St Camillus Health Center

St Camillus Health Center

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at St Camillus Health 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 St Camillus Health Center

St Camillus Health Center is a for profit, 123-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Oxford, Charlton, Leicester, Sutton, Spencer, Millbury, Webster, Worcester, Dudley, Southbridge, and the other towns in and surrounding Worcester County, Massachusetts.

St Camillus Health Center
447 Hill St
Whitinsville, MA 01588

Phone: (508) 234-7306
Website: https://www.stcamillus.com/

CMS Star Quality Rating

St Camillus Health CenterThe 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, St Camillus Health Center in Whitinsville, Massachusetts received a rating of 4 out of 5 stars.

Performance Area Rating
Overall Rating 4 out of 5 (Above Average)
State Health Inspections 3 out of 5 (Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 2 out of 5 (Below Average)

Fines Against St Camillus Health Center

The Federal Government fined St Camillus Health Center $6,500 on 10/15/2015, $59,784 on 01/18/2018 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered St Camillus Health Center committed the following offenses:

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, facility staff failed to alert the Physician in a timely manner that the resident (#58) had increased pain during a dressing change for 1 (#58) of 24 sampled residents.

Findings include:

Resident #58 was admitted to the facility in 4/2015. [DIAGNOSES REDACTED]. The resident was admitted to Hospice in 11/2017. On 1/10/18 from 2:30-3:15 P.M., the Surveyor observed Nurse #1 during 3 dressing changes for Resident #58. The resident had 3 wounds that dressings needed to be changed. The right foot had a Stage II pressure sore, the coccyx had a large unstageable pressure sore and the mid back had an infected surgical wound. During the dressing changes, the patient yelled out in pain and swore at Nurse #1 to hurry up. During interview on 1/10/18 at 5:00 P.M., Nurse #1 said that he medicated the resident at 12:00 noon with the narcotic pain medication [MEDICATION NAME] (Concentrate) Solution 0.25 milliliter (5 milligrams). He told the Surveyor that the pain has increased during the dressing changes and the Resident yells frequently. During interview on 1/11/18 at 8:40 A.M., the Director of Nurses (DON) and Administrator said that Nurse #1 did not report that the resident had increased pain during the dressing change on 1/10/18, and that this was the first they had heard of it. The DON said the Physician would be contacted today regarding pain management. The DON told the Surveyor that there was no pain management plan for the dressing changes and that Nurse #1 should have administered the [MEDICATION NAME] closer to the time of dressing change.

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

Based on observations and record review, the facility staff failed to follow the care plan and/or physician’s orders regarding falls, skin checks, dressing changes and positioning of 3 residents (#24,#58 and #97 out of a total sample of 24 residents.

Findings include:

1. For Resident #97 facility staff failed to ensure the seat alarm on the wheelchair (w/c) was functioning, resulting in a fall from the chair on 1/9/18, and the resident sustained [REDACTED]. Review of the initial Plan of Care addressing falls (initiated 9/26/17) indicated the Resident was identified as a high risk for falls due to falls resulting in a right wrist fracture, mild confusion,[MEDICAL CONDITION] with left sided weakness, gait impairment and need for assist and device. Interventions included:

-cues and reminders as needed

-On a blood thinning medication (Xarelto) and at risk for bruising and bleeding.

-Alarm on chair. Monitor battery and placement

-Transfer and walk with gait belt, rolling walker, 1-2 assist

-Call light and personal items within reach; bed in low position

-Nonskid socks on in bed Review of the Incident Report dated 1/9/18 indicated that at 7:30 P.M., the Resident was found face down on the floor in one of the connecting hallways to another unit. the physician was notified and ordered the Resident be sent to the hospital. Further review of the Incident/Investigation report indicated the w/c alarm was not functioning at the time of the fall, as planned. During interview on 1/16/18 at 10:00 A.M. the Director of Nurses (DON) said that the Resident should have been more closely supervised and the alarm monitored per care plan.

2. For Resident #58, facility staff failed to ensure that dressing changes were conducted according to the Physician orders; that the Resident was kept comfortable per the Plan of Care and that the Care Plan for mobility was followed. a. Review of the Plan of Care addressing mobility (revised on 11/20/17) indicated the Resident required assistance of 2 staff members for positioning due to weakness, decreased endurance, [MEDICAL CONDITION] ( nerve pain), and was at risk for further decline. On 1/10/18 at 2:30-3:15 P.M., the Surveyor observed Nurse #1 during a dressing change for Resident #58. The nurse had to reposition the Resident onto his/her left side in order to change the dressings on the coccyx and mid back wounds. Nurse #1 pushed the Resident onto his/her left side by himself, not using 2 staff members as care planned. While holding the Resident onto his/her on their side with one hand Nurse #1 attempted to remove the dressing on the coccyx. Nurse #1 told the Resident to hold onto the siderail despite the Care Plan indicating 2 staff were needed for bed positioning. The Resident yelled out in pain during the entire treatment.

b. A physician’s order indicated that on 1/10/18 the following treatment should begin: To Right heel, after N/S (Normal Saline) wash, apply Hydrogel ( a gel used in wound care in which the main component is water, to promote wound healing) and cover with a Boarder {sic} (Border) Dressing. Change every 3 days PRN (as needed). During observation on 1/10/18 at 2:30 P.M. Nurse #1 washed the right heel, applied Skin Prep, (a liquid that when applied to the skin forms a protective film and not part of the physician order). Nurse #1 then covered the area with a Border Dressing without applying Hydrogen to the open area as ordered. The Surveyor next observed the coccyx dressing change. The physician order from 10/5/17 was to cleanse the wound gently with N/S and pat dry. Apply [MEDICATION NAME] Cream 1% ( a topical, for the skin, antibiotic cream) to the open wound. Apply Skin Prep to the surrounding tissue. Cover with Border Dressing and apply ZGuard paste (skin protectant) to the surrounding pink skin.

Nurse #1 cleansed the wound as ordered but applied [MEDICATION NAME] gel (different from the ordered [MEDICATION NAME] Cream). Nurse #1 said that the [MEDICATION NAME] Cream had not been available for quite some time. Nurse #1 said the wound looked worse for the past three days. The Surveyor next observed the dressing change for the mid-back wound. The wound was a surgical wound. the physician order from 11/2/17 indicated to apply Xeroform dressing (a sterile petroleum gauze dressing on the wound and cover with a gauze dressing. there was no order to cleanse the wound first. The Surveyor observed Nurse #1 cleanse the wound with N/S and apply the Xeroform dressing. He then covered the dressing with 2 Border dressings and not gauze as per the physician orders. During interview on 1/11/18 at 8:45 A.M. the DON said that Nurse #1 did not follow the Resident’s Plan of Care or Physician orders for the dressings. The DON said that [MEDICATION NAME] Cream and [MEDICATION NAME] gel are two different medications. Further investigation and interview with the DON revealed that the [MEDICATION NAME] Cream was last ordered 10/4/17.

3. for Resident #24, facility staff failed to follow the plan of care/Physician orders regarding conducting weekly skin assessments. Resident #24 was admitted to the facility in 1/2017 and readmitted in 4/2017. [DIAGNOSES REDACTED].

Review of the Facility’s policy regarding Weekly Skin Assessments, revised 8/18/15 included:

– It is the policy of the facility that every resident will receive a head-to-toe skin
assessment by a licensed nurse on a weekly basis.
– It is the purpose of this policy to assure any skin impairment is identified, assessed,
and treated in a timely manner.
– The nurse will assess the skin in a systematic order head-to-toe. If an area exists, the
nurse will confirm that documentation and treatments have been established.
Review of the Plan of Care (dated 1/26/17) addressing skin impairment included the
following interventions:
– pressure relieving mattress
– cushion in chair
– treatments as ordered
– Weekly Skin Assessments
Review of the Resident’s Weekly Skin Assessments indicated:
– 9/7/17 Declined shower and weight this P.M. No new skin issues.
– 9/14/17 no documented skin assessment.
– 9/21/17 Bed bath provided. No new skin issues.
– 9/28 and 10/5/17 No documented skin assessments.
– 10/12/17 No new skin issues.
– 10/19 and 10/26/17 No documented skin assessments.

Review of a Nurses’ Note dated 10/30/17 indicated the the Certified Nursing Assistant who was providing care to the Resident found new open areas. there was an unstageable pressure area on the coccyx. The right buttock had a deep tissue injury (DTI) which was purple and red, nonblanchable. DTI is a pressure-related injury to subcutaneous tissue under intact skin. The left inner thigh had shearing (pressure area as a result of friction) which measured 3.6 X 0.6 centimeters (cm). during interviews on 1/10/18 at 1:30 P.M. and 10/16/18 at 9:00 A.M., Resident #24 told the Surveyor that he/she did not want the Surveyor to observe the dressing change to his/her coccyx. The Resident was observed on both days to be lying in bed on his/her back in bed. the Resident told the surveyor that he/she was told that They should try to stay of their back as much as possible.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that 1 of 4 applicable residents (#24) in a total sample of 24 received the care necessary to avoid the development of a pressure ulcer and to identify skin impairment in a timely manner.

Findings include:

Resident #24 was admitted to the facility in 1/2017 and readmitted in 4/2017. [DIAGNOSES REDACTED].

Review of the facility’s policy Weekly Skin Assessments (revised 8/18/15) included: – It is the policy of the facility that every resident will receive a head-to-toe skin assessment by a licensed nurse on a weekly basis.

– It is the purpose of this policy to assure any skin impairment is identified, assessed and treated in a timely manner.

– The nurse will assess the skin in a systematic order head-to-toe. If an area exists, the nurse will confirm that documentation and treatments have been established.

Review of the plan of care (1/26/17) addressing skin impairment included the following interventions:

– pressure relieving mattress

– cushion in chair

– treatments as ordered

Weekly Skin Assessments (also a physician’s orders [REDACTED].>

Review of the 7/16/17 Quarterly Minimum Data Set (MDS) Assessment indicated the resident: scored 10 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS); required extensive assistance from staff for bed mobility, dressing, toilet use and personal hygiene; required total assistance from staff for transfers (Hoyer lift) and bathing; did not ambulate; had functional limitation in range of motion in both upper and lower extremities; always incontinent of bladder; occasionally incontinent of bowel; weight loss; no pressure ulcers; pressure relieving devices for bed and chair. Review of resident’s Weekly Skin assessments indicated: – 9/7/17, Declined shower and weight this P.M. No new skin issues. – 9/14/17, No documented Skin Check. – 9/21/17, Bed bath provided. No new skin issues. – 9/28 and 10/5/17, No documented Skin assessments. – 10/12/17, No new skin issues. Review of the resident’s MDS Quarterly Assessment of 10/15/17, indicated the following changes from the previous assessment: BIMS score of 15 out of 15; weight loss (physician prescribed). Review of the Norton Plus Pressure Ulcer Scale dated 10/20/17 scored the resident with a total of 11 (moderate risk of developing a pressure sore.)

Review of resident’s Weekly Skin assessments indicated: – 10/19 and 10/26/17, No documented Skin assessments. Review of a Nurse’s Note dated 10/30/17 indicated that the Certified Nursing Assistant who was providing care to the resident found new open areas. Unstageable pressure area to coccyx noted due to wound bed not being able to be visualized. Area measured 0.3 x 0.2 centimeters (cm) with a copious (a lot) amount of sanguineous (bloody) drainage. The right buttock had a deep tissue injury (DTI) which measured 4.3 x 1.6 cm. The area was described as purple and red, non-blanchable. The left inner thigh had shearing which measured 3.6 x 0.6 cm. A physician’s orders [REDACTED].)

A physician’s orders [REDACTED]. Review of the Wound Consultant Sheet dated 11/6/17 indicated the resident had a history of [REDACTED]. The wound measured 0.5 x 0.5 x 0.9 cm. with moderate serous drainage. During interviews on 1/10/18 at 1:30 P.M. and 1/16/18 at 9:00 A.M., Resident #24 told the Surveyor that he/she did not want the Surveyor to observe the dressing change on the coccyx. The resident was observed on both days lying in bed on his/her back in bed.

During an interview on 1/17/18 at 2:00 P.M., the Director of Rehab Services told the Surveyor that prior to the development of the resident’s pressure sores (found on 10/30/17), the resident had a standard facility pressure relief mattress (foam) and that he was unable to find any documentation regarding what type of cushion the resident had in the wheelchair (w/c) or when it was issued prior to finding the pressure sores.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure the resident environment was as free from accident hazards as possible for 3 residents (#3, #51 and #97) in a total sample of 24 residents.

Findings include:

1. For Resident #3, the facility staff failed to correctly use a wheelchair and foot rests to transport the resident, causing the resident to fall out of the wheelchair. Resident #3 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. Review of an undated policy entitled Transporting Residents in Wheelchairs indicated the following:

-Any resident that is issued a wheelchair will also be issued leg rests and/or foot rests.

-If a resident is able to safely self-propel his/her wheelchair using their legs, then the leg rests or foot rests may be removed from the chair while in the building.

-If any resident is receiving assistance in propelling his/her wheelchair from anyone (staff, visitor, outside vendor, etc.), the provided leg rests and/or foot rests should be used.

Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 3/12/17, indicated the resident had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 5 of 15, did not ambulate, required extensive assistance of two for transfers, extensive assistance of one for locomotion on the unit, and used a wheelchair. Review of a Nurse’s Note, dated 4/30/17, indicated the resident was status [REDACTED].M. He/she was being pushed down the hall by a Certified Nurses’ Aide (CNA). At 7:15 A.M. a 1 centimeter laceration was observed on the bridge of the nose, bruising and swelling on the forehead and the resident complained of hip and ankle pain. The resident was sent to the emergency room .

He/she returned at 5:20 P.M. with a nasal fracture, a right ankle fracture and a left distal fibula (leg bone) fracture. Review of the Incident Report, dated 4/30/17, indicated the resident had a fall at 5:45 A.M. and sustained fractures to the nose, lower left extremity and lower right extremity. The CNA wheeled the resident down the hallway to a common area on the unit. The resident, without warning, planted both feet on the floor causing the wheelchair to flip forward and the resident to fall.

On further investigation, it was noted that the foot rests were not under the resident’s feet. Review of the Significant Change of Status MDS, dated [DATE], indicated the resident had severe cognitive impairment as evidenced by a BIMS score of 4 of 15, required extensive assistance for transfers and locomotion on the unit, did not ambulate, and had a fall with a major injury. On 1/17/18 at 3:40 PM during an interview with the Rehabilitation Director, he said the resident should have had foot rests on the wheelchair. Had the foot rests been used, he felt the accident probably would not have happened.

On 1/17/18 at 4:07 P.M. during an interview with CNA #4, she said she was the CNA involved in the accident. She said she was not told the resident wasn’t suppose to get up. She thinks she and another staff member working that night put the resident in the wrong wheelchair (w/c). She couldn’t remember if the wheelchair had leg rests or not, but remembers the resident’s feet were touching the floor. She said the resident flipped forward, but not the chair. She could feel the resident’s feet on the floor, then stop suddenly, and the resident flipped forward out of the wheelchair.

2. For Resident #97, facility staff failed to provide supervision and assistive devices to prevent falls and to ensure the w/c seat alarm was functioning. Resident #97 was admitted to the facility in 9/2017. [DIAGNOSES REDACTED]. Review of the Initial MDS assessment dated [DATE] indicated the resident: could make self understood and could usually understand others (misses some part/intent of message); scored a 12/15 on the Brief Interview for Mental Status (BIMS); required extensive assistance from 2 staff members for bed mobility, transfers and toilet use ambulated in the corridor with limited assistance from 2 person physical assist; required extensive assistance from 1 person physical help for dressing, eating, personal hygiene and bathing; balance was unsteady; history of falls with a right wrist fracture (cast on admission) prior to admission; receiving an anticoagulant. Review of the plan of care addressing forgetfulness (9/25/17) indicated the resident sometimes forgets or misses what is said and has a decreased attention span due to being in a new environment and having [MEDICAL CONDITION] 8/2017. Review of a Nurse’s Note of 9/25/17 indicated the resident’s right wrist cast was removed at an orthopedic appointment and replaced with a splint. Review of an Incident Report of 9/25/17 indicated a visitor reported seeing the resident falling from the wheelchair in an unoccupied room at 4:10 P.M. When staff arrived, the resident was on the floor and told staff that he/she was trying to transfer to another chair. The brakes on the wheelchair (w/c) were not locked. The report indicated that a w/c alarm was added.

There were no apparent injuries. Review of the initial plan of care addressing falls (initiated 9/26/17) indicated the resident was identified as a high risk for falls due to falls with a right wrist fracture, mild confusion,[MEDICAL CONDITION] left sided weakness, gait impairment and need for assist and device. Interventions included:

– Cues and reminders as needed.

– On a blood thinning medication, and at for bleeding or bruising.

– Alarm in chair. Monitor battery and placement.

– Transfer and walk with gait belt, rolling walker and 1-2 assist.

– Call light and personal items within reach; bed in low position.

– Nonskid socks on in bed.

Review of Nurses’ Notes of 10/4/17 and 10/6/17 indicated the resident was self transferring from bed to w/c and into the bathroom, then from the toilet to the w/c. Nurses’ Notes of 10/11, 10/12 and 10/15/17 indicated the resident activated the chair alarm when attempting to stand unassisted. Reminders given to resident.

A Nurse’s Note of 10/18/17 indicated the resident continues to take self to the bathroom. There was no documentation regarding the chair alarm sounding. Resident #97 had subsequent falls on 10/31/17 and 11/30/17 when the Resident was sent out for a CAT scan (due to possibly hitting their head and having increased risk of bleeding due to being on a blood thinner). Review of Nurses’ Notes indicated the resident was having increased periods of lethargy and confusion. The resident was seen by a neurologist on 12/11/17 who prescribed [MEDICATION NAME] for depression.

Review of the Quarterly MDS assessment dated [DATE], indicated the following changes from the Initial MDS of 9/22/17: A decrease in memory with a BIMS of 9 out of 15; no longer ambulated; frequently incontinent of bladder; falls since admission; received an antidepressant; chair alarm used daily.

A Nurse’s Note of 12/27/17 indicated the facility attempted a 2 week alarm reduction (w/c) due to setting off the alarm multiple times. The decision was to keep the w/c alarm in place for safety. There were no other Care Plan revisions despite the number of falls. Review of the Incident Report of 1/9/18 indicated that at 7:30 P.M., the resident was found face down on the floor in one of the connecting hallways to another unit (unsupervised). The resident was alert and confused and lying prone with a hoodie over the head. The resident said that he/she just got out of a meeting. Staff observed a large lump on the side of the left forehead. The Physician was notified and ordered the resident be sent to the hospital due to receiving the blood thinning medication Xarelto. Further review of the Incident/Investigation indicated the w/c alarm was not functioning at the time of the fall. The facility planned on replacing the alarm, placing bolsters on the bed, and evaluating the resident for a lap belt. The resident was admitted to the hospital with [REDACTED]. The resident was placed in a hard cervical collar for complaints of pain in the cervical region of the neck and is to remain in this collar continually until seen by orthopedics. The resident returned to the facility on [DATE] with the collar.

On 1/16/18 at 8:00 A.M., the Surveyor observed the resident sitting in the w/c outside the nurses’ station. The resident had a large black bruise and swelling on and above the left eye and left side of head The left eye was almost closed. The resident had on a hard Cervical Collar, a removable belt, a seat alarm and a personal alarm. During discussion on 1/16/18 at 10:00 A.M., the Administrator and DON told the Surveyor that the resident fell from the w/c on 1/9/18 at 7:30 P.M., was hospitalized and returned on 1/12/18. They said the resident sustained [REDACTED]. They said that a hard Cervical Collar was being worn as a precaution until seen by Orthopedics in approximately 2 weeks. The DON said that the resident should have been more closely supervised and the alarm monitored per care plan. 01/17/18 02:59 P.M., the Surveyor observed that the resident’s bed now had 1 bed bolster on each side of the bed near the foot of the bed, and 2 quarter side rails on the sides near the head of the bed.

3. For Resident #51, the facility staff failed to provide supervision and assistive devices to prevent 7 unwitnessed falls. Resident #51 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. Review of the fall care plan, initially dated 12/30/16, included the following interventions:

– Assist me to rise and change position slowly,
– I use my wheelchair for mobility,
– I transfer with a gait belt and 1 or 2 assist,
– Keep my environment well lit and clutter free,
– Bed in low position,
– I need continual supervision while on the patio, (initiated 8/7/17),
– Provide frequent safety checks, (initiated 11/8/17),
– Monitor my whereabouts, (initiated 11/8/17), and
– Safety Checks every hour on 3:00 P.M. – 11:00 P.M. and 11:00 P.M. to 7:00 A.M.,
(initiated 12/4/17).

Review of the Admission MDS Assessment, dated 12/27/16, indicated the resident had severe cognitive impairment as evidenced by a score of 4 out of 15 on the BIMS, needed assistance of one for transfers and ambulation, and had not experienced a fall. Review of the Incident Report, dated 2/22/17, indicated the resident had an unwitnessed fall at 9:35 P.M. in the hallway. The resident was observed in bed before the fall. The bed was in a low position. To prevent further falls staff should continue to anticipate the resident’s needs and provide frequent checks while in bed. Review of the Incident Report, dated 3/8/17, indicated the resident had an unwitnessed fall at 1:40 P.M. in the shower room. The resident attempted to self transfer to a shower chair. The resident was incontinent at the time of the fall. To prevent further falls, the report indicated that staff should implement a toileting schedule, although there was already one in place, and put a key pad entry on the shower room door. Review of the Incident Report, dated 3/30/17, indicated the resident had an unwitnessed fall at 3:00 P.M. in the common area. To prevent further falls, the report indicated that staff needed to monitor for the resident’s safety, although it did not indicate how the resident’s safety was to be monitored. Review of the Quarterly MDS Assessment, dated 5/28/17, indicated the resident had moderately impaired cognition as evidenced by the staff assessment, needed assistance of 1 for transfers and ambulation, and had experienced two falls since the last MDS Assessment. Review of the Incident Report, dated 8/6/17, indicated the resident had an unwitnessed fall outside on the patio at 2:50 P.M. To prevent further falls, the report indicated not to leave the resident outside alone.

Review of the Incident Reports, dated 9/9/17 and 11/22/17 indicated the resident had an unwitnessed falls and found incontinent. The reports did not indicate the last time the resident was toileted. To prevent further falls the report indicated for staff to anticipate the resident’s toileting needs at night, and to continue with safety checks. There was no change to the toileting schedule. Review of the Annual MDS Assessment, dated 11/5/17, indicated the resident had moderately impaired cognition as evidenced by the staff assessment, needed assistance of one for transfers and ambulation, and had experienced two or more falls since the last MDS assessment. Review of the Incident Report, dated 12/1/17, indicated the resident had an unwitnessed fall at 6:30 P.M. in another resident’s room.

To prevent further falls the report indicated that staff were to anticipate the resident’s needs. On 1/12/18 at 7:55 A.M., the surveyor observed Resident #51 in bed, eyes closed, with the bed in low position. On 1/12/18 at 8:41 A.M., the surveyor observed Resident #51 in the common area, seated in a wheelchair. On 1/16/18 at 11:08 A.M. during an interview with the Director of Nurses (DON), she said that the key pad lock was never put on the shower room door. She did not know why. She could not explain how supervision was provided for Resident #51 to prevent falls. She said looking at all of the falls together, it was obvious that something different should have been done to prevent the resident from falling.

Provide safe, appropriate pain management for a resident who requires such services.

Based on observation and staff interview, facility staff failed to ensure that 1 of 24 residents (#58) had a pain management plan in place prior to dressing changes and failed to respond when Resident #58 yelled out in pain during the dressing change and instead continued to precede.

Findings include:

Resident #58 was admitted to the facility in 4/2015. [DIAGNOSES REDACTED]. The resident was admitted to Hospice on 11/10/17, and at that time had an unavoidable pressure ulcer on the coccyx (unstageable) and developed a pressure ulcer on the right heel (Stage II). Review of the Significant Change in Status Minimum Data (MDS) Assessment (due to being admitted to Hospice) of 11/17/17 indicated the resident required extensive assistance of 2 staff members for bed mobility and had no complaints of pain during the last 5 days. Review of the plan of care addressing mobility (revised on 11/20/17) indicated the resident required assistance of 2 staff members for positioning due to weakness, decreased endurance, [MEDICAL CONDITION] (pain) and at risk for further decline. Review of the plan of care addressing pain (revised 11/30/17) indicated the resident was at risk for pain due to [MEDICAL CONDITION]. The goal was to have a positive effect from any pain relief interventions. Interventions include:

– Ensure a position of comfort

– Monitor/Record pain characteristics: frequency, quality, severity, location, onset, duration, aggravating factors, relieving factors.

– Monitor/record/report any non-verbal signs or symptoms of pain: Vocalizations (moans, yelling out) Mood/behavior (changes, more irritable restless, aggressive)

– Notify the Physician if interventions are unsuccessful or if current pain is a change from the previous experience of pain

– Provide pain medications as ordered and monitor for side effects.

On 1/10/18 at 2:30-3:15 P.M. while observing a dressing change the Surveyor observed that Nurse #1 removed the pressure relieving boot on the resident’s right foot and the resident yelled out in pain. Nurse #1 told the Surveyor that the resident has pain whenever the feet and legs are moved. After washing the wound on the right heel, the nurse applied skin prep (protective ointment), on the perimeter of the wound. The resident was yelling out in pain during the whole process.

The Surveyor observed a non-blanchable red area on the resident’s left heel. There was no treatment in place. The nurse said that he would address it, and then he put the left heel back on the bed. The resident continued to yell out in pain. Nurse #1 told the Surveyor that the resident was medicated 2.5 hours earlier with the pain medication [MEDICATION NAME] (Concentrate) Solution 20 milligrams/milliliter (ml). Give 0.25 ml. by mouth every four hours as needed for pain or distress. Give 5 milligrams (mg)=0.25 ml. every four hours as needed. The resident was turned onto his/her left side by Nurse #1 (care plan indicated to utilize 2 staff for positioning for comfort).

The Resident yelled out in pain and the nurse told the resident that he would be done soon. The nurse removed the old dressing from the wound on the coccyx with one hand while trying to hold the resident off the back with the other hand. The nurse told the resident to hold onto the side rail. The resident was yelling and swearing at the nurse, that she/he had a lot of pain and to hurry up. The wound was cleaned using N/S and patted dry. The resident was yelling in pain and swearing, saying, You’re hurting the[***]out of me! Nurse #1 continued with the dressing change. Nurse #1 told the Surveyor that the wound looked much worse today. Then Nurse #1 removed the old dressing from the resident’s mid back. The Resident was still yelling in pain and saying how much it hurt.

During interview on 1/10/18 at 5:00 P.M., Nurse #1 said that he administered the narcotic medication [MEDICATION NAME] 2.5 hours prior to the treatment, and that it was not effective. He said that he should have had the assistance of another staff member to help position the resident during the dressing change. Nurse #1 did not stop the procedure and call the Physician regarding the pain level of the Resident during the dressing change. During interview on 1/11/18 at 8:40 A.M., the Director of Nurses (DON) and Administrator said that Nurse #1 did not report that the resident had increased pain during the dressing change or the reddened nonblanchable area on the left heel, and that this was the first they heard of it. The DON said that he should have had assistance of another staff member during the dressing change. The DON said that the Physician would be contacted today regarding pain management. The DON told the Surveyor that there was no pain management plan for the dressing changes and that Nurse #1 should have administered the [MEDICATION NAME] closer to the time of the dressing change to be more effective.

Ensure that residents are free from significant medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility staff failed to ensure 1 Resident (#8) was free from a significant medication error in a total sample of 24 residents.

Findings include:

Resident #8 was admitted to the facility in 9/2011 with [DIAGNOSES REDACTED]. Review of the physician’s orders [REDACTED].) daily until 12/28/17, then recheck the resident’s INR (international normalized ratio) on 12/29/17. Review of the Medication Administration Record [REDACTED]. was given as ordered, but the INR was never obtained. Therefore, the facility staff did not obtain orders for the next [MEDICATION NAME] dose.

Review of the MAR indicated [REDACTED]. During an interview with the Director of Nurses (DON) on 1/12/18 at 9:10 A.M., she said that when she investigated the medication error she found that the INR was never done. She said that the INR needed to be done to prompt a new [MEDICATION NAME] order. She said that education was given to the nurse involved with the incident.

Provide timely, quality laboratory services/tests to meet the needs of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility staff failed to provide provide laboratory services to meet the needs of 1 (#8) resident in a total sample of 24 residents.

Findings include:

Resident #8 was admitted to the facility in 9/2011 with [DIAGNOSES REDACTED]. Review of the physician’s orders [REDACTED].) daily until 12/28/17, then recheck the resident’s INR (international normalized ratio) on 12/29/17.

Review of the clinical record indicated the INR was never obtained. Therefore, the facility staff did not obtain orders for the next [MEDICATION NAME] dose, resulting in the resident missing scheduled [MEDICATION NAME] from 12/29/17 through 1/2/18 per review of the 12/2017 and 1/2018 Medication Administration Records. During an interview with the Director of Nurses (DON) on 1/12/18 at 9:10 A.M., she said that when she investigated the medication error she found that the INR was never done.

She said that the INR needed to be done to prompt a new [MEDICATION NAME] order. She said that education was given to the nurse involved with the incident.

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Based on observation and interview, the facility staff failed to conduct regular inspections of all bed frames, mattresses and bed rails as part of a regular maintenance program for 106 out of 106 occupied beds.

Findings include:

During an observation on 1/09/18 at 7:30 A.M., the surveyors observed 1/4 side rails had been installed on all 106 occupied beds. On 1/10/18 at 4:20 P.M. the surveyor, accompanied by the Administrator, measured 4 random beds. Three out of the 4 beds had a space of 4.5 inches or greater at the head of the bed.

The Administrator said the space was too wide at the head of the bed. On 1/10/18 at 4:30 P.M. during an interview with the Administrator, he said that he believed the Maintenance Director had measured the beds but had not documented the measurements.

On 1/16/18 at 2:30 P.M., during an interview with the Maintenance Director he said that he was not aware that he was supposed to have an on going maintenance program to assess all of the bed frames, mattresses and bed rails. He said there was no such program in place. The Maintenance Director also said he was not aware that he was supposed to assess every bed for the risk of entrapment. He said he had previously been responsible for ordering the facility mattress and would order them 80 inches in length. Since someone else in the building had been ordering the mattresses they had been coming in at 76 inches in length leaving, at least, a 4 inch gap at the head of the bed.

St Camillus Health Center, Nursing Home Neglect and Elder Abuse Lawyers

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

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

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

Boston Personal Injury Lawyers for Elder Abuse Cases

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


Sources:

Medicare Nursing Home Profiles and Reports – St Camillus Health Center

Inspection Report for St Camillus Health Center – 01/18/2018

Page Last Updated: October 14, 2018

Call Now Button