Nursing Investigation Results -

Pennsylvania Department of Health
ABRAMSON RESIDENCE
Patient Care Inspection Results

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ABRAMSON RESIDENCE
Inspection Results For:

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ABRAMSON RESIDENCE - 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 September 5, 2019, it was determined that Abramson Residence 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 as it relates to the Health portion of the survey process.

















































 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 review of clinical records, facility documentation, facility policy, and interview with residents and staff, it was determined that the facility failed to conduct complete and thorough investigations of allegations of possible abuse and/or neglect and to report these allegations to the State survey agency for three of four clinical records were reviewed. (Residents R1, R4, and R8)

Findings include:

Review of the facility's policy, "Abuse Investigating and Reporting," revised 03/2019, revealed that. if an allegation of abuse is reported, an investigation of the allegation is initiated and that all individuals involved in the allegation are interviewed. Further, the Director of Nursing and Nursing Home Administrator are made aware of the allegation. This policy also indicated that, once the investigation has been initiated and abuse is suspected, the process for the completion of a PB-22 is initiated on line and that all allegations of abuse must be reported initially through the Department's Electronic Event Reporting System.

Review of the facility's Grievance Log revealed an entry, dated August 7, 2019, that indicated the facility had been made aware of a concern regarding staff care and attitude in providing care to Resident R4.

Review of Resident R4's Minimum Data Set (MDS - assessment of resident need), dated August 8, 2019, revealed that the diagnoses that included amputation of bilateral lower extremities (legs) and that the resident was incontinent of bowel and bladder. This MDS also indicated that this resident was able to make herself understood and that she was able to understand others. In an interview with Employee E3, a licensed nurse, she stated that Resident R4 was alert and oriented as well as able to describe events reliably.

Review of the facility's complaint form, dated August 8, 7, 2019, revealed the following description of an incident regarding care: At 10:00 p.m., Resident R4 had called to be changed after having a bowel movement. The nursing aide, Employee 4, went to the resident's room, opened her incontinence brief, and told the resident she would be back but never came back after repeated calls. Review of the statement signed by Employee E4 indicated that the resident had called to be changed initially at 9:40 p.m. In this statement, Employee E4 also indicated that, at 11:13 p.m., she told the resident that the next shift would change the resident; this reflected a delay greater than one and a half hours between the time Employee E4 became aware of the need for the resident to receive incontinence care and the time the resident received the needed care.

In an interview with Resident R4, at approximately 2:00 p.m. on September 5, 2019, she described the incident. She emphasized that the Employee E4 had opened her incontinence brief, completely exposing her body below the waist, and provided no other covering. Resident R4 described her extreme embarrassment when Employee E4 left her in that position for a prolonger period of time.

In an interview with the Director of Nursing and Assistant Administrator, at approximately 2:30 p.m., it was confirmed that the facility had no documentation for review to indicate that it had completed a completed and through investigation, and had neither submitted a report to the State Department of Health.

Review of the clinical record for Resident R8 revealed a Minimum Data Set (MDS - assessment of resident need), dated June 15, 2019, which included the diagnoses of anxiety disorder and depression. This MDS also indicated that the resident was cognitively intact.

Review of the facility's grievance log revealed an entry on August 26, 2019, indicating a concern had been conveyed in relation to the care provided and staff attitude demonstrated when providing care to Resident R8. Review of the facility's complaint form, dated August 26, 2019, revealed Resident R8 had alleged that, on a previous Friday night, a staff person "was rough" and gave her a "hard time about everything," including medications and food at dinner as well as indicating that the staff person and the resident "didn't get along" and that the resident "was scared."

In an interview with the Director of Nursing and Assistant Administrator, at approximately 2:30 p.m. on September 5 2019, it was confirmed that the facility had no documentation for review to indicate that it had completed a complete and through investigation, and had neither submitted a report to the Department of Health. Additionally, there was no documentation available for review to indicate that the Nursing Home Administrator had been made aware of the allegation.


Review of the clinical record for Resident R1 revealed a Minimum Data Set (MDS - assessment of resident need), dated August 28, 2019, that indicated this resident had diagnoses that included osteoarthritis (degenerative joint disease) and peripheral vascular disease (PVD-poor circulation of the extremities). This MDS also indicated that Resident R1 was cognitively intact.

In an interview with Resident R1, at approximately 1:00 p.m. on September 5, 2019, she stated that there had been an occasion when a staff person had spoken to her in a "disrespectful" manner and had pressured her into taking medication when she was not ready to do so. She also indicated that she had reported this incident to staff.

Review of the facility's complaint form, dated January 3, 2019 revealed an indication that the Employee E5, Care Coordinator (licensed nurse), had been rude and had a "sarcastic attitude." This form also indicated that the Unit Manager would get specific examples and that other alert and oriented residents would be interviewed to get specific examples . The facility had no additional documentation available for review to indicate that more than one other resident had been interviewed.

Continued review of documentation revealed a "Performance Development Counseling Form," dated January 4, 2019 attached to the above-referenced complaint form indicating that licensed nursing staff, Employee E5 had gone back to Resident R1 to confirm what Resident R1 had complained about to the Director of Nursing. This form also indicated that, in doing so, Employee E5 did not follow facility policy.

Further review revealed a statement from licensed nurse, Employee E6 that contained the sentence, "Nurse almost done retaliation behavior." In an interview with the Director of Nursing and Assistant Nursing Home Administrator at approximately 3:00 p.m. on September 9, 2019, they indicated that they could not answer what this pertained to with certainty. It was further confirmed that the facility had no other documentation available for review indicating that it had completed a complete and thorough investigation and had neither submitted a report to the State Department of Health.

The facility failed to conduct a complete and thorough investigation regarding possible abuse and/or neglect for three residents and to report these allegations to the State Survey Agency as required.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/18/18

28 Pa. Code 201.18(b)(1) Management
Previously cited 12/18/18

28 Pa. Code 201.18(e)(1) Management
Previously cited 12/18/18

28 Pa. Code 201.29(c) Resident rights
Previously cited 12/18/18

28 Pa. Code 211.10(d) Resident care policies
Previously cited 12/18/18

28 Pa Code 211.12(d)(1) Nursing services
Previously cited 12/18/18

























 Plan of Correction - To be completed: 10/18/2019

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by state and federal law.

Resident R4, Resident R8 and Resident R1 will be informed of the outcome of the investigations and asked if they believe that the care they receive is appropriate and timely, and if they are treated with respect and dignity.
Every grievance is being evaluated as if it is a possible abuse/neglect allegation.

Accused/suspected employees are suspended pending completion of the investigation in order to protect residents from further abuse/neglect or retaliation.

Grievance investigation procedure has been revised to include that signed statements are received from all staff assigned to the cluster at the time of the grievance, and the clear statement of whether abuse and/or neglect was ruled out and rationale. Nurse Managers, Supervisors and Department Managers have been trained regarding the revised procedure.

An audit of the last 30 days of grievances will be completed to identify possible situations of abuse and/or neglect.

Grievances which identify that the resident felt embarrassed, treated disrespectfully or cause fear will be investigated and reported to the State survey agency as allegations of possible abuse and/or neglect.

The Abuse/Neglect policy/procedure will be revised to include the grievance procedure and will include the obtaining of signed witness statements of all involved.

The grievance log will be audited by the Assistant Administrator to determine compliance with the revised procedure and effective determination of possible abuse and/or neglect. including the type of grievance, whether reported as possible abuse and/or neglect will be reported to the QAA committee monthly.
51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
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 review of clinical records, facility documentation, facility policy, and interview with residents and staff, it was determined that the facility failed to report allegations of possible abuse and neglect to the Department of Health for three of four clinical records were reviewed. (Residents R1, R4, and R8)

Findings include:

Review of the facility's policy, "Abuse Investigating and Reporting," revised 03/2019, revealed that. if an allegation of abuse is reported, an investigation of the allegation is initiated and that all individuals involved in the allegation are interviewed. Further, the Director of Nursing and Nursing Home Administrator are made aware of the allegation. This policy also indicated that, once the investigation has been initiated and abuse is suspected, the process for the completion of a PB-22 (Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property) is initiated on line and that all allegations of abuse must be reported initially through the Department's Electronic Event Reporting System.

Review of the facility's Grievance Log revealed an entry, dated August 7, 2019, that indicated the facility had been made aware of a concern regarding staff care and attitude in providing care to Resident R4.

Review of Resident R4's Minimum Data Set (MDS - assessment of resident need), dated August 8, 2019, revealed that the diagnoses that included amputation of bilateral lower extremities (legs) and that the resident was incontinent of bowel and bladder. This MDS also indicated that this resident was able to make herself understood and that she was able to understand others. In an interview with Employee E3, a licensed nurse, she stated that Resident R4 was alert and oriented as well as able to describe events reliably.

Review of the facility's complaint form, dated August 8, 7, 2019, revealed the following description of an incident regarding care: At 10:00 p.m., Resident R4 had called to be changed after having a bowel movement. The nursing aide, Employee 4, went to the resident's room, opened her incontinence brief, and told the resident she would be back but never came back after repeated calls. Review of the statement signed by Employee E4 indicated that the resident had called to be changed initially at 9:40 p.m. In this statement, Employee E4 also indicated that, at 11:13 p.m., she told the resident that the next shift would change the resident; this reflected a delay greater than one and a half hours between the time Employee E4 became aware of the need for the resident to receive incontinence care and the time the resident received the needed care.

In an interview with Resident R4, at approximately 2:00 p.m. on September 5, 2019, she described the incident. She emphasized that the Employee E4 had opened her incontinence brief, completely exposing her body below the waist, and provided no other covering. Resident R4 described her extreme embarrassment when Employee E4 left her in that position for a prolonger period of time.

In an interview with the Director of Nursing and Assistant Administrator, at approximately 2:30 p.m., it was confirmed that the facility did not submit a report to the Department of Health through its Electronic Event Reporting System nor submitted a PB-22 to the Department as required.

Review of the clinical record for Resident R8 revealed a Minimum Data Set (MDS - assessment of resident need), dated June 15, 2019, which included the diagnoses of anxiety disorder and depression. This MDS also indicated that the resident was cognitively intact.

Review of the facility's grievance log revealed an entry on August 26, 2019, indicating a concern had been conveyed in relation to the care provided and staff attitude demonstrated when providing care to Resident R8. Review of the facility's complaint form, dated August 26, 2019, revealed Resident R8 had alleged that, on a previous Friday night, a staff person "was rough" and gave her a "hard time about everything," including medications and food at dinner as well as indicating that the staff person and the resident "didn't get along" and that the resident "was scared."

In an interview with the Director of Nursing and Assistant Administrator, at approximately 2:30 p.m. on September 5 2019, it was confirmed that the facility did not submit a report to the Department of Health through its Electronic Event Reporting System nor submitted a PB-22 to the Department as required.


Review of the clinical record for Resident R1 revealed a Minimum Data Set (MDS - assessment of resident need), dated August 28, 2019, that indicated this resident had diagnoses that included osteoarthritis (degenerative joint disease) and peripheral vascular disease (PVD-poor circulation of the extremities). This MDS also indicated that Resident R1 was cognitively intact.

In an interview with Resident R1, at approximately 1:00 p.m. on September 5, 2019, she stated that there had been an occasion when a staff person had spoken to her in a "disrespectful" manner and had pressured her into taking medication when she was not ready to do so. She also indicated that she had reported this incident to staff.

Review of the facility's complaint form, dated January 3, 2019 revealed an indication that the Employee E5, Care Coordinator (licensed nurse), had been rude and had a "sarcastic attitude." This form also indicated that the Unit Manager would get specific examples and that other alert and oriented residents would be interviewed to get specific examples . The facility had no additional documentation available for review to indicate that more than one other resident had been interviewed.

Continued review of documentation revealed a "Performance Development Counseling Form," dated January 4, 2019 attached to the above-referenced complaint form indicating that licensed nursing staff, Employee E5 had gone back to Resident R1 to confirm what Resident R1 had complained about to the Director of Nursing. This form also indicated that, in doing so, Employee E5 did not follow facility policy.

Further review revealed a statement from licensed nurse, Employee E6 that contained the sentence, "Nurse almost done retaliation behavior." In an interview with the Director of Nursing and Assistant Nursing Home Administrator at approximately 3:00 p.m. on September 9, 2019, that the facility did not submit a report to the Department of Health through its Electronic Event Reporting System nor submitted a PB-22 to the Department as required.

The facility failed to report these allegations to the State Survey Agency and submit a PB-22 as required.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/18/18

28 Pa. Code 201.18(b)(1) Management
Previously cited 12/18/18

28 Pa. Code 201.18(e)(1) Management
Previously cited 12/18/18

28 Pa. Code 201.29(c) Resident rights
Previously cited 12/18/18

28 Pa. Code 211.10(d) Resident care policies
Previously cited 12/18/18

28 Pa Code 211.12(d)(1) Nursing services
Previously cited 12/18/18

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/18/18







































 Plan of Correction - To be completed: 10/18/2019

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by state and federal law.

The three cited grievances will be entered into the state event reporting website as allegations of abuse or neglect.

Grievances which identify that the resident felt embarrassed, treated disrespectfully or cause fear will be investigated and reported to the State survey agency as allegations of possible abuse and/or neglect.

Accused/suspected employees will be suspended pending completion of the investigation in order to protect residents form further abuse/neglect or retaliation.

An audit of the last 30 days of grievances will be completed to identify possible situations of abuse and/or neglect.

The Administrator and/or DON will be responsible for ensuring that the complaints of abuse/neglect are submitted appropriately to the PA event reporting system.

The grievance log will be audited by the Assistant Administrator to determine compliance with the revised procedure and effective determination of possible abuse and/or neglect, including the type of grievance, whether reported as possible abuse or neglect will be reported to the QAA committee monthly.


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