By Walter F. Roche Jr.
A 73-year-old dementia patient who became combative, was beaten by a state of Pennsylvania employee assigned to care for the him at a state run facility in Franklin County.
The state employee, who was subsequently arrested, slapped the man after he had struck her. Despite pleas from her co-worker to stop, the employee continued to slap the patient on the chest and arms.
Though she stopped momentarily, the employee then slapped the patient two or three more times.
The incident at the South Mountain Restoration Center was described in detail by a state Health Department inspector in a report issued on July 31.
Court records show that the charges against Melinda V. Rutledge were ultimately dismissed by a Franklin County district judge.
"The resident has a right to be free from abuse and neglect," the state inspection report states, adding that the allegation of abuse was substantiated as a result of the investigation. .
The 73-year-old patient, who had impaired vision in addition to deafness, had a history of traumatic brain injury, the report states.
The report on the incident at the 159-bed facility is not the first to show problems with patient care at the facility. Earlier this year state surveyors found that a female patient was the victim of a male patient who sexually abused her. He was found in the female patient's room with his hand in her briefs.
South Mountain describes itself on its web site as a provider of "compassionate, professional quality care" for patients who have "exhausted other alternatives."
According to the state report the July 21 incident began at 10:45 p.m. when two aides went to the male patient's room to provide care.
"Resident 1 (the male patient) was not co-operating and started to become combative," the report states. The resident then struck the aide and she responded by slapping the patient with an open palm
several times on the arm and chest.
"I told her not to hit him and tried to get her to leave the room," a fellow worker told the state surveyors, adding that the employee then struck the patient two or three more times.
She said she then sought help from another employee, but the aide refused to leave the room. Eventually a supervisor was summoned.
One of the other employees told the surveyors that she told the aide that "it was probably not the best to yell at the patient because he did not have his hearing aides on. That worker said she could hear loud slapping and screaming from another patient's room.
Yet another employee reported that she saw red marks on the patient's side following the incident.
In a response to the report, managers of the facility said that by the next day the red marks had "dissipated" and the patient subsequently underwent a psychiatric evaluation.
They also stated that a subsequent investigation showed no other such events and no other reports of patient abuse were discovered.
According to the management response in-service training was provided for staff and steps were taken to avoid future incidents of "caregiver burnout and compassion fatigue."
Employee charged after patient struck in Pa.
SOUTH MOUNTAIN, Pa. — An employee of the South Mountain Restoration Center was charged Tuesday after she allegedly struck a resident, Pennsylvania State Police said.
Melinda Victor Rutledge, 38, of Chambersburg, Pa., was served with a summary harassment/physical contact summons by the office of Magisterial District Judge Kelly Rock.
Police went to the center on South Mountain Road on Sunday at 10:45 p.m. and determined that a staff member struck a resident, identified as a 73-year-old man from Wernersville, Pa.
South Mountain Restoration Center is a 159-bed long-term care facility licensed by the Pennsylvania Department of Health, according to the state’s website.
The center is certified by the Centers for Medicare and Medicaid Services, according to the website.
There are 61 surveys for this facility. Please select a date to view the survey results.
Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
SOUTH MOUNTAIN RESTORATION CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on the findings of an Abbreviated Incident survey completed on July 31, 2019, at South Mountain Restoration Center; the facility was found to be not in compliance with 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:
483.12(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;
Observations:
Based on clinical record review, facility documentation review and staff interview, it was determined that the facility failed to ensure one of three residents reviewed were free from physical abuse (Resident 1).
Findings include:
Review of Resident 1's on July 29, 2019, at approximately 11:00 AM, revealed diagnoses that included a history of traumatic brain injury (injury to the brain that causes an array of possible cognitive and/or psychomotor deficits), and dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and difficulty performing activities of daily living).
Review of Resident 1's comprehensive plan of care revealed a care plan wit a focus of, "[Resident 1] is resistive to care at times [related to] Dementia, hearing impairment, and vision impairment," which was initiated on July 8, 2019, and had a goal of, "[Resident 1] will cooperate with care through next review date," which was initiated on July 8 and revised July 12, 2019. Review of the interventions for Resident 1's resistance to care included, "If [Resident 1] resists with [activities of daily living], reassure [Resident 1], leave and return 5-10 minutes later to re-approach."
Review of facility incident investigation report revealed a witness by Nurse Aide (NA) 2, dated July 21, 2019, that stated, "[NA 1] and I went into [Resident 1]'s bedroom to provide care during last rounds at [10:45 PM]. [Resident 1] was not cooperating and started to become combative. The resident struck [NA 1] and after she was struck she slapped the resident with an open palm multiple times on the left arm and chest. I told her not to hit him and tried to get her to leave the room. She then hit the resident 2 or 3 more times on the arm and chest again. I told her to stop and then went and got my coworker who was in the bedroom across the hall. [NA 3] came to the room with me and her and I both tried to get [NA 1] to leave the room, but she wouldn't...After the incident, the supervisor was notified around [11:00 PM] - [11:05 PM]..."
Review of facility witness statement completed by NA 3, dated July 21, 2019, revealed it stated, "Me [NA 3], [NA 1], and [NA 2] were doing last rounds. Start at 10:30 PM as we approached the residents room [NA 2] and [NA 1] went in to and try to put the resident to bed and change him. I [NA 3] went to the next residents room. As I was caring for another resident I could hear [NA 1] yelling at [Resident 1]. When i finish caring for the other resident I left the room and went to [NA 1] and said 'It's probably not the best idea to yell at him," but [NA 1] continued." During a staff interview on July 29, 2019, at approximately 12:20 PM, Nursing Home Administrator revealed that, at the time, NA 1 was heard yelling and it was explained to NA 3 that Resident 1 did not have his hearing aides in at the time. NA 3's statement continued, "I [NA 3] went on to care for other residents and as I was caring for them I could hear loud slapping and screaming coming from [NA 1]. Then [NA 2] came over to the room I was giving care in and asked me to please help him because [NA 1] won't stop yelling and hitting [Resident 1]...As I was trying to calm [Resident 1] down I noticed red hand prints on the chest and left shoulder, so I proceeded to get the nurse [Licensed Practical Nurse 1]."
Review of Licensed Practical Nurse [LPN] 1's witness statement dated July 21, 2019, revealed it stated, "[NA 3] came and notified me that [Resident 1] was having behaviors and needed help. When I walked into [Resident 1's] room I saw a red mark on his left side of his chest."
Review of facility investigation report revealed that the facility investigation of allegation of physical abuse by NA 1 against Resident 1 was found to be substantiated.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management
28 Pa Code 201.29(j) Resident rights
.
Plan of Correction - To be completed: 08/30/2019
1. The red marks associated dissipated the following day. R1 has been seen by Psychiatry for evaluation with recommended medication timing adjustments to improve acceptance of care. R1 meets with his social worker at least weekly for emotional support and encouragement. There have been no other occurrences or events related to abuse for this resident. Residents care plan for emotional distress related to the incident has been updated to reflect weekly visits from the Social Worker to ensure Psychosocial needs being met and improved interventions for staff approach. NA#1 was immediately removed from duty and remains on suspension pending disciplinary action.
2. Current residents on the unit where NA 1 was assigned will have incident reports for all injuries of unknown origin for the last 30 days reviewed to validate that suspected or reported allegations of abuse have been identified and appropriate follow up has been completed. Residents who are capable of verbally communicating will be interviewed by Social Services to validate that there have been no unknown allegations of abuse. Findings of the reviews will be reported to the Quality Assurance and Performance Improvement Committee.
3. In-service training will be completed for nursing staff to include the components of Abuse regulations and accompanying guidelines for these regulatory components. Resources will be provided to all licensed and non-licensed nursing staff in regards to caregiver burn-out and compassion fatigue. All resident grievances are reviewed by the facility's Executive staff to identify any potential issues related to abuse or rights violations and validate that appropriate actions have been taken.
4. The Quality Assurance Director and/or designee will review and audit all grievances as well as incident reports for injuries of unknown origin weekly for 4 weeks and monthly for 3 months to validate that any identified issues related to abuse have been followed up on accordingly. Audits will be reviewed by the QAPI committee to ensure compliance and quality assurance.
483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: 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.
§483.10(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 observation, clinical record review, facility document review, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed were free of physical restraints (Resident 2).
Findings include:
Review of facility document, with subject of, "Use of Restraints, Seclusion, and Exclusion in State Mental Hospitals and the [South Mountain] Restoration Center," revealed section VII. Restraint," defined a restraint as, "Any method of restricting a person's freedom of movement, physical activity, or normal access to his/her body."
Review of Resident 2's clinical record on July 29, 2019, at approximately 11:30 AM, revealed diagnoses of anoxic brain injury (injury of the brain caused by lack of oxygen that can cause functional and cognitive deficits) and dementia (irreversible, progressive degenerative disease of the brain that results in decreased reality contact and daily functioning ability).
During general observation of the third floor unit on July 29, 2019, at approximately 10:30 AM, Resident 2 was observed ambulating independently in the hallway. Upon observation of Resident 2 it was revealed that Resident 2 had a one-piece suit on that covered Resident 2 from mid-thigh to the neck, and down to mid biceps. Observations of the one-piece suit revaluated an opening in the back of the one-piece suit.
Review of Resident 2's comprehensive plan of care revealed a care plan with a focus of, "Resident 2 has an [activities of daily living] self-care performance deficit," initiated on February 11, 2015 and last revised on June 23, 2017. Review of the interventions for the aforementioned care plan revealed an intervention of, "[Resident 2] wears one piece jumpsuit open in back due to history of frequently exposing himself," which was initiated on February 11, 2015, and last revised on July 23, 2017.
During a staff interview on July 29, 2019, at approximately 12:30 PM, Nursing Home Administrator revealed that Resident 2 is not able to easily remove the one-piece suit.
Review of Resident 2's physician orders revealed no order for the one-piece suit. Review of Resident 2's clinical record revealed no restraint assessment, and no care plan for the one-piece suit.
During a staff interview on July 29, 2019, at approximately 2:30 PM, Nursing Home Administrator revealed that Resident 2's one-piece suit was considered a safety device. During the interview, Nursing Home Administrator revealed that safety devices were not considered restraints.
28 Pa Code 211.8(c)(d)(e)(f) Use of restraints
28 Pa Code 211.12(d)(5) Nursing services
Plan of Correction - To be completed: 08/30/2019
1. The staff began a trial with traditional clothing for Resident #2 immediately following the survey. Staff are working to identify style of clothing best suited to resident's need given activity level and safety awareness.. Resident #2's Plan of Care has been updated to reflect that he no longer wears one piece suits and utilizes typical clothing. The facility has developed a Procedure for the use of one-piece suit for the purpose of health, safety or dignity of residents or peers and the nursing staff and physicians will be educated on this procedure. If R2 presents with the potential need for one piece suits, the procedure will be followed.
2. There are no other residents in this facility using a one piece suit at this time. If a resident presents with the potential need in the future, the facility procedure will be followed.
3. In-service training will be completed with nursing staff and facility staff physicians regarding One Piece Suit Procedure and in relation to the F604 tag, requirements of trial use when implementing, observations, need for physician's order, and proper Care Planning of use. Training completion will be reported to the Quality Assurance and Performance Improvement Committee.
4. The Quality Assurance Director and/or designee will review and monitor all residents in the facility for use on One Piece Suits for a period of 6 months. This review will include proper implementation of the procedures, proper documentation of the trial and implementation of physician order, and communication of need with the staff. Any new implementations of One Piece Suits will be reported to the Executive Staff via the Executive Staff Morning Report. Monitoring will be reported monthly to the QAPI Committee.
______
Tuesday, April 30, 2019
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.
Contact:wfrochejr999@gmail.com
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