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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Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to two complaints completed on February 11, 2020, it was determined that Langhorne Gardens Health 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.

 Plan of Correction:

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

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.
Based on policy review, staff interview, clinical record review, and review of additional facility documentation, it was determined that the facility failed to report an allegation of abuse to the local Area Agency of Aging, the State Survey and Certification Agency, and the local Police Department for one of five sampled residents. (Resident 1)

Findings include:

Review of the facility's policy entitled "Pennsylvania Resident Abuse" dated July 2019, revealed that all allegations of abuse were to be reported immediately to the appropriate supervisor who then reports the allegation to the Admistrator and Director of Nursing. The allegation is then reported to the appropriate agencies including the State Survey Agency.

Clinical record review revealed that Resident 1 was admitted to the facility on February 4, 2020, with diagnoses that include congestive heart failure, Parkinson's Disease, and diabetes. The baseline care plan revealed that the resident required staff assistance for all activities of daily living.

In an interview on February 11, 2020, at 1:31 p.m., the Director of Nursing stated that an allegation of abuse was reported on February 10, 2020, regarding Resident 1. Review of the facility provided documentation of the alleged incident revealed that the allegation was reported to a nursing supervisor on February 8, 2020, however, the incident was not reported to the Nursing Home Administrator until February 10, 2020, which was two days after the incident occurred. Facility staff failed to report the allegation of abuse to the appropriate staff in a timely manner. Additionally, the facility failed to report the allegation of abuse to the State Survey Agency until February 10, 2020.

In interview on February 11, at 1:31 p.m., the Director of Nursing confirmed that the allegation of abuse was not reported to the State Survey Agency in accordance with facility policy and federal and state regulations.

28 Pa. Code 201.14(e) Responsibility of licensee
28 Pa. Code 201.8(b)(1)(e)(1) Management

 Plan of Correction - To be completed: 02/19/2020

1.) R1's allegation dated 2/8/2020 was reported to Area Agency on Aging, State Survey, and Police on 2/10/2020.
2.) All resident's alleging substandard care identified as possible abuse or neglect have the potential to be affected. On 2/13/20 the Nursing Home Administrator (NHA) and/or delegate completed an audit of all outstanding allegations of abuse or neglect. If required, allegations were immediately reported to the Pennsylvania Department of Health (PADOH), and all other required agencies. No outstanding allegations were identified.
3.) On 2/12/20 the NHA and/or delegate educated all staff on reporting abuse with an emphasis on immediately doing so. The NHA and/or delegate also educated all facility Department Managers on the need to report allegations of abuse to the PADOH within 2 hours of receiving them.
4.) To monitor and maintain ongoing compliance the NHA and/or delegate will randomly interview 5 cognitively intact residents 1 time weekly for 3 months to ensure no situation of abuse were reported without immediate follow up. The NHA and/or delegate will also randomly interview 5 staff members 1 time weekly for 3 months to ensure any abuse allegations made to employee were reported to supervisor immediately. The NHA will review all reported abuse claims 1 time weekly for 3 months to ensure that they were reported to the PADOH within 2 hours of allegation being made. Results will then be reported to QAPI committee for further review and recommendations.

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