Pennsylvania Department of Health
POCOPSON HOME
Patient Care Inspection Results

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POCOPSON HOME
Inspection Results For:

There are  119 surveys for this facility. Please select a date to view the survey results.

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


Findings of an Abbreviated Complaint Survey completed on February 14, 2024,, at Pocopson Homes, identified deficient practice, related to the reported complaint allegations, under the 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 as they relate to the Health portion of the survey process.


 Plan of Correction:


483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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.
§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
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)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:

Based on review of facility policies, resident clinical records, and facility investigative reports, as well as staff interviews, it was determined that the facility failed to ensure residents were free from physical restraints not required to treat the medical symptoms for one of one residents reviewed, resulting in harm to Resident R1 who was physically restrained using a pair of pajama pants tied tightly around resident's waist, causing a reddened area on the resident's skin.

Findings include:

Review of the facility policy titled, "Restraint/Device/Siderail," dated March 2023, revealed it is the policy of Pocopson Homes that all residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical condition. "Restraints will be applied only after a physician's order has been obtained and the family has been notified. Consent must also be signed by the responsible party of the resident. The care plan should be updated, and the appropriate record will be initiated to track the use and release of the restraint. The physician order will include the type of restraint, reason for restraint, how often the restraint is removed. Physical or occupational therapy will be consulted."

Further review of the policy revealed that physical restraints include but are not limited to leg/arm restraints, hand mitts, soft ties, vests, meri-walkers, seatbelts which the resident cannot easily open or remove, specialty chairs which resident cannot easily rise from, low beds, bed against the wall, and side rails which prevent the resident from easily getting out of bed.

Review of Resident R1's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated December 19, 2023, revealed the resident was severely cognitively impaired, was not able to make his/her needs known, required extensive assistance for care activities, incontinent of bowel and bladder, and exhibited inattentive behaviors during the assessment period.

Review of Resident R1's care plan, dated December 27, 2021, indicated the resident wandered relative to impaired safety awareness. Interventions indicated were to provide structured activities, toileting, walking inside and outside, reorientation strategies including signs and pictures, wander guard bracelet, conversation, and music.

Review of information received by Department of Health regarding Resident R1, received on February 7, 2024, revealed a witness to Resident R1 tied down to a rolling reclining chair. The incident occurred on 12/30/2023. Review of facility's records failed to reveal an investigation was initiated and Resident R1 was unable to be interviewed due to his/her death on January 13, 2024. The Director of Nursing initially failed to interview staff involved in Resident R1's care.

Review of resident records, facility grievance reports, and electronic reporting system failed to reveal any documentation of incident.

Interview with Nursing Home Administrator on February 12, 2024, at 2:00 p.m., revealed the Administrator was not aware of the incident. The Administrator indicated the incident was not reported to the Department of Health, an investigation was not conducted, nor does the facility use any type of restraint.

Interview with Director of Nursing on February 12, 2024, at 2:10 p.m., revealed witness statements were provided by staff, but no investigation was initiated of the incident since the resident was known for being restless and attempting to get out of bed and/or chair on his/her own, thus increasing fall risk. Further interview with Director of Nursing revealed the belief that being tied to the scoot chair was not considered a restraint, rather as a method of keeping the resident safe from falls.

Review of witness statement from Nurse Assistant (Employee E3) dated December 29, 2023, revealed that non licensed Employee E3 observed Resident R1 tied to a chair at the waist with fleece pajama pants, preventing his/her ability to move or stand up.

Review of witness statement from a Registered Nurse, (Employee E4), dated December 30, 2023, revealed that he/she received a call from Employee E3 to come to the floor as it was urgent. Upon arrival on the unit, he/she was asked to observe Resident R1, who was in the bathroom. Licensed Practical Nurse (Employee E5) stated that Resident R1 was found tied to the scoot chair with a pair of fleece pajamas around her trunk/abdominal region. Per Supervisor, Employee E5 stated "I immediately removed the pajama pants due to red mark noted.' Upon assessment, red mark was resolved, and no other injury noted."

Review of witness statement from a Licensed Practical Nurse (Employee E5), dated February 12, 2024, revealed when Employee E5 took Resident R1 to the bathroom for incontinence care, Employee E5 was not able to lift Resident R1 out of the scoot chair. Employee E5 found a pair of fleece type pajama pants was tied around the midsection of Resident R1, in a knot, behind the scoot chair. Employee E5 immediately called Employee E3 to witness findings. Employee E5 then called the RN Supervisor, Employee E4 to inform of findings. Employee E5 noticed a reddening area on Resident R1's abdomen, therefore, Employee E5 removed the pajama pants prior to Supervisor Employee E4's arrival on the unit.

Review of an undated witness statement from Licensed Practical Nurse (Employee E6), revealed that Employee E6 observed Resident R1 sitting in a scoot chair, Resident R1 was restless, Employee E6 administered PRN (as needed) Morphine around 8:00 p.m., to help with restlessness. Employee E6 denied seeing anything tied around Resident R1 at the time of care.

Interview conducted with nurse aide, Employee E3 on February 14, 2024, revealed Employee E3 indicated Resident R1 was not therapy approved for scoot chair use, Resident R1 was able to get up on his/her own. When licensed Employee E5 took Resident R1 to the bathroom for continence care Employee E5 noticed the resident was tied to the scoot chair with pajama pants. Employee E5 requested Employee E3 observe his/her findings as a witness. Resident R1was unable to move, due to the material being tightly tied. Further interview with Employee E3, Licensed staff member, Employee E4, requested written statements at the time of the incident. Employee E3 stated to his/her knowledge no further investigation was conducted, and he/she was not questioned further regarding the incident.

Review of Resident R1's records revealed a fall risk care plan dated December 27, 2021, documenting Resident R1 was at moderate risk for falls. One of the interventions dated October 10, 2023, noted "staff should monitor resident closely after dinner for signs of fatigue such as gait, slower, more unsteady, assist to bed for rest period or chair for rest period if noted."

Further review of Resident R1's clinical record revealed a care plan dated December 27, 2021, documenting Resident R1 as a wanderer relative to impaired safety awareness. Intervention, dated December 27, 2021, indicated "staff should distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Resident prefers religious activities and music (jazz, gospel, Motown)." Another intervention which was revised June 28,2023 was for staff to "redirect resident to his/her own bed if located in a peer's bed. Encourage rest periods throughout the day, especially in the afternoons."

Review of facility records revealed an occupational therapy treatment encounter note dated January 4, 2024, documenting resident was referred for skilled OT evaluation for concave mattress, (bed positioning), and scoot chair (out of bed positioning), and bed rail assessment per [hospice provider]. Scoot chair with resident's name given to resident. Resident transferred to scoot chair with moderate assist of two persons. Resident exhibited optimal posture in the scoot chair. New order for concave mattress placed, per [hospice provider] request. Skilled OT evaluation only since resident is on hospice. Window side bed rail approved to prevent resident from falling out of bed and safety.

Review of Resident R1's records failed to reveal a care plan for restlessness, scoot chair use, restraints, or bed rails.

Review of Resident R1's records failed to reveal evidence that a pre-restraining assessment and review was completed to determine the need for restraining the resident by tying him/her to a scoot chair.

Interview with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 12:10 p.m. confirmed that no report was made by the facility, no investigation was initiated prior to Department of Health's visit, no pre-restraining assessment was performed, and no restraint documentation was available for Resident R1 since it was the resident was not restrained, rather, staff initiated the restraint to prevent Resident R1 from falling by tying him/her to a scoot chair for safety.

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

28 Pa. Code 201.29(j) Resident rights

28 Pa. Code 211.8(a) Use of restraint




 Plan of Correction - To be completed: 03/08/2024

The fleece pants were immediately removed from resident R1 when discovered revealing no sustained injury. Resident R1 expired 1/13/24 on hospice services. Pocopson Home policy will continue as written stating that all residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical condition. Restraints will be applied only after a physician's order has been obtained and the family has been notified. Consent must also be signed by the responsible party of the resident. Residents in the facility having the potential to be affected by the same deficient practice will be identified by routine audits of residents in wheelchairs. An audit of 10 random residents in wheelchairs will be completed by Nursing on each shift to ensure that they are not physically restrained and are using a chair that meets their current safety and mobility needs. An OT/PT consult will be ordered for any changes deemed necessary. These audits will be done weekly for 4 weeks then monthly for 3 months. In addition to these audits, all residents on hospice services will be reviewed daily during morning meeting to determine if their needs are being met and their comfort level is being maintained. Any issues identified with care or comfort will be discussed with the hospice nurse for intervention.

A restraint QAPI will be initiated in the facility. Audit results will be reported to the QAPI committee and reviewed during quarterly QAPI meetings.

All nursing staff will be re-educated on the facility restraint and resident rights policies as a measure to ensure the practice does not recur. Policy will be revised to include the return of specialty chairs to maintenance within 24 hours of a resident no longer requiring the chair. Specialty chairs will not be provided to any unit without approval of PT/OT.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on clinical record review and interviews with staff, it was determined that the facility failed to develop a comprehensive care plan related to restlessness, scoot chair use, restraints, or bed rails for Resident R1 which resulted in harm to Resident R1 by being tied to a scoot chair and sustaining reddened area on abdomen.

Findings include:

Review of Resident R1's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident R1, dated December 19, 2023, revealed the resident was severely cognitively impaired, unable to make his/her needs known, required extensive assistance for care activities, incontinent of bowel/bladder, and exhibited inattentive behaviors during the assessment period.

Review of Resident R1's clinical record revealed a progress note date December 26, 2023, at 11:01 pm, noting "resident awakened approximately 9:00 pm. Resident continues to try to get up and walk around, Resident has to be redirected several times, but behaviors continue."

Review of Resident R1's clinical record revealed progress note dated December 27, 2023, at 1:45 pm, noting "received resident sitting in front of common area, very restless and anxious. Received PRN [as needed] 0.5 mg Lorazepam tab at 11:01 pm, prior shift ineffective. Interventions toileting, giving snacks/treats and drinks ineffective."

Further review of Resident R1's clinical record revealed a progress note dated December 28, 2023, at 11:41 pm, indicating "during the beginning of shift resident was noted to be extremely restless and fidgety. Visibly tired and shows signs and symptoms of pain and discomfort. Noted to not be comfortable. Redirection, toileting, snack, and fluids provided with unsuccessful outcomes."

Additional review of Resident R1's clinical record revealed a late entry behavior note for 11pm-7 am shift of December 27, 2023, into December 28, 2023, dated December 28, 2023, at 11:41, indicating "resident was awake and extremely restless throughout the shift. Redirection and interventions were all ineffective."

Review of Resident R1's clinical record revealed progress noted dated December 29, 2023, at 9:53 pm, noted "resident awaken around 9:00 pm, and got out of bed and began walking around room. Roommate rang call light to alert staff and resident removed from the bedroom and placed in wheelchair. Resident toileted and placed back into wheelchair. Continued to be restless and grabbing at anyone and anything. Given PRN [as needed] Morphine which had little success."

Continued review of Resident R1's clinical record revealed a progress note dated December 30, 2023, at 2:27 pm, indicating "the resident woken up for lunch and was observed by this nurse trying to get out of bed, leaning over bed as if to fall. This nurse assisted resident to wheelchair. Fed lunch by this nurse, consumed 100%, During lunch resident restless/anxious unable to sit still or be redirected."

Review of Resident R1's records revealed a fall risk care plan dated December 27, 2021, indicating Resident R1 was at moderate risk for falls. One of the interventions, dated October 10, 2023, indicated staff should monitor resident closely after dinner for signs of fatigue such as gait, slower, more unsteady, assist to bed for rest period or chair for rest period if noted.

Further review of Resident R1's records revealed a care plan dated December 27, 2021, documenting Resident R1 as a wanderer relative to impaired safety awareness. One of the interventions dated December 27, 2021, noted staff should distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Resident prefers religious activities and music (jazz, gospel, Motown). One revised intervention dated June 28,2023 was observed noting staff should redirect resident to his/her own bed if located in a peer's bed. Encourage rest periods throughout the day, especially in the afternoons.

Review facility documentation including a witness statement from Nurse Assistant (Employee E3) dated December 29, 2023, revealed non licensed Employee E3 observed Resident R1 tied to a chair at the waist with fleece pajama pants, preventing his/her ability to move or stand up.

Review of facility documentation including a witness statement from a Registered Nurse, (Employee E4), dated December 30, 2023, revealed that he/she received a call from Employee E3 to come to the floor as it was urgent. Upon arrival on the unit, he/she was asked to observe Resident R1, who was in the bathroom. Licensed Practical Nurse (Employee E5) stated that Resident R1 was found tied to the scoot chair with a pair of fleece pajamas around her trunk/abdominal region. Per Supervisor, Employee E5 stated "I immediately removed the pajama pants due to red mark noted.' Upon assessment, red mark was resolved, and no other injury noted."

Review of facility records revealed an occupational therapy treatment encounter note dated January 4, 2024, documenting resident was referred for skilled OT evaluation for concave mattress, (bed positioning), and scoot chair (out of bed positioning), and bed rail assessment per [Hospice provider]. Scoot chair with resident's name given to resident. Resident transferred to scoot chair with moderate assist of two persons. Resident exhibited optimal posture in the scoot chair. New order for concave mattress placed, per [Hospice provider] request. Skilled OT evaluation only since resident is on hospice. Window side bed rail approved to prevent resident from falling out of bed and safety.

Review of witness statement from a Licensed Practical Nurse (Employee E5), dated February 12, 2024, revealed when Employee E5 took Resident R1 to the bathroom for incontinence care, Employee E5 was not able to lift Resident R1 out of the scoot chair. Employee E5 found a pair of fleece type pajama pants was tied around the midsection of Resident R1, in a knot, behind the scoot chair. Employee E5 immediately called Employee E3 to witness findings. Employee E5 then called the RN Supervisor, Employee E4 to inform of findings. Employee E5 noticed a reddening area on Resident R1's abdomen, therefore, Employee E5 removed the pajama pants prior to Supervisor Employee E4's arrival on the unit.

Review of an undated witness statement from Licensed Practical Nurse (Employee E6), revealed that Employee E6 observed Resident R1 sitting in a scoot chair, Resident R1 was restless, Employee E6 administered PRN (as needed) Morphine around 8:00 p.m., to help with restlessness. Employee E6 denied seeing anything tied around Resident R1 at the time of care.

Review of Resident R1's records failed to reveal a care plan for restlessness, scoot chair use, restraints, or bed rails.

Interview with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 12:10 p.m. confirmed that no pre-restraining assessment was performed, and no restraint documentation, including a care plan, was available for Resident R1 since it was the administrations opinion that Resident R1 was not restrained, rather, staff were taking it upon themselves to prevent Resident R1 from falling by tying him/her to a scoot chair for safety. It was confirmed that Resident R1 was approved for window side bedrail and scoot chair yet review of resident records failed to reveal a care plan for either. It was confirmed that Resident R1 showed signs of terminal restlessness yet review of resident records failed to reveal a care plan with interventions for this condition.

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


 Plan of Correction - To be completed: 03/08/2024

Resident R1 expired 1/13/24 on hospice services. All residents will have a comprehensive care plan that will be consistently updated with changes to the resident's condition and care needs. All residents receiving hospice services will have a hospice care plan in place for nursing to reference. Hospice care plans must remain updated with changes to resident interventions as needed to maintain the goals of hospice care.

To identify other residents having the potential to be affected by the same deficient practice, 30 high and medium risk resident care plans will be audited by nursing and resident assessment to ensure that residents have a comprehensive care plan reflecting current care needs and the interventions in place to meet the current needs. Care plans failing to meet these criteria will be updated immediately. These audits will be done weekly for 4 weeks then monthly for 3 months. Audit results will be reported to the QAPI committee and discussed at the quarterly QAPI meeting.

System changes in the facility will include daily reporting of all residents receiving hospice services and/or having changes in condition. Necessary care plan updates will be communicated to resident assessment to validate documentation of same.

All licensed staff will be re-educated on the IDT communication requirements necessary to develop a comprehensive care plan, how to complete a care plan and how to immediately update a care plan when a change occurs for the resident. Facility expectations of hospice communication and documentation management will be discussed with and implemented by contracted hospice leadership.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on clinical record review, facility documentation, and staff interviews it was determined that the facility failed to report allegations of abuse including physical restraint of Resident R1 for one of one residents reviewed.

Findings include:

Review of the facility policy titled, "Restraint/Device/Siderail," dated March 2023, revealed it is the policy of Pocopson Homes that all residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical condition. "Restraints will be applied only after a physician's order has been obtained and the family has been notified. Consent must also be signed by the responsible party of the resident. The care plan should be updated, and the appropriate record will be initiated to track the use and release of the restraint. The physician order will include the type of restraint, reason for restraint, how often the restraint is removed. Physical or occupational therapy will be consulted."

Further review of the policy revealed that physical restraints include but are not limited to leg/arm restraints, hand mitts, soft ties, vests, meri-walkers, seatbelts which the resident cannot easily open or remove, specialty chairs which resident cannot easily rise from, low beds, bed against the wall, and side rails which prevent the resident from easily getting out of bed.

Review of Resident R1's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated December 19, 2023, revealed the resident was severely cognitively impaired, was not able to make his/her needs known, required extensive assistance for care activities, incontinent of bowel and bladder, and exhibited inattentive behaviors during the assessment period.

Review of Resident R1's care plan, dated December 27, 2021, indicated the resident wandered relative to impaired safety awareness. Interventions indicated were to provide structured activities, toileting, walking inside and outside, reorientation strategies including signs and pictures, wander guard bracelet, conversation, and music.

Review of information received by the Department of Health received on February 7, 2024, revealed a witness to Resident R1 tied to a rolling reclining chair. The incident occurred on December 30, 2023. Review of facility's records failed to reveal an investigation was initiated and Resident R1 was unable to be interviewed due to his/her death on January 13, 2024. The Director of Nursing initially failed to interview staff involved in Resident R1's care.

Review of resident records, facility grievance reports, and facility reported incident system failed to reveal any documentation of incident.

Review of documentation provided by Director of Nursing including a witness statement by Nurse Assistant (Employee E3) dated December 29, 2023, revealed, non licensed Employee E3 observed Resident R1 tied to a chair at the waist with fleece pajama pants, preventing his/her ability to move or stand up.

Review of witness statement from a Registered Nurse, (Employee E4), dated December 30, 2023, revealed that he/she received a call from Employee E3 to come to the floor as it was urgent. Upon arrival on the unit, he/she was asked to observe Resident R1, who was in the bathroom. Licensed Practical Nurse (Employee E5) stated that Resident R1 was found tied to a scoot chair using a pair of fleece pajamas around her trunk/abdominal region. Per Supervisor, Employee E5 stated "I immediately removed the pajama pants due to red mark noted.' Upon assessment, red mark was resolved, and no other injury noted."

Review of witness statement from Licensed Practical Nurse (Employee E5), dated February 12, 2024, revealed when Employee E5 took Resident R1 to the bathroom for incontinence care, Employee E5 was not able to lift Resident R1 out of the scoot chair. Employee E5 found a pair of fleece type pajama pants was tied around the midsection of Resident R1, in a knot, behind the scoot chair. Employee E5 immediately called Employee E3 to witness findings. Employee E5 then called the RN Supervisor, Employee E4 to inform of findings. Employee E5 noticed a reddening area on Resident R1's abdomen, therefore, Employee E5 removed the pajama pants prior to Supervisor Employee E4's arrival on the unit.

Review of an undated witness statement from Licensed Practical Nurse (Employee E6), revealed that Employee E6 observed Resident E1 sitting in a scoot chair, Resident R1 was restless, Employee E6 administered PRN (as needed) Morphine around 8:00 p.m., to help with restlessness. Employee E6 denied seeing anything tied around Resident R1 at the time of care.

Interview with Nursing Home Administrator on February 12, 2024, at 2:00 p.m., revealed the Administrator was not aware of the incident. The Administrator indicated the incident was not reported to the Department of Health, an investigation was not conducted, nor does the facility use any type of restraint.

Interview with Director of Nursing on February 12, 2024, at 2:10 p.m., revealed witness statements were provided by staff, but no investigation was initiated of the incident since the resident was known for being restless and attempting to get out of bed and/or chair on his/her own, thus increasing fall risk. Further interview with Director of Nursing revealed the belief that being tied to the scoot chair was not considered a restraint, rather as a method of keeping the resident safe from falls.

Interview conducted with nurse aide, Employee E3 on February 14, 2024, revealed Employee E3 indicated Resident R1 was not therapy approved for scoot chair use, Resident R1 was able to get up on his/her own. When licensed Employee E5 took Resident R1 to the bathroom for continence care Employee E5 noticed the resident was tied to the scoot chair with pajama pants. Employee E5 requested Employee E3 observe his/her findings as a witness. Resident R1was unable to move, due to the material being tightly tied. Further interview with Employee E3, Licensed staff member, Employee E4, requested written statements at the time of the incident. Employee E3 stated to his/her knowledge no further investigation was conducted, and he/she was not questioned further regarding the incident.

Review of Resident R1's records revealed a fall risk care plan dated December 27, 2021, documenting Resident R1 was at moderate risk for falls. One of the interventions dated October 10, 2023, noted "staff should monitor resident closely after dinner for signs of fatigue such as gait, slower, more unsteady, assist to bed for rest period or chair for rest period if noted."

Further review of Resident R1's clinical record revealed a care plan dated December 27, 2021, documenting Resident R1 as a wanderer relative to impaired safety awareness. Intervention, dated December 27, 2021, indicated "staff should distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Resident prefers religious activities and music (jazz, gospel, Motown)." Another intervention which was revised June 28,2023 was for staff to "redirect resident to his/her own bed if located in a peer's bed. Encourage rest periods throughout the day, especially in the afternoons."

Review of facility records revealed an Occupational Therapy (OT) treatment encounter note dated January 4, 2024, documenting resident was referred for skilled OT evaluation for concave mattress, (bed positioning), and scoot chair (out of bed positioning), and bed rail assessment according to Hospice provider notes. "Scoot chair with resident's name given to resident. Resident transferred to scoot chair with moderate assist of two persons. Resident exhibited optimal posture in the scoot chair. New order for concave mattress placed, per [Hospice provider] request. Skilled OT evaluation only since resident is on hospice. Window side bed rail approved to prevent resident from falling out of bed and safety."

Review of Resident R1's records failed to reveal a care plan for restlessness, scoot chair use, restraints, or bed rails.

Review of Resident R1's records failed to reveal evidence that a pre-restraining assessment and review was completed to determine need for restraint usage with Resident R1.

Interview with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 12:10 p.m. confirmed that no report was made by the facility, no investigation was initiated prior to Department of Health's visit, no pre-restraining assessment was performed, and no restraint documentation was available for Resident R1 since it was the resident was not restrained, rather, staff initiated the restraint to prevent Resident R1 from falling by tying him/her to a scoot chair for safety.

28 Pa. Code 201.18(b)(1)(2) Management

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


 Plan of Correction - To be completed: 03/08/2024

The facility will report all allegations of abuse, including the improper use of restraints to all required agencies. When an allegation of resident abuse occurs, including the improper use of a physical restraint, a report will be made to the state department of health event reporting system, the county office of aging, the resident representative, and the facility administrator at a minimum. The facility will immediately begin an investigation of the incident including interviewing the resident and all staff potentially involved in the incident. The facility will complete an incident report and document the allegation in the resident's medical chart to include verification that the supervisor, resident's representative, and physician were notified. This documentation will be added to the 24-hour report and discussed at morning meeting to ensure correct action has been taken by the facility.

All nursing employees who supervise the facility will be re-educated on the regulations regarding event reporting to the Department of Health event reporting system. Events will be audited weekly for 4 weeks then monthly for 3 months to ensure proper submission. Audit results will be reported to the QAPI committee and discussed at quarterly QAPI meetings.

All licensed staff will be re-educated on the process of reporting and documenting allegations of abuse in the resident's electronic medical record.

System changes in the facility will include policy revision on documentation and appropriate reporting of any suspected abuse and/or any improper use of a restraint. A checklist will be developed to ensure all abuse allegations are reported correctly. This will include the type of abuse, the time frame for reporting each type, and the agencies requiring the report.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on policy, facility documentation, and clinical record review, it was determined that the facility failed to thoroughly investigate an allegation of physical restraint in a timely manner for one of one resident reviewed (Resident R1).

Findings include:

Review of the facility policy titled, "Restraint/Device/Siderail," dated March 2023, revealed it is the policy of Pocopson Homes that all residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical condition. "Restraints will be applied only after a physician's order has been obtained and the family has been notified. Consent must also be signed by the responsible party of the resident. The care plan should be updated, and the appropriate record will be initiated to track the use and release of the restraint. The physician order will include the type of restraint, reason for restraint, how often the restraint is removed. Physical or occupational therapy will be consulted."

Further review of the policy revealed that physical restraints include but are not limited to leg/arm restraints, hand mitts, soft ties, vests, meri-walkers, seatbelts which the resident cannot easily open or remove, specialty chairs which resident cannot easily rise from, low beds, bed against the wall, and side rails which prevent the resident from easily getting out of bed.

Review of Resident R1's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated December 19, 2023, revealed the resident was severely cognitively impaired, was not able to make his/her needs known, required extensive assistance for care activities, incontinent of bowel and bladder, and exhibited inattentive behaviors during the assessment period.

Review of Resident R1's care plan, dated December 27, 2021, indicated the resident wandered relative to impaired safety awareness. Interventions indicated were to provide structured activities, toileting, walking inside and outside, reorientation strategies including signs and pictures, wander guard bracelet, conversation, and music.

Review of information received by the Department of Health received on February 7, 2024, revealed a witness to Resident R1 tied to a rolling reclining chair. The incident occurred on December 30, 2023. Review of facility's records failed to reveal an investigation was initiated and Resident R1 was unable to be interviewed due to his/her death on January 13, 2024. The Director of Nursing initially failed to interview staff involved in Resident R1's care.

Review of resident records, facility grievance reports, and facility reported incident system failed to reveal any documentation of incident.

Review of documentation provided by Director of Nursing including a witness statement by Nurse Assistant (Employee E3) dated December 29, 2023, revealed, non licensed Employee E3 observed Resident R1 tied to a chair at the waist with fleece pajama pants, preventing his/her ability to move or stand up.

Review of witness statement from a Registered Nurse, (Employee E4), dated December 30, 2023, revealed that he/she received a call from Employee E3 to come to the floor as it was urgent. Upon arrival on the unit, he/she was asked to observe Resident R1, who was in the bathroom. Licensed Practical Nurse (Employee E5) stated that Resident R1 was found tied to a scoot chair using a pair of fleece pajamas around her trunk/abdominal region. Per Supervisor, Employee E5 stated "I immediately removed the pajama pants due to red mark noted.' Upon assessment, red mark was resolved, and no other injury noted."

Review of witness statement from Licensed Practical Nurse (Employee E5), dated February 12, 2024, revealed when Employee E5 took Resident R1 to the bathroom for incontinence care, Employee E5 was not able to lift Resident R1 out of the scoot chair. Employee E5 found a pair of fleece type pajama pants was tied around the midsection of Resident R1, in a knot, behind the scoot chair. Employee E5 immediately called Employee E3 to witness findings. Employee E5 then called the RN Supervisor, Employee E4 to inform of findings. Employee E5 noticed a reddening area on Resident R1's abdomen, therefore, Employee E5 removed the pajama pants prior to Supervisor Employee E4's arrival on the unit.

Review of an undated witness statement from Licensed Practical Nurse (Employee E6), revealed that Employee E6 observed Resident E1 sitting in a scoot chair, Resident R1 was restless, Employee E6 administered PRN (as needed) Morphine around 8:00 p.m., to help with restlessness. Employee E6 denied seeing anything tied around Resident R1 at the time of care.

Interview with Nursing Home Administrator on February 12, 2024, at 2:00 p.m., revealed the Administrator was not aware of the incident. The Administrator indicate the incident was not reported to the Department of Health, an investigation was not conducted, nor does the facility use any type of restraint.

Interview with Director of Nursing on February 12, 2024, at 2:10 p.m., revealed witness statements were provided by staff, but no investigation was initiated of the incident since the resident was known for being restless and attempting to get out of bed and/or chair on his/her own, thus increasing fall risk. Further interview with Director of Nursing revealed the belief that being tied to the scoot chair was not considered a restraint, rather as a method of keeping the resident safe from falls.

Interview conducted with nurse aide, Employee E3 on February 14, 2024, revealed Employee E3 indicated Resident R1 was not therapy approved for scoot chair use, Resident R1 was able to get up on his/her own. When licensed Employee E5 took Resident R1 to the bathroom for continence care Employee E5 noticed the resident was tied to the scoot chair with pajama pants. Employee E5 requested Employee E3 observe his/her findings as a witness. Resident R1was unable to move, due to the material being tightly tied. Further interview with Employee E3, Licensed staff member, Employee E4, requested written statements at the time of the incident. Employee E3 stated to his/her knowledge no further investigation was conducted, and he/she was not questioned further regarding the incident.

Review of Resident R1's records revealed a fall risk care plan dated December 27, 2021, documenting Resident R1 was at moderate risk for falls. One of the interventions dated October 10, 2023, noted "staff should monitor resident closely after dinner for signs of fatigue such as gait, slower, more unsteady, assist to bed for rest period or chair for rest period if noted."

Further review of Resident R1's clinical record revealed a care plan dated December 27, 2021, documenting Resident R1 as a wanderer relative to impaired safety awareness. Intervention, dated December 27, 2021, indicated "staff should distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Resident prefers religious activities and music (jazz, gospel, Motown)." Another intervention which was revised June 28,2023 was for staff to "redirect resident to his/her own bed if located in a peer's bed. Encourage rest periods throughout the day, especially in the afternoons."

Review of facility records revealed an Occupational Therapy (OT) treatment encounter note dated January 4, 2024, documenting resident was referred for skilled OT evaluation for concave mattress, (bed positioning), and scoot chair (out of bed positioning), and bed rail assessment according to Hospice provider notes. "Scoot chair with resident's name given to resident. Resident transferred to scoot chair with moderate assist of two persons. Resident exhibited optimal posture in the scoot chair. New order for concave mattress placed, per [Hospice provider] request. Skilled OT evaluation only since resident is on hospice. Window side bed rail approved to prevent resident from falling out of bed and safety."

Review of Resident R1's records failed to reveal a care plan for restlessness, scoot chair use, restraints, or bed rails.

Review of Resident R1's records failed to reveal evidence that a pre-restraining assessment and review was completed to determine need for restraint usage with Resident R1.

Interview with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 12:10 p.m. confirmed that no report was made by the facility, no investigation was initiated prior to Department of Health's visit, no pre-restraining assessment was performed, and no restraint documentation was available for Resident R1 since it was the resident was not restrained, rather, staff initiated the restraint to prevent Resident R1 from falling by tying him/her to a scoot chair for safety.

28 Pa. Code 201.18(b)(1)(2) Management

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



 Plan of Correction - To be completed: 03/08/2024

The fleece pants were immediately removed from resident R1 when discovered revealing no sustained injury. Resident R1 expired 1/13/24 on hospice services. Pocopson Home policy will continue as written stating that all residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical condition. Restraints will be applied only after a physician's order has been obtained and the family has been notified. Consent must also be signed by the responsible party of the resident. When the improper use of a physical restraint is found in the facility, a thorough investigation will be started immediately.

An audit of 10 random residents in wheelchairs will be completed by Nursing on each shift to ensure that they are not improperly restrained. If a resident is identified to have been improperly restrained, a thorough investigation into the use of the restraint will be conducted immediately. These audits will be done weekly for 4 weeks then monthly for 3 months.

A restraint QAPI will be initiated in the facility to include investigation of improper restraint use by staff. Audit results will be reported to the QAPI committee and reviewed during quarterly QAPI meetings.

All nursing employees who supervise the facility will be re-educated on the use of restraints in the facility and the necessity for immediate investigation if a restraint is found to be improperly used. All licensed staff will be re-educated on the facility restraint and resident rights policy.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.

51.3 (f) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:


Based on clinical record review, facility documentation, and staff interviews it was determined that the facility failed to report allegations of abuse including physical restraint of Resident R1 for one of one residents reviewed.

Findings include:

Review of the facility policy titled, "Restraint/Device/Siderail," dated March 2023, revealed it is the policy of Pocopson Homes that all residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical condition. "Restraints will be applied only after a physician's order has been obtained and the family has been notified. Consent must also be signed by the responsible party of the resident. The care plan should be updated, and the appropriate record will be initiated to track the use and release of the restraint. The physician order will include the type of restraint, reason for restraint, how often the restraint is removed. Physical or occupational therapy will be consulted."

Further review of the policy revealed that physical restraints include but are not limited to leg/arm restraints, hand mitts, soft ties, vests, meri-walkers, seatbelts which the resident cannot easily open or remove, specialty chairs which resident cannot easily rise from, low beds, bed against the wall, and side rails which prevent the resident from easily getting out of bed.

Review of Resident R1's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated December 19, 2023, revealed the resident was severely cognitively impaired, was not able to make his/her needs known, required extensive assistance for care activities, incontinent of bowel and bladder, and exhibited inattentive behaviors during the assessment period.

Review of Resident R1's care plan, dated December 27, 2021, indicated the resident wandered relative to impaired safety awareness. Interventions indicated were to provide structured activities, toileting, walking inside and outside, reorientation strategies including signs and pictures, wander guard bracelet, conversation, and music.

Review of information received by the Department of Health received on February 7, 2024, revealed a witness to Resident R1 tied to a rolling reclining chair. The incident occurred on December 30, 2023. Review of facility's records failed to reveal an investigation was initiated and Resident R1 was unable to be interviewed due to his/her death on January 13, 2024. The Director of Nursing initially failed to interview staff involved in Resident R1's care.

Review of resident records, facility grievance reports, and facility reported incident system failed to reveal any documentation of incident.

Review of documentation provided by Director of Nursing including a witness statement by Nurse Assistant (Employee E3) dated December 29, 2023, revealed, non licensed Employee E3 observed Resident R1 tied to a chair at the waist with fleece pajama pants, preventing his/her ability to move or stand up.

Review of witness statement from a Registered Nurse, (Employee E4), dated December 30, 2023, revealed that he/she received a call from Employee E3 to come to the floor as it was urgent. Upon arrival on the unit, he/she was asked to observe Resident R1, who was in the bathroom. Licensed Practical Nurse (Employee E5) stated that Resident R1 was found tied to a scoot chair using a pair of fleece pajamas around her trunk/abdominal region. Per Supervisor, Employee E5 stated "I immediately removed the pajama pants due to red mark noted.' Upon assessment, red mark was resolved, and no other injury noted."

Review of witness statement from Licensed Practical Nurse (Employee E5), dated February 12, 2024, revealed when Employee E5 took Resident R1 to the bathroom for incontinence care, Employee E5 was not able to lift Resident R1 out of the scoot chair. Employee E5 found a pair of fleece type pajama pants was tied around the midsection of Resident R1, in a knot, behind the scoot chair. Employee E5 immediately called Employee E3 to witness findings. Employee E5 then called the RN Supervisor, Employee E4 to inform of findings. Employee E5 noticed a reddening area on Resident R1's abdomen, therefore, Employee E5 removed the pajama pants prior to Supervisor Employee E4's arrival on the unit.

Review of an undated witness statement from Licensed Practical Nurse (Employee E6), revealed that Employee E6 observed Resident E1 sitting in a scoot chair, Resident R1 was restless, Employee E6 administered PRN (as needed) Morphine around 8:00 p.m., to help with restlessness. Employee E6 denied seeing anything tied around Resident R1 at the time of care.

Interview with Nursing Home Administrator on February 12, 2024, at 2:00 p.m., revealed the Administrator was not aware of the incident. The Administrator indicated the incident was not reported to the Department of Health, an investigation was not conducted, nor does the facility use any type of restraint.



 Plan of Correction - To be completed: 03/08/2024

The facility will report all allegations of abuse, including the improper use of restraints to all required agencies. When an allegation of resident abuse occurs, including the improper use of a physical restraint, a report will be made to the state department of health event reporting system, the county office of aging, the resident representative, and the facility administrator at a minimum. The facility will immediately begin an investigation of the incident including interviewing the resident and all staff potentially involved in the incident. The facility will complete an incident report and document the allegation in the resident's medical chart to include verification that the supervisor, resident's representative, and physician were notified. This documentation will be added to the 24-hour report and discussed at morning meeting to ensure correct action has been taken by the facility.

All nursing employees who supervise the facility will be re-educated on the regulations regarding event reporting to the Department of Health event reporting system. Events will be audited weekly for 4 weeks then monthly for 3 months to ensure proper submission. Audit results will be reported to the QAPI committee and discussed at quarterly QAPI meetings.

All licensed staff will be re-educated on the process of reporting and documenting allegations of abuse in the resident's electronic medical record.

System changes in the facility will include policy revision on documentation and appropriate reporting of any suspected abuse and/or any improper use of a restraint. A checklist will be developed to ensure all abuse allegations are reported correctly. This will include the type of abuse, the time frame for reporting each type, and the agencies requiring the report.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.


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