Blistering report details nursing home deaths

The Braemoor Health Center in Brockton. Gretchen Ertl for The Boston Globe/Globe Freelance

Braemoor Health Center nurses and aides lacked the training to revive a dementia patient suffering an apparent heart attack, and the patient died, according to a blistering state report released Thursday.

The troubled Brockton nursing home then failed to report the death to the state health department because, nurses told investigators, the patient “had no family.” Braemoor’s administrator, meanwhile, told investigators the nursing home’s clinical team decided against reporting the death because of recent “bad press” about the nursing home’s parent company, Synergy Health Centers.

The 70-page report into the deaths of that patient, in April, and another in March, paints a picture of a nursing home in chaos, with scant staff training in basic life-support care, machines needed to deliver life-saving oxygen standing empty, defective equipment used to restore a regular cardiac rhythm during a sudden heart attack, and missing alarms needed to protect dementia patients from wandering out of the building.

The report is based on a surprise inspection that state regulators, acting on a tip about problems at Braemoor, made at the nursing home June 30 and July 1. They found conditions so troubling they said residents there were in “immediate jeopardy.”

Officials immediately ordered the facility to stop accepting new patients, fined it $200,000, and froze the federal payments that cover many patients’ bills.

The report released Thursday details for the first time what investigators found that prompted the punitive measures.

Braemoor is one of 11 Massachusetts nursing homes owned by Synergy Health Centers of New Jersey, a problem-plagued company that was slapped in April with what regulators characterized as unusually steep federal fines after two deaths at the company’s Wilmington facility, Woodbriar Health Center.

The company released a statement on Thursday night saying it is working with the state health department to improve care.

“We submitted an extensive plan of correction to [the health department], which addresses all of the issues raised in their report. We have already begun to implement a number of the actions outlined in the report and the entire team is focused on assuring that our residents receive high quality, compassionate care,” the statement said.

Synergy recently submitted plans to state and federal regulators detailing how the company planned to correct the many problems uncovered at Braemoor. Those plans indicate Braemoor has conducted extensive staff training to ensure they know how to care for patients experiencing heart attacks and breathing problems.

Additionally, Braemoor said it revised its policies to assure that oxygen and other life-saving equipment is regularly checked.

The state’s investigation also uncovered significant problems with Braemoor’s policies on caring for patients with a history of substance abuse, and for handling incidents of sexual assaults and thefts.

One of the cases investigators scrutinized involved a patient who died at his home in March of an opioid overdose two days after being discharged from Braemoor. The man, who had undergone a partial leg amputation and had a history of drug abuse, had been admitted to Braemoor last August suffering from depression, anxiety, and chronic pain, according to the report. He was taking medications to reduce cravings for opioids and was considered a suicide risk, the report said.

Yet when Braemoor admitted the man, staff immediately put him on a cocktail of narcotics — including the very drugs to which he was addicted.

Investigators found no indication Braemoor conducted a required “comprehensive medical evaluation of the risks related to use of opioid medications, no indication of how the use of the medications would impact the [patient’s] ability to attain or maintain sobriety and no indication of the services necessary to provide the least restrictive but safe level of care, and his risk for relapse,” the report found.

Within days of the man’s admission, staff more than doubled the patient’s Fentanyl, one of the strongest opioids on the market, and discontinued the medication he had been receiving to control his cravings for opioids, the report said.

By November, he was raced to the hospital in an “unresponsive” state, and hospital staff told the nursing home they believed it was because of the “multiple medications” he had been receiving, the report said. Yet the nursing home made no changes to his medications.

Braemoor moved to evict the man in March, after finding he brought alcohol into the nursing home. The Medical Examiner’s office later told state investigators the man was found dead in his home two days after leaving Braemoor, and the cause of death was an overdose of Fentanyl and other opioid drugs.

“There was no indication the facility discussed with the resident a discharge plan for treatment/services to prevent substance use disorder relapse and no plan to manage his pain and pain medication regime upon discharge,” the report concluded.

Synergy defended its care of the man in the report it submitted to state regulators, saying it had provided him and his mother with a list of Alcohol Anonymous meetings in their area, as well as other community services, and directions to the nearest hospital emergency room if problems developed.

It said the man declined visiting nurses services when discharged.

Synergy also said it has since updated its procedures for discharging patients with substance abuse problems to “ensure a comprehensive safe discharge plan was developed prior to discharging.”

In investigating the April death of the dementia patient, investigators found that a nurse aide had been feeding the patient dinner around 6 p.m. when the aide noticed the patient appeared to lose consciousness and the patient’s head tilted back.

The aide called other nurses for help, but none attempted to administer CPR to the resident, investigators found. The nursing supervisor later told investigators she pronounced the resident dead without examining the person because the room was too crowded with other staffers in the minutes after the patient lost consciousness.

Investigators also found that nearly two weeks after they discovered in early July widespread lack of training among staff for responding to emergencies, known as a Code Blue situation, many of the nurses were still unfamiliar with the procedures.

“The [director of nursing] said no further in-service education or training was provided to staff on Code Blue since [April 26] because the facility did not have a Staff Development Coordinator,’’ the investigation found.

Investigators also found that Braemoor had waited eight days to report a June allegation of sexual abuse — one resident groping another — despite the facility’s policy requiring staff to immediately report such cases to the state health department.

Braemoor’s director of nursing later told investigators the nursing home reported the case “as soon as [she] finished the investigation.”

The report noted that Braemoor also delayed reporting an alleged $50 theft from one resident until seven days after the incident, also in violation of the nursing home’s policies.

“I thought the interim administrator was going to report the incident to the Department of Public Health,” the director of nursing later told investigators.

In its plans to correct the problems, Braemoor noted the resident who reported the attempted assault is no longer in the nursing home, and that it has re-educated staff “regarding the facility abuse policies and state and federal guidelines on what constitutes a significant incident and timely reporting.”