South East Healthcare Center

South East Healthcare Center

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at South East 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 South East Healthcare Center

South East Healthcare CenterSouth East Healthcare Center is a for profit, 171-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Easton,  Stoughton, Mansfield,  Brockton, Sharon, and the other towns in and surrounding Bristol County, Massachusetts. South East Healthcare Center focuses on 24 hour care, respite care, hospice care and rehabilitation services.

South East Healthcare Center
184 Lincoln St, North Easton, MA 02356

Phone: 508-238-7053

Website: http://www.athenanh.com/MA_Southeast.aspx

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, South East Healthcare Center in North Easton, 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 South East Healthcare Center

The Federal Government fined South East Healthcare Center $5,983 on April 4th, 2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Injury Lawyers inspected government records and discovered South East Healthcare Center committed the following offenses:

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, interview with the Resident and interviews with staff, the facility failed to ensure that residents did not suffer abuse or mistreatment, that all allegations of abuse or mistreatment were immediately investigated, that the facility took immediate action to protect all residents from potential abuse during the investigation and that all allegations of abuse and mistreatment were reported immediately to the Administrator and State Agency for 1 resident (#19) out of total sample of 26.

Findings include:

For Resident #19, the facility failed to take immediate action to protect all residents following an allegation of mistreatment and abuse by a nurse, failed to immediately report the allegation of abuse to the Administrator and the State Department of Public Health as required by state statute and failed to investigate the allegation immediately and thoroughly. Resident #19 had been admitted in 5/2016 for short term rehabilitation for a non-healing fractured foot. The Resident’s other [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment, with a reference date of 8/4/16, indicated that the Resident had no problems with communication or comprehension, had no cognitive or memory deficits and no symptoms of [MEDICAL CONDITION]. The MDS indicated the Resident required extensive assistance with personal care, and required supervision with mobility.

During the group interview on 9/27/16 at 2:00 P.M., the Resident requested to speak with the surveyor. During the interview on 9/28/16 at 1:45 P.M., Resident #19 said that a particular nurse (Nurse Supervisor) who worked at the facility singled the resident out and was mean to him/her. The Resident said that he/she had several problems with the Nurse Supervisor. The Resident said that in July 2016, the Nurse Supervisor had called him/her names (your psychotic) and threatened to call the doctor and or police and send him to a psychiatric hospital. The Resident said that he/she had a prior incident (prior to the July incident) with the Nurse Supervisor, but was told by the current Administration staff that they could not do anything with a complaint from the previous administration (that it was that administrations issue). Although, the Surveyor requested the Resident to share the allegation, the Resident said that he/she had been told nothing could be done about it and did not tell what had happened. The Resident said the incident in July 2016 occurred after he/she had initially asked the Nursing Supervisor to use the telephone. The Resident said that initially he/she was alright about the Nursing Supervisor not allowing the use of the phone, but did feel singled out. Resident #19 said later that evening he/she was at the nurse’s station and reported he/she had not received medications. The Nurse Supervisor became involved in the conversation.

The Resident said the Nursing Supervisor did not believe him/her and called the Nurse who signed the medication record. Resident #19 said he/she was upset that staff did not believe him/her and that an argument occurred. The Resident said the Nurse Supervisor refused to believe him/her and during points of the conversation called him/her a psycho and crazy. The Resident stated the Supervisor repeatedly told him/her she would call the doctor and/or police and send him/her out of the facility. The Resident said the Nurse Supervisor leaned over and whispered in his/her ear I am sick of your sh–. The Resident said he/she was very upset over the situation and felt threatened. Resident #19 said he/she had not doubt that the Nurse Supervisor would call the police because he/she had witnessed her call the local police on staff. Resident #19 said he/she overheard the Supervisor say they (the staff) were not doing their job. Resident #19 said the Administrator had been made aware and that she had met with him/her and told the Resident it was his/her word against the Nurse Supervisor.

Resident #19 said the Administrator asked what he/she wanted her to do with this situation. The Resident asked that the Nurse Supervisor stay away from him/her. The Resident said that for several weeks the Nurse did stay away from him/her and that the Administrator had checked in with him/her. However, Resident #19 said about 2 weeks ago the Nurse Supervisor was confrontational with him/her while he/she was talking with a facility staff. The Resident said he/she was uncomfortable with the situation and that staff told him/her that the Nurse Supervisor should not have treated him/her the way she did. The Resident said he/she did not report the incident to the Administrator for 2 reasons, (1) was afraid and hoped no other incidents occurred and (2) that the staff had told him/her the State (Department of Public Health Survey) would be conducted very soon.

The Resident said he/she decided to wait it out and wanted to see if the survey team could assist him/her. The Surveyor explained that the Administrator would need to be made aware of the allegation and he/she was agreeable and the Surveyor notified the Administrator on 9/28/16 at 2:15 P.M. of the Resident’s concerns, Review of the facility incident report, dated 7/16/16, indicated that the Nurse Supervisor became involved with the Resident in regards to having not received his/her medications. The Nurse Supervisor’s statement indicated that she told the Resident she would have to immediately call the doctor and have him/her sent to the hospital for an evaluation. Her statement indicated the Resident’s behavior was forceful and was escalating. The Nurse denied calling the Resident psychotic, but other statements support her threat of sending the Resident out of the building. Further, review of the incident indicated the Resident was upset at being called psychotic, as the report indicated he/she repeatedly asked staff if he/she was in trouble. The incident indicated that the certified nursing staff were educated in providing 2 caregivers while providing care to the Resident. There was no evidence the staff, including the Nurse Supervisor was educated on abuse and mistreatment and there was no evidence the Supervisor was given any education and/or parameters to ensure the Resident felt safe. In addition, there was no evidence the allegation was reported to the Department of Public Health.

The medical record was reviewed and there was no evidence that the Resident’s behavior on 7/15/16 – 7/16/16 warranted a mental health evaluation (as indicated by the Nurse Supervisor on 7/16/16). The only mention of any incident was on 7/21/16 in the psychiatric progress note. The Resident was upset over the altercation and reporting that he/she had made sexual comments in the past. The Resident said that the staff had there thoughts and he/she had his/her thoughts. The note indicated the Resident was alert, oriented, compliant and a reliable historian. During interview on 7/29/16 at 1:00 P.M. with Unit Manager #1 and Social Worker #1, they said the Resident did not have behaviors that were problematic, but tended to overly involve self in conversations with staff and other residents. The staff said the Resident had a tendency to be overly sensitive. The 2 staff said the sexual behaviors were misinterpreted and not a problem. The staff said the Resident was very likeable. The Surveyor inquired about the incidents, and the lack of documentation in the record.

The Unit Manager and Social Worker said if the Nurse Supervisor felt the Resident required an immediate evaluation and needed to be sent the hospital, there should be documentation to support the need for the assessment. The staff were unaware of any recent problems between the Nurse Supervisor and the Resident. During interview on 7/29/16 with the Administrator, she said she did not know why the Resident had not reported the second allegation. The Surveyor shared the Resident’s concerns (including the police being called) and she confirmed the incident. The Administrator said that she had not reported the 7/16/16 to the Department, as required by law, but was immediately investigating the most recent allegation.

Failed to provide housekeeping and maintenance services.

The facility failed to maintain a safe, sanitary and homelike environment for the residents, staff and and public. During the initial tour of the facility on 9/26/16, and on all subsequent days of survey (9/27/16, 9/28/16 and 9/29/16), the carpeting on three of four residential units (Ames, Traditions and Borderland) and in common areas throughout the facility was noted to be worn and heavily soiled with multiple areas visibly stained. Additionally the seams of the carpet were separating and unravelling in multiple areas throughout the facility. The facility administrator was interviewed on 9/28/16 at 11:30 A.M. and said she was aware of the condition of carpeting and had made arrangements for the carpeting to be looked at but said there was currently no contract or date in place to address the cleaning or replacement of the carpeting.

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 record review and staff interview, the facility failed to ensure that services provided to 2 Residents ( #8 and #12), of a total sample of 26 Residents, met professional standards of nursing quality. The facility failed to meet professional standards of practice for medication administration and transcription of medical orders (#8) and failed to ensure that insulin and [MEDICATION NAME] injection sites were identified, rotated and documented legibly(#12).

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. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. 1.

Resident #8 was admitted to the facility in 5/2014 with [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) with a reference date of 7/6/16, indicated this resident was dependent for hygiene and required extensive assistance for dressing and bathing with a BIMS (brief interview for mental status) score of 8 out of 15 (moderate cognitive impairment). The resident was incontinent of bowel and bladder and had a chronic diabetic wound on the right ankle. Review of the clinical record on 9/26/16 indicated that the Resident had a physician’s orders [REDACTED].

Review of the MAR(medication administration record) for May 2016 indicated the medication was discontinued on 5/9/16 as ordered. Review of the MAR for June 2016 indicated that the resident was again receiving Ditiazem 90 mg twice a day despite the physician’s orders [REDACTED]. Further review of the clinical record and MAR’s indicated that Resident #8 continued to receive [MEDICATION NAME] 90mg twice daily for the months of July 2016, August 2016 and September 2016 until Surveyor intervention on 9/26/16. The facility ADON(Assistant Director of Nursing)and the RN Supervisor were interviewed on 9/26/16 at 3:00 P.M. and stated that the [MEDICATION NAME] had continued to be administered due to a transcription error and stated it should have been discontinued as ordered by the physician on 5/9/16. 2. Resident #12 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED].

Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 8/1/16 indicated that Resident #12 had significant cognitive impairment, was dependent on staff for all activities of daily living, received insulin injections and anticoagulant medication daily. The medical record was reviewed on 9/26/16. Review of the August 2016 physician’s orders [REDACTED].#12 had an order for [REDACTED]., 12:00 P.M. and 5:00 P.M.; [MEDICATION NAME] 100 units/ml vial, inject 14 units sc every evening at 9:00 P.M.; [MEDICATION NAME] sodium 500 unit/1 ml vial, inject 1 ml sc every 12 hours (initiated 1/24/16) at 9:00 A.M. and 9:00 P.M. Review of the June 2016 through August 2016 Medication Administration Records (MAR) indicated the following: June 2016

  •  Of 120 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was not rotated on 12 occasions.
  • Of 120 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was not identified on 27 occasions.
  • Of 120 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was written illegibly on 12 occasions.
  • Of 60 [MEDICATION NAME] injections administered, the injection site was not rotated on 3 occasions.
  • Of 60 [MEDICATION NAME] injections administered, the injection site was not identified on 10 occasions.

July 2016

  • Of 120 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was not rotated on 19 occasions.
  • Of 120 [MEDICATION NAME] and [MEDICATION NAME] injections, the injection sites was not identified on 12 occasions.
  • Of 120 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was written illegibly on 5 occasions
  • Of 60 [MEDICATION NAME] injections administered, the injection site was not identified on 21 occasions

August 2016

  • Of 120 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was not rotated on 18 occasions.
  • Of 120 [MEDICATION NAME] and [MEDICATION NAME] injections administered, injection sites were not identified on 18 occasions.
  • Of 120 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was written illegibly on 3 occasions
  • Of 60 [MEDICATION NAME] injections administered, the injection site was not rotated on 4 occasions.

Further review of the medical record failed to identify the above noted sites of injections and failed to indicate that the insulin administration omissions on the diabetic monitoring flowsheets were actually administered. During interview with staff nurse #1 and the Assistant Director of Nursing (ADON) on 9/27/16 at 2:35 P.M., Resident #12’s MARs were reviewed. Staff nurse #1 said she was unable to read most of the documentation of injections sites for insulin and [MEDICATION NAME].

Staff nurse #1 and the ADON said that injection sites should have been rotated, identified and documented legibly.

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 and staff interview, the facility failed to implement physician’s orders to administer PPD (purified protein derivative: a skin test that determines if you suffer from [MEDICAL CONDITION]) for 1 Resident (#17) out of a total sample of 26 Residents.

Findings include:

Resident #17 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) with a reference date of 9/4/16, indicated that Resident #17 had moderate cognitive impairment and required extensive assistance from staff for all activities of daily living. Review of the facility policy for a [MEDICAL CONDITION] (TB) control plan (revised April 2016) indicated that all new admissions would receive a two step screening for TB. The medical record was reviewed on 9/29/16. Review of the August 2016 signed physician’s orders and Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. During interview with the facility’s Infection Control Nurse on 9/29/16 at 12:20 P.M., she said that Resident #17 did not receive the two step screening PPD per physician’s order.

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 record review and staff interview, the facility failed to follow their policy/protocol in providing comprehensive care and treatment of [REDACTED].#14) in a total sample of 26 Residents.

Findings include:

For Resident #14, the facility failed to measure the external catheter length during dressing changes per facility protocol/policy for PICCs. Resident # 14 was admitted to the facility with [DIAGNOSES REDACTED]. Clinical Record review indicated the Resident had a Right PICC inserted at the hospital on [DATE] to provide intravenous access for antibiotic administration. Review of the facility’s policy/protocol in providing care and treatment for [REDACTED].

The facility failed to measure the external catheter length with dressing changes on 8/20/16, 8/29/16, 9/5/16, 9/12/16 and 9/19/2016 as required per facility policy/protocol. Review of the clinical record revealed the Resident did not sustain any complications as a result of the facility’s failure to follow their policy/protocol. On 9/26/16 at 2:05 P.M. Unit Manager #1, of the short term rehabilitation unit said the facility failed to measure the external catheter length per facility protocol/policy for a PICC (peripherally inserted central catheter).

Failed to 1) make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that a Resident’s drug regimen was free of unnecessary drugs for one Resident (#8) in a sample of 26 Residents.

Findings include:

Resident #8 was admitted to the facility in 5/2014 with [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) with a reference date of 7/6/16, indicated this resident was dependent for hygiene and required extensive assistance for dressing and bathing with a BIMS (brief interview for mental status) score of 8 out of 15 (moderate cognitive impairment). The resident was incontinent of bowel and bladder and had a chronic diabetic wound on the right ankle. Review of the clinical record on 9/26/16 indicated that the Resident had a physician’s orders [REDACTED]. Review of the MAR(medication administration record) for May 2016 indicated the medication was discontinued on 5/9/16 as ordered.

Review of the MAR for June 2016 indicated that the resident was again receiving Ditiazem 90 mg twice a day despite the physician’s orders [REDACTED]. Further review of the clinical record and MAR’s indicated that Resident #8 continued to receive [MEDICATION NAME] 90mg twice daily for the months of July 2016, August 2016 and September 2016 until Surveyor intervention on 9/26/16. The facility ADON(Assistant Director of Nursing)and the RN Supervisor were interviewed on 9/26/16 at 3:00 P.M. and stated that the [MEDICATION NAME] had continued to be administered due to a transcription error and stated it should have been discontinued as ordered by the physician on 5/9/16.

Failed to give or get quality lab services/tests in a timely manner to meet the needs of residents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that for one resident (#8) of 26 sampled residents, laboratory tests were performed as ordered by the physician.

Findings include:

Resident #8 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. According to the quarterly minimum data set (MDS) with a reference date of 7/6/16, this resident was dependent for hygiene and required extensive assistance for dressing and bathing with a BIMS (brief interview for mental status) score of 8 out of 15. The resident was incontinent of bowel and bladder and had a chronic diabetic wound on the right ankle. Review of the medical record on 9/27/16 indicated a standing physician’s orders [REDACTED]. Resident #8 also had a standing order for hepatic function tests to be done 2 times a year(January/July).

Review of the medical record revealed that the laboratory results for July 2016 were not available for review in the medical record. The Director of Nurses (DON) was interviewed on 9/27/16 at 3:10 P.M. and said that the labs were not obtained as ordered by the physician in July and stated the Nurse Practitioner ordered the labs to be done the next day 9/29/16. The facility failed to ensure that laboratory tests were obtained as ordered by the physician.

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 ensure that the functional mobility plan of care to provide Resident #1 assistance with ambulation and transfers was implemented when on 1/17/17, Resident #1, who had the [DIAGNOSES REDACTED]. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED].

Findings include:

The Facility’s policy titled Care Plans, dated August 2015, indicated the Facility is committed to providing residents with all necessary care and services to enable them to achieve the highest quality of life. Care plans are oriented toward preventing avoidable decline in clinical and functional levels and maintaining a specific level of functioning. Resident #1’s [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired and required extensive assist with ambulation and transfers. A Fall Risk Evaluation, dated 11/6/16, indicated Resident #1 was assessed at high risk for falls. An Individualized Care Plan for Falls, dated 11/12/16, indicated Resident #1 had a history of [REDACTED].

#1’s mobility status. An Impaired Functional Mobility Care Plan, dated 11/12/16, indicated Resident #1 was totally dependent on staff for ambulation and dependent on 2 staff members for transfers. A Resident Daily Flow Sheet, dated January 2017, utilized by the Certified Nursing Assistant (CNA), indicated Resident #1 required extensive assist with ambulation and transfers. An Accident/Incident Report and Investigation Form, dated 1/17/17 at 7:45 A.M., indicated Resident #1 was attempting an unwitnessed independent ambulation, required supervision with ambulation and assist with transfers. The Form further indicated Resident #1 had a hematoma (abnormal collection of clotted blood within the tissues due to trauma) above his/her right eye, swelling to right wrist and was guarding right wrist while complaining of pain. The Facility’s Incident Report Form submitted to the Department of Public Health, dated 1/20/17, indicated Resident #1 was witnessed ambulating independently in the hallway, required assist for ambulation, required supervision at all times while awake and was left unattended by a CNA. Resident #1 was transferred to the hospital and sustained a fractured right wrist from the unwitnessed fall due to being left unattended by a CNA.

A witness statement, dated 1/17/17 at 7:30 A.M., indicated Nurse #2 instructed CNA #1 to assist Resident #1 to a location where he/she could be monitored. A Nurse’s Notes, dated 1/17/17, indicated Resident #1 had an unwitnessed fall in hallway attempting to ambulate independently and was found lying on the floor with swelling and bruising to his/her right eye and swelling with discomfort to his/her right wrist. A Situation Background Appearance and Review (SBAR) Form, dated 1/17/17, indicated Resident #1 was found on the floor at 7:45 A.M., sustained a hematoma to his/her right forehead, an ecchymotic area to his/her right eyebrow, swelling to his/her right wrist and displayed facial grimacing complaining of right wrist pain. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED]. An X-ray report, dated 1/17/17, indicated Resident #1 sustained a comminuted (bone is broken into several parts)impacted and dorsally angulated (posterior and radial displacement) distal radius fractures of his/her right wrist.

The Surveyor interviewed CNA #1 at 12:40 P.M. on 4/4/17. CNA #1 said on 1/17/17 Resident #1 was sitting in a chair at the nurses station. CNA #1 said she was at the nurses station writing the CNA assignments with her back towards Resident #1, when she heard a lot of noise and confusion and when she turned around, she saw Resident #1 lying on the floor in the hallway. CNA #1 said Resident #1 required staff assistance with ambulation and transfers, required supervision at all times, could not be left unattended due being impulsive and frequently getting self up from the chair. CNA #1 said she could not recall Nurse #2 instructing her to bring Resident #1 to an area where he/she could be monitored. The Surveyor interviewed Nurse #1 at 2:02 P.M. on 4/4/17. Nurse #1 said Resident #1 required supervision at all times because she was very quick, would transfer her/himself out of the chair and required assist with ambulation and transfers. Nurse #1 said she heard a bump and saw Resident #1 lying on the floor on his/her right side in the hallway. Nurse #1 said she assessed Resident #1 who complained of right arm pain, had a swollen right wrist, a bump and bruise above right eye. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED].

The Surveyor interviewed Nurse #2 at 1:46 P.M. on 4/10/17. Nurse #2 said on 1/17/17, she saw Resident #1 walking unsteady in the hallway, sat him/her in a wheelchair and asked CNA #1 to take Resident #1 to the day room where he/she could be supervised. Nurse #2 said Nurse #1 notified her that Resident #1 had fallen in the hallway. Nurse #2 said she assessed Resident #1, noted a contusion and lump on his/her forehead, right wrist swelling and Resident #1 was complaining of wrist pain and notified the Nurse Practitioner. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at 4:45 P.M. on 4/4/17. The DON said Resident #1 required assist with ambulation, transfers and required supervision because he/she was a fall risk. The DON said Resident #1 was not supervised or in an area that he/she could be supervised. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED].

A Hospital Discharge Packet, dated 2/8/17, indicated Resident #1 had undergone a right wrist ORIF (open reduction internal fixation-a surgical procedure to fix a severe bone fracture).

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 of 3 sampled residents (Resident #1), who had the [DIAGNOSES REDACTED].#1 who fell and sustained a fracture of the right wrist and required surgery.

Findings include:

The Facility’s policy titled Falls Management, dated April 2015, indicated the interdisciplinary team will develop, initiate and implement an appropriate individualized safety related care plan based on the fall risk evaluation score. Resident #1’s [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired and required extensive assist with ambulation and transfers. A Fall Risk Evaluation, dated 11/6/16, indicated Resident #1 was assessed at high risk for falls. A Resident Daily Flow Sheet, dated January 2017, utilized by the Certified Nurse Assistant (CNA), indicated Resident #1 required extensive assist with ambulation and transfers. An Individualized Care Plan for Falls, dated 11/12/16, indicated Resident #1 had a history of [REDACTED].#1’s mobility status.

An Impaired Functional Mobility Care Plan, dated 11/12/16, indicated Resident #1 was totally dependent on staff for ambulation and dependent on 2 staff members for transfers. The Facility’s Incident Report Form submitted to the Department of Public Health, dated 1/20/17, indicated Resident #1 was witnessed ambulating independently in the hallway, required assist for ambulation, required supervision at all times while awake, was left unattended by a CNA and as a result Resident #1 fell . Resident #1 was transferred to the hospital and sustained a fractured right wrist from the unwitnessed fall due to being left unattended by a CNA. An Accident/Incident Report and Investigation Form, dated 1/17/17 at 7:45 A.M., indicated Resident #1 was attempting an unwitnessed independent ambulation, required supervision with ambulation and assist with transfers and was found on floor by staff. The Form further indicated Resident #1 had a hematoma (abnormal collection of clotted blood within the tissues due to trauma) above his/her right eye, swelling to right wrist and was guarding right wrist while complaining of pain. A witness statement, dated 1/17/17 at 7:30 A.M., indicated Nurse #2 instructed CNA #1 to assist Resident #1 to a location where he/she could be monitored.

A witness statement, dated 1/17/17 at 7:45 A.M., indicated Nurse #1 heard a loud noise and saw Resident #1 lying on the floor. A witness statement, dated 1/17/17, indicated CNA #1 arrived late to work and began working on the CNA assignments and saw Resident #1 sitting in front of the nurses station. A Nurse’s Notes, dated 1/17/17, indicated Resident #1 had an unwitnessed fall in hallway attempting to ambulate independently and was found lying on the floor with swelling and bruising to his/her right eye and swelling with discomfort to his/her right wrist. A Situation Background Appearance and Review (SBAR) Form, dated 1/17/17, indicated Resident #1 was found on the floor at 7:45 A.M., sustained a hematoma to his/her right forehead, an ecchymotic area to his/her right eyebrow, swelling to his/her right wrist and displayed facial grimacing complaining of right wrist pain. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED]. An X-ray report, dated 1/17/17, indicated Resident #1 sustained a comminuted (bone is broken into several parts)impacted and dorsally angulated (posterior and radial displacement) distal radius fractures of his/her right wrist. A Transfer and Referral Record, dated 2/2/17, indicated Resident #1 had a displaced fracture of the right wrist and required operative repair and surgery. The Surveyor interviewed CNA #1 at 12:40 P.M. on 4/4/17. CNA #1 said on 1/17/17

Resident #1 was sitting in a chair at the nurses station. CNA #1 said she was at the nurses station writing the CNA assignments with her back towards Resident #1, when she heard a lot of noise and confusion and when she turned around, she saw Resident #1 lying on the floor in the hallway. CNA #1 said Resident #1 required staff assistance with ambulation and transfers, required supervision at all times, could not be left unattended due being impulsive and frequently getting self up from the chair. CNA #1 said she could not recall Nurse #2 instructing her to bring Resident #1 to an area where he/she could be monitored. The Surveyor interviewed Nurse #1 at 2:02 P.M. on 4/4/17. Nurse #1 said Resident #1 required supervision at all times because she was very quick, would transfer her/himself out of the chair and required assist with ambulation and transfers. Nurse #1 said she heard a bump and saw Resident #1 lying on the floor on his/her right side in the hallway. Nurse #1 said she assessed Resident #1 who complained of right arm pain, had a swollen right wrist, a bump and bruise above right eye. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED].

The Surveyor interviewed Nurse #2 at 1:46 P.M. on 4/10/17. Nurse #2 said on 1/17/17, she saw Resident #1 walking unsteady in the hallway, sat him/her in a wheelchair and asked CNA #1 to take Resident #1 to the day room where he/she could be supervised. Nurse #2 said Nurse #1 notified her that Resident #1 had fallen in the hallway. Nurse #2 said she assessed Resident #1, noted a contusion and lump on his/her forehead, right wrist swelling and Resident #1 was complaining of wrist pain and notified the Nurse Practitioner. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED].

The Surveyor interviewed the Director of Nurses (DON) at 4:45 P.M. on 4/4/17. The DON said Resident #1 required assist with ambulation, transfers and required supervision because he/she was a fall risk. The DON said Resident #1 was not supervised or in an area that he/she could be supervised. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED]. A Hospital Discharge Packet, dated 2/8/17, indicated Resident #1 had undergone a right wrist ORIF (open reduction internal fixation-a surgical procedure to fix a severe bone fracture).

South East 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: August 14, 2017

Call Now Button