At least two times every year, the Centers for Medicare and Medicaid Services (CMS) and the state of Massachusetts conduct surveys to inspect every nursing facility statewide. Through interviews, observations and record reviews, the surveyors identify serious violations and deficiencies that must be corrected promptly.
In egregious cases, nursing home regulators might designate the facility as a Special Focus Facility (SFF) and place the Home on a federal Medicare watch list. This designation places the facility on notice that they may suffer serious financial consequences if much-needed changes are not made to policies and procedures to improve the level of care given to residents. In the most serious cases, the facility may lose their contract to provide care and services to Medicaid and Medicare-funded patients.
Nearly two years ago, state regulators designated Blue Hills Health and Rehabilitation Center as a Special Focus Facility. Now that the Home is added to the Federal watch list, they must undergo additional surveys and unannounced inspections to investigate formally filed complaints and identified deficiencies. Likely, the nursing home will remain on the list for many years until surveyors are satisfied that improvements and corrections made by the nursing staff and Administrator are permanent. Some serious concerns involving violations occurring at this facility have been detailed below.
This facility is a ‘for profit’ 92-certified bed Long-Term Care Center providing cares and services to residents of Stoughton and Norfolk County, Massachusetts. The Home is located at:
1044 Park Street
Stoughton, MA 02072
(781) 344-7300
In addition to providing skilled nursing services, the facility also offers:
State and federal nursing home regulators have the legal authority to levy monetary penalties on any facility in Massachusetts identified was serious violations and deficiencies. These penalties place the facility on notice that significant changes must be made immediately to protect the health and well-being of every resident.
In the last three years, Blue Hills Health And Rehabilitation Center received one fine of $145,373 on July 30, 2015. Additionally, there was one facility-reported issue that resulted in a citation and five additional health citations issued after the most recent standard inspection or complaint inspection occurring within the last twelve months.
Families can review publically available data on every long-term and intermediate care facility in Massachusetts by visiting numerous state and federal government databases including the Medicare.com website. This data is a valuable tool to use when choosing the best location to place a loved one who needs the highest level of services and care in a safe environment. The website details information on all health violations, opened investigations, safety concerns, incident inquiries, dangerous hazards, and filed complaints identified at every nursing home nationwide.
Currently, Blue Hills Health and Rehabilitation Center maintains an overall two out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, four out of five stars for staffing issues, and four stars for quality measures. Some details of serious violations and deficiencies involving this facility are listed below.
In a summary statement of deficiencies dated September 13, 2016, the state investigator noted the facility’s failure “to ensure that a thorough investigation was conducted into the events surrounding a Resident-to-Resident altercation with an initial statement of sexually inappropriate behavior.” A review of the Clinical Record for both residents revealed “an allegation of resident-to-resident altercation regarding socially unacceptable behavior that resulted in [one resident] being placed on a medication for behavior modification.”
On August 11, 2016, a Clinical Record involving the social worker’s progress note indicated that the resident “had an increase of socially unacceptable behavior toward other residents…” The interdisciplinary team (IDT) “met with the physician to discuss the behavioral change and recent weight loss. It was determined to [provide] 15-minute checks to watch behaviors and document behavior specific to help modify behavior.” It was also documented that the “Behavior Tracking sheet to record behavior, the effect of the intervention in redirection and specific activities to help the resident reduce socially unacceptable/inappropriate behaviors.” However, there was “no nursing or physician Progress Notes.”
The August 2016 Clinical Record involving the abused resident indicated that “on August 18, 2016, the physician documented the following, on August 11, 2016, the patient’s family member reported an episode today when the patient was touched inappropriately by another resident.” It was also noted that “there was no documented evidence in the nursing progress Notes of the incident.”
The state surveyor interviewed the facility’s Administrator on September 12, 2016, who was “to review the Event Report an Investigation into the Resident-to-Resident altercation on August 11, 2016. The Administrator said that no incident investigation was filed because no one was harmed. The Administrator said that she witnessed an encounter between the resident getting into the face of another resident and the presence of the family member, but there was no sexual involvement.”
The Administrator stated to the surveyor that “she reported her observation to the Social Worker.” The surveyor asked the Administrator “why the physician ordered [medications] if no behaviors occurred.” The Administrator did not respond.
In a summary statement of deficiencies dated September 13, 2016, the state investigator noted the facility’s failure to “ensure that the drug regimen for [a resident] was free from unnecessary medication, [and] used to modify the resident’s behavior without monitoring or adequate indication for use.”
The investigator’s involved a resident where “the facility failed to ensure that the [prescribed female sex hormones medication] order to modify behavior for an allegation of sexually inappropriate behavior was initiated without adequate indication for its use and adequate monitoring of behaviors.”
In a summary statement of deficiencies dated March 16, 2017, the state investigator noted the facility’s failure “to ensure that all staff received the required initial and annual dementia care training and evaluation.”
The state investigator reviewed the facility’s Tracking List of relevant staff. The report revealed that “two staff members were not documented as having completed the initial eight hours of required dementia training and 21 staff members were not documented as having completed the annual four require dementia training.”
An interview was conducted with the facility’s Admission Coordinator on the morning of March 2, 2017, who stated “she was responsible for the dementia training and tracking of the training in the facility.” The Admissions Coordinator stated that “she had not obtained documentation that two employees completed the initial eight hours of dementia training prior to the release from orientation.” The coordinator also stated that “she was under the impression the staff needed to complete four hours of training within a rolling 12-month period and not at a calendar year rate.”
In a summary statement of deficiencies dated September 26, 2017, the state surveyor noted the facility’s failure “to report an allegation of abuse that a [Certified Nurse Aide (CNA)].” The incident involved the CNA forcing a resident “to go to bed when [they] did not want to, and verbally abuse [the resident] within two hours, to the Department of Public Health.”
A review of the facility’s August 14, 2017, Internal Investigation report revealed that “at approximately 7:00 AM on August 14, 2017 [a family member] left a Grievance Form with a Staff Development Coordinator dated August 13, 2017.” The form “indicated that at approximately 7:00 PM on a 12 2017 [the resident] was forced to go to bed and [they were] verbally abused by a Certified Nursing Aide. The internal investigation indicated that an investigation was started immediately and staff, [the resident and family member] were interviewed.”
However, the incident was “not reported to the Department of Public Health until 9:59 AM on August 18, 2017, approximately four days after the allegation of verbal abuse by [the CNA] toward the [resident] was reported to the Administrator.” The surveyor interviewed the Director of Nursing on the late afternoon of September 26, 2017, who said that “the expectation for reporting Abuse, Neglect, and Misappropriation was always to report it to the Department of Public Health within two hours of hearing of the allegation.”
In a summary statement of deficiencies dated March 16, 2017, the state investigator noted the facility’s failure “to ensure that a resident was provided care and treatment in a dignified manner that recognizes the resident’s individual needs.” The incident involved a resident who “experienced short- and long-term memory impairment was severely impaired cognitive skills for daily decision-making [and] required extensive to total dependence with all activities of daily living.” The document also revealed the resident “was incontinent of bowel and bladder.”
State surveyors reviewed the resident’s medical records and made an observation of the resident on March 1, 2017, that revealed that “the resident displayed additional behaviors of wandering about the facility, including entering other resident’s rooms and was physically kicking and striking and verbally abusive to staff and other residents.”
The surveyor also observed the resident “throughout the day on March 15, 2017, and March 16, 2017.” During one observation, the resident was “wandering aimlessly on the North and These Units, gazing into other residents’ room as [they] wandered about the units. The resident mumbled unintelligently (German is [their] native language) as [they] wanted about.”
Even though the facility’s Activity Director “passed the resident [the Director did not] try to engage or redirect the resident toward the Main Dining Room where activities were underway.” The resident’s “hair was observed to be long and greasing appearance [and they were] observed to be wearing a form-fitting green shirt that was tucked into a loose-fitting pair of blue denim pants.” The female resident “was observed to have no proper support underneath the shirt [and was observed] to be wearing slipper socks for footwear. Observation of the back of the resident’s pants revealed a large bulging area from incontinent briefs that the resident was wearing.”
An interview with both the Activity Director and Director Nursing the surveyor discuss the “facility’s failure to provide the resident with a dignified appearance, meaningful social interaction, or individualized attention/divergence by staff.” The Director stated that “she would address the resident’s manner addressed, to include the incontinent briefs (to order pull-ups) and would find out what happened to the resident sneakers, and replace them if necessary.”
The Director stated that she “was unaware of the undignified manner in which the resident was dressed” when observed by the surveyor. The Director was unaware the resident was not “wearing a bra the entire day [and] had greasy hair, bulging incontinent briefs, a lack of inappropriate footwear, or the resident sleeping in another resident’s bed without staff awareness.”
In a summary statement of deficiencies dated September 7, 2017, the state investigator noted the facility had failed to “obtain a psychiatric consult as ordered by the physician in a timely manner” for a resident. A review of the resident’s medical record “ indicates the physician assessed [the resident] on June 15, 2017” and the resident “was seen by the physician again on June 26, 2017, and the Progress Note indicates the resident would be seen by psychiatric services.”
The surveyor reviewed the resident’s Individualized Care Plan dated June 15, 2017. The document revealed that the resident “indicated behaviors, depression, and anxiety. An intervention listed in the Care Plan indicated the resident would be offered psychiatric services.” The facility’s June 21, 2017, Social Service Progress Note indicated that the resident “agreed to be evaluated by psychiatric services to help determine if the resident had the capacity to make medical decisions.” However, “there was no further documentation in the Progress Notes regarding psychiatric services.”
A review of the resident’s Medical Record “did not include notes from psychiatric services” nor was there any referrals for psychiatric services while the resident was at the facility. The Regional Clinical Support member and Director of Nurses reviewed the resident’s records with the surveyor. The two staff members indicated that there “was no documentation regarding psychiatric services for [the resident]. The Director “said that psychiatric services would not see a resident without a consent form and one was unable to be located in the Medical Records.”
The surveyor interviewed the facility Administrator on the afternoon of September 7, 2017, who stated that “the facility was unable to find the signed admission agreement indicating that the resident and Health Care Proxy had been offered psychiatric services for the resident upon admission.” The Administrator also stated that the “Facility policy procedures for ensuring the resident was offered services upon admission was under review and unavailable.”
If you and your family believe your loved one has suffered injuries or harm while a patient at Blue Hills Health And Rehabilitation Center, or any nursing home, contacting a personal injury attorney can help. With a law firm on your side, your lawyer can ensure that all the necessary documents and paperwork are filed in the appropriate County Courthouse before the Massachusetts statute of limitations expires. Your lawyer can build a case, present evidence, negotiate a settlement or take the case to trial.
No upfront payment is required for legal services because most personal injury law firms accept nursing home neglect cases through contingency fee agreements. This arrangement means the fees are paid only after the lawyers have successfully resolved your claim for compensation. If the law firm is unsuccessful, you pay nothing.
Sources:
Chicago Nursing Home Injury Lawyer Nursing Home Law Center LLC Home