Brookdale Attleboro

EOEA reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency needs situation.

In the months of November 2022, June 2023 and March 2024 there were 758 e-call response times over the ten (10) minutes required by Residence policy.

EOEA reviewed the Special Care Residence (SCR) operations review from calendar year 2022 through the date of the Compliance Review to verify that the SCR is being administered with all the required safeguards.

Documentation to support that the Residence conducted an SCR operations review to address secure entry and exit doors, a 24-hour preparedness plan, unsafe Resident behaviors as well as policies and procedures governing the transition of Residents moving in or out of the Special Care Residence was missing for the second half of the 2022 calendar year reviewed.

Documentation to support that the Residence conducted an SCR operations review to address secure entry and exit doors, staff training, a 24-hour preparedness plan, unsafe Resident behaviors as well as policies and procedures governing the transition of Residents moving in or out of the Special Care Residence was missing for the second half of the 2023 calendar year reviewed.

Documentation to support that the Residence conducted an SCR operations review to address secure entry and exit doors, a 24-hour preparedness plan, as well as policies and procedures governing the transition of Residents moving in or out of the Special Care Residence was missing for the first half of the 2024 calendar year reviewed.

EOEA reviewed the Residence records of 16 Residents utilizing bed rails / U-bars or similar devices for the period of 2022 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.

Documentation of an assessment conducted by a physical/occupational therapist every six months was missing for six (6) Residents utilizing a bed rail/ U-bar for the calendar years reviewed.

EOEA reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Resident Safety Assurances and Medication Quality for the calendar years 2022 through the date of the Compliance Review.

Documentation of the target date for follow up action and clear outcomes was missing for the 2022 and the 2023 calendar years reviewed.

EOEA reviewed the Residence’s quarterly medication documentation audits for the calendar year 2022 through the date of Compliance Review to ensure compliance with SAMM and LMA protocols and Residence policies.

Documentation stated that Medication Quality Reviews for the last two (2) quarters of 2023 and all quarters of 2023 had no findings. EOEA determined that the reviews were insufficient as the Residence reported 17 medication errors since the last compliance review.

EOEA observed one (1) Personal Care (PC) staff and one (1) nurse providing medication assistance to eight (8) Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA.

EOEA observed the Personal Care staff provide [redacted] outside the scope of SAMM.

EOEA observed a note to the Personal Care staff in the medication storage unit referencing Personal Care staff [redacted] which is an action outside the scope of SAMM.

EOEA observed one (1) compromised medication blister stored in one (1) Resident’s medication storage unit.

EOEA reviewed the Residence’s Emergency Plan to ensure compliance that the Residence can address potential disasters and emergencies.

Documentation of elopement drill participant signatures was missing for the second shift for the 2023 calendar year reviewed.

EOEA reviewed the Residence records and incident reports from July 2022 through the date of the Compliance Review to determine whether the Residence complied with the requirement to qualifying incidents to EOEA within 24 hours after the occurrence of the incident or accident.

The Residence filed 69 incident reports greater than 24 hours after the incident or accidents.

EOEA reviewed the records of 13 Residents to determine compliance with the requirements that a nurse review the Resident’s service plan with all relevant personal care workers within 48 hours after the provision of service or with any change of condition for the Resident.

Eight (8) records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff prior to or within 48 hours after the provision of Personal Care (PC) services, at the time of move-in or at the time of change in the Resident’s condition.