KINDRED NURSING & REHABILITATION-LAUREL LAKE
LOCATED: 620 LAUREL STREET, LEE, MA 01238

KINDRED NURSING & REHABILITATION-LAUREL LAKE was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS

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

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure Resident #1’s plan of care for a one assist with ambulation was followed. CNA #1 left Resident #1 in the bathroom without supervision, Resident #1 fell and sustained fractures to the 3rd and 4th metatarsals (foot bones).

The Nursing Care Plan for Falls, dated 6/7/16 indicated Resident #1 was at risk for falls, Resident #1 was a one assist for transfers with the use of a gait belt, and had alarms in bed and in the chair.

An Investigation Report, dated 1/15/17, indicated at 9:40 P.M. Resident #1 was found on the tiled floor in the bathroom, and had removed the alarm. The Report indicated Resident #1 had toileted him/her self and was trying to get a pajamas off the door hook. The attached Radiology Report, dated 2/18/17 indicated Resident #1 had an unwitnessed fall and sustained an acute left foot fracture (the 3rd and 4th metatarsal neck).

The Certified Nursing Assistant #1’s Witness Statement, dated 2/15/17 indicated she observed Resident #1 brushing his/her teeth in the bathroom and told this Resident to ring the call bell if the Resident needed help to ring the bell. CNA #1 saw that the call bell was ringing and found Resident #1 laying on the bathroom floor.

A Nurses Note, dated 2/15/17 and timed at 10:45 P.M., indicated on 2/15/17 Resident #1 was found on the bathroom floor and prior the fall Resident #1 was sitting in the recliner chair and turned off the alarm. The alarm was found in the chair.

The Surveyor interviewed CNA #1 at 10:10 A.M. on 3/15/17. CNA #1 said she was assigned to Resident #1 after 9:00 P.M. on 2/15/17. CNA #1 said she checked on Resident #1 at approximately 9:20 P.M. on 2/15/17. Resident #1 was standing up in the bathroom brushing his/her teeth. CNA #1 said Resident #1 did not need any assistance, so she left the Resident alone in the bathroom and went back to the Nurse’s station to do her charting. CNA #1 heard a call bell ringing from Resident #1’s room about 5 minutes later and found Resident #1 lying on the floor. CNA #1 said she was not aware that Resident #1 was a one assist for ambulation, required an alarm and needed supervision in the bathroom. CNA #1 said she did not review Resident #1’s plan of care prior to providing care.

The Surveyor interviewed the Director of Nursing Services (DNS) at 7:50 A.M. on 3/15/17. The DNS said CNA #1 did not follow Resident #1’s plan for supervision in the bathroom.

Personal Note from NHA–Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.