West Side House of Worcester

West Side House of Worcester

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at West Side House of Worcester? 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.

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About West Side House of Worcester

West Side House of Worcester is a for profit, 91-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Worcester, Shrewsbury, Holden, Leicester, Millbury, Grafton, Northborough, Westborough, Sutton, Spencer, Clinton, Northbridge, Oxford, Marlborough, Hudson, and the other towns in and surrounding Worcester County, Massachusetts.

West Side House of Worcester
35 Fruit St,
Worcester, MA 01609

Phone: (508) 752-6763

CMS Star Quality Rating

West Side House of WorcesterThe 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, West Side House of Worcester in Massachusetts received a rating of 2 out of 5 stars.

Performance Area Rating
Overall Rating 2 out of 5 (Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 2 out of 5 (Below Average)

Fines Against West Side House of Worcester

The Federal Government fined West Side House of Worcester $64,613 on 12/29/2015 and $2,711 on 04/07/2017for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered West Side House of Worcester 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 staff failed to obtain consent for the use of a physical restraint for 1 resident (#11), and informed written consent for the use of [MEDICAL CONDITION] medications, for 2 residents (#5, #11), out of 15 sampled residents.

Findings include:

1. For Resident #11 the facility staff failed to obtain informed written consent from the Health Care Proxy (HCP) for the use of a physical restraint and three [MEDICAL CONDITION] medications. Resident #11 was admitted to the facility in 1/2017 with a [DIAGNOSES REDACTED]. Review of the facility Restraint Policy and Procedure, dated 11/01/02, indicated that any family or resident communication about restraint use should be documented in the nursing and/or social service notes.

Review of the 1/2017 Physician orders [REDACTED]. The restraint needed to be released every two hours and for meals. Further review of the Physician orders [REDACTED]. Further review of the 1/2017 signed Physician orders [REDACTED].M. and 5:00 P.M. Review of the clinical record did not indicate informed written consent was obtained for the use of a physical restraint and/or the psychoactive medications [MEDICATION NAME][MEDICATION NAME]. During an interview on 1/26/17 at 11:30 A.M., the MDS (Minimum Data Set) coordinator said she called the HCP three or four times to obtain verbal consent for the restraint but was unable to reach him. She said she writes a nursing note when she obtains verbal consent and then a copy of the restraint assessment is mailed out for signature. She was unable to provide a signed copy at time of survey.

Review of the Nursing and Social Service notes for 1/2017 did not indicate any discussion with the HCP had taken place to obtain consent for the use of a restraint or the use of [MEDICAL CONDITION] medications. During an interview on 1/26/17 at 3:30 P.M., UM (Unit Manager) #1 said she didn’t locate any consent forms for Resident #11. The Assistant Director of Nursing (ADON) said the consent forms may have been mailed to the HCP and copies should have been in the chart. UM #1 reviewed the chart a second time and was unable to find documented evidence that the [MEDICAL CONDITION] consents had been obtained or mailed. During an interview on 1/27/17 at 2:02 P.M., the MDS coordinator reviewed the Restraint assessment with the surveyor. She said she completed the assessment on 1/13/17. When the surveyor inquired about the section that indicated consent had been obtained by telephone, the MDS coordinator said she didn’t recall speaking with the HCP about restraints, but couldn’t be certain.

2. For Resident # 5 the facility staff failed to obtain informed written consent from the legal guardian for the use of two [MEDICAL CONDITION] medications. Resident #5 was admitted to the facility in 9/2009 with [DIAGNOSES REDACTED]. Review of the 1/2017 signed Physician orders [REDACTED]. Review of the clinical record indicated a psychiatric consult, dated 1/6/17, with a recommendation to trial [MEDICATION NAME] (anti-[MEDICAL CONDITION]) as a secondary mood stabilizer (off label use). Review of the clinical record indicated an interim Physician order, dated 1/16/17 to start [MEDICATION NAME] 100 mg by mouth daily for one week. If well tolerated, increase to [MEDICATION NAME] 100 mg by mouth twice daily. Review of the clinical record did not indicate informed written consent was obtained for the use of [MEDICATION NAME] and [MEDICATION NAME].

During an interview on 1/26/17 at 2:30 P.M., UM #2 said consents was not obtained for the use of [MEDICATION NAME] or [MEDICATION NAME].

Failed to allow residents to easily view the results of the nursing home's most recent survey.

Based on observation and interview, the facility staff failed to post the results of the most recent survey in 3 out of 3 locations.

Findings include:

During environmental tour on 1/26/17 at 11:00 A.M., the surveyor observed a survey results book in the front lobby of the building that did not include the results of the most recent facility survey. Also, the survey results books on both the first and second floors did not have the results of the most recent facility survey. During an interview on 1/26/17 at 12:35 P.M., the Executive Director said the survey books had not been updated because the secretary had been out of the office.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure one Resident (#4) out of 4 applicable residents, in a total sample of 15 residents, was free from a physical restraint.

Findings include:

Review of the facility’s Device/Restraint Policy and Procedure, dated 11/01/02, indicated the following:

-A physical restraint is defined as any manual method or physical or mechanical device material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.

-There must be written, signed, and dated Physician’s orders for devices/physical restraints, and all orders must be reviewed and signed with each required Physician’s visit.

-If a restraint is necessary, a staff member must be assigned to release the resident at least every 2 hours for a minimum of 15 minutes while the restraint is in use

. For Resident #4, the facility staff failed to assess the Resident’s ability to self release a soft belt on the wheelchair. Resident #4 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. Review of the falls care plan, dated 1/25/16, indicated an intervention was added on 11/16/16 for staff to assist Resident into wheelchair and apply a release soft belt. Review of Device/Physical Restraint Assessment, dated 1/20/17, indicated the Resident had a release soft belt that was to enable positioning, and was in place due to unsteady gait. This assessment did not indicate if the Resident was able to self release the belt. Review of the 1/2017 signed Physician’s orders, dated 1/23/17, did not indicate an order for [REDACTED]. Observation on 1/24/17 at 1:10 P.M., Resident was up and dressed sitting in the wheelchair with the soft belt on. During an interview on 1/24/17 at 2:05 P.M., CNA #2 said the Resident is able to self release the soft belt.

During an interview on 1/24/17 at 2:10 P.M., the Assistant Director of Nurses said he thought the belt was a restraint, but then said it wasn’t a restraint. He said if it wasn’t a restraint the staff didn’t document anywhere on the ability to self release. He said if suddenly the Resident was unable to remove the belt, that would be documented. Observation on 1/24/17 at 4:15 P.M., the Resident was up and dressed sitting in the wheelchair with the soft belt on. During an interview on 1/24/17 at 4:15 P.M., Unit Manager (UM) #1 said the Resident could remove the soft belt and there should have been an order in place for it. During an interview on 1/24/17 at 4:20 P.M., the Rehab Aide said she didn’t think they needed an order since the belt was used for positioning. She said the nurses were supposed to be checking on the Resident’s ability to self release at least monthly and it should have been on the Treatment Administration Record (TAR).

During an interview on 1/24/17 at 4:25 P.M., UM #1 said there was no Physician’s order and there was nothing on the TAR that assessed the Resident’s ability to self release the belt at regular intervals. During an interview on 1/24/17 at 5:05 P.M., the Rehab Aide said there should have been an assessment done weekly (not monthly) to show the Resident could release the belt. She said the device wasn’t considered a restraint since the Resident could self release it. Observation on 1/25/17 at 1:10 P.M., the Resident was up and dressed in the wheelchair with belt on, accompanied by Certified Nurses Aide (CNA) #3. During an interview on 1/25/17 at 1:10 P.M., CNA #3 told the surveyor she often took care of this Resident. Surveyor requested she ask the Resident if he/she could remove the belt. CNA #3 asked the Resident to remove the belt and the Resident said he/she couldn’t take it off, didn’t think it came off, and wished someone would take it off. The Resident attempted to touch the belt but quickly stopped and said he/she couldn’t do it. CNA #3 said she didn’t think the Resident could release it, she said she had never seen him/her release it.

Review of Device/Physical Restraint Assessment, dated 1/25/17 at 8:40 A.M., indicated the Resident had a release soft belt, used to restrict freedom of movement, that was in place due to difficulty in walking, muscle weakness, and [MEDICAL CONDITION]. Resident continued with mobility on the unit and was able to self release the soft belt. During an interview on 1/25/17 at 1:30 P.M., the Rehab Aide said there had never been an assessment to see if the Resident could self release the belt when it was put in place. She said the staff didn’t check to see if the Resident could remove it the day before (1/24/17) because they were trying to get the orders in place. She said the Resident would be assessed by the Rehab Department and if he/she was unable to remove the belt the staff would proceed with the restraint protocol. She said if it was appropriate, the staff would initiate a restraint reduction. Review of the Device/Physical Restraint Assessment, dated 1/25/17 at 3:12 P.M., indicated the Resident was unable to release the soft belt and the soft belt was discontinued and a wheelchair alarm was put in place.

Failed to Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property.

Based on review of personnel files, the facility staff failed to perform the required pre-screening background checks for 2 of 5 newly hired Employees (#1 and #2).

Findings include:

Review of the Facility’s Abuse Prevention Policies and Procedures, dated 4/2016, indicated the following: All applicants for employment shall provide personal and professional references. The facility shall conduct reference checks to the fullest extent possible, including but not limited to MA (Massachusetts) Board of Nursing license verification, CNA (Certified Nurse Aide) Registration verification, CORI (Criminal Offender Registry Information) checks, and OIG (Office of Inspector General) Exclusion database checks. Review of the Personnel Files indicated the following:

a. Employee #1 was hired on 10/11/16, as the Activity Director. The Nurse Aide Registry check had not been requested to ensure there were no findings against this employee. The CORI check was completed on 11/16/16, which was not prior to hire.
b. Employee #2 was hired on 10/25/16, as a Social Worker. The Nurse Aide Registry check had not been requested to ensure there were no findings against this employee.

The CORI check was completed on 11/17/16, which was not prior to hire. During an interview with the Executive Director (ED) and Business Office Representative on 1/24/17 at 2:30 P.M., the ED said that the former human resource employee did not consistently complete the requited screenings prior to hiring employees.

Failed to Completely assess the resident at least every twelve months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to complete an Annual Minimum Data Set (MDS) Assessment within the required time frame for 1 resident (#2) in a total sample of 15 residents.

Findings include:

Resident #2 was admitted to the facility in 11/2015 with [DIAGNOSES REDACTED]. Review of the clinical record indicated an Admission MDS Assessment was completed with an Assessment Reference Date (ARD) of 12/9/15.

Review of the clinical record indicated Quarterly MDS Assessments were completed with ARDs of 3/2/16, 5/24/16, 8/16/16 and 11/8/16. Review of the clinical record indicated the last comprehensive MDS Assessment completed was the Annual MDS on 12/9/15, therefore, the next Annual MDS Assessment should have been completed by 12/10/16. During an interview on 1/25/17 at 9:40 A.M., the MDS coordinator said the Quarterly MDS completed on 11/8/16 should have been completed as an Annual MDS Assessment.

Failed to make sure each resident receives an accurate assessment by a qualified health professional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to ensure the Minimum Data Set (MDS) Assessments were accurately coded for 3 residents (#2, #4, and #5) in a total sample of 15 residents.

Findings include:

1. For Resident #2 the facility staff failed to ensure the accuracy of a Quarterly MDS Assessment relative to a diagnosis. Resident #2 was admitted to the facility in 11/2015 with a [DIAGNOSES REDACTED]. Review of the current care plan for alteration in mood, with an original date of 12/12/15, indicated the Resident receives medication, psychiatric services and behavioral interventions for [MEDICAL CONDITION] disorder.

Review of the Quarterly MDS Assessment, dated 11/8/16, indicated [MEDICAL CONDITION] disorder was not coded in the active [DIAGNOSES REDACTED]. During an interview on 1/27/17 at 2:40 P.M., the MDS coordinator said the assessment should have been coded for the [DIAGNOSES REDACTED].

2. For Resident #5 the facility staff failed to ensure the accuracy of a Quarterly MDS Assessment relative to a diagnosis. Resident #5 was admitted to the facility in 9/2009 with a [DIAGNOSES REDACTED]. Review of the 1/2017 Physician orders [REDACTED]. Review of the Quarterly MDS Assessment, dated 11/1/16, indicated [MEDICAL CONDITION] disorder was not coded in the active [DIAGNOSES REDACTED]. During an interview on 1/27/17 at 2:40 P.M., the MDS coordinator said the assessment should have been coded for the [DIAGNOSES REDACTED].

3. For Resident #4 the facility staff failed to accurately code a surgical wound and a fall on two different MDS assessments. Resident #4 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 1/20/16, indicated the surgical wound was not coded in Section M. Review of Progress Note, dated 9/29/16, indicated the Resident lost his/her balance and fell to the floor. Review of the Quarterly MDS Assessment, dated 9/27/16, indicated the Resident had not had any falls since last assessment. During an interview on 1/26/17 at 12:35 P.M., the MDS Coordinator said the surgical wound should have been coded on the 1/20/16 Admission MDS Assessment, and the fall should have been coded on the 9/27/16 Quarterly MDS Assessment. She said she would modify both assessments.

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** For Resident #2 the facility staff failed to document the rotation of injection sites. Resident #2 was admitted to the facility in 11/2015 with [DIAGNOSES REDACTED].

Review of the facility policy for Documentation of Medication Administration, revised (MONTH) 2007, indicated the injection site must be documented immediately after administration.

Findings include:

Review of the 11/2016 Medication Administration Record (MAR) indicated the Resident was administered [MEDICATION NAME] 70/30 (Insulin)100 units (u)/milliliter (ml) given 34 u. subcutaneous daily at 5:00 P.M. from 11/1/16 to 11/30/16. Further review indicated the daily injection site was not recorded on the MAR for 21 out of 28 administrations. Review of the 12/2016 MAR indicated the Resident was administered [MEDICATION NAME] 70/30 (Insulin)100u/ml given 68 u. subcutaneous daily at 9:00 A.M. and 34 u. at 5:00 P.M. from 12/1/16 to 12/31/16. Further review indicated the daily injection sites were not recorded on the MAR for either administration time, except on 12/12/16.

Review of the 1/2017 MAR indicated the Resident was administered [MEDICATION NAME] 70/30 100 u/ml given 68 u. subcutaneous daily at 9:00 A.M. between 1/1/17 and 1/7/17, 74 u. at 9:00 A.M. between 1/18/17 and 1/24/17 and 34 u. at 5:00 P.M. from 1/1/17 to 1/23/17. Further review indicated the daily injection sites were not recorded on the MAR for any of the administration times. During an interview on 1/26/17 at 2:40 P.M. the Unit Manager (UM) #2 said the injection sites should have been documented in the MAR. She said there were no comments or additional documentation logs that would indicate the sites for each administration.

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 record review and interview, the facility staff failed to administer a Physician ordered medication for 1 resident (#5) in a total sample of 15 residents.

Findings include:

Resident #5 was admitted to the facility in 9/2009 with a [DIAGNOSES REDACTED]. Review of the facility policy for Documentation of Medication Administration, revised (MONTH) 2007, indicated that documentation must include the reason why a medication was withheld, not administered or refused.

Review of the 1/2017 signed Physician orders indicated an order for [REDACTED].M. Review of the 1/2017 Medication Administration Record (MAR) indicated there were no documented entries to support that [MEDICATION NAME] was given on 1/2/17, 1/4/17, 1/10/17, 1/11/17, 1/20/17 (boxes were blank).

During an interview on 1/26/17 at 2:30 P.M., Unit Manager #2 reviewed the 1/2017 MAR and said there was no documentation that indicated the [MEDICATION NAME] was given on the 5 dates in question and there was no documented reason if the medication was withheld at that time.

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 observation, record review and interview, the facility staff failed to provide an accurate and thorough assessment of urinary incontinence for 3 residents (#5, #6, and #10) and failed to develop individualized interventions to restore as much bladder function as possible in 2 residents (#6 and #10) out of 4 applicable residents, in a total sample of 15 residents.

Findings include:

Review of the facility Bowel and Bladder Program Policy, revised 1/20/15, indicated the following: The licensed nurse will complete a bowel and bladder assessment for all residents on admission and when continence status changes. 1. For Resident #10 the facility staff failed to accurately assess the Resident’s continence status upon admission to the facility and after multiple falls in the bathroom.

Review of the Bladder Functioning Assessment, dated 10/27/15, indicated the Resident was continent of urine. Review of the Admission Minimum Data Set (MDS) Assessment, dated 11/7/15, indicated the Resident was not on a toileting schedule and was occasionally incontinent of urine. Review of the care plan for incontinence, dated 11/7/15 with a goal date of 4/17/17, indicated the Resident was incontinent of bowel and bladder, and was to be toileted twice per shift and as needed. An intervention of placing the urinal at the bedside was added 2/18/16.

Review of an Incident Report, dated 7/3/16, indicated the Resident fell when attempting to self transfer to the toilet. Review of the Case Management Fall Prevention Care Plan Review, dated 7/5/16, indicated the team recommended a wheelchair alarm. Review of an Incident Report, dated 8/27/16, indicated the Resident fell in the bathroom when attempting to self transfer to the toilet. Review of the Case Management Fall Prevention Care Plan Review, dated 8/29/16, indicated the team recommended a self release softbelt while up in wheelchair with a chair alarm, and staff to toilet before and after meals.

Review of the Annual MDS Assessment, dated 10/11/16, indicated the Resident was not on a toileting schedule and was occasionally incontinent of urine. Review of the Quarterly MDS Assessment, dated 1/3/17, indicated the Resident was not on a toileting schedule and was occasionally incontinent of urine. Review of the undated CNA kardex indicated the Resident was continent of bladder, needed assist for toileting, and was to be toileted twice per shift and as needed, urinal to be kept at bedside. Review of an Incident Report, dated 1/15/17, indicated the Resident was found on the bathroom floor at 3:30 P.M., when attempting to self transfer to the toilet.

Review of the Case Management Fall Prevention Care Plan Review, dated 1/16/17, indicated the team recommended a 3 day bowel and bladder assessment be started. Review of the Bowel and Bladder Pattern Assessment, dated 1/17/17, indicated facility staff documented from midnight thru 7:00 A.M. on 1/17/17 only. The remainder of 1/17/17 and the entire sheets for 1/18/17 and 1/19/17 were blank. During an interview on 1/27/17 at 12:30 P.M., the Rehab Aide said the 3 day bowel and bladder assessment had only been done for 1 shift. She said the Certified Nurses Aids (CNAs) often didn’t complete them, and the assessments then had to be restarted. She said the goal was to figure out why this Resident needed to use the bathroom so much and why multiple falls had happened in the bathroom. She said a 3 day bowel and bladder assessment was restarted on 1/25/17.

During an interview on 1/27/17 at 1:25 P.M., the Corporate Clinical Nurse said the Resident is incontinent of urine and the only bladder assessment that was done, was on 10/27/15, which indicated the Resident was continent.

During an interview on 1/27/17 at 1:35 P.M., CNA #1 said the Resident usually let the staff know when he/she needed to use the bathroom. She said the Resident was sometimes incontinent of urine. During an interview on 1/27/17 at 2:00 P.M., the Director of Nurses (DON) said the Resident had been incontinent of urine since admission (10/2015), and that the nurse who did the admission bladder assessment was wrong to have written that the Resident was continent. The DON said that because the Resident’s continence status hadn’t changed on the MDS assessments, the nursing staff had not been prompted to do a new bladder assessment.

2. For Resident # 6, the facility staff failed to assess the Resident’s continence status upon admission to the facility. Resident #6 was admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 6/3/16, indicated the Resident was not on a toileting schedule, was occasionally incontinent of urine, and needed extensive assistance of one person for toileting.

Review of the care plan for incontinence, dated 6/6/16 with a goal dated of 4/26/17, indicated the Resident was incontinent of bowel and bladder and required staff assist for toileting twice per shift and as needed.

Review of the Quarterly MDS assessment, dated 11/8/16, indicated the Resident was not on a toileting schedule, was occasionally incontinent of urine, and needed limited assist of one person for toileting. Review of the undated CNA kardex indicated the Resident was incontinent of urine, required assistance for toileting, and was to be toileted twice per shift and as needed. Review of the clinical record indicated a bladder assessment was never done for this Resident.

On 1/25/17 at 8:25 A.M., the Resident was observed ambulating to his/her bathroom without a walker. During an interview on 1/25/17 at 10:55 A.M., the Corporate Clinical Nurse said she could not find a bladder assessment for this Resident.

During an interview on 1/25/17 at 11:00 A.M., the DON said the facility policy is to do a 3 day voiding pattern on admission and upon a change of continence. During an interview on 1/26/17 at 9:00 A.M., the DON said the 3 day voiding pattern was never done on admission.

3. For Resident #5 the facility staff failed to assess a change in continence indicated on a Quarterly MDS Assessment. Resident #5 was admitted to the facility in 9/2009 with a [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 2/24/16, indicated the Resident was frequently incontinent of urine and occasionally incontinent of bowel. Review of the Quarterly MDS Assessment, dated 11/1/16, indicated the Resident was always incontinent of bladder and frequently incontinent of bowel. Review of the record did not indicate that a bowel and bladder assessment was completed after the change in continence was coded on the MDS. During an interview on 1/26/17 at 4:05 P.M., the DON said the Resident’s continence was not assessed in (YEAR). She said it was assessed in (MONTH) of (YEAR) as part of his annual MDS that is still in process. During an interview on 1/27/17 at 11:00 A.M., CNA #1 said the Resident is incontinent and dependent on staff for assistance with incontinence care.

Failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to provide effective interventions to prevent 3 unwitnessed falls for 1 Resident (#10) out of 4 applicable residents, in a total sample of 15 residents.

Findings include:

For Resident #10 the facility staff failed to provide effective interventions to prevent 3 unwitnessed falls in the bathroom. Resident #10 was admitted to the facility in 10/2015 with [DIAGNOSES REDACTED]. Review of the Bladder Functioning Assessment, dated 10/27/15, indicated the Resident was continent of urine.

Review of the Admission Minimum Data Set (MDS) Assessment, dated 11/7/15, indicated the Resident was not on a toileting schedule and occasionally incontinent of urine, had no falls since admission, and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of the care plan for incontinence, originally dated 11/4/15 and last revised 1/17/17, indicated the Resident was incontinent of bowel and bladder, and was to be toileted twice per shift and as needed. An intervention of placing the urinal at the bedside was added 2/18/16.

Review of the care plan for falls, originally dated 11/4/15 and last revised 1/17/17, indicated the Resident was at risk for falls due to history of falls, muscle weakness, gait disturbance, right sided hemiparesis, decreased safety awareness, resistive with call light for staff assist, and impulsive with self transfers. Interventions included:

-staff to assist with transfers in and out of bed.
-staff to assist with toileting, urinal at bedside, encourage the Resident to ask for staff assist (dated 6/30/16).
-staff to toilet before and after meals.
-staff to apply soft belt restraint while up in wheelchair, release and reposition every 2 hours, release for all meals and activity. (dated 1/20/17).

Review of an Incident Report, dated 7/3/16, indicated the Resident fell when attempting to self transfer to the toilet. No injuries sustained. Review of the Case Management Fall Prevention Care Plan Review, dated 7/5/16, indicated the team recommended a wheelchair alarm and Resident educated to request help when using the bathroom. Review of an Incident Report, dated 8/27/16, indicated the Resident fell in the bathroom when attempting to self transfer to the toilet. No injuries sustained. Review of the Case Management Fall Prevention Care Plan Review, dated 8/29/16, indicated the team recommended a self release softbelt while up in wheelchair with a chair alarm, and staff to toilet before and after meals. Review of the Quarterly MDS Assessment, dated 1/3/17, indicated the Resident had severe cognitive impairment with a BIMS score of 5 out of 15. Further review indicated the Resident was not on a toileting schedule and was occasionally incontinent of urine, and had one fall without injury since previous assessment. Review of the undated CNA kardex indicated the Resident was continent of bladder, needed assist for toileting, and was to be toileted twice per shift and as needed, urinal to be kept at bedside.

Review of an Incident Report, dated 1/15/17, indicated the Resident was found on the bathroom floor at 3:30 P.M., when attempting to self transfer to the toilet. Further review indicated the Resident refused to ask for staff assistance. Review of the Case Management Fall Prevention Care Plan Review, dated 1/16/17, indicated the team recommended a 3 day bowel and bladder assessment be started. Review of the Bowel and Bladder Pattern Assessment, dated 1/17/17, indicated facility staff documented from midnight thru 7:00 A.M. on 1/17/17 only. The remainder of 1/17/17 and the entire sheets for 1/18/17 and 1/19/17 were blank.

Observation on 1/26/17 at 3:10 P.M., the Resident was laying in bed with bed in low position, alarm box visible, wheelchair at foot of bed.

Observation on 1/27/17 at 9:40 A.M., the Resident was sitting in the wheelchair next to his/her bed with curtain pulled and soft belt on. During an interview on 1/27/17 at 12:30 P.M., the Rehab Aide said the 3 day bowel and bladder assessment had only been done for 1 shift. She said the goal was to figure out why this Resident needed to use the bathroom so much and why multiple falls had happened in the bathroom.

She said a 3 day bowel and bladder assessment was restarted on 1/25/17. During an interview on 1/27/17 at 1:25 P.M., the Corporate Clinical Nurse said the Resident is incontinent of urine and the only bladder assessment that was done, was on 10/27/15, which indicated the Resident was continent. During an interview on 1/27/17 at 1:35 P.M., CNA #1 said the Resident usually let the staff know when he/she needed to use the bathroom. She said the Resident was sometimes incontinent of urine.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure an adequate medication supply for 1 sampled Resident (#5) and 1 non-sampled Resident (NS #2), Resident (#2) out of a total of 15 sampled and 2 non-sampled residents.

Findings include:

1. For Resident #5, the facility staff failed to have two different medications, Taztia XT (for blood pressure/heart arrhythmia) and Divaloprex (antiseizure/mood stabilizer) available for administration. Resident #5 was admitted to the facility in 9/2009 with [DIAGNOSES REDACTED]. Review of the 1/2017 signed physician’s orders [REDACTED].M. Further review indicated to administer Divaloprex Sodium 125 (mg) 8 capsules (total dose 1000 mg) by mouth twice a day.

During the medication pass on 1/25/17 at 7:50 A.M., the surveyor observed Nurse #1 administer medications to Resident #5. Nurse #1 said she was unable to administer the Taztia XT because it was unavailable. She said it was not a medication they had in the Omnicell (a storage unit for certain prescribed medications to avoid missed doses). Nurse #1 did not have the Divaloprex Sodium in her medication cart. She looked in the medication room and there was none for Resident #5 there either. She obtained 6 capsules of the Divaloprex Sodium 125 mg from the Omnicell and administered the 6 capsules to the Resident, which was 2 capsules short of the total dose ordered. Nurse #1 told the surveyor she would update the Resident’s doctor about the medications that were not available or not administered. She said the Agency nurses (nurses supplied by a nursing agency to fill a vacancy on the facility schedule), never reordered medications.

2. For NS #2, the facility staff failed to have 4 different medications: [REDACTED]. NS #2 was admitted to the facility in 11/2008 with [DIAGNOSES REDACTED]. Review of the signed physician’s orders [REDACTED].

-Divaloprex Sodium 125 mg by mouth twice a day.
-Miralax 17 gram oral twice a day mixed in 8 ounces of fluid.
-Spiriva 18 microgram cap via inhalation once a day.
-Calcium 500 mg with Vitamin D 200 mg by mouth twice a day.

During the medication pass on 1/26/17 at 9:50 A.M., the surveyor observed Nurse #2 administer medications to NS #2. Nurse #2 told the surveyor he did not have Miralax to administer, he checked with UM #2 and she said she would order it from the pharmacy. Nurse #2 told the surveyor he also did not have Spiriva inhaler or Divaloprex Sodium 125 mg to administer to the Resident. He again checked with UM #2, she said she would order both of them from the pharmacy. UM #2 and Nurse #2 told the surveyor that the Calcium 500 mg with Vitamin D 200 mg was ordered the night before and was expected to be delivered sometime on 1/26/17. During an interview on 1/27/17 at 12:50 P.M., the Director of Nurses said there was a lot of Agency staff and she would change the reordering of medications from the night shift to the day shift to ensure it is done correctly.

Failed to maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Based on observation and interview, the facility staff failed to properly label and store medications in 2 out of 4 medication carts.

Findings include:

1. On 1/25/17 at 3:45 P.M., inspection of 1st floor Medication Cart East with the Director of Nurses (DON) revealed the following:
– 2 tubes unlabeled antifungal cream
-1 tube unlabeled calazime cream
-1 tube unlabeled bacitracin ointment
-3 tubes unlabeled Nystatin cream
-2 tubes unlabeled Santyl ointment (used to debride wounds)
-1 bottle unlabeled nystop powder
-1 tube unlabeled muscle rub
-one bottle Bisacodyl tablets (laxative) with expiration date 11/2016.

During an interview on 1/25/17 at 4:00 P.M., the DON said all of the treatment products listed above were moved to a treatment closet a few days prior. She said an Agency nurse (nurse supplied by a nursing agency to fill a vacancy on the facility schedule), must have came in and put them in the wrong place. She said they should have been labeled with the Resident’s name.

2. Review of the (YEAR) U.S. Food and Drug Administration information regarding insulin storage indicated that it is recommended to store unopened insulin in a refrigerator at approximately 36-46 degrees Fahrenheit. Unopened and stored in this manner, these products maintain potency until the expiration date on the package. Insulin may be left unrefrigerated at a temperature between 59-86 degress Fahrenheit for up to 28 days. On 1/26/17 at 10:35 A.M., inspection of the 2nd floor Medication Cart East revealed the following:

-1 vial of Lantus insulin- unopened and undated
-1 vial of Humalog insulin- unopened and undated

The base of the third drawer was covered with a red sticky substance that extended more than halfway across the drawer. During an interview on 1/26/17 at 10:40 A.M., Nurse #3 said the drawer needed to be cleaned. She said the unopened insulin should have been in the refrigerator until it was opened.

Failed to set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.

Based on interview and review of the Quarterly Quality Assurance (QA) attendance sign in sheets, the facility staff failed to ensure the Medical Director or his/her designee was in attendance for 2 out of the last 4 quarterly QA Meetings.

Findings include:

During review of quarterly QA attendance sign in sheets for (MONTH) (YEAR) and (MONTH) (YEAR) with the Executive Director present, the surveyor observed there was no signature from the Medical Director or designee, for either of the meetings. The Executive Director (ED) was also unable to observe a signature from the Medical Director or designee for either of those meetings.

During interview on 1/27/17 at 4:00 P.M., the ED said he wasn’t sure why the Medical Director was not in attendance for the (MONTH) (YEAR) meeting. He said the facility staff had not found a replacement for the Medical Director who retired in (MONTH) (YEAR), therefore, there was no Medical Director or designee at the (MONTH) (YEAR) QA meeting.

West Side House of Worcester, 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 – West Side House of Worcester

Inspection Report for West Side House of Worcester – 01/27/2017

Page Last Updated: August 20, 2018