PA Run Home Failed to Protect Patients

By Walter F. Roche Jr.

A Pennsylvania run nursing home has been cited by one of its own agencies for failing to meet federal health care standards including leaving female residents subject to sexual abuse by a male resident, whose behavior could not be controlled.
In a lengthy report issued by the state Health Department, the South Mountain Restoration Center in rural Franklin County, was also faulted for failing to take steps to prevent vulnerable residents from repeated falls, falls resulting in fractures and other injuries.
The report was based on an inspection conducted earlier this year to determine the facilities compliance with minimum standards for the federally funded Medicare and Medicaid programs. The 159-bed facility is licensed as a nursing home and bills itself as a provider of "compassionate, professional quality care" for patients who have "exhausted other alternatives."
According to the state web site for the center, its patients include former residents of state centers and correctional institutions.
Based on a review of patient records and interviews with patients and employees, surveyors from the state Health Department listed multiple examples of the failure to meet minimum standards in categories ranging from infection control to food handling and maintaining proper individual patient records. The facility was cite for similar deficiencies in the past but failed to implement promised corrective action plans filed in response to those prior citations.
The state Department of Human Services did not respond to a request for comment on the report. The facility did file a corrective action plan in which it promised to make needed corrections.
One male resident, was the focus of several citations in the new report, including touching the breast of one patient and placing his hands in the underwear of another.
The facility "failed to ensure patients were free of non-consensual sexual contact," the report states.
In mid-May the male patient was found in the room of a female patient with his hand in her briefs.
He was asked to leave immediately, according to the report.
Later that same month he was cited again for touching the breast of another female.
The male patient, the report concludes "did not receive adequate interventions to prevent him from inappropriately touching female patients."
In a separate incident with another male resident, a staffer was cited for slapping the patient with a wet facecloth after he was observed with his genitals exposed. The aide had taken the male patient into a woman's room which was in use by a female patient.
The surveyors review of records showed that steps were not taken to prevent additional falls by patients who were considered at risk for falls. And even when falls occurred facility personnel failed to investigate the cause.
In addition in some cases patient records failed to include details of the fall and resulting injuries.
The 2019 report states that South Mountain failed to ensure that effective infection control plans ere in effect. Residents who had tested positive for the flu were observed wandering around without protective masks.
Staffers, according to the report, failed to follow a doctor's orders for a patient on a feeding tube and, in one case, wrongly recorded the amount of nutrient the patient had received.
Still other deficiencies included failure to investigate a patient's charge of abuse and placing an in-dwelling catheter in a patient without a physician's order.
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