Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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GINO J. MERLI VETERANS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated complaint survey completed on May 6, 2019, it was determined that Gino J. Merli Veterans Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth Long Term Care Licensure Regulations.

 Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Based on a review of information submitted by the facility, information from local law enforcement, clinical records and select facility policies, interviews with staff and law enforcement officials and observation of video surveillance footage it was determined that the facility failed to prevent the physical abuse of one resident (Resident CR1) perpetrated by another resident (Resident 2), which resulted in serious bodily and physical injury and subsequent death of one resident (Resident CR1) out of nine sampled.

Findings include:

Review of facility policy entitled Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated as reviewed March 22, 2018 indicated the facility shall prevent abuse, neglect, exploitation and misappropriation of resident property, corporal punishment, involuntary seclusion and physical or chemical restraints not required to treat a resident's medical condition. The facility defines serious bodily injury as an injury involving extreme physical pain involving substantial risk of death; involving protracted loss or impairment of a body member, organ, or mental faculty; requiring medical intervention such as a surgery hospitalization or physical rehabilitation. The facility defines serious physical injury as an injury that causes a person severe pain or significantly impairs a person's functioning, either permanently or temporarily.

A review of the clinical record revealed that Resident CR1, was 95 years old and admitted to the facility on November 20, 2018, with diagnoses, which include dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and anxiety. The resident was receiving Plavix 75 mg (prevents platelets in the blood from sticking together) by mouth daily and Aspirin 81 mg (helps to prevent blood clots) by mouth daily.

According to a quarterly MDS (minimum data set assessment -a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 25, 2019, with resident was severely cognitively impaired with a BIMS score of 4 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 0-7 equates to severe cognitive impairment). The resident utilized a wheelchair for mobility and was not steady standing from a seated position or walking independently.

Clinical record review revealed that Resident 2 was admitted to the facility on June 5, 2018, and was 78 years old. This resident had diagnoses, which included Alzheimer's disease and seizure disorder (a medical condition where body muscles contract and relax rapidly and repeatedly, resulting in an uncontrolled shaking of the body).

A quarterly MDS Assessment dated March 6, 2019 indicated this resident had a BIMS score of 4 (severe cognitive impairment). This resident also utilized a wheelchair for mobility and was not steady when walking or moving from a seated to standing position.

A review of information dated December 8, 2018, submitted by the facility revealed that on December 8, 2018, Resident 2's wife, Resident 3, who also resided at the facility, reported that Resident 2 became agitated and struck her in the left leg, while they were sitting next to each other in the 2 South d unit hallway. The residents were separated. Resident 3 was placed on every 15 minutes check by staff. Resident 3 wanted her husband Resident 2's room changed to another floor as she did not want to reside on the same floor as her husband. However, their son was able to convince both residents to remain on the same floor when he visited on December 11, 2018. Clinical record documentation revealed that Resident 2 continued to be combative with staff and attempted self-ambulate. The resident remained on every 15 minute staff checks, until the facility discontinued the watches on December 20, 2018.

Nursing documentation dated January 28, 2019, indicated that at 3:20 AM Resident 2 was redirected out of another resident's room. Staff directed Resident 2 back to the nurse's station in his wheelchair. Resident 2 began to stand up; when asked to sit down he became angry, slammed his hand down on the counter and yelled "don't tell me what to do!". He then fell to the floor without injury.

On February 17, 2019, nursing documentation indicated that Resident 2 was involved in a verbal altercation with another resident (Resident CR2), but he was easily redirected.

Nursing documentation of March 18, 2019, at 3:15 AM revealed that Resident 2 was verbally aggressive with staff, pointing in their faces and had continuous attempts of self-rising out of his wheelchair and aimlessly wandering in the hallways attempting to open doors.

Nursing documentation dated March 25, 2019, revealed that Resident CR1 was attempting to enter the hallway bathroom and Resident 2 was seated outside of the bathroom. Resident 2 kicked Resident CR1's wheelchair, then the two residents began kicking each other. Resident 2 made a fist with his left hand and punched Resident CR1 on the right side of his face, with no injury. Nursing documentation of March 26, 2019, indicated that Resident 2 was very resistant to care; raising his fists and yelling and cursing at staff.

Nursing documentation dated April 18, 2019, at 2:09 AM revealed that the resident was very agitated while using the bathroom with staff. When staff explained to the resident he was not in the sawmill, but that he was in the bathroom, he made a fist and and hit the assist bars on the side of the toilet.

A review of nursing documentation and information provided by the facility dated April 22, 2019, and observation of facility video footage revealed that on April 22, 2019, at approximately 1:14 PM Employee 1, RN (registered nurse) heard an alarm (pad alarm on wheelchair which would sound to alert staff if resident arises from alarmed pad on chair) sounding in resident room 220 (A hallway). Employee 1 attempted to enter resident Room 220, but she was unable to gain access through the doorway of this room. She then entered the resident room through the adjoining bathroom of resident Room 218, which allowed her access to resident room 220.

Employee 1 found Resident CR1 lying on the floor out of his wheelchair. He was lying with his head towards the bathroom and his feet towards the foot of the bed. His wheelchair was against the door, which was the reason Employee 1 could not access the room through the door to Room 220.

According to the facility's submitted information, Employee 1 observed Resident 2 to be at the side of Resident CR1's wheelchair. Resident 2 was bending at his waist stating 'I'm trying to help him." Resident CR1 stated at that time "He just started hitting me, he came from behind, I tried to protect myself!"

Facility nursing staff noted that blood spatter was observed on the walls, door and doorway into bathroom. Blood spatter was observed on the pillow on the back of Resident CR1's wheelchair.

Resident CR1 was observed to have an approximate 2 inch laceration to the left side of his temple area with large amounts of bloody drainage, his left cheek and eye were swollen and purple. His upper and lower lips were split and bleeding.

He was sent to the emergency room for evaluation by 1:33 p.m. on April 22, 2019.

Resident 2 was observed to have dried blood covering the posterior aspect of both of his hands including his fingers. He complained of pain to his right hand. An ecchymotic area 9 bruise) was noted to his 4th right knuckle measuring 0.8 cm by 0.7 cm and a 2.2 cm x 1.7 cm ecchymotic area to the 5th knuckle on his right hand.

Neither resident resided in room 220.

A review of hospital documentation dated April 22, 2019, at 2:05 PM revealed that Resident CR1 was assaulted by another resident while in the nursing care facility or pushed into a wall. Resident CR1 presented with a 4 cm laceration to the left temporal (side of head) region and left periorbital ecchymosis (bruising around the eyes). His eye was swollen shut. Soft tissue swelling noted on the left cheek area.

At 2:15 PM, April 22, 2019, a CT Scan (A computerized tomography (CT) scan combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside your body. CT scan images provide more detailed information than plain X-rays do), was completed and indicated the resident had bleeding on the left side of his brain diagnosed with a left sided subdural hematoma (blood collects between the layers of tissue that surround the brain. The outermost layer is called the dura. In a subdural hematoma, bleeding occurs between the dura and the next layer, the arachnoid). It was noted that the resident had been receiving Plavix 75 mg (prevents platelets in the blood from sticking together) by mouth daily and Aspirin 81 mg (helps to prevent blood clots) by mouth daily at the time of the assault (both of which increase the resident's risk for bleeding).

Hospital records indicated that the resident's neurological condition deteriorated overnight (compared to CT of April 22, 2019) from April 22, 2019, to April 23, 2019. There was an increase in the midline shift from 2-3 mm to 4 mm (Midline shift refers to when a person's brain actually shifts beyond the center line of the brain. The shift is normally caused by a traumatic event involving the brain or head, and can indicate further problems with the brain, such as intracranial pressure or tumor growths) and notable increase in subdural blood products along the left frontal area of the brain

On April 23, 2019, after multiple discussions with family, it was determined that surgical intervention was not an option as per the resident's wishes and his advanced age. Resident CR1 was discharged to inpatient Hospice for end of life care. The resident expired in Hospice care on April 26, 2019.

A review of hospital records for Resident 2's ER evaluation following the incident of April 22, 2019, revealed that Resident 2 was evaluated in the emergency room for aggressive behaviors and assaulting another resident. The resident was observed to have bruising of his right fouth and fifth knuckles. No fractures were identified. This resident was evaluated by psychiatry and was returned to the facility on April 23, 2019 placed in a private room under a two person constant watch, which the facility later decreased to a continous watch by one staff member after seen by the psychiatrist on April 25, 2019 at 8:50 AM.

On the day of the survey ending May 6, 2019, interviews were conducted with staff who were present during Resident 2's physical assault of Resident CR1 on April 22, 2019.

An interview with Employee 1, RN, at 9:50 AM on May 6, 2019, revealed that she was administering medications that day and heard a wheelchair alarm sounding from behind a door. She realized that it was coming from Room 220; when she tried to open the door she could not and heard someone from inside the door yell "I can't open the door!" Employee 1 stated that she recognized Resident 2's voice. She then went through Room 218's doorway through the adjoining bathroom and found Resident CR1 lying on the floor. Employee 1 stated that Resident CR1's wheelchair had been pushed up against the door. She stated that Resident 2 was reaching out to Resident CR1. She stated Resident CR1 stated "He assaulted me. He attacked me!" Employee 1 stated that Resident 2 stated that he was trying to help Resident CR1.

An interview with Employee 2, nurse aide, at 9:45 AM on May 6, 2019, revealed that she arrived in the room shortly after Employee 1 as she also stated she heard an alarm sounding. Employee 2 stated that Resident CR1 stated "He tried to kill me, where is my brother, he was hitting me!" Employee 2 stated that she ran for towels and washcloths. Employee 2 stated that "there was blood everywhere."

The RN supervisor, Employee 3, was also interviewed at 9:13 AM on May 6, 2019. The RN Supervisor stated that neither resident resident in the room 220 where the assault took place. She stated that she was called to the scene at around 1:16 PM April 22, 2019. She stated that Resident CR1 was soaked in blood and Resident 2 had blood on both of his hands.

Observations during the survey ending May 6, 2019, revealed that Resident CR1 had resided in Room 212 on the B hallway. Resident 2 resided in Room 217 in the A hallway. Resident CR1's brother, Resident 4, resided in Room 219 in the A hallway directly across from Room 220.

The facility provided video surveillance footage of the hallway for the date that Resident 2 physically attacked Resident CR1. Obseravtion revealed that at 12:51 PM Resident CR1 was sitting in the hallway, next to his brother Resident 4. At 12:51 PM Resident 2 was observed to pass by Resident CR1 in his wheelchair with no contact. At 12:53 PM Resident 4 went down A hallway, passed Resident 2 and went into his room, 219. At 12:55 PM Resident 2 went down A hallway and went into resident Room 220 (not his room). At 1:03 PM Resident CR1 was observed to go down the A hallway and also entered Room 220, the room which Resident 2 had entered.

It was not until approximately 1:14 PM that Employee 1 heard Resident CR1's wheelchair alarm sounding indicating the resident was no longer in his chair.

As per the video footage and staff interviews it was determined that Resident CR1 and Resident 2 were alone in Room 220 for approximately 11 minutes, during which time Resident 2 had physically assaulted and seriously injured Resident CR1, resulting in Resident CR1's death.

An interview conducted with the assistant nursing home administrator on May 6, 2019 at 9:00 AM revealed and the Coroner's report noted that the cause of Resident CR1's death was blunt force head trauma and that the local police had determined it was homicide. The facility spoke with Resident CR1's son on April 22, 2019, at 2:30 PM who declined to press charges against Resident 2 at that time.

Interview with a representative from the county District Attorney's office on May 13, 2019, at 11 AM revealed that the decision to file charges against Resident 2 remained under review at this time.

28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 201.18 (e)(1)(2) Management

28 Pa. Code 211.5 (f)(g)(h) Clinical records

28 Pa. Code 201.29(a)(c)(d) Resident rights

28 Pa. Code 211.11(a) Resident care plan

28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services
Previously cited 12/7/18

 Plan of Correction - To be completed: 06/10/2019


1. Both residents CR1 and 2 were sent to the hospital for evaluation on 4/22/19. Resident 2 has returned to the facility 4/23/19. Staff is providing continuous 1:1 observation for Resident 2. Resident CR1 had CTB on 4/26/19.

2. Licensed staff will head a behavior huddle conference with staff on the floor upon occurrence for residents displaying verbal or physical aggressive behaviors. A huddle sheet will be completed which identifies the current situation, any precipitating factors and interventions provided. Huddle sheets will be reviewed by the IDT for further suggestions. Quality Assurance/Risk Management (QA/RM) or designee will use a behavior log to track and trend physical and verbal aggressive behaviors and it will be discussed and updated in morning meeting. Interventions for physical and verbal aggressive behaviors will be specific to that resident and their behavior. Residents have been interviewed by Social Service on 4/27/19 and 4/28/19 for interruptions in psychosocial status. Interventions provided as needed.

3. The facility abuse policy has been reviewed to assure it has ways to prevent resident to resident abuse. Prevention of resident to resident altercations, aggression and abuse has been in-serviced to staff with 94% completed by May 3, 2019. A verbal and physical aggressive behavior management program has been developed, and forms will be developed to assist staff to care for residents with verbal and physical aggressive behaviors. These documents will be in-serviced to staff. Staff will be in-serviced on approach. Competencies will be held on educated material going forward to make sure the information is retained.

4. The QA/RM or designee will track verbal and physical aggressive behaviors. Residents with these behaviors will be logged into the behavior management log for tracking and trending. An audit will be conducted to assure a care plan, progress note, and profile are completed with new aggressive verbal or physical behaviors. A QAPI team member will conduct the audit weekly x 12 weeks. A QAPI team member will conduct a random audit on observations of physical and verbal behaviors X12 weeks to assure documentation is in place. Results of the audits will be reported to the regularly scheduled Quality Improvement committee meetings.

5. POC Date Certain June 10, 2019

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