HAVERHILL, MA - Federal inspectors found that The Oxford Rehabilitation & Health Care Center failed to secure a critical gastroenterology appointment for a resident for more than 10 months, despite having necessary medical records available and the resident repeatedly expressing distress about wanting his colostomy reversed.
Critical Medical Care Delayed Despite Repeated Requests
The February 2025 inspection revealed that Resident #92, who was admitted in January 2024 with traumatic brain injury and colostomy status, repeatedly requested help with scheduling an appointment to explore colostomy reversal options. The resident expressed significant emotional distress about the medical device, telling inspectors "it is bullshit and it should have been reversed a long time ago" and that the colostomy "smells bad and it leaks sometimes."
The resident's distress extended beyond physical discomfort to social isolation. During interviews, the resident explained that embarrassment about potential odors prevented him from going out in public at times, and he had begun staying in his room more frequently because of the colostomy bag.
Systemic Breakdown in Medical Records Management
The inspection uncovered a concerning breakdown in the facility's medical records system that directly contributed to the delayed care. In February 2024, facility staff documented that medical records from the resident's previous hospital would need to be obtained before a gastroenterology appointment could be scheduled. However, the facility didn't request these records until August 2024 - six months later.
More troubling, inspectors discovered that the requested medical records had been sitting in a drawer in the Medical Records Coordinator's office since August 2024. The Medical Records Coordinator told inspectors "she found them in a drawer in her office" when asked to locate the documents during the inspection.
A physician's order for a gastroenterology consult was written on April 10, 2024, specifically requesting evaluation for "possible colostomy reversal." Despite this clear medical directive, no appointment was scheduled for over 10 months.
Medical Significance of Delayed Colostomy Evaluation
Colostomy reversal procedures require careful medical evaluation to determine if reconnection of the intestinal tract is possible and safe. The timing of such evaluations can be critical, as surgical candidacy may change over time due to factors like tissue healing, overall health status, and anatomical changes.
Prolonged delays in specialist consultation can have several medical implications. First, the psychological impact of living with a colostomy when reversal might be possible can significantly affect quality of life and mental health. Second, the longer the delay, the more complex the reversal procedure may become due to tissue changes and adhesion formation. Third, complications from the existing colostomy - such as the leakage reported by this resident - can develop or worsen without proper specialist oversight.
The facility's care plan from January 2024 specifically included interventions to "Follow up with GI Consult if indicated" and "Refer to ostomy specialist as/if needed," demonstrating that staff recognized the need for specialist evaluation from the time of admission.
Inadequate Investigation of Abuse Allegations
The inspection also revealed deficiencies in how the facility handled allegations of verbal abuse and threats between residents and involving staff. Resident #55 filed two grievance forms detailing an elevator altercation with another resident who allegedly threatened to roll over his feet, followed by a confrontation with a security guard who threatened to have the resident "thrown out" of the facility.
The Social Worker initially dismissed these allegations as not warranting investigation or reporting, telling inspectors she "did not feel they warranted to be reported as it was a verbal altercation between two residents." However, upon review with inspectors, she acknowledged that threatening to roll over a resident's feet and threatening facility expulsion constituted concerning verbal abuse.
The facility's own policies require immediate investigation of abuse allegations, including identifying all involved persons, determining if abuse occurred, and protecting residents during investigations. The Administration in Training acknowledged that the security guard should have been placed on administrative leave pending investigation of suspected verbal abuse.
Industry Standards for Medical Care Coordination
Nursing homes are required to ensure residents receive necessary medical care, including timely specialist consultations when ordered by physicians. Industry best practices call for systematic tracking of physician orders and specialist referrals to prevent delays that could harm resident health or well-being.
The Centers for Medicare & Medicaid Services requires facilities to have systems in place to monitor the implementation of care plans and physician orders. When specialists are needed, facilities must coordinate appointments promptly and ensure all necessary medical information is available to support continuity of care.
Regarding abuse prevention, federal regulations mandate that nursing homes implement comprehensive policies to prevent, identify, investigate, and report all forms of abuse, including verbal threats and intimidation. Facilities must protect residents during investigations and take immediate action to prevent further incidents.
Administrative Response and Acknowledgment
During the inspection, facility leadership acknowledged the serious nature of these failures. The Director of Nursing stated that the facility "dropped the ball" on the colostomy consultation and that the delay "should have been done sooner if the paperwork has been available since August." Both the Director of Nursing and Administrator in Training acknowledged that the failure to follow up on the resident's medical needs constituted neglect.
Remarkably, when inspectors asked about the medical records, Unit Secretary #1 was able to secure a pending gastroenterology appointment within approximately two hours - demonstrating that proper coordination could have resolved the issue much sooner.
Additional Issues Identified
The inspection documented several other areas where the facility failed to meet federal standards:
- Inadequate implementation of written policies for investigating abuse allegations - Failure to immediately report suspected abuse to state authorities as required - Lack of proper documentation in social service progress notes regarding resident grievances - Insufficient protection measures for residents during abuse investigations - Delayed reporting to the Health Care Facility Reporting System, occurring 24 hours after allegations were made rather than immediately
The facility was cited for violations related to protecting residents from abuse and neglect, as well as failing to properly implement policies and procedures for preventing and investigating abuse. These findings indicate systemic issues with both medical care coordination and resident protection protocols that require immediate attention and ongoing monitoring to ensure resident safety and well-being.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oxford Rehabilitation & Health Care Center, The from 2025-02-27 including all violations, facility responses, and corrective action plans.
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