Pennsylvania Department of Health
DUBOIS NURSING HOME
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
DUBOIS NURSING HOME
Inspection Results For:

There are  87 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
DUBOIS NURSING HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an incident survey completed on January 11, 2024, it was determined that Dubois Nursing Home 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 facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse or neglect caused by staff failing to properly secure a resident in a motor vehicle, which led to a resident sustaining a facial fracture for one of five residents reviewed (Resident 2). This deficiency will be cited as past noncompliance.

Findings include:

The facility's policy regarding resident abuse and neglect, dated January 1, 2023, indicated that each resident has the right to be free from abuse and neglect. The facility's policy for vehicle safety and management, dated January 1, 2023, indicated that the facility will do everything possible to prevent accidents and is committed to providing a safe environment for all employees and residents.

A nursing note for Resident 2, dated December 16, 2023, indicated that the resident was admitted to the facility, was alert to person and place, and had diagnoses that included a fall with rib fractures and end-stage renal disease with dependence on hemodialysis.

A nursing note for Resident 2, dated December 18, 2023, revealed that the nursing home administrator was notified the facility bus had been in an accident and that the resident was transferred by Emergency Medical Service to the local emergency room.

An incident investigation for Resident 2, dated December 18, 2023, revealed that the transportation aide and resident were in an accident and the resident was transferred to the local emergency room. The driver reports that she secured his wheelchair in the transport van and proceeded to leave the facility to take the resident to the dialysis center for his scheduled appointment. While in route the driver did not see a vehicle that had stopped to make a left-hand turn and the facility transport van rear ended the vehicle that was stopped. As a result of the sudden stop, the force caused the resident to fall forward out of the wheelchair hitting his head on the center console. He was subsequently transferred to the local emergency room where he was also diagnosed with a left mandibular condyle fracture and admitted to the hospital for further observation.

A statement from the van driver, dated December 18, 2023, revealed that she brought the resident down to the van but could not push him over the edge because the leg rests would not go over them. She backed him down off the ramp and took the metal attachments off. She then wheeled resident up into the van, locked the wheelchair, put the straps on the back of the wheelchair, went to the passenger side, opened the door, got in and hooked the two straps onto the frame of the wheelchair, made sure they were tight, went back out, put the lap strap around the resident, hooked it on the right side of metal attachment, and made sure the straps were tight. She stated that she did not put the shoulder strap on because she could not figure it out. Everything was tight (the straps), so she got in and put the mileage and time down on a sheet. She then left the nursing home with the resident to transfer him to dialysis. She reached in her pocket when they got to the stop sign on South 8th street to get a cough drop and kept talking to resident. When she got up to top of small hill, she decided to put the cough drop in her mouth. She did not notice the vehicle stopped in front of her. She hit her brakes and hit the vehicle in front of her. She turned off the van and called 9-1-1 at 8:44 a.m. An ambulance was close by. After getting off the phone with 9-1-1, she called the nursing home at 8:46 a.m. She looked back to check on Resident 2 and did not see him. She then noticed he was next to her between the seats. He was bleeding from his right hand and his forehead. She went back to sit with him waiting for the ambulance. She noticed the lap strap was partially under him. Emergency services arrived and assisted the resident and transported him to the local emergency room.

Interview with the Nursing Home Administrator on January 11, 2024, at 11:15 a.m. confirmed that the transportation aide did not strap Resident 2 correctly in the facility van and was involved in a vehicle accident that resulted in a fracture of the resident's mandibular.

A review of the facility's plan of correction revealed that re-education and competencies were completed by the facility's transportation aides. The facility will perform daily and weekly pre-trip checklists and inspections.

Interviews with the facility's transportation aides and Maintenance Director revealed that they received re-education and competencies, and a simulation of transporting a resident safely was conducted. They had knowledge on how to properly secure a resident in the facility's van.

A review of the facility's corrective actions revealed that they were in compliance with F600 on December 21, 2023.

Interview with the Nursing Home Administrator on January 11, 2024, at 11:15 a.m. revealed that staff education was completed, and ongoing audits are to be discussed during the monthly Quality Assurance (QA) meeting.

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

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

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









 Plan of Correction - To be completed: 02/06/2024

Past noncompliance: no plan of correction required.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port