St. Mary Health Care Center

St. Mary Health Care Center

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

St. Mary Health Care Center is a non-profit, 172-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of  Worcester, Leicester, Holden, Shrewsbury, Millbury, Spencer, Grafton, Sutton, Northborough, Westborough, Oxford, Clinton, Charlton, Northbridge, Marlborough, and the other towns in and surrounding Worcester County, Massachusetts.

St. Mary Health Care Center
39 Queen St
Worcester, MA 01610

Phone: (508) 753-4791
Website: http://stmaryhc.com/

CMS Star Quality Rating

St. Mary Health Care 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. Mary Health Care Center in Worcester, 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 St. Mary Health Care Center

The Federal Government has not fined St. Mary Health Care Center in the last 3 years.

Fines and Penalties

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

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 interviews and record review, the facility staff failed to notify the Physician when a prescribed pain medication was not administered as ordered for 1 sampled resident (#1), in a total of 21 sampled residents.

Findings include:

Resident #1 was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. Review of the Physician’s Progress Notes, dated 4/25/17, indicated that the resident stated that he/she was feeling terrible, and had persistent right knee pain that was constant despite use of Tylenol (pain reliever) and movement. The note further indicated to add [MEDICATION NAME] (a stronger pain medication) 25 milligrams (mg.) twice daily, and [MEDICATION NAME] 25 mg. twice daily as needed, for the right knee pain. Review of the Physician’s Interim/Telephone Orders, dated 4/25/17 at 10:30 A.M., indicated an order to start [MEDICATION NAME] 25 mg. twice daily for right knee pain for two weeks, and to start [MEDICATION NAME] 25 mg. twice daily as needed for right knee pain for two weeks.

Review of the Medication Administration Record [REDACTED].) twice daily at 8:00 A.M. and 8:00 P.M. for two weeks. The MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED].M. dose on 4/27/17. Review of the nurse’s note, dated 4/26/17 at 7:34 A.M., indicated that [MEDICATION NAME] was not administered because the medication was not delivered from the pharmacy. Review of the nurse’s note, dated 4/27/17 at 7:19 A.M., indicated that [MEDICATION NAME] was not administered because the medication was not available.

During an interview on 6/27/17 at 2:30 P.M., Nurse #1 said that [MEDICATION NAME] is no longer available in the emergency kits. Nurse #1 said the Physician would complete an order for [REDACTED].#1 said pharmacy services are available 24 hours/7 days a week. The medication is usually delivered on the same day the prescription is sent. She further said that if the medication had not been delivered by the scheduled dose time, she would contact the pharmacy and see if the medication was close to being delivered. If not, she would update the Physician.

During an interview on 6/27/17 at 2:40 P.M., Unit Manager (UM) #1 said that if the prescribed pain medication was not administered as ordered, the Physician would be updated. UM #1 said that this information would be documented in the resident’s record. UM #1 did not provide documentation to indicate the Physician had been notified of the missed pain medication.

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 observation, interviews and record review, the facility staff failed to afford dignity for 1 sampled resident (#14), in a total of 21 sampled residents.

Findings include:

Resident #14 was admitted to the facility in 7/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 6/13/17, indicated the resident had severe cognitive impairment, and was totally dependent for dressing and personal hygiene.

During an observation on 6/27/17 from 9:00 A.M. to 9:30 A.M., Resident #14 was seated in the Dining Room in a high back wheelchair with his/her head down and eyes closed. Eleven other residents were observed in the same dining area. The resident was observed to be in a hospital johnny with his/her back fully exposed. The resident had bare legs and was wearing non-skid socks.

During an interview on 6/27/17 at 9:15 A.M., Certified Nurse Assistant (CNA) #1 said Resident #14 was scheduled to have a shower on this date. She further said the resident should have a towel covering him/her. During an interview on 6/27/17 at 9:30 A.M., Unit Manager (UM) #2 said that Resident #14 was not dressed at the time of the observation, and should have had a blanket on him/her.

Failed to provide activities to meet the interests and needs of each resident.

Based on observations and interviews the facility staff failed to provide an ongoing program of activities to enhance the residents’ highest level of physical, mental and psychosocial well being on two of three nursing units.

Findings include:

Review of the Policy for Activities and Recreation, dated 4/1998, indicated the following: This facility provides an organized program of purposeful activities and recreation suited to the needs and interests of all its residents despite their level of mobility and cognitive status.

The Resident Group Interview with the surveyor was held on 6/23/17 at 10:45 A.M. Ten Residents were in attendance. The residents had the following concerns regarding activities offered by the facility:

-Seven residents said they were bored at night and on the weekends.
-Four residents said they wanted more painting and community outings but were told this was not a good idea.
-Residents said they do not have input into the facility activities.
-The residents stated the calendar consists mostly of music, Bingo, the Rosary and Mass.

1. For Residents residing on the 5th floor, the facility staff failed to provide a program of activities designed to meet each residents individual preferences and needs. Review of the Activity Calendar for 6/23/17 indicated the following:

-From 8:00 A.M. to 9:00 A.M. there would be resident visits on the 5th floor. -From 10:00 A.M. to 11:00 A.M. there would be music and gentle stretch for 4th floor residents because Rosary was canceled.

-At 1:30 P.M. there would be Porch Time.

On 6/23/17 the surveyor made the following observations on the 5th floor nursing unit: -10:00 A.M. ten residents were seated in a common area with no supervision.

The TV was on playing reruns of I Love Lucy. Resident #15 and Resident #18 were present. -10:20 A.M. Two Certified Nurses’ Aides (CNA) handed out snacks with minimal interaction with the residents.

They did assist them with drinking, but spoke very little. None of the residents appeared to be watching TV. Resident #15 was asleep with a puzzle in front of him/her and four were asleep in their wheelchairs. Resident #18 was asleep in a Broda type chair. -At 10:30 A.M. three residents were taken to the Group Meeting with the surveyors by the Activities staff. Seven residents remained in front of the TV. None were watching, three were asleep. A CNA collected snack wrappers and left. Resident #15 was asleep in front of a puzzle.

-11:00 A.M. six residents remained with the TV on, five were asleep. One had been given a magazine.

-1:00 P.M. 8 residents were in the same common area. Resident #15 and Resident #18 were present. In addition, two of the same residents observed this morning were still there. No TV was on and no activity was taking place.

During an interview with Nurse # 1 at this time, she said none of the residents present in the common area had participated in any activity since the surveyor had observed them this morning. Five residents were asleep.

-1:05 P.M. one resident was observed thumbing through a magazine and began to say help me, help me. He/she was taken to his/her room.

-1:15 P.M. the Activity Director told the surveyor that it was too humid for porch time so Bingo was being substituted. Resident #18 was in the same spot, in the same position, as first observed at 10:00 A.M., asleep.

-At 1:30 P.M. Unit Manager #1 turned the radio on. A CNA sat with Resident #15 to help with a puzzle. He/she was then taken to his/her room for a nap. Resident #18 was taken to his/her room.

Review of the Activity Calendar for 6/27/17 indicated the following:

9:00 A.M. to 10 A.M. resident visits on the 5th floor.
10:00 A.M. to 11:00 A.M. visits for Latino residents on the 4th and 5th floor 11:30 A.M.
Patriotic Cook Out 1:45 P.M. to 2:45 P.M. Nail Spa on the 5th floor

On 6/27/17 the surveyor made the following observations on the 5th floor:

-9:30 A.M. eight residents, including Resident #15 and Resident #18 were in the same common area. Reruns of Bewitched were on TV. Resident #15 was doing a puzzle (part of his/her careplan) alone.

Resident #18 was in a Broda chair in the same spot as yesterday. Five residents were asleep. -10:45 A.M. thirteen residents were in the common area. Bewitched was still on TV. One resident appears to be watching. One resident is being given nail care by Activity Assistant #1. Non-sampled (NS) Resident #1 told the surveyor he/she wanted more art activities. NS #2 said he/she was bored on the weekend because the only activity is Bingo.

-11:00 A.M. Activity Assistant #1 observed assisting three residents with nail care. She told the surveyor this was not a scheduled activity. Three of eleven residents in the common area were watching Bewitched on TV.

-12:00 P.M. Most residents had been taken to a scheduled cook out.

-2:45 P.M. Four residents were alone in the common area. Bewitched was still on TV. Resident #18 had not left the common area all day. Nurse #1 said he/she was in the common area since that morning but she and the CNAs check on him/her during the day.

Review of the Activity calendar for 6/28/17 was changed due to weather and indicated the following: 9:00 A.M. to 10:00 A.M. resident visits on 4th floor 10:00 A.M. to 10:45 A.M. Gentle Stretch on 4th floor 10:00 A.M. to 10:45 A.M. Zen Doodle on the 5th floor 1:00 P.M. to 3:00 P.M. Bedside Visits 2:00 P.M. to 3:30 P.M. Make Your Own Ice Cream On 6/28/17 the surveyor made the following observations on the 5th floor nursing unit.

-9:20 A.M. eight residents are in the same common area. Bewitched was on TV. No staff were present. Only one resident appears to be watching. -10:00 A.M. ten residents were in the same common area. Bewitched was on TV. Resident #15 had a puzzle but wasn’t working on it. One resident had newspaper. NS #1 started a small singing group, no staff were involved.

-10:15 A.M. Activity staff entered the common area with art supplies to do Zen Doodle. The activity concluded at 10:45 A.M.

-11:00 A.M. a nurse was observed assisting one resident with a puzzle.

-1:00 P.M. six residents observed in the common area. TV not on, no activity taking place.

-1:15 P.M. Activity Assistant #1 turned Bewitched on TV.

On 6/28/17 at 2:30 P.M. eleven residents were observed in the Make Your Own Ice Cream activity. No other activity was scheduled on the calendar for other residents.

2. For residents residing on the 4th floor, the facility staff failed to provide a program of activities designed to meet each individual’s preferences and needs. On 6/23/17 the surveyor made the following observations on the 4th floor nursing unit:

– At 12:50 P.M. eleven residents were seated in the Dining Room. Three residents had meal trays in front of them.

The remaining eight residents were seated at tables. Resident #14 was seated in a highback wheelchair with his/her head down. There was music playing. One staff nurse was observed retrieving the meal trays at this time. Resident #6 was seated in the hallway near the Dining Room.

– At 1:00 P.M. eight residents remained seated in the Dining Room. There was no music or television observed at this time. The residents were not observed to have any self directed activities and no staff were present.

– At 1:05 P.M. Certified Nurse Aide (CNA) #5 entered the Dining Room and asked one resident if he/she would like to watch television. CNA #5 turned on a black & white film. Five of the eight residents were unable to see the television screen because they were facing the opposite direction.

– At 1:15 P.M. five residents remained in the Dining Room. Four residents had their back facing the television screen, and only one resident was positioned in front of the television and was watching the movie.

– At 1:50 P.M. Three residents remained in the Dining Room. One resident was observed eating ice cream. One resident was watching the television. On 6/27/17 the surveyor made the following observations on the 4th floor nursing unit:

– At 9:00 A.M. twelve residents were in the Dining Room. One CNA was observed charting and not engaged with the residents.

– At 9:15 A.M. a CNA put on the television. One resident appeared to be watching the television. Five residents had their backs to the television and were unable to see the screen, including Resident # 14, whose head was down. He/she was dressed in a hospital johnny with his/her back and bare legs exposed. Another resident was observed in the wheelchair with his/her back to the television, and had a tray table that had fallen and was caught on one of the leg rests. Four of the twelve residents were sleeping. One resident was observed handling a soiled clothing protector and another was observed handling the hoyer sling strap.

– At 9:40 A.M. housekeeping staff were observed mopping the Dining Room floor. The television was on. One resident was repetitively calling out I want a piece, give me a piece. There were no nursing staff present.

– At 10:00 A.M. ten residents remained in the Dining Room. One resident was watching television, three residents were sleeping. One resident had a beverage.

– At 10:05 A.M. a CNA handed out snacks with minimal interaction with the residents. – At 10:10 A.M. eleven residents were present in the Dining Room. Five of the eleven were given snacks and/or beverages. One resident was observed watching television and one resident was observed to be sleeping.

Nine of the other residents were positioned in chairs in the Dining Room. There was no staff present at this time.

– At 10:30 A.M. through 10:47 A.M. a Spanish speaking staff member provided 1:1 visits with 4 Spanish speaking residents in the Dining Room. There were seven other residents in the Dining Room at this time, the television was on and one resident was observed watching the program.

– At 11:00 A.M. twelve residents were in the Dining Room. The Wendy Williams Show was on the television and two of the residents were watching.

– At 11:30 A.M. seven residents remained in the Dining Room. Two CNAs were observed putting tablecloths on the tables. The television was on, and one resident was watching the program. Resident #16 was observed in a geriatric chair sleeping with a straw in his/her mouth. On 6/28/17 the surveyor made the following observations on the 4th floor nursing unit:

– At 10:30 A.M. ten residents were present in the Dining Room. The television was on showing a black & white film. One of the ten residents was watching the program. – At 10:40 A.M. to 10:45 A.M. a CNA handed out snacks with minimal interaction with the residents.

– At 11:20 A.M. Six residents remained in the Dining Room. The television was on. One of the six residents was watching the program. – At 12:00 P.M. lunch was served in the Dining Room. Ten residents were present and the television was still on.

During an interview with the Activity Director on 6/28/17 at 3:45 P.M with the survey team, she said residents who do not attend activities should be given self directed activities. Nurses should be giving the residents crafts, magazines etc. It was everyone’s job to assist the activity staff. She said only one person was scheduled to provide activities per day on the weekend for the fourth and fifth floor nursing units. In addition, if an activity was scheduled on a particular unit, it was only for the residents on that unit. She said part of the problem was that 95% of the residents go to bed after lunch and don’t get up until supper, and the activity staff was only scheduled until 4:00 P.M. She said she felt there was not enough staffing to meet the needs of the residents.

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 interview and record review the facility staff failed to develop a comprehensive care plan for bladder incontinence when a comprehensive assessment determined the need for one resident (#10) in a total sample of 21 residents.

Findings include:

For Resident #10, the facility failed to develop a care plan for bladder incontinence when identified on the Admission Minimum Data Set (MDS) Assessment. Resident #10 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Review of a Bowel and Bladder Assessment, dated 5/30/17, indicated the resident was continent of bladder.

Review of the resident’s care plan, initiated 5/30/17, did not indicate any care plan interventions to address bladder incontinence. Review of the Admission MDS Assessment, dated 6/2/17, indicated the resident was frequently incontinent of bladder (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) during the previous 7 days.

Review of the Care Area Assessment for Urinary Incontinence, dated 6/8/17, indicated the resident was incontinent and a care plan would be developed. During an interview with Certified Nurse’s Aide #1 on 6/22/17 at 1:15 P.M., she said she often provided care for Resident #10. She said Resident #10 was incontinent of bladder at times, but knew of no toileting plan for bladder incontinence. During an interview on 6/22/17 at 1:30 P.M. with the Director of Nurses, she said no care plan had been developed to address bladder incontinence.

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 2 sampled residents (#6 and #14), in a total of 21 sampled residents.

Findings include:

1. For Resident #6, the facility staff failed to apply geri-sleeves and geri-legs (protective limb covering), as care planned. Resident #6 was admitted to the facility in 11/2015 with [DIAGNOSES REDACTED]. Review of the active resident CNA care card, initiated 5/6/16, indicated to apply geri legs to bilateral lower extremities. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 4/18/17, indicated that Resident #6 had severe cognitive impairment, and was dependent on staff for dressing and personal hygiene.

Review of the Potential for Skin Breakdown care plan, reviewed 5/9/17, indicated the resident was at risk for skin breakdown due to fragile skin, cognitive impairment, dependence on use of a wheelchair, and could be resistive to care. The following interventions were included: Geri-legs and Geri-sleeves on at all times, for staff to remove each shift check the resident’s skin integrity.

Review of the Treatment Administration Record (TAR), dated 6/2017, indicated an order (initiated on 12/3/15), for Geri-sleeves to be applied to the resident’s bilateral upper extremities, and for staff to remove for care and check skin integrity every shift. Further review of the TAR indicated that the Geri-sleeves were applied 6/21/17 through 6/27/17.

During an observation on 6/23/17 at 1:50 P.M., Resident #6 was lying in bed with his/her eyes closed. The resident’s arms were exposed and the surveyor observed that he/she did not have Geri-sleeves on. During a observation on 6/27/17 at 8:45 A.M., the resident was seated in a wheelchair in the hallway. The resident was dressed and had on non-skid socks. The resident’s arms were exposed. The surveyor observed that he/she did not have Geri-sleeves on. During an observation on 6/27/17 at 11:30 A.M., the resident was observed seated in a wheelchair in the hallway. The resident did not have Geri-sleeves on. The surveyor observed skin discolorations on both forearms. The resident was observed to have his/her right foot on the seat of the wheelchair and was pulling his/her pants down over his/her knee. The surveyor observed that the resident did not have on Geri-legs. During an interview on 6/27/17 at 2:50 P.M., Certified Nurse Assistant (CNA) #3 said that the resident requires 1-2 staff for care. He further said that the resident should have stockings to his/her arms and legs.

During an interview on 6/27/17 at 2:58 P.M., Unit Manager (UM) # 2 said the resident was to have Geri-sleeves and Geri-legs on. UM #2 said that the resident can sometimes take them off, but if he/she did, the staff would re-apply them. If the resident continued to take them off, the staff would update the Physician and request an alternative. If the Geri-sleeves and Geri-legs are not applied, there should be documentation as to why. UM #2 did not provide documentation to indicate why Resident #6 did not have the Geri-sleeves or Geri-legs on as ordered by the Physician.

2. For Resident #14, the facility staff failed to apply TED hose (compression stockings) to his/her legs, as ordered by the Physician. Resident #14 was admitted to the facility in 7/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 6/13/17, indicated the resident had severe cognitive impairment, was dependent on staff for personal hygiene and dressing, and did not have any episodes of rejection of care. Review of the physician’s orders [REDACTED].M. to 7:00 A.M. shift, and to remove every night.

Review of the TAR, dated 6/2017, indicated an order to apply TED hose (knee high) to both lower extremities every A.M. on 11:00 P.M. to 7:00 A.M. and to remove the TED hose every night. Further review of the TAR indicated that the TED hose were applied to the resident daily except on 6/20/17 (there was no documentation) and on 6/27/17 (resident refused). During an observation on 6/28/17 at 11:40 A.M., the resident was seated in a wheelchair in the Dining Room. The resident was dressed and wearing non-skid socks. The resident did not have TED hose on, as ordered by the Physician. During an interview on 6/28/17 at 11:45 A.M., CNA #1 said that the resident requires total care with dressing. CNA #1 said that the resident did not wear TED hose. During an interview on 6/28/17 at 11:54 A.M., Nurse #2 said that the resident has an order for [REDACTED]. to 7:00 A.M. shift, and that the treatment was signed off on this date as completed. She further said that she did not receive anything in report that the resident refused the TED hose this morning, and that she would make sure that they were put on.

Failed to provide necessary care and services to maintain the highest well being of each resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility staff failed to ensure that treatment and services were provided for 1 sampled resident (#1) relative to pain management as ordered by the Physician in a total of 21 sampled residents.

Findings include:

For Resident #1, the facility staff failed to ensure that the prescribed medication ([MEDICATION NAME]-a pain reliever) was administered as ordered. Resident #1 was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. Review of the Physician’s Progress Notes, dated 4/25/17, indicated that the resident stated that he/she was feeling terrible, and had persistent right knee pain that was constant despite use of Tylenol (pain reliever) and movement. The progress note further indicated to add [MEDICATION NAME] (a stronger pain medication) 25 milligrams (mg.) twice daily and [MEDICATION NAME] 25 mg. twice daily as needed for the right knee pain.

Review of the Physician’s Interim/Telephone Orders, dated 4/25/17 at 10:30 A.M., indicated an order to start [MEDICATION NAME] 25 mg. twice daily for right knee pain for two weeks, and to start [MEDICATION NAME] 25 mg. twice daily as needed for right knee pain for two weeks.

Review of the Medication Administration Record [REDACTED].) twice daily at 8:00 A.M. and 8:00 P.M. for two weeks. The MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED].M. dose on 4/27/17. Further review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED].M. to 3:00 P.M. shift, the resident was reporting a pain level of 7 out 10.

Review of the nurse’s note, dated 4/26/17 at 7:34 A.M., indicated that [MEDICATION NAME] was not administered because the medication was not delivered from the pharmacy. Review of the nurse’s note, dated 4/27/17 at 7:19 A.M., indicated that [MEDICATION NAME] was not administered because the medication was not available. During an interview on 6/27/17 at 2:30 P.M., Nurse #1 said that [MEDICATION NAME] is no longer available in the emergency kits. Nurse #1 said the Physician would fill complete an order for [REDACTED].#1 said that pharmacy services are available 24 hours/7 days a week, and the medication is usually delivered on the same day. She further said that if the prescribed medication had not been delivered by the scheduled dose time, she would contact the pharmacy and see if the medication is close to being delivered. If not, she would update the Physician for further orders.

During an interview on 6/27/17 at 2:40 P.M., Unit Manager (UM) #1 said that an order for [REDACTED].#1 said if the prescribed pain medication was not administered as ordered, the Physician would be updated. UM #1 said this information would be documented in the resident’s record. UM #1 did not provide documentation to indicate the Physician had been notified of the missed pain medication.

Failed to make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility staff failed to assess and provide appropriate treatment and services to achieve or maintain as much normal urinary function as possible for 1 resident (#10) of 14 applicable residents in a total sample of 21 residents.

Findings include:

For Resident #10, the facility failed to conduct an appropriate assessment and develop a care plan for bladder incontinence when the resident was found to have urinary incontinence. Review of the undated facility Policy and Procedure titled Bladder Program indicated the following:

-The Bowel and Bladder Assessment establishes the potential for bladder retraining.

-The assessment can be done within 72 hours of admission or any time a change occurs in the resident’s continence status.

-If the resident is incontinent a 72 hour incontinence tool is implemented and completed by all shifts for 3 days.

-After completion, a plan of management is established.

Resident #10 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Review of a Bowel and Bladder Assessment, dated 5/30/17, indicated the resident was continent of bladder. Review of the resident’s care plan, initiated 5/30/17, did not indicate any care plan interventions to address bladder incontinence.

Review of the Admission MDS Assessment, dated 6/2/17, indicated the resident was cognitively intact as evidenced by a Brief Interview of Mental Status score of 14 of 15, required extensive assistance for toileting and was frequently incontinent of bladder (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) during the previous 7 days. Review of the Care Area Assessment for Urinary Incontinence, dated 6/8/17, indicated the resident was incontinent and a care plan would be developed.

During an interview with Certified Nurse’s Aide (CNA) #1 on 6/22/17 at 1:15 P.M., she said she often provided care for Resident #10. She said Resident #10 was incontinent of bladder at times in the morning, but knew of no toileting plan for bladder incontinence. Review of the 6/2017 CNA Flow Sheets indicated the resident had occasional episodes of bladder incontinence during the night. During an interview on 6/22/17 at 1:30 P.M. with the Director of Nurses, she said a 72 hour toileting pattern had not been done and no care plan had been developed to address bladder incontinence.

Failed to safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist

Based on observation and interview the facility staff failed to ensure emergency medication kits (e-kits) were fully stocked on two of three nursing units.

Findings include:

Review of the Pharmacy Services Policy for Emergency Medication Supplies, revised 1/2017, indicated the Emergency Medication Supply should be maintained by either a mechanism of replacement or exchange, as mutually agreed upon by the Facility and the Pharmacy, and in compliance with Applicable Law. During inspection of the fourth floor medication room on 6/27/17 at 2:00 P.M. the surveyor, accompanied by Nurse #1, observed the Coumadin (blood thinner) e-kit. The e-kit seal was broken indicating the e-kit had been opened. A 1 milligram (mg.) tablet and a 4 mg. tablet of Coumadin had been removed. Nurse #1 said there was suppose to be a form within the kit indicating what was taken and for whom. The pharmacy should be notified by fax or by phone so the kit could be replaced. There was no such form in the kit. Nurse #1 said there was no way to know if the pharmacy had been notified of the open e-kit, when the e-kit had been opened, or who the medication had been used for.

During inspection of the fifth floor medication room on 6/27/17 at 2:30 P.M. the surveyor, accompanied by Nurse #2, observed the Insulin e-kit. A vial of Lantus Insulin had been removed. Nurse #2 said there was no way to know when the e-kit was opened, if the pharmacy had been notified, or who the medication had been used for because it had not been documented on the enclosed form in the e-kit.

St. Mary Health 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.


Sources:

Medicare Nursing Home Profiles and Reports – St. Mary Health Care Center

Inspection Report for St. Mary Health Care Center – 06/28/2017

Page Last Updated: September 3, 2018