Nursing Investigation Results -

Pennsylvania Department of Health
HARMARVILLAGE CARE CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HARMARVILLAGE CARE CENTER
Inspection Results For:

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HARMARVILLAGE CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
A COVID-19 Focused Emergency Preparedness Survey was conducted by The Department of Health (DOH) on November 4, 2021 Harmar Village Care Center was in compliance with 42 CFR 483.73 related to E-0024(b)(6).



























 Plan of Correction:


Initial comments:
Based on a COVID Focus and Abbreviated Survey, in response to a complaint, completed on November 4, 2021, it was determined that Harmar Village Care 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.


















 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 facility policies, clinical records, incident reports, employee statements and staff interview, it was determined that the facility failed to make certain that a resident was free from neglect by not providing the necessary services, which resulted in actual physical harm (laceration to left leg) for two of five residents reviewed (Resident R1) and failed to provide adequate supervision for the transfer needs for Resident R2.

Findings include:

A review of the facility policy "Abuse" dated 1/18/21, indicated the facility will prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all residents through the implementation of screening, training, prevention, identification, investigation, protection, and reporting.

A review of the facility policy "Lift Policy" dated 1/18/21, indicated the facility will utilize a lift program to protect residents and employees from injuries during lifting and transferring. If the transfer is full body or sit to stand (mechanical lift), two staff members are required for transfer.

A review of the resident face sheet indicated that Resident R1 was admitted to the facility on 4/9/21, with diagnoses that included difficulty in walking, rheumatoid arthritis, heart disease. A review of the MDS (Minimum Data Set - resident care assessment screening) dated 8/13/21, indicated the diagnoses remained current.

A review of a physician order dated 4/21/21, indicated transfer status full body mechanical lift.

A review of Resident R1's care plan revised 8/25/21, indicated transfer status is full body mechanical lift.

A review of a nurse progress note dated 10/25/21, indicated sent to ER (emergency room) due to cut leg.

A review of a nurse progress note dated 10/26/21, indicated nursing assistant (NA) states that during transfer resident sustained a skin tear to leg. Outer left calf area open area noted about 6 inches long. Resident states that leg is hurting when moved. Sent to ED (emergency department) for treatment.

A review of the "Emergency Evaluation Final Report" form dated 10/25/21, indicated laceration to left leg through the subcutaneous (below the skin) tissue to the fascia (connective tissue that provides internal structure) minimal adipose (fat tissue) and continuous skin tear 4 cm with laceration. Laceration repair 2 sutures.

A review of an incident report and witness statements, dated 10/26/21, indicated NA Employee E1 transferred Resident R1 from the wheelchair to the bed, using the Hoyer Lift (full body mechanical lift) without assistance.

During an interview on 11/4/21, at 3:00 p.m. NA Employee E1 confirmed they transferred Resident R1 on 10/25/21, using the mechanical lift without assistance, was aware needed two persons, and staff was available to assist. Stated, "I was impatient and did not want to wait for another person to assist." "If another person was there, they may have seen the resident's leg moving too close to the wheelchair."

During an interview on 11/4/21, at 1:35 p.m. the Director of Nursing (DON) confirmed that the facility failed to make certain that a resident was free from neglect by not providing the necessary services for Resident R1's transfer needs which resulted in actual physical harm (laceration to left leg).

A review of the resident face sheet indicated Resident R2 was admitted to the facility on 6/14/21, with diagnoses that included dementia and Parkinson's (neurological disease that causes muscle tremors).

A review of a physician order dated 9/14/21, indicated transfer status minimal assist of two.

A review of Resident R2's care plan revised 9/28/21, indicated transfer status minimal assist of two.

A review of a nurse progress note dated 10/8/21, indicated Resident R2 had a 20 x 24 cm (centimeter) bruise to the left thigh/knee area.

A review of an incident report dated 10/8/21, indicated Resident R2 had a large bruise to the back of the left leg that measured 20 x 24 cm.

A review of a nurse progress note dated 10/14/21, indicated the origin of the bruise was investigated and found to be caused when the resident was lowered to the floor on 10/2/21.

A review of an incident report and witness statements, dated 10/2/21, indicated NA Employee E2 was attempting to transfer Resident R2 into her chair without assistance. The resident's knees buckled, and the resident was lowered to the floor. Large bruise to back of left leg.

During an interview on 11/4/21, at 4:30 p.m. the DON confirmed the facility failed to provide adequate supervision for the transfer needs for Resident R2.

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

28 Pa Code 201.14(a) Responsibility of licensee.

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

28 Pa Code 201.29(a)(j) Resident rights.

28 Pa Code 211.12(d)(1)(5) Nursing services

28 Pa Code 211.12(d)(3) Nursing services.





























 Plan of Correction - To be completed: 12/07/2021

R1 and R2 continue to reside in the facility and are being transferred appropriately.

E1 and E2 have be re-educated on transfer identification, safe lift and the facility abuse policy. Competencies were completed for both employees for safe lift. Disciplinary action per facility personnel policy was done with each employee.

Residents who require a mechanical lift for transfers will be reviewed to ensure transfer recommendations remain appropriate. New transfer recommendations will be implemented and care planned as needed.

Mechanical lift competencies with return demonstration will be completed with facility nurse aides, then annually thereafter.

Directed in-service provider Lewis Litigation Support and Clinical Consulting, LLC will be presenting an interactive PowerPoint titled "Accidents in the Context of Abuse and Neglect" to nursing staff on 11/22/21. The training will be recorded for additional presentations to facility staff that are unable to attend the live version.

The Director of Nursing/designee will audit by direct observation that mechanical lift transfers are being completed per facility policy. Five mechanical lift transfers will be observed daily for two weeks, weekly for two weeks and monthly for two months, then randomly thereafter. Audit results will be reviewed at the facility Quality Assurance meetings until substantial compliance has been met.

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 review of facility policies, clinical records, incident reports, employee statements and staff interview, it was determined that the facility failed to provide adequate supervision for the transfer needs for two of 6 residents (Resident R1 and R2), and utilize a mechanical lift with two staff as required, to promote resident safety resulting in harm for Resident R1.

Findings include:

The facility policy "Lift Policy" dated 1/18/21, indicated the facility will utilize a lift program to protect residents and employees from injuries during lifting and transferring. If the transfer is a full body lift, two staff members are required for transfer.

A review of the resident face sheet indicated that Resident R1 was admitted to the facility on 4/9/21, with diagnoses that included difficulty in walking, rheumatoid arthritis, heart disease.

A review of a physician order dated 4/21/21, indicated transfer status full body mechanical lift.

A review of Resident R1's care plan revised 8/25/21, indicated transfer status is full body mechanical lift.

A review of a nurse progress note dated 10/25/21, indicated sent to ER (emergency room) due to cut leg.

A review of a nurse progress note dated 10/26/21, indicated nursing assistant (NA) states that during transfer resident sustained a skin tear to leg. Outer left calf area open area noted about 6 inches long. Resident states that leg is hurting when moved. Sent to ED (emergency department) for treatment.

A review of the "Emergency Evaluation Final Report" form dated 10/25/21, indicated laceration to left leg through the subcutaneous (below the skin) tissue to the fascia (connective tissue that provides internal structure) minimal adipose (fat tissue) and continuous skin tear 4 cm with laceration. Laceration repair 2 sutures.

A review of an incident report and witness statements, dated 10/26/21, indicated NA Employee E1 transferred Resident R1 from the wheelchair to the bed, using the Hoyer Lift (full body mechanical lift) without assistance.

During an interview on 11/4/21, at 3:00 p.m. NA Employee E1 confirmed they transferred Resident R1 on 10/25/21, using the mechanical lift without assistance, was aware needed two persons, and staff was available to assist. Stated, "I was impatient and did not want to wait for another person to assist." "If another person was there, they may have seen the resident's leg moving too close to the wheelchair."

During an interview on 11/4/21, at 1:35 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide adequate supervision for the transfer, and utilize a mechanical lift with two staff as required, to promote resident safety for Resident R1's transfer needs which resulted in a left leg laceration.

A review of the resident face sheet indicated Resident R2 was admitted to the facility on 6/14/21, with diagnoses that included dementia and Parkinson's (neurological disease that causes muscle tremors).

A review of a physician order dated 9/14/21, indicated transfer status minimal assist of two.

A review of Resident R2's care plan revised 9/28/21, indicated transfer status minimal assist of two.

A review of a nurse progress note dated 10/8/21, indicated Resident R2 had a 20 x 24 cm (centimeter) bruise to the left thigh/knee area.

A review of an incident report dated 10/8/21, indicated Resident R2 had a large bruise to the back of the left leg that measured 20 x 24 cm.

A review of a nurse progress note dated 10/14/21, indicated the origin of the bruise was investigated and found to be caused when the resident was lowered to the floor on 10/2/21.

A review of an incident report and witness statements, dated 10/2/21, indicated NA Employee E2 was attempting to transfer Resident R2 into her chair without assistance. The resident's knees buckled, and the resident was lowered to the floor. Large bruise to back of left leg.

During an interview on 11/4/21, at 4:30 p.m. the DON confirmed the facility failed to provide adequate supervision for the transfer needs for Resident R2.

28 Pa. Code 211.10(d) Resident care policies

28 Pa Code 211.12(d)(1)(2)(5) Nursing services.















 Plan of Correction - To be completed: 12/07/2021

DISCLAIMER: The following is submitted for plan of correct purposes only and should not be construed as an admission.

R1 and R2 continue to reside in the facility and are being transferred appropriately.

E1 and E2 have be re-educated on transfer identification, safe lift and the facility abuse policy. Competencies were completed for both employees for safe lift. Disciplinary action per facility personnel policy was done with each employee.

Residents who require a mechanical lift for transfers will be reviewed to ensure transfer recommendations remain appropriate. New transfer recommendations will be implemented and care planned as needed.
Mechanical lift competencies with return demonstration will be completed with facility nurse aides, then annually thereafter.

Directed in-service provider Lewis Litigation Support and Clinical Consulting, LLC will be presenting an interactive PowerPoint titled "Accidents in the Context of Abuse and Neglect" to nursing staff on 11/22/21. The training will be recorded for additional presentations to facility staff that are unable to attend the live version.

The Director of Nursing/designee will audit by direct observation that mechanical lift transfers are being completed per facility policy. Five mechanical lift transfers will be observed daily for two weeks, weekly for two weeks and monthly for two months, then randomly thereafter. Audit results will be reviewed at the facility Quality Assurance meetings until substantial compliance has been met.


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