KINDRED TRANSITIONAL CARE & REHABILITATION-FORESTVIEW
LOCATED: 50 INDIAN NECK ROAD, WAREHAM, MA 02571
KINDRED TRANSITIONAL CARE & REHABILITATION-FORESTVIEW 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 PROTECT EACH RESIDENT FROM ALL ABUSE, PHYSICAL PUNISHMENT, AND BEING SEPARATED FROM OTHERS.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and records reviewed, for one of three sampled residents (Resident #2) the Facility failed to prevent Resident #2 from being abused on 4/11/17 when Certified Nurse Aide #1, who stood five feet ten inches tall lifted Resident #2 up to his full height and forcefully threw Resident #2 down onto his/her bed and stated what the [***] is the matter with you. The Police Report indicated Resident #2 fell about two feet from CNA #1’s arms to the bed. Although the Surveyor could not interview Resident #2 due to Resident #2’s cognitive impairments, an unimpaired individual would experience pain and mental anguish when being dropped from a height by a caregiver.
Resident #1’s Minimum Data Set Assessment Form, dated 3/29/1, indicated that his/her cognitive patterns were severely impaired and he/she was dependent on the physical assistance of two staff members with bed mobility and transfers between surfaces. CNA #2’s written statement, dated 4/11/17, indicated that around 8:15 P.M. he walked passed Resident #2’s room and observed CNA #1 pick Resident #2 up from the floor. CNA #2’s written statement indicated that CNA #1 told Resident #2 words to the effect of what the [***] is the matter with you. CNA #2’s written statement indicated that CNA #1 stood, brought Resident #2 to his full height and tossed Resident #2 forcefully into the bed. CNA #2’s written statement indicated that Resident #2 began to scream.
The Surveyor interviewed Nurse #1 at 11:00 A.M. on 4/27/17. Nurse #1 said that on 4/11/17, CNA #2 called her and told her that he had seen CNA #1 put Resident #2 into the bed roughly and spoke to him/her using profanity. Nurse #1 said that she suspended CNA #1 pending the Facility investigation and notified the Director of Nurses of the allegation.
The Surveyor interviewed the Director of Nurses at 12:50 P.M. on 4/27/17. The Director of Nurses said that on 4/11/17 Nurse #1 told her that CNA #2 reported that CNA #1 threw Resident #2 onto bed and stated words to the effect of what the [***] are you doing. The Director of Nurses said that she called the Facility and spoke to CNA #2 directly and CNA #2 told her that Resident #2 screamed when CNA #1 threw him/her into the bed.
The Director of Nurses said that she interviewed CNA #1 with the former Administrator on 4/12/17 and CNA #1 told her that he might have sworn at Resident #2 The Director of Nurses said she told CNA #1 that it had been alleged that he held Resident #2 about two feet above the bed dropped him/her onto the bed and CNA #1 told her that he had done that. The Surveyor asked the Director of Nurses whether she asked CNA #1 the reason that he had done that and the Director of Nurses said that she thought CNA #1 said that he had done that because Resident #2 had gotten out of bed onto the mat on the floor beside his/her bed a couple of times during the shift.
The Police Report, dated 4/12/17, was reviewed and indicated CNA #1’s height was five feet ten inches tall. The Police Report indicated that the police measured that the distance from CNA #1’s raised arms to Resident #2’s bed was about two feet. CNA #1’s written statement provided to the Facility indicated that CNA #1 picked Resident #2 up from the floor mat next to her bed and put him/her back into bed. CNA #1’s written statement contained question and answer format notes at the bottom signed by the Nurse Manager. The Nurse Manager’s notes indicated CNA #1 said he did not remember whether he dropped Resident #2 onto the bed and he did not remember whether he previously stated that he had dropped Resident #2 onto the bed.
The Nurse Manager’s notes indicated that CNA #1 said that he did not remember whether he swore at Resident #2. Although Resident #2 was unable to be interviewed by the Surveyor due to Resident #2’s cognitive deficits, the Reasonable Person Concept presumes that an unimpaired person would experience pain or mental anguish from being dropped onto bed from a height and sworn at by a caregiver.
Personal Note from NHAA – 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.
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