KINGSTON, PA – MANORCARE HEALTH SERVICES-KINGSTON

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, review of clinical records, facility documentation and the facility’s abuse prohibition policy and procedure and interviews with staff and residents, it was determined the facility failed to protect one resident (CR1) from physical abuse, which resulted in significant bruising, fractured ribs and transfer to emergency room for one out of nine clinical records reviewed.

Documentation provided by the facility indicated that in the early morning of (MONTH) 30, 2019, at approximately 1:00 AM, Employees 1 and 2 were placing the resident on the bedpan. Employee 2 had been sent from another unit to assist Employee 1 who was assigned to the resident’s care during that shift. Employee 1 was on the resident’s right side and Employee 2 was on the resident’s left side, when Employee 1 went to roll the resident towards Employee 2, Employee 2 grabbed the resident’s hip and right arm and yanked her over. Employee 1 placed the bedpan under the resident. When both nurse aides went to take the resident off the bedpan Employee 2 pushed the resident on her hip so hard she {the resident} almost fell off the bed. Employee 1 stated that she had to put all her weight against the resident so she would not fall out of the bed. Employee 1 reported Employee 2’s rough care of Resident CR1 to Employee 3, the LPN (licensed practical nurse). Employee 1 reported that Employee 3 replied that Employee 2 was acting like that because she actually had to work and not sleep.

A review of a statement from Employee 1 dated (MONTH) 4, 2019, revealed that she stated she had asked Employee 2 to help her with Resident CR1 (on (MONTH) 30, 2019, 11 PM to 7 AM shift). Employee 1 stated that Employee 2 was rough with all the residents she helped her with that night, and in particular Resident CR1. Employee 1 stated Employee 2 pulled Resident CR1 by her arm and pulled her towards her; she then rolled Resident CR1 so hard that she had to put her knees on the side of the bed and her arms behind the resident so she wouldn’t roll off the bed. Employee 1 stated that Resident CR1 sustained a bruise at the location where Employee 2 had pushed the resident.

Resident 1 was interviewed on (MONTH) 9, 2019, at 9:40 AM and she confirmed she didn’t actually see anything the night in question, but she heard the resident moaning and yelling. Resident 1 also stated she heard Employee 1, with whom she is very familiar, saying to Employee 2 you have to be careful you are turning her too hard! Resident 1 also stated Employee 4, an RN (registered nurse), told her to keep her mouth shut regarding her account of the incident.