Kindred Transitional Care and Rehab – Highland

Kindred Transitional Care and Rehab - Highland

 

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Kindred Transitional Care and Rehab – Highland? 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 Kindred Transitional Care and Rehab – Highland

Kindred Transitional Care and Rehab - HighlandKindred Transitional Care and Rehab – Highland is a for profit, 142-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Dedham, Westwood, Norwood,  Needham, Milton, and the other towns in and surrounding Norfolk County, Massachusetts.

Kindred Transitional Care and Rehab – Highland focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Kindred Transitional Care and Rehab – Highland
10 Carematrix Drive
Dedham, MA 02026

Phone: (781) 461-9663
Website: http://www.highgatemanorcenter.com/

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, Kindred Transitional Care and Rehab – Highland in Dedham, 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 2 out of 5 (Below Average)
Staffing 3 out of 5 (Average)
Quality Measures 1 out of 5 (Much Below Average)

Fines Against Kindred Transitional Care and Rehab – Highland

The Federal Government fined Kindred Transitional Care and Rehab – Highland $1,495 on May 5th, 2015 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Kindred Transitional Care and Rehab – Highland committed the following offenses:

Failed to immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to notify the physician of changes in the Resident’s condition for 1 Resident (#9 ) of 24 sampled Residents.

Findings include:

For Resident #9, the facility failed to notify the physician of changes in the Resident’s blood sugar levels.

Resident #9 was admitted to the facility in 6/2016, with [DIAGNOSES REDACTED]. Resident # 9 was re-admitted to the facility on [DATE], following a hospitalization . Record review of the Medication Administration Record [REDACTED].M., 11:00 A.M., and 4:00 P.M. Review of the MAR for the period of 8/6/16 through 8/16/16 revealed elevated blood sugars on each day. These glucose values varied from 96 mg/dl through 526 mg/dl. Normal non fasting, random values range should be below 200 mg/dl according to the American Diabetes Association.

The policy for the facility titled Diabetes Mellitus, Guidelines for Management, dated January 2012 and updated 10/09/12 provides guidelines for care of the diabetic patient. Under procedure for the licensed nurse, section 6 d, on page 2 of the policy indicated Monitor the patient for illness and notify the physician if Glucose levels are higher than 240 mg/dl even though the patient has taken extra Insulin as ordered by the physician. Further record review of the MAR for August 2016, revealed the following: for the period of review dating from 8/6/16 through 8/16/16 the Resident had blood sugars exceeding 240 mg/dl on 28 of 32 instances. The physician was notified only in two of these instances. During interview on 8/24/16 at 10:00 A.M., the clinical coordinator said the nursing staff did not follow the policy for care of the diabetic Resident. She said the entire staff would be inserviced on the house policy for care of the diabetic Resident.

Failed to hire only people with no legal history of abusing, neglecting or mistreating residents; or report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

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

Based on record review and staff interview, the facility failed to ensure that all alleged violations, including injury of unknown etiology, were thoroughly investigated for 1 Resident (#19) and for 1 Resident (#12) failed to report to the proper authorities of a serious injury, from a total of 24 sampled Residents.

Findings include:

1. For Resident #12, the facility failed to report an accident with injury to the proper authorities.

Resident #12 was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. Review of the nurse’s notes dated 7/19/16 indicated Resident #12 was found sitting on the bedroom floor on his/her buttocks with legs out in front and the wheel chair close by with alarm sounding. The nurse documented that there appeared to be no injuries and the Resident was unaware how he/she fell.

A Resident Event Report Worksheet was completed by a nurse on 7/19/16 identifying that the Resident had an unwitnessed fall without injury.

Further review of the nurse’s notes indicated that on 7/20/16 the Resident complained of hip pain and an X-Ray was completed resulting in a Left anterior superior public rami fracture (pelvic fracture). The Resident was sent to the hospital for evaluation. Although the facility was aware of the fracture, they failed to report to the proper authorities.

2. For Resident #19, the facility failed to investigate an injury of unknown etiology and a unwitnessed fall, both resulted in fractures.

Resident #19 was admitted to the facility in 9/2015, with [DIAGNOSES REDACTED]. Review of the nurse’s notes, dated 1/25/16, indicated that Resident #19 complained of right ankle pain and had frank bleeding from his/her right 4th toe and right big toe. The injury of unknown etiology was reported to the Department of Public Health on 2/1/2016. Further review of the nurse’s notes, dated 2/13/2016, indicated that staff heard an alarm sounding from the Resident’s room. When the staff arrived, the Resident was found laying on the floor. The Resident was complaining of pain in the area of the right hip and the right leg was observed to be externally rotated. This fall with injury was reported to the Department of Public Health on 2/22/16.

On 8/23/16 and 8/24/16, the surveyor asked the Director of Nurses multiple times for the facility’s internal investigation of these incidents. The Director of Nurses was unable to provide these investigation to the surveyor and was unable to explain why it was not available for review.

Failed to give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

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

Based on observation, record review and staff interviews, the facility failed to ensure that a comprehensive wound assessment was completed and received necessary care and treatment to promote healing for 1 Resident (#16) of 5 sampled Residents with pressure sores, from a total sample of 24 Residents.

Findings include:

For Resident #16, the facility failed to complete a comprehensive and accurate pressure sore assessment and failed to provide treatment and services to promote healing of a pressure sore.

Resident #16 was admitted to the facility in 5/2016, with current [DIAGNOSES REDACTED]. On 8/23/16 at 3:35 P.M. with treatment Nurse (#2) and accompanied by Unit Manager (UM) #1, the Surveyor observed a dressing change for a left heel pressure ulcer. Nurse #2 said that the Resident’s wound treatment was to wash the heel with normal saline and apply Iodosorb (used for wound debridement) and cover with dry protective dressing daily and as necessary. Nurse #2 was asked if she had recently provided treatment to the wound and she said yes on 8/21/16, but did not document her assessment of the area but recalled that the Resident’s left heel was clean with no drainage.

During the wound treatment observation, Resident #16 was observed lying on his/her back with a sheet covering the Resident’s torso and a folded blanket partially covering the Resident’s feet. Nurse #1 donned the gloves and removed the sheet and blanket to exposing the Resident’s lower extremities. A single pillow was observed placed under the Resident’s lower legs but was not effective in off loading the heels that were observed resting directly on the mattress. No protective dressing was observed on the left heel and the sheet was directly underneath the left heel and was stained a yellow color (the size of a half dollar). Nurse #2 said she had not previously removed the dressing and was unable to explain who had done so. Nurse #2 said that the sheet was wet and stained from the wound drainage.

During the Treatment observation at 4:05 P.M., UM #1 left the room to obtain supplies to measure the Resident’s wound indicating that the Wound Nurse (UM #1 was the interim Wound Nurse) usually completes the measurements. UM #2 said the Resident’s left heel wound measured 3.0 cm length x 3.0 cm width x 0.9 cm depth. Nurse #2 was asked what her assessment of the wound was (since she had previously seen it on 8/21/16) and was unable to describe the wound perimeter or provide a comprehensive explanation of amount of necrosis, slough or granulating tissue observed in the wound bed. At the time of the observation, the surveyor observed the wound to have 25% slough, 25-30% necrotic tissue at the base and the sounding skin had [DIAGNOSES REDACTED].

UM #1 was interviewed on 8/23/16 at 4:20 P.M. and was asked if she had any concerns regarding Nurse #2 wound assessment. U.M. #1 said yes she was concerned that the nurse was unable to provide an accurate explanation of the Resident’s wound bed including percentages of necrosis and slough and an accurate description of the wound perimeter. UM #1 said that she planned to complete immediate education with Nurse #2.

During follow-up interview on 8/24/16 at 8:30 A.M., UM #1 said that Nurse #2 was educated on infection control and proper wound assessment. UM #1 provided the assessment completed by Nurse #2 on 8/23/16 at 6:30 P.M. that indicated that the Resident’s left heel with pink granulating tissue with 25-30% yellow slough with 25 % necrotic tissue, edges pink and blanchable. Wound bed dry. UM #1 was asked if the wound bed dry would be an accurate assessment since the Resident’s previous dressing was removed and the bed was observed with wet yellow stained exudate said no.

The Resident’s left heel was observed resting directly on the soiled sheet while Nurse #2 was observed discarding the plastic disposal bag and the dressing supplies stating that she wanted to start over. Nurse #2 set up the over bed table in similar fashion and UM #1 then measured the wound. Nurse #2 was observed leaving the Resident’s bedside on six occasions to wash her hands but despite this, Nurse #2 did not change her gloves after cleaning the wound (considered contaminated) and proceeding to apply the Iodosorb gel and the clean dry protective dressing.

UM #1 was interviewed on 8/23/16 at 4:20 P.M. and was asked if she had any infection control concerns during the wound care observation said yes. UM #1 said that Nurse #2 was continuously washing her hands but did not change her gloves as required. UM #1 said that the Resident’s left heel was not covered as required and the sheets were stained with wound drainage. UM #1 was asked if Nurse #1 should have created a clean field to cover the soiled sheets said yes.

During follow-up interview on 8/24/16 at 8:30 A.M. UM #1 said that Nurse #2 was educated on infection control and proper wound assessment.

Failed to keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.

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

Based on observation, record review and staff interview, the facility failed to ensure that it had a medication error rate of less than 5%. During the medication pass, the facility was found to have a medication error rate of 13.7 % (4 errors with 29 opportunities for error.)

Findings include:

On 8/16/16, the Endicott Unit medication Nurse #1 was observed administering afternoon medications. Of the 15 total medications administered (including 3 non sampled Residents), 4 medications were administered in error due to an incorrect medication dose and late medication administration.

a. At 2:00 P.M., non sampled (NS) Resident #1’s medication administration pass was observed. According to the physician order’s, the antidepressant medication, [MEDICATION NAME] 12.5 milligrams to be administered orally twice daily at 9:00 A.M. and 2:00 P.M. Nurse #1 was observed pouring two tablets of [MEDICATION NAME] for a total of 25 milligrams (mg) and proceeded to administer the medication and was stopped by the Surveyor who asked the Nurse to clarify the dosage. Nurse #1 said that she made a mistake and said that the order indicated a 12.5 mg dose.

b. At 2:25 P.M., NS #2’s medication administration pass was observed. According to the physician order’s the insulin medication, Humalog 6 units was to be administered subcutaneously three times daily before meals. Nurse #1 was observed drawing up 6 Units of Humalog and proceeded to administer the medication and was stopped by the surveyor. Nurse #1 said that she had not given the insulin before lunch and was going to administer the insulin. The Surveyor asked if the MD or Unit Manager was aware that she planned to administer the insulin late said no.

c. At 3:20 P.M., NS #4’s medication pass was observed. According to the physician order’s the cardiac medication, [MEDICATION NAME] 800 mg orally was scheduled three times daily for administration at 9:00 A.M., 2:00 P.M. and 10:00 P.M. and the antipsychotic medication, [MEDICATION NAME] 50 mg orally was scheduled twice daily at 9:00 A.M. and 2:00 P.M. Nurse #1 was observed pouring both medications which Nurse #1 administered at 3:20 P.M. Nurse #1 was asked about the the timeliness of the medication administration since the medications were ordered for 2:00 P.M. said that the facility allows for a one hour window for medication administration.

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, the facility failed to prevent potential cross contamination among and between residents and care givers during a pressure ulcer dressing change for one resident (#16) in a total sample of 24 and on multiple occasions during the medication pass observation of 8/16/16.

Findings include:

1. Resident #16 was admitted to the facility in 5/2016 with current [DIAGNOSES REDACTED]. On 8/23/16 at 3:35 P.M., with treatment Nurse (#2) and accompanied by Unit Manager (UM) #1, the Surveyor observed a dressing change for a left heel pressure ulcer. Nurse #2 said that the Resident’s wound treatment was to wash the left heel with normal saline and apply Iodosorb (used for wound debridement) and cover with dry protective dressing daily and as necessary.

Nurse #2 approached the Resident, who had a single pillow placed under the Resident’s lower legs but was not effective in off loading the heels that were observed resting directly on the mattress. No protective dressing was observed on the left heel, and the sheet directly underneath the left heel was stained a yellow color the size of a half dollar. Nurse #2 said she had not previously removed the dressing and was unable to explain who had done so. Nurse #2 said that the sheet was wet and stained from the wound drainage. Nurse #2 then removed her gloves, washed her hands and returned and applied gloves. Nurse #2 was not observed creating a clean field over the stained soiled sheets and proceeded to cleanse the left heel with normal saline while UM #1 lifted the Resident’s heel.

At 4:05 P.M., UM #1 left the room to obtain supplies to measure the Resident’s wound. The Resident’s left heel was observed resting directly on the soiled sheet while Nurse #2 was observed discarding the plastic disposal bag and the dressing supplies stating that she wanted to start over. Nurse #2 set up the over bed table in similar fashion and UM #1 then measured the wound. Nurse #2 was observed leaving the Resident’s bedside on six occasions to wash her hands but despite this, Nurse #2 did not change her gloves after cleaning the wound (considered contaminated) and proceeding to apply the Iodosorb gel and the clean dry protective dressing.

UM #1 was interviewed on 8/23/16 at 4:20 P.M. and was asked if she had any infection control concerns during the wound care observation. The U.M. said yes. UM #1 said that Nurse #2 was continuously washing her hands but did not change her gloves as required after cleaning the wound. UM #1 said that the Resident’s left heel was not covered as required and the sheets were stained with wound drainage. UM #1 was asked if Nurse #1 should have created a clean field to cover the soiled sheets said yes. During follow-up interview on 8/24/16 at 8:30 A.M., UM #1 said that Nurse #2 was educated on infection control and proper wound assessment.

b. The facility failed to ensure proper infection control practices during a medication administration pass to prevent the transmission of disease and infection. On 8/16/16, from 1:40 – to 3:50 P.M. the Endicott unit medication Nurse #1 was observed administering afternoon medications. Throughout the medication observation Nurse #1 was observed placing her ungloved fingers in each medication cup and water cup prior to pouring medications. Nurse #1 was observed picking up a remote control that had fallen on the floor and without sanitizing her hands, proceeded immediately picked up a medication cup by placing her fingers inside the cup and began pouring the medication. Nurse #1 was asked by the Surveyor if she was aware that she repeatedly contaminated medication cups said no.

Failed to keep accurate, complete and organized clinical records on each resident that meet professional standards

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that clinical records were complete, accurately documented, readily accessible and systematically organized for 1 Resident (#9) of 24 sampled Residents and 1 non sampled Resident (NS#3) of 4 non sampled Residents.

Findings include:

1. For Resident #9, the Facility failed to document the administration of a one time dose of insulin. Resident #9 was admitted to the facility in 6/2016 with [DIAGNOSES REDACTED]. Record review indicated that on 8/13/16, at 7:45 P.M., the Resident had a blood sugar level of 533 mg/dl. The physician was notified and a recheck of the blood sugar was completed at 8:30 P.M. and indicated that the blood sugar level was now 540 mg/dl . The Nurse Practitioner returned the phone call and ordered 2 units of [MEDICATION NAME], one time dose.

Further record review revealed no evidence on the Medication Administration Record [REDACTED].

The Director of Nursing was interviewed on 8/23/16 at 9:20 A.M. and said he did not know why there was no documented evidence on the MAR indicated [REDACTED]

Nurse #3 (who provided care to Resident #9 the evening of the incident) was interviewed on 8/24/16, at 11:45 A.M., and said she was unfamiliar with the computerized medication administration charting system. Nurse #3 said she was supposed to hit another tab on the electronic medical record system to create the order on the MAR for the one time dose of insulin but failed to do so.

2. For NS #3, the facility failed to document the correct time that a narcotic medication was administered. At 3:10 P.M., NS #3’s medication pass was observed. According to the physician order’s the narcotic medication, [MEDICATION NAME] concentrated solution 0.125 milliliter orally, was scheduled twice daily for administration at 9:00 A.M. and 2:00 P.M. Nurse #1 poured the [MEDICATION NAME] as ordered and signed the narcotic administration record that the medication was administered at 2:00 P.M. (the medication was administered late at 3:10 P.M.).

Nurse #1 said she could not explain why the narcotic book indicated the medication was administered at 2:00 P.M. instead of 3:10 P.M.

Kindred Transitional Care and Rehab – Highland, 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 – Kindred Transitional Care and Rehab – Highland 

Nursing Home Inspection, Safety and Deficiency Report  Kindred Transitional Care and Rehab – Highland 08/24/2016

Page Last Updated: December 5th, 2017

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