Nursing Investigation Results -

Pennsylvania Department of Health
ROSE VIEW NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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ROSE VIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

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ROSE VIEW NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:







Based on an Abbreviated Survey in response to a Complaint Investigation completed on February 26, 2020, it was determined that Rose View Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care 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 review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to thoroughly investigate, implement interventions to prevent, and report all allegations of potential resident to resident abuse for three of six residents reviewed (Residents 18, 58, and 46).

Findings include:

The facility policy entitled, "Abuse Prevention Program," last reviewed on April 24, 2019, revealed that residents have the right to be free from abuse; this includes but is not limited to sexual or physical abuse. Administration will protect residents from abuse by anyone including but not limited to facility staff and other residents. Implementation of the policy included to instruct staff regarding appropriate ways to address interpersonal conflicts, identify and assess all possible incidents of abuse, investigate and report any allegations of abuse within timeframes as required by federal requirements, and protect residents during abuse investigations. All reports of resident abuse shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. The Administrator will ensure that any further potential abuse is prevented. The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. The individual conducting the investigation will, at a minimum, review the completed documentation forms, review the resident's medical record to determine events leading up to the incident, interview the person reporting the incident, interview any witnesses to the incident, interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, interview other residents, and review all events leading up to the alleged incident. Witness reports will be obtained in writing; either the witness will write his/her statement and sign and date it or the investigator may obtain a statement and have him/her sign and date it. The investigator will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process. All alleged violations involving abuse will be reported to the state licensing/certification agency, the local ombudsman, the resident's representative, and law enforcement not later than 24 hours if the alleged violation has not resulted in serious bodily injury. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five working days of the occurrence of the incident.

Interview with Resident 58 on February 26, 2020, at 12:50 PM revealed that (named) Resident 46 has, "the filthiest mouth (she has) ever heard." Resident 58 described an incident that occurred approximately one month ago while she was at the nurse's station making a phone call. Resident 58 stated that she raised her arm and leaned to the right during the phone call and Resident 46 ran his hand along her left side, including her breast. Resident 58 stated that she reported this incident to the Nursing Home Administrator who informed her that the facility was looking for another facility to transfer Resident 46. Resident 58 stated that she perceived the action as sexual as, " ...it wasn't no pat." Resident 58 stated that staff position Resident 46 in his wheelchair at the nurse's station; but, " ...he gets out of it and walks." Resident 58 stated that she witnesses Resident 46 outside her room without staff supervision attempting to open the door to the stairwell, which sets off an alarm.

Resident 58's room is located at the very end of the hallway, across the hall from a stairwell door, and five rooms away from Resident 46's room.

Clinical record review for Resident 46 revealed nursing documentation dated November 28, 2019, at 1:38 PM that nurse aides reported to the nurse that a resident stated Resident 46 came in her room and hit her; however, the incident was unwitnessed.

Nursing documentation dated November 28, 2019, at 2:32 PM, stipulated that staff found Resident 46 coming out of other resident's room and stated, "I have to stop that noise." Although Resident 46 insisted he was in bed the whole time and did nothing wrong, staff observed Resident 46 coming out of the other resident's room (there was no indication of which resident room this referred to).

Interview with the Nursing Home Administrator and Director of Nursing on February 26, 2020, at 8:30 AM and 2:00 PM, revealed that the facility had no incident investigation regarding the above alleged physical abuse perpetrated by Resident 46 as reported on November 28, 2019.

Nursing documentation dated December 30, 2019, at 7:27 AM revealed that the writer became aware that Resident 46 made some inappropriate advances towards another resident causing some concerns.

The documentation did not indicate the nature of the inappropriate action (e.g. sexual or physical), who the other resident was, or if staff initiated any interventions to protect the alleged victim at the time of the incident. The documentation noted a phone call to family to make them aware of the incident; however, it did not indicate if it was Resident 46's family or the alleged victim's family.

Social services documentation dated December 30, 2019, at 2:45 PM revealed that the writer met with Resident 46 who stated that he did not have any recollection of the incident that happened over the weekend with another resident.

The documentation did not provide any additional details regarding the "incident."

Resident 46's clinical record contained no progress note documentation dated December 28 (Saturday) or 29 (Sunday), 2020, that indicated a sexually inappropriate resident to resident interaction.

Review of an incident investigation dated December 29, 2019, at 12:33 PM revealed that the writer observed Resident 46 with his hands down Resident 18's shirt. Per the writer of the incident investigation, Resident 46 stated that he was, " ...just having fun."

Review of the electronic reporting system (ERS, an electronic system utilized by nursing care facilities to report incidents to the local field office of the Department of Health) event dated December 29, 2019, at 12:00 PM, revealed that the facility did not note Resident 46's statement that he was, " ...just having fun;" but, indicated that both parties had cognitive deficits (indicating a lack of intent to perpetuate a sexual act). The field office comments to the facility instructed the facility to continue to report inappropriate sexual behavior by Resident 46 and include behavioral patterns within the description information provided.

Nursing documentation dated January 8, 2020, at 4:48 PM revealed that Resident 46 was exhibiting sexually inappropriate behaviors towards staff and visiting family members.

Nursing documentation dated January 9, 2020, at 6:47 PM revealed that Resident 46 was in the dining room with other residents when he attempted to grab another female resident's left breast. It required two attempts by staff to redirect Resident 46 from the action.

Review of an incident investigation dated January 9, 2020, at 6:25 PM revealed that activities staff witnessed Resident 46 grabbing another resident's left breast and continued to try to put his hand up her shirt after being redirected by staff that it was inappropriate. The investigation did not include an identity of the activities staff or a witness statement from the activities staff.

Interview with the Nursing Home Administrator and Director of Nursing on February 26, 2020, at 8:30 AM and 2:00 PM, revealed that the facility did not report the January 9, 2020, incident to the state licensing/certification agency, local law enforcement, the local ombudsman, or the Area Agency on Aging, as required.

Nursing documentation dated January 16, 2020, at 9:10 AM revealed that Resident 46 continued to have inappropriate sexual behaviors and comments to staff and residents. Although staff attempted to redirect Resident 46, staff noted that the redirection was ineffective.

The documentation did not indicate which residents were affected by Resident 46's sexual comments, enough information to evaluate Resident 46's danger to others (possible plan and intent to sexually assault another resident), or measures (e.g. increased supervision or prevent access to female residents) that the facility implemented to ensure Resident 46 did not act upon his comments or continue to subject other residents to verbal and/or sexual abuse.

Interview with the Nursing Home Administrator and Director of Nursing on February 26, 2020, at 8:30 AM and 2:00 PM, revealed that the facility did not report the January 16, 2020, incident to the state licensing/certification agency, local law enforcement, the local ombudsman, or the Area Agency on Aging. The facility did not initiate an incident investigation or obtain pertinent witness statements.

Nursing documentation dated January 16, 2020, at 2:38 PM revealed that Resident 46 continued to have an increase in his behaviors. He continued to call staff and residents names, make inappropriate sexual comments, and seemed agitated. The writer indicated that staff educated Resident 46 that his behaviors would not be tolerated; however, redirection remained ineffective.

Nursing documentation dated January 26, 2020, at 11:42 PM revealed that Resident 46 was exhibiting inappropriate sexual behaviors. Resident 46 stated to several residents and staff members that, " ...he will pull their panties down and give them what they want." The writer indicated that several female residents expressed concern for their safety; stating that they do not feel safe with him and were afraid that he is going to come into their room at night and touch them.

Interview with the Nursing Home Administrator and Director of Nursing on February 26, 2020, at 8:30 AM and 2:00 PM, revealed that the facility did not report the January 26, 2020, incident to the state licensing/certification agency, local law enforcement, the local ombudsman, or the Area Agency on Aging. The facility did not initiate an incident investigation or obtain pertinent witness statements. Information available during the onsite survey did not identify the female residents referred to in the nursing documentation.

Nursing documentation dated January 28, 2020, at 2:52 AM for January 27, 2020, at 10:47 PM, revealed that Resident 46 was, " ...extremely disruptive .... has agitated many residents with his very foul and abusive statements. Sexually inappropriate language used towards staff and female residents. Not able to redirect (Resident 46) with anything. Will continue to monitor behaviors."

Interview with the Nursing Home Administrator and Director of Nursing on February 26, 2020, at 8:30 AM and 2:00 PM, revealed that the facility did not report the January 27, 2020, incident to the state licensing/certification agency, local law enforcement, the local ombudsman, or the Area Agency on Aging. The facility did not initiate an incident investigation or obtain pertinent witness statements. Information available during the onsite survey did not identify the female residents referred to in the nursing documentation. The documentation did not indicate enough information to evaluate Resident 46's danger to others or measures that the facility implemented to ensure Resident 46 did not act upon his comments or continue to subject other residents to verbal and/or sexual abuse.

Documentation from the certified registered nurse practitioner (CRNP) from the facility's consulting behavioral health services provider dated January 28, 2020, commented that Resident 46 had made inappropriate sexual comments to staff and occasionally tried to grab at "staff private parts." The documentation noted Resident 46 had a recent altercation with another resident (Resident 46 had a physical altercation with a male resident on January 18, 2020); however, stipulated that Resident 46 was not a danger to himself or others. The consult documentation did not address Resident 46's history of inappropriately touching female residents or his sexual comments/threats to other female residents, which resulted in their fear of him.

Nursing documentation dated January 29, 2020, at 6:11 PM revealed that Resident 46 was calling staff and residents, "whore and hoes." Resident 46 was insulting family members that were there to visit residents. Although staff attempted to redirect Resident 46, he became more agitated and was "going down the hall and calling residents in there (their) room "whores." The writer indicated that residents were getting upset and asking staff to do something.

Documentation from the CRNP from the facility's consulting behavioral health services provider dated February 4, 2020, noted that Resident 46's symptoms included making threats to other residents and staff; and now assessed him as a potential threat to himself or others (staff and other residents).

Interview with the Nursing Home Administrator and Director of Nursing on February 26, 2020, at 2:00 PM, confirmed that the plan of care developed by the facility to address Resident 46's behaviors did not provide staff instructions on how to deal with Resident 46's behaviors that affect others when redirection is unsuccessful (e.g. notify the physician, ensure no contact with female residents, increased supervision, etc.). The interview confirmed that the plan of care instructed staff to walk away and return later when Resident 46 continues with inappropriate sexual comments (which would not provide other residents any heightened security from his potential behaviors).

Nursing documentation dated February 6, 2020, at 1:20 AM and 3:47 PM, revealed that Resident 46 continued with sexual inappropriate behaviors towards staff and other residents.

Nursing documentation dated February 11, 2020, at 11:45 PM, noted Resident 46's, " ...behavior continues to be out of control as he verbally threatens both staff and multiple other residents. He is sexually inappropriate with many of the female residents and staff, using inappropriate foul language and making derogatory statements and suggestions."

Nursing documentation dated February 18, 2020, at 3:56 PM revealed that Resident 46 was at the nurse's station, making sexually inappropriate comments to staff and other residents. The documentation indicated that staff continued to redirect but offers of food and drink had minimal effect.

Nursing documentation dated February 23, 2020, at 4:16 PM noted that Resident 46 was sexually inappropriate throughout the day with staff and other residents. The writer indicated that multiple attempts at redirection were unsuccessful.

Interview with the Nursing Home Administrator and Director of Nursing on February 26, 2020, at 2:00 PM confirmed that the facility failed to thoroughly investigate, implement interventions to prevent, and report to the appropriate agencies all allegations of potential resident to resident abuse, for the above incidents noted on January 29, 2020, and February 6, 11, 18, and 23, 2020.

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

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services


 Plan of Correction - To be completed: 03/19/2020

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements.

1. Investigation initiated and completed on resident 58 regarding resident 46 touching her left side. Federal and state agencies notified of allegation and investigation.
Cannot correct previously submitted ERS report for resident 18. Incidents of inappropriate touching will be investigated and reported as indicated to federal and state agencies.

Facility Social Service Director and Unit Manager met with Neuropsychologist for education and recommendations for how to manage behaviors such as resident 46's behaviors. Provided with recommendations to decrease stimulation by providing in-room activities. Recommendations have been implemented. Resident 46 was placed on 15-minute checks and close supervision when diversional interventions are not effective. The interdisciplinary team has initiated an individualized behavioral care plan which includes interventions to initiate when resident exhibits any sexual inappropriate statements or actions.

Staff interviews regarding documented incidents on 1.29.20, 2.6.20, 2.18.20, and 02.23.20 were completed by the Director of Nursing and could not validate any acts of sexual abuse or misconduct to residents. The facility was unable to interview the nurse documenting the 02.11.20 event as she no longer works at the facility.

2. Capable female residents residing on unit with resident 46 will be interviewed to determine any incidents and need for further investigation and reporting. Any identified allegations will be investigated and reported to federal and state agencies as required.

3. Interdisciplinary team will be re-inserviced by the DON/Designee on the abuse policy, and reporting and investigating allegations of abuse, and protecting residents from abuse.

4. Random resident interviews will be completed weekly x 2 weeks then monthly to ensure any allegations are reported and investigated. Incident reports will be audited weekly x2 then monthly x2 to ensure any incidents requiring reporting to federal and state agencies are complete. Results will be submitted to QAPI for recommendations.


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