Mont Marie Rehabilitation and Healthcare Center

Did someone you love suffer elder abuse or neglect at Mont Marie Rehabilitation and Healthcare Center? Our lawyers can help.

MI Elder Abuse Free Legal ConsultationAbuse 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 Mont Marie Rehabilitation and Healthcare Center

Mont Marie Rehabilitation and Healthcare Center a for profit, 84-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Chicopee, South Hadley, Easthampton, West Springfield, Springfield, Ludlow, Northampton, Westfield, and the other towns in and surrounding Bristol County, Massachusetts.

Mont Marie Rehabilitation and Healthcare Center focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Mont Marie Rehabilitation and Healthcare Center
36 Lower Westfield Road
Holyoke, MA 01040

Phone: (413) 538-6050
Website: http://montmarierehab.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, Mont Marie Rehabilitation and Healthcare Center in Holyoke, Massachusetts received a rating of 2 out of 5 stars.

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

Fines and Penalties

Our Nursing Home Injury Lawyers inspected government records and discovered Mont Marie Rehabilitation and Healthcare Center committed the following offenses:

Failed to tell the resident completely about his or her health status, care and treatments.

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

Based on record review and interview, the facility staff failed to obtain informed consent for the use of [MEDICAL CONDITION] medications for two sampled residents (#2 and #8) out of a total sample of 15 residents.

Findings include:

1. Resident #2 was admitted to the facility in 1/2013 with [DIAGNOSES REDACTED]. Review of the clinical record indicated the Health Care Proxy (HCP) was invoked on 5/3/13.  Review of the clinical record indicated a consent for [MEDICATION NAME] (antidepressant) was signed by the resident, and not the invoked HCP, on 2/8/17.  Review of the clinical record indicated a consent for [MEDICATION NAME] (antidepressant) was signed by the resident, and not the invoked HCP, on 7/27/17.  Review of the 10/2017 physician’s orders [REDACTED].

During an interview on 10/5/17 at 3:30 P.M. the Director of Nurses (DON) said the consents should have been signed by the HCP and not the resident.

2. Resident #8 was admitted to the facility in 2/2017, with a readmitted ,[DATE], and with [DIAGNOSES REDACTED]. Review of the 9/2017 signed physician’s orders [REDACTED]. [MEDICATION NAME] (antidepressant) 40 milligrams (mg) give one capsule by mouth daily. [MEDICATION NAME] (antidepressant) 150 mg give one tablet by mouth daily. [MEDICATION NAME] (antianxiety) 1 mg give one tablet by mouth twice a day. [MEDICATION NAME] (antipsychotic) 50 mg give one tablet by mouth three times a day. Review of the 9/2017 and 10/2017 Medication Administration Record [REDACTED]. Review of the clinical record indicated no informed consent was obtained prior to the administration of the [MEDICAL CONDITION] medications.

During an interview on 10/4/17 at 3:50 P.M., the Assistant Director of Nurses reviewed the clinical record and said she could not find any informed consents.

Failed to 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) 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 interview the facility staff failed to properly investigate an allegation of abuse for 1 Resident (#5) in a total sample of 15 residents.

Findings include:

Review of the facility Policy for Abuse Investigations, adopted 3/2016, indicated the following:

a. Should an incident or suspected incident of resident abuse, mistreatment or neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident.

b. The individual conducting the investigation will, as a minimum: -Review the completed documentation forms -Review the resident’s medical record to determine events leading up to the incident -Interview the person(s) reporting the incident -Interview any witnesses to the incident -Interview the resident (as medically appropriate) -Interview the resident’s attending physician to determine the resident’s current level of cognitive function and medical condition -Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident -Interview other residents to whom the accused employee provides care or services; and -Review all incidents leading up to the alleged incident.

c. The Administrator will inform the resident and his/her representative of the results of the investigation.

d. Should the investigation reveal a false report has been made/filed, the investigation will cease. Residents family, ombudsmen, state agencies will be notified of the findings . Resident #5 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 4/28/17, indicated the resident had moderate cognitive deficits with a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review indicated he/she had no mood issues, no [MEDICAL CONDITION] and no behaviors.

Review of a a progress note, dated 6/7/17, indicated the resident was very anxious and demanding that evening and was tearful at times. Nurse #3 documented the resident said the staff was trying to rape her when they were providing incontinent care. Further review of the record did not indicate anyone was notified of the allegation and did not indicate any investigation or follow up had taken place. Review of the current care plan did not indicate the resident had a history of [REDACTED].

During an interview on 10/4/17 at 3:40 P.M., the Regional Director of Clinical Services said Nurse #3 had been a nurse for many years. She went on to say Nurse #3 must have thought the rape allegation was related to complications of a urinary tract infection. She said the nurse did not follow procedure and an investigation was not completed. During an interview on 10/5/17 at 2:00 P.M., the Director of Nursing said Nurse #3 was suspended the afternoon of 10/4/17, pending investigation of the resident’s abuse allegation made on 6/7/17.

Failed to provide housekeeping and maintenance services

Based on environmental tour the facility staff failed to maintain sanitary and orderly clean and dirty utility rooms and keep pathways to emergency eyewash stations accessible and clear from clutter on 2 out of 3 units.

Findings include:

During environmental tour on 10/5/17 at 8:05 A.M., with the Maintenance Director and Project Manager, the following was observed: -Third Floor Clean Utility Room: Multiple cabinet doors were broken, falling off of the hinges.

-Third Floor Dirty Utility Room: Emergency eyewash station did not have caps on either of the spigots, which would allow for debris to fall in.

-Second Floor Clean Utility Room: One cabinet door was loose and falling off of the hinges. A basin with multiple hair rollers and an open bottle of hydrogen peroxide was in the cabinet, along with multiple holiday decorations. Urine specimen cups were stored underneath the sink, both cabinet doors were falling off.

-Second Floor Dirty Utility Room: Emergency eyewash station was blocked by several linen carts.

-First Floor Dirty Utility Room- Emergency eyewash station was blocked by several linen carts and was behind a locked door.

The Maintenance Director was initially unable to locate the key to the room, but then found it at the nurses station. During an interview on 10/6/17 at 8:30 A.M., the Maintenance Director and Project Manager said the clean utility was full of junk and needed to be cleaned. Neither of them knew the codes to the dirty utility rooms and had to ask a nurse for the code. They both said there should not be any items stored underneath the sink, and there should have been a clear path to the emergency eyewash stations.

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 interview, the facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) Assessment relative to falls, for 2 residents (#4 and #9) in a total sample of 15 residents.

Findings include:

1. For Resident #4, the facility staff failed to code a non-injurious fall on a quarterly MDS assessment.

Resident #4 was admitted to the facility in 6/2014 with [DIAGNOSES REDACTED]. Review of a progress note, dated 3/15/17, indicated the resident had a non-injurious fall. Review of the quarterly MDS, with an assessment reference date of 6/2/17, indicated the resident had no falls since the last MDS.

During an interview, on 10/5/17 at 3:45 P.M., the MDS Coordinator said 1 fall without injury should have been coded on the 6/2/17 MDS.

2. For Resident #9, the facility staff failed to code a fall with a fracture, sustained prior to admission, on an admission MDS assessment.

Resident #9 was admitted to the facility in 9/2017 with a [DIAGNOSES REDACTED]. Review of the admission transfer paperwork from the hospital, dated 9/11/17, indicated the resident had a fall in the community on 9/10/17 resulting in a knee fracture.

Review of a progress note date 9/18/17 indicated the resident had been admitted to the facility, from the hospital, after a fall with a fractured knee.

Review of the admission MDS Assessment, dated 9/25/17, indicated the facility staff was unable to determine if the resident sustained [REDACTED].

During an interview on 10/5/17 at 3:45 P.M., the MDS Coordinator said the admission MDS should have been coded to reflect a fall with a fracture 2 to 6 months prior to admission.

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 observation, interview and record review, the facility staff failed to obtain a Physician’s order for the use of [REDACTED]#8) in a sample of 15 residents.

Findings include:

1. For Resident # 9, the facility staff failed to obtain a Physician’s order for the use of [REDACTED].

Resident #9 was admitted to the facility in 9/2017 with a [DIAGNOSES REDACTED]. Review of the record indicated the resident’s weight, on 10/5/17, was 154 pounds (lbs). Review of the record indicated there was no Physician’s order for the use of [REDACTED]. During an observation, on 10/5/17 at 8:27 A.M., the resident was in bed on an air mattress with bilateral side rails. The settings of the mattress were as follows; cycle time: 10 minutes, comfort 270, therapy: alternating.

During an interview on 10/5/17 at 10:15 A.M., Nurse #1 said the resident utilizes the air mattress because she is non-weight bearing and immobile due to a recent knee fracture. She said she usually refers to the Physician’s orders for guidance on what the mattress setting should be.

During an interview on 10/5/17 at 10:45 A.M., the Unit Manager (UM) reviewed the chart and was unable to locate a Physician’s order for the air mattress. Further review indicated the settings and use of the air mattress were not monitored. She said there should have been an order and settings usually go by the resident’s weight. She said she wasn’t sure why the mattress was set at 270 if the current weight is 154. She said it may have been changed for comfort.

2. For Resident #8 the facility staff failed to ensure the Physician’s order included the setting for use of an air mattress.

Resident #8 was admitted in 2/2017 with [DIAGNOSES REDACTED]. Review of the 9/2017 signed Physician’s orders indicated the following order: Air Mattress check to ensure it is inflated every shift for pressure relief. The order did not indicate the mattress setting.

Review of the clinical record indicated the resident weighed 220 lbs on 9/28/17. During the initial tour of the facility on 10/3/17, the resident was observed laying in bed on the air mattress which was set to 280.

During an observation on 10/5/17 at 10:50 A.M., the resident was observed in bed on the air mattress which was set to 280.

During an interview on 10/5/17 at 11:00 A.M., Nurse #2 said the nurses checked the air mattress every shift to be sure it was inflated. When the surveyor asked how the nurses determined if the mattress was on the right setting, Nurse #2 said the staff could tell if it were inflated or not. She went and checked the resident, came back to the surveyor and said the air mattress was set at 280 and that the setting was usually based on weight. The surveyor asked if that were the correct setting and Nurse #2 said she didn’t know, she said the order should include the setting and it didn’t.

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, and record reviews, the facility staff failed to ensure effective interventions were in place to prevent falls for one sampled resident (#2) and failed to assess risk of entrapment from bedrails for four sampled residents (#4, #7, #9, and #13) out of a total of 15 sampled residents.

Findings include:

1. For Resident #2 the facility staff failed to ensure effective interventions were in place to prevent 3 falls.

Resident #2 was admitted to the facility in 1/2013 with [DIAGNOSES REDACTED].
a. Review of the facility policy Safety and Supervision of Residents, dated 12/2007, indicated the following:
– Implementing interventions to reduce accident risks and hazards shall include the following:

Ensuring that interventions are implemented and document interventions.
– Monitoring the effectiveness of interventions shall include the following:
Ensure that interventions are implemented correctly and consistently. Evaluate the effectiveness of interventions. Modify or replace interventions if needed.

Review of the annual Minimum Data Set (MDS) assessment, dated 10/14/16, indicated the resident had impaired short and long term memory with significant impaired decision making ability and required extensive assist of one for transfers. Review of the care plan for falls, with a goal date of 8/7/17, indicated an intervention for a bed alarm, initiated 3/13/16.

Review of a progress note, dated 3/22/17, indicated the resident sustained [REDACTED]. Review of the quarterly MDS, dated [DATE], indicated the resident had severe cognitive impairment with a score of 0 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, and required extensive assistance of one for transfers and toilet use. Review of the care plan for falls, with a goal date of 8/7/17, indicated an intervention to add a chair pressure alarm, initiated 8/24/16.

Review of a progress note, dated 7/18/17, indicated the resident sustained [REDACTED].M. in his/her bathroom and had removed both the bed and chair pressure alarm. Review of a progress note, dated 8/2/17, indicated the resident sustained [REDACTED].M The nurse who was at the nurses station heard a noise and found the resident laying on a floor mat next to his/her bed. The bed alarm did not sound. Review of the Occurrence Report, dated 8/2/17, indicated the resident was last seen at 10:00 P.M. when he/she was repositioned. Further review indicated the alarm did not sound at the time of the fall but did sound when the resident was placed back in the bed. The alarm was replaced.

During the initial tour of the facility on 10/3/17, the resident was observed up and dressed in the wheelchair, seated in the dining room with bilateral heel float boots and glasses on and Velcro seat belt attached. Observation of the resident on 10/4/17 at 8:10 A.M. indicated the resident was up and dressed in the wheelchair, bilateral heel float boots and glasses on. During an interview on 10/5/17 at 1:50 P.M., the Director of Nurses (DON) said the alarms were removed by the resident on both 3/22/17 and 7/18/17, but continued to be used as interventions. She said the bed alarm malfunctioned on 8/2/17.

2. For Resident #7 the facility staff failed to assess the risk of entrapment from bedrails. Review of 9/2017 Physician’s orders indicated an order for [REDACTED]. During the initial tour of the facility on 10/3/17, the resident was observed in bed, sleeping, with bilateral 1/4 bedrails up. Observation on 10/5/17 at 10:05 A.M., the resident was laying in bed with bilateral 1/4 bedrails up. Review of the clinical record indicated risk of entrapment from bedrails was not assessed, as required.

3. For Resident #13 the facility staff failed to assess the risk of entrapment from bedrails. Resident #13 was admitted to the facility in 9/2017 with [DIAGNOSES REDACTED]. During the initial tour of the facility on 10/3/17, the resident was observed in bed with bilateral 1/4 bedrails up. Observation on 10/5/17 at 11:05 A.M., the resident was in bed sleeping with bilateral 1/4 bedrails up. Review of the clinical record indicated risk of entrapment from bedrails was not assessed, as required.

4. For Resident # 4, the facility staff failed to assess the risk of entrapment from bedrails. Resident #4 was admitted to the facility in 6/2014 with [DIAGNOSES REDACTED]. Review of a device assessment, dated 9/7/17, indicated the use of 2 bedrails when in bed to aid in repositioning. Further review of the documentation indicated the risk of entrapment was not assessed, as required. During observations, on 10/3/17 at 8:55 A.M. and 10/4/17 at 2:23 P.M., the surveyor observed the resident in bed with bilateral padded half-bed rails in use.

5. For Resident # 9, the facility staff failed to assess the risk of entrapment from bedrails. Resident #9 was admitted to the facility in 9/2017 with a [DIAGNOSES REDACTED]. Review of a device assessment, dated 9/18/17, indicated the use of 2 bedrails when in bed to aid in repositioning. Further review of the documentation indicated risk of entrapment was not assessed, as required On 10/5/17 at 8:27 A.M., the surveyor observed the resident in bed with bilateral 1/4 bedrails in use. During an interview on 10/5/17 at 1:45 P.M., the Director of Nursing (DON) said the residents are assessed on admission to determine if bedrails are indicated. She said they recently performed a facility wide audit of bedrail usage. She reviewed the bedrail assessment with the surveyor and said there was no assessment of the risk of entrapment. When the surveyor asked the DON if each resident was assessed individually for entrapment risk, in relation to their bedrails and the manufacturer’s guidelines, she said they were not.

Failed to prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.

Based on observation and interview the facility staff failed to ensure food was served at a safe and appetizing temperature.

Findings include:

During a Group Interview with 10 residents, on 10/3/17 at 11:30 A.M., residents complained of cold food (on all three units) and said it was an issue on a daily basis. They said the eggs are often cold at breakfast and that the evening meal is often cold as well. On 10/4/17 at 7:35 A.M., at the start of the breakfast trayline service, the following food and beverage temperatures were obtained by the cook:

-Oatmeal 184 degrees Fahrenheit (F)
-Fried egg 184 degrees F
-Scrambled egg 184 degrees F
-Puree egg 181.3 degrees F
-Grilled ham 165 degrees F
-Ground ham 172 degrees F
-Puree ham 174 degrees F
-Toast 166 degrees F
-Soft toast 166 degrees F
-Puree toast 170 degrees F
-Milk 38.7 degrees F
-Juice 60 degrees F
-Coffee 180 degrees F

A breakfast meal test tray was sent to the following 2 units, temperatures were taken, and some food/drink were tasted after all meals had been served on the unit. The Food Service Director (FSD) and Assistant Director of Nursing (ADON) obtained the temperatures in the presence of a surveyor. The following temperatures were of a concern:

3rd floor at 8:28 A.M.;
-Juice 60.8 degrees F
-Fried egg 91.2 degrees F and tasted cold
-Scrambled eggs 94.3 degrees F and tasted cold
-Ground ham 92.7 degrees F and tasted very salty and cold
-Puree ham 101.7 degrees F and tasted very salty and cold
2nd floor at 8:40 A.M.;
-Juice 61.3 degrees F and tasted luke warm
-Fried egg 104.9 degrees F and tasted cold
-Scrambled eggs 104 degrees F and tasted cold
-Puree eggs 104 degrees F and tasted cold
-Ground ham 105.9 degrees F and tasted very salty and cold
-Puree ham 101.7 degrees F and tasted very salty and cold

During an interview on 10/4/17 at 9:00 A.M., Resident #5 said breakfast was too cold. He/she said the ham was very salty and both the ham and fried eggs were cold. During an interview on 10/5/17 at 8:50 A.M., in the presence of 2 surveyors, the FSD said the food temperature issues would be addressed. He said the facility had plans to implement a new food delivery system in the future that would allow staff to plate meals on the units.

Failed to store, cook, and serve food in a safe and clean way

Based on observation and interview the facility staff failed to ensure that safe and sanitary food handling techniques were maintained during meal preparation and service to minimize the risk of food borne illnesses.

Findings include:

During a tour of the kitchen with the Food Service Director (FSD), on 10/3/17 at 8:20 A.M., the following concerns were observed;
-The convection ovens in back area of kitchen had built up layer of black residue and the front of the oven had dried brown drips from the top of the oven to the bottom.
-The racks in the back room, containing dishware, were coated with dust and bread crumbs.
-A trash can was not available next to the hand washing station.
-The ventilation hood over the newly installed convection ovens had not been serviced since 8/2014.
-The fans (mounted) were very dusty and had debris on the blades and outer cage.
-The Buffalo Chopper had red splattered food dried on the inside.
-The broiler above the oven was coated with dust and grime.
-The pot rack above the steam table was covered with dust.

During an interview, on 10/3/17 at 9:00 A.M., the FSD said he was new to the facility (about 1 month) and was unaware of a cleaning schedule. During a second tour of the kitchen on 10/5/17 at 7:45 A.M., the surveyor observed the cook serving fried eggs, ham and toast without utensils, using her gloved hands. The cook also scooped altered textures of the same food using utensils, but touched the food with her hands. The cook then adjusted the stove knobs and handled a food cart. She returned to the line and served food using her hands, without a change of gloves, hand washing, or utensils. When the surveyor asked the FSD if the cook should be serving with her hands, the FSD intervened and told the cook she needed to use utensils when serving food. During an interview on 10/5/17 at 1:35 P.M., the administrator said the FSD would implement a cleaning schedule.

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

Based on observation and interview the facility staff failed to maintain infection control standards regarding the storage and handling of a wound culture specimen. Review of the Occupational Safety and Health Administration (OSHA) guidelines indicated to use universal precautions (treat specimen as though it were contaminated, use gloves and other personal protective equipment as anticipated and limit exposure to the specimen) when handling potentially infectious materials.

Findings include:

During an observation on 10/5/17 at 11:40 A.M., the surveyor observed a Courier come to the nursing station and ask Nurse #2 where he was to pick up the laboratory specimen. Nurse #2 went to the medication cart and removed a tube (used to collect wound drainage), the tube was not in a biohazard bag or any other self contained bag, and handed it to the Courier who placed it in a cooler. Nurse #2 did not have gloves on and did not wash her hands after handling the tube. A family member of a resident then came to Nurse #2 and asked her to put a hearing aide in the resident’s ear. Nurse #2 opened the medication cart, removed the hearing aide and placed it in the resident’s ear. Nurse #2 then proceeded to the nursing station, and did not wash her hands. During an interview on 10/5/17 at 11:45 A.M., the surveyor asked Nurse #2 if the tube used to collect the wound specimen was considered dirty and she said yes. When asked why she put a dirty item in a clean medication cart, Nurse #2 told the surveyor she didn’t know where else she was supposed to store it. She said she probably should have put the tube in a biohazard bag.

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

Based on records reviewed and interviews, for 1 of 3 employees (Nurse #1), the Facility failed to follow its policies and procedures for pre-employment screening.

Findings include:

The Policy titled, Abuse Prevention Program, dated 11/2016, indicated that the Facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. Nurse #1 was hired in 2012. Review of Nurse #1’s personnel record indicated there was no record that a Massachusetts Nurse Aide Registry check was performed. Surveyor #2 interviewed the Regional Director of Clinical Services at 9:20 A.M. on 4/25/17. The Regional Director of Clinical Services said that the Facility did not obtain a Massachusetts Nurse Aide Registry check on Nurse #1. This was not consistent with the Facility’s Employment Procedures and Abuse Prevention Program Policy, dated 11/2016.

Failed to develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.

Based on records reviewed and interviews, for 1 out of 5 sampled Residents (Resident #1), who was assessed as being at increased risk for falls, the Facility failed to ensure they developed, reviewed and implemented an individualized plan of care for falls with appropriate interventions, to maintain Resident #1’s safety. Resident #1’s plan of care was updated on [DATE] to include the use of personal alarms at all times. Although Resident #1 was known to remove his/her alarms and ambulate without assistance from staff, he/she experienced two falls from [DATE] to [DATE], and no alternative interventions were attempted. On [DATE], Resident #1, who required bed and chair pads alarms at all times for safety, experienced an unwitnessed fall, was found face down on the floor, unresponsive, with bleeding from his/her head and it was determined Resident #1’s chair pad alarm was not in place or functioning at the time of the fall. -On [DATE] at approximately 4:00 P.M., Resident #1 was found on the floor, unresponsive by Family Member. -On [DATE] Resident #1 was transferred to the hospital where he/she was diagnosed [MEDICATION NAME] fracture on sternal body, T11-T12 acute fracture (bottom part of the [MEDICATION NAME] spine-back), bilateral first rib fractures, right third and forth rib fractures, left second through fifth fractures and aspiration pneumonitis (lung disease develops after you inhale food, liquid or vomit into your lungs). Resident #1 transferred back to the facility on [DATE] on hospice care. Resident #1 died on [DATE] at 1:20 A.M.

Findings include:

The Policy titled Comprehensive Care Plans, dated [DATE], indicated the following; comprehensive care plan is based on a through assessment, each Resident’s comprehensive care plan is designed to incorporate identified problem areas and risk factors associated with identified problems, reflect treatment goals and measurable outcomes, aid in preventing or reducing declines in functional status/or functional levels, enhance the optimal functioning of rehabilitative programs and areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan, assessment of residents are ongoing and care plans are revised as information about the resident and the resident’s condition change.

The Policy titled, Assessing Falls and Their Cause, dated [DATE], indicated identifying causes of a fall or fall risk includes the following; for each individual staff will distinguish the root cause of the fall, the Unit Manger or DON should consult with the attending Physician or Medical Director to confirm specific causes from multiple possibilities, the Physician will examine the resident or initiate testing to try to identify causes, if the cause is unknown but no additional evaluation is done, the Physician or nursing should note why, if the resident continues to fall despite attempted interventions the nursing staff will discuss the situation with the Physician or Medical Director.

The Policy titled, Fall Risk Assessment, dated [DATE], indicated the Nursing staff and the Physician will review a resident’s record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The staff will look for evidence of a possible link between the onset of falling or an increase in falling episodes. The staff with the support of the attending Physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. The staff and attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.

The Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1’s medical history included the following; Diabetes Mellitus ([MEDICATION NAME] unable to produce enough insulin), Arthritis (joint swelling), Dementia (memory disorder), Ataxia (abnormalities of gait and mobility), muscle weakness, repeated falls, long term use of Anticoagulants (blood thinners). The MDS indicated Resident #1 Brief Interview for Mental Status (BIMS) Score was 12 out of 15 ( a score of ,[DATE] indicates cognitively intact and a score of 9 to 12 indicates moderate cognitive impairment). The MDS indicated Resident #1 was unsteady during transfers and walking and was only able to stabilize his/her balance with staff assistance.

A Fall Risk Assessment, dated [DATE], indicated Resident #1’s was scored as a moderate risk for falls. A Fall Risk Assessment, dated [DATE], indicated Resident #1’s was scored as a high risk of falls.

A Fall Risk Plan of Care, updated [DATE], indicated Resident #1 required bed and chair pad alarms at all times and Resident #1 to wear non skid socks at night. A Fall Risk Plan of Care, updated [DATE], indicated additional safety interventions included Resident #1 required hands on assistance to move from place to place, he/she was confused and attempts to get up on his/her own, keep Resident #1 in activities as much as possible to provide a diversion to reduce risk of getting up unassisted and educate Resident #1 to always request assistance. Although Resident #1 was known to remove his/her alarms and ambulate without assistance from staff, he/she experienced two falls from [DATE] to [DATE], and no alternative interventions were attempted.

A Physician Order, dated [DATE], indicated Nursing to check placement and function of Resident #1’s bed and chair pad alarm every shift. A Facility’s Occurrence Report, dated [DATE], indicated Resident #1’s call light was not sounding, call light was off and Resident #1 was last seen on [DATE] at 1:00 P.M. A Nurse Progress Note, dated [DATE], indicated Resident #1’s alarm was not sounding because he/she shuts it off and ambulates about room unassisted, even though he/she has been reminded not to turn off the alarm because, it is for his/her safety and to ask for help when ambulating even with the walker.

Review of Resident #1’s Treatment Administration Record (TAR), dated [DATE] for the 3:00 P.M. to 11:00 P.M. shift, indicated (at the time of Resident #1 unwitnessed fall in his/her room) that there was no documentation to support Resident #1’s bed and or chair pad alarm was checked for placement and functioning. Surveyor #1 interviewed Nurse #1 at 2:52 P.M. on [DATE]. Nurse #1 said Resident #1 required alarms at all times when in bed or in the chair. Nurse #1 said Resident #1 was forgetful, liked to keep his/her door closed, would take his/her alarm off and hide the alarm in his/her room.

Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 2:03 P.M. on [DATE]. Nurse #2 said CNA’s check for placement and functioning of personal alarms for all Resident’s at the start of each shift. Nurse #2 said it is the Nurses responsibility to check placement of bed and chairs alarms and functioning at the start of each shift. Surveyor #1 interviewed Unit Manger #2 at 1:50 P.M. on [DATE]. Unit Manger #2 said Resident #1 had a chair pad alarm and she witnessed him/her disconnecting the alarm and placing the alarm in the draw. Unit Manger #2 said a resident would be able to reset the alarm themselves by pressing the alarm button 3 times and the alarm would automatically turn off. Unit Manger #2 said Resident #1 was able to figure out how to turn off his/her alarm and was able to reach it easily on his/her chair. Unit Manger #2 said Resident #1 liked his/her door closed for privacy and said it is hard to hear the alarm when the door was closed. Unit Manger #2 said she was unable to explain why Resident #1’s Plan of Care of personal alarms were not reevaluated.

Surveyor #2 interviewed the Former Medical Director at 6:00 P.M. on [DATE]. The Former Medical Director said he/she did not review the quality of care issues related to Resident #1 on [DATE] nor his/her past falls. The Former Medical Director said there was inadequate communication and inadequate staffing at the facility for the delivery of patient care.

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 1 of 5 sampled Residents (Resident #1), who was a Full Code (Facility to interceded if a patient’s heart stops beating or if the patient stops breathing), the Facility failed to meet the following;

-Failed to ensure a thorough Clinical assessment was performed when Resident #1 (Full Code) was found unresponsive in a prone position (face down) in a pool of blood for unknown length of time at approximately at 4:00 P.M. on [DATE]. -Failed to ensure a first responder certified in Cardiopulmonary Resuscitation (CPR, lifesaving technique to restore [MEDICATION NAME] blood flow to body organs when person stops breathing or heart stops breathing) stayed with Resident #1 and instructed another staff member to announce Code Blue (emergency response) over intercom system, gather emergency equipment and call 911 in accordance with Facility’s Emergency Procedure-Cardiopulmonary Resuscitation.

-Failed to assess Resident #1’s breathing pattern, heart rate, oxygen level, blood glucose level and blood pressure after Resident #1 was found unresponsive at approximately 4:00 P.M., and or prior to Emergency Medical Services (EMS) arrival to the Facility at 4:12 P.M. When EMS arrived Resident #1 was unresponsive with agonal respirations (abnormal breathing characterized by gasping labored breathing) and had a pulse. EMS applied a non-rebreather mask and oxygen to Resident #1 to assist with breathing. Resident #1’s blood glucose level was 20 mg/dl (normal adult range ,[DATE] mg/dl). During transport to the Hospital Resident #1 sustained a [MEDICAL CONDITION], CPR was initiated, Resident #1’s breathing and pulse were recovered on transport. -Resident #1 sustained, [MEDICATION NAME] fracture on sternal body, T11-T12 acute fracture (bottom part of the [MEDICATION NAME] spine-back), bilateral first rib fractures, right third and forth rib fractures, left second through fifth fractures and aspiration pneumonitis (lung disease develops after you inhale food, liquid or vomit into your lungs). -Resident #1 was transferred back to the facility on [DATE] on hospice care. Resident #1 died on [DATE] at 1:20 A.M.

Findings include:

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.

The Massachusetts Board of Registration in Nursing (BORN) issues this Advisory Ruling on nursing practice pursuant to Massachusetts General Laws (M.G.L.), chapter 30A, section 8, and chapter 112, section 80B, dated [DATE], the nurse licensed by the Massachusetts Board of Registration in Nursing (BORN) is expected to engage in the practice of nursing in accordance with accepted standards of practice. It is the Board’s current position that these standards, in the context of practice in a Massachusetts long-term care facility with 24-hour skilled nursing staff on duty, require the initiation of CPR when a patient or resident has experienced a [MEDICAL CONDITION] except when the patient or resident has a current, valid Do Not Resuscitate (DNR) order OR Signs of irreversible death.

In the absence of a DNR order and in the absence of signs of irreversible death, the nurse is required to initiate CPR when a patient or resident has a [MEDICAL CONDITION]. According to the American Heart Association Chain of Survival, dated 2015, survival chances decline with every minute that passes by ,[DATE]%, within ,[DATE] minutes brain damage and permanent death start to occur, and after 10 minutes few attempts at resuscitation succeed.

The Policy titled, Emergency Procedure-Cardiopulmonary Resuscitation, dated revised [DATE], indicated if a resident is found unresponsive and not breathing normally, (briefly assess for abnormal or absence of breathing) a licensed staff member who is certified in CPR/BLS shall initiate CPR, (if sudden [MEDICAL CONDITION] is likely) and the following: Instruct a staff member to activate the emergency response system (Code) and call 911; Instruct a staff member to retrieve the Automated External Defibrillators (AED); Verify or instruct a staff member to verify the code status of the individual and initiate the basic life support (BLS) (level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at the hospital) sequence of events. The Policy indicated personnel have completed training on the initiation of CPR and BLS, including defibrillation, for victims of sudden [MEDICAL CONDITION]. The Policy indicated training in BLS includes recognizing presentations of sudden [MEDICAL CONDITION] such as victims may initially have gasping respirations. The Policy indicated the Facility shall staff at least one licensed nurse with current CPR/BLS certification on each shift. The Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), dated [DATE], indicated Resident #1 was a Full Code (Facility to interceded if a patient’s heart stops beating or if the patient stops breathing). The MOLST indicated to attempt resuscitation, intubate and ventilate, use non-invasive ventilation (breathing mask to support breathing) and transfer to the hospital.

The Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1’s medical history included the following; Diabetes Mellitus ([MEDICATION NAME] unable to produce enough insulin), Arthritis (joint swelling), Dementia (memory disorder), Hypertension, repeated falls, and long term use of anticoagulants (blood thinners).

A Nurse Progress Note, dated [DATE], indicated Resident #1’s Family Member reported to Nurse #1 that Resident #1 was on the floor. The Note indicated, Nurse #1 entered Resident #1’s room and Resident #1 was lying face down on the floor with his/her head towards the bed, feet pointing to the door and he/she was bleeding from the head. The Note indicated Resident #1’s chair pad alarm was not sounding. The Note indicated Resident #1 was unresponsive, 911 was called and Resident #1 was not assessed until EMS arrived. The Note indicated Resident #1 was transferred to hospital and covering Physician was notified. Surveyor #1 interviewed Family Member #1 at 11:55 A.M. on [DATE]. Family Member #1 said she went to visit Resident #1 on [DATE] around 4:00 P.M., when she arrived to his/her room the door was closed and Resident #1 did not respond when she knocked on the door. Family Member #1 said she went into Resident’s #1 room, saw Resident #1 on the floor, face down with blood on his/her face, blood around his/her head on the floor, and sent another family member to get the nurse.

The Fire Department Report, dated [DATE] indicated, the Fire Department arrived at the Facility prior to EMS, found Resident #1 lying face down next to his/her bed, with a pool of dried blood around his/her head, and he/she was unresponsive with snoring respirations (sound due to an obstructed air movement during breathing). The Report indicated the Fire Department stabilized Resident #1’s cervical spine (held head) and rolled him/her onto his back and EMS arrived to assist.

The American Medical Response (AMR) Patient Care Report, dated [DATE], indicated the following:

-At 3:59 P.M. a call was received from the Facility indicating Resident #1 fell and was not alert.
-At 4:02 P.M. EMS was dispatched, arrived at the Facility at 4:09 P.M.
-At 4:12 P.M. EMS were with Resident #1, he/she was unresponsive with agonal respirations and had a pulse. EMS applied a non-rebreather mask and oxygen to Resident #1 to assist with breathing. Resident #1’s skin was cyanotic (bluish or purplish color) and clammy (cold, damp moisture) to the touch.
-At 4:14 P.M. EMS assessed Resident #1’s blood glucose level, reading indicated low at 20 mg/dl, and at this time arrival Advanced Life Support (ALS) arrived at bedside to assist with Resident #1’s care.
-At 4:15 P.M. EMS assessed Resident #1’s radial pulse at 80 (normal adult pulse range ,[DATE] beats per minute) and respiratory rate level of 6 (normal adult respiratory rate level of ,[DATE] breaths per minute) with agonal breathing continued. The EMS assessed Resident #1 who continued to be unresponsive to tactile and verbal stimuli.
-The EMS Report indicated, after ten minutes of chest compressions and treatments Resident

#1 regained strong radial and carotid pulses, prior to arrival to the hospital emergency room . Family Member #1 said Resident #1 was making snoring noises like he/she was sleeping. Family Member #1 said she stayed in Resident #1’s room until EMS arrived, and said facility nursing staff did not do any type of assessments on Resident #1 including; checking his/her blood pressure or blood glucose level, and did not apply oxygen. Family Member #1 said EMS assessed Resident #1 after they arrived at the facility. Surveyor #1 interviewed Nurse #1 at 2:52 P.M., on [DATE], and re-interviewed Nurse #1 at 3:05 P.M. on [DATE], with Surveyor #2. Nurse #1 said she went to check on Resident #1, found him/her face down on the floor, unresponsive, bleeding from his/her head, instructed CNA #1 to stay with Resident #1, and left the room to call 911. Nurse #1 said she called Nurse #2 to inform him that Resident #1 was on the floor and said she called the Physician. Nurse #1 said she only did a visual assessment of Resident #1 because she did not want to move him/her and said she knew Resident #1 was breathing because she watched Resident #1’s back rise and fall. Nurse #1 said she did not obtain Resident #1’s vital signs (heart rate, respirations, blood pressure, oxygen level or blood glucose level) because of the position Resident #1 was lying in, and said she did not want to move Resident #1 because she did not want to cause him/her any further injuries. Nurse #1 said because Resident #1 was bleeding from the head she was unable to give him/her breaths. Nurse #1 said she did not call a Code Blue since Resident #1 was already down and she did not need to know his/her code status since Resident #1 was not safe to turn over. Nurse #1 said she did not obtain Resident #1’s blood glucose level and said she did not apply oxygen.

Surveyor #1 interviewed Certified Nursing Assistant (CNA) #1 at 4:05 P.M. on [DATE]. CNA #1 said on [DATE] she was instructed to stay in the room with Resident #1 after a fall while Nurse #1 left the room to call 911. CNA #1 said she heard Resident #1 make gurgling noises and said Resident #1 started making snoring type noises prior to the EMS arrival. Surveyor #1 interviewed Nurse #2 at 5:40 P.M. on [DATE], and re-interviewed Nurse #2 at 2:03 P.M. on [DATE], with Surveyor #2. Nurse #2 said on [DATE] he went to assist Nurse #1 after she informed him Resident #1 was on the floor. Nurse #2 said he asked Nurse #1 about Resident #1’s vital signs and said Nurse #1 told him she did not do vital signs. Nurse #2 said he did not take Resident #1’s vital signs. Nurse #2 said he did not do an assessment or move Resident #1 because he felt it was not safe to move him/her and his job was to stay with Resident #1 to make sure Resident #1 stayed awake. Nurse #2 said Resident #1 was making a mumbling sound and said when he asked Resident #1 if he/she was okay, Resident #1 did not answer. Nurse #2 said he left CNA #1 with Resident #1 to let the EMS into the Facility.

Surveyor #1 interviewed Director of Nursing #1 (DON) at 12:53 A.M. on [DATE]. DON #1 said on [DATE] Nurse #2 informed her Resident #1 was found face down on the floor, unresponsive and was sent to the hospital. DON #1 said she does not know what type of assessments were done by nursing staff on Resident #1 after he/she was found on the floor. Surveyor #1 interviewed EMS Crew Member #1 at 10:20 A.M. on [DATE]. Crew Member #1 said upon arrival Resident #1 was unresponsive with agonal breathing and Resident #1 was turned from a prone position to recovery position (side) to open Resident #1’s airway. Crew Member #1 said Resident #1 had blood in his mouth, needed assistance with recovery position (maintaining spine precautions), suctioning to prevent Resident #1 from aspiration (liquid going into airway or lungs) was needed and blood was visibly seen on Resident #1 and on the floor. Crew Member #1 said Resident #1 had bruising on his/her forehead, face and skin tears. Crew Member #1 said he did not receive report from Nursing Staff. Crew Member #1 said the Facility did not obtain vital signs including oxygen level or a blood glucose level prior to arrival. Crew Member #1 said Resident #1’s Blood Glucose Level was 20 mg/dl, color of skin was pale/bluish, and Resident #1’s body skin was clammy to the touch.

Failed out 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 records reviewed and interviews, for 1 out of 5 sampled Residents (Resident #1), who was assessed at high risk for falls, the Facility failed to ensure that safety interventions in his/her plan of care were implemented by direct care staff. Resident #1’s plan of care was updated on [DATE] to include the use of personal alarms at all times. Although Resident #1 was known to remove his/her alarms and ambulate without assistance from staff, he/she experienced two falls from [DATE] to [DATE], and no alternative interventions were attempted. On [DATE], Resident #1 sustained an unwitnessed fall and was found face down, unresponsive on the floor with bleeding and it was determined Resident #1’s chair pad alarm was not in place or functioning at the time of the fall. -On [DATE] at approximately 4:00 P.M., Resident #1 was found on the floor, unresponsive by a family member, Resident #1 was transferred to the hospital where he/she was diagnosed [MEDICATION NAME] fracture on sternal body, T11-T12 acute fracture (bottom part of the [MEDICATION NAME] spine-back), bilateral first rib fractures, right third and forth rib fractures, left second through fifth fractures and aspiration pneumonitis (lung disease develops after you inhale food, liquid or vomit into your lungs). Resident #1 transferred back to the facility on [DATE] on hospice care. Resident #1 died on [DATE] at 1:20 A.M.

Findings include:

The Policy titled, Assessing Falls and Their Cause, dated [DATE], indicated identifying causes of a fall or fall risk includes the following; for each individual staff will distinguish the root cause of the fall, the Unit Manger or DON should consult with the attending Physician or Medical Director to confirm specific causes from multiple possibilities, the Physician will examine the resident or initiate testing to try to identify causes, if the cause is unknown but no additional evaluation is done, the Physician or nursing should note why, if the resident continues to fall despite attempted interventions the nursing staff will discuss the situation with the Physician or Medical Director.

The Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1’s medical history included the following; Diabetes Mellitus ([MEDICATION NAME] unable to produce enough insulin), Arthritis (joint swelling), Dementia (memory disorder), Ataxia (abnormalities of gait and mobility), muscle weakness, repeated falls, long term use of Anticoagulants (blood thinners). The MDS indicated Resident #1 Brief Interview for Mental Status (BIMS) Score was 12 out of 15 ( a score of ,[DATE] indicates cognitively intact and a score of 9 to 12 indicates moderate cognitive impairment). The MDS indicated Resident #1 was unsteady during transfers and walking and was only able to stabilize his/her balance with staff assistance.

A Fall Risk Assessment, dated [DATE], indicated Resident #1’s was scored as a moderate risk for falls. A Fall Risk Assessment, dated [DATE], indicated Resident #1’s was scored as a high risk of falls.

A Fall Risk Plan of Care, updated [DATE], indicated Resident #1’s required bed and chair pad alarm at all times and Resident #1 to wear non skid socks at night. A Fall Risk Plan of Care, updated [DATE], indicated additional safety interventions included Resident #1 required hands on assistance to move from place to place, he/she was confused and attempts to get up on his/her own, keep Resident #1 in activities as much as possible to provide a diversion to reduce risk of getting up unassisted and educate Resident #1 to always request assistance.

A Physician Order, dated [DATE], indicated Nursing to check placement and function of Resident #1’s bed and chair pad alarm every shift. A Nurse Progress Note, dated [DATE], indicated Resident #1’s alarm was not sounding because he/she shuts it off and ambulates about room unassisted, even though he/she has been reminded not to turn off the alarm because, it is for his/her safety and to ask for help when ambulating even with the walker.

An Occurrence Report, dated [DATE], indicated Resident #1’s call light was not sounding, call light was off and Resident #1 was last seen on [DATE] at 1:00 P.M. Review of Resident #1’s Treatment Administration Record (TAR), dated [DATE] for the 3:00 P.M. to 11:00 P.M. shift, indicated (at the time of Resident #1 unwitnessed fall in his/her room) there was no documentation to support Resident #1’s bed and or chair pad alarms was checked for placement and functioning.

The Hospital Discharge Summary, dated [DATE], indicated Resident #1’s readmission to Facility revealed rib fractures (bones in the rib cage cracks), [MEDICATION NAME] fracture on sternal body ([MEDICATION NAME] chest trauma), T11-T12 acute fracture (bottom part of the [MEDICATION NAME] spine-back) with widening concerning for hyperextension (extending of a limb or part beyond the normal limit) injury and aspiration pneumonitis (lung disease develops after you inhale food, liquid or vomit into your lungs). Surveyor #1 interviewed Nurse #1 at 2:52 P.M. on [DATE]. Nurse #1 said Resident #1 required alarms at all times when in bed or in the chair. Nurse #1 said was forgetful, liked to keep his/her door closed, would take his/her alarm off and hide the alarm in his/her room. Nurse #1 said if Resident #1’s alarm was found unattached, Nursing would replace the alarm. Nurse #1 said after staff left Resident #1 room he/she would take it off. Nurse #1 said because we knew Resident #1 could remove his/her alarms we would check on him/her more often. Nurse #1 said upon entering Resident #1’s room on [DATE] the alarm on the chair pad was not sounding and the alarm box was disconnected in the draw. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 2:03 P.M. on [DATE]. Nurse #2 said CNA’s check for placement and functioning of personal alarms for all Resident’s at the start of each shift. Nurse #2 said it is the Nurses responsibility to check placement of bed and chairs alarms and functioning at the start of each shift.

Surveyor #1 interviewed Unit Manger #2 at 1:50 P.M. on [DATE]. Unit Manger #2 said Resident #1 had a chair pad alarm and she witnessed him/her disconnecting the alarm and placing the alarm in the draw. Unit Manger #2 said a resident would be able to reset the alarm themselves by pressing the alarm button 3 times and the alarm would automatically turn off. Unit Manger #2 said Resident #1 was able to figure out how to turn off his/her alarm and was able to reach it easily on his/her chair. Unit Manger #2 said Resident #1 liked his/her door closed for privacy and said it is hard to hear the alarm when the door was closed. Unit Manger #2 said she was unable to explain why Resident #1’s Plan of Care of personal alarms were not re-evaluated.

Failed to provide necessary care and services to maintain the highest well being of each resident

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

Based on records reviewed and interviews for 1 of 5 sampled residents (Resident #1) identified as a Full Code (in the event of cardiac or [MEDICAL CONDITION]) and an insulin dependent diabetic, the Facility failed to accurately assess, failed to obtain a blood glucose level, failed to implement their Emergency Procedure-Cardiopulmonary Resuscitation (Code Blue) policy, failed to deliver oxygen via an appropriate delivery source, when on [DATE] Resident #1 was found down face first on the floor, bleeding from the head and was unresponsive to verbal and tactile stimuli. When the Fire Department arrived crew members found Resident #1 lying prone (face down) next to his/her bed, with a pool of dried blood around his/her head, and he/she was unresponsive with snoring respirations. The Fire Department stabilized Resident #1’s cervical spine, rolled Resident #1 onto his/her back, applied a cervical collar, and applied oxygen via a non-rebreather mask, at which point EMS arrived and assumed care. When Emergency Medical Services (EMS) Responders arrived crew members assessed Resident #1 as unresponsive with agonal respirations (abnormal breathing characterized by gasping labored breathing) and he/she had a pulse. EMS assisted Resident #1 with breathing via a bi-valve mask with 15 liters (LPM) per minute of oxygen. Nursing staff stated Resident #1 was a diabetic, blood glucose level indicated Resident #1 was hypoglycemic (low blood glucose) with a blood glucose level of 20 mg/dl (normal adult range ,[DATE] mg/dl). EMS noted Resident #1 had multiple lacerations, swelling and deformity to his/her face and left eye resulting from the fall. Advanced Life Support (ALS) crew arrived and took over care with EMS. When ALS Responders arrived crew members assessed Resident #1, [DIAGNOSES REDACTED] was confirmed, intravenous started with 12.5 milligrams (mg) of D50 ([MEDICATION NAME] 50%, used in emergency care to treat [DIAGNOSES REDACTED]), breathing pattern more sporadic, SPO2 (blood oxygen saturation level, normal range 94% to 99%) level in the low 90’s, Resident #1 went apneic (suspension of breathing), went into [MEDICAL CONDITION], cardiopulmonary resuscitation (CPR) initiated, Resident #1 was intubated (insertion of tube into the trachea (windpipe) for ventilation), after approximately 10 minutes of CPR Resident #1 was noted to have strong carotid and radial pulses and was transported to the Hospital Emergency Department. The Hospital Discharge Summary indicated Resident #1 sustained, [MEDICATION NAME] fracture on sternal body, T11-T12 acute fracture (bottom part of the [MEDICATION NAME] spine-back), bilateral first rib fractures, right third and forth rib fractures, left second through fifth fractures and aspiration pneumonitis (lung disease develops after you inhale food, liquid or vomit into your lungs). Resident #1 was transferred back to the facility on [DATE] on hospice care. Resident #1 died on [DATE] at 1:20 A.M.

Findings include:

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. The Massachusetts Board of Registration in Nursing (BORN) issues this Advisory Ruling on nursing practice pursuant to Massachusetts General Laws (M.G.L.), chapter 30A, section 8, and chapter 112, section 80B, dated [DATE], the nurse licensed by the Massachusetts Board of Registration in Nursing (BORN) is expected to engage in the practice of nursing in accordance with accepted standards of practice. It is the Board’s current position that these standards, in the context of practice in a Massachusetts long-term care facility with 24-hour skilled nursing staff on duty, require the initiation of CPR when a patient or resident has experienced a [MEDICAL CONDITION] except when the patient or resident has a current, valid Do Not Resuscitate (DNR) order OR Signs of irreversible death. In the absence of a DNR order and in the absence of signs of irreversible death, the nurse is required to initiate CPR when a patient or resident has a [MEDICAL CONDITION]. According to the American Heart Association Chain of Survival, dated 2015, survival chances decline with every minute that passes by ,[DATE]%, within ,[DATE] minutes brain damage and permanent death start to occur, and after 10 minutes few attempts at resuscitation succeed.

The Policy titled Emergency Procedure-Cardiopulmonary Resuscitation, dated revised [DATE], indicated if a resident is found unresponsive and not breathing normally, (briefly assess for abnormal or absence of breathing) a licensed staff member who is certified in CPR/BLS shall initiate CPR, (if sudden [MEDICAL CONDITION] is likely) and the following: Instruct a staff member to activate the emergency response system (Code) and call 911; Instruct a staff member to retrieve the Automated External Defibrillators (AED); Verify or instruct a staff member to verify the code status of the individual and initiate the basic life support (BLS) (level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at the hospital) sequence of events. The Policy indicated personnel have completed training on the initiation of CPR and BLS, including defibrillation, for victims of sudden [MEDICAL CONDITION]. The Policy indicates training in BLS includes recognizing presentations of sudden [MEDICAL CONDITION] such as victims may initially have gasping respirations. The Policy indicates the Facility shall staff at least one licensed nurse with current CPR/BLS certification on each shift. The Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), dated [DATE], indicated Resident #1 was a Full Code (Facility to interceded if a patient’s heart stops beating or if the patient stops breathing). The MOLST indicated to attempt resuscitation, intubate and ventilate, use non-invasive ventilation (breathing mask to support breathing) and transfer to the hospital.

The Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1’s medical history included the following; Diabetes Mellitus ([MEDICATION NAME] unable to produce enough insulin), Arthritis (joint swelling), Dementia (memory disorder), Ataxia (abnormalities of gait and mobility), muscle weakness, repeated falls, long term use of Anticoagulants (blood thinners). The MDS indicated Resident #1 Brief Interview for Mental Status (BIMS) Score was 12 out of 15 ( a score of ,[DATE] indicates cognitively intact and a score of 9 to 12 indicates moderate cognitive impairment). The Fire Department Report, dated [DATE] indicated, the Fire Department arrived at the Facility prior to EMS, found Resident #1 lying face down next to his/her bed, with a pool of dried blood around his/her head, and he/she unresponsive with snoring respirations (sound due to an obstructed air movement during breathing). The Report indicated the Fire Department stabilized Resident #1’s cervical spine (held head) and rolled him/her onto his back and EMS arrived to assist.

The American Medical Response (AMR) Patient Care Report, dated [DATE], indicated the following: -At 3:59 P.M. a call was received from the Facility indicating Resident #1 fell and was not alert.

-At 4:02 P.M. EMS was dispatched, arrived at the Facility at 4:09 P.M. -At 4:12 P.M. EMS were with Resident #1, he/she was unresponsive with agonal respirations and had a pulse. EMS applied a non-rebreather mask and oxygen to Resident #1 to assist with breathing. Resident #1’s skin was cyanotic (bluish or purplish color) and clammy (cold, damp moisture) to the touch.

-At 4:14 P.M. EMS assessed Resident #1’s blood glucose level, reading indicated low at 20 mg/dl , and at this time arrival Advanced Life Support (ALS) arrived at bedside to assist with Resident #1’s care. -At 4:15 P.M. EMS assessed Resident #1’s radial (feeling/hearing artery) pulse at 80 (normal adult pulse range ,[DATE] beats per minute) and respiratory rate level of 6 (normal adult respiratory rate level of ,[DATE] breaths per minute) with agonal breathing continued. The EMS assessed Resident #1 who continued to be unresponsive to tactile and verbal stimuli. -The EMS Report indicated, after ten minutes of chest compressions and treatments Resident #1 regained strong radial and carotid pulses (heartbeat), prior to arrival to the hospital emergency room .

A Nurse Progress Note, dated [DATE], indicated Resident #1’s Family Member reported to Nurse #1 that Resident #1 was on the floor. The Note indicated, Nurse #1 entered Resident #1’s room and Resident #1 was lying face down on the floor with his/her head towards the bed, feet pointing to the door and he/she was bleeding from the head. The Note indicated Resident #1’s chair pad alarm was not sounding. The Note indicated Resident #1 was unresponsive, 911 was called and Resident #1 was not assessed until EMS’s arrived due to possible potential head trauma to prevent further injuries. The Note indicated Resident #1 was transferred to hospital and covering Physician was notified.

Surveyor #1 interviewed Family Member #1 at 11:55 A.M. on [DATE]. Family Member #1 said she went to visit Resident #1 on [DATE] around 4:00 P.M., when she arrived to his/her room the door was closed and Resident #1 did not respond when she knocked on the door. Family Member #1 said she went into Resident’s #1 room, saw Resident #1 on the floor, face down with blood on his/her face, blood around his/her head on the floor, and sent another family member to get the nurse. Family Member #1 said Resident #1 was making snoring noises like he/she was sleeping. Family Member #1 said she stayed in Resident #1’s room until EMS arrived, and said facility nursing staff did not do any type of assessments on Resident #1 including; checking his/her blood pressure or blood glucose level, and did not apply oxygen. Family Member #1 said EMS assessed Resident #1 after they arrived at the facility.

Surveyor #1 interviewed Nurse #1 at 2:52 P.M., on [DATE], and re-interviewed Nurse #1 at 3:05 P.M. on [DATE], with Surveyor #2. Nurse #1 said she went to check on Resident #1, found him/her face down on the floor, unresponsive, bleeding from his/her head, instructed CNA #1 to stay with Resident #1, and left the room to call 911. Nurse #1 said she called Nurse #2 to inform him that Resident #1 was on the floor and said she called the Physician. Nurse #1 said she only did a visual assessment of Resident #1 because she did not want to move and said she knew Resident #1 was breathing because she watched Resident #1’s back rise and fall. Nurse #1 said she did not obtain Resident #1’s vital signs (heart rate, respirations, blood pressure, oxygen level or blood glucose level) because of the position Resident #1 was lying in, and said she did not want to move Resident #1 because she did not want to cause him her any further injuries. Nurse #1 said because Resident #1 was bleeding from the head she was unable to give him/her breaths. Nurse #1 said she did not call a Code Blue since Resident #1 was already down and she did not need to know his/her code status since Resident #1 was not safe to turn over.

Surveyor #1 interviewed Certified Nursing Assistant (CNA) #1 at 4:05 P.M. on [DATE]. CNA #1 said on [DATE] she was instructed to stay in the room with Resident #1 after a fall while Nurse #1 left the room to call 911. CNA #1 said she heard Resident #1 make a gurgling noises and said Resident #1 started making snoring type noises prior to the EMS’s arrival.

Surveyor #1 interviewed Nurse #2 at 5:40 P.M. on [DATE], and re-interviewed Nurse #2 at 2:03 P.M. on [DATE], with Surveyor #2. Nurse #2 said that on [DATE] he went to assist Nurse #1 after she informed him Resident #1 was on the floor. Nurse #2 said he asked Nurse #1 about Resident #1’s vital signs and said Nurse #1 told him she did not do vital signs. Nurse #2 said he did not take Resident #1’s vital signs. Nurse #2 said he did not do an assessment or move Resident #1 because he felt it was not safe to move him/her and his job was to stay with Resident #1 to make sure Resident #1 stayed awake. Nurse #2 said Resident #1 was making a mumbling sound and said when he asked Resident #1 if he/she was okay, Resident #1 did not answer. Nurse #2 said he left CNA #1 with Resident #1 to let the EMS into the Facility.

Surveyor #1 interviewed Director of Nursing #1 (DON) at 12:53 A.M. on [DATE]. DON #1 said on [DATE] Nurse #2 informed her Resident #1 was found face down on the floor, unresponsive and was sent to the hospital. DON #1 said she does not know what type of assessments were done by nursing staff on Resident #1 after he/she was found on the floor. Surveyor #1 interviewed EMS Crew Member #1 at 10:20 A.M. on [DATE]. Crew Member #1 said upon arrival Resident #1 was unresponsive with agonal breathing and Resident #1 was turned from a prone position to recovery position (side) to open Resident #1’s airway by Fire Crew Member. Crew Member #1 said Resident #1 had blood in his mouth, needed assistance with recovery position (maintaining spine precautions), suctioning to prevent Resident #1 from aspiration (liquid going into airway or lungs) was needed and blood was visibly seen on Resident #1 and on the floor. Crew Member #1 said Resident #1’s Blood Glucose Level was 20 mg/dl, color of skin was pale/bluish, and Resident #1’s body skin was clammy to the touch. Crew Member #1 said Resident #1 had bruising on his/her forehead, face and skin tears. Crew Member #1 said he did not receive report from Facility nursing staff and said the Facility did not obtain vital signs including oxygen level or a blood glucose level prior to their arrival.

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 5 sampled Residents (Resident #1), who received anticoagulation medication daily and was at increase risk for bleeding, the Facility failed to maintain his/her Resident safety, failed to ensure bed or chair alarms where in place and functioning correctly and as a result Resident #1 experience an unwitnessed fall, and was found unresponsive on the floor by a family member. Although Resident #1 was known to remove his/her alarms and ambulate without assistance from staff, he/she experienced two falls from [DATE] to [DATE], and no alternative interventions were attempted. -On [DATE] at approximately 4:00 P.M., Resident #1 was found face down on the floor of his/her room, bleeding from his/her head and unresponsive by a family member. Resident #1 was transferred to a hospital where he/she was diagnosed transverse fracture on sternal body, T11-T12 acute fracture (bottom part of the thoracic spine-back), bilateral first rib fractures, right third and forth rib fractures, left second through fifth fractures and aspiration pneumonitis (lung disease develops after you inhale food, liquid or vomit into your lungs). Resident #1 transferred back to the facility on [DATE] on hospice care. Resident #1 died on [DATE] at 1:20 A.M.

Findings include:

The Policy titled, Safety and Supervision of Resident’s, dated [DATE], indicated Facility-oriented approach to safety addresses safety and accident hazards for individual Residents. The Policy indicated the care team shall target interventions to reduce the potential for accidents as well as monitoring the effectiveness of interventions. The Policy indicated monitoring shall include ensuring interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed; and evaluating the effectiveness of new or revised interventions. The Policy titled, Assessing Falls and Their Cause, dated [DATE], indicated the following; if a resident has fallen nursing staff will record vitals and evaluate for possible injury and provide appropriate first aid, an incident report must be completed for resident falls and should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing (DON) no later than 24 hours after the fall occurs. The Policy indicated identifying causes of a fall or fall risk includes the following; for each individual staff will distinguish the root cause of the fall, the Unit Manger or DON should consult with the attending Physician or Medical Director to confirm specific causes from multiple possibilities, the Physician will examine the resident or initiate testing to try to identify causes, if the cause is unknown but no additional evaluation is done, the Physician or nursing should note why, if the resident continues to fall despite attempted interventions the nursing staff will discuss the situation with the Physician or Medical Director.

The Policy titled Fall Risk Assessment, dated [DATE], indicated nursing staff and the Physician will review the resident’s record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The policy indicated the staff will look for evidence of a possible link between the onset of falling or increasing in falling episodes. The Policy indicated the staff will seek to identify environmental factors that may contribute to falls. The Policy indicated for resident’s with reoccurring falls staff will implement additional or different interventions or indicate why the current approach remains relevant. The Policy indicated that staff will monitor and document each resident’s response to interventions intended to reduce falling or the risks of falling.

The Policy titled, Falls and Fall Risk Managing, dated [DATE], indicated if falls recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant and if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. The Policy indicated, as needed the attending Physician will help staff reconsider possible causes that may not previously have been identified. The Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1’s medical history included the following; Diabetes Mellitus (pancreases unable to produce enough insulin), Arthritis (joint swelling), Dementia (memory disorder), Ataxia (abnormalities of gait and mobility), muscle weakness, repeated falls, long term use of Anticoagulants (blood thinners). The MDS indicated Resident #1 Brief Interview for Mental Status (BIMS) Score was 12 out of 15 ( a score of ,[DATE] indicates cognitively intact and a score of 9 to 12 indicates moderate cognitive impairment). The MDS indicated Resident #1 was unsteady during transfers and walking and was only able to stabilize his/her balance with staff assistance. Review of Resident #1’s medical record indicated he/she experienced several falls in the Facility since his/her admission on [DATE]. Documentation indicated Resident #1 experienced a witnessed fall on [DATE]; and unwitnessed falls on [DATE]; [DATE]; [DATE] and [DATE]. The Occurrence Report, dated [DATE], indicated Resident #1 experienced a witness fall in the dining room, was found lying on his/her left side, Resident #1 sustained a skin tear below his/her left elbow, complained of a small amount of discomfort to the left elbow, and no other injuries were noted.

A Nurse’s Note at 4:35 P.M. on [DATE], indicated Resident #1 fell after eating breakfast, stood up and lost his/her balance and it was a witnessed fall. The Fall Risk Assessment, dated [DATE], indicated Resident #1 was at moderate risk for falls due to history of falls. An Occurrence Report, dated [DATE], indicated Resident #1 experienced an unwitnessed fall in his/her room, was found by a certified nursing assistant, sitting on the floor with his/her back near the chair and Resident #1 denied pain. Review of Resident #1’s medical record after the fall on [DATE], indicated Licensed Nursing staff did not complete all the documentation required per the Facility’s Fall Documentation Packet protocol and the Facility was unable to provide the Fall Documentation Packet and documentation to support Resident #1’s plan of care was reviewed for fall interventions. A Nurse Note, dated [DATE], indicated contributing factor to Resident #1’s fall included the soles of his/her slippers were noted to be worn, Resident #1 required assistance for ambulation and transfer and required reminders to use the call light for assistance. The Note indicated Resident #1 agreed to the use of Chair and bed pad alarms for safety A Falls At Risk Plan of Care, updated [DATE], indicated Resident #1’s required bed and chair pad alarms at all times. A Fall Risk Assessment, dated on [DATE], indicated Resident #1’s was at high risk of falls and additional triggers included uses short discontinuous steps and/or shuffling steps and decrease muscle coordination. A Physical Therapy (PT) Screen/Referral Form, dated on [DATE], indicated factors that contributed to Resident #1’s fall on [DATE] included, poor safety awareness, decline in ambulation and mobility status and cognitive decline.

Review of Resident #1’s medical record indicated he/she experienced an unwitnessed fall on [DATE], he/she was found on the floor in his/her room lying on his/her back, and Resident #1 stated he/she lost his/her balance. Review of Resident #1’s medical record after the fall on [DATE], indicated licensed nursing staff did not complete all the documentation required per the Facility’s Fall Documentation Packet protocol. The Facility was unable to provide the Fall Documentation Packet to support Resident #1’s plan of care was reviewed for fall interventions. A Nurse’s Note at 7:00 A.M. on [DATE], indicated Resident #1 was found sitting on the floor with his/her back against the bed at 12:30 A.M. and stated he/she was trying to go to the bathroom. The Nurse Note indicated Resident #1 did not have a bed alarm and the Nurse attached the bed alarm to Resident #1’s bed. A physician’s orders [REDACTED].#1’s bed and chair pad alarm where to be checked for placement and functioning every shift.

A Nurse’s Note, dated [DATE], indicated Resident #1 alarm was sounding , upon entering his/her room Resident #1 chair alarm was not sounding and it was determined that Resident #1 had disconnected the chair alarm. A Care Plan Meeting held in the Facility on [DATE], indicated Resident #1 and his/her family member where in attendance. The Care Plan meeting worksheet indicated family members expressed concerns Resident #1 was confused, but there was no indication that family members were informed Resident #1 was removing his/her bed or chair pad alarms. An Occurrence Report, dated [DATE], indicated Resident #1 experienced an unwitnessed fall in his/her room, was found on the floor in a face down bleeding from the head, and his/her chair pad alarm was not sounding. The Fire Department report, dated [DATE], indicated crew members arrived found Resident #1 lying prone (face down) next to his/her bed, with a pool of dried blood around his/her head, and he/she was unresponsive with snoring respirations. The Fire Department stabilized Resident #1’s cervical spine, rolled Resident #1 onto his/her back, applied a cervical collar, and applied oxygen via a non-rebreather mask, at which point EMS arrived and assumed care.

The Fall Review Assessment, dated [DATE], indicated Resident #1 remained at high risk for falls and additional triggers included he/she is confined to a chair and disoriented and exhibits loss of balance when standing. Review of Resident #1’s Treatment Administration Record (TAR), dated [DATE] for the 3:00 P.M. to 11:00 P.M. shift, indicated (at the time of Resident #1 unwitnessed fall in his/her room) that there was no documentation to support Resident #1’s bed and/or chair pad alarm was checked for placement and functioning. Review of Resident #1 medical record after the fall on [DATE], indicated Licensed Nursing staff did not complete all the documentation required per the Facility’s Fall Documentation Packet protocol and the Facility was unable to provide the Fall Documentation Packet.

Surveyor #1 interviewed CNA #4 at 12:14 P.M. on [DATE]. CNA #4 said Resident #1 did not like his/her alarm and staff would find him/her removing the alarm. CNA #4 said she would check on him/her more often. CNA #4 said the last time she saw Resident #1 on [DATE] was around 2:30 P.M. or 2:45 P.M. and Resident #1 was in his/her room sitting on the chair. Surveyor #1 interviewed CNA #5 at 1:10 P.M. on [DATE]. CNA #5 said the last time she saw Resident #1 on [DATE] was around 2:50 P.M. -3:00 P.M. or 3:15 P.M. and Resident #1 sitting on a chair in his/her room. Surveyor #1 interviewed Unit Manger #2 at 1:50 P.M. on [DATE]. Unit Manger #2 said Resident #1 had a chair pad alarm and she witnessed him/her disconnecting the alarm and placing the alarm in the draw. Unit Manger #2 said a resident would be able to reset the alarm themselves by pressing the alarm button 3 times and the alarm would automatically turn off. Unit Manger #2 said Resident #1 was able to figure out how to turn off his/her alarm and was able to reach it easily on his/her chair. Unit Manger #2 said Resident #1 liked his/her door closed for privacy and said it is hard to hear the alarm when the door was closed. Surveyor #1 interviewed Nurse #1 at 2:52 P.M. on [DATE]. Nurse #1 said Resident #1 was forgetful, would keep his/her door to their room closed, would take off his/her alarm off and hide the alarm in his/her room. Nurse #1 said on [DATE] at approximately 4:00 P.M., Family Member #1 informed her that Resident #1 was on the floor in his/her room, upon entering Resident #1’s room the alarm was not sounding, the pad was on the chair and the alarm was in the draw.

Surveyor #1 interviewed DON #1 at 12:53 P.M. on [DATE]. DON #1 said Resident #1 would walk without assistance from staff and wanted his/her door closed at all times. DON #1 said when interviewing staff about Resident #1’s incident on [DATE] a common theme was Resident #1 would unattached his/her bed alarm a lot. DON #1 said she was unaware if Resident #1 turning off his/her alarm and multiple falls were discussed during the daily A.M. meetings. DON #1 said she was unaware if any interventions were in place to ensure Resident #1’s safety. Surveyor #1 interviewed Family Member #1 at 9:42 A.M., on [DATE]. Family Member #1 said she had a meeting at the Facility a few days prior to the fall on [DATE]. Family Member #1 said Resident #1 was not steady on his feet and she expressed her concerns for Resident #1’s safety in the care plan meeting. Family Member #1 said she was unaware Resident #1 was able to disconnect his/her bed and chair alarms. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 2:03 P.M. on [DATE]. Nurse #2 said the nurses are responsible for completion of treatment orders for each resident, Resident #1’s alarms were checked off each shift by nursing on the TAR for placement, and if the nurse does not initial the TAR it indicates the Nurse did not acknowledge the Physician order [REDACTED].

Failed to make sure that doctors visit residents regularly, as required.

Make sure that doctors visit residents regularly, as required.

Findings include:

The Policy titled, Physician Visits, dated 3/2016, indicated the Attending Physician must make visits in accordance with applicable state and federal regulations. The Attending Physician must visit his/her patients at least once every 30 days for the first 90 days following the resident’s admission, and then at least every sixty (60) days thereafter. Resident #1 was admitted to the facility on [DATE], last seen by the Physician on 10/11/16, and not seen by the Physician for 60 days, prior to an emergent transfer to the hospital on [DATE]. Surveyor #2 interviewed the Regional Director of Clinical Operations at 9:15 A.M. on 4/24/17. The Regional Director of Clinical Operations said that Resident #1 was not visited every 30 days after he/she was admitted .

Failed to keep all essential equipment working safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the Facility failed to ensure that the emergency code carts located on 3 of 3 units were checked daily to ensure they were in working condition and readily available for immediate usage. The Facility failed to ensure the Automatic External Defibrillator (AED- a device that can identify an abnormal heart rhythm that needs a shock, which increases the chance of survival) on Unit 2 had a replacement battery.

Findings include:

The manufacturer’s guideline for Early Defibrillation Program, dated 2001, indicated the Automatic External Defibrillator (AED) equipment Sheet for each AED location shall include the following items; Heartsaver AED with battery installed, carrying case, spare battery, and defibrillator pads. The Policy, titled Emergency Procedure- Cardiopulmonary Resuscitation, dated 10/2016, indicated Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden [MEDICAL CONDITION]. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times.

1. Observations on Unit 2 at 8:00 A.M. on 4/24/17, the Emergency Equipment Check List, dated April 2017, indicated the AED documentation was circled from 4/2/17 through 4/24/17 (for 22 days there was no replacement battery for the AED). Surveyor #2 interviewed the Director of Nursing #2 (DON) at 8:05 A.M. on 4/24/17. DON #2 said she realized there was no replacement battery on 4/21/17 and ordered a new replacement battery for the the Automatic External Defibrillator (AED), which has not arrived yet.

2. Observations on Unit 2 at 7:30 A.M. on 4/24/17, indicated the code chart is to be checked daily on the 11:00 to 7:00 A.M. shift. The code cart in the small Dinning Room was not checked to ensure it was working and had the necessary equipment and supplies as follows;

January 2017 it was not checked for 15 days. February 2017 it was not checked for 9 days. March 2017 it was not checked for 8 days. April 2017 it was not checked for 9 days. ; Surveyor #2 interviewed Unit Manager #2 at 7:30 A.M. on 4/24/17. Unit Manger #2 said the code cart was not check daily as required. Observations on Unit 1 at 9:08 A.M., on 4/24/17, indicated the code chart was not checked to ensure it was working and had the necessary equipment and supplies as follows: January 2017 it was not checked for 7 days. February 2017 it was not checked for 3 days. March 2017 it was not checked for 1 days. April 2017 it was not check for 2 days. Surveyor #2 interviewed Unit Manager #1 at 9:08 A.M. on 4/24/17. Unit Manager #1 said the code was not checked daily. Observations on Unit 3 at 9:15 A.M. on 4/24/17, indicated the code chart was not checked to ensure it was working and had the necessary equipment and supplies as follows: February 2107 it was not checked one day. April 2017 it was not checked one day. Surveyor #2 interviewed Nurse #3 at 9:15 A.M. on 4/24/17. Nurse #3 said that the code cart was not checked daily.

Failed to train all employees on what to do in an emergency, and carry out announced staff drills.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews on 3 of 3 units, for 4 of the 4 Nurses (Unit Manager #1, Unit Manager #2, Nurse #1, Nurse #3) were not knowledgeable in the location of [MEDICATION NAME] (an emergency injectable medication for severe low blood sugar reactions **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews on 3 of 3 units, for 4 of the 4 Nurses (Unit Manager #1, Unit Manager #2, Nurse #1, Nurse #3) were not knowledgeable in the location of [MEDICATION NAME] (an emergency injectable medication for severe low blood sugar reactions

Findings include:

American Diabetes Association, ,[DATE] indicated that [DIAGNOSES REDACTED] is a condition characterized by abnormally low blood glucose (blood sugar) levels, usually less than 70 milligrams per deciliter. The only sure way to know whether a person is experiencing [DIAGNOSES REDACTED] is to check the blood sugar. Severe [DIAGNOSES REDACTED] has the potential to cause accidents, injuries, coma and death. [MEDICATION NAME] is a hormone that stimulates the liver to releases stored glucose (sugar) into the bloodstream when the blood glucose levels are too low. Injectable [MEDICATION NAME] is used to treat someone with diabetes that has become unconscious from a severe insulin reaction. The Policy, titled Emergency Procedure- Cardiopulmonary Resuscitation (CPR), indicated that the chances of surviving sudden [MEDICAL CONDITION] may be increased if CPR is intimated immediately upon collapse. Early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. Provide periodic Mock codes (simulations of an actual [MEDICAL CONDITION]) for training purposes.

1. Surveyor #2 interviewed Unit Manager #2 at 7:30 A.M. on [DATE]. Unit Manager #2 said that [MEDICATION NAME] (emergency injectable medication for severe low blood sugar), was in the medication cart and then said it was in the Medication Room on Unit 2, when she could not find it the medication cart or in the Medication Room. Unit Manager #2 then check a medication list and said it is on Unit 1 in the Medication Room. Surveyor #2 interviewed Unit Manager #1 at 8:45 A.M. on [DATE]. Unit Manager #1 said that [MEDICATION NAME] was in the medication cart, and then said it was in the Medication Room when she could not find the [MEDICATION NAME] on the medication cart. Unit Manager #1 then found the [MEDICATION NAME] in the Unit 1 Medication Room. Surveyor #2 interviewed Nurse #3 at 9:15 A.M. on [DATE]. Nurse #3 said that she could not find [MEDICATION NAME] on the Unit 3 medication cart, or in the Medication Room. Surveyor #2 interviewed Nurse #1 at 4:20 P.M. on [DATE]. Nurse #1 was recently assigned to take care of Resident #1 on [DATE] who had a severe low blood sugar reaction. When she was asked to find the [MEDICATION NAME] (an emergency medication for low blood sugar), she could not find it on the Unit 2 medication cart nor in the Medication Room, Nurse #1 attempted to find the [MEDICATION NAME] from 4:22 P.M. to 4:48 P.M. (6 minutes) without success. Nurse #1 was not aware [MEDICATION NAME] was stored in the Unit 1 Medication Room on the 1st floor. Nurse #1 said that the Facility did not educate her to the location of [MEDICATION NAME] (an emergency medication for low blood sugar), which would be beneficial to know in case a Resident had a low blood sugar reaction.

2. Review of 2 of 2 Nursing Educational Records (Nurse #1 and Nurse #2) indicated there was no mock code training sessions prior to Resident #1’s cardiopulmonary arrest on [DATE]. Surveyor #2 interviewed Nurse #1 (the first responder to Resident #1’s cardiopulmonary arrest on [DATE]) at 3:45 A.M. on [DATE]. Nurse #1 said that she did not have mock code training sessions during the 5 years she was employed by the Facility, and that her CPR card expired last month. Nurse #1’s cardiopulmonary certification card, dated ,[DATE], indicated it expired in ,[DATE]. The punch time card for Nurse #1 indicated that she had worked for 16 days after her CPR card expired. Surveyor #2 interviewed the Regional Director of Clinical Operations at 11:50 A.M. on [DATE]. The Regional Director of Clinical Operations said there were not records of mock code training during 2016 nor prior to 2016.

Failed to set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.

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

Based on records reviewed and interviews, the Facility failed to ensure Nurse #1 adequately assessed Resident #1, who sustained an acute fall with bleeding from his/her head and a decline in mental status, the Facility failed to ensure: Resident #1 had an adequate airway for breathing, assess vital signs (clinical measurements that indicate the state of a resident’s essential body function) and the blood sugar (the sugar that the bloodstream carries to all the cell in the body to supply energy, essential to all vital organs) prior to arrival of the Emergency Medical Service (EMS). Resident’s #1 was not assessed at the Facility for his/her treatment with oxygen, [MEDICATION NAME] or cardiopulmonary resuscitation, until EMS arrival (16 minutes after Resident #1 was found down on the floor).

Findings include:

The Policy titled, Quality Assurance Performance Improvement (QAPI), dated ,[DATE], indicated that the Facilities will implement and maintain an ongoing Quality Assurance Performance Improvement committee designed to monitor and evaluate the quality of resident care/services, pursue methods to improve quality care, proactively address areas of concern, and resolve identified problems. The QAPI Committee will identify trends, concerns, and areas of non-compliance in assigned reports. The Policy, titled Emergency Procedure- Cardiopulmonary Resuscitation, dated ,[DATE], indicated Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden [MEDICAL CONDITION]. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. The Facility failed to adequately evaluate the problems and areas of improvement with Resident #1’s [DIAGNOSES REDACTED] (abnormally low blood sugar less than 70 milligrams per deciliter, if Resident #1 was hypoxic (need to administer oxygen and open Resident #1’s airway, determine if respirations were adequate or agonal requiring cardiopulmonary resuscitation. The Facility failed to thoroughly investigate Resident #1’s acute severe hypoglycemic episode, agonal breathing and inadequate intervention with CPR and an Automatic External Defibrillator (AED- a device that can identify an abnormal heart rhythm that needs a shock, which increases the chance of survival). The Medical Director was not aware of Resident #1’s decline and was not given the opportunity to review Resident #1’s acute mental status change post fall, to evaluate the Facilities emergency care to improve Resident outcomes.

The Facility’s QAPI Committee minutes, dated [DATE] added Resident #1 to the falls report and recommended a Fall tool kit be developed to generally address all Residents with falls. The QAPI Committee failed to identify the lack of Nurse #1’s assessment skills and interventions in an emergency and the 16 minute delay in treatment with airway maintenance, oxygen, blood sugar and vital sign assessment for oxygen and or cardiopulmonary resuscitation. The Facility failed to have the Former Medical Director evaluate the quality of care delivered to Resident #1 on [DATE] and his/her falls prior to [DATE]. Surveyopr #2 interviewed the Former Medical Director at 6:00 P.M. on [DATE]. The Former Medical Director said he/she did not review the quality of care issues related to Resident #1 on [DATE] nor for any of his/her past falls. The Former Medical Director said there was inadequate communication and inadequate staffing at the facility for the delivery of patient care. The Facility failed to develop a Quality Improvement process to ensure (Nurse #1) had training with mock codes, experience to perform a respiratory and cardiac assessments, had the knowledge to know when to take vital signs and recognize a resident with a low blood sugar reaction and obtain a finger stick blood sugar, and could locate the [MEDICATION NAME] (an emergency injectable medication to treatment for [REDACTED]. The Facility failed to ensure on 3 of 3 units, 4 of 4 Nurses were knowledgeable in the location of [MEDICATION NAME] (an emergency injectable medication for severe low blood sugar reactions when a Resident is unresponsive or not able to swallow), for 12 of the 22 Residents with diabetes mellitus are insulin dependent. The Facility failed to ensure staff were competent and inserviced in the location of [MEDICATION NAME] an emergency low blood sugar medication. The Facility failed to have staff training and competencies with mock codes for 2 of 2 Nurses who were responsible for responding to Resident #1’s [MEDICAL CONDITION]. The Facility failed to ensure that the emergency code cart located on 3 of 3 units were checked daily to ensure they were in working condition and ready for immediate use. The Facility failed to ensure the Automatic External Defibrillator (AED- a device that can identify an abnormal heart rhythm that needs a shock, which increases the chance of survival) on Unit 2 had a replacement battery for administering a heart rhythm and shock. The Facility failed to monitor and adequately critique an emergency at the facility, i.e., not calling a code, delay in assessing Resident #1’s cardiac and respiratory status and initiating CPR, not following the American Heart Association guidelines for initiating Cardiopulmonary resuscitation with an Automatic Electrical Defibrillator (AED) – a device that can identify an abnormal heart rhythm that needs a shock, which increases the chance of survival in an unresponsive resident with agonal breathing (ineffective breathing).

Mont Marie Rehabilitation and Healthcare 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: January 22, 2018

Call Now Button