Quabbin Valley Healthcare

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Quabbin Valley Healthcare? 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 Quabbin Valley Healthcare

Quabbin Valley Healthcare is a for profit, 142-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Athol, Gardner, Winchendon, Fitchburg, Ware,  Amherst,  Holden, Greenfield, and the other towns in and surrounding Worcester County, Massachusetts.

Quabbin Valley Healthcare
821 Daniel Shays Hwy
Athol, MA 01331

Phone: (978) 249-3717
Website: www.quabbinvalleyhealthcare.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, Quabbin Valley Healthcare in Athol, Massachusetts received a rating of 4 out of 5 stars.

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

Fines Against Quabbin Valley Healthcare

The Federal Government fined Quabbin Valley Healthcare $2,500 on January 14th, 2016 for health and safety violations.

Fines and Penalties

Our Nursing Home Abuse Lawyers inspected government records and discovered Quabbin Valley Healthcare committed the following offenses:

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 record review, observation and interviews, the facility failed to follow the plan of care for one resident (#20) who received [MEDICAL TREATMENT], out of a total sample of 24 residents.

Findings include:

For Resident #20, the facility failed to administer the following:
a. Misoprostol 200 mcg (micrograms) tab,
b. Sevelamer [MEDICATION NAME] 800 mg (milligrams) tab,
c. [MEDICATION NAME] 24 hr, extended release 240 mg tab,
d. [MEDICATION NAME] sodium extended release 250 mg tab, as ordered by the physician, while the resident was out of the facility at [MEDICAL TREATMENT].

Resident #20 was admitted in 10/2010 and had a [DIAGNOSES REDACTED]. Record review indicated the Resident was scheduled for [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday every week.

a. The current physician’s orders [REDACTED].M., 12:00 P.M., 4:00 P.M., and 8:00 P.M., including the days the resident was out of the facility at [MEDICAL TREATMENT]. Review of the Medication Administration Record [REDACTED].M. dose of Misoprostol 200 mcg was not given for 10 out of 22 days, while the resident was out of the facility at [MEDICAL TREATMENT].

b. The current physician’s orders [REDACTED].M., 12;00 P.M., and 5:00 P.M., including the days the resident was out of the facility at [MEDICAL TREATMENT]. Review of the MAR, for 8/2017, indicated Sevelamer [MEDICATION NAME] 800 mg, 2 tabs was not given for 10 out of 22 days, while the resident was out of the facility at [MEDICAL TREATMENT].

c. The current physician’s orders [REDACTED].M., daily. Review of the MAR for 8/2017, indicated [MEDICATION NAME] 24 hour, extended release, 240 mg capsule was not given for 1 of 22 days, when the resident was out of the facility at [MEDICAL TREATMENT].

d. The current physician’s orders [REDACTED].M., 2:00 P.M., and 8:00 P.M. Review of the MAR for 8/2017 indicated the 2:00 P.M. dose of [MEDICATION NAME] Sodium, extended release, 250 mg tab was not given for 8 out of 22 days, when the resident was out of the facility at [MEDICAL TREATMENT].

Observation, on 8/22/17 at 8:30 A.M., found the resident lying in bed, with the head of the bed elevated. Resident #20 accepted the morning medications and said that he/she was not feeling well and did not want to go to [MEDICAL TREATMENT]. After encouraging conversation by Nurse #1, the resident agreed to go to [MEDICAL TREATMENT].

During an interview, on 8/23/17 at 11:03 A.M., Resident #20 said that he/she goes to [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. Resident #20 said that he/she does not take any medication to [MEDICAL TREATMENT] when he/she goes, only a bagged lunch. During an interview, on 8/23/17 at 12:55 P.M., Nurse #1 said that Resident #20 does not take any medications to [MEDICAL TREATMENT] and does not get the ordered medications when he/she is out of the facility at [MEDICAL TREATMENT]. Nurse #1 said that the [MEDICAL TREATMENT] times were recently changed, but the medication times were not. During an interview, on 8/23/17 at 1:35 P.M., Unit Manager #1 said that the physician would be notified to have the medication times adjusted to the [MEDICAL TREATMENT] schedule.

Failed to give each resident enough fluids to keep them healthy and prevent dehydration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that one resident (#22) received sufficient fluid intake to maintain hydration, in a total sample of 24 residents.

Findings include:

Resident #22 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment, with an Assessment Reference Date of 7/17/17, indicated a Brief Interview for Mental Status score of 7/15 (severe cognitive impairment). The resident exhibited verbal and physical behavior 4 to 6 days a week, required assist with eating and was not dehydrated.

Review of the 8/6/17 Intake and Output (I and O) Daily Worksheet indicated that fluid intake was not recorded for all 3 shifts. The resident voided once on the 11:00 P.M. to 7:00 A.M. shift, once on the 7:00 A.M. to 3:00 P.M. shift, and the 3:00 P.M. to 11:00 P.M. shift was left blank.

Review of Progress notes, of 8/6/17 at 9:39 A.M., indicated that the resident was unable to stand or bear weight., had increased confusion and was difficult to redirect. Review of the 8/7/17 I and O Worksheet indicated that fluid intake was not recorded for all 3 shifts. The resident voided 275 cubic centimeters (cc) on the 11:00 P.M. to 7:00 A.M. shift, was incontinent twice on the 7:00 A.M. to 3:00 P.M. shift, and the 3:00 P.M. to 11:00 P.M. shift was left blank.

Review of Progress notes, of 8/8/17 at 5:00 A.M., indicated that the resident voided 125 cc of dark yellow urine. Continued on Intake and Output. Review of the 8/8/17 I and O Worksheet indicated that the resident consumed a total of 960 cc of fluid. The resident voided 125 cc on the 11:00 P.M. to 7:00 A.M. shift, was incontinent twice on the 7:00 A.M. to 3:00 P.M. shift, and was incontinent once on the 3:00 P.M. to 11:00 P.M. shift.

Review of the 8/9/17 I and O Worksheet indicated that the resident had no fluid intake and voided once on the 11:00 P.M. to 7:00 A.M. shift. The resident consumed 60 cc of fluid and no output was recorded on the 7:00 A.M. to 3:00 P.M. shift. Review of Progress notes, of 8/9/17 at 9:45 A.M., indicated that the resident went out to a neurology appointment. The neurologist called the facility to inform them that the resident was sent to the emergency room due to a change in mental status. Review of the 8/9/17 hospital history and physical indicated the following blood work: a Blood Urea Nitrogen (BUN) of 113 (normal range 7 to 23), a Creatinine of 2.52 (normal range 0.6 to 1.3), a Calcium of 11.4 (normal range 8.7 to 10.7) and a Sodium of 149 (normal range 135 to 145). Family provided history and stated that since (8/4/17), they noticed a drastic decline in resident’s functioning and increased agitation.

Assessment/Plan: Presented with acute on chronic mental status change with worsening hallucination and lethargy. Multiple factors probably contributing: Dehydration, acute kidney injury (in the setting of no [MEDICAL CONDITION]), uremia, hypercalcemia, [MEDICAL CONDITION] and [MEDICAL CONDITION]. CT scan was negative for [MEDICAL CONDITION]. On exam appeared significantly dehydrated. The resident received 4 liters of normal saline intravenously for rehydration, and then changed to [MEDICATION NAME] (D) 5 and 1/2 Normal Saline (NS). A nasogastric tube was inserted on 8/12/17, and the resident was given free water and nutrition.

Review of the Nurse Practitioner’s (NP) progress note (of 8/11/17) indicated that a family meeting was held. The resident was still in the hospital but anticipating return to the facility. The NP note indicated that the cause of the resident’s altered activity appeared [MEDICAL CONDITION], and it was determined that it was caused by severe dehydration. The resident was hospitalized for [REDACTED]. Review of Progress Notes indicated that the resident was discharged to the hospital on [DATE].

During an interview, on 8/24/17 at 10:45 A.M., Unit Manager (UM) #3 said that she wasn’t sure why I and O was initiated, because she had been off for 2 weeks. UM #3 said that the nurses were responsible on each shift to monitor for adequate intake and output. UM #3 said that the I and Os were incomplete. UM #3 said that she did not monitor the I and Os, but she would be monitoring them now.

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

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

Based on observation, record review and interview, the facility failed to ensure that 1 resident (#14) received the proper treatment and care of bilateral nephrostomy tubes in accordance with professional standards of practice, in a total sample of 24 residents.

Findings include:

Resident #14 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The facility’s Nephrostomy Tube Care policy/procedure, dated 6/1/12, included the following:

Equipment For Dressing Change:
*sterile gloves
*clean gloves
*2 sterile 4 by 4 (4 inch by 4 inch gauze square) dressings
*sterile normal saline
*sterile split dressing
*tape

Procedure:
24. Put on sterile gloves.
25. Wash skin surrounding tube with normal saline.
27. Place split dressing over entrance site.
29. Tape tube with tension loop.

According to the National Institute of Health Clinical Center, Caring for Your Percutaneous Nephrostomy Tube: *Secure the nephrostomy drainage bag to calf, thigh or waist with safety pins or straps. The admission Minimum Data Set assessment, with an Assessment Reference Date of 7/12/17, indicated a Brief Interview for Mental Status score of 6/15 (severe cognitive loss). The resident required assist with transfers, wheelchair mobility, bathing, dressing, hygiene and toilet use. The resident was incontinent of bowel and had an indwelling catheter.

Review of the 7/2017 physician’s orders [REDACTED]. Review of the 7/25/17 Interim physician’s orders [REDACTED]. Review of Progress Notes indicated that on 8/8/17, the right nephrostomy came out. On 8/22/17 at 1:15 P.M., the following treatment procedure was observed with Unit Manager (UM) #2: The nephrostomy tube drainage bag was removed from the indwelling catheter privacy bag hanging from the back of the lower portion of the wheelchair (the nephrostomy tube drainage bag was not secured to the resident’s thigh, calf or waist). Resident #14 was transferred from a wheelchair to the bed. Nurse #2 cleansed hands, donned clean gloves, removed the old dressing and discarded. The left nephrostomy tube was noted to have a suture that had become detached from the skin surrounding the tube insertion site and was approximately 1 inch above the insertion site. Nurse #2 cleansed hands, donned clean gloves (did not use sterile gloves per policy), cleansed the nephrostomy tube site with sterile saline and clean 4 by 4’s (did not use sterile 4 by 4’s per policy). Nurse #2 covered the site with a sterile 4 by 4 (did not apply a sterile split dressing per

policy). Nurse #2 secured the dressing with tape (did not tape the tube with a tension loop per policy). During an interview, on 8/23/17 at 8:30 A.M., the Surveyor asked UM #2 for the facility’s policy/procedure for Nephrostomy Tube Dressing Change. UM #2 provided the Surveyor with the policy/procedure for Clean Dressing Change. UM #2 said that was the procedure the nurses were following.

During an interview, on 8/23/17 at 9:15 A.M., Nurse #2 said that she had obtained the physician’s orders [REDACTED]. Nurse #2 said that she was not aware that the dressing should be sterile and that sterile gloves should be used. Nurse #2 said that she had never cared for a nephrostomy tube before, and the facility had not provided her with any instruction.

During an interview, on 8/23/17 at 9:30 A.M., the Director of Nurses said that the facility provided the nurses with education and competency testing, but the care of nephrostomy tubes was missed.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow proper infection control practices for the prevention and spread of infection for 1 resident (#14), in a total sample of 24 residents.

Findings include:

For Resident #14, the facility failed to ensure that the indwelling catheter bag and tubing were kept off the floor.

Resident #14 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment, with an Assessment Reference Date of 7/12/17, indicated a Brief Interview for Mental Status score of 6/15 (severe cognitive loss). The resident required assist with transfers, wheelchair mobility, bathing, dressing, hygiene and toilet use. The resident was incontinent of bowel and had an indwelling catheter. The 7/2017 physician’s orders [REDACTED].#16 with a 10 cubic centimeter balloon. Observation, on 8/21/17 at 3:00 P.M., found Resident #14 sitting in a wheelchair in his/her bedroom. The indwelling catheter bag was inside a privacy bag attached to the lower half of the wheelchair back. The indwelling catheter tubing was laying on the floor.

Observation, on 8/22/17 at 7:35 A.M., 8:40 A.M., 8:50 A.M., 9:00 A.M., 11:30 A.M. and 1:00 P.M., found Resident #14 sitting in a wheelchair in the unit dining room. The indwelling catheter bag was inside a privacy bag attached to the lower half of the wheelchair back. The indwelling catheter tubing was laying on the floor.

Observation, on 8/22/17 at 1:15 P.M., found Resident #14 sitting in a wheelchair in the bedroom. The indwelling catheter bag was inside a privacy bag attached to the lower half of the wheelchair back. The indwelling catheter tubing was laying on the floor. Certified Nursing Assistant (CNA) #1 removed the indwelling catheter bag from the privacy bag. CNA #1 put the indwelling catheter bag on the floor, and then shoved it under the wheelchair to the front of the wheelchair. CNA #1 left the indwelling catheter bag and tubing on the floor, until Resident #14 was transferred into bed. During an interview, on 8/23/17 at 2:00 P.M., the Staff Development Nurse said that the indwelling catheter bag and tubing should be off the floor at all times. The Staff Development Nurse said that she would inservice the staff.

Failed to provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Based on interview and document review, the facility failed to ensure 15 resident bedrooms measured the required square footage of 80 square feet per resident in a multi-bed room.

Findings include:

During the entrance conference on 8/21/17 at 10:05 A.M., the Administrator provided a copy of the waiver, dated 7/22/16, related to the required square footage of resident bedrooms. Review of this waiver indicated that rooms 101, 102, 103, 104, 105, 107, 118, 119, 120, 121, 122, 124, 125, 126, and 128 measured 75 square feet per resident, rather than 80 square feet. The Administrator said there had been no changes since the last recertification survey, and she intended to apply for a new waiver.

At the time of the survey, the size of the rooms did not compromise the health and safety of the residents residing in the bedrooms.

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 records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the facility failed to follow Resident #1’s plan of care for two assist with bed mobility when CNA #1 rolled Resident #1 in bed, without assistance, and Resident #1 began to slide out of bed and had to be lowered to the floor.

Findings include:

The Admission Record [DIAGNOSES REDACTED].#1’s [DIAGNOSES REDACTED]. The Certified Nursing Assistant (CNA) Activities of Daily Living (ADL) Care Card, updated on 11/6/15, indicated Resident #1 was total dependence with a 2 person physical assist for bed mobility.

The Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was total dependence with a 2 person physical assist for bed mobility. The Resident Care Plan for ADL’s/Mobility, date initiated 11/22/16, indicated Resident #1 was dependent with a 2 person assist for mobility.

An Accident/Incident Report, dated 1/6/17, indicated Resident #1 was on the floor, against the wall, across from the bed, with no signs or symptoms of pain or injury. The Report indicated CNA #1 rolled Resident #1 over in bed without assistance and Resident #1 rolled out of bed and CNA #1 guided him/her to the floor. A Progress Note, dated 1/7/17, indicated on 1/6/17 Resident #1 was found on the floor sitting across from bed against the wall with no injuries or signs and symptoms of pain noted.

The Surveyor interviewed CNA #1 at 12:21 P.M. on 2/17/17. CNA #1 said while she provided care to Resident #1, she went to roll Resident #1 over in bed without assistance and Resident #1’s legs started to fall off the bed and she had to lower Resident #1 to the floor. CNA #1 said she was not aware Resident #1 was a 2 person assist with bed mobility and that she did not review Resident #1’s plan of care prior to providing care. The Surveyor interviewed the Director of Nursing Services (DNS) at 4:42 P.M. on 2/17/17. The DNS said CNA #1 did not follow Resident #1’s plan of care for bed mobility.

Quabbin Valley Healthcare, Nursing Home Neglect and Elder Abuse Lawyers

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

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

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

Boston Personal Injury Lawyers for Elder Abuse Cases

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


Sources:

Medicare Nursing Home Profiles and Reports – Quabbin Valley Healthcare

Nursing Home Inspection, Safety and Deficiency Report – Quabbin Valley Healthcare 08/24/2017

Complaint Inspections Quabbin Valley Healthcare 02/17/2017

Page Last Updated: February 28th, 2018

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