Troubled Sunderland care home is focus of inquiry

Synergy facility ranks among state’s worst; possible medication error prompts probe

A Synergy Health Centers nursing home in Sunderland, already ranked among the worst in Massachusetts, is being investigated by the state following repeated complaints about patient care.

Inspectors from the state Department of Public Health, which oversees nursing homes, spent 12 hours last Thursday at New England Health Center in Western Massachusetts probing a suspected medication error involving two patients, according to a staffer who asked to remain anonymous because the worker was not authorized to speak publicly.

Inspectors are also examining events surrounding a July accident at the facility in which a 96-year-old resident fell and broke her leg while left unattended, the worker said.

The probe comes as advocates for the elderly are lobbying for more scrutiny of nursing homes, amid a surge of facilities being sold or closed and concerns that patient care is suffering.

The suspected medication error occurred in May, when intravenous solution was mistakenly given to two patients who should not have received that medicine, according to another worker who has since left the facility. The worker, who was not involved with the medication mix-up, said the two patients have since died, but it is not clear whether the suspected medication error played a role in their deaths.

The health department “continues to closely monitor this facility, as we do all facilities, to maintain the safety of residents,” department spokesman Scott Zoback said in a statement Thursday. “We are investigating the medication error allegations and, if found true, will take corrective action, if necessary.”

A Synergy spokesman said in a statement that the company conducted its own investigation of the medication incident and concluded “the cause of death had nothing to do with our facility. Our condolences, however, are with the families.”

Workers and family members of residents at New England Health Center said the facility has struggled with staffing shortages since Synergy took over in December 2012. The purchase marked the company’s entry into the Massachusetts nursing home industry, and similar complaints about quality and staffing soon followed as it bought 10 more facilities statewide.

It is not clear whether staffing issues played a role in a July 21 incident involving a 96-year-old resident who is nearly deaf, has fading eyesight, and uses a walker. The woman was found wandering the hallway by an activity aide, who helped her walk to the bathroom, then left her there unattended while the aide went to notify staff that the woman was alone, according to a report the company filed with the health department last week.

When staff returned, they found the woman lying on the floor, clutching the “grab” bar along the wall. The nurse’s aide assigned to the woman had received a warning the week before for not taking residents to the bathroom as directed, the report said. The company’s investigation into the fall, however, was “unable” to determine whether the aide’s actions contributed to the fall, the report said.

The resident broke her leg and was hospitalized, according to her sister and a staffer who was not involved with the incident.

Staffing shortages at New England Health Center have been especially acute the past month, as several workers quit and have not been replaced, the staffer said.

“There has been a lot more falls, and residents starting to develop really bad bed sores, because [nurse’s aides] aren’t able to get to that stuff when they are answering alarm bells because someone is trying to get up,” the staffer said.

A Synergy spokesman said the company could not comment on the July incident, citing patient confidentiality, but said in a statement, “Synergy follows established protocols for preventing and minimizing falls by residents.”

The statement also said New England Health Center “is staffed significantly above state requirements.” Federal records, however, indicate the facility’s residents receive measurably less nursing time than the average reported by other Massachusetts facilities.

This is not the first time this summer state inspectors investigated New England Health Center. Federal records show inspectors visited the facility in June, after complaints that residents rarely receive fresh fruits.

Inspectors scrutinized a month’s worth of food records and found that fresh fruit had been served just once during that time, and that purchase orders indicated the facility had bought just one order of fruit — some honeydew melons — in mid-May.

Food service supervisors told the inspectors that Synergy’s vendors only sold fruit in 40- and 50-pound cases, too large for the small home with just 39 residents. The supervisors said they occasionally resorted to buying fruit with their own money for residents.

Inspectors slapped the nursing home with four violations involving its food service. Synergy said in a statement that it has since corrected those problems.