Senior Abuse Law

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interviews, the Facility staff failed to ensure that a Roger’s treatment plan was extended for one Resident (#4) who was prescribed an antipsychotic medication out of total sampled of 17 Residents.

Findings include:

Resident #4 was admitted to the Facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of Resident #4’s clinical record indicated that upon admission to the Facility in ,[DATE] the Resident had a temporary court appointed legal guardian. In ,[DATE] the legal guardian became permanent with the authority to admit the Resident to a nursing facility and to apply for health insurance benefits. Review of the clinical record included a Treatment Plan from the Commonwealth of Massachusetts Probate and Family Court dated [DATE]. The form indicated that Resident #4 was approved to receive between 0.0 milligrams (mg) – 4 mg of [MEDICATION NAME] (antipsychotic medication) per day. The Treatment Plan indicated that the plan would be reviewed on or before [DATE] and, if not sooner extended, would expire on [DATE]. Review of the clinical record indicated that there was no further documentation from the court for a treatment plan since the treatment plan had expired on [DATE]. Review of Resident #4’s clinical record indicated that the Resident had a physician’s orders [REDACTED].

The Surveyor interviewed Unit Manager (UM) #1 at 3:40 P.M. on [DATE]. The UM #2 said she did not know about the court approved treatment plan. The UM #2 said the Surveyor should talk to the Social Worker (SW).

The Surveyor interviewed the Social Worker (SW) at 3:50 P.M. on ,[DATE]//17. The SW said she was unable to find a court authorized Treatment Plan in the clinical record or in her office and did not know if the Treatment Plan was renewed by the court before it expired on [DATE]. The SW was unaware of the expired Treatment Plan prior to the Surveyor inquiry. The SW said she would call the attorney’s office. The SW said the attorney’s office did not have a copy of a court signed Treatment Plan either. The secretary at the attorney’s office said she would try to obtain a copy from the court. The Surveyor interviewed the SW at 2:15 P.M. on [DATE]. The SW said she she called Probate Court and spoke with someone, she didn’t know the person’s name or title, but thought it was a clerk. The SW said the clerk said she could see the paperwork but it was not signed by a judge. The SW said the clerk said she would leave the paperwork for the judge when he returned on Monday ([DATE]).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that services were provided that met professional standards of quality for 6 Resident (#1, #2, #3, #10, #13 and #14), from a total of 17 residents.

Findings include:

1. For Resident #1, the facility failed (a) to ensure that a medication with a stop date was reassessed to prevent the medication from being administrated which resulted in a medication error; (b) the facility failed to ensure a new physician’s orders [REDACTED].

Resident #1 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. During review of the physician’s orders [REDACTED]. The order indicated the staff were to start the medication on 5/4/17, administer through 7/4/17, and have the physician re-evaluate the medication on 7/4/17.

On 7/6/17, the Surveyor observed the Medication Administration Records (MAR) for 5/2017, 6/2017 and 7/2017 for Resident #1. The MARs indicated that the [MEDICATION NAME] was transcribed onto the MAR and included the time frame for administration of the [MEDICATION NAME] which indicated the medication was to be stopped on 7/4/17 and reassessed by the physician (before continuing the administration of the medication). Review of the 7/2017 MAR indicated that the [MEDICATION NAME] was administered for 2 days, after the stop date on 7/5/17 and 7/6/17. Further review of the medical record failed to indicated the nursing staff contacted the physician and obtained an order to continue the medication.

During interview on 7/6/17 at 2:40 P.M., Unit Manager #1 (UM #1) said she was aware that the facility staff had not contacted the physician on 7/4/17. UM #1 said she had contacted the physician on 7/6/17. The UM said (and according to the Facility policy for Transcribing Physician Orders) the staff are suppose to block off the stop date on the MAR to prevent the medication being administered without a reassessment and causing a medication error.

(b) Review of the physician orders [REDACTED]. Review of the 3/2017 MAR indicated the medication was discontinued, as evident of a physician order [REDACTED]. Observation of the 4/2017 MAR indicated the medication was not included on MAR. On 7/6/17, the Surveyor observed the Medication Administration Records (MAR) for 5/2017. According to the observation, the staff hand transcribed the medication [MEDICATION NAME] 50 mg, PRN onto the MAR. The staff signed that the medication was administered on 5/15/17, 5/20/17 and 5/23/17. Review of the clinical record failed to indicate the staff obtained a physician order [REDACTED]. During interview on 7/7/17 at 10:40 A.M., Unit Manager #1 (UM #1) said that the nurse had not obtained a reinstatement order and caused a discontinued medication to be administered.

(c) Review of the physician orders [REDACTED]. Observation of the 4/2017 MAR indicated that the staff documented that the supplement was discontinued on 4/11/17 Review of the 5/2017, 6/2017 and 7/2017 MARs indicated the staff failed to ensure that the supplement was discontinued. According to the MARs for these 3 months indicated the Resident was administered the frozen supplement three times daily without a physician order. During interview on 7/6/17 at 2:40 P.M., the information was shared with the UM #1. She said the staff during editing should have ensured the supplement was discontinued from the MAR and orders.

2. For Resident #2, the facility failed to ensure that the Resident received the antidepressant medication [MEDICATION NAME] as ordered by the physician. Resident #2 was admitted in 8/2015 and had [DIAGNOSES REDACTED]. Review of the medical record on 7/7/17 indicated the Resident’s medications included the antidepressant medication [MEDICATION NAME] be administered daily (30 mg). Review of the 5/2017 MAR indicated that the medication [MEDICATION NAME] had not been administered 19 out of 31 times. Further review indicated that the medication was refused by the Resident on 3 occasions and administered as ordered on 9 occasions. The medical record including nurses notes and physician notes failed to indicate why the medication had not been administered. During an interview on 7/7/17 at 10:40 A.M. the Unit Manager (#1) said she did not know why the medication had not been administered as ordered. During a follow-up interview on 7/10/17 at 2:40 P.M. UM #1 had no additional information about the staffs not administering the [MEDICATION NAME].

3. For Resident #3, the facility failed to meet professional standards of quality by failing to document the actual time of the medication administration of [MEDICATION NAME] (a [MEDICAL TREATMENT] medication). Resident #3 was admitted to the facility in 7/2016 with [DIAGNOSES REDACTED]. The Resident goes out of the facility to a [MEDICAL TREATMENT] clinic three times a week (leaves at 6:15 A.M. and returns at 10:30 A.M.) for [MEDICAL TREATMENT]. On 7/6/17 during the medication pass observation at 9:00 A.M., the Surveyor observed the Medication Administration Record (MAR) for Resident #3. The MAR indicated that [MEDICATION NAME] was to be administered at 8:00 A.M., but had not been signed off as given. Review of the physician’s orders [REDACTED]. by mouth everyday with meals, but on [MEDICAL TREATMENT] days, with breakfast ([MEDICATION NAME] is used to control serum phosphorus levels in people with [MEDICAL CONDITION] who are on [MEDICAL TREATMENT]. [MEDICATION NAME] binds to phosphorus in the foods you eat so your body doesn’t absorb as much and therefore, needs to be taken with meals per the manufacturer’s specifications.). Review of the MAR for 6/2017 and 7/2017 indicated that all staff were documenting that [MEDICATION NAME] was administered at 8:00 A.M. everyday, despite that the Resident was at [MEDICAL TREATMENT] 3 days per week from 6:15 A.M. to 10:30 A.M. The Surveyor interviewed Nurse #1 on 7/6/17, shortly after the medication pass observation. Nurse #1 said that the Resident did get breakfast before [MEDICAL TREATMENT] three days per week, but that the Resident did not receive [MEDICATION NAME] until he/she returned from [MEDICAL TREATMENT]. Nurse #1 did not know the significance of taking the medication with meals. Nurse #1 also said that she signed off that the [MEDICATION NAME] was administered at 8:00 A.M., despite actually being administered upon return from [MEDICAL TREATMENT] at approximately 10:30 A.M., three days per week. According to Centers for Medicare and Medicaid (CMS) standards of practice are integral to the provision of appropriate medication therapy for nursing facility residents. The standards of practice are designed to fulfill Federal mandates to:
· Decrease medication errors and adverse drug events;
· Assure proper medication selection;
· Monitor drug interactions, over-medication, and under-medication;
· Improve the documentation of medication administration.

4. For Resident #10, (a) the staff administered medications that had been identified as a medication the Resident was allergic to; and (b) the facility failed to obtain parameters as to notification of the physician when the Resident became either hypoglycemic (low blood sugar) or hyperglycemic (high blood sugar) Resident #10 was admitted in 1/2015 with [DIAGNOSES REDACTED].

(a) Review of the medical record, including the hospital discharge record dated 9/27/16 indicated the Resident had multiple medication’s allergies [REDACTED]. Review of the 6/2017 and 7/2017 physician orders [REDACTED]. [REDACTED]. During interview on 7/11/17 at the Director of Nurses was asked about the procedure for medications identified as an allergy. She said that staff were to notify the physician for instruction.

(b) Review of the physician orders [REDACTED].#10 was administered the oral anti-diabetic medication [MEDICATION NAME] 5 mg daily and the staff were to obtain Fingerstick blood sugars (FSBS) twice a day at 6:30 AM. and 4:30 P.M. There was no sliding scale and the facility failed to obtain parameters as to notification of the physician when the Resident became either hypoglycemic (low blood sugar) or hyperglycemic (high blood sugar). Review of the Resident #10’s 7/2017 Diabetic Monitoring Record indicated that his/her blood sugars results ranged from 98 mg/dL to 275 mg/dL; and 15 results were over 126 mg/dL, 5 results were over 150 mg/dL, 3 results were over 200 mg/dL and 1 result was over 250 mg/dL. According to the American Diabetic Association a normal blood sugar range was below 126 mg/dL. During interview on 7/10/17 at 10:40 A.M., UM #1 said that there were no parameters for either high or low blood sugars for the Resident.

5. For Resident #13, the facility staff failed to follow the Facility’s Policy and Procedure for anticoagulation therapy, by failing to daily assess the injection site and rotating the injection site. Resident #13 was admitted to the facility in 5/2017 and had [DIAGNOSES REDACTED]. Review of the closed medical record on 7/10/17 indicated the physician ordered the anticoagulant medication [MEDICATION NAME] 0.7 ml, subcutaneous, twice daily. Review of the medical record including the 5/2017 MAR and nurses notes failed to indicate the Staff were monitoring and rotating the injection site. The MAR indicated the medication was administered but failed to indicate the location. During review of the medical record with the Director of Nurses on 7/11/17 at 11:20 A.M., she said that the nursing staff (and according to the Facility policy) were to rotate the injection cite when administering a subcutaneous anticoagulant.

6. For Resident #14, the staff administered a medication that had been identified as a medication the Resident was allergic to. Resident #14 was admitted in 5/2017 with [DIAGNOSES REDACTED]. Review of the closed medical record, including the hospital discharge record dated 5/2/17, indicated the Resident had multiple medication’s allergies [REDACTED]. Review of the physician orders [REDACTED]. On 5/3/17, the psychiatric consultant noted the allergy to the medication in his assessment. The assessment indicated he question what the medication allergy was and noted it may (?) cause a rash. Subsequent review of the clinical record failed to indicate the Facility staff identified the problem and they subsequently administered the medication from 5/2/17 through 6/8/17, without evidence they were monitoring for an allergic reaction to the medication. During interview on 7/11/17 at the Director of Nurses was asked about the procedure for medications identified as an allergy. She said that staff were to notify the physician for instruction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed and interviews, for 1 of 3 sampled residents (Resident #1), who required supervision during meals, and out of a total sample of 17 Residents, the facility failed to maintain Resident #1’s safety to avoid injury or an accident. Resident #1 was left in bed unattended with a cup of hot liquid which spilled down the corner of his/her mouth to the anterior chest at the level of the clavicles and under his/her jaw. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED].

Findings include:

Resident #1’s medical history included diabetes, glaucoma and dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 1/29/17, indicated Resident #1 had severe cognitive impairment and required supervision for eating. An Individualized Care Plan for feeding, dated 2/12/17, indicated Resident #1 required supervision for eating. A Certified Nurse Aide (CNA) Flow Sheet, which documents activities of daily living, dated 04/2017, indicated Resident #1 required continuous supervision with eating.

A Statement, dated 4/9/17, indicated CNA #1 gave Resident #1 a cup of coffee, left the room, went back into Resident #1’s room and noticed Resident #1 had spilled coffee on his/her comforter.

A Statement, dated 4/9/17, indicated CNA #2 was wiping Resident #1’s face when he/she screamed out in pain. CNA #2 noted Resident #1’s face and neck was really red, peeling and CNA #2 notified the nurse.

A Bruise/Skin Tear Report, dated 4/8/17, indicated Resident #1 was found with a burn, reddened areas and peeled skin on the side of his/her face and neck.

A Department of Public Health (DPH) Incident Report, dated 4/8/17, indicated Resident #1, who required supervision with meals, sustained a second degree burn to his/her neck area from a hot liquid and was transferred to the hospital.

A Nurse’s Progress Note, dated 4/8/17, indicated Resident #1 stated he/she spilled hot liquid on his/her chest area which was noted to be red.

A physician’s orders [REDACTED].#1 to the hospital.

A Patient Care Referral Form, dated 4/8/17, indicated Resident #1 complained of pain, sustained second or third degree burns to his/her neck and upper chest area which had worsened, were peeling, bright red with blistered areas and was transferred to the hospital.

A Nurse’s Progress Note, dated 4/9/17, indicated Resident #1 complained of pain, second degree burns were noted to his/her upper chest and neck areas which were peeling, bright red with lemon size blisters. Physician was notified and Resident #1 was transferred to the hospital.

A Hospital Discharge Summary, dated 4/9/17, indicated Resident #1 spilled hot liquid on his/her face neck and presented with second degree burns (red, blistered area) to his/her corner of mouth to anterior chest at the level of clavicles and under jaw. A physician’s orders [REDACTED].

A Physician’s Progress Note, dated 4/14/17, indicated Resident #1 had a second degree burn from hot fluid to his/her neck and upper chest.

The Surveyor interviewed CNA #1 at 11:37 A.M. on 7/7/17. CNA #1 said Resident #1 was in bed when CNA #1 placed a cup of hot liquid on Resident #1’s over bed table and left Resident #1’s room. CNA #1 said she returned to Resident #1’s room a while later and noticed that Resident #1 had spilled the hot liquid on the blanket and changed the blanket. CNA #1 said she did not supervise Resident #1 while he/she drank the hot liquid. The Surveyor interviewed Nurse #1 at 12:41 P.M. on 7/7/17. Nurse #1 said CNA #2 notified her that Resident #1’s chest, jaw and neck areas were red and peeling. Nurse #1 said she asked Resident #1 what happened and Resident #1 said he/she spilled the hot tea. Nurse #1 said she assessed Resident #1 and noted pink areas with peeling skin on Resident #1’s neck, jaw and chest area, applied cool compress and notified the 3-11 Nurse. The Surveyor interviewed Unit Manager #1 at 1:19 P.M. on 7/7/17. Unit Manager #1 said Resident #1 required supervision with eating and should not have been left unattended in bed in his/her room with a hot liquid. Unit Manager #1 said CNA #1 did not supervise Resident #1 while he/she was drinking a hot liquid and Resident #1 sustained a second degree burn from the hot liquid. The Surveyor interviewed the Director of Nurses at 4:40 P.M. on 7/7/17. The Director of Nurses said Resident #1 required supervision with eating and CNA #1 was supervising Resident #1 from the hallway when she was passing out nourishments. The Director of Nurses said Resident #1 should not have been in bed with a hot liquid. The Director of Nurses said Resident #1 sustained a second degree burn from the hot liquid CNA #1 gave him/her while Resident #1 was in bed.

Based on observations, staff interviews and policy review, the facility failed to prevent the potential spread of infection in the following ways: 1.) failed to sanitize a shared stethoscope between residents during the medication pass observation 2.) failed to disinfect a shared glucometer with the appropriate bleach solution between residents on one unit and from a total sample of 17 residents.

Findings include:

1.) On 6/6/17 at 11:30 A.M., during the medication pass observation, Surveyor 1 observed Nurse #1 listening to the bowel sounds of Resident #7, prior to the administration of medication through a gastrostomy tube (gtube). The Nurse was observed to place the stethoscope under the Resident’s brief, below the umbilicus (belly button). The Resident was complaining of active diarrhea to the Nurse. The Nurse was observed to leave the room, put the stethoscope back onto the medication cart without disinfecting it and continue down to the next resident room for additional medication administrations. Nurse #1 was also caring for Resident #3 who had an arterio-venous fistula (AVF) for dialysis. (According to CMS ESRD guidance an AVF is assessed for a bruit every shift with a stethoscope. A bruit can be heard using a stethoscope to assure that an AV fistula has blood flow. Once your AV fistula is strong enough to be used for hemodialysis, it is crucial that you keep it clean.) During the observation the Nurse continued with her medication pass and the Surveyor asked about the procedure for disinfecting medical equipment. The Nurse initial had no response, then said that she should have disinfected the stethoscope before putting it back onto the medication cart. The Nurse was unable to state the product used for disinfecting.

2.) On 7/11/17 at 11:10 A.M., during environmental rounds on Unit A, the Surveyor asked Nurse #2 how many glucometers were on the unit. Nurse #2 said 1. The Surveyor asked how the staff cleaned the glucometer. Nurse #2 brought the Surveyor into the medication room. The Surveyor observed a carry caddy with alcohol wipes and the glucometer. Nurse #2 said that staff cleaned the glucometer with alcohol wipes between each resident use. The Surveyor asked if there were any bleach wipes available. Nurse #2 looked around the medication room and said no. During an interview with the Clinical Consultant on 6/11/17 at 2:00 P.M., the Consultant said that the facility policy was to use the EPA Registered Bleach Wipes (with purple top) for cleaning glucometers.

Based on observation and interviews the Facility staff failed to provide a functioning call light system to allow for Residents to directly contact staff caregivers.

Findings include:

On 07/06/17 at 9:00 A.M. on Unit A, the Surveyor observed two rooms (Room 8 and Room 10) to have a light on above their door indicating a call light in the room had been activated. The Surveyor observed the nurses station on Unit A to have no sound indicating a call light had been turned on. The Surveyor also observed a call light panel at the nurse’s station to be covered with a greeting card. On 07/06/17 from 9:00 A.M. until 9:18 A.M. the Surveyor observed the lights above Room 8 and Room 10 to remain on. At 9:18 A.M. Nurse #1 said the panel (behind the greeting card) lights up and that some of the rooms initiated a sound when turned on and some did not. Neither call light was observed to be responded to at that time.

Room 10 was observed to be set back from the straight hallway of Unit A and was unable to be observed from the nurse’s station area or where the nurse was standing with the medication cart. Room 10 was observed to have the door closed. The Surveyor observed four staff members enter and exit Unit A while passing by Room 10. None of the staff members were observed to open the door to Room 10 or respond to the activated call light. At 9:24 A.M. a Certified Nursing Assistant (CNA) was observed to respond to a bed/chair alarm sound in Room 8 and asked one of the Residents if anything was needed before deactivating the call light. At 9:25 A.M. the Surveyor inquired about the call light for Room 10. CNA #1 said the light does not shut off, she was unsure why, but believed the Resident had pulled the call light cord out of the wall. The CNA was observed to go to Room 10 at that time.

On 07/06/17 at 11:00 A.M. the Administrator said that the call light cord for Room 10 was replaced and the call light system was functioning. The Surveyor went with the Administrator and observed the activation of one of the call lights for Room 8. There was no sound from the call light system at the nurse’s station and the light for Room 8 on the call light panel was not lit to indicate it had been activated. The Unit Manager said words to the effect of, the call lights do not make a sound and the call light panel was out of commission.

On 07/06/17 at 3:30 P.M. the Administrator said the Facility staff had provided Residents on Unit A with hand bells to ring if assistance was needed. She said the call lights made sound intermittently and that it was not previously brought to her attention by staff. The Administrator said an electrician had to contact the company who made the call light system as the electrician was unsure how it was supposed to be fixed.