Patient Abuse at PA Vets Home

By Walter F. Roche Jr.

A resident at a Pennsylvania veterans nursing home was subjected to mental abuse, according to a report from the state Department of Health.
The incident occurred at the Hollidaysburg Veterans Center in Blair County, one of six state run nursing facilities for veterans in Pennsylvania. A second veterans home, the Southwestern Veterans Center in Pittsburgh also was cited recently for an incident in which a patient suffered a finger fracture.
According to the Hollidaysburg report, an unnamed employee interacted inappropriately with a male patient who was cognitively impaired.
The nurse's aide prompted the patient to repeat vulgar/sexual statements which then provoked laughter from other unidentified employees.
The incident was reported by a dietary aide, who witnessed it a day earlier. The incident was not immediately reported to the home administrator as required, the report states, adding that the details were verified by another employee.
Noting that employees were instructed to err on the side of reporting if they were unsure of an abuse incident, the state Health Department surveyors noted that it wasn't until four days after the incident when the home administrator was notified.
In a plan of correction filed by the veterans center, officials promised to conduct a re-education program for staffers on the requirements for reporting suspected physical or mental abuse. The patient, according to the surveyors, had no recollection of the incident
The center also was faulted for failing to respond promptly and properly to an incident in which a resident's midline catheter fell out.
Yet another resident had been administered an opioid 32 times in a three month period without a proper assessment of the level of pain the resident was experiencing.
The home's quality improvement team also was criticized for failing to complete compliance audits despite repeated deficiencies.
At the Pittsburgh veterans home surveyors reported that a resident was found to have a bruised finger. A subsequent X-Ray showed the patient had a fractured finger as a result of a fall during a wheelchair to bed transfer.
The certified nursing assistant involved, however, failed to report the incident as required.
In a plan of correction home officials said the nursing assistant was "immediately in-serviced" on fall management practices.
Another resident complained that mail from her daughter had been opened and an herbal supplement contained in the package had been removed.
Center employees said they had opened the package due to concern that it contained unapproved medications.
In a plan of correction home officials said staff would be instructed not to open patient mail and audits would be conducted to ensure compliance.
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