Golden Living Center – Oak Hill

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Golden Living Center – Oak Hill? 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 Golden Living Center – Oak Hill

Golden Living Center – Oak Hill is a for profit, 123-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Lakeville,  Carver, Bridgewater,  East Bridgewater, Kingston,  and the other towns in and surrounding Plymouth County, Massachusetts.

Golden Living Center – Oak Hill focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Golden Living Center – Oak Hill
Address: 76 North St,
Middleborough, MA 02346

Phone: (508) 947-4775
Website: Golden Living Centers Locator

CMS Star Quality Rating

The 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 2017, Golden Living Center Oak Hill in Middleborough, Massachusetts received a rating of 1 out of 5 stars.

Performance Area Rating
Overall Rating 1 out of 5 (Much Average)
State Health Inspections 2 out of 5 (Below Average)
Staffing 3 out of 5 (Average)
Quality Measures 1 out of 5 (Much Below Average)

Fines Against Golden Living Center – Oak Hill

The Federal Government fined Golden Living Center – Oak Hill $5,720 on July 5th, 2016 and $6,120 on March 31st, 2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Golden Living Center – Oak Hill committed the following offenses:

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 observations, staff interviews and record review the Facility staff failed to follow facility policy and individual plan for the least restrictive use of a restraint for 1 Resident (#2) out of a total sample of 21 residents.

Findings include:

Resident # 2 was a long term care resident admitted to the Facility in 08/2015 with a [DIAGNOSES REDACTED]. Upon admission, the resident was assessed for a velcro seat belt restraint, related to attempting to stand or transfer alone and decreased safety awareness.

Review of the initial Minimum Data Set ((MDS) dated [DATE] indicated Resident # 2 was in need of assistance with activities of daily living including transfers, ambulation, dressing, hygiene and bathing.

Review of Resident #2’s care plan indicated the velcro seat belt was to be released every 2 hours and as needed with a goal of using the least restrictive device.

Review of the Quarterly Restraint and Device Assessment Review dated 11/4/15, 02/02/16 and 04/24/16 indicated that Unit Manager # 2 signed a narrative stating Resident # 2 used a velcro seat belt as a reminder to wait for assistance with transfers. There was no documentation regarding a reduction trial or alternative interventions.

Record review indicated that Resident #2 was evaluated by Physical Therapy on 05/18/16 and found to have a neutral trunk and pelvic alignment with both feet on the floor. Physical Therapy documented that the resident was able to independently return to neutral with visual cues.

Resident # 2 was observed throughout the survey to be seated across from the nurses station in a wheelchair with a velcro seat belt, the Resident was not slouching or leaning during any observations. On 06/30/16 at 12:10 P.M., the Resident was observed to be provided with a lunch tray and helped with set up for the meal, the Resident’s seat belt was not released at this time. On 07/01/16 at 8:00 A.M., Resident was observed to be provided with a breakfast tray and helped with set up for the meal, the Resident’s seat belt was not released at this time.

During an interview with the resident’s nurse on 06/30/16 at 4:20 P.M. the Licensed Practical Nurse (LPN) # 1, said that the resident will occasionally release the belt, but responds to verbal cue to put the belt back. LPN #1 said he releases Resident #2’s velcro seat belt once per shift (8 hour time), and not every 2 hours per the plan of care. During an interview with LPN # 2 on 07/01/16 at 09:15 A.M. she said the velcro seat belt was released during meal times during the day for Resident # 2, although 2 meals were observed with the seat belt on.

An interview was conducted with Unit Manager (UM) # 2 on 07/01/16 at 9:00 A.M. UM # 2 stated the facility policy is for a seat belt to be released every 2 hours and as needed. UM # 2 stated a determination to reduce the use of a seat belt is based on safety. The UM #2 stated for Resident #2 a visual assessment was done, there had been no trial reductions on the resident at that time as she was afraid the Resident would fall out of the wheelchair.

In an interview, on 07/01/16 at 10:15 A.M. with the Director of Nursing (DON) confirmed the facility policy is to release restraints during meal time and every two hours.

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 staff interview, the Facility failed to provide adequate supervision and assistive devices to prevent accidents/injury for 3 Residents (#5, #10, and #4), of a total sample of 21 Residents.

Findings include:

1. For Resident #5, the Facility failed to provide adequate supervision, implement safety devices, and/or functioning alarms. Resident #5 was admitted with [DIAGNOSES REDACTED].

According to the most recent MDS, signed as being completed 6/15/16, the Resident was sometimes understood/understands and scored 4/15 on the most recent Brief Interview of Mental Status, indicating severe cognitive loss. The Resident also displayed inattention and disorganized thinking. The MDS indicated that the Resident required extensive assistance with bed mobility, transfers, ADLs (activities of daily living), and was incontinent of bowel and bladder.

Record review on 6/29/16, indicated that on 9/5/15 at 11:15 P.M., Resident #5 experienced a fall from the wheelchair, landing head first on the floor sustaining a 3 cm x 2 cm laceration on the right side of the forehead. The Incident Report, completed by Nurse #4 at the time of the fall, indicated that Resident #5 was unable to verbalize what happened or explain what he/she was doing. Nurse #4’s statement indicated that the Resident was found lying on the right side, putting hands to forehead which was bleeding. According to the report, the fall was not witnessed but heard, staff responded quickly, the Resident never lost consciousness and remained at baseline MS (mental status). The report also indicated that seat alarm in place, however did not sound until staff arrived,tabs alarm not found. The Resident was sent to the hospital for evaluation and treatment.

The Charge Nurse Fall Checklist was completed by the nurse on 9/6/15. Contributing factors to possibly cause the fall included:

  • Cognitive impairment -Poor Safety awareness
  • Resident reaching down to floor for object
  • Alarm not in place, not turned on
  • Malfunctioning alarm

Although, the Resident had a seat alarm and personal alarm ordered for his/her safety, neither of these devices proved effective in maintaining the Resident’s safety. The seat alarm did not sound when the Resident rose from the chair, and only sounded after the Resident had fallen from the chair and sustained the forehead laceration. The tabs (personal) alarm that was supposed to be in place as a safety measure could not be found at the time of the fall. The DON (Director of Nursing) said during interview on 7/5/16, that the Resident’s room had recently been changed from Room 2-D to 18-D on 9/13/15 at the request of the family, one day prior to the fall.

The DON (Director of Nursing ) was interviewed regarding Resident #5’s fall and safety interventions intended to keep the Resident safe. The DON said when asked by Surveyor #1 about the status of the tab alarm, that the last time the tab alarm was checked by staff was on 9/5/15 at 5:38 P.M. The DON said that the tab alarm should have been in place at the time of the fall but wasn’t. She said that the tab alarm is a device meant to keep the Resident safe. The DON also said that the chair alarm was ineffective in preventing the Resident’s fall. She explained that there is a delay in the alarm sounding.

The two CNAs on duty on 9/5/15 at 11:15 P.M., responsible for the care and safety of the 33 Residents on the B-Wing, including Resident #5, were at the nurses station completing paperwork and getting ready for the shift at the time of the Resident’s fall. The Resident was in his/her wheelchair wandering the hallways, and not provided adequate supervision to maintain the Resident’s safety.

The Facility failed to provide adequate supervision and failed to ensure that safety interventions were in place and functioning in accordance with the Resident’s plan of care.

2. For Resident #10, the Facility failed to supervise and prevent the Resident from eloping from the Facility. Resident #10 was a long term care resident admitted in 01/2014 with a [DIAGNOSES REDACTED].

Record review indicated that upon admission, Resident #10 had been identified as an elopement risk and had a plan of care that indicated a history of attempts to elope in a previous facility. The initial plan of care was for the resident to wear a watchmate (a bracelet that sets off an alarm if the Resident exits the doors) and to redirect resident from exit doors.

Review of an investigation for Resident # 10 indicated that on 07/08/15, Resident #10 left the Facility at around 7:30 P.M. and walked through nearby neighborhoods for approximately 20 minutes. Resident #10 was picked up by the police for lurking in a backyard. He was taken in to custody by the police, handcuffed and placed in a cruiser. Resident #10 was then transported to the police station where he was booked and placed in a cell. The Facility initiated a missing resident code at around 8:30 P.M, approximately one hour after Resident had left the building. At that time, the nurse in charge notified the staff, searched the facility, and called the Director of Nursing (DON). The nurse then notified the police who stated the resident was in their custody. The resident was sent to the emergency room to be medically cleared and returned to the facility.

Review of the investigation revealed that around 07:30 P.M. on 07/08/15, a Certified Nursing Assistant (CNA) heard the front door alarm (which is triggered by a resident wearing a specific bracelet indicating they are not to leave the building unattended). The CNA saw a family member accompanying a different resident and assumed this resident set off the alarm. The CNA then de-activated the alarm without checking the outside premises to ensure no residents had exited the building.

In a Social Service progress notes dated 06/29/15, it was documented that Resident #10 would ask about discharge back to the community. Record review of a Quarterly Interdisciplinary Resident Review dated 06/30/15 indicated Resident # 10 was at risk for elopement by triggering yes for 5 out of 8 questions. During an interview with the DON on 06/30/16 at 11:20 A.M. the DON stated the current facility protocol is to move a resident to the secured unit if they are an elopement risk, look like a visitor and/or make repeated requests to leave the building. Resident #10 was not moved to the secured unit until after the incident.

3. For Resident #4, the Resident fell due to staff not using a gait belt during a transfer which resulted in the Resident falling, banging his/her head on the floor, which necessitated a transfer to the hospital (Emergency Department). The facility policy reads that a gait belt must be used during all transfers including to the commode

Resident #4 was a long term care resident with [DIAGNOSES REDACTED].M., the resident requested to use the commode. CNA #1 was present to assist the resident onto the commode. CNA #1 reported that while trying to stand up the resident became tense and was getting frustrated. CNA #1 was holding on to Resident #4’s Foley catheter with one hand and the other hand was holding on to the back of Resident #4’s pants.

CNA#1 was not using a gait belt during the transfer. Resident #4 then lost his/her balance and began sliding backward. CNA#1 used her leg to slide Resident #4 to the floor. Resident #4 hit his/her head on the floor and complained of pain at the back of his/her head. Resident #4 was transferred to the ED (Emergency Department) for an Evaluation. The X-rays and CT Scan performed in the ED were negative.

On 6/12/16, CNA#1 provided a written statement stating I didn’t have a gait belt on him/her. That was my mistake.

On 6/30/16, at 11:05 P.M., the DON was interviewed about this incident. The DON stated that CNA #1 did not use a gait belt when transferring Resident #4 to the commode. CNA#1 did not follow the policy for Resident #4.

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

Base on observation and staff interview, the Facility failed to provide pharmacy services to meet the needs of each Resident. Pharmaceuticals were not stored and maintained in a manner to ensure their integrity and availability for use. Emergency Drug Kits were not reordered in accordance with the Facility’s policy. Dust and dirt were noted in various areas of the medication room.

Findings include:

The C Wing Medication Room was inspected on 7/5/16 at 8:50 A.M. The following issues were noted:

  • A large accumulation of ice was noted in the freezer tray of the refrigerator, situated directly above the Emergency Insulin Kit.
  • The Insulin Emergency Kit was observed to have ice on the outside and inside of the plastic storage container.
  • An unopened vial of Novolin 70/30 insulin was observed to be frozen and ice was noted throughout the cardboard container.
  • An unopened vial of Novolin R insulin was observed inside a frozen cardboard box. -An unopened vial of Novolin N insulin was observed inside of a frozen cardboard box.
  • An Emergency Antibiotic Kit was observed open. Six tablets of Levofloxacin 250 mg had been removed for a resident on 7/2/16.
  • The Emergency Coumadin Kit was opened (date unknown).
  • The white, plastic storage bins containing various intravenous and medical supplies was observed to have a thick coating of dust/dirt on the left hand side.
  • The floor behind the medication refrigerator had a significant accumulation of dust and dirt on it.

According to the Facility policy, Emergency Drug Kits are to be replaced within 24 hours of opening. Both, the Emergency Coumadin and Antibiotic Kits were not reordered from the Pharmacy until the morning of 7/5/16, per the C-Wing Unit Manager.

The A Wing Medication Room was inspected on 7/5/16 at 9:23 A.M. The following issues were noted:

  • The Emergency Antibiotic Kit was opened on 7/3/16.
  • The Emergency Coumadin Kit was opened on 7/3/16.
  • The Emergency Respiratory kit was opened on 7/3/16.

All three of the above emergency kits were not reordered until 7/5/16 per interview with the A Wing Nurse.

Failed to have a program that investigates, controls and keeps infection from spreading.

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

Based on observation, record review and interview, for 1 Resident (#12) out of a total sample of 21 residents the Facility failed to ensure that infection control practices were maintained during a dressing change on 7/1/16.

Findings include:

Resident #12 was admitted to the Facility 2/2016, and his/her [DIAGNOSES REDACTED]. The care plan, dated 2/27/16, indicated that Resident #12 was identified with an actual pressure ulcer of the left buttock area. The clinical record indicated Resident #12 was admitted to Hospice services on 4/7/16 for end of life care.

The most recent significant change in status Minimum Data Set (MDS) assessment, dated 4/14/16, indicated Resident #12 required assistance with all of his/her activities of daily living (ADL) he/she did not ambulate, he/she was incontinent of bowel and bladder, and he/she had an unstageable pressure ulcer of the left buttock. (full thickness loss in which the base of the ulcer is covered with slough).

The Surveyor reviewed the Facility policy for handwashing and hand hygiene, dated August, 2014. The policy indicated the following:

  • All personnel shall follow the handwashing/hand hygiene procedures to help spread of infections to other personnel, residents and visitors.
  • Wash hands with soap and water for the following situations, when hands are visibly soiled.

The Surveyor reviewed the clean dressing change policy, dated 2/4/16. The policy indicated the following:

  • Create clean field with paper towels or clean barrier
  • Open dressing pack
  • Perform hand hygiene
  • Put on disposable gloves
  • Remove soiled dressing and discard in paper bag
  • Dispose of gloves in plastic bag
  • Perform hand hygiene
  • Put on another pair of gloves to cleanse wound
  • Apply dressing as ordered and remove gloves and discard
  • Perform hand hygiene

The Surveyor reviewed the Lippincott Manual of Nursing Practice, 2014, and reviewed fundamentals of hand hygiene. The manual indicated that handwashing was the single most recommended measure to reduce the risks of transmitting infection. Hand hygiene should be performed after contact with excretions, and before donning and after removing gloves. Review of the physician’s orders [REDACTED].#12’s buttock pressure sore included the following: wash the buttock pressure sore with normal saline, pat dry, apply [MEDICATION NAME] spray, followed by a [MEDICATION NAME] dressing, every other day.

The Surveyor observed the dressing change for Resident #12 on 7/1/16 at approximately 11:00 A.M. The Surveyor observed the Wound Nurse and Certified Nurse Aide (CNA) #1 reposition Resident #12, who was incontinent of bowel. The Surveyor observed CNA #1 perform incontinence care for Resident #12, which included touching the soiled bed linens and brief and bunching up the soiled linens to discard. The Surveyor observed that when CNA #1 was finished with incontinence care, she removed her gloves, and reapplied gloves without hand hygiene. The Surveyor asked the CNA if she usually washed her hands after incontinence care and she was not sure.

The Surveyor observed the Wound Nurse remove Resident #12’s soiled dressing during the provision of incontinence care and the Wound Nurse failed to remove her gloves and perform hand hygiene. The Surveyor observed The Wound Nurse start to cleanse Resident #12’s buttock pressure sore with the same gloves and the Surveyor intervened. The Wound Nurse said she usually performed hand hygiene but was nervous during the observation by the Surveyor.

The Facility failed to ensure that infection control practice was maintained by CNA #1 and the Wound Nurse during a dressing change on 7/1/16.

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**

Based on records reviewed and interviews, for 2 of 3 sampled residents (Resident #1 and Resident #3), the facility failed to provide services in accordance with professional standards of practice by not ensuring proper procedures were followed during the administration of medications and by not ensuring physician’s orders [REDACTED].#1 ingested 4 residents unidentified medications and required hospitalization and admission for somnolence, slightly elevated [MEDICATION NAME] level and [MEDICAL CONDITION] (low heart rate) due to medication error.

Resident #3 received twice the dosage of [MEDICATION NAME] (an anti-anxiety medication) for 8 days.

Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice.

Findings include:

The Facility’s Policy and Procedure, titled Storage of Medication, dated 3/7/17, indicated medication supplies are accessible only to licensed nursing personnel, medication supplies are locked and medications are kept in containers in a controlled environment such as medication carts.

The Facility’s Policy and Procedure, titled Administration Procedures for All Medications, dated 6/2015, indicated for security: all medication storage areas, medication carts, are locked at all times unless in use and under the direct observation of the medication nurse.

The Facility’s Policy and Procedure, titled Medication Error Reporting and Adverse Drug Reaction Prevention and Detection, dated 9/2010, indicated a medication error is defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional. Medication errors are considered significant if they require hospitalization . The Facility’s Policy and Procedure, titled Narcotic Book, undated, indicated a narcotic book is a permanently bound book with pre-numbered pages used to record the receipt, dispensing/administration and destruction of controlled substances. The Policy indicated for the first entry each page should be co-signed by a second nurse, verifying the right amount was entered for the right patient, right drug and right dose. When the drug is reordered, add the new amount to the same page and have a second nurse co-sign the new entry again.

The Facility’s Policy and Procedure, titled Control Substance Check Sheet, undated, indicated there is a system of records of receipt and disposition of all controlled substances. The Policy indicated delivery receipts are routinely cross referenced against narcotic book, pharmacy order book, patient record and Physician order. Drug is properly entered into designated controlled substance tracking documentation/index page, two nurses sign and verify receipt of drugs in controlled substance tracking documentation.

The Facility’s Medication Pass Observation, undated, indicated medications are not left on top of medication cart.

A) Resident #1’s [DIAGNOSES REDACTED].

The Minimum Data Sheet (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, wandered daily and required supervision with ambulation.

An Individualized Care Plan for eating disorder, PICA (involves eating items that are not typically thought of as food) due to dementia, dated 6/3/16, indicated Resident #1 was found to be eating several different non-food items, staff were to monitor Resident #1 for eating non-food items and intervene as needed.

An Individualized Care Plan for short attention span, dated 12/26/16, indicated Resident #1 exhibited wandering behaviors with constant need to keep looking, walking and moving. An Event Report, dated 2/28/17 at 7:45 P.M., indicated Resident #1 took medication from medication cart and was found by staff ingesting medication.

Resident #1 was transferred to the hospital. A witness statement, undated, indicated Nurse #1 poured medications into labeled cups for 4 residents and left the medications on top of the medication cart unattended.

A Situation Background Assessment Response (BAR) Progress Note, dated 2/28/17, indicated Resident #1 was wandering throughout the unit, took medications from the medication cart, was found chewing the medications and was transferred to the hospital for evaluation. A Nursing Home to Hospital Transfer Form, dated 2/28/17, indicated Resident #1 ingested several medications from the med cart, unable to identify how many, but included [MEDICATION NAME], Trazadone, [MEDICATION NAME], Tylenol and [MEDICATION NAME], and Resident #1 was transferred to the hospital. The Surveyor interviewed Nurse #1 at 1:08 P.M. on 3/31/17. Nurse #1 said she pre-poured 4 residents medications into plastic cups, left the cups on top of the medication cart, walked away from the medication cart without putting the cups in the medication cart and did not lock the medication cart. Nurse #1 said she did not follow facility policy or acceptable nursing practice. Nurse #1 said she made a massive mistake when she pre-poured medications, left medications on top of the medication cart where Resident #1, who had dementia and was a wanderer, ingested the medications and was transferred to the hospital. Nurse #1 said it was an accident that should not have ever happened.

The Surveyor interviewed the Director of Nurses (DON) at 2:00 P.M. and throughout the day on 3/31/17. The DON said Nurse #1 did not follow facility policy for medication administration, resident safety and accident prevention when she pre-poured 4 residents medications into cups, left the cups with medications in them on top of the medication cart, and left the medication cart unlocked and unattended. Resident #1, who had dementia and was a wanderer, ingested the medications and was transferred to the hospital.

B) Resident #3’s [DIAGNOSES REDACTED].

The Minimum Data Sheet (MDS), dated [DATE], indicated Resident #3 was severely cognitively impaired. An Individualized Care Plan for potential for drug related complications associated with use of anti-anxiety medication, dated 2/19/17 indicated provide medications as ordered by the Physician.

A physician’s orders [REDACTED]. (milligrams) daily at 6:00 P.M. A Pharmacy Shipping Manifest Form, dated 12/6/16, indicated the Facility received thirty tablets of [MEDICATION NAME] (Generic name for [MEDICATION NAME]) 0.25 mg. for Resident #3. There was no signature on the form to indicate who received the medication at the Facility.

A Medication Administration Record [REDACTED].M. A Narcotic Book Patient Page, un-numbered, indicated Resident #3 was administered [MEDICATION NAME] 0.5 mg at 6:00 P.M.

on 12/7/16, 12/8/16, 12/9/16, 12/10/16, 12/11/16, 12/12/16, 12/13/16, and 12/14/16. A Narcotic Book Patient Page, numbered 146 and dated 12/14/16, indicated [MEDICATION NAME] 0.25 mg. give one tab by mouth at hour of sleep. The first entry indicated the Facility received thirty [MEDICATION NAME] 0.25 mg. tablets for Resident #3 on 12/14/16 with a single nurses signature. There was no co-signature by a second nurse. This was not consistent with the Facility’s Narcotic Book Policy.

A Medication Error Reporting Form, dated 12/15/16, indicated Resident #3 received [MEDICATION NAME] 0.5 mg. at 6:00 P.M. instead of the [MEDICATION NAME] 0.25 mg. at 6:00 P.M. ordered by the Physician. The form was incomplete and did not indicate resident experienced any negative effects from the error.

The Surveyor interviewed the Director of Nurses (DON) and Assistant Director of Nurses (ADON) at 2:00 P.M. and throughout the day on 3/31/17. The DON and ADON said Nurse #4 did not follow the Facility’s narcotic book policy, placed the medication card in a locked drawer that was not in use, and did not enter the narcotic, [MEDICATION NAME] 0.25 mg. tablets into the narcotic book index or patient page when it was received from the pharmacy on 12/6/16. The DON and ADON said staff did not follow the Facility’s medication administration policy and administered the incorrect dose of [MEDICATION NAME] for 8 days. The ADON said a per diem nurse notified her of the medication error on 12/14/16. The DON said the facility did not reconcile the pharmacy delivery receipts with the narcotic book and did not always require two nurses sign and verify receipt of narcotics. This was not consistent with the Facility’s Control Substance Check Sheet Policy.

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 records reviewed and interviews, for 1 out of 3 sampled residents, (Resident #1), who had the [DIAGNOSES REDACTED].#1 who was found with medications in his/her mouth from 4 other Residents pre-poured medications that were left unattended on top of the medication cart. Resident #1 required hospitalization and admission for somnolence, slightly elevated acetaminophen level and bradycardia (low heart rate) due to medication error.

Findings include:

The Facility’s Accident’s Critical Element Pathway, dated 7/2015, indicated to use pathway for residents who require supervision to prevent accidents and ensure the environment is free from accident hazards. The pathway indicated to observe wandering residents by doing routine visual checks, adequately supervising the residents and ensuring the environment is safe.

The Facility’s Policy and Procedure, titled Storage of Medication, dated 3/7/17, indicated medication supplies are accessible only to licensed nursing personnel, medication supplies are locked and medications are kept in containers in a controlled environment such as medication carts.

The Facility’s Policy and Procedure, titled Administration Procedures for All Medications, dated 6/2015, indicated for security: all medication storage areas, medication carts, are locked at all times unless in use and under the direct observation of the medication nurse.

The Facility’s Medication Pass Observation, undated, indicated medications are not left on top of medication cart. Resident #1’s [DIAGNOSES REDACTED]. The Minimum Data Sheet (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, wandered daily and required supervision with ambulation.

An Individualized Care Plan for eating disorder, PICA (involves eating items that are not typically thought of as food) due to dementia, dated 6/3/16, indicated Resident #1 was found to be eating several different non-food items, staff were to monitor Resident #1 for eating non-food items and intervene as needed.

An Individualized Care Plan for short attention span, dated 12/26/16, indicated Resident #1 exhibited wandering behaviors with constant need to keep looking, walking and moving. An Event Report, dated 2/28/17 at 7:45 P.M., indicated Resident #1 took medication from medication cart and found by staff ingesting medication. Resident #1 was sent to the hospital.

A witness statement, undated, indicated Nurse #1 poured medications into labeled cups for 4 residents and left the medications on top of the medication cart unattended.

A Situation Background Assessment Response (BAR) Progress Note, dated 2/28/17, indicated Resident #1 was wandering throughout the unit, took medications from the medication cart, was found chewing the medications and was transferred to the hospital for evaluation. A Nursing Home to Hospital Transfer Form, dated 2/28/17, indicated Resident #1 ingested several medications from the med cart, unable to identify how many, but included:

  • Neurontin ( a medication used for seizures)
  • Trazadone (an antidepressant medication used for insomnia)
  • Ativan (a medication used for anxiety)
  • Tylenol (a medication used for pain, inflammation, fever)
  • Lopressor ( a beta blocker medication used for high blood pressure).

The Surveyor interviewed Nurse #1 at 1:08 P.M. on 3/31/17. Nurse #1 said she pre-poured 4 residents medications into plastic cups, left the cups on top of the medication cart, walked away from the medication cart without putting the cups in the medication cart and did not lock the medication cart. Nurse #1 said she did not follow facility policy and nursing practice. Nurse #1 said she made a massive mistake when she pre-poured medications, left medications on top of the medication cart where Resident #1, who had dementia and was a wanderer, ingested the medications and was transferred to the hospital. Nurse #1 said it was an accident that should not have ever happened.

The Surveyor interviewed the Director of Nurses (DON) at 2:00 P.M. and throughout the day on 3/31/17. The DON said Nurse #1 did not follow facility policy for medication administration, resident safety and accident prevention when she pre-poured 4 residents medications into cups, left the cups with medications in them on top of the medication cart, and left the medication cart unlocked and unattended. Resident #1, who had dementia and was a wanderer, ingested the medications and was transferred to the hospital. The Hospital Discharge Summary, dated 3/2/17, indicated Resident #1 was admitted to the hospital for somnolence (drowsiness), elevated acetaminophen level and bradycardia (low heart rate) due to accidental drug ingestion.

Golden Living Center – Oak Hill, 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.


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Page Last Updated: November 18, 2017

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