Nursing Investigation Results -

Pennsylvania Department of Health
JEWISH HOME OF GREATER HARRISBURG
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
JEWISH HOME OF GREATER HARRISBURG
Inspection Results For:

There are  119 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
JEWISH HOME OF GREATER HARRISBURG - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on an abbreviated survey to investigate a complaint completed on February 19, 2019, it was determined that The Jewish Home of Greater Harrisburg was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.











 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on observations, interviews, and review of an incident/accident report it was determined that the facility failed to ensure the residents' environment was free of accident hazards for 55 residents who required the use of mechanical lifts, which resulted in actual harm to Resident 2 when the lift (mechanical device used to transfer residents) broke and the resident fell to the floor and struck his head, requiring transport to the hospital with a diagnosed brain bleed.

Findings include:

Review of the manufacturer service manual for the Viking M lift, dated December 27, 2012, revealed, "The lift must be thoroughly inspected when the Service Light at the control unit CBL illuminates (a display on the equipment that indicates serving is required), or at least once per year. Vikings with other control units shall be thoroughly inspected at least once per year. Inspection and service must be carried out by authorized personnel."

Review of the manufacturer instruction guide for the Uno 102 lift, dated August 22, 2013, revealed, "A periodic inspection of the lift should be carried out at least once per year. Periodic inspection, repair and maintenance should be performed only in accordance with the (manufacturer) Service Manual, and by personnel authorized by (manufacturer) and using original spare parts."

Review of the manufacturer instruction guide for the Sabina II sit to stand lift, dated March 12, 2012, revealed, "Sabina should be periodically inspected at least once a year. Periodic inspection, repair and maintenance should be performed only in accordance with the (manufacturer) Service Manual, and by personnel authorized by (manufacturer) and using original (manufacturer) spare parts."

Observation of the lifts in the facility revealed they had 5 Viking M lifts-the oldest being a 2007, 5 Sabina or Sabina II lifts-the oldest being a 2002, and 5 Uno 102 lifts-the oldest being a 2001.

Review of an incident/accident investigation information form provided by the facility dated February 2, 2019, revealed that on February 2, 2019, at approximately 8:38 PM Resident 2 was being returned to bed, when the Viking M lift, which was being used broke, and the resident fell to the floor and struck the back of his head on the floor, resulting in a laceration to the left posterior (back) of the head with bleeding present. Resident 2 was assessed and transported to the hospital where Resident 2 was diagnosed with an intraparenchymal hemorrhage of the brain (intracerebral bleeding), a subdural hematoma (blood gathering between the inner layer of the dura mater and the arachnoid mater surrounding the brain), and a subarachnoid hemorrhage (bleeding into the area between the arachnoid membrane and the pia mater surrounding the brain).

The facility investigation revealed that a metal pin which connects the lift arm (the part of the lift that articulates up and down to provide lift to the resident) to the slingbar (a metal bar with hooks on each end used to attach the sling, which the resident is sitting in) had broken, causing the slingbar, the sling and the resident to fall to the floor.

An interview with the Facilities Director on February 14, 2019, at 3:42 PM revealed, "they (the lifts in the facility) have not been serviced by the manufacturer" and that the facility staff had not been trained by the lift manufacturer to service the lifts.

The facility was unable to provide a policy related to the lifts, that included the required annual inspection and maintenance provided by the manufacturer's authorized service provider.

The facility failed to ensure the resident's environment was free of accident hazards for 55 residents that required the use of mechanical lifts, which resulted in actual harm to Resident 2 when the lift broke and the resident fell to the floor and struck his head. The resident was sent to the hospital and diagnosed with a brain bleed.

42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices.
Previously cited 1/31/19.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 1/31/19, 1/12/18.

28 Pa. Code 201.18(b)(1)(3) Management.
Previously cited 1/31/19, 7/19/18.

28 Pa. Code 201.18(d) Management.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 7/19/18.

28 Pa. Code 201.29(d) Resident rights.
Previously cited 7/19/18.

28 Pa. Code 207.2(a) Administrator's responsibility.

28 Pa. Code 211.10(c)(d) Resident care policies.
Previously cited 7/19/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/31/19, 10/4/18, 8/15/18, 7/19/18, 1/12/18.

































 Plan of Correction - To be completed: 03/07/2019

Development and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed by provisions of Federal and State Law.

1.R2's health status is back to baseline.
R1 and R3-R55 were not affected.
Facility will continue quarterly preventative maintenance on the lifts.
Upon further investigation it was determined that the lift broke due to a manufacturer defect.

2.Lift Maintenance Policy updated.

3.NHA/designee educated maintenance personnel on updated Lift Maintenance Policy.
LW Consulting completed a directed in-service on 3/6/19 and 3/7/19 with nursing staff, maintenance and administration. Staff who did not attend the meetings will be required to watch a recording of the directed in-service prior to their next scheduled shift.

4.NHA/designee will complete annual audits to ensure lift inspections are completed by authorized personnel annually.
Findings of the audits will be reported to the facility Quality Assurance/Performance Improvement committee to determine need for additional actions and or monitoring.

5.Date of Compliance: 3/7/19

483.70 REQUIREMENT Administration: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.
483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:


Based on review of job descriptions, clinical records, observations and staff interviews, it was determined that the Nursing Home Administrator (NHA) did not effectively manage the facility to ensure that the facility had an authorized service provider inspect and service each mechanical lift on an annual basis as per the manufacturer guidelines. This failure placed 55 residents that required the use of mechanical lifts, (Residents 1 through 55) at risk for harm. This failure to inspect and service the lifts resulted in actual harm to Resident 2 when the lift (mechanical device used to transfer residents) broke and the resident fell to the floor and struck his head. Resident 2 was sent to the hospital and diagnosed with a brain bleed.

Findings include:

The job description for the Nursing Home Administrator (NHA) specified the primary purpose of the job position is to direct the day-to-day functions of the facility in accordance with current Federal, State and local standards, guidelines, and regulations that govern the long-term care facility and the philosophy and goals determined by the Board of Directors in concert with the mission of JHGH to assure that the highest degree of quality care is maintained at all times.

Review of the manufacturer service manual for the Viking M lift, dated December 27, 2012, revealed, "The lift must be thoroughly inspected when the Service Light at the control unit CBL illuminates (a display on the equipment that indicates serving is required), or at least once per year. Viking with other control unit shall be thoroughly inspected at least once per year. Inspection and service must be carried out by (distributor/manufacturer) authorized personnel."

Review of the manufacturer instruction guide for the Uno 102 lift, dated August 22, 2013, revealed, "A periodic inspection of the lift should be carried out at least once per year. Periodic inspection, repair and maintenance should be performed only in accordance with the (manufacturer) Service Manual, and by personnel authorized by (distributorand using original (manufacturer) spare parts."

Review of the manufacturer instruction guide for the Sabina II sit-to-stand lift, dated March 12, 2012, revealed, "Sabina should be periodically inspected at least once a year. Periodic inspection, repair and maintenance should be performed only in accordance with the (manufacturer) Service Manual, and by personnel authorized by (manufacturer) and using original (manufacturer) spare parts."

Review of an incident/accident investigation information form provided by the facility dated February 2, 2019, revealed that on February 2, 2019, at approximately 8:38 PM Resident 2 was being returned to bed, when the Viking M lift, which was being used broke, and the resident fell to the floor and struck the back of his head on the floor, resulting in a laceration to the left posterior (back) of the head with bleeding present. Resident 2 was assessed and transported to the hospital where Resident 2 was diagnosed with an intraparenchymal hemorrhage of the brain (intracerebral bleeding), a subdural hematoma (blood gathering between the inner layer of the dura mater and the arachnoid mater surrounding the brain), and a subarachnoid hemorrhage (bleeding into the area between the arachnoid membrane and the pia mater surrounding the brain).

An interview with the Facilities Director on February 14, 2019, at 3:42 PM revealed, "they (the lifts in the facility) have not been serviced by the manufacturer" and that the facility staff had not been trained by the lift manufacturer to service the lifts.

During an interview with the NHA on February 14, 2019, at 4:50 PM the NHA revealed that the facility did not have a contract with an authorized service company to inspect and service the lifts in the facility annually, as specified in the Instruction Guides and Service Manuals for the three types of lifts being utilized in the facility. When asked for her expectation regarding the contracts she replied, "we should have had them."

The NHA failed to ensure that the lifts were inspected and serviced by authorized service providers which resulted in actual harm to Resident 2 when the lift broke and the resident fell to the floor and struck his head resulting in a brain bleed.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 1/31/19, 1/12/18.

28 Pa. Code 201.18(b)(1)(3) Management.
Previously cited 1/31/19, 7/19/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 7/19/18.

28 Pa. Code 207.2(a) Administrator's responsibility.














 Plan of Correction - To be completed: 03/07/2019

Development and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed by provisions of Federal and State Law.

1.R2's health status is back to baseline.
R1 and R3-R55 were not affected.
Facility will continue quarterly preventative maintenance on the lifts.
Upon further investigation it was determined that the lift broke due to a manufacturer defect.

2.CEO reviewed job description with NHA.

3.NHA and administration staff completed directed in-service on 3/6/19 and 3/7/19.

4.CEO will review job description with NHA at the annual evaluation.

5.Date of Compliance: 3/7/19

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition: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.
483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:


Based on review of incident/accident investigation information and clinical records, as well as staff interviews, it was determined that the facility failed to maintain essential resident care equipment in a safe manner for 55 residents that required the use of mechanical lifts, (Residents 1 through 55), which resulted in actual harm to Resident 2 when the lift broke and the resident fell to the floor and struck his head. The resident was sent to the hospital and diagnosed with a brain bleed. .

Findings included:

Review of the manufacturer service manual for the Viking M lift, dated December 27, 2012, revealed, "The lift must be thoroughly inspected when the Service Light at the control unit CBL illuminates (a display on the equipment that indicates serving is required), or at least once per year. Viking with other control unit shall be thoroughly inspected at least once per year. Inspection and service must be carried out by (distributorauthorized personnel."

Review of the manufacturer instruction guide for the Uno 102 lift, dated August 22, 2013, revealed, "A periodic inspection of the lift should be carried out at least once per year. Periodic inspection, repair and maintenance should be performed only in accordance with the (manufacturer) Service Manual, and by personnel authorized by (distributorand using original (manufacturer) spare parts."

Review of the manufacturer instruction guide for the Sabina II sit-to-stand lift, dated March 12, 2012, revealed, "Sabina should be periodically inspected at least once a year. Periodic inspection, repair and maintenance should be performed only in accordance with the (manufacturer) Service Manual, and by personnel authorized by (manufacturer) and using original (manufacturer) spare parts."

Review of an incident/accident investigation information form provided by the facility dated February 2, 2019, revealed that on February 2, 2019, at approximately 8:38 PM Resident 2 was being returned to bed, when the Viking M lift, which was being used broke, and the resident fell to the floor and struck the back of his head on the floor, resulting in a laceration to the left posterior (back) of the head with bleeding present. Resident 2 was assessed and transported to the hospital where Resident 2 was diagnosed with an intraparenchymal hemorrhage of the brain (intracerebral bleeding), a subdural hematoma (blood gathering between the inner layer of the dura mater and the arachnoid mater surrounding the brain), and a subarachnoid hemorrhage (bleeding into the area between the arachnoid membrane and the pia mater surrounding the brain).

An interview with the Facilities Director on February 14, 2019, at 3:42 PM revealed, "they (the lifts in the facility) have not been serviced by the manufacturer" and that the facility staff had not been trained by the lift manufacturer to service the lifts.

During an interview with the Nursing Home Administrator (NHA) on February 14, 2019, at 4:50 PM the NHA revealed that the facility did not have a contract with an authorized service company to inspect and service the lifts in the facility annually, as specified in the Instruction Guides and Service Manuals for the three types of lifts being utilized in the facility. When asked for her expectation regarding the contracts she replied, "we should have had them."

The facility failed to ensure that the mechanical lifts were maintained, inspected and serviced by authorized service providers which resulted in actual harm to Resident 2 when the lift broke and the resident fell to the floor and striking his head, resulting in a brain bleed.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 1/31/19, 1/12/18.

28 Pa. Code 201.18(b)(1)(3) Management.
Previously cited 1/31/19, 7/19/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 7/19/18.

28 Pa. Code 207.2(a) Administrator's responsibility.










 Plan of Correction - To be completed: 03/07/2019

Development and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed by provisions of Federal and State Law.

1.R2's health status is back to baseline.
R1 and R3-R55 were not affected.
Facility will continue quarterly preventative maintenance on the lifts.
Upon further investigation it was determined that the lift broke due to a manufacturer defect.

2.Lift Maintenance Policy updated.

3.NHA/designee educated maintenance personnel on updated Lift Maintenance Policy.
LW Consulting completed a directed in-service on 3/6/19 and 3/7/19 with nursing staff, maintenance and administration. Staff who did not attend the meetings will be required to watch a recording of the directed in-service prior to their next scheduled shift.

4.NHA/designee will complete annual audits to ensure lift inspections are completed by authorized personnel annually.
Findings of the audits will be reported to the facility Quality Assurance/Performance Improvement committee to determine need for additional actions and or monitoring.

5.Date of Compliance: 3/7/19


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port