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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GERMANTOWN HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on June 9, 2022, it was determined that Germantown Home, 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 the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
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;

Based on review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident was free from physical abuse for one of six residents reviewed (Resident R1). This failure resulted in an immediate jeopardy situation for Resident R1 who was hit on the back of the head by a nursing staff.

Findings include:

Review of facility policy, "Abuse Prohibition" dated last revised March 9, 2021, revealed that, "Residents will be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Residents will not be abused by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals." Continued review revealed that physical abuse includes, "hitting, slapping, pinching, kicking, etc."

Review of Resident R1's significant change MDS (Minimum Data Set - a periodic mandatory assessment) dated April 27, 2022, revealed that the resident was admitted to the facility December 22, 2014, with the diagnoses of stroke, osteoporosis (weak and brittle bones), malnutrition and dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Continued review revealed that the resident required extensive assistance from staff with bed mobility, transfers and hygiene. Further review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of three, which indicated that Resident R1 was severely cognitively impaired.

Review of progress notes revealed a nurses note, dated April 30, 2022, at 5:59 a.m. which indicated that at 5:00 a.m. Employee E22, licensed nurse, heard Resident R1 "yell out." Employee E5 went to the resident's room and observed a nurse aide "leaning over [Resident R1] and punched her with a closed fist in the back of the head." Employee E22 noted that Resident R1 was medicated for complaints of pain to her head and face, swelling was noted to the resident s right eye and bruises noted to bilateral wrist area.

Review of facility documentation submitted to the Department of Health dated April 30, 2022, at 1:41 p.m. revealed that Resident R1 was allegedly hit by a nurse aide, Employee 21.

Review of facility documentation revealed a witness statement regarding the incident from Employee E22, which noted, "At 5:00 a.m. I heard [Resident R1] yell out, I just saw her CNA (nurse aide) take her into her room, I immediately walked into [Resident R1's] room and I saw the CNA [Employee E21] punch [Resident R1] in the back of the head. [Resident R1] was laying in the bed at the time of the incident."

Continued review of facility documentation revealed a witness statement regarding the incident from Employee E25, licensed nurse, which noted, "Resident noted with some redness surrounding right eye and slight swelling. Resident reported pain touching her forehead ... [Resident R1] states she was hit on her head, back and stomach."

Continued review of facility documentation revealed a witness statement regarding the incident from Employee E23, licensed nurse. Employee E23 noted that, "upon speaking to the resident she verbalized that she hit her three times in the face, once in the eye and two times in the mouth chin area." Employee E23 noted that he "saw the area around the right eye socket reddening and signs of swelling to the area." Employee E23 further noted that he took a "statement from resident's roommate."

Continued review of facility documentation revealed a witness statement, dated April 30, 2022, from Resident R3. Resident R3 noted that she slept in the same room as Resident R1 and that she "over heard the care nurse fussing at the resident and heard the care nurse strike my roommate with three pops sounds and overheard her tassling."

Interview on June 9, 2022, at 3:12 p.m. Resident R3 stated that she recalled the incident and confirmed that she heard Employee E21 hit Resident R1 three times.

Review of Resident R1's physician evaluation, dated May 2, 2022, revealed that the resident was evaluated for follow-up after the reported altercation. The physician noted that the resident was unable to recall the incident due to her advanced dementia. The physician noted that the resident was thin, frail and that erythema (redness) was noted along the resident's right periorbital (eye socket) region.

Interview on June 9, 2022, at 4:01 p.m. the Nursing Home Administrator (NHA) confirmed that the allegation of physical abuse was substantiated and that Employee E21 was terminated from her position at the facility.

Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to ensure that a resident was free from physical abuse from a nursing staff. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator, on June 9, 2022, at 4:01 p.m.

On April 30, 2022, the facility initiated a plan of correction to address the failure of ensuring that a resident was free from physical abuse. Facility plan of correction included the following:
1. The aide was removed from the facility and suspended pending investigation on April 30, 2022.
2. The local authorities were notified within two hours of observed incident on April 30, 2022.
3. Message was left on the Pennsylvania Depart of Aging elder abuse hotline within two hours of incident on April 30, 2022.
4. Message was left with Philadelphia Corporation for Aging protective services on April 30, 2022.
5. An event report was submitted via Pennsylvania Department of Health event report website on April 30, 2022.
6. The resident's physician was notified. Orders were given to initiate neurological checks and to monitor for pain on April 30, 2022.
7. The resident's guardian was notified on April 30, 2022.
8. Other residents in aide's assigned area were interviewed to identify any concerns regarding care. No other concerns were identified on April 30, 2022.
9. Statements were obtained from staff with relevant knowledge regarding incident on April 30, 2022.
10. Security footage was reviewed to validate the reported timeframe of events on April 30, 2022.
11. The aide subsequently submitted to an interview on May 2, 2022. The allegation was substantiated and the aide was terminated.
12. The facility policy on prohibition from abuse was reviewed on May 4, 2022.
13. A facility-wide directed education including all departments regarding facility policy on prohibition from abuse, including physical, was initiated on May 4, 2022. The education was recorded and training continued through May 8, 2022, for all staff. Any staff not scheduled to work during this time were scheduled to complete education.
14. An audit was initiated, including review of electronic health record, weekly, to identify and monitor resident behavior that may identify abuse per CMS (Center of Medicare and Medicaid) regulation related to resident freedom from abuse and neglect.
15. Plan of corrections reviewed during Quality Aassurance Performance Improvement (QAPI) meeting in May 2022 including freedom from abuse, neglect and exploitation.
16. Next QAPI is scheduled June 21, 2022.
17. Facility continues to review resident rights during monthly resident council meeting, on admission, and during quarterly resident care conferences. Residents are encouraged per policy to immediately report allegations of abuse, neglect and exploitation.

Review of facility documentation revealed that the corrective action plan was immediately developed and initiated April 30, 2022. Audits were initiated to monitor residents and resident behaviors. The facility reviewed their policy related to abuse. Review of Directed in-service training related to abuse was completed with staff from all departments.

Interviews were conducted with staff from various departments. All staff reported that they received the in-service training. It was confirmed during interview that they were able to recognize signs of resident abuse and that they were knowledgeable on reporting resident abuse as well as their role in the abuse investigation process.

The Immediate Jeopary was lifted on June 9, 2022.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 201.18(b)(2) Management

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

28 Pa. Code 201.29(c) Resident rights

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

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

 Plan of Correction - To be completed: 06/29/2022

The resident affected by this incident was assessed and treated. All parties were notified of the incident and the investigation started immediately.

All residents in the perpetrators assignment were interviewed and assessed. It was determined that no other resident was affected or hit by that CNA. The CNA was removed immediately from facility and later terminated.

Staff education was initiated and continued throughout with our Directed Inservice and additional Abuse training.
We have increased out rounding and unannounced visits on different shifts to monitor compliance.

Any unfavorable finding will be addressed immediately and all findings will be discussed in QAPI by Administration monthly for the next year.

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