Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-POTTSVILLE
Patient Care Inspection Results

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MANORCARE HEALTH SERVICES-POTTSVILLE
Inspection Results For:

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MANORCARE HEALTH SERVICES-POTTSVILLE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on October 1, 2019, it was determined that Manorcare Health Services-Pottsville 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(a)(1) REQUIREMENT Free from Abuse and Neglect: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 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;
Observations:

Based on a review of clinical records and select investigative reports and staff interviews it was determined that the facility failed to prevent verbal and/or physical abuse of three residents out of six sampled (Residents 42, CR1 and 48) perpetrated by another resident (Resident 84).

Findings included:

A review of the facility's patient protection, abuse, neglect, exploitation, mistreatment and misappropriation prevention policy, dated as reviewed by the facility August 21, 2019, revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

A review of the clinical record of Resident 84 revealed that the resident had diagnoses to include a traumatic brain injury and dementia. Further review of the resident's clinical record revealed that Resident 84 had a history of physical altercations with other residents in the facility.

A review of a quarterly Minimum Data Set assessment (MDS, - a federally mandated standardized assessment process completed periodically to plan resident care) dated July 24, 2019, revealed that Resident 84 was severely cognitively impaired with a BIMS score of 4 (brief interview for mental status - a tool to assess cognitive function - a score of 0-7 indicates severe cognitive impairment) and was independent with activities of daily living, including ambulation.

A review of the resident's plan of care, initiated November 28, 2018, and revised May 6, 2019, revealed a problem of the resident's history of unsettled relationships/conflicts as evidenced by striking other residents behaviors/verbalizations. The identified goals was for the resident to demonstrate improvements in relationships with planned interventions of ensuring that the resident has his room door closed when target resident is in the dining room for activities or meals.

The resident's plan of care also included the problem of cognitive loss as evidenced by confusion, anxiety and disorientation related to closed head injury, behaviors, dementia with depressed mood and behavioral disturbance revised on October 19, 2014. The identified goal was that the resident would display appropriate response to situation with interventions planned for medication administration and approaching this resident in a calm manner.

The resident's current plan of care, reviewed during the survey ending October 1, 2019, did not specifically identify the resident's current, ongoing, physically aggressive behaviors towards other facility residents.

A review of facility incident and accident investigation report dated September 10, 2018 at 10 AM revealed that Resident 84 entered the resident dining room (Resident 84's room at the facility was located directly across the hall from the first floor resident dining room. Resident 84 ate all his meals in his room) and walked up to Resident CR1 using profanity. Resident 84 then hit Resident CR1 in the face. The report indicated that staff separated the two residents and redirected Resident 84 back to his room.

A review of nursing documentation dated September 10, 2018, at 10:45 AM revealed that Resident CR1 was in the first floor resident dining room after breakfast. Staff in the dining room at that time noted that he was yelling, as per his usual behavior. Resident 84 entered the room, using profanities directed towards Resident CR1 and then hit him in the face. Staff intervened and separated the residents.

Additional nursing documentation dated September 10, 2018, at 12:46 PM indicated that nursing staff assessed Resident 84 after he had initiated a verbal and physical altercation with Resident CR1. Resident 84 refused to cooperate with the nursing assessment. The facility updated the resident's plan of care at that time to include shutting the door to Resident 84's room as per his request. Resident 84 denied any physical contact with Resident CR1 and stated "he's a retard," referring to Resident CR1.

A review of facility incident and accident investigation report dated November 25, 2018, at 12:30 PM revealed that Resident 42, a cognitively impaired resident, had been seated in the first floor resident dining room and was yelling out. Resident 84 approached Resident 42 and slapped Resident 42 with an open hand. The body area hit was not identified in the report or in the nursing documentation. Both residents were separated. The noted intervention was again to shut Resident 84's room door during mealtimes.

A review of a facility incident investigation report and a Pennsylvania Department of Health PB-22 report form for investigation of alleged abuse, neglect and misappropriation of property dated July 25, 2019, at 6 PM revealed that Resident 48, a cognitively intact resident was seated in the first floor dining room doorway, talking to himself. Resident 84 walked up to Resident 48, grabbed his shirt and yelled "shut up, shut up." The report noted that Resident 48 had not immediately informed staff of the incident and the report findings indicated that there was no witness to the event. However, Resident 84 had reported the event to his nursing assistant at bedtime the evening of the event.

A review of a witness statement dated July 25, 2019, no time indicated, noted that Resident 48 stated that "around 6 PM, I was sitting in the first floor dining room, talking with another resident and watching TV. Then Resident 84 came over to me, grabbed the front of my shirt and started pulling me saying , shut up, shut up. I was just shaking my head. I didn't say anything back to him. Then he left."

The facility planned intervention was again to close Resident 84's room door during times of activities, as he allows.

A review of a facility incident investigation report and a Pennsylvania Department of Health PB-22 report form for investigation of alleged abuse, neglect and misappropriation of property
dated July 29, 2019 at 5:30 PM revealed that Resident 48 was in the first floor dining room eating dinner and conversing with peers when Resident 84 entered the dining room and slapped Resident 48 on the right cheek and again on the resident's back. This incident was witnessed by other residents in the dining room at that time. Immediately following the altercation, Resident 84 turned and rapidly exited the dining room. Upon exiting, he was stopped by Employee 1, nurse aide. Employee 1 asked Resident 84, "what did you do?" Resident 84 replied "I had to shut his f-----g mouth." Employee 1 told Resident 84 to please leave the dining room and return to his dinner meal that was served in his room.

The summary of the information contained in this facility's report revealed that Resident 84 has had a prior altercation with Resident 48, telling him to shut up. The facility identified that Resident 48 seems to be a target for Resident 84 and that Resident 48 seems to escalate Resident 84's behaviors. The prior intervention was to encourage Resident 84 to close his bedroom door when activities or dining is ongoing in the dining/activity room.

Both above abuse reports indicated that the facility will continue the prior intervention of closing Resident 84's room door in times of activities in the first floor dining room. Additional interventions added following the July 29, 2019, abuse included nursing charting for Resident 84's cooperation with staff closing his door during times of activity in the resident dining room and a request for the contract psychiatric services to see the resident to assist in behavior modification. Additionally, Resident 48 was offered a room change. The facility noted that should Resident 84 refuse to allow his room door to be closed when Resident 48 is in the dining room for meals and activities, Resident 48 will have a staff member with him for one to one observation during these times.

A review of a facility incident investigation report and a Pennsylvania Department of Health PB-22 report form for investigation of alleged abuse, neglect and misappropriation of property
dated August 20, 2019, at 7 PM revealed that Resident 48 was in the first floor hallway talking to another resident's family when Resident 84 came out of his room into the hallway, called Resident 48 an "asshole" and struck Resident 48 in the head.

The residents were separated. The residents' physician and the responsible parties were notified and Resident 84 was moved from the first floor to the third floor. Additionally Resident 84 was placed on every 15 minute checks for 24 hours at this time

During an interview October 1, 2019 at 11 AM, Employee 2, Licensed Practical Nurse (LPN) stated that Resident 84's current room is the third floor is away from the dining/activity areas. Employee 2 confirmed that he has not had any physical altercations since he was transferred to the third floor following the incident on August 20, 2019.

The facility repeatedly failed to protect residents from physical and verbal abuse perpetrated by Resident 84. The facility was aware that the actions and behaviors of select residents and activities in the dining room were triggers for Resident 84's aggressive behaviors. The facility identified that Resident 48 was a particular target for Resident 84 and was the victim of multiple instances of abuse perpetrated by Resident 84. However, the facility failed to timely implement sufficient measures to protect residents from abuse and mistreatment by Resident 84.



28 Pa. Code 201.18 (e)(1) Management
previously cited 5/10/19

28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services
previously cited 5/10/19, 6/14/19

28 Pa. Code 201.29 (c)(d) Resident Rights
previously cited 5/10/19, 6/14/19










 Plan of Correction - To be completed: 10/24/2019

1) R 84 has moved to another floor. R 42 and R 48 have had no incidents of resident to resident altercation.
2) New admissions and current residents have potential to be affected by the deficient practice.Using the behavior QAPI tool, interdisciplinary team will review new admissions and current residents with incidents of physical and/or verbal abuse for appropriate and timely interventions.
3) To ensure the deficient practice does not recur, current employees will be educated on Abuse Focus on Ftag 600 and behavioral practice guide by DON/designee.
4) Using behavior QAPI tool, NHA/designee will conduct random audits weekly X 4 weeks. Trends will be reported to QAA committee.
483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:

Based on observation, a review of clinical records, investigative reports and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of six residents (Resident 84 ).

Findings include:


A review of the clinical record of Resident 84 revealed that the resident had diagnoses to include a traumatic brain injury and dementia. Further review of the resident's clinical record revealed that Resident 84 had a history of physical altercations with other residents in the facility.

A review of a quarterly Minimum Data Set assessment (MDS, - a federally mandated standardized assessment process completed periodically to plan resident care) dated July 24, 2019, revealed that Resident 84 was severely cognitively impaired with a BIMS score of 4 (brief interview for mental status - a tool to assess cognitive function - a score of 0-7 indicates severe cognitive impairment) and was independent with activities of daily living, including ambulation.

A review of the resident's plan of care, initiated November 28, 2018, and revised May 6, 2019, revealed a problem of the resident's history of unsettled relationships/conflicts as evidenced by striking other residents behaviors/verbalizations. The identified goals was for the resident to demonstrate improvements in relationships with planned interventions of ensuring that the resident has his room door closed when target resident is in the dining room for activities or meals.

The resident's plan of care also included the problem of cognitive loss as evidenced by confusion, anxiety and disorientation related to closed head injury, behaviors, dementia with depressed mood and behavioral disturbance revised on October 19, 2014. The identified goal was that the resident would display appropriate response to situation with interventions planned for medication administration and approaching this resident in a calm manner.

The resident's current plan of care, reviewed during the survey ending October 1, 2019, did not specifically identify the resident's current, ongoing, physically aggressive behaviors towards other facility residents.

A review of facility incident and accident investigation report dated September 10, 2018 at 10 AM revealed that Resident 84 entered the resident dining room (Resident 84's room at the facility was located directly across the hall from the first floor resident dining room. Resident 84 ate all his meals in his room) and walked up to Resident CR1 using profanity. Resident 84 then hit Resident CR1 in the face. The report indicated that staff separated the two residents and redirected Resident 84 back to his room.

A review of nursing documentation dated September 10, 2018, at 10:45 AM revealed that Resident CR1 was in the first floor resident dining room after breakfast. Staff in the dining room at that time noted that he was yelling, as per his usual behavior. Resident 84 entered the room, using profanities directed towards Resident CR1 and then hit him in the face. Staff intervened and separated the residents.

Additional nursing documentation dated September 10, 2018, at 12:46 PM indicated that nursing staff assessed Resident 84 after he had initiated a verbal and physical altercation with Resident CR1. Resident 84 refused to cooperate with the nursing assessment. The facility updated the resident's plan of care at that time to include shutting the door to Resident 84's room as per his request. Resident 84 denied any physical contact with Resident CR1 and stated "he's a retard," referring to Resident CR1.

A review of facility incident and accident investigation report dated November 25, 2018, at 12:30 PM revealed that Resident 42, a cognitively impaired resident, had been seated in the first floor resident dining room and was yelling out. Resident 84 approached Resident 42 and slapped Resident 42 with an open hand. The body area hit was not identified in the report or in the nursing documentation. Both residents were separated. The noted intervention was again to shut Resident 84's room door during mealtimes.

A review of a facility incident investigation report and a Pennsylvania Department of Health PB-22 report form for investigation of alleged abuse, neglect and misappropriation of property dated July 25, 2019, at 6 PM revealed that Resident 48, a cognitively intact resident was seated in the first floor dining room doorway, talking to himself. Resident 84 walked up to Resident 48, grabbed his shirt and yelled "shut up, shut up." The report noted that Resident 48 had not immediately informed staff of the incident and the report findings indicated that there was no witness to the event. However, Resident 84 had reported the event to his nursing assistant at bedtime the evening of the event.

A review of a witness statement dated July 25, 2019, no time indicated, noted that Resident 48 stated that "around 6 PM, I was sitting in the first floor dining room, talking with another resident and watching TV. Then Resident 84 came over to me, grabbed the front of my shirt and started pulling me saying , shut up, shut up. I was just shaking my head. I didn't say anything back to him. Then he left."

The facility planned intervention was again to close Resident 84's room door during times of activities, as he allows.

A review of a facility incident investigation report and a Pennsylvania Department of Health PB-22 report form for investigation of alleged abuse, neglect and misappropriation of property
dated July 29, 2019 at 5:30 PM revealed that Resident 48 was in the first floor dining room eating dinner and conversing with peers when Resident 84 entered the dining room and slapped Resident 48 on the right cheek and again on the resident's back. This incident was witnessed by other residents in the dining room at that time. Immediately following the altercation, Resident 84 turned and rapidly exited the dining room. Upon exiting, he was stopped by Employee 1, nurse aide. Employee 1 asked Resident 84, "what did you do?" Resident 84 replied "I had to shut his f-----g mouth." Employee 1 told Resident 84 to please leave the dining room and return to his dinner meal that was served in his room.

The summary of the information contained in this facility's report revealed that Resident 84 has had a prior altercation with Resident 48, telling him to shut up. The facility identified that Resident 48 seems to be a target for Resident 84 and that Resident 48 seems to escalate Resident 84's behaviors. The prior intervention was to encourage Resident 84 to close his bedroom door when activities or dining is ongoing in the dining/activity room.

Both above abuse reports indicated that the facility will continue the prior intervention of closing Resident 84's room door in times of activities in the first floor dining room. Additional interventions added following the July 29, 2019, abuse included nursing charting for Resident 84's cooperation with staff closing his door during times of activity in the resident dining room and a request for the contract psychiatric services to see the resident to assist in behavior modification. Additionally, Resident 48 was offered a room change. The facility noted that should Resident 84 refuse to allow his room door to be closed when Resident 48 is in the dining room for meals and activities, Resident 48 will have a staff member with him for one to one observation during these times.

A review of a facility incident investigation report and a Pennsylvania Department of Health PB-22 report form for investigation of alleged abuse, neglect and misappropriation of property
dated August 20, 2019, at 7 PM revealed that Resident 48 was in the first floor hallway talking to another resident's family when Resident 84 came out of his room into the hallway, called Resident 48 an "asshole" and struck Resident 48 in the head.

The residents were separated. The residents' physician and the responsible parties were notified and Resident 84 was moved from the first floor to the third floor. Additionally Resident 84 was placed on every 15 minute checks for 24 hours at this time

During an interview October 1, 2019 at 11 AM, Employee 2, Licensed Practical Nurse (LPN) stated that Resident 84's current room is the third floor is away from the dining/activity areas. Employee 2 confirmed that he has not had any physical altercations since he was transferred to the third floor following the incident on August 20, 2019.

The facility was aware that the actions and behaviors of select residents and activities in the dining room were triggers for Resident 84's aggressive behaviors. The facility identified that Resident 48 was a particular target for Resident 84 and was the victim of multiple instances of abuse perpetrated by Resident 84. However, the facility failed to timely act upon these identified triggers and develop and implement a person-centered plan to address, deter and/or modify Resident 84's dementia-related symptoms.

During an interview with the Nursing Home Administrator on October 1, 2019, at 12 PM, the Nursing Home Administrator confirmed that the facility failed to timely develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms to protect residents from Resident 84's abusive behaviors and to promote Resident 84's psychosocial well-being and functioning. .


Refer F600


28 Pa. Code 201.18(e)(1) Management
previously cited 5/10/19

28 Pa. Code 211.11(d) Resident care plan






 Plan of Correction - To be completed: 10/24/2019

1)R 84's care plan has been reviewed by IDT and adjusted as warranted for behavior interventions.
2) New admissions and current residents have potential to be affected by deficient practice. Using the Behavior QAPI tool, IDT team will review new admissions and current residents for individualized, person centered care plans for dementia related behavior symptoms.
3) To ensure deficient practice does not recur, current employees will be educated on Focus on Ftag 744 treatment/services for dementia and Ftag 656 develop and implement comprehensive care plan by SS/designee.
4) Using care planning QAPI tool, SS/designee will conduct random audits weekly X 4 weeks. Trends to be reported to QAA committee.

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