Sexual Assault at PA Nursing Home

By Walter F. Roche Jr.

An elderly disabled female patient was sexually assaulted late last year by a male patient at a Norristown, PA. nursing home, according to a report by the Pennsylvania Health Department.
According to the report, which was just recently made public, the assault took place at the Norriton Square Nursing and Rehabilitation Center, a 99-bed home, part of Genesis Healthcare.
The report, based on an investigation in December, charges that the nursing home failed to protect a patient from abuse and neglect. It also charges that the nursing home failed to develop a care plan for the male patient to deal with his behavioral problems and his cognitive impairment.
The male patient, the report states, was taken away by police shortly after the incident.
The male was discovered in the female patient's room atop the female "and both residents were naked from the waist down."
In a subsequent interview with police, the female patient, who was identified as Resident 2, said that "a man came into her room and attempted to rape her."
Officials of Genesis did not respond immediately to a series of questions regarding the incident and the state report.
The female patient had been admitted to the facility a little over two years before the attack, while the male was admitted in August of 2018.
In addition to his cognitive impairment, the male patient had been diagnosed with a heart condition and diabetes and was subject to periods of temporary unconsciousness.
The female patient had been diagnosed with dementia, a urinary tract infection and was "moderately cognitively impaired." She also needed extensive assistance.
The male was discovered in the female patient's room by a nursing home employee, who then left to seek assistance from a nurse.
"Resident 1 was observed thrusting himself against Resident 2," the report states.
The residents were separated, the report continues.
The female resident was subsequently sent to a hospital for evaluation "and testing with a rape kit."
The male patient, when questioned by a staffer, said that "one of the nurses had caught him having sexual relations and (he) wanted to know why police were at the facility."
He later said that he hadn't done anything wrong and "that nurse is lying."
"The facility failed to protect one cognitively impaired resident from the sexual advances of another resident. This failure resulted in actual harm to Resident 2," the report concludes.
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Einstein Failed to Investigate Abuse Complaint

By Walter F. Roche Jr.

A complaint of patient abuse at the Einstein Medical Center in Montgomery County was not properly investigated, according to a report issued by the Pennsylvania Health Department.
The report, which was just made public states that the patient abuse complaint was filed in behalf of a patient on Aug. 29 of last year, yet when a state surveyor visited the facility in mid-December the only records available on the incident were unsigned, undated handwritten notes.
When the inspector asked for additional records including "documentation of signed and dated statements for all staff and witnesses who involved or who witnessed the alleged patient abuse. None were provided," the report states.
The document does not disclose the nature of the complaint or give any indication if it was substantiated.
Einstein also was faulted for failing to respond in writing within seven days to grievances filed by or in behalf of patient
The two examples of delayed response were the abuse allegation and another unspecified grievance by another patient.
lso cited by the state surveyors was the lack of documentary evidence that some patients were provided with a copy of a notice from the Centers for Medicare and Medicaid Services stating the rights of covered patients at least two days before discharge.
The notice called An Important Message from Medicare.
Einstein officials did not respond to requests for comment.
In a plan of correction filed in response to the state report, the hospital said it was creating a new investigative team to look into all complaints charging patient abuse. The panel includes top hospital executives.
The facility also said it would set up audit procedures to ensure that responses to grievances are issued within the seven day time limit. The plan also calls for a series of re-training sessions to make staff aware of proper procedures in handling abuse complaints and other grievances.
Also cited by the state surveyors was the lack of documentary evidence that some patients were provided with a copy of a notice from the Centers for Medicare and Medicaid Services listing the rights of covered patients at least two days before discharge.
The notice called An Important Message from Medicare.
In a plan of correction filed in response to the state report, the hospital said it was creating a new investigative team to look into all complaints charging patient abuse. The facility also said it would set up audit procedures to ensure that responses to grievances are issued within the seven day time limit. The plan also calls for a series of re-training sessions to make staff aware of proper procedures to handle abuse complaints and other grievances.
Also cited by the state surveyors was the lack of documentary evidence that some patients were provided with a copy of a notice from the Centers for Medicare and Medicaid Services stating the rights of covered patients at least two days before discharge.
The notice is called An Important Message from Medicare.
Contact: wfrochejr999@gmail.com

Philly Patient Gets Double Morphine Dose

By Walter F. Roche Jr.

A patient at a Philadelphia nursing home was given a double dose of morphine for some three weeks, according to an inspection report from the Pennsylvania Department of Health.
The overdose was discovered in an annual inspection of the Maplewood Nursing and Rehabilitation conducted just after Christmas. The report concludes that the 180-bed facility was out of compliance with the standards for participation in the federally funded Medicaid program.
In addition to the multi-week morphine overdose, the report states that the morphine was administered by sublingual pills instead of by feeding tube as prescribed by the physician.
Yet another patient state surveyors found, was administered a second dose of morphine after a two hour interval instead of the three hour limit prescribed.
Overall the report found that the facility's medication error rate was 5.4 percent, exceeding the 5 percent standard.
Other medication errors include a patient getting a double dose of a blood pressure medication and another getting the wrong dose of lidocaine.
Officials of Maplewood filed a plan of correction with the state in which they agreed to re-educate staff on medication and other standards.
The surveyors also cited the home, located in the city's Germantown neighborhood, for unsanitary conditions in food preparation areas.
The facility "did not ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety," the report states.
Cited was a heavy build up of dust, dirt and "a white powdery substance on the floor."
The inspectors also found that the facility failed to maintain temperature logs for a freezer and allowed a pooling of water on floor surfaces.
In patient rooms, surveyors reported finding dirty conditions.
"The facility failed to provide a clean, comfortable environment for their residents," the report continues.
The home's plan of correction calls for those deficiencies to be eliminated promptly.
In the review of individual patient records, the state found that the facility failed to update records of a patient who had changed her status from "full code" to reflect that she did not want to be intubated.
Other issues include improper handling of linens, and failure to inform a physician of a patient's low blood sugar levels.
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Philly Home Left Patient in Pain

By Walter F. Roche Jr.

A Philadelphia nursing home has been cited for failing to respond to the pleas for help and medication from a female patient enduring excruciating pain.
In a report recently made public by the state Health Department, the Caring Heart Rehabilitation and Nursing Center in the city's Germantown section was cited for failing to respond to a patient in severe pain. In fact a state surveyor reported hearing the patient crying out for help during a November inspection.
"The patient was lying in bed and appeared dishevilled, her lips were dry and swollen," the report states. The patient "tearfully cried out several times saying that her legs hurt and she couldn't move them."
As a result of the inspection, the home was found out of compliance with the requirements of the federally funded Medicare program.
In addition to ignoring the patient's cries for help, the report charges that the facility failed to investigate multiple charges of abuse and neglect registered by multiple patients.
Officials of the 269 bed facility at 6445 Germantown Ave. could not be reached for comment, but they did file an abbreviated plan of correction with the state agency.
According to that filing staffers were to undergo a re-education program on the proper response to requests for relief from pain. The response also states that the female patient was re-assessed and had her medications and treatment revised.
As for the abuse and neglect charges, home officials said the six patients involved had been discharged.
The report states that the woman crying out for help had a neurological disorder and multiple pressure ulcers including one that went all the way to the bone. In addition she was totally dependent on staff for eating, toileting, bed mobility and hygiene.
"The patient verbalized constant pain at rest," the surveyors reported.
"The resident revealed that she had hollered out for help to a couple people that passed her room and they never stopped. They just kept on walking."
The resident told the inspector that when a janitorial staffer came in her room she told him she was in pain and needed water. She said the worker finished mopping and left, closing the door behind him.
Other residents recounted that their pleas for help were ignored and one staffer said, "Don't bug me," in response to a complaint.
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