Staff at Woodbriar Health Center received special training on falls prevention in January, but that training went unheeded.
State regulators, during the course of their investigation into the death of Mary Meuse, found that a second resident died in February from fall-related injuries. Regulators blame the second death on deficient care because of the retraining, The Boston Globe reports.
The training sessions were part of a revised plan Woodbriar submitted to the Massachusetts Department of Public Health to address reports of substandard care and infection outbreak. The plan also revealed staff members reviewed the records of all residents who had fallen and received an X-ray three months prior to Meuse’s Christmas Day fall to see if X-rays were accurately interpreted and results shared with families.
Regulators declared residents are in "immediate jeopardy" and ordered the Wilmington, Mass., facility to take immediate actions "to prevent further harm to residents." Woodbriar has been ordered to stop accepting new residents. Regulators recommended federally imposed fines between $3,050 and $10,000 a day until the problems are corrected and the facility be terminated from Medicaid and Medicare if conditions do not substantially improve by April 14.
A 21-year-old nursing assistant had used a mechanical lift without assistance to move Meuse, 83, from her bed to her wheelchair. Meuse slipped and fell. An X-ray taken within two hours found she broke bones below both knees but three shifts of nurses failed to let Meuse or her family know the results. She was notified and hospitalized the next day, where she was found to be bleeding internally from her injuries. Meuse died Dec. 27.
On a surprise inspection, state investigators learned a resident fell out of bed at about 9 p.m. Feb. 8 with no obvious injuries. Nursing home workers helped the resident back to bed and contacted a physician, who ordered resident checks every two hours until the next morning, then checks every four hours. The resident was found dead in bed by 5:30 a.m. with no record of checks, the state wrote in a letter to Woodbriar. The state now ranks Woodbriar in the bottom 6 percent of all Massachusetts nursing homes, based on repeated health and safety problems.
Woodbriar is owned by Synergy Health Centers, a New Jersey based-company that owns 10 other nursing homes in the state and is licensed to care for more than 1,200 residents. Synergy is appealing the state’s action and issued a statement that the February resident death was not related to the resident’s fall the night before.
“The procedures established by the Plan of Correction were followed in this case,” according to the statement. “Our staff was properly trained, the performed their duties according to that training, and we stand by their actions.”