Sachem Center for Health & Rehabilitation

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Sachem Center for Health & Rehabilitation? 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 Sachem Center for Health & Rehabilitation

Sachem Center for Health & Rehabilitation is a for profit, 111-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of East Bridgewater, Bridgewater, Whitman,  Brockton, Hanson, Abington, Rockland, Pembroke, Raynham, Easton, and the other towns in and surrounding Plymouth County, Massachusetts.

Sachem Center for Health & Rehabilitation
66 Central St,
East Bridgewater, MA 02333

Phone: (508) 378-7227
Website: http://sachemcenterrehab.com/

CMS Star Quality Rating

The Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2018, Sachem Center for Health & Rehabilitation in East Bridgewater, 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 Against Sachem Center for Health & Rehabilitation

The Federal Government has not fined Sachem Center for Health & Rehabilitation in the last 3 years..

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Sachem Center for Health & Rehabilitation committed the following offenses:

Failed to tell the resident completely about his or her health status, care and treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain informed written consent for the use of [MEDICAL CONDITION] medications including antidepressants, anxiolytics and antipsychotics prior to administration as required for 7 Residents (#2, #4, #9, #10, #13, #14 and #17) out of a total sample of 20 Residents.

Findings include:

1. For Resident #2, the facility failed to obtain informed written consent from the Resident’s activated health care proxy prior to administration of [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (axiolytic/sedative/hypnotic), [MEDICATION NAME] (anxiolytic/sedative/hypnotic) and [MEDICATION NAME] (used for mood stabilization). The medical record was reviewed on 1/12/16. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 11/23/16, indicated that Resident #2 had severe cognitive impairment as evidenced by a score of 3 out of 15 on the Brief Interview for Mental Status, was dependent on staff for activities of daily living, took antipsychotic, antianxiety and antidepressant medications and had an activated health care proxy.

Resident #2 was admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. Review of January 2017 signed physician’s orders [REDACTED].#3 had orders for [MEDICATION NAME] (antipsychotic) 10 milligrams (mg) daily at bedtime (initiated 5/31/16), [MEDICATION NAME] (anxiolytic/sedative/hypnotic) 10 mg, 2 tablets for a total dose of 20 mg twice daily (initiated 6/15/16), [MEDICATION NAME] (used for mood stabilization) 50 mg twice daily (initiated 5/20/16), [MEDICATION NAME] (used for mood stabilization) 250 mg, 3 tablets twice daily (initiated 5/20/16), [MEDICATION NAME] 250 mg once daily (initiated 5/20/16) and [MEDICATION NAME] .05 mg twice daily as needed (initiated 11/15/16). Further review of the medical record failed to indicate that informed written consent from the Resident’s health care proxy was obtained for the administration of the above noted [MEDICAL CONDITION] medications as required.

During interview with Unit Manager #3 on 1/13/17 at 9:15 A.M., she said that she was unaware that written informed consents was required prior to administration of [MEDICAL CONDITION] medication. 2. For Resident #4, the facility failed to obtain informed written consent from the Resident’s legal guardian prior to administration of [MEDICATION NAME] (used for mood stabilization).

The medical record was reviewed on 1/12/16. Resident #4 was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS with a reference date of 10/27/16, indicated that Resident #4 had severe cognitive impairment, required extensive assistance from staff for all activities of daily living, took antipsychotic and , antidepressant medications, and had a legal guardian.

Review of January 2017 signed physician’s orders [REDACTED].#4 had orders for [MEDICATION NAME] 375 mg daily at bedtime (initiated 12/27/15). Further review of the medical record failed to indicate that informed written consent from the Resident’s legal guardian was obtained for the administration of the above noted [MEDICAL CONDITION] medications as required. During interview with Unit Manager #3 on 1/13/17 at 9:15 A.M., she said that she was unaware that written informed consents was required prior to administration of [MEDICAL CONDITION] medication.

3. Resident #9 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. The medical record was reviewed on 1/11/17. The admission MDS was not yet completed. Review of January 2017 physician’s orders [REDACTED]. Review of the January 2017 Medication Administration Record [REDACTED]. Further review of the medical record failed to indicate that informed written consent had been obtained for the medication [MEDICATION NAME] prior to its administration. During interview with Unit Manager #3 on 1/13/17 at 9:15 A.M., she said that she did not obtain written informed consent prior to administration of [MEDICAL CONDITION] medication.

4. For Resident #10, the facility failed to obtain informed written consent from the Resident’s legal guardian for the administration of [MEDICATION NAME] (nerve pain medication also used in the treatment of [REDACTED]. The medical record was reviewed on 1/13/17. Resident #10 was admitted to the facility in 5/2015 with [DIAGNOSES REDACTED]. Review of the most recent significant change MDS with a reference date of 11/3/16, indicated that Resident #10 was cognitively intact, was dependent for all activities of daily living and had a legal guardian. Review of January 2017 physician’s orders [REDACTED]. Review of the facility’s psychiatric consultant’s progress note dated 6/14/16, indicated that Resident #10 was prescribed [MEDICATION NAME] for the treatment of [REDACTED]. Further review of the medical record failed to indicate that informed written consent from the Resident’s legal guardian was obtained for the administration of the above noted [MEDICAL CONDITION] medications as required. During interview with Unit Manager #3 on 1/13/17 at 9:15 A.M., she said that she was unaware that written informed consents was required prior to administration of [MEDICAL CONDITION] medication.

5. For Resident #13, the facility failed to obtain informed written consent from the Resident’s legal guardian prior to administration of [MEDICATION NAME] (used in the treatment of [REDACTED]. The medical record was reviewed on 1/17/17. Resident #13 was admitted to the facility in 3/2014 with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS with a reference date of 11/17/16, indicated that Resident #13 had severe cognitive impairment as indicated by a score of 1 out of 15 on the BIMS, required assistance from staff for all activities of daily living, and had a legal guardian. Review of January 2017 signed physician’s orders [REDACTED].M. and 125 mg daily at bedtime. Review of the facility’s psychiatric consultant’s progress notes dated 9/29/15, indicated that Resident #13 was prescribed [MEDICATION NAME] for the treatment of [REDACTED]. Further review of the medical record failed to indicate that informed written consent from the Resident’s legal guardian was obtained for the administration of the above noted [MEDICAL CONDITION] medication as required. During interview with Unit Manager #3 on 1/17/17 at 1:45 P.M., she said that she was unaware that written informed consents was required prior to administration of [MEDICAL CONDITION] medication.

6. For Resident #14, the facility failed to obtain informed written consent from the Resident’s legal guardian prior to administration of [MEDICATION NAME] (used for mood stabilization) and [MEDICATION NAME] (antidepressant) as required. The medical record was reviewed 1/17/17. Resident #14 was admitted to the facility in 8/2010 with [DIAGNOSES REDACTED]. Review of the most recent significant change MDS dated [DATE], indicated that Resident #14 had severe cognitive impairment as evidenced by a score of 0 out of 15 on the BIMS, required assistance from staff for activities of daily living and had a legal guardian. Review of the January 2017 signed physician’s orders [REDACTED]. Further review of the medical record failed to indicate that informed written consent from the legal guardian was obtained for the administration of the above noted medications as required. During interview with Unit Manager #3 on 1/17/17 at 1:45 P.M., she said that she was unaware that written informed consents was required prior to administration of [MEDICAL CONDITION] medication.

7. Resident #17 was admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. The medical record was reviewed on 1/17/17. Review of the quarterly MDS with an assessment date of 11/24/16, indicated the was capable of understanding, making self understood and had no cognitive deficits. Record review indicated that on 11/15/16, the physician ordered the antidepressant medication [MEDICATION NAME] 25 mg at hour of sleep. Review of the medical record failed to indicate that informed written consent had been obtained from the Resident for the medication [MEDICATION NAME] prior to its administration, beginning in 11/2016. Review of the Medication Administration Records from 11/2016 through 1/2017 indicated that [MEDICATION NAME] 25 mg daily had been administered as ordered. During interview on 1/17/17 at 11:00 A.M., Resident #17 said he/she did not know what medications he/she was receiving. Resident #17 said that he/she did not recall being informed of any medication changes and/or additions of medications. During discussion with the Director of Nurses on 1/17/17 at 2:00 P.M., Surveyor shared concern that the medication [MEDICATION NAME] was started without evidence of consent. The Director said he/she would follow up with staff.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician and the Resident’s responsible person of changes in condition for 4 Residents (#4, #10, #13, #14) out of a total sample of 20 Residents.

Findings include:

1. For Resident #4, the facility failed to notify the physician and legal guardian of a.) his/her refusal to take medication on 12 separate occasions, and b.) failed to notify the legal guardian of changes in condition on 2 occasions which resulted in the commencement of new treatment. Resident #4 was admitted to the facility in 3/2015 with [DIAGNOSES REDACTED]. The medical record was reviewed on 1/12/17. Review of the most recent quarterly MDS with a reference date of 10/27/16, indicated that Resident #4 had severe cognitive impairment, required extensive assistance from staff for all activities of daily living, took antipsychotic, and antidepressant medications, and had a legal guardian.

a.) Review of October 2017 through January 2017 nursing progress notes indicated that Resident #4 refused, spitting out, or threw on the floor medications on the following dates: 10/18/16 – (3-8 P.M.) Resident refused medication (which included anxiolytic, antidepressant and antipsychotic medications). 11/1/16 – (3-7 P.M.) Resident took some medication and spit out some. Unable to ascertain how much he/she retained (included anxiolytic, antidepressant and antipsychotic medications). 11/5/16 – (3-11 P.M.) Resident spit out all 6:00 P.M. medication (which included anxiolytic, antidepressant and antipsychotic medications). 11/16/16 – (3-11 P.M.) Resident refused 6:00 P.M. medication multiple times (which included anxiolytic, antidepressant and antipsychotic medications). 12/10/16 – Resident spit out all of his/her A.M. medications; attempted 3 times and continued to refuse (which included antipsychotic medications). 12/21/16 – Resident threw pill on the floor in the afternoon. 12/23/16 – (3-11 P.M.) Resident refused 6:00 P.M. medication; attempted 3 times (which included anxiolytic, antidepressant and antipsychotic medications). 12/25/16 – Resident took some morning medication and spit some out (which included antipsychotic medication). 12/31/16 – Resident spits out or throws them on the floor (which included anxiolytic, antidepressant and antipsychotic medications). 1/1/17 – (3-11 P.M.) Resident continues to spit out medication or throwing them on the floor (which included anxiolytic, antidepressant and antipsychotic medications). 1/5/17 – (7-3 P.M.) Resident refused medication after 6 attempts (which included anxiolytic, antidepressant and antipsychotic medications). 1/10/17 – (3-11 P.M.) Resident spit out all medication (which included anxiolytic, antidepressant and antipsychotic medications). Further review of the medical record failed to provide documented evidence that either Resident #4’s physician or legal guardian were notified of the Resident’s refusal to take medications on 12 separate occasions as required.

b.) Review of the medical record indicated that on 12/21/16, Resident #4 was diagnosed with [REDACTED]. Additionally, on 1/11/17, Resident #4 was diagnosed with [REDACTED]. Further review of the medical record failed to include documented evidence that the legal guardian was informed of the changes in condition and subsequent treatments on 12/21/16 and 1/11/17. During interview with Unit Manager #3 on 1/17/17 at 1:45 P.M., she could not say if the legal guardians were informed of the Residents’ changes in condition and commencement of new treatments.

2. For Resident #10, the facility failed to notify the legal guardian of changes in condition on 3 occasions which resulted in the commencement of new treatment. Resident #10 was admitted to the facility in 5/2015 with [DIAGNOSES REDACTED]. The medical record was reviewed on 1/13/17. Review of the most recent significant change MDS with a reference date of 11/3/16, indicated that Resident #10 was cognitively intact, was dependent for all activities of daily living and had a legal guardian. Review of the medical record indicated that on 8/4/16, Resident #10 complained of feeling sick, having chills, an had an elevated temperature of 100.6. The Nurse Practitioner (NP) ordered a chest X-ray which revealed right mid lung pneumonia and ordered [MEDICATION NAME] (antibiotic) 750 mg daily for 7 days and [MEDICATION NAME] 250 mg daily for 10 days.

Additionally, on 9/28/16, Resident #10 complained of shortness of breath, had an elevated temperature of 100.7 and had a decreased oxygen saturation level. The NP ordered a chest X-ray which revealed right lower lobe pneumonia. The physician ordered [MEDICATION NAME] 750 mg daily for 7 days and [MEDICATION NAME] 250 mg for 10 days. Review of the medical record indicated on 10/18/16, Resident #10 was seen by the facility’s psychiatric consultant service to review his/her medication regimen. The consultant recommended to discontinue [MEDICATION NAME] 7.5 mg at bedtime, due to increased drowsiness reported by staff. The physician agreed with this recommendation and the medication was discontinued. Further review of the medical record failed to include documented evidence that the Resident’s legal guardian was informed of the changes in condition, subsequent commencement of new treatments and the discontinuation of an antidepressant medication as required.

3. For Resident #13, the facility failed to notify the legal guardian of changes in condition which resulted in the commencement of a new treatment and abnormal lab results which initiated a discontinuation of medication. The medical record was reviewed on 1/17/17. Resident #13 was admitted to the facility in 3/2014 with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS with a reference date of 11/17/16, indicated that Resident #13 had severe cognitive impairment as indicated by a score of 1 out of 15 on the BIMS, required assistance from staff for all activities of daily living, and had a legal guardian.

a.) Review of the medical record indicated a physician’s orders [REDACTED]. Further review of the medical record failed to include documented evidence that the Resident’s legal guardian was informed of the change in condition and subsequent commencement of a new treatment as required.

b.) Review of the medical record indicated that after reviewing Resident #13’s lab results on 10/17/16 and identifying abnormal results (elevated liver function), the NP discontinued an order for [REDACTED].>Further review of the medical record failed to include documented evidence that the legal guardian was informed of the change in condition, subsequent commencement of a new treatment, abnormal lab results and discontinuation of a medication.

4. For Resident #14, the facility failed to notify the legal guardian of changes in condition on 2 occasions which resulted in the commencement of a new treatment . The medical record was reviewed 1/17/17. Resident #14 was admitted to the facility in 8/2010 with [DIAGNOSES REDACTED]. Review of the most recent significant change MDS dated [DATE], indicated that Resident #14 had severe cognitive impairment as evidenced by a score of 0 out of 15 on the BIMS, required assistance from staff for activities of daily living and had a legal guardian.

a.) Review of the medical record indicated a new order on 6/4/16 [MEDICATION NAME] mg twice daily for 10 days and [MEDICATION NAME] 250 mg daily for 14 days for the treatment of [REDACTED].

b.) Review of nursing progress notes indicated on 11/30/16, Resident #14 was noted to have a red, swollen, and tender to the touch skin area with a blister on his/her right hand thumb nail. The NP was alerted and gave an order for [REDACTED]. Further review of the medical record failed to include documented evidence that the legal guardian was informed of the changes in condition, subsequent commencement of new treatments.

During interview with Unit Manager #3 on 1/17/17 at 1:45 P.M., she could not say if the legal guardians were informed of the Residents’ changes in condition, commencement of new treatments and medication changes.

Failed to provide medically-related social services to help each resident achieve the highest possible quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that adequate and timely social services were provided to ensure that a petition with a Resident’s guardian for advance directives was acted upon for 1 Resident on Hospice services (#14) out of a total sample of 20 residents.

Findings include:

The medical record was reviewed 1/17/17. Resident #14 was admitted to the facility in 8/2010 with [DIAGNOSES REDACTED]. Review of the most recent significant change MDS dated [DATE], indicated that Resident #14 had severe cognitive impairment as evidenced by a score of 0 out of 15 on the BIMS, required assistance from staff for activities of daily living, had a legal guardian, had no identified advance directives and was on Hospice.

Review of the medical record indicated that Resident #14 was admitted to Hospice services on 10/27/16 due to a progressive decline in the Resident’s condition. Review of a 10/27/16 social service progress note indicated that the social worker was going to contact #14’s legal guardian/attorney to alert her of the need to start a petition for a do not resuscitate (DNR) code status because the Resident was now on Hospice services. There was no documented evidence in the medical record that the social worker followed up with the attorney regarding changing Resident #14’s advance directive status.

Review of the care plan for advanced directives, last reviewed 7/2016 (with a target date of 10/2016), indicated that Resident #14 had a legal guardian responsible for making informed consent regarding health care decisions, and that the Resident did not have an advance directive. Further review of the medical record failed to indicate that the petition for a DNR had been initiated.

During interview with the facility social worker (SW) on 1/17/17 at 12:30 P.M., she reviewed documents related to Resident #14’s guardianship and was unable to locate documents regarding the petition for a DNR. At 1:05 P.M., the SW said that she had contacted Resident #14’s legal guardian and was told that they never received the petition from the facility and no one had contacted her office regarding the Resident’s advance directive status. The facility failed to provide adequate social service interventions to ensure that the Resident’s advance directive status was identified and authorized by the legal guardian prior to Surveyor inquiry.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure nursing staff provided services in accordance with professional standards of quality for 5 Residents (#1, #6, #8, #11 and #16) out of a total sample of 20 residents. Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice.

Findings include:

1. For Resident #1, the facility staff failed to follow medication standards to ensure the sliding scale insulin was administered correctly. Resident #1 was admitted to the Facility in 4/2016 and his/her [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/20/16, indicated that Resident #1 was cognitively impaired with a BIMS (Brief Interview for Mental Status)score of 8 out of 15, and he/she required limited assistance with all activity of daily living skills.

Review of the current 1/2016 Physician’s orders, indicated that Resident #1 had an order for [REDACTED]. The Physician’s order indicated that the blood glucose levels were to be obtained at 6:00 A.M., 12:00 P.M., 5:00 P.M. and 9:00 P.M. Review of the sliding scale order indicated the following:

Blood Sugars (BS) less than 70 call the physician.
150-200=2 units
201-250= 4 units
251-300=6 units
301-350= 8 units
351-400= 10 units
BS above 400 call the physician.

The medical record was reviewed on 1/18/17. Review of the Medication Administration Records (MAR), the Diabetic Monitoring Flow Sheet records and the nursing notes for 8/2016, 9/2016, 10/2016, 11/2016 and 1/2017, indicated that staff failed to follow medication standards to ensure the sliding scale was administered correctly.

The medical record indicated that the nursing staff either did not administer the sliding scale insulin, as ordered and/or administered the incorrect dose. In addition, the documentation for the administration was not standardized, as staff did not document consistently on any of the administration forms available in the medical record. For example, a nurse may document the BS and the insulin dose amount on the MAR, but not the Diabetic Flow Sheet, another nurse may document in a nurse’s note but not the MAR and/or Diabetic Flow sheet. Record review revealed the following August 2016 On 8/1/16 at 6:00 A.M., Resident #1’s blood glucose level was 196, and according to the sliding scale, the Insulin coverage should have been 2 units. Record review indicated that there was no documented Insulin coverage.

On 8/5/16 at 12:00 P.M., the BS level was 176. According to the sliding scale the Resident should have received 2 units, however the record failed to document that Insulin coverage was administered.

On 8/7/16 at 6:00 A.M., the BS was 176, and there was no evidence that the 2 units of Insulin was administered. On

8/8/16 at 6:00 A.M., the BS was 172, at 5:00 P.M. the BS was 266 and at 9:00 P.M. the BS was 200. Record review indicated that according to the sliding scale for the Insulin, coverage should have been administered, however there was no evidence the staff administered the Insulin.

On 8/9/16 at 6:00 A.M., the BS was 176, at 12:00 P.M., the BS was 382, at 5:00 P.M. the BS was 174 and at 9:00 P.M. the BS was 200. Record review indicated that according to the sliding scale for the Insulin, coverage should have been administered, however there was no evidence the staff administered the Insulin.

On 8/10/16 at 6:00 A.M., the BS was 156, at 5:00 P.M. the BS was 184 and at 9:00 P.M. the BS was 200. Record review indicated that according to the sliding scale for the Insulin, coverage should have been administered, however there was no evidence the staff administered the Insulin.

On 8/11/16 at 6:00 A.M., the BS was 188, and according to the sliding scale insulin should have been administered. Record review failed to indicate the staff administered the Insulin.

On 8/13/16 at 5:00 P.M., the BS was 380 and the 9:00 P.M. BS was 188, and there was no evidence documenting the staff administer the Insulin coverage as ordered.

On 8/14/16, the 6:00 A.M. BS was 152, the 12:00 P.M. BS was 293 and the 9:00 P.M. was 266. Record review indicated that insulin should have been administered, but staff failed to indicate that the Insulin was administered.

On 8/15/16 at 6:00 A.M., the BS was 188 and on 8/16/16 at 12:00 P.M., the BS was 279. The record failed to indicate that staff administered the Insulin coverage as ordered. In addition, on 8/16/16 at 9:00 P.M., staff failed to document the Resident’s Blood Sugar level.

On 8/18/16 at 6:00 A.M., the BS was 200, on 8/19/16 at 6:00 A.M., the BS was 186, on 8/22/16 at 6:00 A.M., the BS was 187, on 8/23/16 at 6:00 A.M., the BS was 152, on 8/25/16 at 6:00 A.M., the BS was 198 and 190 at 5:00 P.M., on 8/28/16 at 10:00 P.M. the BS was 188, on 8/29/16 at 6:00 A.M. the BS was 162, and according to the sliding scale insulin the staff should have administered Insulin, however the record failed to document that Insulin coverage was administered. In addition, on 8/31/16 at 6:00 A.M., the staff did not document a Blood Sugar level. September, 2016 On 9/3/16 at 4:30 P.M., the BS was 320, according to the sliding scale the staff should have administered 8 units of insulin, however, staff documented that they administered 6 units (less than the order indicated) of Insulin coverage.

On 9/11/16 at 5:00 P.M., the BS was 200, according to the sliding scale the staff should have administered 2 units of insulin, however, staff documented that they administered 4 units of Insulin coverage and no evidence 2 units of Insulin was administer.

On 9/26/16 at 9:00 P.M., the BS was 254, according to the sliding scale the staff should have administered 6 units of insulin, however, staff documented that they administered 4 units of Insulin coverage.

In addition, on 9/1/16 (BS 188), 9/3/16 (BS 186), 9/4/16 (BS 166), 9/5/16 (BS 267), 9/6/16 (BS 266), 9/7/16 (417), 9/8/16 (BS 196, 295, and 178), 9/916 (BS 271), 9/10/16 (BS 212), 9/11/16 (BS 271, 156 and 178), 9/13/16 (BS 263 and 211), 9/15/16 (BS 200), 9/18/16 (BS 176), 9/19/16 (BS 188), 9/20/16 (BS 156, 202 and 176), 9/22/16 (BS 188), 9/25/16 (BS 219, 188, 200 and 156), 9/28/16 (BS 198 and 199), 9/29/16 (BS 176), and 9/30/16 (BS 179), the staff were to administer Insulin according to the sliding scale order. Record review failed to indicate that staff administered the Insulin coverage.

On 10/22/16 at 9:00 P.M., the BS was 344 and according to the sliding scale the Resident should have been administered 8 units of insulin, however, the staff documented they administered 6 units; and on 10/29/16 at 5:00 P.M., the BS was 256, the staff administered 4 units of insulin instead of the prescribed 6 units. On 10/5/16 (BS 156), 10/6/16 (BS 192), 10/8/16 (BS 178), 10/9/16 (BS 159), 10/11/16 (BS 189), 10/12/16 (BS 156), 10/13/16 (BS 201), 10/14/15 (BS 188), 10/15/16 (BS 188), 10/19/16 (BS 156), 10/20/16 (BS 188), 10/24/16 (BS 152), 10/25/16 (BS 176) and 10/30/16 (BS 186 and 174), the staff were to administer insulin according to the sliding scale order. Record review failed to indicate that staff administered the Insulin coverage. November 2016 On 11/26/16 at 5:00 P.M., the BS was 321 and according to the sliding scale the Resident should have been administered 8 units of insulin, however, the staff documented they administered 4 units. On 11/1/16 (BS 156), 11/5/16 (BS 245), 11/6/16 (BS 162), 11/13/16 (BS 176), 11/14/16 (BS 152), 11/21/16 (BS 300), 11/26/16 (BS 222), 11/27/15 (BS 229), 11/28/16 (BS 150) and 11/29/16 (BS 186), the staff were to administer insulin according to the sliding scale order. Record review failed to indicate that staff administered the Insulin coverage. January 2017 On 1/7/17 at 4:00 P.M., the BS was 197 and no evidence the 2 units of insulin was administered as ordered. On 1/8/17 at 9:00 P.M., the BS was 300 and the staff administered 8 units of Insulin instead of the 6 units ordered. During interview on 1/18/17 at 9:30 A.M., the Surveyor and Unit Manager #2 (UM) reviewed the medication administration records (MAR), orders and Diabetic Flow sheets. The Surveyor shared the observations with the UM and she reviewed parts of the medical record and said she saw that the record indicated that the Insulin coverage for BS within the sliding scale parameters were not administer in accordance with the orders and that the documentation for the administration was not consistent. The Surveyor interviewed and shared the information with the Director of Nurses (DON) on 1/18/17 at 2:00 P.M The DON said that she would look into the issues with the nurses.

2. For Resident #11, the facility staff failed to ensure admission physician orders included treatment of [REDACTED]. Resident #11 was admitted in 12/2016 with [DIAGNOSES REDACTED]. Record review on 1/12/17 indicated the hospital discharge summary dated 12/30/16 identified that the Resident had a right side portacath and a right elbow wound. The discharge record indicated the Portacath had been deaccessed on 12/30/16 and the right elbow treatment included cleansing with normal saline, followed by xeroform ([MEDICATION NAME] dressing gauze) then [MEDICATION NAME] (foam dressing) every three days and PRN.: Review of the admission orders [REDACTED].

Review of the Treatment Administration Record (TAR) for 12/2016 included a treatment for [REDACTED]. There was no physician order for [REDACTED]. Record review indicated that during staff’s editing of the TAR from 12/2016 to 1/2017, the treatment on the TAR for the right order was changed from daily to every three days. Record review failed to indicate that staff obtained a physician order for [REDACTED]. During interview on 1/13/17 at 11:00 A.M., the Surveyor reviewed the medical record with Unit Manager #1. Unit Manager #1 said he did not know that there were no physician orders for the elbow treatment and the portacath. Unit Manager #1 said that the facility flushed the portacath monthly and that it was scheduled for around the 20th of January. He said the portacath was covered with a dry protective dressing and that staff monitored the area daily. During subsequent interview on 1/13/16 at 2:00 P.M., the Director of Nurses confirmed that staff had not obtain orders for the care and treatment of [REDACTED].

3. For Resident #8 the facility failed to administer insulin as per the sliding scale/physician’s order. Resident #8 was admitted to the facility 12/2016 with [DIAGNOSES REDACTED]. Clinical record review indicated a physician order for [REDACTED].M., 12:00 P.M., 5:00 P.M. and 9:00 P.M. The Resident’s sliding scale was as follows: [MEDICATION NAME] Insulin sliding scale before meals at 7:00 A.M., 12:00 P.M. and 5:00 P.M. FSBS of 101-150-Do not administer Insulin FSBS of 151-199-Administer 1 unit of [MEDICATION NAME] Insulin FSBS of 200-249-Administer 2 units of [MEDICATION NAME] Insulin FSBS of 250-299-Administer 3 units of [MEDICATION NAME] Insulin FSBS of 300-349-Administer 4 units of [MEDICATION NAME] Insulin FSBS 350 or higher, administer 5 units of [MEDICATION NAME] Insulin and call the physician or nurse practioner. The [MEDICATION NAME] Insulin Sliding Scale for the FSBS at 9:00 P.M. was as follows: FSBS of 200-249-Do not administer Insulin FSBS of 250-299-Administer 1 unit of [MEDICATION NAME] Insulin FSBS of 300-349-Administer 2 units of [MEDICATION NAME] Insulin FSBS 350 or higher, administer 2 units of [MEDICATION NAME] Insulin and call the physician or nurse practioner. Further clinical record review indicated that On:

-1/2/17 at 5:00 P.M.,FSBS was 165, no insulin was administered when according to sliding scale the Resident should have received 1 unit of [MEDICATION NAME] insulin
-1/3/17 at 12:00 P.M. FSBS was 150, the Resident received 1 unit of [MEDICATION NAME]when according to the sliding scale no insulin should have been administered
-1/4/17 at 6:00 A.M., FSBS was 187, no insulin was administered when according to sliding scale the Resident should have received 1 unit of [MEDICATION NAME] insulin
-1/5/17 at 6:00 A.M., FSBS was 197, no insulin was administered when according to sliding scale the Resident should have received 1 unit of [MEDICATION NAME] insulin
-1/6/17 at 6:00 A.M., FSBS was 156, no insulin was administered when according to sliding scale the Resident should have received 1 unit of [MEDICATION NAME] insulin
-1/6/17 at 12:00 P.M., FSBS was 283, the Resident received 1 unit of [MEDICATION NAME]when according to the sliding scale the Resident should have received 3 units of [MEDICATION NAME] insulin.
-1/8/17 at 9:00 P.M., FSBS was 176, the Resident received 1 unit of [MEDICATION NAME]when according to the sliding scale no insulin should have been administered On 1/12/17 at 12:30 P.M., the Director of Nursing said the facility did not administer insulin as per the sliding

4. For Resident #6, the facility failed to transcribe a physician interim order to hold a standing dose of [MEDICATION NAME] (steroid) while the Resident was receiving a [MEDICATION NAME] taper. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Clinical record review revealed an interim physicians order for a [MEDICATION NAME] taper as follows:

a). [MEDICATION NAME] 60 milligrams (mg) by mouth for 3 days b). [MEDICATION NAME] 50 milligrams (mg) by mouth for 3 days c). [MEDICATION NAME] 40 milligrams (mg) by mouth for 3 days d). [MEDICATION NAME] 30 milligrams (mg) by mouth for 3 days e). [MEDICATION NAME] 20 milligrams (mg) by mouth for 3 days f). [MEDICATION NAME] 10 milligrams (mg) by mouth for 3 days, then discontinue

The Resident had a standing dose of [MEDICATION NAME] for, [MEDICATION NAME] 5 mg by mouth twice a day. Further clinical record review indicated that an order to hold the standing dose of [MEDICATION NAME] had not been transcribed as a physicians interim order. The standing dose of [MEDICATION NAME] was held but without a physicians order to do so. On 1/11/17 at 9:55 A.M. the Unit Manager #2 said that although the standing dose of [MEDICATION NAME] had been held, there was not an physician interim order to do so.

5. For Resident #16, the facility failed to obtain physician orders to clarify if the standing order for the [MEDICATION NAME] medication [MEDICATION NAME], was to be administered in conjunction with new orders for the same [MEDICATION NAME]; and the facility failed to obtain a physician order to change the time of a prescribed medication. Resident #16 was admitted in 12/2016 with [DIAGNOSES REDACTED]. The Resident was hospitalized in 1/2017 for chest pain and abnormal laboratory results (elevated troponin levels). Record review indicated the Resident was readmitted with an order for [REDACTED]. On 1/9/16, an interim physician order for [REDACTED]. Review of the clinical record failed to indicate that the staff recognized the standing order of [MEDICATION NAME] and clarified with the physician if he/she wanted to have the Resident receive both doses of the [MEDICATION NAME] during the 14 days. In addition, the Resident’s admission medications (1/2/17) included the insulin [MEDICATION NAME] 33 units at 8:00 P.M. (hour of sleep). Review of 1/2017 MAR record indicated that staff transcribed the [MEDICATION NAME] to be administered at 8:00 P.M. On 1/7/17, an interim physician order changed the dose of [MEDICATION NAME] from 33 units to 30 units at hour of sleep. The staff transcribed the medication onto the MAR to be administered at 8:00 P.M., however from 1/7/17 through 1/17/17 the 8:00 was crossed out and 6:00 was written onto the MAR. Further review of the clinical record failed to find a physician order to change the time of the administration of the insulin. During interview on 1/17/17 at 1:00 P.M., Unit Manager #2 said she did not know if the physician had been aware that the Resident had been receiving the [MEDICATION NAME] twice daily or if the staff had obtained an order for [REDACTED].

Failed to provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and staff interview, the facility failed to ensure a signed discharge summary, including a recapitulation of the Resident’s stay, was completed for 1 of three closed records (#18) out of a total sample of 20 records.

Findings include:

Clinical record review of the closed medical record for Resident #18, who expired at the facility on [DATE], indicated no evidence that a discharge summary/recapitulation was completed. On [DATE] at 12:10 P.M., the Director of Nursing said there was no evidence that the discharge summary/recapitulation was completed.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policies and staff interview, the facility failed to provide proper care and treatment for [REDACTED].#19) from a total sample of 20 Residents.

Findings include:

For Resident #19 the facility failed to ensure the dressing was changed, including a measurement of the external length of the PICC line, every 7 days after insertion or admission per facility policy/protocol. When the PICC was removed, the facility failed to document the status and measurement of the PICC. Resident # 19 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Clinical record review indicated that a PICC line was inserted at the hospital on [DATE] for the administration of intravenous antibiotics.

Review of the facility policy/protocol for care of the PICC line is: -The transparent dressing is to be changed upon admission or 24 hours post insertion and every 7 days there after or sooner if the dressing is compromised. – With each dressing change, the external catheter length is to be measured and notify the physician if problem exists such as a deviation from previous measurement. – When the PICC is removed the measurement of the PICC should be obtained with a description of the tip of the catheter to ensure no portion of the catheter remained in the body.

Further clinical record review indicated that the dressing/external catcher length was done as per facility policy/protocol on 10/28/16 (upon admission). The dressing was changed on 11/4/17, 11/11/16 and 11/18/16. The dressing was due to be changed on 11/25/16, but was changed on 11/28/16 which was 10 days from the previous dressing change and not 7 days as per policy/protocol. The dressing was then changed on 12/5/16, but the external catheter length was not obtained. The PICC line was removed on 12/5/16 by the nurse practioner, but there was no documentation of the appearance/intactness of the catheter or how long the removed PICC was, On 1/17/16 at 1:10 P.M. the Director of Nursing the facility failed to follow facility policy/protocol for care of the PICC

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that it was free of a medication error rate of 5 percent or less. One of three licensed nurses observed during the medication pass made errors while administering medications. Two medication errors out of 30 opportunities were observed during the medication pass observation for 1 Residents (NS#1) resulting in an error rate of 6.6%.

Findings include:

A medication pass observation was conducted on 1/12/17 on the 1st and 2nd floor nursing units. There was a total of 30 opportunities observed with 3 medication nurses. Two medications were not administered in accordance with physician’s orders [REDACTED]. For Resident NS#1, the facility failed to administer medications as ordered by the physician On 1/12/17 at 8:30 A.M., Medication Nurse #3 proceeded to Resident NS #1 to administer 12 different medications in total. Medication Nurse #3 poured and administered the following medications: [REDACTED] a). [MEDICATION NAME] 100 mg one capsule b). Magnesium Oxide 400 mg one tablet c). [MEDICATION NAME] 5 mg one tablet d). [MEDICATION NAME] 0.1 mg one tablet e). [MEDICATION NAME] 100 mg one capsule f). Cranberry Tablet 450 mg one tablet g). [MEDICATION NAME] Extended Release 50 mg one tablet h). Multivitamin one tablet i). [MEDICATION NAME] 40 mg one tablet j). [MEDICATION NAME] 17 grams, one dosing capful k). [MEDICATION NAME] 5000 units in one milliliter, one ml subcutaneously l). [MEDICATION NAME] 325 mg one tab On reconciliation with the current physician orders, it was noted that the Resident had an order for [REDACTED].>1). Colchine 0.6 mg by mouth every day for one week (the order was transcribed on 1/11/17)

2). [MEDICATION NAME] taper, 40 mg daily for 3 days then taper by 10 mg every three days (the order was transcribed on 1/11/17) Upon review of the Medication Administration Record [REDACTED]. During an interview on 1/12/17 at 9:00 A.M., Medication Nurse #3 said that she said that she had not administered the medications, resulting in 2 omissions during the medication pass observation. On 1/12/16 at 3:00 P.M., the Director of Nursing was made aware of the 2 omissions and that the Medication Pass Observation rate was 6.6%.

Failed to give or get quality lab services/tests in a timely manner to meet the needs of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the physician’s orders for laboratory tests were timely and in accordance with the physician orders for 1 Resident (#12) out of a total sample of 20 Residents.

Findings include:

Resident #12 was admitted in 1/2016 and had [DIAGNOSES REDACTED]. According to the physician orders, this resident were to have scheduled laboratory tests every three months (November, February, May, August), that included TSH ([MEDICAL CONDITION] stimulating hormone) and [MEDICATION NAME] level (test to determine therapeutic drug levels). Review of the laboratory test results indicated that the [MEDICATION NAME] level were not obtained in August 2016 nor November 2016. During follow-up interview on 1/13/16 at 8:00 A.M., the Director of Nurses confirmed that the [MEDICATION NAME] level had not been obtained as ordered.

Failed to quickly tell the resident's doctor the results of lab tests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the physician was notified of laboratory results that the clinical reference was outside the range for laboratory tests for 1 Resident (#11) out of a total sample of 20 Residents.

Findings include:

Resident #11 was admitted in 12/2016 and had [DIAGNOSES REDACTED]. Review of the medical record on 1/12/17 indicated that the physician had order multiple admission laboratory tests on 12/30/16, which included a [MEDICATION NAME] level (a test to determine therapeutic drug levels). Record review indicated that the [MEDICATION NAME] level was obtained as ordered on [DATE]. The therapeutic level for [MEDICATION NAME] was considered critically low <2.5 out of a reference range of 10.0-20.0 ug/mL. The medical record indicated the physician was notified and ordered a repeat [MEDICATION NAME] level be obtained in 1 week. However, further reviewed failed to indicate the laboratory test was done. During interview on 1/12/17 at 12:30 P.M., Resident #11 said that the [MEDICAL CONDITION] were new to him/her and he/she was worried about them. The Resident said that the physician was ordering tests to find out more about the [MEDICAL CONDITION]. During interview with the Director of Nurses on 1/12/17 at 2:00 P.M. and subsequent follow-up discussion on 1/13/17 at 8:00 A.M. indicated that the [MEDICATION NAME] level had been done but was not in the facility until the Surveyor identified the missing laboratory result, therefore the sub-therapeutic test result had not been reported to the physician. Review of the [MEDICATION NAME] level dated 1/9/17 indicated that it was identified as low in comparison with the reference range, 2.7 and reference range 10.0-20.0 ug/mL.

Sachem Center for Health & Rehabilitation, Nursing Home Neglect and Elder Abuse Lawyers

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

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

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

Boston Personal Injury Lawyers for Elder Abuse Cases

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 – Sachem Center for Health & Rehabilitation

Inspection Report for Sachem Center for Health & Rehabilitation – 01/17/2017

Page Last Updated: May 4, 2018

Call Now Button