, so CNA #6 went to go help him/her. CNA #6 said she was getting the resident’s shoes and hit the over the bed table knocking over the resident’s puzzle by accident. CNA#6 said she put the resident’s shoe on and tried to help him/her sit up by putting her hand on the resident’s left shoulder to assist him/her and the resident started yelling that it hurt, so she removed her hand. CNA #6 indicated in the statement that she ambulated with the resident to the bathroom and when he/she sat down, she left the room and a day CNA (CNA #8) took over the resident’s care. Review of CNA #7’s written statement, dated 4/23/17, indicated that at 6:45 A.M., she was providing care to the the roommate of Resident #19 in the same room and overhead the interaction between Resident #19 and CNA #6. The written statement indicated CNA #6 entered the room and she heard Resident #19 say that he/she really had to use the bathroom. The written statement indicated she heard CNA #6 tell the resident to get up and when the resident asked for assistance, CNA #6 said no, you can do it yourself, you get up on your own all the time .hurry up, I still have people to do, I thought I was leaving on time today but you’re going to make me late. CNA #7 indicated in her written statement she heard Resident #19 start to cry and the she heard CNA #6 say you’re such an actor/actress, you should move to Hollywood. CNA #7 said she heard Resident #19 say you will be old like me one day and know how hard this is and indicated in the statement that CNA #6 said that she’s had major surgery and that she knows what its like. CNA #7 indicated in her written statement that she did not see any interaction because the privacy curtain was pulled. CNA #7 indicated in the written statement that CNA #6 left the room and CNA #8 took over Resident #19’s care.

Review of CNA #8’s written statement, dated 4/23/17, indicted that she entered Resident #19’s bathroom at 7:00 A.M., and the resident was shaking, crying and appeared frightened. The statement indicated Resident #19 reported that CNA #6 got in his/her face, forehead to forehead telling him/her that she has more problems then then the resident and he/she doesn’t know what sick is .she’s had major surgeries, and that CNA #6 grabbed him/her by the arm.

Review of Nurse #6 written statement, dated 4/23/17, indicated she heard Resident #19 yell, but was not concerned because he/she has behaviors. Review of the investigation summary, undated and unsigned, indicated CNA #6 was taken off the schedule the day after the reported incident (on 4/24/17).The summary indicated there were inconsistencies identified during the investigation. The investigation summary indicated Resident #19’s health care agent was contacted to discuss the findings of the investigation on 4/28/17 at 9:45 A.M.

Review of the Correction Action Form, signed by the DON and CNA #6 on 5/2/17, indicated CNA #6 received a documented verbal action for her witnessed statements to Resident #19 on 4/23/17. The form indicated CNA #6 admitted telling Resident #19 the he/she was making her late to get out of work, and that he/she should go to Hollywood, that he/she is such an actor/actress, and that she has had major surgeries so she knows what its like. The Corrective Action Form indicated CNA #6 received education regarding her interaction with Resident #19. During an interview on 9/26/17 at 3:10 P.M., with two other surveyors present, the DON said CNA #6 returned to work on 4/25/17, but was not allowed to care for Resident #19. The DON further said the investigation was completed sometime on 4/28/17, with a finding that there is no evidence that abuse occurred and therefore the incident was not reported to DPH. When the surveyor asked the DON if she would consider the witnessed statements and the admission of CNA #6 to Resident #19 to be abuse, the DON said yes. When the surveyor asked the DON if the facility policy was followed relative to protection of the resident during the investigation, the DON said they did not follow their policy. REFER TO F226

2. For Non-Sampled Resident (NS) #1 the facility staff failed to ensure the resident was free from repeated episodes of verbal abuse by his/her roommate, Resident #16. Resident #16 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. NS #1 was admitted to the facility in 5/2014 with [DIAGNOSES REDACTED]. Review of a Progress Note, dated 5/10/17, indicated NS #1 was very anxious. Further review indicated the resident and his/her roommate, Resident #16, had issues because Resident #16 believed that NS #1’s bed belonged to a family member. Review of a Progress Note, dated 6/17/17, indicated Resident #16 yelled at NS #1 that he/she did not belong in the room and their bed belonged to his/her granddaughter. Review of a Progress Note, dated 6/18/17, indicated that Resident #16 was acting out and caused NS #1 to shake. Resident #16 was removed and NS #1 regained his/her composure sitting quietly in his/her room.

Review of a Progress Note, dated 6/21/17 at 9:50 P.M., indicated Resident #16 yelled at NS #1 that he/she did not belong in the room and their bed belonged to his/her mother. Review of a Progress Note, dated 6/21/17 at 10:23 P.M., indicated NS #1 was extremely anxious about Resident #16’s behavior which caused him/her to bang the walker on the floor. NS #1 was moved to a different room within the facility for the night. Review of a Progress Note, dated 6/23/17, indicated Resident #16 yelled at NS #1 that he/she did not belong in the room. Review of a Progress Note, dated 6/27/17, indicated Resident #16 kicked bumper pads and thoroughly annoyed NS #1.

Review of a Progress Note, dated 7/8/17, indicated Resident #16 harassed NS #1 and told him/her to leave. Review of a Progress Note, dated 7/12/17 at 8:15 P.M., indicated Resident #16 yelled at NS #1 that he/she did not belong in their bed because the bed belonged to his/her spouse. NS #1 was escorted out of the room by staff and upon return the room was again yelled at by Resident #16. Review of a Progress Note, dated 7/12/17 at 10:01 P.M., indicated Resident #16 pulled the curtain that separated the beds and yelled at NS #1 that he/she did not belong in the room. Review of a Progress Note, dated 7/15/17, indicated Resident #16 yelled at NS #1 that he/she did not belong in the room. Review of a Progress Note, dated 7/21/17 at 8:27 P.M., indicated Resident #16 yelled at NS #1 that he/she did not belong in their bed. Review of a Progress Note, dated 7/21/17 at 8:50 P.M., indicated Resident #16 yelled at NS #1 that he/she did not belong in their bed. Resident #16 was redirected but then returned to the room and again yelled at NS #1, (3 incidents in one evening). Review of a Progress Note, dated 7/22/17 at 8:05 P.M., indicated Resident #16 yelled at NS #1 that he/she did not belong in their room.

Review of a Progress Note, dated 8/10/17, indicated the NS #1 had issues with Resident #16 because the he/she believed that NS #1’s bed belonged to a family member. The facility staff would offer a private room to Resident #16 when one was available. Further review of the clinical record did not indicate an intervention to keep NS #1 safe and free from verbal abuse, nor did it indicate that NS #1’s activated Health Care Proxy (HCP) was notified of the situation or offered alternative living arrangements. Review of a Progress Note, dated 8/31/17, indicated Resident #16 was transferred to a private room because he/she continued to have issues with NS #1. During an interview on 9/26/17 at 1:30 P.M., with two other surveyors present, Social Worker (SW) #1 said the above mentioned residents had lived in the same room for several months. She said they had been kept together until a private room became available. She said she thought both of the resident’s families knew about the situation but there was no documentation to reflect that. She said they were careful not to put Resident #16 in the same room with a resident who couldn’t get out on their own, and she didn’t think the situation was horrific. When the surveyor asked what other options or interventions were put in place to protect NS #1, SW #1 did not answer. During an interview on 9/26/17 at 2:00 P.M., the Director of Nurses said they were aware that Resident #16 had a difficult time with having a roommate but they were waiting for a private room to become available. She said she didn’t think NS #1 was bothered by being yelled at by Resident #16.

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 observations, interviews and record reviews, the facility staff failed to ensure their policies were followed for thorough investigations for 4 sampled residents (#3, #11, #16 and #19), in a total of 24 sampled residents.

Findings include:

Review of the facility Abuse, Neglect and/or Misappropriation of Resident Funds or Property Prohibition Policy, effective 9/2016, indicated the following:
-Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish
-Verbal abuse refers to any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance
-Mental abuse includes, but not limited to, humiliation, harassment, threats of punishment, deprivation -Injuries of unknown origin are classified as such when both of the following conditions are met:
-source of the injury was not witnessed by any person or the source of the injury could not be explained by the resident, and -the injury is suspicious because of the extent of the injury or the location of the injury
-Protection:
-if colleague is accused or suspected: immediately remove from the facility and the work schedule pending the outcome of the investigation
-Investigation: -interview the resident, the accused, and potential witnesses (may include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident
-all interviews should be summarized into a written statement, which is signed and dated Review of the facility Accidents/Incidents Unusual Occurrence Reports Policy, dated 5/2008, indicated the following:
-accidents or incidents/unusual occurrences involving residents .occurring on the premises must be investigated and reported to the administrator
-regardless of how minor an accident or unusual occurrence may be, including injuries of unknown source, it must be reported to the department supervisor as soon as such occurrence is discovered
-an occurrence report must be completed for all reported accidents/incident or unusual occurrences

1. For Resident #19, the facility staff failed to ensure the resident was protected during an active investigation by removing the accused CNA from the schedule. Resident #19 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 3/16/17, indicated that Resident #19 had severe cognitive impairment, exhibited no behaviors, and required assistance of 1 staff for transfers, ambulation and toileting. Review of the Nursing Note, dated 4/23/17 at 10:54 A.M., indicated Resident #19 called Nurse #5 to his/her room in the morning to report Certified Nurse Aide (CNA) #6 had answered his/her call bell and when the resident asked for assistance to use the bathroom, CNA #6 told the resident to get up and go, I have more problems then you will ever have. Nurse #5 documented that Resident #19 was very upset and did not want CNA #6 to take care of him/her again.

Review of the Nurses Note, dated 4/23/17 at 1:13 P.M., indicated Nurse #5 contacted the DON by phone to inform her of the incident that occurred earlier including Resident #19’s accusations and the testimony of a CNA who was also in the room at the time of the incident and heard the interaction. The note indicated the DON will look into the allegation and instructed that CNA #6 is not to take care of Resident #19 for that night. Review of the investigation summary, undated and unsigned, indicated CNA #6 was taken off the schedule for 4/24/17. The investigation summary indicated Resident #19’s health care agent was contacted to discuss the findings of the investigation on 4/28/17 at 9:45 A.M. Review of the facility schedule, dated 4/25/17 through 4/29/17, indicated CNA #6 worked third shift. Review of the Correction Action Form, signed by the DON and CNA #6 on 5/2/17, indicated CNA #6 received a documented verbal action for her witnessed statements to Resident #19 on 4/23/17.

During an observation on 9/26/17 at 9:45 A.M., Resident #19 was dressed and seated in a stationary chair in his/her room. During an interview on 9/26/17 at 3:10 P.M., with two other surveyors present, the DON said CNA #6 returned to work on 4/25/17, but was not allowed to care for Resident #19. The DON said the investigation was completed sometime on 4/28/17 with a finding that there is no evidence that abuse occurred.

2. For Resident #16 the facility staff failed to complete an investigation for injuries of unknown origin. Resident #16 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 7/28/17, indicated the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review indicated the resident required extensive assist of two staff for bed mobility, extensive assist of one staff for transfers, extensive assist of two staff for toilet use, and limited assist of one staff for ambulation in his/her room. Review of Progress Note, dated 9/4/17 at 6:57 P.M., indicated the resident had a bruise to the forehead that measured 0.5 centimeters (cm) x 0.6 cm and a complete skin check was done that revealed a large bruise to the right inner thigh that measured 14 cm x 14.5 cm and the resident was unable to say how the bruises occurred.

Review of the Incident Report, dated 9/4/17, indicated the resident had a bruise to the forehead and to the right front thigh. Further review indicated the following sections were left blank: Level of pain, Mental status and Predisposing environmental factors. Review of the witness statements indicated that two out of three caregivers asked to provide statements had not provided care to this resident since two weeks prior. Review of the Injury of Unknown Source Follow-Up, dated 9/4/17 (the same shift the injuries were discovered), indicated the bruise was on the right forehead and right inner thigh, also, the following questions were answered with unknown : -What might have caused the injury? -When and how was the resident last transferred? -When and how was the resident last repositioned? -After investigation, what do you conclude caused the injury? During the initial tour of the facility on 9/19/17 the resident was observed eating breakfast in his/her room. During an observation on 9/20/17 at 11:00 A.M., the resident was up and dressed in his/her wheelchair self propelling near the Nurses Station. During an interview on 9/26/17 at 12:00 P.M., with two other surveyors present, the Director of Nurses (DON) said the investigation regarding the bruises on 9/4/17 was done by the Unit Manager. She said the conclusion to the investigation was the resident puts books on his/her thigh which could have caused the bruise. The surveyor asked the DON if she herself had seen the bruises and the DON said no. The surveyor referenced the incident report that indicated the large bruise was on the inner thigh not the top of the thigh and also asked the DON what her conclusion was given both bruises (forehead and inner thigh) were in suspicious areas, the DON said the documentation was conflicting.

3. For Resident #11 the facility staff failed to initiate an investigation for a reported fall.

Resident #11 was admitted to the facility in 6/2012 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 2/3/17, indicated the resident had moderate impaired cognition with a BIMS score of 11 out of 15, was independent with transfers/toilet use, had no limitations in range of motion, and was able to turn around while walking but was unsteady. Review of a Progress Note, dated 2/17/17 at 2:13 P.M., indicated the resident reported to staff that he/she fell the night before. The light in the hall was on and the resident’s door was open so he/she got up to close the door and to turn a fan on. When the resident went to turn the fan on, he/she felt dizzy, lost their balance, and fell to their knees which resulted in a dark purple bruise to the right knee. Review of a weekly skin assessment, dated 2/17/17, indicated the resident had a dark purple bruise to the right knee that measured 3 centimeters (cm) x 2 cm. During an interview on 9/20/17 at 10:45 A.M., the DON said she couldn’t find an incident report regarding the reported fall on 2/17/17. She said the resident reported falling but the staff didn’t think he/she really did. The DON said the resident did have a bruise to the right knee and no incident report or investigation was done but a skin assessment was completed. During an interview on 9/20/17 at 10:55 A.M., Unit Manager (UM) #1 said the staff was aware of the right knee bruise. She said they didn’t do an incident report or start an investigation because if the resident had fallen the staff didn’t think he/she could get up on their own. During an interview on 9/20/17 at 11:15 A.M., UM #1 said the staff should have filled out an incident report and completed an investigation since the resident reported a fall and had an injury. During initial tour of the facility on 9/19/17, the resident was observed ambulating around his/her room with no assistive device. During an observation on 9/20/17 at 8:50 A.M., the resident was observed standing over the bedside table, cutting up his/her breakfast items, no assistive device in use.

4. For Resident #3 the facility staff failed to initiate an investigation for a resident to resident altercation. Resident #3 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Review of the Progress Note, dated 10/31/16, indicated the resident returned to the facility following an inpatient psychiatric hospital stay. The resident was combative, difficult to redirect, and hit another resident. During an interview on 9/20/17 at 8:30 A.M., the DON said there was no investigation done for the resident to resident altercation on 10/31/16 because she was pretty sure Resident #3 just tapped another resident. During an interview on 9/27/17 at 9:45 A.M., with DON and Administrator and two other surveyors present, the Administrator said multiple investigations had been identified as being incomplete and not all investigations were signed and dated by them, as their policy indicated. The Administrator said there was a breakdown in the process.

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 and interview, the facility staff failed to maintain dignity during dining by not assisting one sampled resident (#3) out of a total sample of 24 residents, to eat in a timely manner when all other tablemates were eating.

Findings include:

Resident #3 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. to use and understand language). Review of the current Activities of Daily Living care plan indicated an intervention, dated 10/6/16, to feed the resident at all meals. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 7/21/17, indicated the resident had impaired short and long term memory, severely impaired decision making ability, and was dependent on staff for eating. During an observation on 9/22/17 at 8:35 A.M. in the Solarium, the resident was dressed and seated in the wheelchair with seatbelt attached. At 8:45 A.M. the covered breakfast tray was placed in front of the resident. Continued observation indicated at 8:55 A.M. the covered breakfast tray remained in front of the resident while two other residents at the same table were being fed. Resident #3 reached forward to touch the breakfast tray and took two sugar packets off of the tray. Continued observation indicated at 9:15 A.M. (30 minutes after the breakfast tray was placed in front of the resident) Unit Manager (UM) #1 began to feed the resident. She did not offer to reheat the meal.

During an observation on 9/22/17 at 12:15 P.M. in the Solarium, the resident was dressed and seated in the wheelchair with seatbelt attached. At 12:25 P.M. the covered lunch tray was placed in front of the resident. Continued observation indicated that three out of five residents at Resident #3’s table required staff assistance to be fed. Two residents were feeding themselves and two residents were being fed while Resident #3 sat at the same table and watched. Continued observation indicated at 12:40 P.M. the resident reached for the covered lunch tray and UM #1 assigned a Certified Nurses Aide to feed him/her (15 minutes after the lunch tray was placed in front of the resident). During an observation on 9/26/17 at 8:35 A.M. in the Solarium, the resident was dressed and seated in the wheelchair. At 8:45 A.M. the covered breakfast tray was placed on a bedside table located behind the resident. Continued observation indicated the resident sat at the table while five other residents ate their breakfast, three fed themselves and two were being assisted by staff. Continued observation indicated at 9:15 A.M. the resident reached for the table and began playing with his/her clothing protector. A staff member then uncovered the breakfast tray and began to feed the resident (30 minutes after the tray had been delivered), and he did not offer to reheat the meal. During an interview on 9/26/17 at 9:25 A.M., the Director of Nurses said they do have mixed tables, some residents were able to feed themselves and others were not. She said the dining set up would be reviewed to be sure no residents had to wait long periods of time to eat.

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 record review and interview, the facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) Assessment relative to falls, for 2 residents (#5 and #10) in a total sample of 24 residents.

Findings include:

1. For Resident #5, the facility staff failed to code a non-injurious fall on a Quarterly MDS assessment. Resident #5 was admitted to the facility in 6/2014 with [DIAGNOSES REDACTED]. Review of the progress notes indicated the resident had falls on 11/14/16 and 12/11/16. Review of the quarterly MDS, with an assessment reference date of 1/27/17, indicated the resident had one fall since the last MDS. During an interview, on 9/26/17 at 4:15 P.M., the MDS Nurse said 2 falls without injury should have been coded on the 1/27/17 MDS. 2. For Resident #10, the facility staff failed to code a non-injurious fall on a significant change MDS assessment. Resident #10 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. Review of a facility incident report, dated 4/16/17, indicated the resident had a non-injurious fall. Review of the Significant Change of Status MDS Assessment, with an assessment reference date of 5/25/17, indicated the resident had not fallen since the last assessment. During an interview on 9/26/17 at 4:10 P.M., the MDS Nurse said the fall that occurred on 4/16/17 should have been coded on the 5/27/17 MDS.

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 observations, record review and interviews, the facility staff failed to develop, review and revise an individualized program of activities for 1 sampled resident (#10) in a total of 24 sampled residents.

Findings include:

Resident #10 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. Review of the Admission Activity Assessment, dated 12/5/16, indicated the section on Activity Pursuit Patterns was incomplete for 4 out of 10 activity interests. Review of the Interview for Activity Preferences in the Significant Change of Status Minimum Data Set (MDS) Assessment, dated 5/25/17, indicated the following activities were very important to the resident: listening to music, being around animals or pets, keeping up with the news, getting fresh air and participating in religious activities. Further review indicated impaired short and long term memory and moderately impaired decision making ability. The Care Area Assessment (CAA) indicated activities to be a potential area of concern and staff elected to develop a care plan.

Review of the interdisciplinary care plan did not indicate the resident’s activity preferences and did not include any goals or interventions to meet the individual activity/social needs of the resident. Review of the care card, printed 9/6/17, did not indicate any activity preferences or plans for engagement. Review of a Quarterly Activity Note, dated 9/1/17, indicated the resident was having crying episodes where he/she did not want to participate in activities and recommended the current activity care plan should continue. Review of a Care Plan Meeting Note, dated 9/5/17 indicated the resident no longer participated in activities. The meeting minutes indicated the team reviewed the care plan at that time.

On 9/20/17 at 10:30 A.M., the resident was observed sitting in his/her room watching TV and at 2:00 P.M., the resident was observed in bed. During an interview on 9/22/17 at 9:30 A.M., Certified Nurses Aide (CNA) #1 said the resident needs a lot of encouragement to participate in activities otherwise he/she will sit and watch the shopping channel on TV in his/her room. He said if he asks to bring the resident to bingo, he/she refuses. He said the resident likes to go to Happy Hour so they try to get him/her there once a week. On 9/22/17 at 11:15 A.M., the resident was observed sitting in his/her room watching TV and at 2:20 P.M., the resident was observed in bed. On 9/26/17 between 9:30 and 11:00 A.M. the resident was observed watching TV in his/her room or napping in the wheelchair.

During an interview on 9/26/17 at 2:30 P.M., Unit Manager (UM) #2 and the surveyor reviewed the current care plan as well as the history of all revised/discontinued interventions. UM #2 said she could not locate an activity plan, goal or interventions for Resident #10. During an interview on 9/26/17 at 4:00 P.M., with two surveyors present, the Activity Assistant (AA) reviewed the resident’s interdisciplinary care plan and said she wasn’t sure why there were no activity interventions. She said she usually adds interventions under an existing problem because the activity staff is not able to start a problem in the care plan software. The AA reviewed three months of activity participation sheets, and when the surveyor asked why the resident had only been invited to 3 activities since the beginning of the month, she said the resident had recent medication changes and has periods of weepiness so he/she is difficult to engage in activities. During an interview on 9/27/17 at 8:50 A.M., with two surveyors present, the Activity Director (AD) said an admission assessment is usually completed after the staff observes the resident and talks to the family. She said interventions are then added to existing areas of the care plan for engagement, usually under adjustment or cognitive deficits. After reviewing the resident’s current care plan, she said she wasn’t sure why there were no activity care plan or interventions in place. She said there was no other documentation that indicated which activities the resident should be encouraged to attend.

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 observations, interviews and record reviews, the facility staff failed to follow the plan of care for 4 sampled residents (#1, #3, #4, and #5), in a total of 24 sampled residents.

Findings include:

1. For Resident #1, the facility staff failed to ensure the plan of care was followed relative to the use of a chair alarm, personal alarm, and supervision with ambulation and toileting. Resident #1 was admitted to the facility in 3/2014 with [DIAGNOSES REDACTED]. Review of the Falls care plan, revised 3/13/15, indicated the resident was at risk for falls related to unsteady gait and wandering. The care plan included the following interventions: monitor safety during activities, non-skid tape in front of the recliner, staff to ensure resident is wearing appropriate footwear for ambulation, and staff to cue resident to keep walker near him/her and not across the room.

Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/22/16, indicated the resident had severe cognitive impairment, required assistance of 1 staff for transfers, toileting and dressing, supervision of 1 staff member for ambulation, utilized a walker and had unsteady balance requiring staff assistance to stabilize with transfers and ambulation. Review of the Falls care plan, revised 1/23/17, included the following interventions: ensure appropriate non-slip footwear at all times (non-slip socks to bed). Further review of the care plan included the following conflicting information: resident to keep walker near her (previous intervention from 3/13/15), and for the walker to be stored in the solarium when not in use.

Review of the facility investigation, dated 6/24/17, indicated the resident had a witnessed fall in his/her bathroom. The report indicated the resident’s knees started to bend and was lowered to the floor. The intervention added to the resident plan of care included: continue to ambulate with contact guard (staff member to stand beside resident) and use of a gait belt, use chair pad alarm and a personal (TAB) alarm while in the recliner.

Review of the Falls care plan, revised 6/29/17, indicated the following interventions: transfer with walker and assist of 1 staff member, bed alarm, chair pad alarm, and a personal alarm while in recliner/transport chair. Review of the facility investigation, dated 9/13/17, indicated the resident had an unwitnessed fall, in his/her room while ambulating to the bathroom. The report indicated that the resident’s walker was between the closet and the chair, and that the resident was sitting in the recliner prior to the fall. The report also indicated that the resident did not utilize the call bell to ask staff for assistance, nor did he/she utilize the walker to ambulate. The resident had a chair alarm in place, but the alarm did not sound, and also indicated that the resident was to have a personal alarm on him/her which was not in place at the time of the fall, as care planned. The interventions added to the resident plan of care after the fall included: staff to ensure chair pad alarm is properly placed in the recliner, and staff to ensure the walker is placed near the resident before leaving the resident’s room. Review of the active Falls care plan, revised 7/5/17, indicated the resident was to ambulate with contact guard, walker and a gait belt to all destinations, required assist of 1 staff with transfers with the use of the walker, utilized a bed alarm, chair pad alarm, cue resident to keep walker near her, staff to ensure walker is placed near the resident before leaving the room, do not leave in bathroom alone, and personal alarm while in recliner/transport chair.

Review of the Physical Therapy Discharge Summary, dated 7/14/17, indicated the resident was moderately independent with transfers and ambulation in his/her room with the use of a walker and required supervision for ambulation outside of his/her room. On 9/19/17 at 2:45 P.M., the surveyor observed Resident #1 standing in his/her room, opening drawers. The resident was dressed, had shoes on and a wanderguard on his/her walker. The surveyor observed the resident exit the bedroom and ambulate independently down the hallway with his/her walker to the main foyer. Upon entering the main foyer, the resident was directed by a staff member to sit in a stationary chair. There was no chair pad alarm in place, as care planned. On 9/19/17 at 3:40 P.M.- 3:45 P.M., the surveyor observed the resident ambulate from the stationary chair in the foyer to the bathroom across from the nursing station, enter the bathroom alone and exit 5 minutes later. There was no chair pad alarm in place or supervision provided in the bathroom, as care planned. On 9/22/17 at 7:55 A.M., the surveyor observed Resident #1 in his/her room, seated in the recliner. The walker was in placed in front of him/her. The resident had a seat cushion alarm, but there was no personal alarm on as care planned. On 9/22/17 at 11:25 A.M., the surveyor observed the resident ambulating with his/her walker down the hallway from his/her room towards a common bathroom at the end of the hallway. The resident entered the bathroom alone and closed the door. The surveyor noted there was no staff visible in the hallway at this time, nor was staff present in the bathroom with the resident, as care planned. During an interview on 9/22/17 at 12:30 P.M., Certified Nurse Aide (CNA) #2 said Resident #1 requires supervision (eyes on) while ambulating in the hallway and when using the bathroom. She said the resident requires a personal alarm while he/she is seated in the recliner. During an interview on 9/22/17 at 2:00 P.M., the Director of Nurses (DON) said the resident was to have a chair alarm and a personal alarm while seated in the recliner, and this is to alert the staff that the resident is ambulating so that staff can supervise him/her. The DON said that no alarms sounded in the 9/13/17 fall, and if the personal alarm was on at this time as care planned, it would be noted as sounding in the investigation.

2. For Resident #5, the facility staff failed to follow the Physician order [REDACTED]. Resident #5 was admitted to the facility in 6/2014 with [DIAGNOSES REDACTED]. Review of the 9/2017 physician’s orders [REDACTED]. On 9/19/17 at 11:45 A.M. and 2:55 P.M., the surveyor observed Resident #5 seated in a wheel chair across from the nurses station. The resident was dressed, was wearing shoes and had both his/her feet positioned on leg rests. On 9/20/17 at 8:20 A.M., the surveyor observed Resident #5 seated in a wheel chair in the hallway near a common bathroom. The resident was dressed and had on shoes. On 9/22/17 at 8:20 A.M., the surveyor observed Resident #5 seated in a wheel chair in the unit dining room eating breakfast. The resident was dressed and was wearing shoes. Review of the 9/2017 Treatment Administration Record (TAR), indicated an order to apply padding between the right great toe to keep pressure off second toe, keep shoe off (has soft slipper with cut out at toes), to check for placement every shift and change daily. Further review of the TAR indicated nursing staff signed off as completed on 9/19/17 through 9/22/17. During an interview on 9/22/17 at 9:00 A.M., Nurse #2 said Resident #5 receives a treatment to his/her feet daily, and he/she has a physician’s orders [REDACTED].#2 said that she has signed off on the TAR that the order is completed but also said that Resident #5 wears soft shoes and not the slippers as indicated in the Physician Orders. 3. For Resident #3 the facility staff failed to ensure a personal alarm was on as care planned to help prevent falls.

Resident #3 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 11/6/16, indicated the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 0 out of 15 and sustained a fall prior to admission. Review of the current falls care plan indicated an intervention for a personal alarm when in bed, initiated on 10/6/16. Review of an Incident Report, dated 11/21/16, indicated the resident was found on the floor in front of his/her bed and stated, I fell . Further review indicated the alarm was not on as ordered. Three out of three witness statements indicated the alarm was not on as ordered. During an interview on 9/20/17 at 8:30 A.M., the Director of Nurses (DON) said the alarm was not on at the time of the 11/21/16 fall. 4. For Resident #4 the facility staff failed to ensure Geri sleeves (sleeves worn to protect skin) were in place to prevent injury to bilateral arms as ordered. Resident #4 was admitted to the facility in 10/2015 with [DIAGNOSES REDACTED]. Review of the Significant Change of Status MDS assessment, dated 11/18/16, indicated the resident had impaired short and long term memory and severely impaired decision making ability.

Review of a Progress Note, dated 2/8/17, indicated the staff found a 2.5 centimeter (cm) x 5.5 cm dark blue bruise on the right upper extremity. Review of the Incident Report, dated 2/8/17, indicated the resident had a 2.5 centimeter (cm) x 5.5 cm dark blue bruise on the right upper extremity, and the staff concluded that the resident may have banged him/herself on furniture or a side rail. Review of the care plan for skin integrity, with a goal date on 11/7/17, indicated an intervention was initiated on 6/8/17 to ensure Geri sleeves are worn at all times. During an observation on 9/20/17 at 8:50 A.M., the resident was up and dressed in the wheelchair in the Solarium, Geri sleeves were not on. During an observation on 9/20/17 at 11:20 A.M., the resident was in an activity group in the Solarium, Geri sleeves were not on. During an observation on 9/20/17 at 2:20 P.M., the resident was in bed for a nap, Geri sleeves were not on. During an interview on 9/20/17 at 2:20 P.M., Certified Nurses Aide #4 said she often took care of the resident and the resident did not wear Geri sleeves. During an interview on 9/22/17 at 1:20 P.M., Unit Manager (UM) #1 said she was unaware the resident was supposed to wear Geri sleeves at all times.

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 ensure effective interventions were in place to prevent accidents for sampled 2 residents (#1 and #20), and failed to assess risk of entrapment from bed rails for 4 sampled residents (#3, #5, #10 and #17) out of a total of 24 sampled residents.

Findings include:

a. Review of the facility policy Accidents/Incidents/Unusual Occurrence Reports, dated 5/2008, indicated the following: -accident or incident/unusual occurrences involving residents, employees, or visitors occurring on the premises must be investigated and reported to the administrator -regardless of how minor an accident or unusual occurrence may be, including injuries of unknown source, it must be reported to the department supervisor as soon as such occurrence is discovered or when information is learned -an occurrence report must be completed for all reported accident/incident or unusual occurrences -the nurse supervisor/charge nurse/and or department director of supervisor must complete an immediate investigation of the occurrence -the following data, as it may apply, must be included on the Occurrence Report: a. the circumstances surrounding the accident or occurrence; b. any corrective action taken c. follow up information -a completed Occurrence report form must be submitted to the Director of Nursing (DON)/designee after the occurrence. The Administrator will also receive the report for review following the DON. -treatment and follow up interventions will be determined according to the practicing physician and the care giving team -Additional follow up investigations for unknown injuries or injuries of concern will be completed by the charge nurse/DON/designee and completed on a Proof of Investigation tool. This is a tool utilized for proof of investigation process.

1. For Resident #1, the facility staff failed to ensure effective interventions and supervision were in place to prevent falls. Resident #1 was admitted to the facility in 3/2014 with [DIAGNOSES REDACTED]. Review of the Falls care plan, revised 3/13/15, indicated the resident was at risk for falls related to unsteady gait and wandering. The care plan included the following interventions: monitor safety during activities, non-skid tape in front of the recliner, staff to ensure resident is wearing appropriate footwear for ambulation, and staff to cue resident to keep walker near him/her and not across the room. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/22/16, indicated the resident had severe cognitive impairment, required assistance of 1 staff for transfers, toileting and dressing, supervision of 1 staff member for ambulation, utilized a walker and had unsteady balance requiring staff assistance to stabilize with transfers and ambulation.

Review of the facility investigation, dated 1/10/17, indicated the resident had an unwitnessed fall in his/her room at 2:00 A.M. The resident was found on the floor next to his/her chair with slippers on. The resident was last seen sleeping in the recliner chair in his/her room. The resident stated he/she was walking to the bathroom and fell . The report indicated the resident had a chair alarm in place at the time of the fall, and that the alarm sounded. Further review of the report indicated that the resident was very forgetful, had poor safety awareness, and gets up without regards to the alarms or use of the call bell. The intervention added to the resident plan of care after the fall included: replace slippers with slipper socks. Review of the Falls care plan, revised 1/23/17, included the following interventions: ensure appropriate non-slip footwear at all times (non-slip socks to bed). Further review of the care plan included the following conflicting information: resident to keep walker near her (previous intervention from 3/13/15), and for the walker to be stored in the solarium when not in use.

Review of the Annual MDS Assessment, dated 1/14/17, indicated Resident #1 had severe cognitive impairment, required limited assist of one staff with transfers, toilet use and personal hygiene, utilized a walker, was occasionally incontinent of bowel and bladder, and had 1 fall with no injury during the assessment period. Review of the facility investigation, dated 6/24/17, indicated the resident had a witnessed fall in his/her bathroom. The report indicated the resident’s knees started to bend and the Resident was lowered to the floor. The intervention added to the resident plan of care included: continue to ambulate with contact guard (staff member to stand beside resident) and use of a gait belt, use chair pad alarm and a personal (TAB) alarm while in the recliner. Review of the Falls care plan, revised 6/29/17, indicated the following interventions: transfer with walker and assist of 1 staff member, bed alarm, chair pad alarm, and a personal alarm while in recliner/transport chair.

Review of the facility investigation, dated 9/13/17, indicated the resident had an unwitnessed fall, in his/her room while ambulating to the bathroom. The report indicated that the resident’s walker was between the closet and the chair, and that the resident was sitting in the recliner prior to the fall. The report also indicated that the resident did not utilize the call bell to ask staff for assistance, nor did he/she utilize the walker to ambulate. The resident had a chair alarm in place, but the alarm did not sound, and also indicated that the resident was to have a personal alarm on him/her which was not in place at the time of the fall. The interventions added to the resident plan of care after the fall included: staff to ensure chair pad alarm is properly placed in the recliner, and staff to ensure the walker is placed near the resident before leaving the resident’s room. Review of the active Falls care plan, revised 7/5/17, indicated the resident was to ambulate with contact guard, walker and a gait belt to all destinations, required assist of 1 staff with transfers with the use of the walker, utilized a bed alarm, chair pad alarm, cue resident to keep walker near her, staff to ensure walker is placed near the resident before leaving the room, do not leave in bathroom alone, and personal alarm while in recliner/transport chair.

Review of the Physical Therapy Discharge Summary, dated 7/14/17, indicated the resident was moderately independent with transfers and ambulation in his/her room with the use of a walker and required supervision for ambulation outside of his/her room. On 9/19/17 at 2:45 P.M., the surveyor observed Resident #1 standing in his/her room, opening drawers. The resident was dressed, had shoes on and a wanderguard on his/her walker. The surveyor observed the resident exit the bedroom and ambulate independently down the hallway with his/her walker to the main foyer. Upon entering the main foyer, the resident was directed by a staff member to sit in a stationary chair. There was no chair pad alarm in place, as care planned.

On 9/19/17 at 3:40 P.M.- 3:45 P.M., the surveyor observed the resident ambulate from the stationary chair in the foyer to the bathroom across from the nursing station, enter the bathroom alone and exit 5 minutes later. There was no chair pad alarm in place or supervision provided in the bathroom, as care planned. On 9/22/17 at 7:55 A.M., the surveyor observed Resident #1 in his/her room, seated in the recliner. The walker was in placed in front of him/her. The resident had a seat cushion alarm, but there was no personal alarm on as care planned. On 9/22/17 at 11:25 A.M., the surveyor observed the resident ambulating with his/her walker down the hallway from his/her room towards a common bathroom at the end of the hallway. The resident entered the bathroom alone and closed the door. The surveyor noted there was no staff visible in the hallway at this time, nor was staff present in the bathroom with the resident, as care planned. During an interview on 9/22/17 at 12:30 P.M., Certified Nurse Aide (CNA) #2 said Resident #1 requires supervision (eyes on) while ambulating in the hallway and when using the bathroom. She said the resident requires a personal alarm while he/she is seated in the recliner.

During an interview on 9/22/17 at 2:00 P.M., the Director of Nurses (DON) said that the resident could sometimes remember to use walker, sometimes not, but also said the intervention to cue/remind a resident with severe cognitive impairment to have his/her walker near them is not an appropriate intervention. She said that the resident was to have a chair alarm and a personal alarm while seated in the recliner, and this is to alert the staff that the resident is ambulating so that staff can supervise him/her. The DON said that no alarms sounded in the 9/13/17 fall, and if the personal alarm was on at this time as care planned, it would be noted as sounding in the investigation. 2. For Resident #20, the facility staff failed to ensure effective interventions were in place to prevent multiple skin tears.

Resident #20 was admitted to the facility in 2/2013 with [DIAGNOSES REDACTED]. Review of the Skin Integrity care plan, revised 10/14/16, indicated Resident #20 was at risk for skin breakdown related to incontinence and decreased mobility due to vascular dementia. Interventions included the following: encourage intake of fluids and nutrition, monitor skin for breakdown and report changes to charge nurse and physician. Review of the Quarterly MDS Assessment, dated 12/10/16, indicated Resident #20 had moderate cognitive impairment, was non-ambulatory, and required extensive assistance from 1 staff for dressing and personal hygiene.

Review of the facility investigation, dated 5/24/17, indicated Resident #20 had four skin tears found by his/her family on his/her left forearm, measuring 2.0 centimeters (cm), 1.5 cm, 0.8 cm, and 2.0 cm. The investigation indicated the resident was recently repositioned by staff, nails were trimmed, and had dry, tenting and fragile skin. The conclusion of the investigation indicated the cause of the injury was the resident’s side rail. There was no intervention that was added to the resident’s plan of care to prevent further reoccurrence noted on the investigation or in the resident’s plan of care. Review of the facility investigation, dated 7/16/17, indicated Resident #20 had a skin tear to his/her left elbow found by his/her family. The report indicated the resident and the family member stated the skin tear was caused by the side rail. There was no intervention that was added to the resident’s plan of care to prevent further reoccurrence noted on the investigation or in the resident’s plan of care.

Review of the Significant Change in Status (COS) MDS Assessment, dated 8/19/17, indicated Resident #20 had severe cognitive impairment, required extensive assistance of 1 staff for transfers, dressing and personal hygiene, and was at risk for developing pressure ulcers. On 9/26/17 at 9:05 A.M., the surveyor observed Resident #20 lying in bed, with his/her eyes closed. Bilateral half side rails were in the up position. During an interview on 9/27/17 at 9:35 A.M., the DON said that there were no new interventions that were added to the resident’s plan of care after the 5/24/17 and 7/16/17 skin incidents to prevent further reoccurrence.

3. For Resident #5, the facility staff failed to ensure that the safety of the bedrails were assessed for entrapment. Resident #5 was admitted to the facility in 6/2014 with [DIAGNOSES REDACTED]. Review of the Restraint/Assistive Device Assessment, dated 7/5/17, indicated Resident #5 did not utilize side rails. On 9/22/17 at 7:55 A.M., the surveyor observed Resident #5 lying in bed with his/her eyes closed. Bilateral half rails with in place. Review of the clinical record did not indicate there was a safety assessment completed for the risk of entrapment, as required.

4. For Resident #3 the facility staff failed to ensure that the safety of the bedrails were assessed for entrapment. Resident #3 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. Review of the Restraint/Assistive Device Assessment, dated 8/11/17, indicated that the resident used 2 1/2 bedrails as an enabling device to provide stabilization during care and to aide with positioning. During an observation on 9/19/17 at 11:15 A.M., the resident was in bed with covers on, bilateral 1/2 bedrails up with mat on the floor next to the bed. Review of the clinical record did not indicate there was a safety assessment completed for the risk of entrapment, as required.

5. For Resident # 10, the facility staff failed to ensure that the safety of the bedrails were assessed for entrapment. Resident #10 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. Review of a written consent form, undated, indicated the use of 2 half bedrails when in bed to aid in repositioning. During the initial tour on 9/19/17 and on 9/20/17 at 2:00 P.M , the surveyor observed the resident in bed with 2 quarter bed rails in use. Review of the clinical record did not indicate any safety assessment was completed for the risk of bed rail entrapment, as required.

6. For Resident # 17, the facility staff failed to ensure that the safety of the bedrails were assessed for entrapment. Resident #17 was admitted to the facility in 7/2015 with [DIAGNOSES REDACTED]. Review of a written consent form indicated the use of 2 half bedrails when in bed, to aid in repositioning. Review of the clinical record did not indicate any safety assessment was completed for the risk of bed rail entrapment, as required. On 9/26/17 at 10:05 A.M.,, the surveyor observed the resident in bed with 2 quarter bed rails in use. During an interview on 9/22/17 at 1:45 P.M., the DON said the Maintenance Department assessed the side rails for safety in relation to the bed, but did not assess the safety of the resident while in the bed. She further said that there is no assessment to look at the entrapment risk of an individual resident who utilize side rails.

Failed to provide routine and 24-hour emergency dental care 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 one sampled resident (#7) received replacement partial dentures, out of a total sample of 24 residents.

Findings include:

Resident #7 was admitted to the facility in 9/2009 with [DIAGNOSES REDACTED]. Review of the Progress Note, dated 12/29/16, indicated the resident’s Health Care Proxy (HCP) requested the resident receive maximum dental care including replacement of a partial denture that was lost during a hospitalization in 2015. Review of the Dental Consult, dated 1/20/17, indicated the resident needed new dentures and was missing enough teeth to warrant a denture. Review of the Progress Note, dated 3/31/17, indicated the facility’s business office received a call from the dental office that the resident had been fitted for dentures and the dental office was waiting for a consent form. Further review indicated that Unit Manager (UM) #1 was notified of this and reported that the resident was doing fine with the dentures (resident didn’t have dentures) and the resident did not need to proceed with the partial dentures.

Observation of the resident on 9/19/17 at 2:05 P.M., indicated the resident self propelled the wheelchair to the surveyor and said, I am tired as I imagine everyone is. The resident was missing several front teeth, no partials were in place. Observation of the resident on 9/19/17 at 3:10 P.M., indicated the resident in his/her wheelchair, came to the surveyor to ask where the bus was. The resident was missing several front teeth, no partials were in place. During an interview on 9/20/17 at 12:20 P.M., UM #1 said the resident’s partial dentures were lost at the hospital in 2015 and were never replaced by the hospital or the facility. She said the resident didn’t wear or have partials and she didn’t remember when the HCP requested the replacements. She said a follow up should have been done and it wasn’t.

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

Based on record review and interviews, the facility staff failed to maintain an accurate medical record for 1 sampled resident (#10) in a total of 24 sampled residents.

Findings include:

Resident #10 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. The resident was enrolled in a Program of All-Inclusive Care for the Elderly (PACE). Review of a signed Physician Order, dated 12/14/16, indicated the request for a mental health consult. Review of a progress note, dated 12/28/17, indicated the mental health practitioner was unable to see the resident because PACE authorization had not yet been obtained. Further review of the record indicated the mental health consult was not authorized until 4/2017.

During an interview on 9/26/17 at 2:30 P.M. Unit Manager (UM) #2 said the Physician made medication changes while awaiting authorization from PACE to proceed with the mental health consult. Review of the record indicated there were no Nurse Practitioner or MD notes indicating what medication changes had occurred. UM #2 contacted PACE and they faxed over documentation of visits provided on 2/20/17, 4/21/17, and 5/9/17. The fax also included documentation for 8 LICSW visits provided since admission, that were not accessible in the facility’s record Review of a Physical Therapy Screen (performed by the facility therapy department), dated 2/14/17, indicated the resident had a significant decline in the ability to ambulate. Further review indicated the PACE program was contacted to request authorization to provide therapy services due to a decline in the resident’s ability to ambulate.

Review of a progress note, dated 2/23/17, indicated the resident had been assessed by a physical therapist from the PACE program. Further review of the record indicated there was no documentation of the therapy assessment or recommendations. During an interview, on 9/26/17 at 2:30 P.M., UM #2 said the PACE therapy consults were not kept in the facility record. She contacted PACE on 9/26/17 and received documentation by fax. Review of the faxed records indicated the facility record did not include information from the 11 therapy consultations provided since admission. Review of the faxed PACE therapy documentation (previously not accessible to the facility staff), indicated the resident sustained [REDACTED]. Further review of the nursing notes did not indicate any documentation of a fall on 4/16/17. At the request of the surveyor, the Director of Nursing provided a copy of an Incident report for the 4/16/17 fall. During an interview with UM #2, she said the fall incident may have been classified improperly in the software which in turn failed to generate a progress note or trigger the necessary follow-up assessments.

Mount Saint Vincent Care Center, Nursing Home Neglect and Elder Abuse Lawyers

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

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

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

Boston Personal Injury Lawyers for Elder Abuse Cases

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


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Page Last Updated: January 21, 2018

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