Royal Braintree Nursing and Rehabilitation Center

Royal Braintree Nursing and Rehabilitation Center

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Royal Braintree Nursing and Rehabilitation 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 Royal Braintree Nursing and Rehabilitation Center

Royal Braintree Nursing and Rehabilitation CenterRoyal Braintree Nursing and Rehabilitation Center is a for profit, 204 bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Braintree, Quincy, Weymouth, Milton, Randolph, Holbrook, Hingham, Hull, Rockland, Stoughton, Abington, Dedham, Canton, Brockton, Brrokline, Boston, and other towns in and surrounding Norfolk County, Massachusetts.

Royal Braintree Nursing and Rehabilitation Center focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Royal Braintree Nursing and Rehabilitation Center
95 Commercial Street
Braintree, MA 02184

Phone: (781) 848-0596
Royal Braintree Nursing and Rehabilitation Center Website

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, Royal Braintree Nursing and Rehabilitation Center in Braintree 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 4 out of 5 (Above Average)

Fines Against Royal Braintree Nursing and Rehabilitation Center

The Federal Government fined Royal Braintree Nursing and Rehabilitation Center Royal Braintree Nursing and Rehabilitation Center for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Royal Braintree Nursing and Rehabilitation Center committed the following offenses:

The facility failed to ensure each resident receives an accurate assessment by a qualified health professional.

Based on interview and record review, for one of fifteen non-sampled Residents (non-sampled Resident C), non-sampled Resident C’s At risk for Elopement Assessment completed on 6/7/17 was inaccurate.

Findings include:

The Resident Elopement and Wandering Policy, dated as revised 4/28/17, indicated that all residents admitted with a known history of dementia, wandering or elopement shall have an Elopement Assessment done and Immediate Plan of Care for risk of wandering and elopement developed on admission, Non-sampled Resident C’s clinical record was reviewed and contained an At Risk for Elopement Resident Assessment Form, dated 6/7/17 completed by Unit Manager #1. The At Risk for Elopement Resident Assessment Form indicated a ‘No’ answer for the three assessment questions, including the first question to the effect of has the resident exhibited wandering behaviors in the last sixty days. The Surveyor interviewed Unit Manager #1 at 12:05 P.M. on 6/20/17.

The Surveyor asked Unit Manager where she obtained the information to answer the questions on the At Risk for Elopement Resident Assessment Form and she said that she based her responses on her own observation and not on review of any other clinical documentation. Non-sampled Resident C’s Quarterly Minimum Data Set Assessment, dated 6/7/17, was reviewed and indicated he/she wandered one to three times during the week long assessment reference period. Non-sampled Resident C’s prior Annual Minimum Data Set Assessment, dated 3/15/17, was reviewed and indicated he/she wandered daily during the week long assessment reference period. The Surveyor interviewed the MDS Nurse at 12:15 P.M. on 6/20/17. The MDS Nurse said that she based her assessments of non-sampled Resident C’s behavioral symptoms documented on the MDS Assessment on staff member observation and documentation in the medication and treatment administration records, progress notes and the Nurse Aides Behavior Monitoring Chart.

The Surveyor reviewed documents provided by the MDS Nurse which indicated non-sampled Resident C exhibited eight instances of wandering between 6/1/17 and 6/7/17, the date that Unit Manager #1 completed his/her At Risk for Elopement Resident Assessment. This is not consistent with the Facility Policy.

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

Based on interview and record review, for two of three sampled residents (Resident #1 and Resident #3) and two non-sampled Residents (Residents A and B) multiple staff members could not consistently identify that Residents #1 and #3 and non-sampled Residents A and B were at high risk to elope.

Findings include:

The Facility Wandering and Elopement Policy, dated as last revised on 4/28/17 indicated that each employee shall be informed of their responsibility regarding being aware of residents who are at risk fro elopement, their photos, resident specific indications of potential elopement and individual care plans and approaches.

The At Risk for Elopement Resident Assessment Form, dated 4/19/17 indicated that Resident #1 was at risk to elope. The Care Plan concern dated 1/24/17 and updated 4/27/17 indicated that Resident #1 was at risk to elope. Resident #1’s dateless ADL (Activity of Daily Living) Plan of Care indicated that Resident #1 had a high elopement risk.

The At Risk for Elopement Resident Assessment Form, dated 5/31/17 indicated that Resident #3 was at risk to elope. The Care Plan concern dated 5/31/17 indicated that Resident #3 was at risk to elope. Resident #3’s dateless ADL (Activity of Daily Living) Plan of Care indicated that Resident #3 had a high elopement risk. The At Risk for Elopement Resident Assessment Form, dated 4/5/17 indicated that non-sampled Resident A was at risk to elope. The Care Plan concern dated 4/17/17 indicated that non-sampled Resident A was at risk to elope. Non-sampled Resident A’s dateless ADL (Activity of Daily Living) Plan of Care indicated that Resident #1 had a high elopement risk.

The At Risk for Elopement Resident Assessment Form, dated 5/29/17 indicated that non-sampled Resident B was at risk to elope. The Care Plan concern dated 5/30/17 indicated that non-sampled Resident B was at risk to elope. Non-sampled Resident B’s dateless ADL (Activity of Daily Living) Plan of Care indicated that Resident #1 had a high elopement risk. The Surveyor interviewed Nurse #1 at 11:00 A.M. on 6/19/17. The Surveyor interviewed CNA #1 at 1:45 P.M. on 6/19/17. The Surveyor interviewed CNA #2 at 2:15 P.M. on 6/19/17. The Surveyor interviewed CNA #4 at 3:40 P.M. on 6/19/17. The Surveyor interviewed CNA #5 at 7:10 A.M. on 6/20/17.

The Surveyor interviewed the Social Worker at 10:00 A.M. on 6/20/17. The Surveyor interviewed Nurse #2 at 10:30 A.M. on 6/20/17. The Surveyor interviewed Activity Aide #1 at 10:40 A.M. on 6/20/17. The Surveyor interviewed CNA #3 at 11:30 A.M. on 6/20/17. None of the staff members interviewed could consistently identify that Resident #1, Resident #3 and non-sampled Residents A and B were the residents on Resident #1’s unit who were at high risk to elope.

-Nurse #1 said Resident #1, Resident #3 and non-sampled Resident E were at risk to elope.

-CNA #1 said non-sampled Resident A was the only resident at risk to elope.

-CNA #2 said non-sampled Resident A was the only resident at risk to elope.

-CNA #4 said there were no residents on Resident #1’s unit who were at risk to elope.

-CNA #5 said that non-sampled Resident F was the only resident on Resident #1’s unit at risk to elope.

Although the Social Worker identified that Resident #1, Resident #3 and non-sampled Resident A and B were at risk to elope, she also said that non-sampled Residents C, F and G were at risk to elope.

-Nurse #2 said that Resident #1 and non-sampled Residents A and H were at risk to elope.

-The Activity Aide said that there were no residents on Resident #1’s unit at risk to elop.

-CNA #3 said that there were no residents on Resident #1’s unit, including Resident #1, at risk to elope although non-sampled Resident A always said that he/she would like to leave. Nurses, CNAs, social workers and activity aides, who were assigned to care for residents on the unit where Resident #1 eloped, were unable to provide accurate information regarding those residents at risk for elopement.

The nursing home failed to ensure that the nursing home area was free from accident hazards and risks and failed to provide supervision to prevent avoidable accidents.

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

Based on observation, interview and record review, for one of three sampled residents (Resident#1), the Facility failed to:

-ensure that Resident #1, a cognitively impaired resident assessed to be at high risk for elopement, was provided adequate supervision to prevent an elopement on 6/18/17.

-ensure staff members were deployed in a manner which ensured all residents were provided supervision and assistance based on assessed care needs during meal service.

-ensure all direct care staff, including nurses, nurses aides, and activities staff members, were aware of which residents were assessed to be an elopement risk; how to identify residents’ care plan interventions supervision needs; and, related elopement assessment, care plan policies.

-ensure that assessments, care plans, nurse aide care cards, related to elopement risk and supervision needs and materials identified as the Elopement Book, were accurate and consistently reflected individual resident’s care needs.

At 12:10 P.M. on 6/18/17, a window air conditioning unit was found on the floor next to the open window in Resident #1’s room and Resident #1 could not be located. Resident #1 was located at 9:30 P.M. on 6/21/17 by police from a neighboring town, about 57 hours after he/she was last seen at the Facility.

Findings include:

1)Resident #1’s most recent Minimum Data Set Assessment Form, completed 4/19/17, indicated that his/her cognitive patterns were moderately impaired. Resident #1’s Brief Interview for Mental Status indicated a score of 9 out of 15. The Brief Interview for Mental Status indicated that a score of 12 to 15 indicated the resident was cognitively intact, a score of 8 to 12 indicated the resident was moderately cognitively impaired and a score below 7 indicated the resident was severely cognitively impaired. The MDS indicated that Resident #1 ambulated without a device or physical assistance from staff members although he/she required supervision. Resident #1’s History and Physical Form completed in January 2017 indicated that his/her [DIAGNOSES REDACTED]. The At Risk for Elopement Resident Assessment Form, dated 4/19/17 indicated that Resident #1 was at risk to elope and the missing resident profile should be completed and placed in the Elopement Book and a care plan should be developed. The At Risk for Elopement Resident Assessment Form indicated that Resident #1 was at risk to elope because he/she wandered in the previous sixty days and had history of exiting/eloping and had the physical capacity to exit/elope.

The Surveyor reviewed the Elopement Book at the Reception Desk at 11:00 A.M. on 6/19/17 and the Elopement Book contained an Elopement Profile for Resident #1. The Care Plan concern dated 1/24/17 and updated 4/27/17 indicated that Resident #1 was at risk to elope. The Care Plan interventions included encouraging him/her to attend activities, redirection when needed, monitoring for restlessness, pacing and agitation, redirecting away from exit doors, walking with him/her several times daily and assessing and determining when elopement risk is at its highest and intervening. Resident #1’s dateless ADL (Activity of Daily Living) Plan of Care indicated that Resident #1 was at high risk for elopement. The Surveyor reviewed the Schedule for Resident #1’s unit during the 7:00 A.M. to 3:00 P.M. on 6/18/17. The Schedule indicated that Nurse #1, CNA #1, CNA #2 and CNA #3 were the staff members working on Resident #1’s unit during the shift.

The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 1:45 P.M. on 6/19/17. The Surveyor interviewed CNA #2 at 2:15 P.M. on 6/19/17. The Surveyor interviewed CNA #3 at 11:30 A.M. on 6/20/17. The Surveyor interviewed Nurse #1 at 11:00 A.M. on 6/19/17. The Surveyor reviewed the written statements of CNA #1, CNA #2, CNA #3 and Nurse #1 dated 6/18/17. CNA #1, CNA #2, CNA #3 and Nurse #1 said and their written statements indicated that they saw Resident #1 between 11:30 A.M. and 11:45 A.M. on 6/18/17 in the large dining room on his/her unit. CNA #1, CNA #2, CNA #3 and Nurse #1 said that after Resident #1 had his/her coffee and soup he/she left the dining room. CNA #1, CNA #2, CNA #3 and Nurse #1 said that it was Resident #1’s usual routine to return to his/her room after he/she had his/her coffee and soup and to return to the dining room when the main entrée was delivered. CNA #1, CNA #2 and CNA #3 said that they remained in the large dining room supervising residents until the main entrée was delivered around 12:10 P.M. and Nurse #1 said she divided her time between the large dining room and the nurses’ station while she waited for the entrees to be delivered to the unit. Nurse #1 said that she made rounds on Resident #1’s unit at 12:00 P.M. and saw Resident #1 in his/her bed. Nurse #1 said that she did not know whether the window in Resident #1’s room was open at that time or whether the window air condition was in place. Nurse #1 could not explain how she did not notice the window. Nurse #1’s written statement dated 6/18/17 did not indicate that she made rounds and observed Resident #1 in bed at 12:00 P.M. on 6/18/17. Nurse #1 could not explain the reason that she omitted this on her statement. Nurse #1 said that around 12:10 P.M., the dietary cart with the entrees arrived on the unit. Nurse #1 said that she went to Resident #1’s room to remind him/her to return to the dining room for lunch. Nurse #1 said that when she entered Resident #1’s room, the air conditioning unit was on the floor at the end of his/her roommate’s bed (Resident #2). Nurse #1 said that the window in the room was open, the screws which mounted the air conditioner were in a pile on the window sill and the window blind was on Resident #2’s dresser. Nurse #1 said that she alerted CNA #1, CNA #2 and CNA #3 and they searched the unit. Nurse #1 said when Resident #1 was not located on the unit a Code Yellow was called to initiate a search of the entire Facility and the perimeter and the police were notified. Resident #1 was located at 9:30 P.M. on 6/21/17 by police from a neighboring town, about 57 hours after he/she was last seen at the Facility.

2) The Surveyor interviewed the Director of Maintenance at 9:30 A.M. on 6/19/17 and 12:00 P.M. on 6/20/17. The Surveyor and the Director of Maintenance toured Resident #1’s unit during the interviews. The Director of Maintenance said that the part of the Facility where Resident #1’s unit was located was originally an old home. The Surveyor observed that the nurses’ station was the central point of the unit with four distinct areas of rooms leading away from the nurses’ station in four directions. Resident #1’s room was the second to the last room down one hallway. There was no direct line of sight from the nurses’ station to the door way of Resident #1’s room. Walking from the nurses’ station to Resident #1’s required turning around a corner to the left and proceeding down the hallway. The Director of Maintenance measured the distance from Resident #1’s room up the first hallway, around the corner through the second hallway and across the open area in front of the nurses’ station to be thirty feet. The Director of Maintenance measured the distance from the nurses’ station and down a different hallway into the dining room to be thirty feet. The Director of Maintenance said the distance from Resident #1’s room to the dining room was sixty feet. The Surveyor observed that walking from Resident #1’s room to the dining room required moving around six corners and proceeding through six hallways or

There was no staff member assigned to supervise the area near Resident #1’s room at the time of Resident #1’s elopement as Nurse #1, CNA #1, CNA #2 and CNA #3 said that CNA #1, CNA #2 and CNA #3 were in the dining room from 11:45 A.M. until 12:15 P.M. and Nurse #1 said between 11:45 A.M. and 12:15 P.M. she was in the dining room and at the nurses’ station. The Surveyor observed the unit during lunch on 6/19/17 and breakfast and lunch on 6/20/17. The Surveyor observed that CNAs and nurses primarily spent meal time in the unit dining where all of the residents ate their lunch and most of the residents ate their breakfast. Nurse #1 and Unit Manager #1 occasionally exited the main dining to complete tasks at the nurses’ station. Although most of the residents remained in the dining room throughout the meal, the Surveyor observed occasions in which a resident left the dining room and was encouraged by staff to return. The statements of CNA#1, CNA #2, CNA #3 and Nurse #1 and the Surveyor’s observations on the unit with the Director of Maintenance indicated that Resident #1, a cognitively impaired resident with an identified elopement risk, was between thirty and sixty feet away from the nearest staff member with no direct line of sight to his/her room and separated by several hallways and corners for between fifteen and thirty minutes just prior to him/her being identified as missing. 3) The Surveyor interviewed Unit Manager #1 at 3:20 P.M. on 6/19/17. Unit Manager #1 said that Resident #1, Resident #3 and non-sampled Residents A and B resided on the unit and were assessed to be at high risk to elope. Unit Manager #1 said care plans were developed to address their elopement risk. However, staff members interview by the Surveyor were unable to articulate who was at risk for elopement. The Facility Resident Elopement and Wandering Policy, dated as revised 4/28/17, was reviewed and indicated that each employee received training upon hire and annually to be informed of their responsibility to be aware of residents who were at risk for elopement, resident specific indications of potential elopement and individual care plans and approaches. The Surveyor asked Unit Manager #1 how she communicated information of residents elopement risk to the CNAs and nurses who worked on the unit. Unit Manager #1 said that for the CNAs, elopement risk was listed on the ADL Plan of Care and for nurses they received the information in a change of shift report. Although Unit Manager #1 said that the elopement risk for residents was indicated on the ADL Plan of Care, when the Surveyor reviewed the ADL Plans of Care and the At Risk for Elopement Resident Assessment Forms for all the residents on the unit, one resident was identified whose At Risk for Elopement Resident Assessment did not indicate elopement risk, but the ADL Plan of Care indicated that he/she was at risk to elope (non-sampled Resident H). The Surveyor asked Unit Manager #1 whether she used a system to verify that the CNAs and nurses on the unit were aware which residents were at risk for elopement, resident specific indications of potential elopement and individual care plans and approaches and she said that she did not. Unit Manager #1 said that she was not aware that any other Facility staff person conducted an audit of how knowledgeable CNAs and nurses were about resident’s elopement risk and care plans. The Surveyor interviewed Nurse #1 at 11:00 A.M. on 6/19/17. The Surveyor interviewed CNA #1 at 1:45 P.M. on 6/19/17. The Surveyor interviewed CNA #2 at 2:15 P.M. on 6/19/17. The Surveyor interviewed CNA #4 at 3:40 P.M. on 6/19/17. The Surveyor interviewed CNA #5 at 7:10 A.M. on 6/20/17. The Surveyor interviewed the Social Worker at 10:00 A.M. on 6/20/17.

The Surveyor interviewed Nurse #2 at 10:30 A.M. on 6/20/17. The Surveyor interviewed Activity Aide #1 at 10:40 A.M. on 6/20/17. The Surveyor interviewed CNA #3 at 11:30 A.M. on 6/20/17. None of the staff members interviewed could identify that Resident #1, Resident #3 and non-sampled Residents A and B were at risk to elope.

-Nurse #1 said Resident #1, Resident #3 and non-sampled Resident E were at risk to elope.

-CNA #1 said non-sampled Resident A was at risk to elope and no other resident, including Resident #1, was at risk to elope. -CNA #2 said non-sampled Resident A was at risk to elope and no other resident, including Resident #1, were at risk to elope.

-CNA #4 said no residents on Resident #1’s unit who were at risk to elope. -CNA #5 said that non-sampled Resident F was the only resident on Resident #1’s unit who was at risk to elope.

-Although the Social Worker identified that Resident #1, Resident #3 and non-sampled Resident A and B were at risk to elope, she also said that non-sampled Residents C, F and G were at risk to elope. -Nurse #2 said that Resident #1 and non-sampled Residents A and H were at risk to elope.

-The Activity Aide said no residents on Resident #1’s unit were at risk to elope -CNA #3 said no residents on Resident #1’s unit, including Resident #1, were at risk to elope although non-sampled Resident A always said that he/she would like to leave. During interviews, five staff members were not able to identify how information about residents assessed risk for elopement was communicated to direct care staff. – Nurse #1 said CNAs were shown the Elopement Book by the Staff Development Coordinator

– CNA #1 said that she knew who was at risk to elope because the resident would talk about wanting to leave. The Surveyor asked CNA #1 whether the ADL Plan of Care indicated a resident’s elopement risk and CNA #1 did not respond. The Surveyor showed CNA #1 Resident #1’s ADL Plan of Care which indicated that he/she was at risk to elope. The Surveyor asked CNA #1 whether the ADL Plan of Care indicated that Resident #1 was at risk to elope. CNA #1 was not able to locate the notation on the ADL Plan of Care which indicated his/her elopement risk.

-The Surveyor asked CNA #2 whether there was any documentation that she could look at which could assist her to know a residents elopement risk and she said that there was not. The Surveyor showed CNA #2 Resident #1’s ADL Plan of Care and asked her whether she could locate information about his/her elopement risk and she said that she could not. The Surveyor asked CNA #2 about the Facility Elopement Book and CNA #2 said that because she was a CNA she did not know about everything kept at the nurses’ station.

-CNA #4 said that she knew which residents were at risk to elope because she knew which residents talked about wanting to leave the Facility. CNA #4 said that nurses did not communicate information about resident’s elopement risk to her and she did not know what the Elopement Book was. The Surveyor showed CNA #4 Resident #1’s ADL Plan of Care and she said that there was nothing on the ADL Plan of Care which indicated that he/she was at risk to elope.

-CNA #4 said that she really did not know how the nurses’ let the CNAs know which residents were at risk to elope. The Surveyor showed CNA #4 Resident #1’s ADL Plan of care. Although CNA #4 identified the notation which indicated that Resident #1 was at risk to elope she said that she had never looked at that space on the ADL Plan of Care before.

4)The Facility Resident Elopement and Wandering Policy indicated that all residents with a known history or dementia, wandering or elopement would have an Elopement Assessment done and immediate Plan of Care for risk of wandering and elopement developed on admission.

Unit Manager #1 said that residents identified to be at risk for elopement had elopement care plans completed. Unit Manager #1 said that CNAs were alerted to residents at risk to elope by indication on the ADL Plan of Care. Unit Manager #1 said and the Resident Elopement and Wandering Policy indicated that information about residents identified to be at risk to elope was placed into an Elopement Book. Unit Manager #1 said and the Resident Elopement and Wandering Policy indicated that a facial photograph and a Missing Resident Profile Form which provided more in depth information about residents, including eye and hair color.

The Resident Elopement and Wandering Policy indicated that material from the Elopement Book was readily accessible for providing to law enforcement in the event of a missing resident. The Regional Nurse and the Director of Nurses were interviewed together at 1:00 P.M. on 6/20/17. The Regional Nurse and the Director of Nurses said that identical copies of the Elopement Book were maintained on each of the Facility’s nurses’ stations and at the Reception Desk.

The Surveyor reviewed the At Risk for Elopement Resident Assessment Form, Care Plans, ADL Plans of Care and portions of clinical records for all of the residents on Resident #1’s unit as well as the Elopement Book containing information for all Facility residents and identified the following inconsistencies regarding resident’s elopement risk. -although the At Risk Elopement Resident Assessment Form for non-sampled Resident C, dated 6/7/17, indicated no elopement risk, Unit Manager #1 said she based her response to the question regarding whether non-sampled Resident C wandered during the prior sixty days solely on her own observation.

Review of the Nurses’ Aides Behavior Monitoring Charts for non-sampled Resident C, for June 2017, indicated eight instances of wandering. -although non-sampled Resident H’s At Risk Elopement Resident Assessment Form, dated 5/3/17 indicated he/she was not at risk for elopement, non-sampled Resident H’s dateless ADL Plan of Care indicated that he/she was at risk to elope.

-The Surveyor interviewed the Director of Nurses at 1:00 P.M. on 6/20/17. The Director of Nurses said that although on 6/19/17 the Elopement Profile contained photographs and Missing Resident Profiles for sixty-nine residents, the Facility had only thirty-three residents at risk to elope. On 6/19/17 at 10:45 A.M., the Surveyor reviewed the Elopement Book at the Reception Desk. At that time, the Elopement Book contained photographs and Missing Resident Profiles for sixty-nine residents. Seventeen residents from Resident #1’s unit had photographs and Missing Resident Profiles in the Elopement Book (Residents #1 and #3 and non-sampled Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N and O) although Unit Manager #1 said that only Residents #1 and #3 and non-sampled Residents A and B were at risk for elopement. The Elopement Book at the Reception Desk indicated that it had been reviewed by the Facility Department Heads on 6/8/17.

The facility failed to ensure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

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

Based on interview and record review, for fourteen of twenty-five Residents on Resident #1’s unit (Residents #1, #2 and #3 and non-sampled Residents C, F, H, I, J, L, M, P, Q and R) the Facility failed to maintain a safe environment. The Director of Maintenance installed window air conditioners in the rooms of Residents #1, #2 and #3 and non-sampled Residents C, F, H, I, J, L, M, P, Q and R on 6/12/17 and 6/13/17. On 6/18/17 the window air conditioner was found on the floor beneath the window in Resident #1’s room and Resident #1, a resident with dementia with an identified risk for elopement, was missing after apparently having eloped through the window.

Findings include:

The Surveyor interviewed the Director of Maintenance at 9:50 A.M. on 6/19/17. The Director of Maintenance said that he installed window air conditioners on 6/12/17 and 6/13/17 in the rooms on Resident #1’s unit that did not have wall mounted air conditioning units. The Director of Maintenance said that he used three screws into the window to hold the air conditioner in place and its side fins fully open.

Resident #1’s most recent Minimum Data Set Assessment Form, completed 4/19/17, indicated that his/her cognitive patterns were moderately impaired. Resident #1’s Brief Interview for Mental Status indicated a score of 9 out of 15. The Brief Interview for Mental Status indicated that a score of 12 to 15 indicated the resident was cognitively intact, a score of 8 to 12 indicated the resident was moderately cognitively impaired and a score below 7 indicated the resident was severely cognitively impaired. The MDS indicated that Resident #1 ambulated without a device or physical assistance from staff members although he/she required supervision. The At Risk for Elopement Resident Assessment Form, dated 4/19/17 indicated that Resident #1 was at risk to elope and a Care Plan concern dated 1/24/17 and updated 4/27/17 indicated that Resident #1 was at risk to elope. Resident #1’s dateless ADL (Activity of Daily Living) Plan of Care indicated that Resident #1 had a high elopement risk.

The Surveyor interviewed Nurse #1 at 11:00 A.M. on 6/19/17. Nurse #1 said that she made rounds on Resident #1’s unit at 12:00 P.M. and saw Resident #1 in his/her bed. Nurse #1 said that she did not know whether the window in Resident #1’s room was open at that time or whether the window air condition was in place. Nurse #1 could not explain how she did not notice the window. Nurse #1’s written statement dated 6/18/17 did not indicated that she made rounds and observed Resident #1 in bed at 12:00 P.M. on 6/18/17. Nurse #1 could not explain the reason that she omitted this on her statement. Nurse #1 said that around 12:10 P.M., the dietary cart with the entrees arrived on the unit. Nurse #1 said that she went to Resident #1’s to remind him/her to return to the dining room for lunch. Nurse #1 said that when she entered Resident #1’s room, the air conditioning unit was on the floor at the end of his/her roommate’s bed (Resident #2). Nurse #1 said that the window in the room was open, the screws which mounted the air conditioner were in a pile on the window sill and the window blind was on Resident #2’s dresser. The Director of Maintenance said that he came to the facility on [DATE] and observed that the window air conditioning unit had been removed from Resident #1’s window. On 6/19/17, The Facility was found to be in past non-compliance. In response to the incident, the Facility took the following corrective action: A) Facility wide audit of all windows was conducted on 6/18/17. B) Two additional screws were added, at least one with a different type of head requiring a different tool to remove, were added to all window air conditioning units on 6/18/17.

Royal Braintree Nursing and Rehabilitation 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: December 14, 2017

Call Now Button