Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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

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YORK NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to a complaint completed on February 19, 2020, it was determined that York Nursing and Rehabilitation Center 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 related to the health portion of the survey process.

 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 observation, interviews with staff and residents, review of clinical record and facility documentation, it was determined that the facility failed to ensure that Resident R1 was free from abuse from another resident (Resident R2) resulting in actual harm to Resident R1 sustaining a laceration to the resident's left eyebrow and five sutures to the eyebrow for one of four residents reviewed. (Resident R1)

Findings include:

Review of facility policy title "Abuse, Neglect or Mistreatment," dated September 2019, revealed "Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when the facility staff fails to monitor and/or supervise delivery of resident care and services to assure care is provided as required. Further review of the policy under "prevention" it indicated to provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse/neglect and/or misappropriation of resident property is more
likely to occur. The assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/ or are totally dependent on staff. Under "Identification" it stated to identify events such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse.

Review of Room Change Policy (undated) indicated, "If a resident or the Resident Representative express a concern about a roommate(s) and request a room change, the resident who expresses the concern and request for a change in roommates, the resident expressing the concern will be offered another room."

Review of Resident R1's quarterly Minimum Data Set Assessment (MDS-an assessment of resident's needs) dated February 10, 2020, revealed the Resident R1 was admitted to the facility on June 2, 2016 with diagnoses including: dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), major depressive disorder (major loss of interest in pleasurable activities characterized by changes in sleep pattern, appetite and/or routine) and schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized speech and behaviors.) Further review of the MDS assessment identified the resident with a BIMS (Brief Interview of Mental Status) Score of 99, indicating Resident R1 was confused and unable to participate in this brief screening. A staff assessment was completed and the resident was assessed with short and long term cognitive impairments. The resident's cognitive skills for daily decision making were moderately impaired. The resident did not demonstrate any mood symptoms. The resident was assessed as requiring supervision with transfers and ambulation with the use of a walker. Further review revealed Resident R1's MDS indicated that the resident received antipsychotic and antidepressant medication daily. The assessment indicated Resident R1 demonstrated no physical behavioral symptoms or verbal behaviors directed toward others and no changes were noted with his current behavioral status.

Review of Resident R2's quarterly Minimum Data Assessment dated November 26, 2019 revealed that the resident was admitted to the facility on October 26, 2018, with diagnoses of schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized speech and behaviors), dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and ischemic cardiomyopathy (disease process of the heart). The resident was assessed as requiring limited assistant with transfer and ambulation.

Review of Resident R2's nursing notes dated November 27, 2019, revealed, "Patient noted with increased behaviors, yelling, throwing computer equipment, refusing care, refusing to let the other resident in his room, refusing redirection and intractable refusing care." Resident R2 was transferred to a psychiatric hospital form November 27, 2019 and readmitted to the facility on December 18, 2019. Further review of Resident R2's clinical record revealed a second admission to a psychiatric facility on December 27, 2019 until January 8, 2020 due to acute psychosis. Review of Resident R2's January 2020, Medication Administration Record revealed that the resident was ordered the antipsychotic medication Haldol 10 milligrams (mg) 1 tablet at bedtime for diagnosis of schizophrenia on January 8, 2020.

Review of Resident R2's care plan dated November 27, 2019, revealed "The resident can be verbally aggressive (yelling/screaming racial slurs/vulgar profanity) and physically (throwing equipment) aggressive to patients and staff related to schizophrenia. Interventions included to analyze times, places, circumstances, triggers and what de-escalates behavior and document and to assess resident's needs: food, thirst, toileting need and comfort level.

Review of Resident R1's nursing note dated January 29, 2020, noted " Observation with skin alteration to right side of neck and below right eye. Injuries were reported to responsible party and physician. An X-ray of right shoulder revealed no fracture and no acute abnormality. Resident now with abrasion bilaterally to bridge of nose, bruise to right cheek and open area to right side of neck. Topical treatment was provided and resident had no complaint of pain."

Interview conducted on February 18, 2020, at 11:00 a.m. with Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that Resident R1's responsible party (his son) reported to the facility on January 30, 2020. Son was assured by facility administration that an investigation into his father's injuries of unknown origin was being conducted. The NHA and DON indicated that the resident's son requested that the resident's roommate be transferred out of the room. After being advised of facility policy (Room Change Policy) Resident R1's son did agree to have his father transferred out of the room for his safety.

Review of Resident R1 nursing note dated January 30, 2020, indicated that the resident was transferred from Room 224 to Room 211. Resident R1 was oriented to the new room by a charge nurse who speaks Spanish and the resident was "adjusting well to room change."

Further review of Resident R1's nurse's note dated February 15, 2020, revealed a "Resident to Resident Altercation: At 2:00 p.m., charge nurse heard yelling from Room 224. Upon entering room, charge nurses observed [Resident R1] seated in a chair holding his left eye, with the [Resident R2] who occupies the room standing over him with his fist balled up. Upon further observation, charge nurse noted a laceration to resident's left eyebrow with some bleeding noted. First aid provided, bleeding stopped and dry dressing applied. When asked what happened, resident did not respond. Both residents were separated, and resident seated in the common area under staff supervision. When the other resident was interviewed, he informed charge nurses that the resident would not leave his room so he punched him in his face. Supervisor notified. Physician notified and ordered [Resident R1] to be sent to the hospital for evaluation. Neuro checks initiated and within normal limits. Vital signs were also within normal limits. Resident's son (responsible party) notified."

Nursing note dated February 15, 2020, noted that Resident R1 returned to the facility from the hospital at 11:45 p.m. "Res (resident) has 5 sutures to the area of above the right eyebrow, no c/o (complain) of pain. Res (resident) at baseline ambulating with walker on unit."

The facility failed to provide to provide an environment free from physical abuse to Resident R1, which resulted in actual harm to Resident R1 sustaining a laceration to the resident's left eyebrow, transfer to the hospital and requiring five sutures to the eyebrow.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Coode 211.10(d) Resident care policies

28 Pa. Code Resident care plan

28 Pa. Code Nursing services

28 Pa. Code Nursing services

 Plan of Correction - To be completed: 03/15/2020

1. Resident R1 was assessed and treated for the injury he sustained during the Resident to resident altercation. Resident R2 no longer resides at the facility.

2. The facility will conduct for all staff a directed in-service F600 Freedom from Abuse, Neglect and Exploitation on 3/9/2020.

3. The facility will audit documentation in the electronic medical record to determine potential for Resident to Resident abuse.

4. The Potential for Resident to Resident Abuse Audit will be reviewed by the Interdisciplinary Team weekly, times 3 months.

5. The Potential for Resident to Resident Abuse Audit will be brought to QA Meeting monthly times 3.

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