Westborough Healthcare

Westborough Healthcare

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Westborough Healthcare? 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 Westborough Healthcare

Westborough Healthcare is a for profit, 117-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Worcester, Leicester, Millbury, Holden, Shrewsbury,  Spencer, Sutton, Grafton, Oxford, Charlton, Northborough, Westborough, Northbridge, Clinton, Webster, and the other towns in and surrounding Worcester County, Massachusetts.

Westborough Healthcare
1407, 8 Colonial Dr,
Westborough, MA 01581

Phone: (508) 366-9131

CMS Star Quality Rating

Westborough HealthcareThe 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, Westborough Healthcare in Westborough, Massachusetts received a rating of 1 out of 5 stars.

Performance Area Rating
Overall Rating 1 out of 5 (Much Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 3 out of 5 (Average)
Quality Measures 4 out of 5 (Above Average)

Fines Against Westborough Healthcare

The Federal Government fined Westborough Healthcare $6,500 on 06/13/2016 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Westborough Healthcare committed the following offenses:

Failed to reasonably accommodate the needs and preferences of each resident.

Based on observations and interview, the facility staff failed to ensure call lights were within a resident’s reach and able to be used if needed for 5 sampled residents (#42, #44, #48, #55 and #79) out of a total of 21 sampled residents.

Findings include:

During a tour of Spruce Unit on 2/9/18 at 9::00 A.M., the Surveyor observed the following: -Resident #42 was resting in bed with eyes closed. The call light was hanging on the wall and was not within the resident’s reach. -Resident #44 was eating breakfast in bed with the assist of a speech therapist at bedside. The call light was not within the resident’s reach. The call light on the wall had a plug in it with no string attached for the resident to be able to use if needed.

-Resident #48 was resting in bed with eyes closed. The call light was hanging on the wall and was not within the resident’s reach.

-Resident #55 was awake and sitting in a recliner at the bedside in his/her room. The call light was on the opposite side of where the resident was sitting. The call light was not within the resident’s reach.

-Resident #79 was resting in bed with eyes closed. The call light was hanging on the wall and was not within the resident’s reach.

During an interview on 2/9/18 at 9:30 A.M., Unit Manager #1 said the call lights were not within each resident’s reach and unable to be used if needed as they should have been.

Failed to let each resident or the resident's legal representative access or purchase copies of all the resident's records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to provide a copy of medical documents requested by 1 Resident (#31) in a sample of 21 residents

Findings include:

Resident #31 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, with a reference date of 9/6/17, indicated the resident was cognitively intact based on a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS).

During an interview on 2/8/18 at 11:30 A.M., Resident #31 said he/she had been transferred against his/her will to the hospital emergency room to be evaluated, in 11/2017. The resident said he/she asked the facility for a copy of the Section 12 (a transportation order to a hospital against a person’s wishes) and was told the facility did not have a copy of the document.

Review of the health record indicated there were no copies of the Section 12 documents authorizing the facility initiated hospital transfer in 11/2017. During an interview on 2/16/18 at 9:42 A.M., the Consultant Social Worker said the facility staff did not retain a copy of the Section 12 paperwork that was sent with the resident to the hospital. She further said a copy of the bed hold and transfer notice was sent with the resident to the hospital but the facility did not retain a copy.

During an interview on 2/16/18 at 11:49 A.M., the Director of Nurses (DON) said she had a conversation with Resident #31 on 11/30/17 and the resident requested a copy of the Section 12 documents. She said when she followed up on the resident’s request, she was unable to locate a copy of the Section 12 paperwork in the record. She said she requested a copy of the document from the hospital but they did not have a copy in their files. The DON further said the copy should have been retained as part of the medical record.

Failed to allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Based on observations and interviews, the facility staff failed to post notice of the availability of the Department of Public Health (DPH) Survey results binder. During a Resident Council Meeting on 2/13/18 at 11:00 A.M. with 15 residents present, the Surveyor was informed that residents were not aware of the location of the DPH Survey binder in the facility.

Findings include:

During a tour of the facility with the Administrator on 2/16/18 at 8:41 A.M., the survey binder was located in a sleeve on a wall in the lobby. There was no notice posted to indicate location of the binder. In addition, the Administrator said there was a DPH Survey binder on each of the three nursing units. During a tour of each nursing unit with the Administrator, no posting or DPH Survey binder was found. During an interview on 2/16/18 at 9:00 A.M., the Administrator said there was no DPH Survey binder located on each nursing unit as she had indicated.

Failed to honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility staff failed to ensure the accuracy of resident’s Advance Directives in the medical record for 2 sampled residents (#16 and #71) in a total sample of 21 residents.

Findings include:

1. For Resident #16, the code status documented in the medical record conflicts with the resident wishes indicated by the signed Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form. Resident #16 was admitted to the facility in 2/2016 with [DIAGNOSES REDACTED]. Review of the medical record indicated 2 signed MOLST forms. Review of a signed MOLST form, dated 9/8/17, indicated Do Not Resuscitate, Do Not Intubate and Ventilate, Do Not Use Non-Invasive Ventilation and Do Not Transfer to Hospital. Another signed MOLST form, dated 1/30/18, indicated to Attempt Resuscitation, Do Not Intubate and Ventilate, Use Non-Invasive Ventilation and Transfer to Hospital. Review of the 2/1/2018 Medication Review Report indicated an order: * As of 9/18/17- Do Not Resuscitate (DNR), Do Not Intubate (DNI), Do Not Hospitalize (DNH), No [MEDICAL TREATMENT], Use Artificial Hydration and Nutrition. During an interview on 2/14/18 at 10:42 A.M., the Administrator said the most current MOLST form in the medical record does not reflect the MOLST order listed on the 2/1/2018 Medication Review Report as it should have.

2. For Resident #71, the code status documented in the medical record conflicts with the resident wishes indicated by the MOLST. Resident #71 was admitted to the facility in 5/2015 with [DIAGNOSES REDACTED]. Review of the MOLST form, dated 3/9/16, indicated the resident is DNR, DNI, Do Not Transfer to Hospital.

Social Service Quarterly Assessment, dated 1/12/18, stated resident is a DNR, DNI, DNH. Review of the 2/1/2018 Medication Review Report indicated the resident is a Full Code. During an interview on 02/14/18 at 09:00 A.M., Unit Manager #1 said the order on the 2/1/2018 Medication Review Report does not reflect the choices indicated on the MOLST form. She said the Medication Review Report and MOLST form should contain the same information and they do not.

Failed to give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to provide 1 of 3 residents with a Notice of Medicare Non-Coverage (NOMNC), as soon as reasonably possible, to allow the resident/resident representative time to request an appeal of the decision.

Findings include:

Review of a NOMNC indicated the resident’s last covered day of skilled Medicare Part A benefits was [DATE]. Further review of the document indicated the resident’s representative had been notified of the decision on [DATE] (the day after the benefits expired). During an interview on [DATE] at 10:34 A.M., the Administrator said the NOMNC was signed on the day of discharge and not within a reasonable timeframe to allow the resident/resident representative time to request an appeal of the decision if requested.

Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility staff failed to report an allegation of resident to resident abuse to Department of Public Health (DPH) within 2 hours after the allegation was made for one one sampled resident (#79) out of total sample of 21 residents.

Findings include:

Resident #79 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of the medical record indicated Resident #79 was involved in a witnessed altercation with another resident on 5/16/17. Resident #79 was observed in unit dining room standing on one side of a table and reaching over and hitting another resident in the face. Both residents were immediately separated, both residents assessed and investigation initiated. Review of the DPH Incident Report Form indicated the report was submitted to DPH on 5/23/17. This is 7 days after incident occurred and not within 2 hours as required due to alleged physical abuse violation.

During an interview on 2/16/18 at 9:01 A.M., the Administrator said the incident reported to DPH was out of compliance and not reported within the 2 hours as required.

Failed to not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility staff failed to notify one sampled resident (#25) representative of Notice of Bed Hold Policy upon transfer to hospital out of a total sample of 21 residents.

Findings include:

Resident #25 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) OF 8/25/17 indicated the resident had severe cognitive impairment as evidenced by a score of 4 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Review of the medical record indicated the resident had sustained a fall on 9/14/17 and was transferred to the hospital for further evaluation and treatment. Review of the medical record indicated Resident #25 signed a Notice of Bed Hold Policy Form on 9/14/17.

Review of the Court Order Appointing Temporary Guardian for Incapacitated Person indicated a Guardian was in place until 10/25/17. There was no documentation in the medical record indicating the resident’s Guardian received the Notice of Bed Hold Policy. Review of the facility Bed Hold and Readmission Policy, dated 11/28/17, indicated that when an emergent transfer is initiated, the Notice of Bed Hold Policy is provided to the patient, surrogate, or representative upon transfer. During an interview on 2/16/18 at 11:00 A.M., Unit Manager #1 said the resident should not have been issued the Notice of Bed Hold Policy since the resident had a guardian in place at the time of transfer.

Failed to create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to implement a baseline care plan within 48 hours for 1 resident (#69) in a sample of 21 residents.

Findings include:

Resident #69 was admitted in 11/2017 with [DIAGNOSES REDACTED]. Record review did not indicate that a person-centered baseline careplan had been initiated within 48 hours of admission that included necessary interventions to care for the resident. Further review indicated the care plan was initiated 6 days post admission. During an interview on 2/13/18 at 3:02 P.M., the Minimum Data Set (MDS) Nurse said she reviewed the record and said she had no evidence that a baseline care plan had been established within 48 hours of admission for Resident #69. She said the care plan was initiated six days post admission.

Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility staff failed to develop a care plan to address pain management for 1 resident (#51) in a total sample of 21 residents.

Findings include:

Resident #51 was admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, with a reference date of 12/6/17, indicated the resident was cognitively intact based on a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated the resident was totally dependent on 2 staff for transfers and was non-ambulatory. The MDS also indicated the resident reported frequent pain, 7 out of 10 on the pain scale. Review of the MDS Care Area Assessment (CAA) indicated the resident’s pain would be addressed in the care plan. Review of the care plan indicated there were no problems, goals or interventions established to address the resident’s neuropathic pain. During an interview on 2/09/18 at 9:03 A.M., Resident #51 said he/she suffered from [MEDICAL CONDITION] (nerve pain: tingling, numbness and weakness in hands and feet). The resident said he/she was taking [MEDICATION NAME] and it had not been effective. Resident #51 said he/she had spoken to the Physician and they had not come up with an effective way to manage the pain.

During an interview on 2/13/18 at 2:58 P.M., the MDS Nurse reviewed the CAA and said the resident triggered for frequent pain and the decision on the CAA was to proceed with a pain management care plan. She reviewed the resident’s current care plan (and care plan history) and said she could not find evidence that a pain management care plan had been established.

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 observation, interview and record review, the facility staff failed to provide care in accordance with the written plan of care for 2 residents (#25 and #30) out of a total sample of 21 residents.

Findings include:

1. For Resident # 30 the facility staff failed to apply a Carrot (positioning device to maintain resting alignment and prevent further contractures) to the right hand daily when the resident is out of bed.

Resident #30 was admitted to the facility 2/2011 with [DIAGNOSES REDACTED]. Review of the current care plan indicated the resident was to have a Carrot applied to the right hand when out of bed. Observation of Resident #30 on 2/08/18 at 12:08 P.M., seated in a high back reclining wheel chair.

The resident’s right hand was observed in a closed fist position with no Carrot in the hand. During an interview with Unit Manager (UM) #2 on 02/13/18 at 3:23 P.M., she said the resident does not use a Carrot to the right hand.

During an interview with UM #2 on 2/16/18 at 11:35 A.M., she said after speaking to the Surveyor on 2/13/18, the resident was evaluated by Occupational Therapy. She further said that a new Carrot was obtained for the resident as he/she did not have one and one was not being used.

2. For Resident #25, the facility staff failed to ensure wheelchair and bed alarms were in place as care planned. Resident #25 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 11/23/17, indicated the resident had severe cognitive impairment as evidenced by a a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Review of the Falls Care Plan, initiated 5/26/17, indicated resident is at risk for falls related to gait/balance problems due to motor vehicle accident with multiple fractures of left side. Resident can be impulsive at times and presents with cognitive deficits due to dementia with behavioral disturbance. Intervention initially put in place 6/15/17 and revised 12/01/17 was for a bed alarm. Intervention initially put in place 8/10/17 and revised 12/1/17 was talking chair alarm on wheelchair and to check placement every shift. Review of the 2/1/2018 Medication Review Report indicated to place bed and chair alarm every shift.

During an observation on 2/13/18 at 9:00 A.M., found resident awake and in bed. No alarm was noted on the bed. During an observation on 2/13/18 at 1:21 P.M., found resident sitting in the unit dining room in a wheelchair. No chair alarm was noted on the wheelchair. During an observation on 2/14/18 at 7:26 A.M., found resident awake and in bed. No alarm was noted on the bed and no alarm was noted on wheelchair present in resident’s room. During an interview on 2/14/18 at 7:30 A.M., Certified Nursing Assistant (CNA) #2 said the resident has a bed alarm but she could not locate one on the bed. She also said the resident has a talking alarm on wheelchair but she could not locate one on the wheelchair.

Failed to 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 interview and record review, the facility staff failed to complete periodic assessments for 1 of 3 residents who smoke (# 7), out of a total sample of 21 residents.

Findings include:

Review of the Smoking Campus policy provided by the facility, dated 5/28/16, indicated that the Interdisciplinary Team (IDT) evaluates patients desiring to smoke for their ability to smoke independently or dependently on admission, quarterly, with a significant change or as deemed necessary. Record review indicated a Smoking Evaluation, dated as completed 8/11/2016, indicated the resident required assistance with smoking and had a smoking schedule. Review of the current smoking care plan for Resident #7 indicated the resident was a dependent smoker and would be assessed quarterly, annually and with a change of condition that affects his/her ability to smoke.

On 2/09/18 at 10:31 A.M., Resident # 7 was observed outside in the smoking area seated in a wheel chair and had a smoking apron on over his/her coat. Resident #7 was holding a Styrofoam cup in the left hand and a lit cigarette in the right hand. There was one Certified Nursing Assistant (CNA) and one other resident present in the smoking area. During an interview on 2/14/18 at 12:43 P.M., Nurse #1 said the last smoking assessment completed for Resident #7 was on 8/11/16. She further said the smoking assessment is to be completed quarterly, annually and with significant changes.

Failed to provide safe, appropriate pain management for a resident who requires such services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to ensure that comprehensive and person-centered pain management, consistent with the resident’s goals and preferences, was provided to 1 resident (#51) in a total sample of 21 residents.

Findings include:

Resident #51 was admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, with a reference date of 12/6/17, indicated the resident was cognitively intact based on a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated the resident was totally dependent on 2 staff for transfers and was non-ambulatory. The MDS also indicated the resident reported frequent pain, 7 out of 10 on the pain scale. Review of the MDS Care Area Assessment (CAA) indicated the resident’s pain would be addressed in the care plan. Review of the care plan indicated there were no problems, goals or interventions established to address the resident’s neuropathic pain. During an interview on 2/09/18 at 9:03 A.M., Resident #51 said he/she suffered from [MEDICAL CONDITION] (nerve pain: tingling, numbness and weakness in hands and feet). The resident said he/she was taking [MEDICATION NAME] and it had not been effective. Resident #51 said he/she had spoken to the Physician and they had not come up with an effective way to manage the pain.

Review of a nurses note, dated 12/12/17, indicated the resident requested the trial of [MEDICATION NAME] (pain medication) be discontinued, as it was not effective. During an interview on 2/12/18 at 11:00 A.M., when the Surveyor inquired about an order (dated 2/11/18) to start [MEDICATION NAME] 100 milligrams three times per day for neuropathic pain and reassess in one week, Nurse #2 said she had not noted and posted the order because she needed to speak with the Physician. She said the resident had started taking [MEDICATION NAME] in 12/2017 and the Nurse Practitioner had discontinued it in 1/2018 due to adverse reactions to the medication. She further said she would communicate that to the Physician and add [MEDICATION NAME] to the resident’s list of allergies [REDACTED].>During an interview on 2/13/18 at 2:58 P.M., the MDS Nurse reviewed the CAA and said the resident triggered for frequent pain and the decision on the CAA was to proceed with a pain management care plan. She reviewed the resident’s current care plan (and care plan history) and said she could not find evidence that a pain management care plan had been established.

Failed to try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility staff failed to attempt bed rail alternatives prior to installation, for 2 residents (#18 and #82) out of 21 sampled residents.

Findings include:

Review of the facility Bed Rail Policy (NCD Restraints), revised 11/28/17, indicated the facility attempts to use appropriate alternatives prior to installing a bed rail. 1. Resident #18 was admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. Review of a Bed Safety Evaluation, dated 12/19/17, indicated the resident used bilateral 1/4 bed rails. The section entitled List least restrictive measures that have been trialed prior to side rail use was marked NA (not applicable). Review of a document NSH Side Rail Evaluation, dated 12/19/17, did not indicate bed rail alternatives were trialed.

2. Resident #82 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. Review of a Bed Safety Evaluation, dated 11/3/17, indicated the resident used bilateral 1/4 bed rails. The section entitled List least restrictive measures that have been trialed prior to side rail use was left blank. Review of a document NSH Side Rail Evaluation, dated 12/19/17, did not indicate bed rail alternatives were trialed. During an interview on 2/14/18 at 4:35 P.M., the Director of Nurses said she did not have documented evidence that bed rail alternatives were trialed for Resident #18 and Resident #82 prior to the use of bed rails.

Failed to provide or obtain dental services for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to provide routine dental services for 1 resident (#31) in a total sample of 21 residents.

Findings include:

Resident #31 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, with a reference date of 9/6/17, indicated the resident was cognitively intact based on a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). During an interview on 2/8/18 at 11:40 A.M., Resident #31 said he/she has not seen a dentist since prior to admission to the facility. When the Surveyor asked if the facility staff asked if he/she wished to enroll in dental services onsite or to be followed by a dentist in the community, the resident said he/she was never asked. Record review indicated there was no documentation that the resident was offered routine dental services and there was no record of dental consultation. During an interview on 2/13/18 at 3:18 P.M., the Director of Nurses (DON) said she would check with medical records to see if they had any record of enrollment into dental services or evidence of dental consultations.

During an interview on 2/14/18 at 8:24 A.M., the DON said she couldn’t find any evidence that dental services had been offered or provided since admission.

Failed to safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility staff failed to ensure accurate medical records for 6 sampled residents (#2, #19, #31, #42, #48 and #90) out of total of 21 sampled residents.

Findings include:

1. For Resident #2, the facility staff failed to complete the required documentation on 3 Informed Consents for [MEDICAL CONDITION] Administration. Resident #2 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Medication Review Report indicated orders for:

– [MEDICATION NAME] (antipsychotic) 0.25 milligrams (mg) by mouth at bedtime.
-[MEDICATION NAME] (antidepressant) 50 mg by mouth at bedtime.
-[MEDICATION NAME] 25 mg by mouth two times a day.
-[MEDICATION NAME] 12.5 mg by mouth every 12 hours as needed for agitation.
-[MEDICATION NAME] (antidepressant) 30 mg by mouth once daily.

Review of the Informed Consent forms, signed [DATE], for the use of [MEDICATION NAME] and [MEDICATION NAME], indicated missing required information. During an interview on [DATE] at 3:14 P.M., Unit Manager (UM) #1 said the Informed Consents for [MEDICATION NAME] and [MEDICATION NAME] were incomplete due to required information not listed on the forms.

2. For Resident #19, the facility staff failed to complete the required documentation on 3 Informed Consents for [MEDICAL CONDITION] Administration. Resident #19 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Medication Review Report indicated orders for:

-[MEDICATION NAME] Sodium (mood stabilizer) Capsule Delayed Release Sprinkle 125 mg by mouth 6 capsules by mouth two times daily.
-[MEDICATION NAME] HCL 50 mg by mouth two times a day.
-[MEDICATION NAME] HCL 25 mg by mouth every 12 hours as needed for agitation.
-[MEDICATION NAME] HCL 25 mg by mouth daily in the morning.
-[MEDICATION NAME] (antidepressant) 50 mg by mouth every morning.

Review of the Informed Consent forms, signed [DATE], for the use of [MEDICATION NAME] and [MEDICATION NAME] indicated missing required information. During an interview on [DATE] at 3:30 P.M., UM #1 said the Informed Consents for [MEDICATION NAME] and [MEDICATION NAME] were incomplete due to required information not listed on the forms.

3. For Resident #42, the facility staff failed to ensure the medical record was complete and accessible and include documentation from the Hospice provider. Resident #42 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the medical record indicated the resident was placed on Hospice services in ,[DATE]. Review of the Hospice binder on the unit indicated a Nursing Clinical Note, dated [DATE], with no other current documentation noted in binder. During an interview on [DATE] at 1:24 P.M., UM #1 and Hospice Nurse both said that the documentation in the Hospice binder was not current and up to date.

4. For Resident #48, the facility staff failed to complete the required documentation on 3 Informed Consents for [MEDICAL CONDITION] Administration.

Resident #48 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the ,[DATE] Medication Administration Record [REDACTED]

-[MEDICATION NAME] (antianxiety) 1 mg by mouth every 4 hours as needed for agitation. -[MEDICATION NAME] 125 mg give 4 capsules by mouth at bedtime. -Klonopin (used to treat [MEDICAL CONDITION] and anxiety) 1 mg by mouth three times a day. Review of the Informed Consent for the use of [MEDICATION NAME] indicated only a verbal consent was obtained from the Health Care Proxy (HCP) on [DATE] and no signature was noted on the consent as required. Review of the [MEDICATION NAME] and Klonopin consents indicated missing required information on both consents. During an interview on [DATE] at 9:02 A.M., UM #1 said the [MEDICATION NAME] consent was obtained only verbally and there was no HCP signature. UM #1 said the [MEDICATION NAME] and Klonopin Informed Consents contained missing required information.

5. For Resident #31, the facility staff failed to maintain a complete medical record that included copies of documentation required for a facility initiated transfer. Resident #31 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Record review indicated there was no Physician’s order or Section 12 document (a transportation order to a hospital against a person’s wishes) for a hospital transfer in ,[DATE]. During an interview on [DATE] at 9:42 A.M., the Consultant Social Worker said the facility staff did not retain a copy of the Section 12 paperwork that was sent with the resident to the hospital. During an interview on [DATE] at 11:49 A.M., the Director of Nurses (DON) said she requested a copy of the section 12 document from the hospital but they did not have a copy in their files. The DON further said the copy should have been retained as part of the medical record and a Physician’s order should have been obtained.

6. For Resident #90, the facility staff failed to ensure the medical record was complete and readily accessible. Resident #90 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Record review indicated Resident #90 was receiving Hospice end of life care. Review of a nurses note dated [DATE], indicated the resident had expired and a Registered Nurse (RN) Pronouncement was completed by the Hospice Nurse. Although the RN pronouncement form was in the record, there was no Nurses note including the clinical assessment of death available in the clinical record. During an interview with the Minimum Data Set (MDS) Nurse on [DATE] at 2:30 P.M., she said the note had been completed by the hospice nurse at the time of the RN pronouncement, however, it was not in the record. She further said that she called the Hospice provider after surveyor inquiry and they faxed the note to the facility.

Failed to provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to 1. follow transmission based precautions to prevent cross contamination and possible spread of infection related to use of personal protective equipment (PPE) on 1 of 3 resident units and 2. failed to follow appropriate technique to prevent cross contamination during a dressing  change for one sampled resident ( #42) out of a total sample of 21 residents.

Findings include:

1. Observation on 2/8/18 at approximately 8:20 A.M. of two adjacent resident 4 bed rooms on the 3rd floor unit indicated by signage that you needed to check with the nurse before entering the room. There was PPE including disposable gloves, masks and gowns hanging in a holder on the outside of the room. The signage posted outside the 2 resident rooms indicated that Droplet Precautions were required and included the following:

-hand hygiene was to be performed before entering and before leaving the room
-visitors and healthcare workers were to wear a mask when entering the room
-dietary may not enter Listed on the back side of the sign was the following: Droplet Precautions
-Used for patients/residents that have an infection that can be spread through close respiratory or mucous membrane contact with respiratory secretions.
-Wear a mask and gloves upon room entry of the patient/resident on droplet precautions.
-Gowns should be worn if working within approximately 3-6 feet of patients/residents that have an acute infection that can be spread through close respiratory or mucous membrane contact with respiratory secretions.
-A single patient resident room is preferred. If not available, spatial separation of more than 3-6 feet and drawing the curtain between beds is especially important.

On 2/8/18 at approximately 8:30 A.M., the facility Activity Director was observed to enter and exit both of the droplet precaution resident rooms to deliver breakfast trays. No PPE mask or gloves were observed to be worn or hand washing completed upon entering or exiting the resident rooms.

During an observation on 2/8/18 at approximately 8:35 A.M., Certified Nursing Assistant (CNA) #1 pulled open the curtain and gathered up linen from an occupied resident’s bed in one of the precaution rooms. The CNA was observed to be wearing gloves and no mask or gown. During the interview, she said she had just completed incontinent care to the resident and wore only gloves not a mask. During an interview on 2/8/18 at 8:40 A.M., the facility Minimum Data Set (MDS) Nurse said that 1 of 8 residents in the two precaution rooms had tested positive for influenza A and was out at the hospital. She further said that the other 7 residents in the two precaution rooms had not been tested , but had been put on the medication [MEDICATION NAME] (an [MEDICAL CONDITION] medication that blocks the actions of [MEDICAL CONDITION] types A and B in your body) on 2/7/18 and placed on droplet precautions.

During an interview on 2/8/18 at 8:45 A.M., the facility Activity Director said she had delivered a breakfast tray to one of the residents who resided in the precaution room. She showed the Surveyor where the PPE was located outside the room but said she was delivering food to a resident and would not need to wear anything. During an observation on 2/9/18 at 11:25 A.M., a laundry staff member placed a covered clothing rack outside one of the precaution room doorways. She was observed to remove personal resident clothing from the rack and brought it into the room and put it in a resident’s closet. No mask or gloves were worn on entering the room. She then crossed the room and greeted a resident on precautions, without PPE. The Surveyor asked the Laundry staff member what the signage outside the resident’s room was for and she said precautions, she then said that she did not understand English and needed to get an interpreter.

On 2/9/18 at 11:35 A.M., the Housekeeping Manager came to the resident unit to speak with the laundry staff member. The Housekeeping Manager told the surveyor she had just in-serviced the laundry staff person and that the laundry staff person delivers the personal laundry.

2. For Resident #42, the facility staff failed to follow infection control practice during a dressing change. Resident #42 was admitted to the facility in 8/2007 with [DIAGNOSES REDACTED]. Review of the facility Clean Dressing Change Competency, dated 12/20/16, indicated that during a dressing change procedure, hands are washed after each time soiled gloves are removed and a new pair is applied. Review of the medical record indicated the resident had a Stage 2 (an open area that extends into deeper layer of skin) Pressure Ulcer on coccyx. Review of the 2/01/2018 Medication Review Report indicated an order to wash coccyx with normal saline and apply Hydrogel ( a water based gel used to keep wounds slightly moist) followed by Biatin (foam absorbent dressing) every day shift. During an observation of the coccyx dressing change on 2/14/18 at 11:50 A.M., the following was noted during the procedure: Unit Manager (UM) #1 applied gloves, removed the old dressing and discarded it. She then removed the soiled gloves and put on a new pair of gloves, washed the coccyx area with normal saline, removed gloves and discarded them. She then put on a new pair of gloves and applied Hydrogel and Biatin. UM #1 was never observed washing hands after removing soiled gloves or before applying new gloves during the dressing change procedure. During an interview on 2/14/18 at 12:19 P.M., UM #1 said she did not wash her hands each time she removed her soiled gloves during the dressing change procedure and she should have.

Westborough Healthcare, 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 – Westborough Healthcare

Inspection Report for Westborough Healthcare – 02/16/2018

Page Last Updated: August 22, 2018