Hebrew Rehabilitation Center — Poor Care
On July 23rd, 2012, almost a month after her initial collapse, my youngest sister, AP, was transferred to the Hebrew Rehabilitation Center located at 1200 Centre Street Roslindale, MA. The facility looked nice enough, it was clean, the front line staff was very professional, courteous and inviting and also it had free parking. However, the care was absolutely atrocious, to say the least. The level of incompetence, negligence and utter disregard for the patients’ needs was sadly beyond belief.
I arrived at the facility on Friday July 27th, 2012, my first visit. Upon my arrival I found my sister extremely annoyed at the beeping sounds coming from the monitors at the side of her bed, she complained that she had a tremendous headache because she was hearing the beeps for so long. I came out of her room and asked someone to please see what the problem was, I was quickly told “oh, that’s just telling us the medication is finished”… I asked that if it was that simple to identify then why didn’t anyone go shut it off. She said, “I’ll be right back” and it took her another 20 minutes to come back to shut off the beeping noise. My sister AP continued to tell me all of her grievances with the facility’s staff members. How they didn’t pay attention to her when she called out to them, how she asked for water sometime in the middle of the night and was told they’d be right back and she never got the water, how she asked for coffee at 7:45am that very same morning and she was told “it’s too early for coffee, you should be sleeping, go back to sleep” and how she complained about monitors beeping and no one would come to turn them off… (Well, I was a witness to that one)
Later that day, my sister AP soiled her diaper. I advised the nurse of this and offered to change her, as I have the skill, training & experience to do so. It was explained to me that it had to be done by staff because there was a need to inspect for any skin breakdown. I must admit that although I was disappointed to not be able to do it myself so I could quickly help my sister feel better and clean her, at that moment, I was pleased to hear that such carefulness was being taken to assure the well being of my sister’s skin. Sadly to say, I was wrong. It took almost an hour for someone to come to her room to change the diaper. When the diaper was removed and the stool wiped away, I could observe many areas of raw skin on her genitals and at the bottom of her buttocks. This, I can only conclude, was due to the delay of diaper changes and by the large, sand paper like, bath towel that was used in harsh thrusts to wipe her skin… along with possibly the wrong medication to correct the rash. Needless to say, I could understand my sister’s discomfort and cries for help. I was not pleased to see that at all.
Saturday afternoon about 12:10 PM, when I arrived (along with my other sister YF) we found my sister AP sitting in a wheel chair with a tray of food in front of her, mind you, she does not have full range use of her arms or hands, and she cannot grip anything at all or lift her hands to her mouth. My immediate thought was “what ### would put a tray of food in front of a patient who can’t eat by themselves”. We also found that she had spilled a cup of coffee all over herself (she said she burned herself) and it was all over her gown, floor, and on the side of the bed… I had to mop the floor with wet towels, clean my sister up, change her gown and switch out the linens on her bed. Indubitably no one was coming to clean it as when we arrived the spilled coffee had already dried on the floor, on her and on the bed sheets. As I removed the tray from the room, I noticed that there was a fork piercing through a couple of noodles on the plate; so apparently someone had been feeding her but then obviously the person got up, left my sister alone w/the tray in front of her and never came back.
Later on around 8:00 PM, when my sister was being moved from the wheelchair to her bed, the nurse and his assistant were not being careful at all and kept bumping her feet (which are both afflicted with gangrene) up against the poles of the lift, had it not been for my vigilance my sister could’ve been more seriously injured. As they are working this procedure someone calls out for D, (the assistant nurse) working with C (the male nurse) to get my sister back into bed. D yells out to her, “I’m in 14”, meaning room 314. The person in the hallway yells back “I’m not waiting, I’m leaving”. I thought that was the end of it but a minute later there is someone standing that the doorway calling out again. I was upset at this point and I told the woman “don’t you see she is busy working”; “she is working with a patient”. The woman comes into the room, with a huge smile on her face (like it’s a joke) and looks behind the curtain to verify if D was really busy I guess and kept giggling like a school girl… Now I’m FURIOUS! I loudly say to the woman, “what are you doing here, don’t you see she is busy with a patient, you are not supposed to be rushing her while she is working with her patients”. The woman said, “I just needed her help with another patient”. I said, “well do you expect her to drop what she’s doing now and run over to you, besides, what you said was you were leaving without her”, “so you don’t have another patient”. She continued to argue with me trying to not take any responsibility for her unprofessionalism, irresponsibility and misconduct. I asked nurse C who she was, “is this a patient” I kept asking him until he finally said she was an employee, an aid. I told him I wanted her name but he never gave it to me. He kept avoiding me for the rest of the night I didn’t see him again.
Toward the end of the night about 10 minutes to 10:00 PM, my sister started to cough a lot and asked for her asthma pump. I went out into the hallway to find it had been totally abandoned. There was absolutely no one anywhere in the hallway (from one end to the other) expect for a woman sitting diagonally across my sister’s room facing a freestanding computer. I told her my sister was having trouble breathing and needed her asthma pump. She said I had to wait for the nurse… I asked if he could be paged and asked where was everyone, her reply was “it’s the shift change”. About 10 minutes later the same woman comes in with the asthma inhaler for my sister and watches while my sister’s wife administers the pull. (Keep in mind my sister can’t use her hands).
Even with the asthma medication my sister AP was still coughing a lot and my other sister YF and my sister AP’s wife are noticing phlegm coming out of the trach they remove the cap to find old build up yellow phlegm in it… I go back out into the hallway, still no one is around, and I tell the same woman that it seems like the phlegm in her trach has to suctioned out. She said “okay, I’ll be right there”. When she comes back in, I ask are you a nurse, she then identifies herself as the Respiratory Therapist… “WHAT!!!”… I said to her, “ you mean to say we’re going thru all of this waiting for the other staff to come back from whatever shift change break they were on and you’re the person who should’ve been up front and present from the minute I first told you she was having trouble breathing! Really???”; She ignored my comment obviously noting her blunder.
She comes in with a tube, removes the trach valve and begins to suction out the phlegm. When she’s done she proceeds to put the valve back on without cleaning it… I mean, she didn’t even look at it to make sure it was okay. It was only after my sister YF pointed out to her that it was dirty and explained to her that the ICU team at BIMC stressed to us how important it was to keep it clean so to avoid infections and pneumonia did she agree and go wash it. I was dumbfounded to see the lack of professionalism from this so called “Respiratory Therapist”. From her tight facial expression I could tell she was non-to-pleased with us either; how dare the family ask for care & attention for our loved one… was how she made us feel.
After all of this was over, we met the evening nurse Ch and we felt we could leave our sister for the evening and after saying our goodbyes made our way toward the elevators. I remembered a cup I left behind in her room and returned for it. As I was walking toward AP’s room I could hear my sister’s voice arguing with someone. The curtain had been pulled, which was not as we had left it just moments before, and then I heard another voice, a woman’s voice. I stepped back into the bathroom doorway to listen to the conversation. I could hear my sister pleading, “no, please don’t take it off, it’s not supposed to come off, no please, stop don’t touch me”… and I could hear the other woman’s voice saying “I have to take it off, it’s the rules everyone takes it off at night, stop moving your head, stop moving your head, it has to come off”… then my sister yelled out, “I’m going to scream if you don’t get away stop, stop, stop”, the woman then said, “well I’m going to check in the reports” then she came out from behind the curtain; it was the Respiratory Therapist! The same woman we had been dealing with just moments before we left, with a look of pure evil on her face. When she looked up saw me standing there and realized I may have heard everything, her eyes almost popped out of their sockets! She gave a nervous grin from ear to ear, nodded her head and quickly moved right pass me… didn’t say a thing nor did she ask if I had heard the conversation just made a quick hasty exit. I approached my sister AP, who was sobbing, and asked what had happened. She was so happy to see me, she explained that she was calling out in pain for her nurse “and that the other lady came” in (the respiratory therapist)… “she wanted to take off the valve so I don’t talk or call out for anybody”… the use of the trach valve is the only way she can communicate and verbalizing her needs to her nurse and or anyone else. It is her lifeline!!! I could not understand what was going on. My sister has a heart condition, the argument put her in such a state of frenzy that it could've caused her a heart attack.
As I exited the room the Respiratory Therapist was at the free standing computer again, where I had first seen her. I told her emphatically she was not to remove the valve, she said “this is the first time I’m seeing her so I have to check the record”… I replied, “Okay, so what you’re telling me is that without checking the record you took it upon yourself to just want to remove the valve”, “why?” Her tongue stumbled with the foot she had just put in her mouth, and I couldn’t make out anything she was trying to say… I told her that AP had already been there for six days and the valve had never been removed… (Which should have been obvious to her as she had to clean out the filth in it just prior to our leaving), she didn’t respond to that, she just kept working on her computer and I left… the knot in my stomach made me fear for my sister’s life in the place.
Sunday morning we arrived to find my sister A sobbing softly in her bed, tears flowing down her face and saying, “I don’t want to be here, they’re going to kill me here”… (My gut feeling the night before had become her reality) she pleaded with me not to return to New York and then pleaded for me to bring her with me… it broke my heart to leave my sister in such a God forsaken place. My other sister Y stayed behind and was leaving on a later bus, she got the opportunity, along with AP’s wife RP, to voice all of the horrific accounts of the weekend to the Charge Nurse (K) and the Nursing Supervisor (E). We thought that would be the end of it and maybe now my sister would receive better care. Such was not the case!
Monday morning RP called the rehab center to inquire about AP, she was advised in a very nonchalant way, “oh by the way, did they tell you she fell out of bed this morning”. No one called to tell RP what had happened. RP rushed over to the facility to find A with additional pain to her back, neck and head. A said she doesn’t know how she fell out of bed… My question is: how does anyone who has NO core strength, cannot grip the side banisters, or turn on their side fall out of bed??? When I assisted D during the diaper change on Friday I had to hold on to A’s side because she wasn’t strong enough to hold herself on her side… so how could she roll over on her stomach and then roll over again to fall out of bed??? My sister was sent to the ER at BIMC to check for any injuries. More tests have to be done because there could be further infections that may have occurred due to the negligence of the Hebrew Rehabilitation Center Medical Staff.
All of these horrific things happened in the span of 72 hours. I cannot put into words the disappointment, outrage and indignation our family feels. Not to mention the pain and suffering my sister A has endured. We placed our loved one (AP) in the hands of people who we believed to be accredited with the skills, experience and devotion to help our loved one recover from traumatic injuries and what do we get… Ringling Bros. And Barnum & Bailey Circus. Everything is a joke, people are suffering and they are chatting it up in the hallway, huddled together badmouthing some other staff member or in the family room toasting raisin bread & drinking up the free juice! Bells, beeps and whistles are going off everywhere and they are all immune to the noise… everything is done in such a laid back fashion, no one seems to feel the urgency to get things done in a timely manner.
Saturday afternoon I was told by a staff member that the night before there were two huge mistakes made. The staff member could not tell me what exactly had happened but just kept repeating that they were really bad mistakes… I don’t know what it was, but my sister being left in a soiled diaper for over four hours was apparently not one of the mistakes… I was emphatically urged to write this letter detailing the sequence of events.
Before writing this letter please know that yesterday, Monday July 30th, 2012, I contacted the Hebrew Rehabilitation Center’s Social Services Department at [protected], the Department of Quality at [protected] and the Complaint number listed on the web site at [protected]. My call was returned by a Ms. M (I believe from the Dept. of Quality) and I was able to log a formal verbal complaint. I received a second return call from Ms. M later that day advising that the matter would be placed under investigation and profusely apologizing for all that had ensued. I also received a return call from the Social Services Dept. Ms. S. I explained to her that Ms. M had my report and she should speak to her to get the details of our complaint. Ms. S suggested that maybe that facility was not the appropriate facility for my sister to have been placed at. I shudder to think what type of patients the facility is appropriate for.
I truly believe that as a result of the poor care my sister received at the Hebrew Rehabilitation Center added to the questionable fall from her bed, my sister finds herself back in the ICU at Beth Israel Medical Center with additional infections and additional painful injuries. This has been a tremendous set back in her recovery.
I write this letter to ask that this facility be investigated at the highest levels. We cannot allow these calamities to continue. Who can people in this situation turn to? Please help the helpless!
A loving Big Sister