Pennsylvania Department of Health
HEMPFIELD MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

HEMPFIELD MANOR
Inspection Results For:

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HEMPFIELD MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to two complaints completed on July 15, 2024, it was determined that Hempfield Manor 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(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

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)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§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 facility policies, documents and staff interviews it was determined that the facility failed to conduct a through investigation three of three allegations of possible abuse and neglect. (5/20/24, 6/11/24, and 6/26/24)

Findings include:

A review of facility " Abuse, Neglect, Exploitation and Misappropriation of Resident Property" policy date 12/23/23,
revealed that abuse, neglect, exploitation and misappropriation of resident property will not be tolerated. An investigation of the allegations will be conducted.

A review of grievance form dated 5/20/24. revealed Resident R4 alleged that Licensed Practical Nurse (LPN)Employee E1 refused to provide treatment on 5/18/24. A statement written date 5/18/24, by LPN Employee E1 confirmed that she refused to complete the treatment as she was unaware of the physician order. A review of Resident R4's May Electronic Treatment Administration Record (ETAR) revealed that LPN Employee E1 signed off on completing the treatment on 5/16/24, and 5/17/24.

A review of grievance form dated 6/11/24, Resident R5 alleged that a staff member was bullying her and refused to complete her care needs.

A review of grievance form date 6/26/24, Resident R5 alleged that staff are "haters" and refused to engage in conversation with the resident which as the resident stated made her feel like a second class citizen.

During an interview on 7/9/24, the Nursing Home Administrator confirmed that the facility failed to complete a through investigation including the possible identification of alleged perpetrators and report to regulatory agencies for the incidents of 5/20/24, 6/11/24, and 6/26/24 as required.

PA Code: 201.18(e)(1) Management.

Plan of Correction - To be completed: 08/15/2024

Resident R4 was discharged to home on 6/29/2024. On 7/16/2024, Event Report #1019835 was submitted to Pennsylvania Department of Health with a PB-22 in regards to the allegation voiced on 5/20/24. Westmoreland County Area on Aging was also contacted as a regulatory agency with oversight of allegations of abuse/neglect. An internal investigation was also completed 5/24/24 with unsubstantiated finding. LPN was educated and counseled on appropriate communications with residents and customer service on 5/21/24. All staff receive in service education upon hire and yearly on Abuse/Neglect Prevention and Reporting. All staff will be inserviced by NHA or designee regarding Abuse/Neglect Prevention and Reporting. This will completed in July and August all staff inservices by August 14th, 2024. Education will be provided by DON or designee to all licensed nursing staff on documenting and signing off in the MAR and TAR correctly; this will be completed by August 14th, 2024.NHA or designee will audit resident concerns/grievances on weekly basis for 3 weeks, then monthly for 3 months, then quarterly to ensure any allegations of abuse/neglect were thoroughly investigated and reported as required to the appropriate regulatory agencies. DON or designee will audit correct documentation and sign offs of MARs/TARS weekly for 3 weeks, then monthly for 3 months, then quarterly to ensure correct documentation/sign off on orders. The results of the audits will be reported on at the quarterly QAPI meeting.

Resident R5 continues to reside in the facility. Event Report #1020090 was submitted to Pennsylvania Department of Health on 7/17/2024 with two PB-22s in regards to the allegations voiced by the resident. Westmoreland County Area on Aging was also contacted as a regulatory agency with oversight of allegations of abuse/neglect. Internal investigations were also completed 6/12/24 for the 6/11/24 concern and 7/03/24 for the 6/26/24 concern, both with unsubstantiated findings. Ombudsman, resident, NHA, and staff nurse that resident chose attended a meeting to discuss resident's ongoing concerns 7/08/24. Both C.N.A.s were educated on responding appropriately to resident requests and documentation of any behaviors. Both C.N.As received education on abuse and neglect prevention and maintaining good customer service skills. Both C.N.As were removed as caretakers for the resident per the resident's request. All staff receive in service education upon hire and yearly on Abuse/Neglect Prevention and Reporting. All staff will be inserviced by NHA or designee regarding Abuse/Neglect Prevention and Reporting. This will completed in July and August all staff inservices. NHA or designee will audit resident concerns/grievances on weekly basis for 3 weeks, then monthly for 3 months, then quarterly to ensure any allegations of abuse/neglect were thoroughly investigated and reported as required to the appropriate regulatory agencies. The results of the audit will be reported on at the quarterly QAPI meeting.

483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property:

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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

Observations:
Based on a review of facility policy, resident medical records, facility provided documents, staff statements and staff interviews, it was determined that the facility failed to provide a dignified living experience for one of three residents (Resident R4).

Findings include:

A review of facility " Resident Rights" policy dated 12/13/23, indicated that the residents have the right to a dignified existence, self determination, communication with access to persons and services within and outside the facility.

A review of facility grievance form dated 5/20/24, revealed that Resident R4 filed a grievance on 5/18/24, Licensed Practical Nurse (LPN) E1 called the resident by her non preferred name.

Review of a handwritten employee statement submitted on 5/18/24, by LPN Employee E1 confirmed that she had called the resident by her non preferred name. LPN Employee E1's statement indicated that LPN Employee E1 and Resident R4 were discussing a treatment for the resident when LPN Employee E1 stated she said " ***** (resident's non preferred name) I have to go look at the computer." The resident became very confrontational and stated " My name is **** (Resident's preferred name). LPN Employee E1 stated ***** was the name in the computer.

A review of Resident R4 computerized medical record revealed that the resident's proper name ***** is listed on her medical record. Next to that name is quotation marks is listed "****" the resident's preferred name.

During an interview on 7/15/24, at 11:15 am Nursing Home Administrator confirmed that LPN Employee E1 confirmed in her statement that she failed to call Resident R4 by the resident's preferred name that was listed in the resident's medical record which created a non dignified living experience for the resident.

PA Code: 211.29(a) Resident rights.

Plan of Correction - To be completed: 08/15/2024

This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Hempfield Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Hempfield Manor credible allegation of compliance.
Resident R4 was discharged to home on 6/29/2024. LPN was educated on resident rights and using the preferred name of the residents. All residents are assessed upon admission for preferred name, and this is charted in the medical record and in the care plan. Residents are also asked if they would like their preferred name on the name plate outside their room. The dashboard of the EHR record is also updated to reflect the preferred name in " ". All staff are oriented upon hire and yearly on resident rights, including dignity. All staff will be inserviced by NHA or designee regarding resident rights and dignity, with emphasis on communications used with residents. This will be completed in July and August all staff inservices by August 14th, 2024. A chart audit of all current residents was completed on 7/26/2024 to ensure the preferred name for all residents is being used. Social Services or designee will audit all new admissions weekly for 3 weeks, then monthly for 3 months, then quarterly to ensure preferred name is being used and appropriately care plan any nicknames/special names per the resident's choice. The audit results will be presented at quarterly QAPI meeting.

51.3 (g)(1-14) LICENSURE NOTIFICATION:

51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:
Based on a review of facility documents and staff interviews, it was determined that the facility failed to port to the State agency allegations of possible abuse and neglect for three of three incidents (5/20/24, 6/11/24, and 6/26/24)

Findings include:

A review of facility grievance form dated 5/20/24, revealed Resident R4 filed a grievance form that alleged facility staff refused to provide treatment prescribed by the physician and treated the resident with a lack of dignity and respect by failing to use the resident's preferred name which caused the resident anxiety.

A review of facility grievance form dated 6/11/24, revealed Resident R5 filed a grievance form that alleged a staff member was bullying her and refused to provide care.

A review of facility grievance form dated 6/26/24, revealed Resident R5 filed a grievance form that alleged staff members are "haters" and refuse to carry on conversations with the resident.

A review of of facility documents failed to provide evidence that the facility reported the incidents to the State agency as required.

During an interview on 7/15/24, at 11:10 am the Nursing Home Administrator confirmed that the facility failed to report the incidents o alleged abuse and neglect to the State agency as required.

Plan of Correction - To be completed: 08/15/2024

Resident R4 was discharged to home on 6/29/2024. On 7/16/2024, Event Report #1019835 was submitted to Pennsylvania Department of Health with a PB-22 in regards to the allegation voiced on 5/20/24. Westmoreland County Area on Aging was also contacted as a regulatory agency with oversight of allegations of abuse/neglect. An internal investigation was also completed 5/24/24 with unsubstantiated finding. LPN was educated and counseled on appropriate communications with residents and customer service on 5/21/24. All staff receive in service education upon hire and yearly on Abuse/Neglect Prevention and Reporting. All staff will be inserviced by NHA or designee regarding Abuse/Neglect Prevention and Reporting. This will completed in July and August by August 14th, 2024 all staff inservices. NHA or designee will audit resident concerns/grievances on weekly basis for 3 weeks, then monthly for 3 months, then quarterly to ensure any allegations of abuse/neglect were thoroughly investigated and reported as required to the appropriate regulatory agencies. The results of the audit will be reported on at the quarterly QAPI meeting.

Resident R5 continues to reside in the facility. Event Report #1020090 was submitted to Pennsylvania Department of Health on 7/17/2024 with two PB-22s in regards to the allegations voiced by the resident. Westmoreland County Area on Aging was also contacted as a regulatory agency with oversight of allegations of abuse/neglect. Internal investigations were also completed 6/12/24 for the 6/11/24 concern and 7/03/24 for the 6/26/24 concern, both with unsubstantiated findings. Ombudsman, resident, NHA, and staff nurse that resident chose attended a meeting to discuss resident's ongoing concerns 7/08/24. Both C.N.A.s were educated on responding appropriately to resident requests and documentation of any behaviors. Both C.N.As received education on abuse and neglect prevention and maintaining good customer service skills. Both C.N.As were removed as caretakers for the resident per the resident's request. All staff receive in service education upon hire and yearly on Abuse/Neglect Prevention and Reporting. All staff will be inserviced by NHA or designee regarding Abuse/Neglect Prevention and Reporting. This will completed in July and August all staff inservices by August 14th, 2024. NHA or designee will audit resident concerns/grievances on weekly basis for 3 weeks, then monthly for 3 months, then quarterly to ensure any allegations of abuse/neglect were thoroughly investigated and reported as required to the appropriate regulatory agencies. The results of the audit will be reported on at the quarterly QAPI meeting.

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