Wingate at Worcester

Wingate at Worcester

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Wingate at Worcester? 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.

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About Wingate at Worcester

Wingate at Worcester is a for profit, 173-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Worcester, Millbury, Shrewsbury, Grafton, Sutton, Leicester, Westborough, Northborough, Holden, Northbridge, and the other towns in and surrounding Worcester County, Massachusetts.

Wingate at Worcester
59 Acton St,
Worcester, MA 01604

Phone: (508) 791-3147
Website: https://wingatehealthcare.com/location/wingate-at-worcester/

CMS Star Quality Rating

Wingate at WorcesterThe 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 2018, Wingate in Worcester, Massachusetts received a rating of 4 out of 5 stars.

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

Fines Against Wingate at Worcester

The Federal Government fined Wingate at Worcester $5,850 on June 30th, 2016 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Wingate at Worcester committed the following offenses:

Failed to keep each resident free from physical restraints, unless needed for medical treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility staff failed to ensure 3 residents (#7, #11 and #15) out of 4 applicable residents, in a total sample of 24 residents, were free from physical restraints.

Findings include:

Review of the facility’s Restraint Policy, revised 2/2017, indicated the following:
– Physical Restraints are defined as any manual method or physical or mechanical device, material or equipments attached or adjacent to the resident’s body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one’s body.

-All efforts will be exhausted to ensure the least restrictive method of restraint is used. This facility will use the least restrictive alternative for the least amount of time and will document the evaluation of the continued need of the restraint. -Monitoring requirements: Restraints are released every two hours for positioning, toileting, skin checks or exercise, and then reapplied and are documented on the Certified Nurses Aide (CNA) restraint flow records.

-All restraints will have a specific physician’s orders [REDACTED].> *What device is to be used and the medical symptom.

*How often the device is to be used *The restraint will be released for reposition, toileting, skin checks or exercise, every two hours and reapplied. -A resident specific care plan for restraint reduction will be developed by the interdisciplinary team.

1. For Resident #11, the facility staff failed to follow a systematic process of evaluation and care planning prior to using a restraint, did not identify the presence of a specific medical symptom that would require the use of restraints and failed to document when the restraint was released.

Resident # 11 was admitted to the facility in 5/2014 with a [DIAGNOSES REDACTED]. Review of the 5/2017 physician’s orders [REDACTED]. Release for toileting and care at least every 2 hours. The order did not indicate the medical symptom treated by the restraint.

Review of the CNA Care Card indicated the pelvic restraint was a special behavioral intervention for self transferring (dated 2/17/17). Review of the restraint section of the care card indicated a pelvic restraint seat belt was used. The care card did not indicate a release schedule.

Review of the fall care plan, with a goal date of 8/8/2017, indicated an intervention with a start date of 2/17/17 to provide the resident with safety device/appliance: pelvic seat belt restraint while in wheelchair Further review of the care plan did not indicate any goals or interventions to release and/or reduce the use of the restraint.

Review of the POS [REDACTED].

Review of medical record indicated Fall Review Meeting Minutes, for a fall on 12/16/16, indicated the last time the resident had fallen was on 12/9/16, over 2 months prior. The minutes recommended a pelvic seat belt restraint but did not include the rationale. During an observation on 7/14/17 at 9:35 A.M. Resident #11 was observed sitting in the hallway. The resident was in a wheelchair with a pelvic restraint that came up between the legs and tied behind the chair.

During an interview on 7/14/17 at 4:00 P.M., Unit Manager #2 (UM) said the alarm was ineffective because the resident frequently got up on his own despite re-education and had several near falls in addition to his recorded falls. She said the restraint had been issued to prevent the resident from self transferring and that the resident was in agreement with the plan. (The Resident had an activated Health Care Proxy. There was no mention or documentation of discussion with Proxy.) The UM reviewed the CNA flowsheets and said she could not say for sure that the pelvic restraint was released every two hours because the CNAs left that section blank. She also said she did not complete a full comprehensive pre-restraint assessment form (because of confusion over the form) but that the team discussed the intervention.

2. For Resident #15, the facility staff failed to identify the presence of a specific medical symptom that would require the use of restraints and failed to document when the restraint was released. Resident #15 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of the 6/2017 physician’s orders [REDACTED]. The order did not indicate the medical symptom that the restraint was treating. Review of the POS [REDACTED]. Review of the CNA Care Card indicated a pelvic restraint was used. The care card did not indicate a release schedule.

Review of the fall care plan, with a goal date of 8/20/2017, indicated a care plan problem that said the resident needed a soft pelvic restraint when in wheelchair due to decreased safety awareness secondary to [MEDICAL CONDITION], ([MEDICAL CONDITION], stroke). Review of a consent form, dated 12/14/16, indicated a soft pelvic belt was used due to decreased cognition and decreased safety awareness secondary to a [MEDICAL CONDITION]. During an observation on 7/14/17 at 3:00 P.M., the resident was observed sitting in a wheelchair with a soft pelvic restraint that came between the legs and tied at the back of the chair. The resident was self propelling in the hallway and stopped to fist bump the surveyor.

During an observation on 7/18/17 at 11:00 A.M., the resident was observed sitting in a wheelchair with a soft pelvic restraint that came between the legs and tied at the back of the chair. The resident was self propelling, using the lower extremities, up and down the unit while the surveyor was at the desk. During an interview on 7/14/17 at 4:00 P.M. the Director of Nursing (DON) said the CNAs should have documented restraint release on the flowsheets. She said that form has remained on paper and was not in the electronic record.

3. For Resident #7, facility staff failed to identify the presence of a specific medical symptom that would require the use of each restraint and failed to document when the restraints were released.

Resident #7 was admitted to the facility in 2/22/17 with [DIAGNOSES REDACTED]. Review of the 6/2017 physician’s orders [REDACTED]. Pelvic seat belt in chair in wheelchair, remove for care, positioning, and toileting every two hours (start date 3/2/17). 2. Patient transfer to low wheelchair with use of pelvic restraint (start date 5/22/17). 2. Initiate use of Veil bed (enclosure bed with bars or netting designed to restrain a person within the boundaries of the bed) for motor restlessness (start date 3/28/17).

Review of a Physical Restraint Informed Consent form for a soft pelvic belt, dated 2/28/17, indicated a veil bed was used due to the resident climbing on hands and knees over the siderail, and a pelvic seat belt (in wheelchair) for fall prevention and injury prevention due to [MEDICAL CONDITION].

Review of the CNA Care Card, updated 6/2017, indicated the enclosure bed was in place and a pelvic restraint was used when out of bed. The care card did not indicate a release schedule. Review of the POS [REDACTED].

During the initial tour on 7/11/17 at 9:25 A.M., the resident was seated in a wheelchair during an activity. The wheelchair seat angle was tilted to 45 degrees and a seat belt was on. The resident was looking out the window. The surveyor observed an enclosure bed in the resident’s room that the Unit Manager said was in use nightly. The UM said the resident cannot release the belt and it was considered a restraint.

During an observation on 7/14/17 at 1:40 P.M., the resident was seated in an activity with his/her seat belt on and the (low) wheelchair seat was wedged at a 45 degree angle. During an interview on 7/14/17 at 3:30 P.M., UM #3 went to observe the resident with the surveyor. The resident was in an activity, seated in a low wheelchair with a button release seatbelt. The wheelchair was tilted to approximately 45 degrees, creating a wedged seating angle. UM #3 said the use of the veil bed and seat belt restraint is to keep him/her safe and the resident’s Health Care Proxy was in agreement. He reviewed the current Positioning/Restraint release forms and said he was not sure why it was not signed off every two hours to indicate the restraint was released. He showed the surveyor where the nursing staff signed off once a shift but could not locate documentation by the aides that they released the restraint every two hours.

Failed to Hire only people with no legal history of abusing, neglecting or mistreating residents; or 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 and staff interview, the facility staff failed to ensure that two injuries of unknown source were thoroughly investigated for one resident (#4) out of a total sample of 24 residents.

Findings include:

Review of the facility’s policy for Event/Incident Report, dated 7/20/15, indicated the following: Policy: .The intent of this policy is that the center identifies each resident at risk for accidents .and adequately plans care and implements procedures to prevent accidents. Accident/incidents include: .skin tears.

Procedure: In the event an accident occurs:

-The Licensed Nurse completes an incident report and additional assessments, follow up reports as applicable.
-The Director of Nurses (DON) conducts a review of each incident/accident.
-The DON ensures appropriate interventions are implemented .to prevent re-occurrence.

Associated Forms: Skin Tear/Bruise Investigations Resident #4 was admitted to the facility in 2/2007 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 11/2/16, indicated the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 8 out of 15, was dependent for transfers with assist of 2 staff, was non-ambulatory, had impaired range of motion of upper and lower extremity on one side, and used a wheelchair.

Review of the SOAP (subjective/objective/assessment/plan) note by the Nurse Practitioner (NP), dated 3/10/17, indicated that the resident had a new skin tear to the left knee and nursing reported that the resident’s knee leaned to the left side of his/her wheelchair. Review of the Wound Assessment Progress Report, dated 3/13/17, indicated the resident had an open area to the left knee that measured 1.1 centimeters (cm) x 1.2 cm x 0.1 cm. Review of the nursing Progress Notes from 3/9/17-3/17/17 indicated no mention of a wound to the left lateral knee.

Review of the nursing Progress Note dated 3/18/17, indicated the resident had an open area to left lateral knee that was red, warm, and sensitive to touch. The NP was notified and the resident was prescribed an antibiotic to treat the [MEDICAL CONDITION] (infection). Review of the Wound Assessment Progress Note, dated 4/19/17, indicated the resident had a wound to the lateral knee that measured 1.2 cm x 1 cm. The wound bed had 30% necrotic (dead) tissue and 70% granulation (new healing) tissue. Review of the Wound Care Specialist Evaluation, dated 5/3/17, indicated the wound was due to probable trauma.

During an interview on 7/14/17 at 11:30 A.M., with the Administrator present, the DON said the facility staff considered the wound to be due to trauma based on the Wound Care Specialist Evaluation. When the surveyor asked where the incident report was to determine the cause of the wound and to prevent reoccurrence, the DON had no response. During an interview on 7/14/17 at 12:30 P.M., with the Administrator present, the DON said the wound was caused by trauma both times and she thought it was due to wheelchair positioning. When the surveyor asked if staff interviews were done to determine if the wound was due to a transfer, positioning, or a mishap, the DON said no interviews were done. She said in retrospect, incident reports/investigations should have been done both times and they weren’t.

Failed to provide necessary care and services to maintain the highest well being of each resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interviews, the facility staff failed to provide treatment and care to prevent reoccurrence of a wound for one resident (#4) out of a total sample of 24 residents.

Findings include:

Review of the facility’s Wound and Skin Care Protocols, dated 2015, indicated the following:

-Unit Managers (UM) will be responsible for assessing, staging/measuring, and documentation of each wound each week until closed.
– Interventions are directed toward minimizing and/or eliminating the effects of the causal/contributing factors pressure .friction/shear.
– Protocols for high risk residents (Norton Plus Scale score of between 5 and 10) included to limit time out of bed to 2 hours or less at a time if indicated.

Resident #4 was admitted to the facility in 2/2007 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 11/2/16, indicated the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 8 out of 15, was dependent for transfers with assist of 2 staff, was non-ambulatory, had impaired range of motion of upper and lower extremity on one side, and used a wheelchair.

Review of the Norton Plus Pressure Ulcer scale, dated 2/1/17, indicated the resident was at high risk for skin breakdown with a score of 6 (score of 10 or less indicated high risk).

Review of the SOAP (subjective/objective/assessment/plan) note by the Nurse Practitioner (NP), dated 3/10/17, indicated that the resident had a new skin tear to the left knee and nursing reported that the resident’s knee leaned to the left side of his/her wheelchair. Further review indicated that Physical Therapy (PT) was contacted in regards to the resident’s wheelchair and PT told the NP that staff had recently been inserviced on how to properly position the resident in the wheelchair to avoid skin breakdown, but PT would address patient’s positioning again.

Review of the clinical record indicated there were no PT or Occupational Therapy (OT) screens or treatments done in 3/2017.

Review of the Wound Assessment Progress Report, dated 3/13/17, indicated the resident had an open area to the left knee that measured 1.1 centimeters (cm) x 1.2 cm x 0.1 cm. Review of the nursing Progress Notes from 3/9/17-3/17/17 indicated no mention of a wound to the left lateral knee.

Review of the nursing Progress Note, dated 3/18/17, indicated the resident had an open area to left lateral knee that was red, warm, and sensitive to touch. The NP was notified and the resident was prescribed an antibiotic to treat the infection. Review of the Wound Assessment Progress Note, dated 4/11/17, indicated the wound to the left lateral knee resolved.

Review of the Decubitus (skin wound due to pressure) Prevention sheet, dated 4/2017, indicated the following: on 4/11/17 the resident was weight shifted in the wheelchair every 2 hours from 8:00 A.M.- 6:00 P.M., 4/12/17 the resident was weight shifted in the wheelchair every 2 hours from 10:00 A.M.- 6:00 P.M., on 4/17/17 the resident was weight shifted in the wheelchair every 2 hours from 8:00 A.M.- 6:00 P.M. and on 4/19/17 was weight shifted in the wheelchair every 2 hours from 8:00 A.M.-6:00 P.M.

Review of the Wound Assessment Progress Note, dated 4/19/17, indicated the resident had a wound to the lateral knee (bony prominence) that measured 1.2 centimeters (cm) x 1 cm. The wound bed had 30% necrotic (dead) tissue and 70% granulation (new healing) tissue. Review of the quarterly MDS assessment, dated 5/2/17, indicated the resident was dependent for transfers with assist of 2 staff members and mechanical lift, was dependent for bed mobility, non-ambulatory, used a wheelchair, refused care 1-3 times per week, and had an unstageable pressure ulcer.

Review of the Wound Care Specialist Evaluation, dated 5/3/17, indicated the left knee wound was due to probable trauma, measured 1 cm x 1.8 cm x not measurable due to 100% black necrotic tissue at wound base. The wound was surgically debrided at the bedside to remove the necrotic tissue. Further review indicated the wound required surgical debridement on 5/10/17, 5/17/17, and 5/24/16.

Review of the Wound Care Specialist Evaluation, dated 6/1/17, indicated the left lateral knee wound measured 2 cm x 2 cm x immeasurable due to 100% necrotic tissue and required debridement. Further review indicated the wound was debrided on 6/15/17, 6/21/17, and 6/29/17.

Review of the PT evaluation, dated 6/22/17, indicated the resident was referred to PT due to positioning deficits, including poor position of trunk and pelvis while in the wheelchair resulting in significant pressure being placed along the lateral aspect of left knee and foot. Resident has an open area on the left lateral aspect of knee due to continued poor position in the wheelchair. Review of the Wound Care Specialist Evaluation, dated 7/6/17, indicated the left lateral knee wound measured 2.2 cm x 4 cm x 0.2 cm.

Review of the care plan for skin breakdown, with goal date of 8/31/17, indicated no new interventions to prevent skin breakdown since 2010.

Observation on 7/12/17 at 1:25 P.M., the resident was asleep in custom tilt in space wheelchair in the dining room, head leaning to right side, padded boots to both feet, tray in front of wheelchair and bilateral leg rests.

Observation on 7/12/17 at 3:25 P.M., the resident was up and dressed in custom tilt in space wheelchair in the dining room, head leaning to right side, tray in front of wheelchair, left leg externally rotated.

During an interview on 7/12/17 at 3:50 P.M., Unit Manager (UM) #3 said the wound to the left lateral knee was necrotic, unstageable, and due to pressure.

During an interview on 7/13/17 at 8:30 A.M., UM #3 said he wanted to clarify what he said the day before. He said the left knee wound was considered a skin tear, he didn’t know how since the wound had eschar (dead tissue), but that’s what the NP had originally written. During an interview on 7/13/17 at 12:25 P.M., Nurse #1 said she was the one who found the initial left lateral knee wound when it first occurred in 3/2017. She said it presented as a red, pimple like area, was on the left lateral side of the knee, and was non-blanchable (tissue does not return to normal color when pressure is applied). She said she didn’t know what caused the wound, but the Certified Nurses Aides (CNAs) told her they thought it was from the wheelchair. She said she didn’t write a nurses note or fill out a report but she did leave a message for the NP.

Interview on 7/13/17 at 1:10 P.M., with Assistant Director of Nurses (ADON), DON, UM #3 and Director of Rehab (DOR) indicated the following: the ADON said she thought that both of the wounds to the left lateral knee were due to rubbing the left knee on the leg rest padding of the wheelchair. She said she didn’t know why the NP wrote that it was a skin tear. The DON said if it were a skin tear there would have been an incident report and there wasn’t one. The DOR said a referral to PT for positioning wasn’t made until June 2017 when the resident’s wound deteriorated. UM #3 said he didn’t know why a referral to PT for positioning wasn’t done when the wound was found the first time.

During an interview on 7/13/17 AT 1:30 P.M., the DOR brought the surveyor education that was done in 2/2016 (not 2/2017 when the resident had last been discharged from therapy). She said the resident had been seen for positioning in 1/2017 and 2/2017 but nothing of significance had changed so the PT hadn’t done any formal education with staff. She said the PT grabbed who she could to review proper positioning for the resident but did not keep a record of who had been educated and discharge instructions for positioning should have been with the CNA care card.

Observation of the left knee dressing change, done on 7/13/17 at 11:05 A.M., with UM #3 and the ADON, indicated a wound to the resident’s left lateral knee (on the bone) that had beefy red tissue at the wound base, small amount of yellow tissue, surrounding skin was pink and intact.

During an interview on 7/13/17 at 2:35 P.M., CNA #1 said the resident usually got out of bed around 8:00 A.M. and went back to bed after lunch, around 1:30 P.M. She reviewed the Decubitus Prevention sheet, dated 4/2017, and said the W reflected weight shift and was used when the resident was in the wheelchair. The R/L indicated the resident was positioned on the right side or left side in the bed. The surveyor asked to see the current CNA care card for the resident, CNA #1 said the only direction for positioning was to use 2 assists. There were no separate directions from the Rehab Department regarding positioning with the CNA care card.

During an interview on 7/13/17 at 2:50 P.M., the MDS Coordinator said the left knee wound was coded as unstageable pressure because there was 100 % necrotic tissue on a bony area. During an interview on 7/14/17 at 8:10 A.M., the MDS Coordinator said he made an error and the wound should have been coded as traumatic and not as an unstageable pressure ulcer, he said he modified the MDS.

Observation on 7/14/17 at 9:55 A.M., the resident was asleep and dressed in a custom tilt in space wheelchair, tray and seat belt in place, head and shoulder leaning to the right side. Bilateral padded boots on. The left hip guide ended at lateral side of the left knee. Additional padding was on the upper left leg rest near the knee.

During an interview on 7/14/17 at 11:10 A.M., the PT said she had discharged the resident from services on 2/2017. She said she did not provide any formal education to the staff regarding the resident’s positioning. She said when the resident was positioned correctly in the wheelchair there was no pressure on the left lateral knee, but when the resident slid down in the chair his/her left leg turned out and hit the leg rest. The PT said she added extra padding to what was already on the leg rest. She also said that she didn’t remember speaking with the NP in 3/2017, but if she had spoken with her she would have told her the resident just came off of therapy and likely wouldn’t have needed rehab again so soon.

During an interview on 7/14/17 at 11:30 A.M., with the Administrator present, the DON said the facility staff considered the wound to be due to trauma based on the Wound Care Specialist Evaluation. When the surveyor asked where the incident report was to determine the cause of the wound and to prevent reoccurrence, the DON had no response. During an interview on 7/14/17 at 12:30 P.M., with the Administrator present, the DON said the wound was caused by trauma both times, she thought it was due to wheelchair positioning. When the surveyor asked if staff interviews were done to determine if the wound was due to a transfer, positioning, or a mishap, the DON said no interviews were done.

Failed to ,ake 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 record review, observations and staff interviews, the facility staff failed to provide adequate supervision and effective interventions to prevent accidents for 1 of 4 applicable residents (#21), in a total sample of 24 residents

Findings include:

Resident # 21 was admitted to the facility in 1/2010 with [DIAGNOSES REDACTED]. Review of the behavioral care plans with a start date of 2/8/10 and a goal date of 9/7/17, indicated the resident had a history of [REDACTED]. The care plan indicated the resident had difficulty understanding why propelling the wheelchair backwards was a concern and at times became upset on redirection, yelling loudly, threatening and using offensive language.

Review of the fall care plan with a start date of 2/3/10 and a goal date of 9/7/17, indicated there were no interventions related to the level of assist/supervision required for safe mobility indoors/outdoors, despite multiple falls.

Review of the Quarterly MDS Assessment, dated 6/17/16, indicated the resident independent for locomotion off the unit and had impaired range of motion (ROM) in the left upper and lower extremity. The MDS Assessment also indicated the Resident scored 15/15 for Brief Interview of Mental Status (BIMS), indicating intact cognition.

Review of an Event/Incident Report, indicated the resident had an unwitnessed fall , on 8/2/16 at 11:00 A.M., while propelling his/her wheelchair backwards on a facility entrance ramp. The report indicated the chair tipped backwards and the resident got himself/herself back in the chair. The resident sustained [REDACTED]. The Post Fall Investigation said the resident was going outside to smoke. The follow-up reports indicated the resident refused vitals and any treatment to the leg injury. The new post fall intervention was to add anti-tippers to the wheelchair (an appliance that prevents the chair from tipping over backwards). The anti-tippers were added to the wheelchair by rehab (per screen dated 8/3/16). The resident was also educated that propelling the wheelchair backwards was an unsafe practice.

Review of an Event/Incident Report, indicated the resident had an unwitnessed fall, on 9/8/16 at 9:55 A.M., while ambulating on the patio. The resident was ambulating with a walker (with a platform supporting his/her left arm) and turned, resulting in a loss of balance. The resident landed on the ground without sustaining any injuries. The new post fall intervention was education provided to the resident to turn slowly. Review of the Quarterly MDS Assessment, dated 9/16/16, indicated the resident required supervision for locomotion off the unit and had impaired ROM in the left upper and lower extremity.

Review of the progress notes indicated the resident fell on [DATE] at 12:30 P.M. when he/she attempted to sit down, landed on the arm of the chair and fell to the floor. Further review of the progress notes indicated the resident fell again on 11/17/16 at 2:00 P.M. while ambulating with a walker, turned and fell due to a loss of balance. Resident educated post fall to ambulate at a safe pace and ask for assistance as needed. Review of an Event/Incident Report, indicated the resident had a witnessed fall, on 12/2/16 at 10:00 A.M., while propelling his/her wheelchair backwards on a facility entrance ramp. The report indicated the chair tipped backwards and staff had to assist the resident back into the chair. The resident said he/she went down the ramp backwards to avoid having to hold up his/her leg. The report indicated the fall was witnessed by a staff member, but a witness statement was not included in the investigation packet. During an interview (on 7/18/17 at 1:45 P.M.), UM #1 said she did not obtain a written witness statement from the employee who witnessed the fall. The Incident Report Conclusion form said the resident tipped over backwards while going backwards down the ramp. There was nothing in the report that indicated if the anti-tippers were in place and functioning and if the chair tipped over despite them being in place. The Post Fall intervention was resident education to go forward down the ramp. The root cause of the fall was determined to be non-compliance. The UM said she did not recall discussing if the anti-tippers and education were effective interventions in preventing falls for this resident.

Review of the Annual MDS Assessment, dated 12/6/16, indicated the resident was independent for locomotion off the unit and had impaired ROM in the left upper and lower extremity. Review of a social worker’s progress note, dated 1/6/17 indicated the resident’s room was changed to the third floor (locked unit) for his/her safety. He/She was verbally reminded not to propel his/her wheelchair backward for his/her safety and the safety of other residents. Education regarding this previously appeared not to be effective. This intervention did not address falls secondary to loss of balance or wheeling the wheelchair backwards.

Review of a behavioral progress note dated 1/23/17 indicated the resident continued to roll his/her wheelchair backwards, but had shown some improvement. He/she continued to be non-compliant with adaptive equipment.

Review of the Quarterly MDS Assessment, dated 6/7/17, indicated locomotion off the unit only occurred once or twice, but assistance was not required from staff. Resident had impaired ROM in the left upper and lower extremity.

During an observation and interview on 7/18/17 at 1:15 P.M., Resident #21 said my privileges to go outside alone have been revoked for a few months. During the interview, the surveyor observed the right rear anti-tipper was not on the wheelchair as planned, but was on the floor in the corner of the room. The resident told the surveyor he/she had removed them because they have not fit properly for almost a year.

During an interview at 7/18/17 at 1:30 P.M., UM #3 said he put the right anti-tipper back on the wheelchair and it was longer than the left anti-tipper. He said he would notify the rehab department. He said he was not sure how long the anti-tipper had been off the chair. When the surveyor asked if the resident was allowed to go outside alone, he said he was not sure what his/her privileges were outside the building.

During an interview at 7/18/17 at 1:35 P.M., Behavior Aide #1 said the resident was allowed to ambulate off the locked unit as long as he/she let someone know the destination. She said the resident needed a staff member to activate the elevator to get off the locked unit and then he/she was free to go to activities, the gym and the entrance lobby independently. She said the resident is not allowed outside. (Note: the resident did not have supervision when off the locked unit and had access to entrance/exit ramp once he/she left the unit)

During an interview, on 7/18/17 at 1:45 P.M., UM #1 said the resident’s status at the time of each fall (8/2/16, 9/8/16 and 12/22/16) was that he/she was allowed outside without supervision. When the surveyor asked if post-fall team discussions included an assessment of the resident’s safety with mobility outside, UM #1 said she could not recall. She said rehabilitation department is responsible for determining level of supervision with mobility inside/outside the facility. Review of the Fall Review Minutes from 7/11/16 through 1/4/17 did not indicate discussion about safety outdoors.

During an interview with the Director of Rehab (DOR), Director of Nursing (DON) and Assistant Program Director (APD) on 7/18/17 at 3:00 P.M., the DOR said the therapists request a Physician order [REDACTED]. The DOR said copies of the order requests were kept in rehab, but did not locate copies pertaining to resident #21 for the surveyor. During that same interview, the APD said when a resident was granted independence or those privileges were revoked it was posted in the behavior office and the information was put in the supervisors box to be passed on to nursing. When the surveyor asked if there was any place in the medical record that the direct care staff could reference to determine if a resident was allowed outside without supervision, they were unable to demonstrate where that would be indicated in the record. Review of the Physician orders, care plan and care card did not indicate any restrictions on going outside for this resident.

Wingate at Worcester, Nursing Home Neglect and Elder Abuse Lawyers

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

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

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

Boston Personal Injury Lawyers for Elder Abuse Cases

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


Sources:

Medicare Nursing Home Profiles and Reports – Wingate at Worcester

Inspection Report for Wingate at Worcester – 07/18/2017

Page Last Updated: April 5, 2018

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