Nemasket Healthcare Center

Nemasket Healthcare Center

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Nemasket Healthcare Center? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About Nemasket Healthcare Center

Nemasket Healthcare CenterNemasket Healthcare Center is a for profit, 102 -bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Lakeville, Carver, Bridgewater, East Bridgewater, Plymouth, Kingston, Pembroke, Hanson, Somerset, Raynham, Taunton, Whitman, Wareham, Easton, Brockton, and the other towns in and surrounding Plymouth County, Massachusetts.

Nemasket Healthcare Center focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Nemasket Healthcare Center
314 Marion Road
Middleborough, MA 02346

Phone: 508) 947-8632
Website: http://www.whittierhealth.com/nursing_homes/nemasket.html

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, Nemasket Healthcare Center in Middleborough Massachusetts received a rating of 2 out of 5 stars.

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

Fines Against Nemasket Healthcare Center

The Federal Government fined Nemasket Healthcare Center $5,000 on July 12, 2016 and $3,941 on October 26, 2016 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Attorneys inspected government records and discovered Nemasket Healthcare Center committed the following offenses:

The nursing home was cited for a failure 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.

Based on interview and record review the Facility staff failed to ensure that an allegation of abuse was thoroughly investigated for one Non-sampled Resident (NS #1).

Findings include:

Resident #1 was admitted to the Facility in 01/2017 with [DIAGNOSES REDACTED]. Review of an Incident Report form submitted to the State Agency on 6/02/17 indicated Non-sampled Resident #1 had a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS), indicating a moderate impairment. The report indicated that NS #1 needs assistance of two staff members for transferring between surfaces and was completed dependent of one staff member for bathing, dressing and personal hygiene.

The Incident Report indicated that on 06/01/17 Resident #1 reported to the nurse that CNA #1, who assisted with transferring the Resident from a wheelchair to bed on 05/31/17, made him/her uncomfortable. Review of the investigation indicated that NS #1 reported to the nurse that CNA #1 makes him/her uncomfortable during personal care and reported CNA #1 walked in to the room during care and stared inappropriately. A statement given by the Resident to the House Manager on 06/01/17, said there was an incident when CNA #1 was assisting with a change of clothing and stated words to the effect of nice set, referring to NS #1’s breasts. The investigation conducted by the Director of Nurses and House Manager included staff statements.

A statement from CNA #1 indicated he assisted with transferring NS #1 on 05/31/17, but did not provide personal care. A statement from CNA #2 confirmed that CNA #1 left the room on 05/31/17 after assisting with transferring NS #1. The Director of Nurses (DON) and the Administrator were interviewed on 08/03/17 at 1:00 P.M. The DON said she was unsure if CNA #1 had provided personal care to NS #1 prior to 05/31/17 and had not asked CNA #1.

The Administrator said there were no other witness statements available as the roommate was confused. The DON said interviews were not conducted with other Residents who received care from CNA #1 because no one else had made any complaints.

The nursing home failed to provide care by qualified persons according to each resident's written plan of care.

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

Based on observation, record review and staff interviews, the Facility failed to follow the physician’s order and the written plan of care for air mattresses for the relief of pressure and comfort. For 3 sampled residents(#5, #10 and #13) identified with specialty air mattresses, the facility failed to calibrate the settings according to the manufacturer’s design and physician orders.

Findings include:

Review of the manufacturer’s manual instructions (12/2016) for the Low Air Loss and Alternating Pressure Mattress Replacement indicates that the system set up is designed to adjust the pressure settings according to the height and weight of the patients for comfort and the settings can be adjusted for seat inflation and air cycle times. 1. The facility failed to follow the medical plan of care for Resident #10 identified at risk for skin breakdown and to ensure comfort with proper settings with the use of specialty air mattress.

Resident #10 had been admitted to the facility in 6/2017 with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 6/2/17, indicated Resident #10 scored a 14 out of 15 on a Brief Interview of Mental Status, indicating the Resident was able to understand, be understood and had minimal difficulty with his/her memory. The MDS indicated the Resident required extensive assistance in transfers, dressing, bathing, was non ambulatory and experienced urinary and bowel incontinence, weight status at 167 pounds and height of 68 inches. The MDS noted the Resident had venous ulcers (2) and at risk for developing pressure ulcers.

Review of the medical record indicated that the Resident was admitted for rehabilitation with plans to return to community setting with services. During rehabilitation the Resident developed lower extremity [MEDICAL CONDITION] and was treated for [REDACTED]. Although the plan of care and facility protocol indicated heels are to be off loaded when in bed Resident #10 developed a blister on the left heel on 7/24/17. Due to worsening condition of the lower extremities, documented with green drainage and foul odor, the physician sent Resident #10 for acute evaluation and wound clinic on 7/27/17. The Resident returned on an antibiotic with wound consultation report dated 7/27/17, which indicated a Stage I and II on the sacral areas (coccyx and left inner gluteal fold) and left heel blister area.

Review of 2017 physician’s orders and plan of care indicated that Resident #10’s air mattress was to be set at 200 pounds with air rotation every 25 minutes and to elevate legs above heart except for meals, toileting and therapy.

Additional orders included turn Resident side to side every 2 hours, encourage intake, consider supplements and nutrition consult. Treatments ([MEDICATION NAME] and duoderm) to legs and sacrum affected areas. Unna boots mid foot to upper calf and change every other day, lift ankle off bed to protect heel. Interview with the West nurse manager 8/2/17 said that the stage areas were related to moisture associated excoriation and that the Resident made own choices and it was difficult to have the resident elevate legs. Observation on 8/2/17 at 4:30 P.M., Resident #10’s specialty mattress settings read 280 pounds and to run for 10 minute cycle rotation. During the morning at 7:55 A.M. on 8/3/17 the mattress settings read the same 280 pounds and for 10 minute cycle and not the settings identified in the physician’s order, or the 7/2017 and 8/2017 treatment sheets for nursing to monitor.

Further interview with the West unit manager on 8/3/17 at 12:45 P.M. regarding the discrepancy with the physician’s orders for the specialty mattress settings, the unit manager said that maintenance sets up the air mattress, but had no response why the treatment sheets noted by the nurse did not identify any discrepancy. 2. For Resident #13, the facility failed to follow the medical plan of care for potential skin breakdown and to ensure comfort with the proper settings for use of specialty air mattress.

Resident #13 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/2/17, indicated Resident #13 scored a 12 out of 15 on his Brief Interview of Mental Status, indicating the Resident was able to understand, be understood and had minimal difficulty with his/her memory. The MDS indicated the Resident required limited assistance with transfers, dressing, and bathing. The MDS indicated the resident was ambulatory, continent, with weight status at 93 pounds and height of 64 inches.

Resident #13 was observed in his/her room on 8/3/17 at 10:00 A.M. The Resident’s air mattress settings was observed and read 160 pounds and to alternate air flow for 25 minutes. During interview, the Resident stated that he/she does not like the bed, as it is too firm.

Review of the medical record indicated that Resident #13 had an area on left heel on 7/20/17. Review of the 8/2017 treatment sheets identified Resident #13 with redness on buttocks. Further review of the 8/2017 treatment administration record indicated that the air mattress settings was listed at 200 pounds with air change flow at 25 minutes. During interview on 8/3/17 at 12:40 P.M., as the Certified Nurse Aide #3 transported resident #13 from the dining area said that she did not know about the bed settings but maintenance staff would know.

At 1:30 P.M., the assistant maintenance director was interviewed regarding the air mattress settings and saw that the bed was set at 160 pounds and said that the setting had not been locked out so that it could not be changed. Follow-up with the Nurse #1 stated that the 200 pounds setting was incorrect. 3. For Resident #5, the facility failed to follow the medical plan of care for skin breakdown and to ensure comfort with proper settings for specialty air mattress. Resident #5 had been admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. A readmission Minimum Data Set (MDS) assessment, dated 6/26/17, indicated Resident #5 scored a 13 out of 15 on his Brief Interview of Mental Status, indicating the Resident was able to understand, make decisions and had minimal difficulty with his/her memory. The MDS indicated the Resident required extensive assistance in transfers, dressing, bathing, was non ambulatory and experienced bowel incontinence, weight status at 181 pounds and height of 71 inches. The MDS noted the Resident was at risk for developing pressure ulcers. Resident #5 had a specialty mattress in place.

Review of 8/2017 physician’s orders and treatment records indicated that Resident #5’s air mattress was to be set at 200 pounds with air rotation every 25 minutes. Observation on 8/2/17 during breakfast observation at 8:35 A.M., Resident #5’s specialty mattress settings read 280 pounds and to run for 10 minute cycle rotation. On 8/3/17 at 12:00 P.M. the mattress settings read the same 280 pounds and for 10 minute cycle and not the settings identified in the physician’s order, or the 7/2017 and 8/2017 treatment sheets for nursing to monitor.

Record review indicted that Resident #5 had a significant weight loss (over 8 % in one month) due to poor appetite, refusal of additional food and chronic infection. Weight documentation reviewed on 8/3/17 indicated the Resident weighed 158.3 pounds. Further interview with the West unit manager on 8/3/17 at 12:45 P.M. regarding the discrepancy with the physician’s orders for the specialty mattress settings, the unit manager said that maintenance sets up the air mattress, but had no response why the treatment sheets noted by the nurse did not identify any discrepancy.

The nursing home facility failed to ensure that residents are safe from serious medication errors.

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

Based on records reviewed and interviews, for 1 of 3 sampled Residents (Resident #1), the Facility failed to ensure he/she received only the medications as ordered by the physician. On 8/1/16, Nurse #3 poured Resident #2’s medications and went into Resident #1’s room and administered the medications to Resident #1. Resident #1 experienced a significant change in medical condition and required hospitalization and admission for symptomatic [MEDICAL CONDITION] (low heart rate), symptomatic [MEDICAL CONDITION] (low blood pressure), and beta blocker toxicity (low blood pressure) due to medication error.

Findings include:

The Facility’s Policy and Procedure, titled Medication Administration General Guidelines’, dated 3/3/09, indicated medications are administered in accordance with written orders of the attending physician; residents are identified before medication is administered by checking identification band, checking photograph attached to medical record, calling resident by name and if necessary, verifying resident identification with other facility personnel.

Resident #1’s [DIAGNOSES REDACTED]. Resident #1’s Minimum Data Set (MDS), dated [DATE], indicated his/her Brief Interview for Mental Status (BIMS) score was 8 (score range 00-15), which indicates moderate cognitive impairment.

A Medication Error Occurrence Report, dated 8/10/16, indicated Resident #1 received another resident’s medication, om error at 11:15 P.M. An Incident Investigation Occurrence Witness Statement, dated 8/11/16 and documented as signed by Nurse #3, indicated Nurse #3 administered Resident #2’s medication to Resident #1. Nurse #3 documented that she administered medications to the wrong patient and did not use the 5 rights of medication administration to identify patient.

A Situation Background Assessment Request (SBAR) Progress Note, dated 8/11/16, indicated Resident #1 received another resident’s medication, in error, which included: -Atorvastatin 10 milligrams ( a medication used to lower cholesterol) -[MEDICATION NAME] 12.5 mg (a beta blocker medication used to treat high blood pressure) -Vitamin C 500 mg (a vitamin) -Tylenol 1000 mg (a pain reliever) -[MEDICATION NAME] 0.25 mg (a medication used for anxiety) -[MEDICATION NAME] 50 mg (used to treat moderate to severe pain) -Calcium 500 mg (a mineral supplement) -[MEDICATION NAME] 30 mg (a calcium-channel blocker used to treat high blood pressure and chest pain) -[MEDICATION NAME] 7.5 mg (an antidepressant use to treat depression) -Trazadone 37.5 mg (an antidepressant used to treat [MEDICAL CONDITION].

The SBAR Progress Note indicated Resident #1 was difficult to arouse, unable to answer questions, pulse was 56 and respirations were 12. The SBAR Progress Note indicated Resident #1 was transferred to the hospital for evaluation. The Surveyor interviewed Nurse #3 at 3:07 P.M. on 10/31/16. Nurse #3 said she went into the wrong resident room, administered the wrong medications to Resident #1 and failed to identify Resident #1 prior to administering his/her medications on 8/10/16. The Surveyor interviewed the DON at 9:00 A.M. on 10/26/16 and throughout the day. The DON said it is her expectation, Facility policy and a minimum standard of practice that nurses positively identify the resident prior to the administration of any medication.

The Hospital Discharge Summary, dated 8/12/16, indicated Resident #1’s discharge [DIAGNOSES REDACTED]. Resident #1 received intravenous (administered directly into a vein) fluids for his/her low blood pressure and heart rate and was given [MEDICATION NAME] 5 mg IM (a medication given into the muscle to treat symptomatic [MEDICAL CONDITION] secondary to a beta blocker overdose). Resident #1 was also extremely somnolent with pinpoint pupils and was given a dose of [MEDICATION NAME] (a medication used to treat opiod overdose). On 10/26/16, the Facility was found to be in past noncompliance. In response to the incident the Facility took the following corrective action:

A) The Agency Nurse who made the medication error no longer works at the Facility.

B) A Facility wide audit was completed on 8/15/16 on all Medication Administration Records (MAR) to ensure accuracy and completeness of the MAR.

C) An in-service education on Medication Administration was completed on 8/16/16 for all Licensed staff. Proper medication administration including the six standards of medication administration was reviewed.

D) All agency Nurses will complete a Medication Administration test and Evaluation during their first shift in the Facility.

E) Weekly audits were conducted by the Nurse Manager to monitor for proper procedure during medication administration and documentation of the MAR.

F) The Director of Nurses will be responsible for ensuring on-going audits and present the findings to the Quarterly Performance Improvement Committee for 3 quarters.

G) A Quarterly Performance Improvement Committee Meeting was held on 10/14/16 with the Medical Director present and the results of the audits were reported to the Committee.

H) The Quarterly Performance Improvement Committee will continue to review findings with additional measures to be implemented as needed.

Nemasket Healthcare Center, Nursing Home Neglect and Elder Abuse Lawyers Serving the South Shore and all Plymouth County

If someone you love has suffered neglect or elder abuse by a senior caregiver, nursing home, or other care facility, our lawyers may be able to help. Regardless of whether or not criminal charges are filed against an alleged abuser, you may still be able to pursue compensation in a civil claim. Compensation in elder abuse cases may be awarded if someone in the care of another suffers harm due to intentional or negligent actions (including failure to take action).

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation. Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

Oftentimes, victims of abuse either cannot or will not speak up for themselves out of fear. If you notice any warning signs or symptoms of neglect of abuse an an elderly person, it is important you contact an elder abuse lawyer immediately. Not only are there statute of limitations on filing a claim, but the sooner we start helping you, the easier it will be to collect evidence and talk to any witnesses before important details are lost, hidden, or forgotten.

 

Boston Personal Injury Lawyers for Elder Abuse Cases

We offer a free, no-obligation legal consultation to help you understand your rights and the value of your case. Our personal injury law firm takes cases involving elder abuse and neglect. We offer legal service to clients in Massachusetts, Rhode Island and New Hampshire.


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Page Last Updated: September 27, 2017

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