South Hadley Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at South Hadley Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, patternF684Nov 4, 2021

  Based on observations, interviews, and record reviews, the facility failed to ensure that seven sampled Residents ( #15, #33, #35, #58, #72, #216, and #268), out of 43 total sampled residents, received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, relative to non-pressure related skin conditions and medication administration. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing practice, revised April 2018, included the following: - Licensed nurses accept, verify, transcribe, and implement orders received by various methods, including verbal and written orders, in emergent and non-emergent situations. […]

• Actual harm, patternF686Nov 4, 2021

  Based on observations, interviews and record reviews, the facility failed to ensure necessary treatment and services were provided to promote healing and/or prevent decline in pressure ulcers for four sampled Residents ( #12, #64, #98 and #216), out of a total sample of 43 residents. Review of the facility policy titled Wound Care, dated 2017, indicated the purpose of the guidelines for the care of wounds was to promote healing. The policy also included the following: -verify that there is a physician's order for the procedure -review the resident's care plan to assess for any special needs of the resident -the following should be recorded in the resident's medical record: --type of wound care given --date and time the wound care was given --any changes in the resident's condition --all… […]

• Actual harm, patternF740Nov 4, 2021

  Based on observations, interviews, and record reviews the facility failed to ensure behavioral health care and services were provided to attain or maintain the highest practicable mental and psychosocial well-being for five sampled Residents (#15, #16, #97, #62 and #86), out of a total sample of 43 residents. Findings include: 1. For Resident #16 the facility failed to obtain a psychiatric consult as ordered by the Physician/Practitioner. Resident #16 was admitted to the facility in June 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, patternF760Nov 4, 2021

  Based on interviews and record reviews, the facility failed to ensure that four sampled Residents (#34, #61, #64, and #69) were free from significant medication errors, out of a total sample of 43 residents. Findings include: Review of the facility policy titled Administering Medications, dated 2017, indicated that medications were required to be administered according to physician orders. Review of the facility policy titled Adverse Consequences and Medication Errors, dated 2017, indicated the following: -Any medication that has a potential for adverse consequences will be monitored to ensure that any such consequences are promptly identified and reported. […]

• Actual harm, patternF725Jun 10, 2021

  Based on records reviewed and interviews, for three of three nursing units, East One, East Two and West Two, during May 1, 2021 through June 1, 2021, the Facility failed to ensure sufficient staffing levels were maintained to meet resident's needs safely and adequately, per their plans of care. The Facility failed to ensure that there was sufficient staffing levels to provide the level of assistance needed for residents with physical limitations, failed to ensure call lights were responded to timely, failed to provide adequate supervision to prevent falls, failed to ensure residents received assistance with feeding for meals, that requests for, as needed, medications where addressed timely and incontinence care needs were met, which resulted in residents becoming upset, feeling… […]