Twin Oaks Center
TWIN OAKS CENTER in DANVERS, MA — inspection on July 11, 2024.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #24's most recent Nurse Practitioner progress note, dated 7/4/24, indicated Depakote level to be obtained on Monday, 7/8/2024.
Review of Resident #24's active physician orders, indicated the Resident receives Depakote by mouth twice daily.
Review of Resident #24's physician order, dated 7/4/24, indicated Check Depakote level on Monday 7/8/24.
Review of Resident #24's nursing progress notes did not indicate that the Resident had refused a lab draw.
During an interview on 7/10/24 at 10:40 A.M., the Director of Nurses said Monday is not the facility's regular lab day but nursing staff could have called the lab to book the lab draw for 7/8/24.
The Director of Nurses said the lab was not drawn yet.
Review of the Nurse Practitioner progress note, dated 12/29/23, does not indicate that the Nurse Practitioner addressed the elevated lab values.
There is no indication in the clinical record that any hydration protocol was put in place for Resident #37 to address the elevated labs.
Review of a second lab panel, dated 1/3/24, 5 days after the initial labs drawn, indicated Resident #37 had a critically high sodium level of 160, an elevated chloride level of 122, and an elevated BUN of
During an interview on 7/10/24 at 1:18 P.M., the lab company confirmed that Nurse #1 was notified of the critically high labs via telephone on 1/3/24 at 8:06 P.M.
Review of the progress note, dated 1/4/24 at 12:01 P.M., 16 hours after the facility received notification of the elevated labs, indicated to send the Resident to the hospital due to dangerously high sodium levels.
Review of the progress note, dated 1/4/24, indicated Note Text: Resident alert and confused, new order from NP to send resident to ER for abnormal result, 2 attends of Beauport ambulance picked him up at 5:30 pm.
Review of Resident #37's hospital discharge paperwork indicated Resident #37 was treated in the hospital for hypernatremia (elevated blood sodium), dehydration, and an acute kidney injury.
During an interview on 7/11/24 at 7:54 A.M., the Medical Director said that if a resident comes back with an elevated sodium level, then he would expect that resident to be treated with D5W (intravenous dextrose solution to treat dehydration) and if that could not be performed, then the resident should be sent out to the hospital.
The Medical Director said he would expect to be notified immediately of any critically high or high laboratory levels and any sodium above 145 is considered to be high.
The Medical Director said that Nurse #1 should have notified the Nurse Practitioner or physician immediately and considers this a delay in treatment for Resident #37.
See tag F-F773.
225198 07/11/2024
Twin Oaks Center 63 Locust Street Danvers, MA 01923
During an interview on 7/10/24 at 1:18 P.M., the lab company confirmed that Nurse #1 was notified of the critically high labs via telephone on 1/3/24 at 8:06 P.M.
Review of the clinical record failed to indicate that the physician or NP was notified of the critically high sodium level upon notification from the laboratory.
Review of the progress note, dated 1/4/24 at 12:01 P.M., 16 hours after the facility's initial notification of the elevated labs, indicated to send the Resident to the hospital due to dangerously high sodium levels.
Review of the progress note, dated 1/4/24, indicated Note Text: Resident alert and confused, new order from NP to send resident to ER for abnormal result, 2 attends of ambulance picked him up at 5:30 pm.
Review of Resident #37's hospital discharge paperwork indicated Resident #37 was treated in the hospital for hypernatremia (elevated blood sodium), dehydration, and an acute kidney injury.
During an interview on 7/11/24 at 7:54 A.M., the Medical Director said that if a resident comes back with an elevated sodium level, then he would expect that resident to be treated with D5W (intravenous dextrose solution to treat dehydration) and if that could not be performed, then the resident should be sent out to the hospital.
The Medical Director said he would expect to be notified immediately of any critically high or high laboratory levels and any sodium above 145 is considered to be high.
The Medical Director said that Nurse #1 should have notified the Nurse Practitioner or physician immediately and considered this a delay in treatment for Resident #37.
225198 07/11/2024
Twin Oaks Center 63 Locust Street Danvers, MA 01923
Review of the Laboratory Services Agreement indicated the following:
- Notification of Findings: As applicable, Laboratory shall provide immediate telephone notice of results of any critical lab value.
Laboratory shall promptly report all other findings as appropriate to the facility.
Resident #37 was admitted with 10/2018 with diagnoses including nontraumatic acute subdural hemorrhage, hypertension, peripheral vascular disease, and cognitive decline.
Review of Resident #37's most recent Minimum Data Set (MDS) assessment, dated 6/19/24, indicated that Resident #37 scored a 9 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment.
Review of the MDS, dated [DATE], indicated Resident #37 required limited assist to one person physical assistance with eating and drinking.
225198
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 225198 B.
Wing 07/11/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Twin Oaks Center 63 Locust Street Danvers, MA 01923
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.