Pennsylvania Department of Health
OAK HILL CENTER FOR REHABILITATION AND NURSING
Patient Care Inspection Results

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OAK HILL CENTER FOR REHABILITATION AND NURSING
Inspection Results For:

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OAK HILL CENTER FOR REHABILITATION AND NURSING - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on April 8, 2024, it was determined that Oak Hill Center for Rehabilitation and Nursing 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;
Observations:

Based on facility policy review, nurse aide job description review, clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility failed to ensure that residents were free from neglect, which resulted in actual harm as evidenced by a right femur fracture, for one of five residents reviewed (Resident 1).

Findings include:

Review of facility policy, titled "Abuse Prevention Program", dated January 1, 2022, revealed "Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation...'Neglect' is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness....Signs of Actual Physical Neglect: 6. Inadequate provision of care."

Review of facility's nurse aide job description revealed, "Purpose of Your Job Position- To provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan...".

Review of Employee 1's education revealed Employee 1 was most recently provided abuse training on November 15, 2023.

Review of Resident 1's clinical record revealed diagnoses that included gastro-esophageal reflux disease (GERD-occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), hypertension (elevated blood pressure), and depression.

Review of Resident 1's care plan revealed an intervention initiated on November 29, 2023, for "BED MOBILITY: The resident requires (max assistance) by (2) staff to turn and reposition in bed."

Review of Resident 1's nursing progress note dated March 31, 2024, revealed that at 3:50 PM, the Nurse was notified that Resident 1 rolled out of bed onto the floor. The note stated that Resident 1 was observed laying on the floor on her left side, parallel to her bed. Resident 1 was complaining of right knee and right ankle pain, and was not able to move her right leg due to pain. A hematoma (a collection of blood outside of blood vessels) was also noted on the left side of Resident 1's head. Resident 1 was assisted back to bed via a hoyer lift with the assist of five staff members. A new order was received to send Resident 1 to the emergency department for evaluation and treatment. Resident 1 left the facility for the hospital at 4:20 PM.

Review of Resident 1's nursing progress note dated April 1, 2024, revealed that Resident 1 returned to the facility from the hospital at 2:30 PM, with an immobilizer in place to the right leg.

Review of Resident 1's hospital discharge instructions dated April 1, 2024, revealed that Resident 1 was diagnosed with a right femur fracture after falling out of bed. Resident 1 was evaluated by orthopedic surgery, who recommended non-operative management and to follow-up as outpatient.

Review of facility's investigation dated March 31, 2024, revealed that Employee 1 was providing Resident 1 with care. Resident 1 was on her left side in bed and, as Employee 1 was attempting to change Resident 1's sheets, Resident 1 rolled out of bed.

Review of Employee 1's witness statement dated March 31, 2024, revealed that Employee 1 was providing care to Resident 1, as her bed, sheets, and clothes were wet. Employee 1 stated that as she turned Resident 1 to the other side and started fixing her sheets, Resident 1 fell onto the floor.

Review of facility's investigation revealed that there were no additional witness statements obtained and no evidence that any other staff member was present when Resident 1 rolled out of bed.

Review of the facility reported incident for the fall on March 31, 2024, revealed that Employee 1 was changing the bed linen and rolled Resident 1 away from her, slightly beyond the perimeter of the mattress, resulting in Resident 1 falling out of bed.

Review of the facility reported incident revealed that Employee 1 was suspended, pending investigation, and Employee 1 was immediately educated regarding ensuring that Resident care plans are followed when providing care.

Review of the facility's investigation revealed that a written warning was given to Employee 1 dated April 1, 2024, stating, "On 3/31/2024 while providing care on a Resident she rolled out of the bed and sustained injury. Resident is care planned for 2 [person] assist for bed mobility. It is important to follow the care plan and to seek clarification if you are unsure. This is for the safety of the Residents. When rolling Residents they should be rolled toward you to prevent falls."

During an interview with the Nursing Home Administrator on April 8, 2024, at 12:10 PM, she confirmed that Employee 1 rolled Resident 1 away from her in the bed and did not follow the care plan of two-person assist when Resident 1 rolled out of bed.

The facility failed to ensure that Resident 1 was free from neglect when Employee 1 did not follow Resident 1's care planned interventions for two-person assist with bed mobility, resulting in Resident 1 rolling out of bed and sustaining a right femur fracture.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services




 Plan of Correction - To be completed: 04/30/2024

1. Cannot retroactively correct for resident affected. Employee #1 was immediately educated on ensuring that they followed the residents' care plan when providing care.
2. The DON/Designee completed an audit of current residents to ensure that their care plan was current and reflective of the residents' transfer/bed mobility status.
3. Clinical staff will be re-educated on the components of this regulation with an emphasis on abuse and neglect and how these topics are connected to following the care plan related to transfer status/bed mobility to safely meet the needs of the residents.
4.Direct observation Audits will be completed by NHA or designee 2x week for 4 weeks, biweekly x2 months, then monthly for 2 months to ensure compliance with policies related to abuse, neglect and providing safe care to residents. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.
5. Date of compliance 4/30/2024.

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 facility policy review, nurse aide job description review, clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in a fall and actual harm as evidenced by a right femur fracture, for one of five residents reviewed (Resident 1).

Findings Include:

Review of facility policy, titled "Activities of Daily Living (ADLs), Supporting", undated, revealed "Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:...b. Mobility (transfer and ambulation, including walking)..."

Review of facility's nurse aide job description revealed, "Purpose of Your Job Position- To provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan...".

Review of Resident 1's clinical record revealed diagnoses that included gastro-esophageal reflux disease (GERD-occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), hypertension (elevated blood pressure), and depression.

Review of Resident 1's care plan revealed an intervention initiated on November 29, 2023, for "BED MOBILITY: The resident requires (max assistance) by (2) staff to turn and reposition in bed."

Review of Resident 1's nursing progress note dated March 31, 2024, revealed that at 3:50 PM, the nurse was notified that Resident 1 rolled out of bed onto the floor. The note stated that Resident 1 was observed laying on the floor on her left side, parallel to her bed. Resident 1 was complaining of right knee and right ankle pain, and was not able to move her right leg due to pain. A hematoma (a collection of blood outside of blood vessels) was also noted on the left side of Resident 1's head. Resident 1 was assisted back to bed via a hoyer lift with the assist of five staff members. A new order was received to send Resident 1 to the emergency department for evaluation and treatment. Resident 1 left the facility for the hospital at 4:20 PM.

Review of Resident 1's nursing progress note dated April 1, 2024, revealed that Resident 1 returned to the facility from the hospital at 2:30 PM, with an immobilizer in place to the right leg.

Review of Resident 1's hospital discharge instructions dated April 1, 2024, revealed that Resident 1 was diagnosed with a right femur fracture after falling out of bed. Resident 1 was evaluated by orthopedic surgery, who recommended non-operative management and to follow-up as outpatient.

Review of facility's investigation dated March 31, 2024, revealed that Employee 1 (Nurse Aide) was assisting Resident 1 with care independently. Resident 1 was on her left side in bed and, as Employee 1 was attempting to change Resident 1's sheets, Resident 1 rolled out of bed.

Review of Employee 1's witness statement dated March 31, 2024, revealed that Employee 1 was providing care to Resident 1, as her bed, sheets, and clothes were wet. Employee 1 stated that, as she turned Resident 1 to the other side and started fixing her sheets, Resident 1 fell onto the floor.

Review of the facility reported incident for the fall on March 31, 2024, revealed that Employee 1 was changing the bed linen and rolled Resident 1 away from her and outside of the perimeter of the mattress. This resulted in Resident 1 falling off the side of the bed.

Review of facility's investigation revealed that there were no additional witness statements obtained and no evidence that any other staff member was present when Resident 1 rolled out of bed.

Further review of the facility's investigation revealed a written warning given to Employee 1 dated April 1, 2024, stating, "On 3/31/2024 while providing care on a Resident she rolled out of the bed and sustained injury. Resident is care planned for 2 assist for bed mobility. It is important to follow the care plan and to seek clarification if you are unsure. This is for the safety of the Residents. When rolling Residents they should be rolled toward you to prevent falls."

During an interview with the Nursing Home Administrator on April 8, 2024, at 12:10 PM, she confirmed that Employee 1 rolled Resident 1 away from her in the bed and did not follow the two-person assist when Resident 1 rolled out of bed.

Employee 1 failed to provide the appropriate assistance and technique with bed mobility for Resident 1, resulting in Resident 1 falling out of bed and sustaining a right femur fracture.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services




 Plan of Correction - To be completed: 04/30/2024

1. Cannot retroactively correct for this resident affected.
2. The DON/Designee completed an audit to determine that relevant information related to (transfer status, bed mobility) was present and up to date in both the resident care plan and the Nursing assistant task list.
3. Clinical staff re-educated on the components of this regulation with an emphasis on ensuring that they are aware of the residents' transfer/bed mobility status and ensuring that they are following the care plan when providing resident care.
4. The DON/Designee to perform random visual audits of 2 staff members providing care to ensure that they are following the residents' care plan and random audits of medical records of 5 residents to ensure that their care plan related to transfer status/bed mobility is accurate. Audits to occur 1x a week x4 weeks, biweekly x2 months, then monthly x2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.
5. Date of compliance 4/30/2024.


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