Nursing Investigation Results -

Pennsylvania Department of Health
HOMETOWN NSG & REHAB CTR
Patient Care Inspection Results

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HOMETOWN NSG & REHAB CTR
Inspection Results For:

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HOMETOWN NSG & REHAB CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on June 22, 2022, it was determined that Hometown Nursing and Rehabilitation 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 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 interviews with staff and clinical record review, it was determined that the facility failed to implement planned interventions, to include staff assistance with transfers and ambulation as required, to prevent a fall with serious injuries, multiple fractures, for one of five residents reviewed ( Resident CR1).

Findings include:

A review of the Resident CR1's clinical record revealed that the resident was admitted to the facility on January 9, 2018, with a diagnosis of dementia and anxiety

The resident's care plan dated November 12, 2018, noted that the resident was at risk for falls related to deconditioning, gait/balance problems and weakness. Planned interventions were to ensure that the resident is wearing non-skid footwear when ambulating and to follow the facility fall protocol.

The plan of care also noted that the resident was an elopement risk/wanderer related to impaired safety awareness, dated September 24, 2020. Planned interventions were to identify a pattern of wandering, de-escalate by redirecting or diverting her attention and offer her snacks.

Nursing documentation dated January 18, 2021 at 12:43 PM, a Fall Intervention Note, status post fall on January 17, 2021 at 10:49 AM, revealed " \ had a fall resulting in redness and swelling to Right fingers, hand and wrist. Observed sitting on floor in bathroom, back against door frame with pants down around ankles. Non-skid sneakers on. Call bell in reach, but not on at time of incident. When asked about incident resident stated, "I don't know." Staff last observed that the resident was in bed sleeping at 1000. Resident independent with transfers. New Interventions: Bowel and Bladder review, need for possible program r/t weakness, Therapy eval to see transfer status is appropriate or if should be changed to assist of 1 rollator walker due to weakness with covid dx, x-ray to R hand from elbow to finger tips, increase fluids. MD and POA aware of all changes. Continue to monitor."

Nursing documentation dated January 18, 2021, 8:21 PM revealed " X-rays of right hand and wrist were done today. Right hand impression: No definite evidence of acute fracture, significant deformity or soft tissue swelling. Moderate multifocal chronic and degenerative changes particularity involving the first carpometacarpal joint and multiple proximal and distal interphalangeal internally fixed forth metacarpal fracture."

A physician order was noted after the resident's fall dated January 26, 2021, to discontinue independent transfers and initiate transfers assist of 1 with rollator walker.

A review of the resident's care plan dated April 7, 2021, revealed the problem/need of self care deficit related to intermittent confusion and dementia. The planned interventions identified were that the resident required limited assistance of one for ambulation in room and in the corridor, and assistance of one with the rollator walker for transfers.

A fall evaluation completed by the facility dated March 14, 2022, indicated that the resident was at high risk for falls.

A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 14, 2022, revealed that the resident's BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) score of 0, indicating that the resident was severly cognitively impaired. The resident required the assisstance of one person for transfers and bed ambulation, utilized a rollator walker and was not steady with ambulation and only able to stabilize with staff assistance.

During an interview conducted on June 22, 2022 at approximately 1 PM, the Director of Nursing stated that due to Resident CR1's repeated unsafe transfers and ambulation attempts, a therapy screen was requested and obtained March 24, 2022.

A review of a therapy screen dated March 24, 2022, revealed that Resident CR1 was screened by therapy for ambulation status. The resident was a limited assist of one for ambulation with a rollator walker, a history of non-compliance, walking in the hallway at times without the rollator walker present due to cognition limitations/safety/non compliance and BIMs score of 0. Therapy recommend to continue safe ambulation with assistance of one and the rollator walker in the room/hallway at this time.

Nursing documentation dated May 27, 2022, at 2:23 PM revealed noted "Called to room 243 at 13:30 PM (1:30 PM) to assess \ status post fall. Resident lying on back in her room with legs facing towards window. Resident's head was against wall connecting to resident's closet. Resident's feet were tangled in walker, which was also lying on floor. Moderate amount of blood coming from laceration on forehead (4 cm x 4 cm) as well as, a 10 cm laceration on posterior aspect of head. Wearing shoes with good traction. Environment clear. Cervical neck stabilization provided throughout assessment/intervention/transfers. Lacerations cleansed with normal saline to facilitate better visualization then pressure applied with good effect. VS assessed/stable. Awake and alert to self- at baseline. Responding to verbal stimuli. At baseline, resident only speaks in small phrases and answers occasionally to yes and no questions with clear speech-- this remained the same during assessment. Calm with periods of anxiety exhibited by attempting to strike and kick staff x 4 extremities. Range of motion x 4 extremities at baseline in supine position. Unable to assess strength of hand grasps as resident choose not to complete exercise due to increased anxiety x 3 attempts. No decorticate or decerebrate posturing. Pupils equally round with size of 4 mm. Left pupil noted with brisk reaction and Right pupil reactive but slightly sluggish. Anatomical assessment noted with no deformity to inspection or pain with palpation. Transferred to bed via mechanical lift. Head of bed up to 30 degrees to decrease inter cranial pressure. Multiple staff 1:1 with resident to keep calm, provide emotional support, and assist with cervical neck stabilization and injury treatment. Physician made aware. New order noted to send to emergency room for evaluation and treatment. Call placed to 911 ambulance for transport."

A review of nurses notes dated May 27, 2022 at 5:12 PM revealed "Call received from RN at the emergency room. Resident CR1 is admitted and is being transferred to a different hospital with a trauma unit with diagnosis of Cervical spine 1 and Cervical spine 2 fractures."

A review of an incident/accident report investigation dated May 27, 2022, at 1:29 PM indicated that the resident was found in her room on the floor with her legs tangled in her walker. There was a moderate amount of blood coming from a laceration on her forehead, measuring 4 cm x 4 cm as well as a 10 cm laceration on the posterior aspect of her head. She was wearing shoes with good traction according to the report. The immediate action taken by the facility included an assessment by the licensed nurse, pressure and ice applied to lacerations. The physician and responsible parties notified and the resident was sent to the emergency room for evaluation and treatment

A review of a witness statement May 27, 2022, (no time indicated) from Employee 1 (housekeeping) revealed, "I walked Resident CR1 back to her room after lunch. Resident was pleasant and her walking was like always. She sat in a chair in her room. I didn't notice anything out of the ordinary."

A review of a witness statement May 27, 2022 at 1:30 PM, Employee 2 stated, " I was walking down the hallway when I saw a coffee cup go flying into the hallway. I went to go pick it up and that is when I saw Resident CR1 on the floor. The resident's head was up against the wall with blood pouring out. The resident's feet were tangled in her walker. I notified the nurse and I rolled her onto her back."

X-rays were ordered and obtained in the emergency room. Results were as follows:

-closed, stable burst fracture (a burst fracture is a descriptive term for an injury to the spine in which the vertebral body is severely compressed. They typically occur from severe trauma, such as a motor vehicle accident or a fall from a height. With a great deal of force vertically onto the spine, a vertebra may be crushed) of the first cervical vertebra,

-closed, non displaced fracture of the second cervical vertebra,

-closed, wedge compression fracture (a compression fracture is a collapse of a vertebra. It may be due to trauma) of Thoracic 5 vertebra and,

-an epidural hematoma (Accumulation of blood between the dura matter (tough outer membrane covering the brain), and the skull).

A review of hospital documentation dated May 27, 2022 revealed Resident CR1 was admitted to the trauma service. Neurosurgery was consulted. Her C/1-C/2's fractures were treated conservatively with a cervical collar. A thoracic X-ray was ordered to evaluate her T/5 vertebral compression fracture. Resident CR1 did not tolerate the X-ray and subsequently was not completed. Heparin (blood thinning medication) was held due to the epidural hematoma.

Nursing documentation dated May 30, 2022 at 5:50 PM revealed "at 4:45 PM to room 243D from the hospital. Resident is being readmitted following a fall on May 27, 2022, sent to the emergency department then transferred to an additional hospital for trauma service with a neurosurgery consult. Per records, noted with left sided scalp laceration, with 16 staples. Resident noted with C1 burst fracture and C2 nondisplaced fracture with an epidural hematoma, in a VISTA (cervical) collar at all times. Also noted with a T5 compression fracture, no brace or treatment. "

During an interview June 22, 2022 at 11 AM, Employee 1 (Housekeeping) stated that on May 27, 2022, she noticed Resident CR1 get up out of her seat in the dining room and independently ambulate with her rollator walker out of the dining room. Employee 1 stated that she did not see any nursing staff in that area at that time. Employee 1 stated that she followed behind Resident CR1 from the dining room back into there resident's room. Resident CR1 sat in a chair in her room and placed the walker in front of her. Employee 1 then left the room. Employee 1 (housekeeping) stated that she did not assist Resident CR1 in transfers or ambulation as she was not trained in ambulation or transfer assistance for residents.
Employee 1 (housekeeping) then left Resident CR1's room and walked down the hallway. She then saw a coffee cup coming out of the resident's room. Employee 1 (housekeeping) went to Resident CR1's room and saw her on the floor with her feet tangled up in the rollator walker legs. Employee 1 stated that Resident CR1 often ambulated independently in the facility and transferred herself.

During an interview June 22, 2022 at 11:15 AM, Employee 3, nurse aide, stated that Resident CR1 often ambulated independently in her room and in the hallway. Employee 3, nurse aide, stated that she was aware that staff should assist Resident CR1 when she is transfering and ambulating.

During an interview June 22, 2022 at 11:20 AM, Employee 4 (agency LPN) stated that Resident CR1 had a long history of self transfering and ambulating without staff assistance. She stated that she was also aware that Resident CR1 required the assistance of one staff for ambulation.

The interview conducted with Employee 1, housekeeper, during the survey of June 22, 2022, verified that on May 27, 2022 after the lunch meal, Resident CR1 transferred herself out of her chair in the dining room and then self-ambulated down the hallway towards her room without any staff assistance. Employee 1 confirmed that no nursing staff was aware that the resident had left the dining room and was ambulating independently back to her room. The housekeeper (Employee 1) stated that she saw the resident walking by herself and followed behind Resident CR1, as Resident CR1 independently ambulated back to her room. The resident sat down in the chair by herself and positioned the walker directly in front of her, which allowed the resident easy access to continue to transfer and ambulate at will while also posing an accident hazard to the resident as the resident required assistance with transfers and ambulation.

Employee 1 verified during interview at the time of the survey of June 22, 2022, that she did not assist the resident's transfer or ambulation in the dining room, corridor or resident's room as the housekeeper was not trained to assist residents in transfers or assistance in ambulation. Employee 1 also confirmed that there was nursing staff was in the dining room to assist this resident back to her room and with the transfers from the chair in the dining room or into the chair in her room, and to safely secure the walker to prevent an accident hazard to the resident, as the resident was shortly thereafter found with her legs tangled in the legs of the walker.

Nursing staff interviews at the time of the survey of June 22, 2022, also verified that the nursing staff was aware of the resident's independent transfers and ambulation and repeatedly allowed it, although they acknowledged that the resident required assistance with transfers and ambulation.

The resident was assessed to require the assistance of one staff for safe transfers and ambulation with the walker. Staff interviewed during the survey were aware that the resident required the assistance of one staff for transfers and ambulation with the walker, but also acknowledged that the resident frequently transfers herself and ambulates independently in the halls and her room and has done so in the past. The resident's walker also remained readily accessible to the resident when in her room allowing her ambulate independently at will. The facility failed to develop and implement adequate safety measures to promote this resident's safety and prevent falls related to the resident's known history of unassisted transfers and ambulation.

The DON (director of nursing) confirmed during interview on June 22, 2022, that the facility staff allowed Resident CR1 to transfer and ambulate independently with the walker and failed to consistently implement the planned intervention of providing one person assistance with transfers and ambulation, and necessary supervision, to prevent this fall with serious injuries.



28 Pa. 28 Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services.
























 Plan of Correction - To be completed: 07/20/2022

Resident CR1's care plan reflected interventions to be used when observed self-transferring. When attempting to transfer/ambulate independently, staff frequently would attempt to intervene, resulting in resident CR1 becoming easily distressed. These behaviors included yelling loudly and using walker to physically attempt to harm staff. Since resident is no longer at the facility, the ability to further alter the care plan cannot occur.

To prevent occurrence with other residents, the care plan of each resident who chooses not to comply with their ambulation/transfer status is being updated with appropriate interventions to maintain their safety. OT/PT screens were processed for these residents as deemed appropriate. In addition, staff report sheets and the resident Kardex are being updated with each resident's transfer/ambulation status; thus, this information is readily to the staff.

Facility staff are being re-educated regarding new safety procedures for residents who choose not to comply. This education will include educating non-clinical staff to summon clinical staff when a resident is observed ambulating/transferring independently.

The DON or designee will complete a Quality Assessment Performance Improvement (QAPI) project regarding resident compliance with ambulation/ transfer status and appropriate interventions to be used by staff when there is non-compliance. This will occur until 100% compliance has been achieved for 3 consecutive months. Results will be shared at the monthly QAPI/Infection Prevention/Safety/Compliance Meeting and if indicated, corrective action will be taken.


483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on a review of clinical records, information provided to the State Agency via the Electronic Reporting System, electronic email communication with the facility and staff interview, it was revealed that the facility failed to provide evidence that all instances of alleged resident abuse were thoroughly investigated and the complete results submitted to the State Survey Agency within five working days of the incident as evidenced by two of seven allegations of abuse reviewed (Residents 2 and 3 ).

Findings include:

According to review of incidents of abuse, neglect and misappropriation of property, the facility reported the following incidents to the State Survey Agency via the Electronic Reporting System (ERS) but failed to report the completed investigative findings and corrective actions taken in response to the following allegations of abuse as evidenced by the facility's failure to submit a complete PB22 (Pennsylvania Bulletin 22- form used to detail investigation, findings and actions) within five working days of occurrence:

On December 6, 2021, the facility reported that Resident 2's son-in-law had written checks from the resident's personal checking account without the resident's permission. Four of the involved checks were for amounts over $500 dollars and the signatures on the checks appeared to be forged. The facility submitted a PB22, which was reviewed and then rejected by the State Survey Agency, because it lacked the detailed information necessary to process the PB22.

A review of the facility's file maintained in the State Survey Agency Field Office, the facility administration had been contacted by a field office surveyor via email on March 10, 2022, March 21, 2022, and April 7, 2022 to resubmit the completed required abuse investigation, PB22, to include the information that had been omitted from the original submission. On April 19, 2022, an onsite visit was conducted at the facility, and the Field Office representative/surveyor again requested that the completed PB22 be resubmitted with the needed details.

The complete PB22 with all required/necessary information for State Agency completion was not resubmitted to the Field Office, after its original rejection, until May 26, 2022.

The facility reported that Resident 3 had alleged mental abuse by a staff member on the nurse aide registry on January 4, 2022. The allegations included the aide refusing to answer the resident's call bell and making derogatory remarks to her.

A review of the facility file maintained in the State Agency Field Office, revealed that the facility administration had been contacted by a field office surveyor via email on March 10, 2022, March 21, 2022, April 7, 2022 and June 2, 2022, to submit a required abuse investigation, a PB22, as one had never been submitted in response to this allegation. On April 19, 2022, an onsite visit was completed at the facility, and a Field Office representative/surveyor again requested the PB22 be submitted to the State Survey Agency.

A review of the State Agency ERS, revealed a PB22 investigation was not submitted to the Field Office until June 13, 2022. A review of the submitted PB22/investigation on June 22, 2022, revealed that the facility failed to include witness statements and the registry number or date of birth of the accused, which was necessary for processing of the PB22 and confirmation that the facility investigation contained all the components necessary for a complete investigation.

A review of the State Agency ERS completed on June 22, 2022, revealed that the facility submitted a PB22, which contained a witness statement, but did not include the required contact information for the witness. The PB22 still did not contain a date of birth or registry number, necessary to confirm the accused status on the registry. The PB22 was again rejected on June 22, 2022, as remained incomplete as of the time of this survey.

A review of the State agency ERS completed on June 23, 2022, revealed that the facility failed to submit results of the abuse investigations, which contained all elements necessary for completion, for the above instances of alleged resident abuse or neglect to the State Survey Agency within 5 working days of the occurrence. When areas of missing information were identified and the information required was requested by the State Agency, the facility continued to delay submission of this necessary data and failed to submit the completed investigations.

A review of electronic email communication with the facility revealed that on February 2, 2022 the Nursing Home Administrator had notified the Field Office that the facility had been having migration issues with emails, related to another issue. They had expressed no other concerns subsequently and had successfully communicated about other matters after that date with the State Survey Agency field office. There was no indication that the facility notified the field office before the June 2, 2022 email communication, that they had been having difficulty submitting information or requested/completed assistance with submission.


28 Pa. Code 201.14(a) Responsibility of licensee.

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

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






 Plan of Correction - To be completed: 07/22/2022

Despite the inability to properly submit two PB-22's via the EHRS System, both events were fully investigated by the facility leadership at the time of the occurrence and the reporting to the Department of Health occurred as required. Multiple efforts were made to resubmit these PB-22's as requested by the Field Office.

The PB-22 for resident 2 was submitted successfully on 5/26/22, while the PB-22 for resident 3 was successfully submitted on 6/13/22. Admittingly, the facility encountered difficulty with submitting these two PB-22's. All other PB-22's were submitted successfully by the facility leadership.

Moving forward, all PB-22's will be completed and submitted in their entirety within 5 working days.

The NHA and DON have reviewed the required reporting requirements related to this F-tag and will ensure adherence moving forward. The NHA or DON will immediately report concerns, on a consistent basis, to the Field Office.

The NHA will complete a Quality Assessment Performance Improvement (QAPI) project to ensure that all PB-22's are completed and successfully submitted within 5 working days. This will occur until 100% compliance has been achieved for 3 consecutive months. Results will be shared at the monthly QAPI/Infection Prevention/Safety/Compliance Meeting and if indicated, corrective action will be taken.


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