POTTSVILLE, PA-POTTSVILLE REHABILITATION AND NURSING CENTER

ABUSE

Based on review of clinical records, select facility policy and investigative reports, observation, and resident and staff interview, it was determined that the facility failed to ensure that four residents were free from abuse out of 25 residents sampled (Residents 96, 124, 21, and 83).

A review of information submitted by the facility and a facility incident investigation dated November 23, 2022, at 8:15 a.m., revealed that Employee 3 witnessed Resident 121 walk behind Resident 124 and slap her twice upside the head. Employee 3 stated there was no previous interaction between these two residents. Resident 124 was assessed by nursing and was without injury. New intervention planned was for Resident 121 to be in staff’s line of sight when the resident was out of bed.

A review of information submitted by the facility and a facility incident investigation dated December 2, 2022, at 1:50 p.m., revealed that Employee 3 heard yelling down the hallway. Employee 3 found Resident 121 sitting on the floor outside his room and two other residents standing nearby. Resident 21 stated he was hitting me. Residents 121 and 21 were assessed for injury. Resident 121 had a small skin tear and Resident 21 was without injury. It was noted that Resident 121 would be put on a 1-1 supervision.

Nursing Home Administrator and Director of Nursing made surveyors aware on December 8, 2022, that Resident 121 had another resident-to-resident incident on the evening of December 7, 2022. The information available on time of survey ending December 9, 2022, indicated that Resident 83 attempted to take food from Resident 121’s dinner tray and Resident 121 stabbed Resident 83 on her right index finger with his fork. Resident 83 was assessed to have minor skin tears to her right index finger. Employee 4 (NA) stated she was standing behind Resident 121 and attempted to stop Resident 83 from grabbing Resident 121’s food, but was unable to stop the incident.

The facility failed to ensure that Residents 96, 124, 21, and 83 were free from physical abuse perpetrated by Resident 121.

An interview with the DON (director of nursing) and NHA (nursing home administrator) on December 09, at approximately 10:15 AM confirmed the facility substantiated physical abuse of Residents 96, 124, 21, and 83 by Resident 121.

STAFFING

Based on a review of the facility’s abuse policy and employee personnel files and staff interviews, it was determined that the facility failed to implement their established procedures for screening two of five employees for employment (Employee 1, and 2).

Interview with the Director of Human Resources on December 9, 2022, at 10:15 a.m. she confirmed the Pennsylvania State Police background checks were not obtained for Employee’s 1 and 2 until December 7, 2022, which was more than 30 days after hired.