A nursing facility in Worcester is under fire after a report released last week shows understaffing, poor conditions, and overmedication of patients, including people with brain injuries, according to a state watchdog agency.
The report, called “A Failure of Care: An Investigation of the Neurobehavioral Unit at Bear Mountain at Worcester,” was authored by the Disability Law Center, a private, nonprofit organization. The DLC investigated the facility at Bear Mountain over a two year period from October 2021 through 2023 after patients and family members complained about conditions.
During six site visits, the DLC found that the facility, including the neurobehavioral unit, were severely understaffed, especially on weekends. Patients were left in bed through the weekend, and many were overmedicated with antipsychotics, the report said.
The home had around 140 patients in 2022, the report said, most of whom were long-term residents.
The report noted some positive changes by the end of their investigation, including at the final, announced visit in October.
“Our investigation uncovered deeply troubling practices at Bear Mountain’s Worcester facility. The treatment of patients in this facility violates their rights and reflects a wider issue within the industry,” DLC Senior Attorney and lead author Nina Loewenstein said.
The report also called for stronger state guidelines.
In a statement, Bear Mountain said their “top priority” is the wellbeing of their patients.
“Our facility provides unique, highly specialized, and high-quality services to the neurobehavioral residents. As such it is subject to scrupulous review and oversight by the Department of Public Health and the Centers for Medicare & Medicaid Services. Many of the claims in the report are based on overgeneralizations and inferences gleaned from outdated data and reports unrelated to Bear Mountain at Worcester,” their statement read. “Nevertheless, Bear Mountain takes the report seriously and will consider it in its ongoing efforts to improve the quality of care delivered to its residents.”
In the report, Bear Mountain denied that it has insufficient staffing.
The state’s Department of Public Health visited, six months late
The state’s Department of Public Health also reported low staffing levels when they visited in 2022, the report said. They visited again 18 months later, which was six months late, the DLC said. During both visits, patients were allegedly found poorly groomed and not fully clothed.
One patient told DPH that they were not receiving sufficient wound care, while another, whose treatments were not documented, didn’t have a properly inflated mattress for pressure ulcers. Another didn’t have a footrest on his wheelchair, and another fell from her wheelchair onto the floor multiple times without any staff member assessing her injury, the report lists.
In 2023, DPH found a lack of privacy for residents, stained clothing, dirty rooms with foul odors, and failures to follow professional care plans in regards to G-tube medication and catheter care.
While DPH put together a plan of correction, “without substantial improvements in staffing, training, professional oversight, and support, DLC is not confident that such incidents will not reoccur,” the report said.
The DLC said all of their visits, except their last visit in Oct. of 2023, showed similar conditions to DPH’s findings. Common rooms had very little decoration, and mice and rats run through resident’s bedrooms.
The DLC also said the lack of staff interaction with patients was “striking.”
“Rooms were often bare and noticeably bleak, with dirty floors observed on DLC’s weekend visit. Strikingly, conditions remained unchanged following the facility’s approved plan of correction for the 2022 DPH survey,” the DLC wrote. “Smells of feces and/or urine were noted outside some of the rooms on the units. Many people were observed lying in beds in the middle of the day, sleeping or watching television.”
While more activities were planned by the DLC’s last visit in October 2023, many patients were bored by the coloring sheets handed out by the then-neurobehavioral program director, who was a certified nursing assistant, the nonprofit said.
Neurobehavioral unit concerns
Bear Mountain’s neurobehavioral unit houses around 80 patients and has a high rate of antipsychotic usage, the report said. While DLC noted improvements, the agency said Bear Mountain’s neurobehavioral unit needs clinician leadership to “coordinate care, develop therapeutic programming, and fully support residents to realize their full potential.”
According to the report, the Neurobehavioral Program director position has not been held by a clinician. With a turnover around every six months, the director role included a certified recreational director, a certified nurse assistant, and someone with a bachelor’s degree in psychology.
“In their research, DLC uncovered evidence of a reliance on antipsychotic drugs, questionable schizophrenia diagnoses, isolation, a lack of effective interdisciplinary behavior plans, and minimal engagement with patients in the neuro-behavioral unit,” the DLC said in their summary of the report. “These typically derive from a severe lack of staffing and clinical expertise at facilities, a common issue within the industry, particularly among for-profit providers.”
In the report, Bear Mountain replied to the DLC’s findings and said their staff are “substantially trained” to care for patients in the neurobehavioral unit.
Bear Mountain at Worcester was purchased in 2019, the DLC said, and is currently owned by a real estate investment trust, structured as both a limited liability company and limited partnership. The DLC said this keeps owners from personal liability such as malpractice claims.
The DLC asked the Commonwealth to strengthen oversight of corporate owners’s financial operations, as well as licensing and staffing standards enforcements.
According to the DLC, Bear Mountain will be making changes by certifying staff in the neurobehavioral unit, refurbishing a van for offsite social and community activities, and offering more therapeutic programs to residents.
“The conditions at Bear Mountain have been appalling,” DLC Executive Director Barbara L’Italien said in a release. “It has been a dire situation, and we must hold the Commonwealth accountable for its duty to inspect and ensure proper care in these facilities.”
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