Nursing home fined for not reporting fall that led to death of a facility founder, expects restitution from staffing company

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A Massachusetts nursing home where a resident fell and was shuffled back to bed without an official report was issued a $140,000 fine following the man's death. The facility says it expects to be reimbursed by a staffing company that sent a nurse who apparently didn't follow protocols.

Holy Trinity Nursing and Rehabilitation Center agreed to waive an appeal and paid the Centers for Medicare & Medicaid Services a reduced penalty just over $91,000 on Jan. 31. The Worcester facility also has come into compliance by implementing corrective measures since the Aug. 7 incident, according to a report cited by the Worcester Telegram.

Walter E. Haddad, 87, was a retired accountant who helped found Holy Trinity. He moved into the nursing home in 2016 after being diagnosed with Parkinson's disease.

According to CMS, a certified nursing assistant and a licensed practical nurse found Haddad lying on the floor in the middle of the night. They took him to use the restroom, then helped him back to bed.

The CNA told investigators he did not make a fall report because the LPN asked him not to. The LPN told investigators in a phone interview that he did not remember anyone falling during his overnight shift.

The LPN was working his first shift at Holy Trinity but had signed orientation papers outlining fall procedures, which require that a resident not be moved from the floor after a fall unless an assessment rules out serious injury. The policy also requires family and physician notification.

About six hours after he fell, Haddad told staff he had hit his head on a nightstand. But it was  at least another hour — after his visiting family noticed his speech was slurred and his mental status declined — until a physician was finally called.

The doctor ordered a trip to the hospital, where Haddad was diagnosed with a traumatic subdural hemorrhage. He died the next morning.

Investigators noted that Haddad's condition was “exacerbated” by Plavix, a blood-thinner he took along with his other regular medications the morning after the accident.

Executive director Gerald E. Shaffer told the Telegram this week he “hopes and expects” Holy Trinity will be reimbursed for the fine by Omni Healthcare Staffing Inc., which employed the LPN who was working at Holy Trinity when Haddad fell.

Shaffer said the certified nursing assistant was fired, and that he has not used nurses from Omni since Haddad's fall. The newspaper said Omni's owner did not return its phone calls seeking comment.