Quabbin Valley Healthcare

In the surveyor’s words

From the most serious findings on record at Quabbin Valley Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Mar 5, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was newly admitted to the Facility seven days post-surgical repair for a [MEDICAL CONDITION] with stent placement (a tube placed in the brain to act as an artery for supplying blood to the brain that requires an anti-platelet medication to prevent its occlusion), and was prescribed the medication Brilinta (anti-platelet medication used to prevent blood clots), the Facility failed to ensure nursing staff notified Resident #1's Physician that he/she missed two consecutive doses of his/her Brilinta medication. On [DATE], Resident #1 experienced a significant change decline in condition, was transferred to the Hospital Emergency Department for further evaluation and was diagnosed with [REDACTED]. […]

• Immediate jeopardy, isolatedF726Mar 5, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was newly admitted to the Facility, seven days post-surgical repair for a [MEDICAL CONDITION] with stent placement (a tube implanted to function as an artery) and required Brilinta (an anti-platelet medication used to prevent occlusion of the stent) to be administered every 12 hours, the Facility failed to ensure nursing staff were competent with providing the necessary care and services to adequately treat Resident #1. […]

• Immediate jeopardy, isolatedF760Mar 5, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was newly admitted to the Facility, was seven day post-surgical repair of a cerebral aneurysm with a stent placement (a tube placed in the brain to act as an artery for supplying blood to the brain), and whose physician's orders [REDACTED]. On [DATE], Resident #1 experienced a significant decline in condition, was transferred to the Hospital Emergency Department, was diagnosed with [REDACTED]. tissue most often due to brain swelling or bleeding), requiring an emergency decompressive craniectomy (removal of a small portion of the skull). Resident #1's condition continued to decline, he/she was made comfort care measures only and died six days later in the Hospital. […]

• Actual harm, isolatedF689Sep 17, 2024

  Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #3), who resided on a secure unit, had a history of wandering on the evening shift, and staff said they needed to have their eyes on Resident #3 while he/she was ambulating on the unit, the Facility failed to ensure he/she was provided an adequate level of staff supervision in an effort to maintain his/her safety and prevent a fall resulting in an injury, when on 08/25/24, although Resident #3 was out of bed and ambulating in the hallway, he/she was not being supervised by unit staff, Resident #3 fell in the hallway, complained of pain, was transferred to the Hospital Emergency Department (ED) and diagnosed with intertrochanteric (hip) fracture of the left femur, which required surgical… […]

• Actual harm, isolatedF600May 1, 2024

  Based on record reviewed and interviews, for two of three sampled residents (Resident #1 who was severely cognitively impaired and required assistance from staff for mobility and Resident #2 who was cognitively intact and dependent on his/her call light to alert staff of his/her needs), the Facility failed to ensure they were free from abuse by a staff member when: A). On 03/28/24 at approximately 6:00 P.M., Certified Nurse Aide (CNA) #1, was witnessed by Visitor #1 as she forcefully transferred Resident #1 to his/her bed. CNA #1 was then witnessed by both Visitor #1 and Nurse #1, as she forcefully pushed Resident #1 down on his/her bed when he/she tried to get up. […]