Nursing Investigation Results -

Pennsylvania Department of Health
MAYBROOK HILLS REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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MAYBROOK HILLS REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

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MAYBROOK HILLS REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a complaint survey completed on June 9, 2022, it was determined that Maybrook Hills Rehabilitation and Healthcare 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(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;
Observations:


Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of six residents reviewed (Resident 1).

Findings include:

The facility's abuse policy, dated June 1, 2021, indicated that every resident has the right to be free from mistreatment, neglect, abuse, exploitation, and misappropriation of property. This is a Zero Tolerance policy and will be strictly enforced.

A comprehensive admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 20, 2022, indicated that the resident was cognitively intact, had physical and verbal behaviors one to three days of the seven-day look-back period, required the assistance of staff with transfers, it was very important for her to choose her own bedtime and to take care of her personal belongings, and had diagnoses that included dementia (decline in mental ability severe enough to interfere with daily life).

Facility investigation documents, dated April 29, 2022, revealed that on April 28, 2022, at approximately 7:30 p.m. Resident 1 was interacting with other residents and staff on her unit and was propelling herself down the hallway to look out the glass window on the door to the activity/dining room. At that time Nurse Aide 1 stepped in front of Resident 1 blocking her path and sat down on the floor preventing the resident from continuing towards the door. The resident attempted to propel her wheelchair around Nurse Aide 1 but was stopped when Nurse Aide 1 put her left hand on top of the resident's hand preventing her from moving while placing her right hand on the wheel and brake of the chair to keep it from moving. The resident became visibly upset and was observed crying as Nurse Aide 1 informed Resident 1 that she must turn around and go to bed (it was 7:30 p.m.). The resident continued to resist, and Nurse Aide 1 went to the rear of the resident's wheelchair, lifted the front of the wheelchair slightly into the air, while the resident kicked her legs back and forth and cried. Licensed Practical Nurse 2 then came over and told Resident 1 that she needed to go to bed, and assisted Nurse Aide 1 to force Resident 1 to get into her room. Nurse Aide 1 and Licensed Practical Nurse 2 held down Resident 1's arm and pushed her wheelchair down the hall without using leg rests and forced her into her room. They placed Resident 1 in her room and put a stop sign barrier across her door. Licensed Practical Nurse 2 then stood in Resident 1's doorway to prevent her from exiting her room. Nurse Aide 1 then pushed Resident 1's wheelchair backwards into her room and placed her into bed.

An interview with Resident 1 on April 29, 2022, at 5:30 p.m. revealed that staff made her go to her room when she just wanted to look out the door. She further stated that she put her feet over the edge of her bed and put herself on the floor of her room because she did not want to be in bed. Resident 1 was tearful during the interview and stated that two girls were mean to her and made her go to her room when she just wanted to look out the door.

A witness statement by Housekeeper 3, dated April 29, 2022, revealed that Resident 1's hands gripped the wheelchair wheels so tightly that they could not move them and that Nurse Aide 1 and Licensed Practical Nurse 2 pried her hands from the chair while yelling at her the entire way to her room.

A witness statement by Housekeeper 4, dated April 29, 2022, revealed that Resident 1 was near the nurse's station and Licensed Practical Nurse 2 tried to take the resident back to her room and pried her hands from her wheelchair and yelled at her the whole way to her room.

A written statement from Nurse Aide 1, dated April 30, 2022, at 11:33 a.m. revealed that Licensed Practical Nurse 2 told her to put Resident 1 in her room and the resident was resisting. Therefore, Nurse Aide 1 and Licensed Practical Nurse 2 worked together to put Resident 1 in her room, even though she was screaming and did not want to be in there. Nurse Aide 1 stated that Resident 1 was yelling that she wanted to go to the hospital. Nurse Aide 1 said that about an hour later they attempted to transfer Resident 1 into her bed and she was still upset and was physically aggressive to the staff at that time. Nurse Aide 1 confirmed that she had been educated regarding resident rights and the right to be free from abuse and stated "yes, most definitely, I know that I was following what my Licensed Practical Nurse told me to do."

A written statement from Licensed Practical Nurse 2, dated April 30, 2022, at 12:13 p.m. revealed that she was told that on the evening of the incident Resident 1 was attempting to hit and kick another resident and that Nurse Aide 1 was trying to calm her down. She stated that Resident 1 was attempting to go into an activity room where the floor was being waxed and Nurse Aide 1 attempted to stop her. When Nurse Aide 1 was unable to redirect the resident she grabbed her hands to move the wheelchair around. She further stated that she did grab both of Resident 1's hands to get the wheelchair turned around and then took her to her room. She indicated that Resident 1 bit her arm while she was trying to help Nurse Aide 1 get her into her bed.

Interview with the Director of Nursing on June 9, 2022, at 12:42 p.m. confirmed that Nurse Aide 1 and Licensed Practical Nurse 2 were terminated for forcing Resident 1 into her room and into her bed when she did not want to be in there.

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

28 Pa. Code 201.14(a) Responsibility of licensee.

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

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

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 201.29(j) Resident rights.

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





 Plan of Correction - To be completed: 07/06/2022

Certified Nursing Assistant and Licensed Practical Nurse were both immediately suspended and subsequently terminated.
All residents have the potential to be affected by the alleged deficient practice.
Assistant Administrator interviewed alert and oriented residents who were cared for by the two alleged staff members.
Approved Directed Inservice will be completed for facility staff including agency currently being used.
Facility staff including agency will be re-educated on the abuse policy.
Education will continue to be provided to new staff including agency during orientation regarding facility abuse policy.
Assistant Administrator will complete routine visits with residents to ensure resident satisfaction and that they are free from abuse, neglect, and exploitation.
Director of Nursing or designee will conduct random interviews to ensure residents are free from abuse, neglect and exploitation weekly x 4 and monthly x 3. Findings will be reviewed by the Quality Assurance Performance Improvement Committee during monthly meetings x 3 months or until substantial compliance.



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