Loomis House Nursing Center

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Loomis House Nursing Center? 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.

Loomis House Nursing Center

Loomis House Nursing Center is a for non-profit, 92-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Holyoke, Chicopee, South Hadley, Easthampton, West Springfield, Springfield, Ludlow, Northampton, Westfield, and the other towns in and surrounding Bristol County, Massachusetts.

Loomis House Nursing Center
298 Jarvis Avenue
Holyoke, MA 01040

Phone: (413) 538-7551
Website: https://www.loomishouse.org/

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, Loomis House Nursing Center in Holyoke, Massachusetts received a rating of 3 out of 5 stars.

Performance Area Rating
Overall Rating 3 out of 5 (Average)
State Health Inspections 2 out of 5 (Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 3 out of 5 (Average)

Fines Against Loomis House Nursing Center

The Federal Government fined Loomis House Nursing Center $3,121 on April 4th, 2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Injury Attorneys inspected government records and discovered Loomis House Nursing Center committed the following offenses:

Failed to properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for 1 of 3 Residents (Resident #2), who used continuous continuous oxygen, the Facility failed to: – Ensure Resident #2’s oxygen plan of care was followed for 3 liters per minute of oxygen for approximately 2 months. The Surveyor observed that Resident #2 had a nasal cannula in his/her nostrils, but the portable oxygen tank was turned off while he/she propelled him/herself in a wheelchair down the hall. CNA #2 later turned Resident #1’s oxygen to 2 liters per minute (the incorrect flow rate). Five Nurse’s notes from 11/2016 through 12/2016 documented the incorrect flow rate, as 2 liters per minute, not 3 liters per minutes as ordered by the physician.

Findings include:

The Facility’s Policy on Oxygen Therapy, dated 10/2016, stated that oxygen therapy will be administered according to the specific order of the physician. Obtain a physician’s orders [REDACTED]. 2. Resident #2’s [DIAGNOSES REDACTED]. The quarterly Minimum Data Set, dated dated [DATE], indicated Resident #2 had a Brief Interview for Mental Status score of 14, cognitively intact with no rejection of care that would be necessary to achieve the resident’s health and well being. The physician’s orders [REDACTED].#2 was to receive continuous oxygen via nasal cannula at 3 liters per minute to maintain an oxygen saturation greater than 89% (normal greater than 90%).

The Nursing Assistant Care (CNA) Card, dated 8/2016, indicated the CNAs were to check Resident #2’s portable oxygen every shift. On 12/16/16, at 8:20 A.M., the Surveyor observed Resident #2 propelling his/her wheelchair down the hall with a nasal cannula in his/her nostrils, and the dial on the portable oxygen tank was on 0, indicating the oxygen was off with no oxygen being supplied to Resident #2.

The Surveyor interviewed CNA #2 at 8:21 A.M. (the CNA taking care of Resident #2 on 12/16/16 on the 6:00 A.M. 2:00 P.M. shift). CNA #2 said she transferred Resident #2 from bed to his/her wheelchair, but she did not check if Resident #2’s portable oxygen was turned on. The Surveyor observed CNA #2 then turn Resident #2’s oxygen to 2 liters per minute.

At 8:22 A.M. on 12/16/16, CNA #3 came out of a Resident Room and said (in front of Resident #2) to the Surveyor that Resident #2 shuts off his/her own oxygen. The Surveyor interviewed Resident #2 at 8:23 A.M. on 12/16/16. Resident #2 said No, I don’t touch the dial on my oxygen, only the Nursing staff does. At 8:40 A.M. the Surveyor observed Resident #2 in the Dining Room having breakfast, and his/her portable oxygen was set at 2 liters per minute. At 9:45 A.M. the Surveyor observed Resident #2 in his/her room, and his/her portable oxygen was set at 2 liters per minute.

The Surveyor interviewed Nurse #3 at 9:55 A.M. on 12/16/16. Nurse #3 said Resident #2’s oxygen was ordered at 3 liters per minute. Nurse #3 and the Surveyor observed together that Resident #2’s the oxygen flow rate was at 2 liters per minute. Nurse #3 said that is the incorrect flow rate, and she changed the flow rate to 3 liter per minute. The Surveyor interviewed CNA #2 at 9:57 A.M. on 12/16/16. CNA #2 said that Resident #2’s

oxygen flow rate is 2 liters per minute. The Nurses’ notes indicated Resident #2 oxygen was administered at 2 liters per minute on the following dates:.
– on 11/16/16 at 12:51 P.M.
– on 11/16/16 at 10:10 P.M.
– on 12/06/16 at 11:26 A.M.
– on 12/07/16 at 12:03 P.M.
– on 12/14/16 at 1:08 P.M.

The Surveyor interviewed the DON at 2:00 P.M. on 12/16/16. The DON said that the progress notes in Resident #2’s record, indicated an incorrect oxygen flow rate of 2 liters per minute, and it should have been 3 liters per minute.

Failed to develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility staff interview, the facility failed to follow their policy to complete the Nurse Aide Registry screening, of potential new employees, for a history of abuse, neglect or mistreatment of [REDACTED].#3 and #5).

Findings include:

Review of the facility Abuse Policy and Procedure, dated as revised 2/3/17, indicated that screening of all potential employees would include checking the Certified Nurse Aide (CNA) Registry.

1. Review of the personnel file for new employee #3, hired 2/13/17, indicated no CNA registry check. During an interview, with the facility Sr. Human Resource Generalist on 4/4/17 at 9:50 A.M., he said that a CNA registry check had not been completed for new employee #3, as required.

2. Review of the personnel file for new employee #5, hired 3/13/17, indicated that no CNA registry check. During interview, with the facility Sr. Human Resource Generalist on 4/4/17 at 9:50 A.M., he said that a CNA registry check had not been completed for new employee #5, as required.

Failed to completely assess the resident at least every twelve months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to complete a comprehensive Annual Minimum Data Set (MDS) Assessment within the required time frame for 1 resident (#5), in a total sample of 17 residents.

Findings include:

Resident #5 was admitted to the facility in 12/2015, with [DIAGNOSES REDACTED]. Review of the clinical record, indicated a comprehensive Significant Change MDS Assessment was completed, with an Assessment Reference Date (ARD) of 3/9/16.

Review of the clinical record, indicated no further comprehensive assessments were completed. Quarterly MDS Assessments had been completed as scheduled, however, the last MDS Assessment found in the record was a Quarterly, with an ARD of 3/2/17, and not the comprehensive Annual MDS, as required. During an interview on 3/29/17 at 4:45 P.M., the MDS Coordinator said the Quarterly MDS completed on 3/2/17 was completed as a Quarterly MDS Assessment in error, and should have been completed as a comprehensive Annual MDS Assessment.

Failed to make sure each resident receives an accurate assessment by a qualified health professional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) Assessments for 3 residents (#4, #9 and #16), in a total sample of 17 residents.

Findings include:

1. For Resident #4, the facility staff failed to correctly code a urinary tract infection [MEDICAL CONDITION] on a Quarterly Minimum Data Set (MDS) Assessment. Resident #4 was admitted to the facility in 6/2016, with [DIAGNOSES REDACTED].

Resident #4 was sent to the emergency roiagnom on [DATE] and diagnosed with [REDACTED]. Review of Section I of the Quarterly MDS Assessment, dated 3/9/17, indicated the resident did not have a UTI in the past 30 days.

During an interview, on 4/4/17 at 8:30 A.M., the MDS Coordinator said that section N was inaccurately coded and should have included the UTI.

2. For Resident #9, the facility staff inaccurately coded the presence of a Urinary Tract Infection [MEDICAL CONDITION], on a Quarterly MDS. Resident #9 was admitted to the facility in 5/2015, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, with an Assessment Reference Date (ARD) of 1/16/17, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (moderate cognitive impairment). During an observation, on 3/30/17 at 12:50 P.M., the resident was sitting at a table in the main dining room, and was eating lunch. The resident was dressed neatly and had brown knee high compression stockings on his/her bilateral lower extremities. Review of the Quarterly MDS Assessment, with an ARD of 1/16/17, indicated in Section I2300, that the resident had a UTI within the last 30 days of the ARD. Review of the medical record, indicated there was no documentation of a [DIAGNOSES REDACTED]. During an interview, on 3/30/17 at 2:50 P.M., the Clinical Reimbursement Specialist said that the MDS was miscoded, and there was no presence of a UTI within the last 30 days of the Quarterly MDS Assessment, with an ARD of 1/16/17.

3. For Resident #16, the facility staff failed to code Hospice Care for 2 MDS Assessments. Resident #16 was admitted to the facility in 9/2016, with [DIAGNOSES REDACTED]. Review of the Physician’s Telephone Orders, dated 11/21/16, indicated an order for [REDACTED].>Review of the Interdisciplinary Notes, dated 11/23/16, indicated that the resident was admitted to hospice services on 11/23/16.

a. Review of the Significant Change in Status MDS Assessment, with an ARD of 11/23/16, indicated in Section , that the resident was not receiving Hospice Care. During an interview, on 4/4/17 at 2:00 P.M., the MDS Nurse said that the MDS Assessment, with an ARD of 11/23/16, was miscoded and should have indicated that the resident was receiving Hospice Care.

b. Review of the Quarterly MDS Assessment, with an ARD of 12/26/16, indicated in Section O0100, that the resident was not receiving Hospice Care. During an interview, on 4/4/17 at 2:00 P.M., the MDS Nurse said that the MDS Assessment, with an ARD of 12/26/16, was miscoded and should have indicated that the resident was receiving Hospice Care.

Failed to provide care by qualified persons according to each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility staff failed to follow the plan of care for 3 sampled residents (#1, #2, #8), in a total of 17 sampled residents.

Findings include:

1. For Resident #2, the facility staff failed to adhere to the physician’s orders [REDACTED]. Resident #2 was admitted to the facility in 1/2017, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/24/17, indicated that Resident #2 exhibited a Brief Interview of Mental Status (BIMS) score of 6 out of 15 (severe cognitive status), required extensive assistance of 1 staff for dressing and personal hygiene, was at risk for developing pressure ulcers, and did not any skin issues present during the assessment period. Review of Interdisciplinary Notes, dated 2/24/17, indicated that blisters were noted to the resident’s heels during morning (A.M.) care. The right heel was measured at 1.5 x 1.3 centimeters (cm.), and the left heel was measured at 1 cm. diameter. Both blisters were noted to be intact and non-fluid filled. Further review of the notes, indicated that a treatment was applied to the areas.

Review of the current physician’s orders [REDACTED]. Review of the Resident ADL (Activity of Daily Living)/Daily Care List, did not indicate for the resident to wear slipper socks and no shoes.

The surveyor observed Resident #2 on 3/30/17 at 1:30 P.M. The resident was seated in a wheel chair in the hallway, was dressed, and had on shoes. The resident was observed to be escorted by a staff member downstairs to attend the hair dresser. The resident was not observed to be wearing slipper socks, as ordered. The surveyor observed Resident #2 on 3/30/17 at 2:30 P.M. The resident was observed to be seated in the Dining Room, in his/her wheelchair. The resident was dressed, had on shoes. The resident was not observed to be wearing slipper socks, as ordered. The surveyor observed Resident #2 on 3/31/17 at 12:30 P.M. The resident was observed to be in the Dining Room, seated in a wheel chair, with a tray table in front of him/her. The resident was dressed, was wearing shoes, and was eating lunch. The resident was not observed to be wearing slipper socks, as ordered.

During an interview, on 3/31/17 at 2:30 P.M., Unit Manager (UM) #2 said that she was not aware that resident had an order for [REDACTED].>During a follow up interview, on 4/4/17 at 8:50 A.M., UM #2 said that Resident #2 should not be wearing shoes unless he/she is working with therapy. She further said that resident is still receiving a treatment to his/her heels, and that the ADL/Daily Care List was updated to reflect that the resident is to not wear shoes at this time.

2. For Resident #8, the facility staff failed to supervise meals, as care planned. Resident #8 was admitted to the facility in 2/2012, with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, with an ARD of 1/3/17, indicated that Resident #8 exhibited moderate cognitive impairment, displayed inattention, required supervision with meals, and was on a mechanically altered diet Review of the current Resident ADL/Daily Care List, indicated that the resident was on a chopped diet, and required supervision and increased cueing during meals. On 3/31/17 at 9:15 A.M., the surveyor observed Resident #8, seated in a recliner, in his/her room. The resident had a tray table in front of him/her, and was eating breakfast. The surveyor observed that no staff were present in the room, supervising the resident during the meal, as care planned. On 4/4/17 at 9:45 A.M., the surveyor observed Resident #8, seated in a recliner in his/her room. The resident had a tray table in front of him/her, and was observed eating a yogurt. The surveyor observed that no staff were present in the room, supervising the resident, as care planned.

During an interview, on 4/4/17 9:45 A.M., Certified Nursing Assistant (CNA) #6 said that the resident ate breakfast in his/her room today. She further said that the resident is not on any special diet, and does not require any special needs. During an interview, on 4/4/17 at 11:05 A.M., Unit Manager (UM) #1 said that Resident #8 needed to be supervised with all meals. UM #1 said that the resident was not supervised for breakfast on this date, as care planned.

3. For Resident #1, the facility staff did not provide glasses, as care planned. Resident #1 was admitted to the facility in 9/2016, with [DIAGNOSES REDACTED]. Review of the current Resident ADL/Daily Care list, initiated 9/23/16, indicated that the resident utilized glasses. Review of the Quarterly MDS Assessment, with an ARD of 3/13/17, indicated that the resident had adequate vision with corrective lenses, exhibited moderate cognitive impairment, and required extensive assistance of 1 staff for dressing. Review of the Health Drive Eye Care Group form, dated 3/27/17, indicated that the resident required glasses for full time use for distance and reading. On 3/30/17 at 9:40 A.M., the surveyor observed Resident #1, seated in a regular chair, in the Dining Room. The resident was dressed and did not have glasses on, as care planned. On 3/30/17 at 1:10 P.M., the surveyor observed Resident #1, seated in a regular chair, in the Dining Room where music was playing. The resident was dressed but did not have glasses on, as care planned. On 3/31/17 at 10:00 A.M., the surveyor observed Resident #1, seated in the Dining Room. The resident had a paper in front of him/her detailing the day events. The resident was dressed but did not have glasses on, as care planned. During an interview, on 3/31/17 at 1:40 P.M., CNA #5 said that the resident requires extensive assistance with his/her ADLs and that the resident utilizes glasses.

Failed to make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and facility staff interview the facility staff failed to ensure all necessary Physician orders [REDACTED].#4), in a total sample of 17 residents.

Findings include:

Resident #4 was admitted to the facility in 6/2016, with [DIAGNOSES REDACTED]. On 3/30/17 at 10:00 A. M., Resident #4 was observed sitting in a wheelchair, in the television/sitting room open area, on the resident’s unit. The urinary catheter continuous drainage bag was observed to be hanging below the wheelchair inside a privacy bag. Review of the current signed 3/2017 Physicians orders, included an order to change the Foley (indwelling urinary catheter) and bag as needed. However, the order did not include the size of the catheter and retention balloon to use when changing the catheter. During interview, with Unit Manager #1 on 3/30/17 at approximately 10:30 A.M., she said that the Physicians order did not include the catheter size to use if it needed to be changed.

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 observations, interviews, record review, the facility staff failed to ensure an environment that was free of accidents/hazards relative to providing adequate supervision to prevent accidents, resulting in harm, for 1 sampled resident (#11), in a total of 17 sampled residents.

Findings include:

Resident #11 was admitted to the facility in 10/2013, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/12/16, indicated that Resident #11 exhibited a Brief Interview for Mental Status (BIMS) score of 3 out of 15 (indicating severe cognitive impairment), required extensive assistance of 1 staff for eating, was at risk for developing pressure ulcers, and had Moisture Associated Skin Damage (MASD). Review of the Nutritional Status care plan, initiated 12/15/16, indicated that the resident had an increased risk of nutritional decline relative to a [DIAGNOSES REDACTED]. The interventions added to the care plan at this time included: Monitor meal and fluid intake, provide a covered glass and straws at meals, and make sure beverages are not too hot (let cool off or add ice cube). Review of the Cognitive Loss/Dementia care plan, initiated 12/21/16, indicated that the resident’s memory loss puts him/her at risk for confusion, unmet needs, and a decreased sense of well being.

Review of the Communication care plan, initiated 12/21/16, indicated that the resident was hard of hearing, had difficulty making him/herself understood, and had difficulty understanding others. Review of the Activity of Daily Living (ADL) care plan, initiated 12/21/16, indicated that Resident #11 required self care assistance related to poor activity tolerance, immobility and cognitive loss. The ADL care plan indicated that the resident required minimal to extensive assistance with eating depending on the day, assist of 1 staff (provide glass and straw at meals), and encourage resident to self feed as able. Review of the Interdisciplinary Notes, dated 2/24/17, indicated the resident was noted to have a red area on his/her left thigh, with 7 raised clear fluid filled blisters, measuring 13 centimeters (cm) x 6 cm. The Physician, Director of Nurses (DON) and Health Care Proxy (HCP) were notified, and orders were obtained. Review of the facility internal Incident/Accident Report, dated 2/24/17, indicated Resident #11 was noted to have a large reddened area on his/her left upper thigh, when the Certified Nursing Assistant (CNA) was providing care at 6:00 P.M. Further review of the investigation, indicated that the resident was in the Dining Room and said that his/her tea had spilled. The facility noted in the report that the resident had weakened strength in his/her hands, which may have contributed to the burn. Further review of the investigation, indicated the following interventions were added at the time of the incident: rehabilitation screen was submitted to review meal assistive devices, staff to pour hot beverage and let sit for a few minutes prior to giving it to the resident, and provide warm beverage- no hot beverages, in a cup with a lid and provide assistance, if needed.

Review of the staff statement #1, dated 2/24/17, indicated that the staff member was in the process of serving drinks to other residents in the dining room, and that her back was turned away from Resident #11. The staff member stated that when she turned back around, she saw that Resident #11 had spilled his/her tea on the table. The staff member said that she cleaned up the table, and assisted Resident #11 with his/her meal. The statement also indicated that the staff member was not present to provide assistance and/or supervision to the resident, while the resident had his/her hot beverage, as care planned. Review of the staff statement #2, dated 2/24/17, indicated that the CNA was asked by the resident’s daughter to get him/her into bed because the resident was observed to be wet. The CNA stated that the resident was transferred into bed, and a red area was noted on the resident’s upper left leg, where his/her pants were observed to be wet. The CNA indicated that he/she reported the area to the nurse. Review of the Medication, Treatment and Task Administration Record report, dated 2/2017, indicated an order on 2/24/17 for Silvadene 1% cream, apply topically to affected area on left upper thigh twice daily and cover loosely with ABD pad (type of wound dressing for large wounds and/or wounds with heavy drainage).

Review of the completed Rehabilitation Screen, dated 2/27/17, indicated that Resident #11 had a blister on his/her left thigh from spilled hot tea in the dining room at supper on 2/24/17. Further review of the screen, indicated that a Provale cup and a Spout sup cup were trialed, and refused by the family, due to the inability for the resident to utilize a straw to maintain independence. The screen further indicated that there was no therapy evaluation requested at that time. Review of the physician progress notes [REDACTED]. Further review of the note, indicated that the area affected required gentle debridement with normal saline and gentle gauze daily, and application of an anti-bacterial agent. The physician ordered Doxycycline (an antibiotic), 100 milligrams (mg), once daily for 5 days prophylactically, to treat concerning bacterial co-infection. Review of the Interdisciplinary Notes, dated 2/28/17, indicated that the blister to the resident’s left thigh was open. The physician was in the facility, assessed the resident, the area was cleansed and a new treatment was ordered. Review of the the Medication, Treatment and Task Administration Record report, dated 4/2017, indicated that the wound continued to require a daily treatment and measured 8.5 cm x 3.75 cm, and had slough (yellow tissue) present.

On 3/30/17 at 1:00 P.M., surveyor observed the Main Dining Room, where a resident and his/her visitor were seated at a table. The surveyor observed a coffee/hot water dispenser, located on a counter, within the main dining room, that was accessible to residents. The surveyor was able to dispense the coffee and hot water from the machine. The surveyor noted that no staff were present in the area at the this time.

On 3/31/17 at 9:50 A.M., the surveyor observed the Main Dining Room was empty, although the doors to the area were open. The surveyor observed a coffee/hot water dispenser, located on a counter within the main dining room, that was accessible to residents. The surveyor was able to dispense hot water into a disposable paper cup from the stack of paper cups, located on the counter. The surveyor observed the outside of the paper cup to be very hot.

On 4/4/17 at 2:50 P.M., the surveyor observed that the Main Dining Room was accessible/open. The surveyor observed that the coffee/hot water dispenser, located on the counter within the Main Dining Room, was accessible, and the surveyor was able to dispense hot water from the machine without assistance/supervision from staff.

During an interview on 4/4/17 at 3:15 P.M., the Food Service Director (FSD) said that the coffee/hot water dispenser was for staff and family use, and was not for residents. The FSD said that families and/or staff can serve residents from this dispenser with supervision. The surveyor observed, during the time of the interview with the FSD, that there was no signage indicating that assistance is needed for residents to utilize the coffee/hot water dispenser. The FSD further said that she started taking temperatures of the coffee/hot water dispenser in the Main Dining Room, after a resident was burned. During an interview, on 4/4/17 at 3:45 P.M., CNA #7 said that she assists with serving residents beverages in the Main Dining Room. CNA #7 said that the staff utilize the refrigerator and the coffee/tea dispenser to serve the residents.

During an interview, on 4/4/16 at 3:50 P.M., CNA #4 said that CNAs serve the beverages to residents who eat meals in the Main Dining Room. CNA #4 said that the kitchen staff stock the refrigerator with cold items, and stock cups/mugs on the counter and pull out drawers. She further said that CNAs use the coffee/hot water dispenser on the counter for coffee/hot water for residents. During an interview, on 4/4/17 at 4:20 P.M., the Assistant Director of Nurses (ADON) said that at the time of the incident, Resident #11 was able to hold a cup independently. She further said that after the incident occurred, staff were instructed to stay with the resident during the meal, as care planned.

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 observations, interviews, and record review, the facility failed to ensure that staff maintain complete and accurate clinical records for 4 residents (#4, #8, #9 and #10), in a total sample of 17 residents.

Findings include:

1. For Resident #4 the facility Nursing staff failed to ensure a medication order included the dose to be administered. Resident #4 was admitted to the facility in 6/2016, with [DIAGNOSES REDACTED]. Review of the current signed 3/2017 Physician orders [REDACTED]. During an interview with Unit Manager (UM) #1, on 3/30/17 at approximately 10:00 A.M., she said that there was no dosage indicated for the TUMS in the current Physicians order.

2. For Resident #10, the facility staff failed to indicate the code status on the Advanced Directives care plan. Resident #10 was admitted to the facility in 12/2016, with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated 12/21/16, indicated that the resident had Advanced Directives which included: Do Not Resuscitate (DNR), and had a Health Care Proxy (HCP) that was invoked. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 3/6/17, indicated that Resident #10 had severe cognitive impairment, and had Advanced Directives including: DNR, Do Not Hospitalize (DNH), Do Not Intubate (DNI), feeding and other treatment restrictions, and had a HCP that was invoked, at the time of the assessment. Review of the clinical record, on 3/31/17, indicated an Advanced Directives care plan, initiated on 12/01/16, that did not indicate the resident’s choice for medical treatment decisions. The surveyor observed Resident #10 on 3/31/17 at 7:40 A.M. The resident was observed lying in bed, on an air mattress set at 125, and had bilateral floor mats in place. During an interview, on 4/4/17 at 10:00 A.M., Social Worker #2 said that Advanced Directives care plans are put in place for every resident, and include the resident’s wishes regarding code status, and if the HCP is in place/invoked. Social Worker #2 said that care plans are reviewed every three months. Social Worker #2 further said that the Advanced Directives for Resident #10 were not indicated in the care plan, and that it should be.

3. For Resident #8, the facility staff failed to accurately reflect continence status on the Bladder Assessment. Resident #8 was admitted to the facility in 2/2012, with [DIAGNOSES REDACTED]. Review of the Bladder Assessment/Evaluation policy, dated 3/14/13, indicated that residents will be assessed for the need for a program on admission, with a significant change and annually. Review of the Certified Nurses Aide (CNA) daily charting, from 12/25/16- 1/10/17, indicated that the resident had 30 episodes of urinary incontinence. Review of the Bladder Assessment, dated 1/3/17, indicated that at the time of the annual assessment, Resident #8 was continent of bladder, and further evaluation was not indicated. Review of the Annual MDS Assessment, with an ARD of 1/3/17, indicated that Resident #8 had moderate cognitive impairment, required extensive assistance of one staff for toileting, was frequently incontinent of bladder, and was on a toileting program. The surveyor observed Resident #8 on 3/31/17 at 12:15 P.M. The resident was ambulating, using a walker, down the hallway, with a staff member. The resident was dressed and was wearing glasses. During an interview, on 4/4/17 at 9:45 A.M., CNA #6 said that the resident is incontinent of bladder and is toileted at scheduled times (before/after meals) to decrease episodes of incontinence. During an interview, on 4/4/17 at 11:05 A.M., Unit Manager #1 said that Resident #8 has been incontinent of bladder, and that the Bladder Assessment, dated 1/3/17, was incorrect.

4. For Resident #9, the facility failed to maintain an accurate care plan in reference to the application of a left hand splint. Resident #9 was admitted to the facility in 5/2015, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, with an ARD of 1/16/17, indicated a BIMS score of 12 out of 15 (moderate cognitive impairment). Review of the Pressure Ulcer/Skin Integrity Care Plan, indicated an intervention, with a start date of 1/26/17, that the resident was to have a left hand splint placed in the morning and removed 6 hours later, as tolerated. Review of the Pain Care Plan, indicated an intervention, with a start date of 1/26/17, that the resident was to have a left hand splint, on in the morning and removed at bedtime. During an observation, on 3/30/17 at 10:00 A.M., the resident was in his/her room, dressed neatly, and was sitting in a wheelchair. The resident was not wearing a left hand splint. During an observation, on 3/30/17 at 1:00 P.M., the resident was in the unit dining room, and was eating his/her lunch. The resident was not wearing a left hand splint. During an interview, on 3/30/17 at 1:10 P.M., CNA #1 said that the resident did not wear a left hand splint. During an interview, on 3/30/17 at 4:00 P.M., UM #1 said that the resident did not utilize a left hand splint, and she would update the Pressure Ulcer /Skin Integrity, and Pain Care Plans to indicate the current level of care.

Loomis House Nursing Center, 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:

Page Last Updated: February 10, 2017

Call Now Button