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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MENNONITE HOME, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on October 28, 2019, in response to information submitted by the facility, it was determined that The Mennonite Home 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 for the Health portion of the survey.

 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;

Based on review of facility policy, job descriptions, documentation, clinical record, staff interview, and coroner report, it was found that the facility failed to protect residents from neglect which resulted in actual harm to resident CL1, who was improperly transferred in a lift, fell, and sustained head and neck trauma resulting in death for one of two residents reviewed (Resident CL1).

Findings include:

Review of facility policy Full Body Lift Resident Transfers, last revised August 2015, revealed "Floor lift requires two (2) trained care giving staff members."

Review of the job description for caregiver revealed: "Proper use of mechanical lifts requires 2 staff for all transfers." The job description was acknowledged and signed by nursing assistant Employee E5 on December 5, 2018.

Review of nursing assistant Employee E5's facility orientation revealed that Employee E5 signed that they received training on resident transfers and mechanical lifts on December 19, 2018.

Review of Resident CL1's clinical record revealed diagnoses including, but not limited to, cerebral infarction (stroke), hemiplegia affecting right dominant side, contracture of the left hand, and chronic atrial fibrillation.

Review of Resident CL1's care plan identified the resident as requiring staff assistance to complete activities of daily living due to mobility deficits resulting from hemiparesis with an intervention for staff to utilize a hoyer lift with two staff members for transfers per therapy recommendations.

Review of Resident CL1's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) from June 26, 2019 revealed the resident was totally dependent on two staff persons for transfers.

Review of Resident CL1's progress notes revealed a nurse's note dated September 8, 2019 which stated: "Received call from LPN [(licensed practical nurse)] at 10:30 that there was an emergency on the floor and to come up right away. This RN [(registered nurse)] and other RN supervisor ran up and immediately were on unit. We were directed to [Resident CL1's] room. Upon entering resident's room, noted resident to be seated in her wheelchair. Her head was tilted back, her eyes were closed, she's unresponsive and mouth was open. Observed resident take one shallow breath. This RN ran to confirm code status which is DNR/comfort [(do not resuscitate)] and ran back to resident's room. No further breathing noted from resident. Asked LPN if resident was a stroke alert, she said no. Assessed pupils which were fixed and dilated. Assessed head for injuries. PO2 [(pulse oximetry - measure of the amount of oxygen in the blood. Normal is 95-100)] was 62 and falling. Resident's apical heart rate was 16 [(normal is 60-100)] and sporadic. Continued to assess resident who had absence of breath sounds. Noted small skin tear to resident's [left] shin which had scant amount of blood that had clotted. Resident was transferred to bed via hoyer lift and 3 assist for further assessment. No other injuries noted. Resident remained without respirations, unresponsive, pupils remained fixed and dilated. Her apical heart rate at that time was 6 beats per minute and remained slow and irregular. Her heart rate slowed again at around 11:12 to 4 beats per minute and she passed away at 11:15 when she had an absence of a heart beat x 2 minutes. Family aware. Social work aware. [Director of Nursing] aware. [Medical director] aware."

Review of statement from nursing assistant Employee E5 revealed that on September 8, 2019 Employee E5 transferred Resident CL1 "alone while [nursing assistant Employee E13] was trying to keep other resident calm in hallway. When I went to transfer resident the sling top string came unloose. I then lower resident to the floor and her back hit the pole of the hoyer lift. The reasoning for my action was because I had another resident very upset and needed to use the bed pan."

Review of statement from nursing assistant Employee E13 on September 8, 2019 revealed: "[Employee E5] told me she needed help getting someone up. We walked down the hall, [Employee E5] said she was going to ...get [Resident CL1] ready. I was on the computer. I heard a resident making growling sounds, and there was another resident sitting in the hall that said it sounds like someone fell in there ...I walk in the room, the curtain is pulled, I can see something on the floor. I opened the curtain and the resident was on the floor with her head up against the wheel of the wheelchair with a pillow behind her head. [Nursing assistant E5] was hooking her up to the lift and she put her in the wheelchair. I said the resident usually not responsive and doesn't talk? [Employee E5] answered yes. I went and got [Licensed Nurse Employee E12.] When I seen the resident on the floor she had bubbles coming out side of her mouth and was humming. When I was on the computer, [Employee E5] never said she was ready to transfer. Resident was not connected to the lift when I opened the curtain."

Review of statement from licensed nurse Employee E12 on September 8, 2019 revealed: "At approximately 10:20 a.m. on 9/8/19, I was notified by [Employee E13] ...that she had walked into [Resident CL1's room] and observed [the resident] on the floor beside her wheelchair. [Employee E5], who had been assigned to care for [Resident CL1] on this shift was attempting to put the hoyer lift pad under [the resident] according to [Employee E13.] At this time, [Employee E5] walked up to me and asked me if [Resident CL1] had a history of difficulty breathing ...Upon my arrival to [Resident CL1's] room, she was sitting in her wheelchair facing the door. She looked pale on her face. I touched her on her shoulder and called her name, she did not respond to me. I immediately left the room call and notify my supervisor."

Review of statement from licensed nurse Employee E14 on September 8, 2019 revealed "Asked [Employee E5] what happened and she made statements about a strap coming loose and she tried to lower the resident to the floor but the resident had hit her buttocks hard on the floor. She stated she wasn't sure if resident had hit her head."

Review of statement from licensed nurse Employee E15 on September 8, 2019 revealed "Questioned [Employee E5] involved in incident who said resident was alert and talking prior to transfer. She said she was in a hurry and transferred the resident by herself. She was transferring resident when she noticed one of the straps wasn't fully hooked and resident began to fall. She said she tried to lower her to the floor and resident's [buttocks] hit off the floor. When asked if resident hit her head she said 'I don't think.'"

Interview with the Medical Director on September 20, 2019 at 12:10 p.m. revealed that he was Resident CL1's physician at the time of the resident's death. The medical director further stated that he was not aware of any decline in the resident's condition prior to September 8, 2019 and had received no concerns from the staff prior to September 8, 2019.

Interview with the Nursing Home Administrator (NHA) on September 20, 2019 at 12:30 p.m. revealed that the deputy coroner stopped by the facility on September 9, 2019 and gave verbal confirmation that Resident CL1 sustained a C6 fracture (neck fracture) and that the cause of death would be listed as head and neck trauma/injury. The NHA confirmed that nursing assistant Employee E5 made a "stupid mistake" by not following facility policy and transferring Resident CL1 without the assistance of another staff person.

Review of the official coroner's report, requested by the Department, and received on October 28, 2019 revealed that the cause of Resident CL1's death was traumatic head and neck injury, with the manner of death ruled accidental.

The above information was conveyed to the Director of Nursing on October 28, 2019.

The facility failed to ensure Resident CL1 was free from neglect, evidenced by the resident being improperly transferred by nursing assistant Employee E5 and sustaining a traumatic head and neck injury and subsequently dying.

28 Pa. Code 201.14(a) Responsibility of licenseePreviously cited 2/26/19, 4/11/19

28 Pa. Code 201.18(b)(1)(3)(e)(1) ManagementPreviously cited 10/27/17, 2/26/19, 4/11/19

28 Pa. Code 201.29(c)(d) Resident rights

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.10(d) Resident care policiesPreviously cited 10/27/17, 2/26/19

28 Pa. Code 211.11(d) Resident care planPreviously cited 2/26/19

28 Pa. Code 211.12(c)(d)(1)(5) Nursing servicesPreviously cited 10/27/17, 2/26/19, 4/11/19

 Plan of Correction - To be completed: 11/25/2019

The Mennonite Home submits the Plan of Correction under procedures established by the Department of Health and the Center for Medicare and Medicaid Services in order to comply with the Department's directive to change conditions, which the Department alleges, are deficient under State and Federal regulations relating to long-term care. This Plan of Correction should not be construed as either a waiver of the Mennonite Home's right to appeal or an admission of past or ongoing violations of Federal or State regulatory requirements.

Investigation initiated immediately. Employee E 5 immediately suspended pending investigation. Upon conclusion of investigation, Employee E5 was terminated on 9/10/19 for failure to follow facility transfer policy.

Education initiated regarding required use of 2-person support with Hoyer lift transfers. Nursing administration completed this education for the clinical team.

Facility completed a review/audit of resident specific transfer status.

Policy for transfer status reviewed.

Policy for freedom from abuse, neglect, and exploitation reviewed.

Staff development completed education for staff related to proper transfer techniques, definitions of abuse and neglect, including failure to follow care plan.

Director of Nursing/designee initiated an audit process following the completion of education to conduct random reviews of resident transfer status. Additional audits were initiated to review understanding of Freedom from Abuse, Neglect, and Exploitation policy. Audits completed daily for 1 week, weekly for 2 months.

A Quality Assurance/Performance Improvement plan will be developed and utilized to monitor for freedom from abuse and neglect related to transfer status and services being provided to the residents. Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee to determine need for additional actions and or monitoring.

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