Nursing Investigation Results -

Pennsylvania Department of Health
GINO J. MERLI VETERANS CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GINO J. MERLI VETERANS CENTER
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 a Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on December 3, 2021, it was determined that Gino J. Merli Veterans Center was not in compliance with the following requirements of 42 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:


483.12(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;
Observations:

Based on review of the facility's abuse prohibition policy, select investigative reports and clinical records, and staff interview, it was determined that the facility failed to ensure that four residents (Resident 48, Resident 22, Resident 122 , Resident 17 ) were free from physical and/or verbal abuse, which resulted in physical injuries, a fractured finger, lacerations and contusion to one resident (Resident 22) out of 26 sampled residents


Findings include:

Review of facility policy titled "Freedom from Abuse, Neglect, Exploitation, and Misappropriation of Resident Property" that was last reviewed by the facility November 15, 2021, revealed that the facility will provide protections for the health, welfare, and rights of each resident residing in the facility. The facility shall prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, involuntary seclusion. The facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.

A review of Resident 22's clinical record revealed that the resident was admitted to the facility on June 13, 2019, with diagnoses, which included vascular dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).

A review of Resident 22's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 7, 2021, revealed that the resident was severely cognitively impaired.

A review of Resident 131's clinical record revealed that the resident was admitted to the facility on April 14, 2015, with diagnoses, which included dementia.

A review of Resident 131's Quarterly Minimum Data Set Assessment dated August 6, 2021, revealed the Brief Interview for Mental Status (BIMS section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being Cognitively Intact) that the resident scored a 15, which indicated that he was cognitively intact.

A review of Resident 22's clinical record revealed a nursing progress note dated October 27, 2021, at 7:15 AM noted that at 1:20 AM on that date, staff were called to the "C" lounge where a resident was on the floor and bleeding. Resident 22 was found in his wheelchair, lying on right side, on the floor. Resident 22 had a laceration to the top of left lip, measuring 3 cm x 0.5 cm, his right elbow was skinned and swollen, and had a right dorsal hand skin tear 0.5 cm x 0.5 cm. When asked what happened, Resident 22 stated "I was punched in the face by a man with white hair, my wheelchair fell over with me in it."

A nursing progress note dated October 27, 2021, at 4:32 PM revealed Resident 22 returned from an evaluation at the emergency room in good spirits with no complaints of pain or discomfort. Resident 22 received 3 sutures to the linear laceration to his left upper lip. The resident had swelling in the right dorsolateral hand and 5th metacarpal (the little finger or pinky finger) due to a fracture and right elbow swelling with redness. The resident had no complaints of pain or discomfort.

A review of a progress note dated October 27, 2021, at 7:15 AM revealed an interview with Resident 131 related to the morning's incident. Resident 131 stated that he went into the "C" lounge with Resident 97 to play cards when Resident 22 came over and grabbed the cards, so he pushed Resident 22 and he fell over in his wheelchair.

A review of a facility investigation, which included video footage dated October 27, 2021, at 7:37 AM revealed that Resident 131 struck Resident 22, which caused Resident 22 to fall over in his wheelchair to the floor. Resident 22 sustained a laceration to his left upper lip, skin tear to his left hand, and fracture to his right 5th metacarpal (little finger/pinky finger).

The facility failed to ensure that Resident 22 was free from physical abuse perpetrated by Resident 131.

A review of Resident 48's clinical record revealed that the resident was admitted to the facility on March 25, 2021, with diagnoses, which included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and the elderly) and unspecified dementia [chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning] without behavioral disturbances.

Review of the resident's quarterly MDS Assessment dated June 6, 2021, indicated that the resident had severe cognitive impairment and did not display any behaviors.

A review of Resident 72's clinical record revealed that the resident was admitted to the facility on May 25, 2021, with diagnoses, which included unspecified dementia with behavioral disturbance, impulse disorder (is a condition in which a person has trouble controlling emotions or behaviors), and generalized anxiety.

Review of the resident's Admission MDS dated June 1, 2021, indicated that the resident had severe cognitive impairment and displayed behaviors of wandering occurred four to six times per week.

Nursing progress notes dated July 11, 2021, at 4:48 PM, revealed that Resident 72 approached Resident 122 in the hallway near the nurse's station and said "get the f*** out" while making gestures towards the door. Space/distance was provided between the residents and redirection was met with negative comments. Every 30-minute visualization of Resident 72 and documentation was initiated according to nursing progress notes.

Review of Resident 122's "Progress Notes - Social Services" dated July 12, 2021, at 3:50 PM, revealed that the resident was pleasant and friendly and could not identify any concerns related to peer relationships and stated that he did not remember any problems.

Nursing progress notes dated August 4, 2021, at 4:38 PM, revealed that Resident 72 approached Resident 17 and pointed his index finger towards his peer's face and told him in a loud voice to "shut the f**k up." Staff separated both residents. Resident 72 continued to curse at staff but returned to his room. Every 30-minute visualization documentation related to aggressive behaviors was initiated.

Review of Resident 17's "Progress Notes - Social Service" dated August 5, 2021, at 3:20 PM, revealed that the resident presented in pleasant mood and could not recall the interaction with Resident 72 and no distress observed.

Nursing progress notes completed by Employee 1, LPN (licensed practical nurse), dated August 29, 2021, at 4:35 PM, revealed that Resident 72 came out of resident room 322 (his room) and struck Resident 48 with closed fists multiple times to the right top of head in which caused Resident 48 to fall out of his wheelchair. Resident 48 had been seated in his wheelchair by the nurse's station to the left side of Resident 72's room (room 322 ) prior to being physically abused by Resident 72. Both residents were separated and assessed with no complaints of pain or discomfort.

Resident 72 was transferred to an acute care facility for a Geropsychiatric evaluation. However, returned to the facility later that evening and was immediately placed on one-to-one observation.

A review of the facility's serious incident report dated August 29, 2021, at 3:54 PM, revealed video footage showing Resident 48 seated in a wheelchair in the hallway when Resident 72 walked up to him, pulled his wheelchair back and positioned it against the wall, pointed his finger near Resident 48's face and begun to strike him in the head/face with a closed fist approximately five times, while wearing a winter glove. Resident 72 turned and entered his room briefly, and then returned to the hall, and reapproached Resident 48 and struck him several more times in the head/face while wearing his gloves, which caused Resident 48 to fall out of his wheelchair onto his knees. Staff immediately responded and separated the residents and assessed Resident 48 with no evidence of injuries noted.

A review of Employee 1 witness statement dated August 29, 2021, at 4:00 PM, indicated that she was down hallway "E" passing medications when she heard residents yelling and when she came around the corner, Resident 48 was getting back into his wheelchair and Resident 72 was in his doorway when she arrived. When Employee 1 arrived, both residents were immediately separated.

Review of Resident 48's "Progress Notes - Social Services" dated August 30, 2021, at 1:15 PM, revealed that the resident presented as alert and appeared comfortable and did not recall interaction with Resident 78 that occurred on August 29, 2021.

The facility failed to ensure that Resident 48 was free from physical abuse perpetrated by Resident 72.

An interview with the nursing home administrator (NHA) on December 3, 2021, at approximately 2:30 PM, confirmed the facility failed to ensure that these residents were free from physical and verbal abuse perpetrated by other residents.

483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition

28 Pa. Code 201.18(e)(1) Management
Previously cited 1/31/20

28 Pa. Code 201.29(a) Resident Rights
Previously cited 1/30/20, 5/27/20

28 Pa. Code 201.29(c) Resident Rights
Previously cited 1/30/20

28 Pa. Code 201.29(d) Resident Rights

28 Pa. Code 211.12(a)(c)(d)(5) Nursing Services
Previously cited 1/30/20, 2/5/21





















 Plan of Correction - To be completed: 01/11/2022

Abuse 0600
1. Resident 72 remains on 1:1 observation. There have been no further incidents between Resident 72 and Residents 48, 122 or 17. The incident involving 131 was isolated since his admission on 4/14/15. Resident 131 accepted a room change post incident on 10/27/21 and there have been no further incidents involving this resident.
2. Residents presenting with verbal or aggressive behaviors will have intervention put in place and will be tracked in the behavior log. Residents in the behavior log will be tracked in stand-up meeting daily to ensure interventions in place are effective in preventing resident to resident incidents.
3. The abuse policy and the behavior tracking policy will be reviewed/revised to ensure procedures are in place to reduce/prevent resident to resident physical and verbal abuse. The policies will be in-serviced to staff.
4. The NHA/Designee will audit behavior logs for accuracy and for appropriate interventions to reduce/prevent resident to resident physical and verbal abuse. The audit will be performed weekly x 8.
5. January 11, 2022

483.10(f)(4)(ii)-(v) REQUIREMENT Right to Receive/Deny Visitors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(f)(4) The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident.
(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time;
(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time;
(iv) The facility must provide reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time; and
(v) The facility must have written policies and procedures regarding the visitation rights of residents, including those setting forth any clinically necessary or reasonable restriction or limitation or safety restriction or limitation, when such limitations may apply consistent with the requirements of this subpart, that the facility may need to place on such rights and the reasons for the clinical or safety restriction or limitation.
Observations:

Based on observation, review of CMS guidance, select facility policy and documentation and interviews with residents, it was determined that the facility failed to allow residents to receive visitors of their choosing, at time desired by six of 26 residents reviewed (Residents 6, 126, 124, 131, 45, and 62).

Findings include:

Review of CMS (Centers for Medicare and Medicaid Services) Memorandum QSO-20-39-NH, "Nursing Home Visitation - COVID-19 (Revised)" dated revised November 12, 2021, revealed that, "Visitation is now allowed for all residents at all times." Continued review revealed, "Facilities must allow indoor visitation at all times and for all residents as permitted under the regulations ... Facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits." Further review revealed "Effective Date: Immediately" for this Memorandum.

During observations in the facility on November 30, 2021, at approximately 8:00 a.m., signage was observed outside of elevators dated August 23, 2021, stating that due to local positivity rates all visits are restricted to the MPR (Multipurpose Room) or the patio and "there will be no visits on the unit."

Review of the facility's current visitation policy revealed it had not been updated to reflect the most recent QSO memorandum revised 12, 2021.

During an interview with Resident 6, he stated he was tired of not being allowed to have visitors in his room. The resident stated "I miss my friends and family. I feel like a prisoner."

During a group meeting held on December 1, 2021 at 10:00 a.m., with five alert and oriented residents (Residents 126, 124, 131, 45, and 62) all residents in attendance stated they were not allowed to have visitors in their rooms and they wanted visits at locations of their choosing.

Interview on December 1, 2021, at 2:00 p.m. the Nursing Home Administrator (NHA) confirmed that the facility had not updated the facility policy regarding visitation based on the updated guidance issued by CMS (Memorandum QSO-20-39-NH Revised November 12, 2021).



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

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







 Plan of Correction - To be completed: 01/11/2022

Visitation 0563
1. Residents 6, 126, 124, 131, 45 and 62 have been made aware that we will arrange for visitation in resident areas. Families were made aware that visitation can be safely set up on the units.
2. GMVC Residents have been made aware that we will arrange for visitation in resident areas. Families were made aware that visitation can be safely set up on the units.
3. Pennsylvania Veterans' Home (PVH) policy and has been updated to allow visitation to take place in resident areas. The policy has been in-serviced to facility staff.
4. QA will audit visitation by interviewing a random sample of 5 residents/family members per week X 8 to see if they are aware of PVH policy. The results of the audit will be turned in to the QAPI team for review.
5. January 11, 2022

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

483.10(f)(6) The resident has a right to participate in family groups.

483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:

Based on review of select facility policy and minutes from Resident Council meetings and resident and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints/grievances expressed during Resident Council Meetings including those voiced by five of five residents attending a group meeting (Residents 126, 124, 45, 131, and 62)

Findings include:

Review of the facility's current Grievance policy indicated that it is the facility's policy to provide an opportunity for residents to express concerns at any time. The facility's goal is to resolve resident and family concerns in a timely basis.

Review of the minutes from the Resident Council meetings held between June 4, 2021 through November 3, 2021, revealed that residents in attendance at these resident group meetings voiced their concerns regarding their care and facility services during the meetings.

During the August 4, 2021, Resident Council meeting the residents relayed concerns with the timeliness of staff response to their requests for assistance via the nurse call bell system, snack delivery, and visitation limitations.

During the September 1, 2021, Resident Council meeting the residents relayed concerns with the timeliness of staff response to their requests for assistance via the nurse call bell system, and snack delivery.

During the October 6, 2021, Resident Council meeting the residents relayed concerns with the timeliness of staff response to their requests for assistance via the nurse call bell system.

During the November 3, 2021, Resident Council meeting the residents relayed concerns with the timeliness of staff response to their requests for assistance via the nurse call bell system.

During a group meeting held on December 1, 2021, at 10:00 a.m., with five (5) alert and oriented residents, 4 residents (Residents 126, 124, 45, and 62) stated that untimeliness of staff response to their call bells and meeting their needs for assistance in a timely manner remains a problem for them. Five of five residents (Residents 126, 124, 45, 131, and 62) at this meeting stated they are still unsatisfied with visitation limitations in place at the facility due to COVID-19 pandemic. The residents stated that they have repeatedly brought these particular complaints to the facility's attention without resolution to date.

The facility was unable to provide documented evidence that the facility had determined if the residents' felt that their complaints/grievances had been resolved through any efforts taken by the facility in response to the residents' expressed concerns regarding untimely staff response to call bells and delays in meeting residents' needs for assistance, snacks and visitation.

During an interview with the Assistant Nursing Home Administrator (ANHA) on December 3, 2021, at 11:00 a.m. the ANHA was unable to provide documented evidence that the facility had followed-up with the residents to ascertain the effectiveness of the facility's efforts in resolving their complaints regarding facility services and resident care.



28 Pa. Code 201.18(e)(1)(3)(4) Management

28 Pa. Code 201.29(i)(j) Resident Rights





 Plan of Correction - To be completed: 01/11/2022

Grievances 0565
1. Residents 126, 124, 131, 45 and 62 met with social services regarding their concerns. Grievances were filed for any voiced concerns. The residents did receive follow up to their grievance.
2. A grievance form will be completed for Residents or Families with concerns received individually or while in resident group. The resident/family member will receive follow up to their grievance.
3. The grievance policy has been reviewed/revised to ensure concerns are handled with a grievance form and follow up to the concern is provided. The policy has been in-serviced to facility staff.
4. QA will audit a random sample of 5 residents per week X 8 weeks to see if they have any concerns and if they do see if there was a grievance form filled out. The results of the audit will be turned in to the QAPI team for review.
5. January 11, 2022


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