Nursing Investigation Results -

Pennsylvania Department of Health
ST. IGNATIUS NURSING & REHAB CENTER
Patient Care Inspection Results

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ST. IGNATIUS NURSING & REHAB CENTER
Inspection Results For:

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ST. IGNATIUS NURSING & REHAB 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 completed on February 19, 2020, was determined that St. Ignatius Nursing 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(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:


Based on review of a clinical record, facility documentation, facility policy and an interview with the facility staff, it was determined that the facility failed to implement their policies and procedures to prohibit and prevent abuse for one resident of four resident records reviewed (Resident R1).

Findings include:

Review of the facility's policy titled Abuse Reporting and Investigation revised on May 2017 stated, "Any employee who has knowledge or reason to believe that a resident has been a victim of abuse has a duty to immediately report such incident or suspicion to his/her supervisor."

Review of Resident R1 Quarterly Minimum Data Set (a MDS- periodic assessment of needs) dated December 4, 2019 revealed the resident was totally dependent upon two staff members with transfers. The resident's diagnoses included a Cerebrovascular Accident (a stroke), Dementia (mental illness), hemiplegia (weakness to one side of the body) and used a wheelchair for mobility.

Review of the physician's orders dated February 26, 2019 revealed that Resident R1 required a Hoyer lift (mechanical lift) for transfers with at least two people.

Review of the documentation received by the facility dated January 25, 2020 stated that Nursing Assistant (NA) Employee E3 used a mechanical lift without the assistance of an additional staff member.

Review of Resident R1's nursing progress note dated January 25, 2020, at 11:15 p.m. stated, "Resident complaints right arm pain while touch on right arm, slight swelling noted on right elbow area...got an stat (immediate) x-ray order."

Review of Resident R1's nursing progress note dated January 26, 2020, at 1:45 a.m. stated, "Resident's x-ray result obtained, result's conclusion stated: Acute right humeral shaft fracture. On call Dr. (name) notified."

Further review of the facility's documentation revealed three staff witness statements that stated Resident R1 complained to them about Nursing Assistant, Employee E3. The witness statements were as follows:

A written statement dated January 26, 2020 by NA Employee E4 stated that Resident R1 "Expressed the aide was rough on her during her a.m. care. The aide (Employee E3) said that Resident R1 resisting care. When the aide walked away Resident R1 expressed to me that her arm hurts, the aide said she reported (sic) the charge nurse resisting care."

Review of the witness statement dated January 31, 2020 revealed the Nursing Home Administrator (NHA) asked NA, Employee E4 why the NA didn't report Resident R1 yelling out in pain to the charge nurse. The NA responded, 'Because I assumed that her care aide reported it to the charge nurse.' The NHA then asked the NA when the resident stated to you, she hurt my arm and keep her away from me, didn't that trigger anything for you to tell the nurse yourself? The NA responded, 'No, because the nurse was in the vicinity' 'I assumed the nurse heard everything' and 'That's her norm saying that her arm hurts.'

A written statement dated January 26, 2020 by NA Employee E5, stated on January 25, 2020, "Myself and Employee E4 seen Resident R1 upset. I tried calming her down and she keep (sic) saying, she, meaning her aide, hurt her. I said you sure, she said yes, her aide (Employee E3) said that Resident R1 was giving her a hard time." "Resident R1 said no I don't want her, she hurt my arm."

Review of the witness statement dated January 30, 2020 revealed the NHA asked NA, Employee E5 why she didn't report Resident R1 yelling out in pain to the charge nurse and when the resident stated, No I don't want her she hurt my arm and she yelled out loudly when lifting her up her arm. The NA replied, "Because I told Employee E3 she had to report it to the nurse.

A written statement dated January 26, 2020 by the activity assistant Employee E6 stated on January 25, 2020 Resident R1 was brought from her room and yelled out loud that her arm hurt. In the dining room Resident R1 also told me her arm hurt.

Review of the witness statement dated January 30, 2020 revealed the NHA asked NA Employee E6 why she did not report Resident R1's pain. The employee replied, "I thought the nurse's aide (Employee E3) told the Charge Nurse."

The facility failed to implement their policies and procedures to prohibit and prevent abuse for one resident who complained to staff members of an allegation of abuse that caused pain during care. Further facilty staff failed to immediately report the allegation of possible resident abuse to the nursing supervior and/or administration.


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

28 Pa.Code 211.10(d) Resident care policies








 Plan of Correction - To be completed: 02/12/2020

For R1, the care nurse who provided direct care to the resident resigned. The other staff who failed to report what was reported to them by R1 have been re-inserviced on reporting behaviors such as yelling out, stating someone is harming a person, and reporting suspected resident abuse.

No other residents have been identified as being affected by the same deficient practice. The staff member directly involved no longer works at the facility. All staff in the facility have been re-inserviced on reporting behaviors such as yelling out, stating someone is harming a person, and reporting suspected resident abuse.

Staff have been informed that they must immediately report any behavior that could be considered abuse or neglect

Facility managers will continue to reinforce with staff the importance of timely reporting of any behavior that could be considered abuse or neglect and will follow up with the Administrator and Director of Nursing to ensure that any incidents reported to the managers have also been reported to the Administrator and Director of Nursing.


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on review of clinical records, review of facility policies, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect while receiving care and being transfer via mechanical lift for one of four residents reviewed. (Resident R1)

Findings include:

Review of the facility's policy titled, Abuse Reporting and Investigations revised on May 2017, stated the residents have the right to be free from abuse and neglect. Employees must immediately report any incident or suspected incident of resident abuse/neglect. It further defines resident abuse as failure to provide goods and services necessary to avoid physical harm or abuse resulting in physical harm or pain.

Review of the facility's policy titled Mechanical Lift revised on March 2017 stated, "Never operate the Mechanical Lift alone. At least two staff members should be present when transferring a resident with a mechanical lift."

Review of Resident R1's quarterly Minimum Data Set (a MDS- periodic assessment of needs) assessment dated December 4, 2019, revealed the resident diagnoses of Cerebrovascular Accident (CVA, a stroke), Dementia (mental illness), hemiplegic (weakness to one side of the body). Further review of the MDS identified the resident with severe cognitive impairment. The resident was assessed as required total dependence of two staff members with transfers and no ambulatory capabilities.

Review of the physician's orders dated May 23, 2019, revealed an order for a right T-bar hand splint due to the resident's right hand contracture. Review of the resident's care plan dated June 16, 2019 developed for alterations in comfort and pain related to the resident's right hemiparesis and right-hand contracture was to monitor for both verbal and nonverbal signs of pain: crying, moaning, guarding, withdrawal or changes in mood.

Review of physician's orders dated February 26, 2019-January 26, 2020, revealed an orders for Hoyer lift (mechanical lift) for transfers. Transfer with at least two person as per policy.

Review of the resident's care plan dated June 19, 2019, identifed the resident with alterations in activities in daily living related to Resident R1's diagnoses of CVA, hemiparesis and right-hand contracture. Interventions included to maintain paired care (two staff members) at all times.

Review of Resident R1's nursing progress note dated January 25, 2020, at 11:15 p.m. stated, "Resident complaints right arm pain while touch on right arm, slight swelling noted on right elbow area...got an stat (immediate) x-ray order."

Review of Resident R1's nursing progress note dated January 25, 2020, at 11:55 p.m. stated, "Resident complains of right arm pain, resident state (sic) the pain level 10/10. Pain to touch elbow area. No redness, no edema noted."

Review of Resident R1's nursing progress note dated January 26, 2020, at 1:45 a.m. stated, "Resident's x-ray result obtained, result's conclusion stated: Acute right humeral shaft fracture. On call Dr. (name) notified."

Review of Resident R1's radiology results, dated January 25, 2020, stated an acute spiral fracture (occurs when the bone is torn in half by twisting or grabbing) involving the mid humeral shaft, extending proximally to the neck of the right humerus (middle section of the upper arm) with mild displacement (where the bone fragments of the shaft do not line up).

Review of the facility's investigation, dated of the incident, January 25, 2020, stated when nursing touched the resident's right arm, "She would yell in pain." It indicated that the resident was "Holding contracted right arm, elbow area." The facility's documentation further revealed "Resident R1 had expressed [Employee E3] was rough with her, mean to her, as she shared this with two aides and one activity assistant. [Employee E3] did not report anything to the charge nurse even though the resident stated she hurt me to the NA."

Review of the interview that occurred between the Nursing Home Administrator (NHA) and Employee E3 dated, January 27, 2020, revealed Nursing Assistant, Employee E3 indicated she washed and dressed Resident R1 during morning care. The NA stated the resident, "Became combative in bed when I was doing her personal care." The NHA asked if the resident told her she was hurting her, and the NA replied "Yes". The NA was asked if she asked staff to help her with the Hoyer lift and bathing, the NA stated, "I didn't ask anybody". Employee E3 stated, "I did hear her tell the girl in recreation she did not like the girl who got her up." At the end of the interview, the NA admitted "I should have gotten help and should not have gotten her up".

An interview conducted on, February 19, 2020, at 11:55 a.m. with the recreation assistant, Employee E6. stated, "I was in the dining room when I saw [Employee E3] and two other NAs reposition her in her wheelchair. I heard her holler, 'My arm!'. "Resident R1 was brought over to the table and told me her arm hurt. I told [Employee E3], but she looked at me and turned away. It's not normal for her to complain of pain. Later that day during activities she sat with her arms folded and was unusually quiet."

An interview conducted on, February 19, 2020, at 12:00 p.m. with nursing assistant, Employee E4 stated, "The first time I saw [Resident R1] was in the doorway by the dining room. I noticed the seat cushion was not properly positioned; it wasn't under her. I asked another co-worker to help me re-position her. Before we touched her, she started saying her arm hurt and that [Employee E3] was rough. I told Employee E3 what the resident said, and she said that the resident gave her a hard time getting ready. I told the NA to tell the nurse her arm hurt, and that she said she was rough."

An interview conducted on, February 19, 2020, at 12:34 p.m. with nursing assistant, Employee E5 stated, "The first time I saw [Resident R1] that day was in the hallway by the dining room. The resident kept saying her arm hurt, 'She hurt my arm.' Then [Employee E3] walked to the front of [Resident R1's] wheelchair where she saw her and stated, 'There she is!' I told [Employee E3] to tell the nurse. The NA told me she gave her a hard time. It's normal for [Resident R1] to be combative during care if she doesn't know the NA or she is in her mood. She will push back on you, lock her legs or start swinging with her good arm."

During an interview on February 18, 2020, at 4:06 p.m. NA, Employee E7 stated, "I took care of [Resident R1] that night. When I started getting [Resident R1] ready for bed she cried out in pain. I did not touch her I went and got a nurse."

Review of the documentation received by the facility dated January 25, 2020, stated that nursing assistant (NA) Employee E3, "Lifted the resident in the lift, without the assistance of an additional caregiver." The documentation further stated, "The facility substantiated the act of neglect."

The facility failed ensure that Resident R1 was free from neglect while receiving care and being transfer via mechanical lift.

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

28 Pa. Code 211.19(d) Resident care policies

28 Pa. Code 211.11(b) Resident care plan

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

28 Pa. Code 211.12(5) Nursing services
































 Plan of Correction - To be completed: 04/19/2020

Resident R1 did not return to the facility following hospitalization for the injury.

Residents that are paired care and require two caregivers for transfers will be identified via physician orders and the 24-hour report.

Residents that are paired care or require Hoyer lift transfers will be listed on the 24-hour report to assure communication to staff from shift to shift.

The Unit Manager or their designee will audit 24-hour reports for compliance. Results will be reported to and reviewed by the Performance Improvement (PI) team monthly for three months and afterwards as needed.
483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training: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.
483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12.

483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

483.95(c)(3) Dementia management and resident abuse prevention.
Observations:

Based on review facility policy and procedures, interview with facility staff, and review of personnel files, it was determined the facility failed to ensure that the annual abuse training was completed for one of five employees reviewed. (Employee E6).

Findings include:

Review of the facility's policy titled Abuse Reporting and Investigation revised on May 2017 stated, mandated staff training programs which include topics as abuse prevention, identification and reporting of abuse.

Review of activity assistant, Employee E6's personnel file rvealed no evidence of 2019 annual abuse training.

Interview with the Nursing Home Administrator on February 5, 2020 at approximately 3:00 p.m. revealed that activity assistant, Employee E6 failed to meet her 2019 abuse training because she was on a leave of absence from February 6, 2019 to April 12, 2019.

and the facility failed to ensure the annual abuse training was completed upon her return.

The facility failed to ensure that Employee E6 completed the annual abuse training upon return from a leave of absence.

Pa. Code: 201.14(a) Responsibility of Licensee

Pa. Code: 201.19 Personnel Policies and Procedures

Pa. Code: 201.20(a) Staff Development

Pa. Code: 201.20(b) Staff Development

Pa. Code: 201.20(c)Staff Development

Pa. Code: 201.20(d) Staff Development







 Plan of Correction - To be completed: 04/19/2020

For Resident R1, E6 was re-inserviced on abuse training.

Personnel files will be audited by the Director of Human Resources to ensure that employees have received annual abuse training. Any employee who has not received their annual abuse training will be re-inserviced immediately.

Annual abuse training lists will be updated by the Staff Development Coordinator according to the hire date of the employee to ensure that training is occurring at least annually.

The Director of Human Resources will review the abuse training lists for compliance. Results will be reported to and reviewed by the Performance Improvement (PI) team monthly for three months and afterwards as needed.

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