Blackstone Valley Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Blackstone Valley Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 17, 2022

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had a history of exit seeking behavior, was assessed as being at increased risk for elopement, and whose care plan interventions included the use of a wander guard bracelet, the Facility failed to ensure his/her safety was maintained to prevent an incident/accident (elopement) resulting in an injury. On 8/05/22, Resident #1 who was in a wheelchair, exited the Facility through an alarmed (wander guard sensor unit) door, the staff member that responded to the exit door alarm sounding, looked out the window in the door, did not search the area to determine the cause of the alarm, canceled the alarm, and went back to work. […]

• Actual harm, isolatedF658Dec 29, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure nursing transcribed orders for medications according to professional standards of practice. On 12/11/21, nursing obtained a physicians' order for [MEDICATION(S)] insulin for Resident #2, however Nurse #2 transcribed the order onto Resident #1's medication administration record, Resident #1 was administered the insulin and experienced a decline in condition. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. […]

• Actual harm, isolatedF760Dec 29, 2021

  Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2) who both had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #2 who had an elevated blood glucose level of 454 mg/dl ([CONDITION(S)], blood sugar greater than 125 mg/dl), and for whom the one time insulin order was obtained for, was not administered the eight units of [MEDICATION(S)] and his/her hyperglycemic episode was not treated as ordered. Findings include: Review of the Facility's Medication Administration Guide, dated 6/18/2020, indicated, nursing staff must check the medication against the label; label against the electronic medication administration (eMAR) to prevent errors. […]

• Actual harm, isolatedF600Nov 4, 2021

  Based on records reviewed and interviews, for three of five sampled residents (Resident #1, Resident #3, and Resident #5), who were incontinent and required staff for assistance to meet care needs, the Facility failed to ensure residents were free from neglect when Certified Nurse Aide (CNA) #1 refused to assist Resident #1, Resident #3, and Resident #5 with incontinent care and purposely left the residents in soiled briefs. Resident #1, Resident #3, and Resident #5 said they felt angry and upset after CNA #1 refused to assist them with care. Findings include: The Facility's Investigation, dated 9/27/21, indicated that during the overnight shift (11:00 P.M. […]

• No harm, potential for more than minimal, widespreadF880Aug 31, 2021

  Based on document review, record review, observation, policy review and interview, the facility failed to ensure standard infection control practices, related to: 1.) Implementation of quarantine for all residents on the [NAME] Haven Unit, that were exposed to a COVID-19 positive staff member 2.) Implementation of quarantine for a newly admitted , unvaccinated Resident (#256) and contact precautions for one Resident (#76) and 3.) Proper use of Personal Protective Equipment (PPE) on three out of three units, to help prevent the development and transmission of COVID-19. […]