Senior Abuse Law

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to keep one resident (#7) free from verbal abuse, in a total sample of 24 residents.

Findings include:

For Resident #7 the facility staff failed to keep the resident free from verbal abuse. Resident #7 was admitted to the facility in 5/2015 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 5/21/15, indicated the resident was cognitively intact as evidenced by a score of 14 of 15 on the Brief Interview of Mental Status (BIMS).

Review of a facility Grievance Concern Form, filed by Resident #7 on 1/20/16, indicated he/she had a concern relative to a seating change that was made during a meal. The report indicated the resident was told by Nurse #2 that his/her seat was changed to another table because the ladies at the table hated his/her guts. The Social Services Director who completed the form was no longer employed by the facility. Review of an Incident Report, dated 1/21/16, indicated an allegation of verbal abuse was reported to the Massachusetts Department of Public Health.

Review of the Risk Management Report, dated 1/21/16, indicated Nurse #2 was suspended pending investigation. In addition, the report indicated that verbal abuse was substantiated by witness statements made during the investigation, and indicated the resident was uncomfortable with Nurse #2 providing further care. The Director of Nursing who completed the investigation was no longer employed by the facility. Review of Witness Interview Records, dated 1/22/16 and 1/26/16, indicated Nurse #2 raised her voice and told the resident if he/she didn’t move to another table, he/she would not be allowed to eat. In addition, witness statements indicated a staff member overheard Nurse #2 tell the resident to shut his/her mouth and said the other residents at the table don’t like you.

Review of an Individual Performance Improvement Plan indicated Nurse #2 was terminated on 1/28/2016 as the result of substantiated verbal abuse towards a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) Assessment for 8 residents (#1, #2, #3, #5, #7, #9, #12, #13) in a total sample of 24 residents.

Findings include:

Review of the MDS Assessment tool indicates to attempt interviews for all residents. One reason not to conduct an interview would be if the resident was assessed as rarely understood.

1. For Resident #1 the facility staff failed to conduct the Brief Interview for Mental Status (BIMS) on the Annual MDS Assessment. Resident #1 was admitted to the facility in 07/2005 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 9/23/16, indicated the BIMS was not conducted even though the resident was coded as always understood. During an interview on 11/9/16 at 3:25 P.M., the MDS Coordinator said the BIMS should have been conducted because the resident was coded as always understood.

2. For Resident #2, the facility staff failed to conduct the BIMS and resident Mood interview on a Quarterly MDS Assessment. Resident #2 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 9/22/16, indicated the BIMS and the Mood interview were not conducted even though the resident was coded as always understood. During an interview on 11/9/16 at 3:25 P.M., the MDS Coordinator said the BIMS and Mood interview should have been conducted because the resident was coded as always understood.

3. For Resident #7 the facility failed to correctly code ambulation on a Quarterly MDS Assessment. Resident #7 was admitted to the facility in 5/2015 with [DIAGNOSES REDACTED]. Review of the nursing documentation indicated the resident ambulated with a walker and extensive assistance of one on 10/5/16, 10/6/16 and 10/8/16. Review of the Quarterly MDS Assessment, dated 10/8/16, indicated ambulation did not occur in the room or on the unit. During an interview on 11/9/16 at 3:25 P.M., the MDS Coordinator said, based on the nursing documentation, ambulation should have been coded on the MDS as extensive assist of one.

4. For Resident #9 the facility failed to conduct the BIMS and Mood interviews on one Quarterly MDS Assessment. Resident #9 was admitted to the facility in 1/2014 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 9/5/16, indicated the BIMS and the resident Mood interview were not conducted even though the resident was coded as always understood. During an interview on 11/9/16 at 3:25 P.M., the MDS Coordinator said the BIMS and Mood interviews should have been conducted because the resident was coded as always understood.

5. For Resident #12, the facility staff failed to conduct the pain interview and indicate why vaccines were not administered for an Admission MDS Assessment. Resident #12 was admitted to the facility in 7/20/16 and readmitted to the facility in 9/2016 with [DIAGNOSES REDACTED].

Review of the clinical record indicated a signed consent, dated 8/23/16, in which the resident declined the administration of the Pneumococcal vaccine. Another signed consent, dated 8/23/16, indicated the resident gave the facility permission to administer the Influenza vaccine annually.

Review of the Admission MDS Assessment, dated 9/19/16, indicated the resident did not receive the Influenza and Pneumococcal vaccines, however the reason not received was coded as not assessed. Further review of the MDS indicated the resident was always understood. Review of the MDS indicated the individual and staff interviews for pain were not conducted. During an interview with the MDS Coordinator on 11/9/16 at 3:25 P.M., she said the pain interview should have been conducted because the resident was coded always understood. She said the interviews were not conducted because the required pain assessment had not been done within the MDS assessment reference date (ARD). She also said the reasons for not administering the vaccines were not coded correctly.

6. For Resident #13, the facility staff failed to do the pain interviews for an Admission MDS Assessment. Resident #13 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 9/20/16, indicated the resident was coded as always understood. Further review of the MDS indicated the individual and staff interviews for pain were not done and coded as not assessed.

During an interview with the MDS Coordinator on 11/9/16 at 3:25 P.M., she said the pain interview should have been conducted because the resident was coded always understood. She said the interviews were not conducted because the required pain assessment had not been done within the MDS assessment reference date.

7. For Resident #5, the facility staff failed to conduct a BIMS and the interviews for Mood and Pain on a Significant Change in Status Assessment (SCSA) MDS. Resident #5 was admitted to the facility in 11/2014 with [DIAGNOSES REDACTED]. Review of a SCSA MDS, dated [DATE], indicated the resident was usually understood. The BIMS was not conducted, nor was the resident interviewed for mood or pain. During an interview with the MDS Coordinator on 11/9/16 at 3:25 P.M., she said the resident interviews should have been conducted because the resident was usually understood.

8. For Resident #3, the facility staff failed to conduct the BIMS and the resident interview for Mood. Resident #3 was admitted to the facility in 8/2015 with a [DIAGNOSES REDACTED]. Review of a Quarterly MDS Assessment, dated 8/8/16, indicted the resident was understood. The BIMS was not conducted, nor was the interview for mood. During an interview with the MDS Coordinator on 11/9/16 at 3:25 P.M., she said the resident interviews should have been conducted because the resident was understood.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to meet professional standards of quality for 2 residents (#14 and non-sampled (NS) #1), in a total sample of 24 residents.

Findings include:

1. For Resident #14, the facility staff failed to maintain the cleanliness of the oxygen equipment as per the policy, and failed to rotate injection sites for insulin and [MEDICATION NAME] (blood thinner) administration. Resident #14 was admitted /readmitted to the facility in 9/2016, and again in 10/2016, with [DIAGNOSES REDACTED].

A. Review of the facility Oxygen: Nasal Cannula Policy, dated revised 12/8/14, indicated to replace entire set-up every seven days, date and store in treatment bag when not in use. Review of the 11/2016 Medication Administration Record (MAR) indicated oxygen was being administered from 0 to 3 liters per minute (lpm) via nasal cannula to maintain an oxygen saturation of 90% or greater. Further review of the MAR did not indicated when to replace or how to store the oxygen equipment.

B. Review of the Nursing 2014 Drug Handbook indicated the following; As with any insulin therapy, [DIAGNOSES REDACTED] (hardening of tissue) may occur at the injection site and delay absorption. Reduce this risk by rotating the injection site with each injection. Review of the facility policy, Medication Administration: Injectable, date revised 12/8/14, indicated to document the administration and site of medication. Review of the 10/2016 MAR indicated 16 units of [MEDICATION NAME] were administered subcutaneously (sc) daily, at bedtime (HS), between 10/3/16 and 10/23/16. The MAR did not indicate documentation of the injection site for 14 of the 20 days.

Review of the 10/2016 MAR indicated [MEDICATION NAME] Insulin was administered sc per a sliding scale 37 times between 10/1/16 and 10/23/16. The MAR did not indicate documentation of the injection sites. Review of 11/2016 MAR indicated 10 units of [MEDICATION NAME] was administered sc daily at HS between 11/1/16 and 11/3/16, but did not indicate documentation of the injection sites. Review of the 11/2016 MAR indicated [MEDICATION NAME] Insulin was administered sc per a sliding scale 6 times between 11/1/16 and 11/3/16. The MAR did not indicate documentation of the injection sites.

During an interview on 11/9/16 at 10:00 A.M., the Director of Nurses and Unit Manager #1 said the insulin injection sites should have been documented on the MAR. UM #1 also said the MAR should have included the care and services for the oxygen equipment.

2. For Non-sampled (NS) Resident #1, the facility staff failed to document the rotation of injection sites for [MEDICATION NAME] (blood thinner) injections. Review of the Nursing 2016 Drug Handbook indicated to alternate the injection site for [MEDICATION NAME] every 12 hours and record location. NS #1 was admitted to the facility 9/2016 with [DIAGNOSES REDACTED].

During observation of the medication pass on 11/8/16 at 8:30 A.M., the surveyor observed Nurse #1 prepare a [MEDICATION NAME] injection. She administered the injection to NS #1, to the left side of the abdomen. Immediately after administration of the injection, the surveyor reviewed the MAR, from 11/1/16 to 11/8/16, with Nurse #1. The Resident was administered [MEDICATION NAME] every twelve hours. Nursing staff failed to document the injection sites eight times. Nurse #1 said the nurses were not consistently documenting the injection site of the [MEDICATION NAME].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, facility staff failed to follow Physician’s orders and/or care plans relative to obtaining daily weights, obtaining orthostatic blood pressures and using floor mats per care plan for two residents (#3, #15) out of a total sample of 24 residents.

Findings include:

1. For Resident #15, facility staff failed to obtain (A.) daily weights and (B.) orthostatic blood pressures as ordered by the Physician. Resident #15 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. A. Review of a Physician’s order, dated 10/18/16, indicated to obtain daily weights. Review of the Admission Minimum Data Set (MDS) Assessment, with reference date of 10/25/16, indicated the resident was alert and oriented and able to make decisions independently, required limited assistance from staff for bed mobility, transfers, ambulation and toilet use and required extensive assistance from staff for dressing, personal hygiene and bathing.

Review of the clinical record and Medication Administration Record [REDACTED] – 10/22, 10/23, 10/28, 11/1, 11/4, 11/5, 11/6, 11/7 and 11/9/16. During interview on 11/9/16 at 3:15 P.M., Unit Manager (UM) #1 said the weights were not conducted as ordered and a new system for obtaining weights was needed.

B. Review of a Physician’s order, dated 10/22/16, indicated to conduct orthostatic blood pressures and pulse (sitting, standing, lying) for 3 days. Review of the clinical record and 10/2016 MAR indicated [REDACTED]. Further review of the clinical record and 11/2016 MAR indicated [REDACTED]. Further review of the clinical record and 11/2016 MAR indicated [REDACTED]. During interview on 11/9/16 at 3:15 P.M., UM #1 said the orthostatic blood pressures were not conducted by nursing staff as ordered. She said the Therapy staff obtained some of them, but the results were not communicated or discussed with the nursing staff.

2. For Resident #3, the facility failed to follow the care plan for fall prevention. Resident #3 was admitted to the facility in 8/2015 with [DIAGNOSES REDACTED]. Review of the resident’s care plan for fall prevention included an intervention, initiated 4/15/16, for floor mats to both sides of the bed.

On 11/8/16 at 3:10 P.M. the surveyor, accompanied by the Assistant Director of Nurses (ADON), observed the resident in bed. There were no floor mats on either side of the bed. The ADON said the fall care plan indicated an intervention for fall mats, but there were no fall mats in place.

Based on records reviewed and interviews for 2 of 3 sampled residents (Resident #1 and Resident #2), the facility failed to maintain medical records that were complete.

Findings include:

The Facility Policy, titled Health Information Record and Chart Order, revision date 11/28/16, indicated the facility will maintain a uniform chart order for paper health information records including active, overflow, and discharged records.

At the time of survey, Resident #1’s clinical record did not include the November 2016 Treatment Administration Record, dated 11/1/16 through 11/25/16. The surveyor interviewed the Director of Nurses (DON) at 9:13 A.M. on 3/31/17. The DON said the November 2016 Treatment Administration Record for Resident #1 has not been located and should have been in the clinical record.

The Facility Policy, titled Discharge Record Processing, review date 10/19/15, indicated discharge documentation must include a discharge summary completed within 30 days or per state regulations and signed by appropriate disciplines.

Resident #1 was admitted to the Facility in May 2014, and was discharged in December 2016. There was no documentation at the time of survey of a completed Interdisciplinary Discharge Summary, 115 days after Resident #1’s discharge from the facility. Resident #2 was admitted to the Facility in July 2016, and was discharged in December 2016.

There was no documentation at the time of survey of a completed Interdisciplinary Discharge Summary, 103 days after Resident #2’s discharge from the facility. The Surveyor interviewed the Senior Center Nurse Executive at 11:50 A.M. on 3/27/17. The Senior Center Nurse Executive said there were no discharge summaries for Resident #1 and Resident #2 and that the physician did not complete them.