Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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HAMILTON ARMS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on November 12, 2019, in response to a complaint at Hamilton Arms Center, it was determined that the facility was not in compliance with the following requirements of the 42 CFR part 483, Subpart B, Requirements for Long Term Care and the PA 28 Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.

 Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 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;

Based on facility policy, clinical review, facility documentation, and staff interviews, it was determined the facility failed to ensure that residents are free from neglect as indicated by the improper transfer of the resident resulting in a fall for one of three residents reviewed. (Resident R1)

Findings include:

Review of the facility policy titled "Safe Resident Handling/Transfer Equipment," states that the use of two persons when using a total lift or sit to stand lift will be used. The total lift will be used as the primary intervention to manual lifting, transferring and repositioning and it requires a minimum of two persons to perform the lift.

Review of Resident R1's clinical record revealed a Quarterly Minimum Data Set (MDS- A resident assessment tool) dated August 12, 2019, Section G Functional Status states that for transfers Resident R1 was a 4 (total dependence) and 3 (two persons physical assist).

Resident R1's care plan dated January 26, 2019, revealed a focus of assistance for mobility with the intervention is to provide resident with 2 assist using full body mechanical lift to safely transfer to and from a bed to a chair (or wheelchair).

Further review of the clinical record revealed that on October 29, 2019, at approximately 11:35 p.m. the resident was being transferred in a total body lift when he fell to the floor. Resident was noted to have a skin tear on the left elbow measuring 10cm x 6cm and some scrapes to his toes on the right foot.

Review of the facility documentation revealed that Employee E3 was getting Resident R1 up for lunch and put him on the lift pad. Employee E3 "looked for help and didn't see anyone and attempted to get Resident R1 out alone". "The lower strap was not hooked but it was to late and he fell on the left side of his body."

An interview with the Nursing Home Administrator on November 12, 2019 at approximately 11:15 a.m. revealed that bruises on the foot were noticed on October 30, 2019 and the physician ordered for the foot to be X-rayed on November 1, 2019 when follow-up X-Rays were being completed.

Further review of the clinical record revealed on November 1, 2019 a fracture of the base of the second toe on the right foot was noted.

A second interview with the Nursing Home Administrator on November 12, 2019 at approximately 1:30 p.m. revealed that Employee E3 did not use two people to transfer Resident R1 as instructed in the care plan and in the facility policy.

28 Pa Code 201.14(a) Responsibility of licensee
Previously cited 4/26/2019

28 Pa Code 201.18(b)(1)(3)(e)(1) Management

 Plan of Correction - To be completed: 12/03/2019

Resident R1 was re-evaluated to make sure his lift size was appropriate. His care plan was updated and safe resident transfer policy was followed. The facility conducted mandatory inservicing for all Certified Nursing Aides. This inservicing included a hands on demonstration to a trainer to insure appropriate usage of the lifts. All residents had their lift assessments reviewed to ensure that the appropriate transfer/lift device is in place and care planned. The lift assessments will be reviewed for 4 weeks and then monthly for 4 months with these audits being presented at the Quality Improvement Meetings. CNAs will be spot checked for appropriate use of lift devices. This will be monitored by Nursing Administration and Administration

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