395896
08/31/2023
Homewood Living Martinsburg, Inc
437 Givler Drive Martinsburg, PA 16662
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm or potential for actual harm
Based on the review of the facility policies, clinical records and facility investigation records, as well as staff interviews, it was determined that the facility failed to ensure that an allegation of abuse was reported timely for one of six residents reviewed (Resident 1).
Residents Affected - Few
Findings include: The facility's policy regarding abuse, dated January 2, 2023, indicated that all allegations of abuse shall be reported immediately to the charge nurse/Registered Nurse supervisor, Director of Nursing, and resident physician for investigation into the incident. The staff member who discovers the incident, suspected abuse situation, or has initial knowledge of such incidents will be responsible for immediately notifying his or her supervisor. The executive Director and/or the Director of Nursing must immediately report, or no later than 24 hours, the incident to the state survey agency. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 12, 2023, indicated that the resident was confused, required extensive assistance of two staff for hygiene and required total assistance of two staff for bed mobility and transfers. Facility investigation documents, dated July 25, 2023, included a statement from Nurse Aide 1 that indicated there was an incident she witnessed 10 to 11 months ago regarding Resident 1. Nurse Aide 1 and Nurse Aide 2 were providing care and while wiping the resident's buttocks the resident was yelling out. Nurse Aide 2 stated that she felt it would be funny to put her two fingers into the resident's butt to shut him up. Nurse Aide 1 physically saw Nurse Aide 2 putting her fingers in and he screamed then went back to his yelling. Nurse Aide 2 then laughed. Nurse Aide 1 thought of reporting the incident but she did not want to get in trouble. Information reported by the facility revealed that the above incident occurred approximately ten to eleven months ago but was not reported to the Director of Nursing until July 25, 2023, at 5:00 p.m. A follow-up interview with Nurse Aide 1 during the on-site investigation revealed that she would not confirm seeing the actual abuse, only that Nurse Aide 2 made the threat. Interview with the Director of Nursing on July 21, 2023, at 9:35 a m. confirmed that Nurse Aide 1 did not report the allegation of abuse immediately and that she should have. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.
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395896
395896
08/31/2023
Homewood Living Martinsburg, Inc
437 Givler Drive Martinsburg, PA 16662
F 0607
Level of Harm - Minimal harm or potential for actual harm
Based on the review of the facility policies, clinical records and facility investigation records, as well as staff interviews, it was determined that the facility failed to ensure that an allegation of abuse was reported timely for one of six residents reviewed (Resident 1).
Findings include:
Residents Affected - Few The facility's policy regarding abuse, dated January 2, 2023, indicated that all allegations of abuse shall be reported immediately to the charge nurse/Registered Nurse supervisor, Director of Nursing, and resident physician for investigation into the incident. The staff member who discovers the incident, suspected abuse situation, or has initial knowledge of such incidents will be responsible for immediately notifying his or her supervisor. The executive Director and/or the Director of Nursing must immediately report, or no later than 24 hours, the incident to the state survey agency. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 12, 2023, indicated that the resident was confused, required extensive assistance of two staff for hygiene and required total assistance of two staff for bed mobility and transfers. Facility investigation documents, dated July 25, 2023, included a statement from Nurse Aide 1 that indicated there was an incident she witnessed 10 to 11 months ago regarding Resident 1. Nurse Aide 1 and Nurse Aide 2 were providing care and while wiping the resident's buttocks the resident was yelling out. Nurse Aide 2 stated that she felt it would be funny to put her two fingers into the resident's butt to shut him up. Nurse Aide 1 physically saw Nurse Aide 2 putting her fingers in and he screamed then went back to his yelling. Nurse Aide 2 then laughed. Nurse Aide 1 thought of reporting the incident but she did not want to get in trouble. Information reported by the facility revealed that the above incident occurred approximately ten to eleven months ago but was not reported to the Director of Nursing until July 25, 2023, at 5:00 p.m. A follow-up interview with Nurse Aide 1 during the on-site investigation revealed that she would not confirm seeing the actual abuse, only that Nurse Aide 2 made the threat. Interview with the Director of Nursing on July 21, 2023, at 9:35 a m. confirmed that Nurse Aide 1 did not report the allegation of abuse immediately and that she should have. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.
395896
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