Pennsylvania Department of Health
SWAIM HEALTH CENTER
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


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SWAIM HEALTH CENTER
Inspection Results For:

There are 95 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.


SWAIM HEALTH CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Findings of an abbreviated survey, in response to a facility reported incident, completed on January 27, 2025, at Swaim Health Center identified that the facility 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:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

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.

§483.25(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 clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that interventions were put into place to prevent accident hazards during a transfer, resulting in actual harm as evidenced by a skin tear requiring treatment, for one of three residents reviewed (Resident 1).

Findings include:

Review of Resident 1's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), abnormalities of gait and mobility, and muscle weakness.

Review of nursing progress notes entered by Employee 1 (Registered Nurse) dated January 16, 2025, revealed that she was called to Resident 1's bedside to assess a skin tear that was acquired while transferring Resident 1 into bed. Further review of the note revealed, "Two aides present, transferring resident d/t [due to] resident dislodging hoyer pad from correct positioning. During transfer right forearm sustained a 9 cm x 11.5 cm long skin tear. Bleeding controlled. Area cleansed. Per ADON [Assistant Director of Nursing], Xeroform, ABD, kling wrap [types of wound dressings] applied."

Review of Resident 1's current and active physician orders revealed an order for a transfer status of two assist with a full mechanical lift, effective December 17, 2024.

Review of Resident 1's care plan that was in place at the time of the incident on January 16, 2025, revealed a care plan related to his impaired functional status with an intervention of a two-person assist using a hoyer lift for transfers.

Review of Employee 2's (Nurse Aide) witness statement obtained by Human Resources on January 20, 2025, revealed, "[Employee 3 - Nurse Aide] took resident to room and asked [Employee 2] to assist with the transfer. He noticed the Hoyer Pad was wedged under his bottom.. so they could not do a Hoyer Lift. [Employee 2] stated they were both on the same page and decided to do a stand/pivot transfer due to safety concerns. [Employee 3] put the Broda [type of wheelchair] next to the bed. [Employee 3] was watching from the opposite side of the bed when [Employee 2] transferred the resident by himself. He put both arms under the resident's armpits and lifted the resident by himself. The resident's arms were on his waist. He heard the resident yell and pivoted him to the bed... When asked why he did it by himself, he stated that it was easier to do that. He also stated that it was safer. When he [the resident] sat down [Employee 3] looked at his arm and saw blood saturated through his sweatshirt. [Employee 2] stated the resident was noncombative. Once in bed, [Employee 3] rolled his sleeve back and saw the skin tear. [Employee 2] went to get the nurse to look at the skin tear."

During an interview with Employee 2 on January 27, 2025, at 10:26 AM, he stated that on the date in question, Employee 3 took Resident 1 to his room. She asked Employee 2 for assistance, and he agreed. Once he arrived in the room, they discovered that Resident 1's lift pad was not properly positioned under his bottom. Employee 2 stated that both he and Employee 3 knew that Resident 1 was to be transferred with a lift, but they knew they had to do something else. Employee 2 states that he transferred Resident 1 by himself. During the transfer, Employee 3 was on the other side of the bed, but was paying attention enough to help if needed. Employee 2 stated that he did a stand/pivot transfer with Resident 1's arms around his waist. After he stood Resident 1 up, Resident 1 "screamed". Employee 2 stated he then sat Resident 1 down on his bed. That's when they noticed the injury and went to get the nurse. Employee 2 stated that he had never encountered the situation before where a lift pad was not positioned where it was useable, and he just used his best judgement at the time. He acknowledged that he was aware that Resident 1 was to be transferred with a lift.

Review of Employee 3's witness statement, obtained by the ADON, Employee 6 (Registered Nurse Unit Manager), and Human Resources on January 20, 2025, revealed, [Employee 3] stated that she had placed the Resident in his room by his bed, between his bed and the roommate's bed. [Employee 3] stated that she went to get [Employee 2] to help her. [Employee 3] stated she walked away, to get gloves on prior to the transfer. [Employee 3] stated as she turned around, [Employee 2] had stood the Resident to transfer him into his bed...[Employee 3] admitted she did not assist with the transfer; however, she watched the transfer occur. She stated [Employee 2] had his arms positioned under the resident's armpits, and the Resident put his arms around [Employee 2's] neck. [Employee 3] stated that the Resident stated "ouch" as he was placed in a sitting position on his bed. [Employee 3] stated they laid the Resident on his back, when [Employee 3] noted the Resident's right sleeve was "saturated" with what she assumed was blood. [Employee 3] also stated that she pulled the Resident's sleeve back to see what was wrong with the Resident's right arm...[Employee 3] saw the skin tear on Resident's right forearm and had [Employee 2] go get the Nurse....[Employee 3] stated, they told the nurses, that her and [Employee 2] both transferred the Resident. [Employee 3] also admitted that she told a CNA [Certified Nurse Aide], Friday 1/17/25, the "real story" of what occurred...During the re-enactment of the incident in the Resident's room, [Employee 3] admitted that she stood on the opposite side of the bed and watched [Employee 2] transfer the Resident by himself and did not help nor ask him to stop. [Employee 3] was asked why they were standing and pivoting the Resident instead of using the mechanical lift per care plan. She said the sling was scrunched up under the Resident's bottom. [Employee 3] was asked why they did not stand and fix the sling, she stated, "I didn't think of that."

Review of wound consult dated January 20, 2025, revealed that Resident 1's right forearm skin tear was assessed on that date, and it was noted that a moderate amount of serosanguinous exudate (wound drainage), and FLACC pain level of 3 (1-10 scale used to assess pain of individuals unable to verbalize pain levels) was present at the time. Orders were given for a wound dressing to be applied twice per day and as-needed.

During an interview with the Nursing Home Administrator (NHA) on January 27, 2025, at 10:45 AM, she revealed that she would have expected Employee 2 and 3 to stand Resident 1 and fix his lift pad, or seek assistance from a nurse.

During an interview with the Director of Nursing (DON) on January 27, 2025, at 11:40 AM, she revealed that nursing staff were educated in November 2024 about following the care plan, and that failure to do so could rise to the level of neglect. She also revealed that transfer status was specifically reviewed during this training, and staff were instructed to seek help if they have questions about transfer statuses.

The facility's corrective action was reviewed during the onsite survey.

After the investigation, the facility terminated both Employees 2 and 3.

On January 20, 2025, the DON completed a review of incident reports for the previous 30 days to determine negative outcome from failure to follow the Resident's care plan. The finding were negative.

On January 20, 2025, a full sweep of all residents was completed to ensure that each had an accurate transfer status noted on their care plan.

Review of education dated January 17 - 23, 2025, revealed that nurse aides, licensed staff, and therapy staff were educated on abuse and neglect, and the facility's "Transfer of a Resident" policy.

Ongoing audits were initiated on January 20, 2025, and are to continue three times per week for one month, then weekly for one month, then monthly for three months. The results are to be reviewed at the Quality Assurance and Performance Improvement Committee.

Review of the audits revealed they are monitoring if appropriate transfer status was used by staff, and if a mechanical lift was utilized properly, if applicable.

Review of the facility's education, audits, and staff interviews revealed no concerns.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(e)(1) Management
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 02/03/2025

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