Webster Park Rehabilitation and Healthcare Center

Webster Park Rehab Healthcare Center Rockland MA Elder Abuse Attorneys

Rockland Elder Abuse and Nursing Home Neglect Attorneys Serving the South Shore

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Webster Park Rehabilitation and 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.

Webster Park Rehab Healthcare Center Rockland MA Elder Abuse AttorneysAbout Webster Park Rehabilitation and Healthcare Center

Webster Park Rehabilitation and Healthcare Center is a for profit, 110-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Rockland, Norwell, Hanover, Hingham, Duxbury, Scituate, Pembroke, Hanson, Weymouth, Hull, Holbrook, Abington, Braintree, Marshfield, Whitman, and Kingston, as well as other surrounding towns in and near Plymouth County, Massachusetts.

The legal business name for Webster Park Rehabilitation and Healthcare Center is registered as Webster Park Operator  LLC.  Webster Park Rehabilitation and Healthcare Center focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Webster Park Rehabilitation and Healthcare Center
56 Webster Street
Rockland, MA  02370

Phone: (781) 871-0555

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, Webster Park Rehabilitation and Healthcare Center in Rockland, Massachusetts received a rating of 2 out of 5 stars (a below average rating.)

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 Webster Park Rehabilitation and Healthcare Center

The Federal Government has not fined Webster Park Rehabilitation and Healthcare Center for health and safety violations in the past three years as of August 2017.

Fines and Penalties

Our Atorneys inspected government records and discovered Webster Park Rehabilitation and Healthcare Center committed the following offenses:

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

The facility failed to immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.

Based on record review and staff interview, the facility failed to notify the physician and legal guardian of a 13.6 lb (pound) weight loss for 1 Resident (#6), out of a total sample of 16 Residents.

Findings include:

The facility’s Weight Assessment and Intervention policy (last revised 9/2008) indicated the following:

  • Any weight change of 3% or more since the last weight assessment will be retaken in the presence of a nurse for confirmation.
  • The Dietician and physician will review weights on a routine basis to address changes.

The medical record was reviewed on 11/8/16, 11/9/16, 11/10/16 and 11/14/16.Resident #6 was admitted in 10/2016 with [DIAGNOSES REDACTED].

Review of the Admission Minimum Data Set (MDS) assessment, dated 11/1/16, indicated the Resident scored an 14 out of 15 on the BIMS (Brief Interview for Mental Status), indicating intact cognition, and required limited assistance of staff for activities of daily living and was capable of eating independently. The MDS indicated that he/she did not receive a therapeutic diet, was 70 inches tall, weighed 171 lbs (pounds) and had a legal guardian.

Review of the care plan for nutritional status indicated the following:

  • Advise dietician and physician of 5 lb weight change times 30 days or less.
  • Review of the weight record indicated that Resident #6 was weighed on 10/25/16 and 11/2/16. The record showed a weight shift on 11/2/16. The Resident’s weight decreased from 171 lbs on 10/25/16 to 165.8 lbs on 11/2/16 (a weight loss of 5.2 lbs or 3% in 8 days). Review of the medical record failed to indicate that the dietician, physician or legal guardian was notified of the 5.2 lb weight loss.
  • During interview with the Dietician on 11/9/16 at approximately 1:00 P.M., she said that she had not been notified by staff of the amount of Resident #6’s weight loss. Further review of the weight record indicated that Resident #6’s weight decreased again from 168.5 lbs on 10/28/16 to 157.4 lbs on 11/10/16 (a weight loss of 8.4 lbs in 13 days).
  • Further review of the medical record again failed to indicate that the dietician, physician or legal guardian was notified of the 8.4 lb weight loss.
The nursing home failed to provide enough notice before discharging or transferring a resident.

Based on interviews and record review of 1 of 16 sampled residents (Resident #10), the Facility failed to provide written notification to Resident #10, his/her Health Care Agent or family members 30 days or expedited notice prior to transfer/discharge on 8/18/16. The Facility failed to provide written notification of the reason for his/her transfer/discharge and information regarding Resident #10’s rights to appeal the decision to transfer/discharge or the process for initiating an appeal.

Findings include:

The Facility’s Admission Agreement indicated that when a resident was transferred or discharged, he/she had a right to a written notice of the transfer or discharge and a right to appeal. Resident #10’s original admission was in 2/2016 and his/her readmitted was in 10/2016.

Resident #10’s [DIAGNOSES REDACTED].

The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident scored an 11 out of 15 on his/her BIMS (Brief Interview of Mental Status) score, indicating some problems with cognition. The MDS indicated the Resident did not exhibit behaviors, but would reject care. The MDS indicated the Resident required extensive assistance with dressing, toilet use and personal hygiene. The MDS indicated the Resident had a Health Care Proxy, but it was not invoked. However, per record review on 11/10/16 indicated the Resident had informed the Facility that he/she wanted the Family Member involved in all aspects of his/her care.

The Surveyor interviewed Family Member #1 on 11/9/16 at 12:00 P.M. and 11/10/16 at 11:30 A.M. Family Member #1 said Resident #10 had lived in the Facility since 2/2016. Family Member #1 said from time to time the Resident had to be hospitalized for [REDACTED]. The Family Member said on 8/18/16 the Resident had exhibited combative behavior and was transferred to the hospital for a psychological evaluation. The Family Member said the Resident was evaluated by the hospital psychiatric service and was cleared to return to the Facility in less than 24 hours after the transfer. Family Member #1 said the hospital attempted to send the Resident back to the Facility and the Facility refused to take the Resident back.

Family Member #1 said the Facility had not indicated why the Resident could not return and had not provided a written notice of intent to transfer/discharge or been advised of the bed hold policy or appeal rights upon transfer to the hospital.

The Family Member said with the assistance of the hospital he/she filed an appeal. A decision dated 10/14/16 indicated that the Facility had not given proper notice following their decision not to readmit the Resident. The Facility was informed of the decision and were instructed to readmit the Resident to the first available bed.

The Family Member said that he/she nor Resident #10 had never received or had been advised of the bed hold policy or appeal rights upon transfer to the hospital.

During interview on 11/10/16 at approximately 10:00 A.M., the Director of Nurses (DON) and the Administrator said they did not issue a notification of discharge letter or send information about Resident’s right of appeal at the time of his/her discharge from the facility.

During interview on 11/14/16 at 12:20 P.M., Social Worker #1 said the nursing staff usually completed Transfer Notice Letters, listing appeal rights and sent them directly to the hospital with other admission paperwork. Social Worker #1 did not know if the written notification was given directly to the Resident, and/or a copy mailed to his/her Health Care Agent or Family Member. She said she did not know if the notice had been completed for the transfer.

The nursing home failed to tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed.

Based on interviews and record review of 1 of 16 sampled residents (Resident #10), the Facility failed to provide written information regarding the Facility’s bed-hold to Resident #10, his/her Health Care Agent or family members following Resident’s #10 transfer and admissions on 3/10/16, 5/10/16, 7/22/16, 7/27/16 and 8/18/16.

Findings include:

Resident #10’s original admission was in 2/2016 and his/her readmitted was in 10/2016.
Resident #10’s [DIAGNOSES REDACTED].

The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident scored a 11 out of 15 on his/her BIMS (Brief Interview of Mental Status) score, indicating some problems with cognition. The MDS indicated the Resident did not exhibit behaviors, but would reject care. The MDS indicated the Resident had a Health Care Proxy, but it was not invoked. Record review on 11/10/16 indicated that the Resident had informed the Facility that he/she wanted the Family Member involved in all aspects of his/her care.

The Surveyor interviewed Family Member #1 on 11/9/16 at 12:00 P.M. and 11/10/16 at 11:30 A.M. Family Member #1 said Resident #10 had lived in the Facility since 2/2016. Family
Member #1 said from time to time the Resident had to be hospitalized for [REDACTED]. The Family Member said on 8/18/16 the Resident had exhibited combative behavior and was transferred to the hospital for a psychological evaluation.

The Family Member said that he/she, nor Resident #10 had never received or had been advised of the bed hold policy or appeal rights upon transfer to the hospital on [DATE], 5/10/16, 7/22/16, 7/27/16 and 8/18/16.

The Facility’s Bed Hold Policy indicated Medicaid will pay to hold a bed for a maximum of twenty (20) days only. Any resident still in the hospital after twenty (20) days was considered discharged . The Policy indicated the Facility will readmit the resident to the first available bed, if the resident requires services provided by the Facility and was eligible for Medicaid nursing services.

Review of Resident #10’s clinical record indicated there was no documentation to indicate that written notification of the Bed-Hold policy had been provided to Resident #10 at the time of transfers or within 24 hours of when Resident #10 was transferred to the Hospital.

The Surveyor interviewed the Assistant Director of Nurses (ADON) on 11/15/16 at 2:00 P.M. she said that there was confusion about the bed hold notice or bed hold information. She said that the Facility thought the information was included on the Notice of Intent to Transfer Notice. She said that the bed hold notice and bed hold information had not been
provided.

Failed to hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

Based on record review and staff interview,the facility failed to investigate an allegation of misappropriation immediately and thoroughly, failed to take immediate action to protect this resident and other residents in the facility following an allegation of misappropriation, and failed to report the results of the investigation to the designated representative and to other officials in accordance with State law (including to the State survey and certification agency). The facility failed to report unwitnessed falls with injury to the State Agency in accordance with regulations for reporting, for 1 residents (#11), out of a total sample of 16 residents.

Findings include:

For Resident #11, the facility failed to investigate an allegation of misappropriation immediately and thoroughly, failed to take immediate action to protect this resident and other residents in the facility following an allegation of misappropriation, and failed to immediately report the allegation to the Administrator and the State Department of Public Health as required by state statute.

Resident #11 was admitted to the facility in 5/2015 with [DIAGNOSES REDACTED]. The medical record was reviewed on 11/15/16.

A review of the facility’s policy for Abuse Prevention Program:
The facility alleges that they have comprehensive policies and procedures developed to aid
the facility in preventing, identifying and reporting abuse, neglect and theft/misappropriation. All alleged violations are thoroughly investigated, the facility implements corrective action and reports findings in accordance of federal or state law. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 9/20/16 indicated that Resident #11’s long and short term memory were intact and required minimum assistance with activities of daily living. The Resident scored a 15 out of 15 on his/her Brief Interview of Mental Status (BIMS), indicating the Resident was cognitively
intact.

During review of the Facility grievance log, Resident #11 had reported 2 $20.00 bills stolen from his/her wallet. The report indicated that on 3/29/16, the Resident got out his/her wallet and noticed that the wallet fastener was attached, which the Resident stated he/she never did. Resident #11 reported that when he/she checked the wallet 2 $20.00 bills ($40 total) were missing from the wallet. The grievance report indicated that the incident was reported to the Director of Nurses and Social Worker on 3/29/16. The grievance indicated that the facility had resolved the incident by informing the Resident to not leave items out and to use the lock box. The form indicated the money was replaced. During interview with the Director of Nurse (DON) on 11/15/16 at 12:50 P.M., she was unsure if the incident had been fully investigated and reported to the Department of Public Health. The DON said she would check with the Social Worker, as there had been a lot of changes in facility staff (including her being relatively new to the facility). The DON later stated, at 2:20 P.M. on 11/15/16, that she had checked with the Facility’s Social Worker and the incident had not been investigated and reported to the Department of Public Health.

During interview with Resident #11 on 11/15/16 at 1:45 P.M., the Resident said that he/she recalled the incident but was not sure of the outcome. Resident #11 said he/she was told not to leave things out in the open and that he/she may have been reimbursed for half of the $40.00.

Failed to ensure services provided by the nursing facility meet professional standards of quality.
Based on record review and staff interview, the facility failed to ensure that services
provided to 2 Residents (#1 and #11), of a total sample of 16 Residents, met professional standards of nursing quality for correct medication administration.

Findings include:

1. For Resident #11, the Facility failed to ensure the Resident received the appropriate prescribed treatment following 3 eye assessments and treatments.

Resident #11 was admitted to the facility in 5/2015 with [DIAGNOSES REDACTED]. The medical record was reviewed on 11/15/16.

Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 9/20/16 indicated that Resident #11’s long and short term memory were intact and required minimum assistance with activities of daily living. The Resident scored a 15 out of 15 on his/her Brief Interview of Mental Status (BIMS), indicating the Resident was cognitively intact. The MDS indicated the Resident had some vision problems associated with diabetes. Further review indicated that the Resident had been seen by a eye health provider for diabetic eye disease on 7/26/16, 8/15/16 and 11/1/16.

Review of the eye health consults/referrals indicated the following:

  • 7/26/16 – indicated the Resident was evaluated by the eye doctor and he/she indicated the Resident had a left eye infection. The physician indicated that the staff were to instill lubricating tears to the left eye every hour while awake, for one day. The recommendations indicated this is very important and underlined the very.
  • Review of the physician orders [REDACTED] 8/15/16 – indicated the eye health provider gave the Resident an injection to the left eye, and ordered to instill lubricating eye drops into the left eye every hour while awake
    for the day.
  • Review of the physician orders [REDACTED]. 11/1/16 – indicated the Resident received an injection in the right eye and order eye lubricating drops hourly to the right eye, while awake, the physician wrote please.
  • Review of the physician orders [REDACTED].  During interview on 11/15/16 at 1:30 P.M., the Assistant Director of Nurses (ADON) said that the Resident had received the drops following the eye treatments, but that she would check. The ADON later confirmed that the orders were not obtained and the eye drops were not instilled as ordered.

During interview with Resident #11 on 11/15/16 at 1:45 P.M., the Resident was asked about his/her eyes. The Resident said he/she had problems with his/her eyes due to the diabetes. Resident #11 said that he/she had received about 6 treatments from the eye doctor and that some included injections. Resident #11 said that the injections have been spread out during the past 6 months or more. The Surveyor asked about the drops and the Resident laughed. Resident #11 said that the staff did not do the drops and that the eye doctor was aware. Resident #11 said that the eye doctor was frustrated and when filling out the referral form after the injection, he would write in large letters, underline his request and wrote please.

2. For Resident #1, the Facility incorrectly transcribed medication orders after the Resident was evaluated at the [MEDICAL CONDITIONS] Clinic, resulting in giving the incorrect dose of the diuretic medication [MEDICATION NAME] and not obtaining orders for compression stockings, Resident #1 was admitted in 1/2015 and had [DIAGNOSES REDACTED].

Review of the most recent MDS assessment with a reference date of 8/30/16, indicated the Resident was cognitively impaired and required assistance in all areas of his/her activities of daily living.

Record review indicated that the nurse’s note dated 11/7/16 noted the increase in the [MEDICATION NAME] and that the nurse had verified the order with the Resident’s physician to increase the [MEDICATION NAME] from 40 mg twice daily to 60 mg twice daily. The order was transcribed into the order sheets and Medication Administration Record [REDACTED].

Record review indicated that the nurse’s note dated 11/7/16 noted the increase in the [MEDICATION NAME] and that the nurse had verified the order with the Resident’s physician to increase the [MEDICATION NAME] from 40 mg twice daily to 60 mg twice daily. The order was transcribed into the order sheets and Medication Administration Record [REDACTED]. Review of the MAR for 11/2016 indicated the Resident missed 6 doses of the [MEDICATIOn NAME]. In addition, there was no indication the compression stockings were ordered and applied.

During interview with the ADON on 11/14/16 at 9:30 A.M., she reviewed the record with the Surveyor and said the transcription was incorrect and she would complete a medication error sheet. She also said she would make sure there was an order for [REDACTED].

During observation on 11/15/16 at 10:40 A.M., the Resident was observed in the day room. The Resident was not wearing the compression stocking, but was wearing slip on shoes and low sport socks

The facility failed to make sure that each resident received a nutritional and well balanced diet, unless it is not possible to do so.

Based on record review and staff interviews, the facility failed to ensure that Residents maintained acceptable parameters of nutritional status based on a comprehensive nutritional assessment and provide interventions timely to prevent further weight loss (of 7.9 % in 16 days) and stabilize weight for 1 Resident (#6), out of a total sample of 16 Residents.

Findings include:

The medical record was reviewed on 11/8/16, 11/9/16, 11/10/16 and 11/14/16.
Resident #6 was admitted in 10/2016 with [DIAGNOSES REDACTED].

The medical record was reviewed on 11/8/16, 11/9/16, 11/10/16 and 11/14/16. Resident #6 was admitted in 10/2016 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 11/1/16, indicated the Resident scored an 14 out of 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was cognitively intact and required limited assistance of staff for activities of daily living and was capable of eating independently. The MDS indicated that he/she did not receive a therapeutic diet, was 70 inches tall, weighed 171 lbs (pounds) and had a legal guardian.

The October 2016 physician’s orders [REDACTED].#6 was to be weighed weekly for 4 weeks. Review of the weight record indicated that Resident #6 was weighed on 10/25/16 and 11/2/16. The record showed a weight shift on 11/2/16. The Resident’s weight decreased from 171 lbs on 10/25/16 to 165.8 lbs on 11/2/16 (a weight loss of 5.2 lbs or 3% in 8 days). The weight record failed to indicate that the Resident’s weight was retaken in the presence of a nurse for confirmation according to facility policy.

The Dietician conducted an initial nutritional assessment on 11/6/16 (4 days after the Resident had a 5.2 lb weight loss) and documented that the Resident ate between 50-100% of most meals, but his/her intake varied and there were times when he/she may only eat 25-50% of a meal. The Dietician recommended that labs be done and health shakes be offered to the Resident when his/her intake is less than 50% of a meal. Review of November 2016 physician’s orders [REDACTED]. During interview with the Dietician on 11/9/16 at approximately 1:00 P.M., she said that she was aware that Resident #6 had variable meal intake, but wasn’t aware of the amount of Resident #6’s weight loss. Further review of the weight record indicated that Resident #6 was weighed on 11/10/16. Again, the Resident’s weight showed a shift from 165.8 lbs on 11/2/16 to 157.4 lbs on 11/10/16 (a weight loss of 8.4 lbs or 5% in 8 days). The Resident’s weight was retaken in the presence of a nurse and the weight of 157.4 lbs was confirmed. Review of November 2016 Medication Administration Record [REDACTED]. Review of 11/14/16 progress note indicated that subsequent to Surveyor inquiry regarding Resident #6’s weight loss, a physician’s orders [REDACTED].#6 to be weighed 3 times a week, would receive Med Pass nutritional supplement 240 ml twice a day and the physician
and legal guardian were updated.

The nursing home failed to prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.

Based on observation, staff interview, the Resident group interview and food temperature checks, the facility failed to provide Residents with foods that were served at the proper temperature as evidenced by the results of 2 test trays.

Findings include:

During the group meeting on 11/9/16 at 11:00 A.M., 15 out of 15 Residents in attendance complained of cold food, with not one specific meal time being more problematic than an other, stating that it could be up to all 3 meals.
On 11/14/16 at 8:05 A.M., the surveyor proceeded to the third floor unit and observed the food trucks which contained trays with the Residents breakfast food. The staff on the unit were in the process of passing the breakfast trays to the Residents. At 8:09 A.M. the third and final food truck arrived on the unit. The staff continued to pass the breakfast trays to the Residents.

At the request of the Surveyor, at 8:15 A.M.the Food Service Director arrived on the third floor unit and it was relayed to him the last tray off the food truck would be a test tray.
The following temperatures were taken and the results were as follows:

  • Scrambled eggs with cheese-98 degrees Fahrenheit (F)
  • Cream of Wheat-132 degrees F
  • Black coffee-124.2 degrees F
  • Orange Juice-66.1 degrees F
  • Milk-55.3 degrees F

The Surveyor and the Food Service Director then proceeded to the second floor unit. At 8:30 A.M. there were two food trucks on the unit. The last tray on the food truck was picked for another test tray.

The following temperatures were taken and the results were as follows:

  • Scrambled eggs with cheese-112 degrees Fahrenheit (F)
  • Cream of Wheat-152 degrees F
  • Black coffee-136 degrees F
  • Orange Juice-57.5 degrees F
  • Milk-45.4 degrees F

The food delivery system did not include a heating unit for plates or insulated food trucks.The test tray was taste tested by the Surveyor and the Food Service Director, specifically the Scrambled eggs with cheese and both agreed that the eggs were luke warm, boarding on cold however the food was palatable. The coffee was luke warm and the cold items did not register at 41 degrees F or below.

The Surveyor then questioned the Food Service Director regarding the temperatures of the food when it left the kitchen. The Food Service Director told surveyor that the temperatures of the breakfast foods had not been taken prior to the food leaving the kitchen and then being delivered to the Residents.

Administrative staff were advised of the food temperature concerns based on the Resident group interview and test tray food temperatures at 3:00 P.M. on 11/15/16.

The nursing home failed to provide or obtain dental services for each resident.

Based on record review and interviews, the Facility failed to promptly refer residents with lost dentures to a dentist for 1 Resident (#1) out of a total sample of 16 residents.

Findings include:

Resident #1 was admitted in 1/2015 and had [DIAGNOSES REDACTED]. Review of the most recent MDS assessment with a reference date of 8/30/16, indicated the Resident was cognitively impaired and required assistance in all areas of his/her activities of daily living.

During interview with Resident #1’s family on 11/14/16 at 10:30 A.M. and 11/15/16 at 12:00 P.M., the Family said they reported the loss of the Resident’s bottom denture in 5/2016. The Family said despite their advocacy the Resident has remained without dentures for more than 5 months. The Family said that they had been told a number of times that the dentist would be in but that nothing had happened. They said that the Resident required speech therapy due to the missing lower denture on and off since May, yet the Facility had not pursued getting the teeth replaced timely. The Family said they had been told the Resident was seen in June and August, but after calling the dentist found that the Resident had not been seen, because the dentist told the Family that the Facility had not ensured payment of the replacement denture. The Family said that the Facility said the dentist had seen the Resident in October and that the dentures would be arriving shortly. The Family said the Facility’s poor response and delay concerned them.

Record review indicated that the Resident’s teeth were noted to be missing and on 5/23/16 was seen by speech therapist due to recent loss of bottom denture (of 1 week) and weight loss. The evaluation indicated the Resident was on a regular textured diet and weight loss was minimum (and further review indicated may be associated with diuretic medications). The speech therapist downgraded the diet texture to mechanical soft and continued to treat the Resident through 11/2016.

Review of the grievance complaint indicated the Facility was notified of the missing denture on 5/24/16. The form indicated a thorough search had been conducted and that the Facility would replace the denture on 5/24/16. An additional notation by the Administrator dated 8/26/16 indicated the Facility had resolved the problem and had contacted the dentist to make the replacement denture.

During interview on 11/14/16 at 2:30 P.M., the Director of Nurses (DON) and the Administrator said they were aware that the Family had reported the lost denture in 5/2016. The DON gave a number of reasons for the delay in replacing the denture. The DON first said the reason for the delay was that the grievance was ambiguous; she then said the dentist had lost any and all tracking of his visit in August 2016 and therefore had to reschedule his visit. The DON was aware the Family were upset of about the delay and said providing speech therapy and decreasing the texture of the Resident’s diet were to make sure the Resident swallowed safely.

The facility failed to keep accurate, complete and organized clinical records on each resident that meet professional standards.

Based on record review and staff interview, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for one sampled resident (Resident #10) in a total sample of 16 residents.

Findings include:

For Resident #10, the facility failed to document a fall in the Resident’s record. Resident #10 was readmitted to the facility in 10/2016 and had [DIAGNOSES REDACTED]. During observation on 11/9/16 at 11:30 A.M., Resident #10 was observed in the hallway and it he/she had a bruise under his/her left eye. During interview with the Resident’s Family on 11/9/16 at 12:00 P.M., the Family Member said he/she had been notified that the Resident had fallen on 10/24/16 at 3:45 A.M.

Review of the nurses progress notes failed to indicate the Resident had a fall on 10/24/16. The only documentation was a 48 hour neuro signs form that was initiated on 10/24/16 at 3:35 A.M.
During review of accidents and incidents, the Assistant Director of Nurses (ADON) provided
an occurrence report.

Review of the report indicated the Resident had fallen on 10/24/16 at 3:45 A.M. and sustained 2 hematoma’s to his/her head, one on the left side of head and one on the front forehead.

During interview on 11/15/16 at 2:00 P,M., the ADON was unaware that the nursing staff had not documented an assessment in the medical record following the fall.

Failed to ensure that residents received proper treatment and assistive devices to maintain their vision and hearing.

Based on record review and interviews the Facility failed to ensure for 1 Resident (#1), out of a total sample of 16 residents, that his/her eyeglasses were replaced after they had been reported lost.

Findings include:

Resident #1 was admitted in 1/2015 and had [DIAGNOSES REDACTED]. Review of the most recent MDS assessment with a reference date of 8/30/16, indicated the Resident was cognitively impaired and required assistance in all areas of his/her activities of daily living. The MDS indicated the Resident had difficulty with vision and wore glasses.

The second time the Family noticed the Resident’s eye glasses were missing was on 10/1/16. The Family reported the loss to the Director of Nurses (DON) and after 2 weeks re-contacted the DON. The Family said the Facility had no information about the missing eye glasses or when they would be replaced. The Family said they offered to assist in replacing the glasses, because the Facility had made no effort in finding or getting the eye glasses replaced. The Family said they were told they could if they wanted to, but that they would not be reimbursed, unless they used a provider contracted under the Resident’s insurance. The Family said they felt this was a deterrent, were frustrated and left thinking the Facility would have their eye provider replace the glasses. The Family said that the eye glasses have not been replaced. and that the Facility has had no further contact with them about them. They did not know if the Facility had scheduled an appointment to replace the glasses or not. The Family said that the Facility did not seem to take responsibility in prevention of the Resident losing their eye wear.

Review of the medical record failed to indicate the report of the missing eye glasses or evidence that arrangements had been made to replace the eye glasses.

Review of the grievance log, which included multiple complaints of lost eye glasses, hearing aides and teeth, failed to include the loss reported by the Family on 10/1/16. However, during interview with the DON on 11/14/16 at 2:27 P.M., the DON said she was aware the glasses were lost and thought the Family was having them replaced and were bringing the bill in. She said it had been their choice to do it this way. The DON said she was unaware the Family had not interpreted the conversation the same way as she had and had not followed up with the Family about the glasses. The Surveyor asked if she was aware this had been the second time the Resident’s eye glasses had been lost. The DON had not and said it would be impossible to keep track of all the time.

Failed to provide the right treatment and services to residents who have mental or psychosocial problems adjusting.

Based on record review and interview the facility failed to ensure that for 1 resident (#10) in a total sample of 16 residents, who displayed mental or psychological adjustment difficulties received and was provided the appropriate treatment and services to correct the assessed problem.

Findings include:

For Resident #10, the Facility failed to provide alternative interventions to Resident #10 with identified [MEDICAL CONDITIONS] who had refused services from the Facility’s psychiatric consultant.

Resident #10 was admitted to the facility in 2/2016 and readmitted in 10/2016. The resident had [DIAGNOSES REDACTED].

The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident scored a 15 out of 15 on his/her BIMS (Brief Interview of Mental Status) indicating the Resident was cognitively intact and exhibited some verbal and physical behaviors. The MDS indicated the Resident required extensive assistance with dressing, toilet use and personal hygiene. The MDS indicated the Resident was hard of hearing and wore hearing aides. The MDS indicated the Resident had a Health Care Proxy, but it was not invoked. However, record review on 11/10/16 indicated the Resident had informed the Facility that he/she wanted the Family Member involved in all aspects of his/her care.

During interview with Family Member #1 on 11/9/16 at 12:00 P.M., he/she said the facility did not know how to care for Resident #10. Family Member #1 said he/she did not believe the staff were properly trained in caring for a resident (Resident #10) who had [MEDICAL CONDITION] and dementia.

The Family Member said that the Resident was a combat veteran and has had significant behavior problems associated with his/her [MEDICAL CONDITION] and dementia. The behavioral issues included resistance to care, noncompliance, guardedness, and suspiciousness leading to verbal and sometimes physical arguments with others. Family Member #1 said that anything can exacerbate the flashbacks and memories. The Family Member said that he/she has tried to support the Facility with Resident’s #10 care but that they only want the Resident to be seen by the facility’s consulting psychiatric service and have ignored the information offered by the Family Member and Veteran’s service.

Record review indicated that the Resident had lived in a veteran’s facility and was admitted to the Facility for long term care in 2/2016. According to the transferring facility the Resident had a complex medical history and was a combat veteran who displayed [MEDICAL CONDITION] and dementia based behaviors.

Further review indicated that the resident displayed behaviors of aggression towards staff and on 2/25/16 the Facility approached the Resident and Family Member to have the Facility’s psychiatric service evaluate the Resident. The Family Member was hesitant but allowed a consult.

On 2/25/16, the psychiatric consultant assessed the Resident and recommended a change in the Resident’s medication to increase the [MEDICATION NAME] from 5 mg, twice daily to [MEDICATION NAME] XR (a medication used with dementia residents) 14 mg daily. The assessment noted that the Resident spoke about his/her [MEDICAL CONDITION], but said that he/she was able to work through it.

Subsequently to the psychiatric consult, the order for the [MEDICATION NAME] was changed, however the Resident continued to display agitation and had conflict with the staff. On 2/29/16, the physician ordered the antidepressant medication [MEDICATION NAME] 50 mg at hour of sleep. In addition, the physician ordered [MEDICATION NAME] as needed, 25 mg for mild agitation and 50 mg for severe agitation, every 8 hours.

Further review of the interdisciplinary progress notes (3/2/16 – 3/28/16) indicated the Resident exhibited verbally abusive language towards staff and had changes in his/her medical condition. The notes were generic and did not specify what the Resident said or if there was a trigger that might have caused the behavior. For exampled on 3/2/16, the Resident was verbally abusive during the morning and was difficult to redirect. The nurse’s note indicated upset with care and his/her breakfast was cold.

On 3/6/16 the Resident had medical changes that included treatment for [REDACTED]. On 3/13/16 he/she had verbal outburst during breakfast and on 3/25/16 and 3/26/16 was agitated, throwing tissue boxes, verbally abusive, accusatory and resistive to redirection.

On 3/28/16 the Resident reported that he/she thought a staff had fondled him/her. The Facility arranged for the consulting psychiatric practitioner to evaluate the Resident. The psychiatric consultant indicated the Resident stated that it may have been a nightmare associated with [MEDICAL CONDITION]. The consultant recommended a medication change to include the medication Klonopin (a [MEDICAL CONDITION] medication used as a tranquilizer). On 3/30/16, the Family Member and Resident were informed of the psychiatric’s recommendations and they refused. The nurse’s note indicated the Family Member informed the Facility that the Resident did not do well with medication changes and that before any further changes are recommended or ordered that he/she would arrange to have the Resident evaluated by an outside psychiatric service.

Review of the interdisciplinary notes from 3/30/16 through 6/2/16 indicated the Resident exhibited yelling out, agitation, verbal abuse towards others and refusal of care. These notes were generic and did not identify specifics about the behaviors.

On 4/5/16, the Facility indicated in a nurses’s note that conversation with the Family Member indicated that he/she acknowledge the Resident could be difficult and reassured the Facility he/she would help. On 4/15/16, the nurse documented the Resident was upset and was not able to be redirected. The Resident wanted to contact the VA and on 4/20/16 was agitated and was talking about a French medal.

Following a fall on 4/26/16, the nurse’s note, dated 4/27/16, indicated a conflict with the Family Member erupted following discussion of medications and suggestion for care. The note was unclear what the conflict was, but that the Family wanted to speak with the Resident’s physician. On 4/28/16, the nurse indicated there was another discussion with the Family Member, surrounding the refusal to have the Resident cared for by the Facility’s psychiatric provider. The note indicated that the Resident would be sent out for increase behaviors and the Family Member said the Resident would be followed by the VA for psychiatric care. The Family Member spoke with the physician about care.

The Resident exhibited fairly frequent outburst and agitation during the month of May. On 5/10/16, the nurse’s note indicated the Resident was making delusional statements about other residents (not specific) and was threatening. The physician ordered the Resident be sent for an evaluation.

On 5/24/16, the Resident was readmitted and the nurse documented the hospitalization was for [MEDICAL CONDITION] and acute kidney injury. Although, the hospital discharge record indicated these [DIAGNOSES REDACTED]. The nurse’s note indicated the physician was updated and approved medications changes, but the nurse made no mention of the psychiatric component of the hospitalization , even though she documented the Resident was verbal abusive and aggressive upon readmission.

On 6/2/16, the Family Member had arranged for the Resident to be evaluated by his/her (outside) psychiatrist. The psychiatrist indicated that [MEDICAL CONDITION] was a problem for the Resident and may contribute to behaviors and identified the Resident’s significant problems associated with his/her [MEDICAL CONDITION]. The psychiatrist recommended the Facility to take over the psychiatric service, but knew this was in conflict with the Resident and Family Member choice.

On 6/2/16, the nurse’s note indicated that he/she approached the Resident and Family Member about the recommendation to use the facility psychiatric service and that they refused. Interdisciplinary notes through 6/27/16 indicated the Resident continued to exhibit behaviors of yelling and refusal of care. The notes tended to be generic and the notes indicated a conflict remained between the Resident, Family Member and Facility over their choice of not using the facility’s psychiatric consultant.

On 6/27/16, the Resident was evaluated by an outside physician (there was no indication who or the reason for the consult). However, the consult indicated that the Facility should investigate behavioral neurologist measures rather then rely on medication. The consult indicated that the Resident should be gotten up as much as possible and to monitor the sedating effects and blood sugars as side effects of medication.

The nurse’s note only indicated the resident returned from an appointment on 6/27/16. On 7/2/16 the Resident had an altercation with Non Sampled Resident #1 (NS #1). Resident #10 was sitting in wheelchair in the hallway and when NS #1 approached Resident #10 he/she grabbed his/her arm and caused a superficial bruise. Resident #10 was sent to hospital for evaluation of aggressive behaviors and returned with recommendations for psychiatric services.

The interdisciplinary notes following the 7/2/16 incident indicated the Resident continued to exhibit aggressive behaviors.

On 7/3/16, the nurse’s note indicated at 2:00 A.M., the Resident said he/she was trying to change the light and when the staff said it was working, the Resident became aggressive. On 7/4/16, the nurse’s note indicated the Resident was delusional stating he/she was a state cop. But in fact the Resident was a state policeman as confirmed during an interview with Family Member #1 on 11/9/16 at 12:00 P.M.

On 7/5/16, the Social Worker’s and nurse’s notes indicated that the Facility Administration and the Social Worker met with Family Member #1. The Social Worker indicated that the Resident and Family have refused the facility’s psychiatric service and due to the Resident’s recent aggressive behaviors, the physician has directed the Facility to increase the [MEDICATION NAME] from 50 mg daily to three times per day and to have the Resident be seen by psychiatry. The notes indicated if the Family did not agree, the Resident would be directly admitted to a psychiatric facility. The Social Worker’s note indicated the Family Member telephoned the Resident’s psychiatrist and made arrangements for the Resident to be evaluated on 7/11/16. The Social Worker documented that this was not soon enough and that the Resident needed to be seen sooner. The note indicated the Family left the meeting and that she (the Social Worker) would monitor.

On 7/6/16, the nurse documented the Resident was agitated on the 11:00 P.M. to 7:00 A.M. shift. Although, the medical record had no documentation of the outcome of the 7/5/16 meeting, a consult was located in the medical records overflow file, which indicated the Resident was evaluated on 7/6/16, by his/her psychiatric provider at the VA. Review of the assessment indicated it had been done on an emergency basis. The psychiatric provider indicated he/she was willing to assist in caring for the Resident. The practitioner indicated the behaviors are associated with [MEDICAL CONDITION], depression and dementia. Mediation changes were agreed upon and a plan included diagnostic (labs etc.), an evaluation with neuro services for memory and followup with psychiatric services at the hospital. The day shift on 7/6/16 indicated the Resident returned from the an appointment with his/her psychiatrist. Recommendations for medication changes were implemented, there was no indication that the other parts of the plan were identified and implemented. Review of the record indicated there was a Behavior Care Plan for verbally and abusive behaviors with care, refusing treatment at times and resident and family have decided to not allow psych services to follow at the facility (2/23/2016), but no careplan for [MEDICAL CONDITION]. There was not documentation or care plan update after any of the events documented in the nursing notes, or consult recommendations regarding the behaviors and [MEDICAL CONDITION].

Review of the monthly behaviors logs for the Resident indicated that the staff were monitoring for the following behaviors agitation, verbal abuse, swearing, hits, sexual inappropriate (never mentioned in the medical record but on the behavior sheet) and depression.

Review of the interdisciplinary notes from 7/6/16 through 8/18/16 indicated the Resident exhibited episodic incidents of aggression and verbal outburst.

7/7/16 – grabbed a housekeeper arm.

  • 7/9/16 – agitated and refused night time care.
  • 7/14/16 – argumentative with staff
  • 7/17/16 – resident attempting to call the police
  • 7/18/16 – confrontational and slamming fists on table
  • 7/22/16 – massive nose bleed and sent to hospital until 7/26/16 and returned exhibiting verbal aggression and attempting to throw self on floor (rehosptalized on [DATE] with a pneumothorax after a fall).
  • 8/18/16 – the Resident was readmitted and the nurse (note) indicated that during skin check and care the resident became abusive towards staff and was hitting, punching, kicking, biting and pulling. Redirection was unsuccessful and the facility did not call the VA psychiatric service but called the family member. The nurse contacted the facility’s psychiatric service to have the Resident evaluated and was told that the Resident and Family had refused the service and to contact 911 if abusive behavior occurs.  Although, there was not documentation that the Resident’s behavior continue, the nurse wrote an additional note indicating she was waiting for a call from the physician. She said the Family Member arrived and informed the Family Member of the plan to send the Resident to the hospital for a psychiatric evaluation.

A subsequent note on 8/18/16 indicated that the physician called back and ordered the Resident be assessed by Geri-psychiatric services and the Resident was transferred to the
hospital.
The Resident was evaluated by the hospital psychiatric service and was cleared to return to the Facility in less than 24 hours after the transfer. However when the hospital attempted to send the Resident back to the Facility and the Facility refused to take the Resident back.

A meeting was held with the Family Member on 9/8/16 to discuss an appropriate plan of care for readmission. The facility wanted the consulting psychiatrist to care for the Resident and the Family Member said he/she wanted the Resident to be seen by the VA psychiatric services and that he/she would continue to make the arrangements. The facility did not agree with the Resident and Family’s decision and would not readmit the Resident. Family Member #1 appealed the discharge and a decision dated 10/14/16 indicated that the Facility had not given proper notice and was subsequently readmitted to the facility on ,[DATE].

Upon readmission, on 10/21/16, the nurse’s note indicated the Resident exhibited aggressive behavior during care.

The care plan (10/21/16) indicated that the Resident and/or family member refused the facility’s psychiatric service, but did not include any mention of [MEDICAL CONDITION] and did not indicate what they would do in the event the Resident exhibited [MEDICAL CONDITION] or exacerbated to possible cause harm.

The plan did not include any reference to use the VA psychiatric service, but focused on the refusal, not that the family and resident offered other alternatives to treat the behaviors associated with the [MEDICAL CONDITION] and dementia.

On 10/21/16, the Social Worker’s note was a summation and although, included the rejection by the Resident and Family of the psychiatric service at the facility, she did not include an assessment or a plan other than she will available.

During interview on 11/10/16 at approximately 10:00 A.M., the Director of Nurses (DON) and the Administrator said that there had been issues and continued to view the non use of the facility’s psychiatric service as a problem. They did not know about the Resident’s history and combat related [MEDICAL CONDITION]. The DON and Administrator said if the Resident exhibit aggression that the Resident would be sectioned out of the Facility for a psychiatric evaluation.

During interview on 11/14/16 at 12:20 A.M. Social Worker #1 said that she had not been involved since the meeting held with the Family Member before the readmission in 10/2016. Social Worker #1 said she did not know what the Facility would do if the Resident became aggressive, but thought the Resident would be sent out for an evaluation. The Social Worker did not know the Resident’s history and did not consider the outside psychiatric provider as an integrated services to ensure the Resident’s [MEDICAL CONDITION] was addressed. The Surveyor asked the Social Worker what might provoke the Resident’s behavior and she said approach.

During interview on 11/14/16 at 2:00 P.M., the Surveyor reviewed the medical record with the Assistant Director of Nurses (ADON). After reviewing the record and the consults she said she had not seen the consults. The Surveyor asked the ADON how the facility was managing the Resident’s [MEDICAL CONDITION] and use of the outside psychiatric provider. She said the Family Member made the arrangements and the facility relied on him/her. The Surveyor asked if they had the phone number of the psychiatric consultant available for an emergency to assist in treating the [MEDICAL CONDITION] and she said she did not know.

Webster Park Rehabilitation and Healthcare Center Nursing Home Neglect and Elder Abuse Lawyers

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

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

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

Boston Personal Injury Lawyers for Elder Abuse Cases

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


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Page Last Updated:  November 14, 2017

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