Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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HOMEWOOD AT MARTINSBURG, PA, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an incident survey completed on October 14, 2021, it was determined that Homewood at Martinsburg, PA, Inc. 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(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
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 clinical records and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect, by failing to follow a resident's care plan while providing care for one of two residents reviewed (Resident 1), resulting in harm due to a fall from the bed with a fracture. This deficiency was cited as past non-compliance.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 24, 2021, revealed that the resident had severe cognitive impairment; had impaired hearing; required the extensive assistance of two staff for bed mobility, transfers and toilet use; and had a history of falls. The resident's care plan, dated February 27, 2019, indicated that she had a potential for falls related to confusion and poor mobility.

A fall report for Resident 1, dated July 10, 2021, at 6:25 a.m. revealed that staff was providing incontinent care when the resident rolled off the right side of her bed. A hematoma (collection of blood under the skin) was noted to left side of her head. A statement by Nurse Aide 1, dated July 10, 2021, revealed that while doing morning care for Resident 1, the resident fell off the bed. The nurse aide indicated that she rolled the resident toward her to change her, and she thought she had the resident well braced. The resident's weight shifted and the nurse aide was not able to catch/roll her back in time. Nursing notes for Resident 1, dated July 10, 2021, revealed that during a fall that morning, the resident bumped her head on the nightstand and had bruising and a small open area to the head.

Resident 1's fall risk care plan was updated on July 10, 2021, to include that the resident required the assistance of two staff for incontinent care, and staff were educated to have two people assist with incontinent care to prevent such an incident from happening in the future.

A fall report for Resident 1, dated September 22, 2021, at 7:50 a.m. revealed that the resident had a fall in her room. Nurse Aide 2 was providing morning care to the resident and rolled her onto her left side. The nurse aide took her hand away from the resident for a second when reaching for a wash cloth, and the resident rolled forward off the side of the bed before the nurse aide could reach her.

A statement by Nurse Aide 2, dated September 22, 2021, at 7:50 a.m. revealed that she was providing morning care for Resident 1 and rolled her onto her side. She was reaching for the wash cloth and the resident rolled out of bed.

A nursing note for Resident 1, dated September 22, 2021, at 11:04 a.m., and marked as a late entry for 7:50 a.m., revealed that the resident was lying on her right side between her bed and the wall with a pillow under her head. A nurse aide reported that while she was providing care to the resident, and had her rolled onto her left side, she took her hand off the resident for a second to reach the a wash cloth that was out of reach. The resident rolled forward, fell out of the bed, and landed on her right side before she could reach her. The resident complained of right shoulder pain. The physician was updated and gave orders for x-rays of the resident's right shoulder and arm.

An x-ray report for Resident 1, dated September 22, 2021, at 11:31 p.m. revealed an acute displaced fracture (a bone break in which two ends of a fractured bone are separated and out of their normal positions) mid-shaft of the right clavicle (collarbone).

A reenactment of the incident by Nurse Aide 2 on September 22, 2021, revealed that she pulled Resident 1 to the resident's right side of the bed and positioned her on her left side, in the middle of bed. Nurse Aide 1 rolled the resident away from her to perform morning care to the resident's back, and stated that she left the resident's legs on top of each other. Nurse Aide 2 stated her supplies were at the foot of the bed at the level of the resident's knees to ankle. Nurse Aide 2 demonstrated that she removed her hand from the resident's hip to turn and reach for the supplies at the end of the bed. When she reached for the supplies, the resident fell face first onto the edge of the bed and rolled out onto floor. Nurse Aide 2 denied having the resident's top knee bent or having her hand positioned on the bed to prevent the resident from rolling.

An investigation follow-up for Resident 1, dated September 30, 2021, revealed that on September 29, 2021, during a review of incident reports, the facility identified a similar incident for Resident 1 in July, 2021. Her care plan was updated at that time to include that two staff persons were necessary while providing care to the resident in bed. Nurse Aide 2 was re-interviewed and stated that she did not review Resident 1's care plan and was not aware of changes.

An employee statement by Nurse Aide 2 on September 29, 2021, confirmed that she did not review Resident 1's care plan prior to providing care and was not aware that two staff persons were required while providing care in bed.

Interview with the Director of Nursing on October 14, 2021, at 9:30 a.m. confirmed that Resident 1 should have had two staff present while care was provided in bed on September 22, 2021.

Following the incident on September 22, 2021, the facility's corrective actions included:

On September 28, 2021, the facility's policy regarding identification of a resident's assistance level was changed. The registered nurse completing a new resident admission was to identify residents who required the assistance of two staff with bed mobility, which was to be documented in the resident's care plan and the facility's electronic care record system. The therapy department was to evaluate all new residents on admission to establish the resident's bed mobility requirements. Residents were to be reevaluated quarterly, upon request, or with a decline in condition. Two hands were to be placed on the resident's door by therapy staff if the resident required the assistance of two with bed mobility. Bed mobility was to be documented in the care plan and the electronic care records by therapy or nursing staff. Education regarding this system was to be included in new hire orientation.

On September 29, 2021, staff education was initiated regarding accident hazards, abuse, neglect, resident assistance level, repositioning and bed mobility. Review of the facility's education sign-in sheets revealed that 98 percent of the staff education was completed as of October 3, 2021.

Interviews on October 14, 2021, with Nurse Aide 3 at 1:33 p.m., Nurse Aide 4 at 1:51 p.m., Nurse Aide 5 at 2:13 p.m., and Licensed Practical Nurse 6 at 2:15 p.m. confirmed that they were aware that they had to check a resident's care plan prior to care, and if there were two hands located on the resident's door, this indicated the need for assistance from two staff with care.

The facility's daily audit sheets for October 4, 5, 6, 7 and 8, 2021, revealed that new residents and current residents with a change in condition were assessed by therapy staff, their assistance levels were placed on the residents' doors, and care plans and electronic care documents were updated appropriately. A plan was developed on September 29, 2021, to do weekly audits for four weeks, then monthly audits for two months. The results of the audits were to be discussed during the monthly Quality Assurance meeting.

42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition.

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

 Plan of Correction - To be completed: 11/01/2021

Past noncompliance: no plan of correction required.

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