Veterans Home Cited in Multiple Falls

By Walter F. Roche Jr.

The same state run nursing home where 42 patients died in a Covid-19 outbreak this year has been cited by Pennsylvania regulators for failing to take corrective action when the same patient fell four times, two of them resulting in actual harm - hip fractures.
A report issued this week on the Southeastern Veterans Center in Chester County said the the falls occurred between March 29 and May 29. The first and last landed the patient in a local hospital with hip fractures.
The seven-page report notes that because of the falls the patient could no longer get out of bed or walk without assistance.
The state Health Department surveyors were actually in the 238-bed facility on the day of one of the falls and observed the patient lying on the floor in the dining area.
In all four cases, the report states, officials of the state run home failed to thoroughly investigate the incidents and take steps to avert yet another fall.
Though it is now under different management, the home has been cited for multiple violations in the deaths of 42 patients from Covid-19 earlier this year.
The facility's management filed a plan of correction in response to the latest July 16 report in which it promised to review and conduct root causes analyses on all patient falls. Officials of the state Department of Military and Veterans Affairs, which runs the home, did not respond to questions about the report.
The lack of action on the multiple falls came despite the prior determination that the patient was at high risk of falling and was in severe cognitive decline.
According to the report on March 29 a staff nurse heard a loud noise around 4 p.m.The patient was found on the floor near the bathroom. He complained of leg pain and was ultimately diagnosed with a hip fracture requiring surgery.
On his return, the surveyors reported, no new interventions were initiated to prevent future falls and there was no final determination of the cause.
Two Other falls, apparently without injury, were reported on April 8 and early May. Though a special wheel chair had been promised, he never got it.
After the May 29 fall the patient reported pain in his left hip and wrist and was sent to the hospital for surgery.
"The facility failed to thoroughly review, determine the cause and develop new or effective fall preventions after the fall," the report concludes, noting that the March 29 fall "resulted in a decrease in transfer and walking ability."
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