Two Pa Veterans Homes Cited for Violations

By Walter F. Roche Jr.

Two of the six Pennsylvania run nursing homes for veterans have been found out of compliance with the minimum standards required for participation in the federally financed Medicare and Medicaid programs.
In detailed inspection reports recently posted on the state Health Department's web site, the violations were found at the 339-bed Hollidaysburg Veterans Center in Blair County and the 238 bed Southeast Veterans Center in Chester County.
Joan Nissley, spokeswoman for the state Department of Military and Veterans Affairs, which runs the homes, said that corrective action plans to address the deficiencies have been implemented and accepted by the state Health Department.
"We remain committed to providing quality long-term care for Pennsylvania's veterans and their spouses in a safe, secure and caring environment," Nissley stated, adding that she could not comment on specific personal patient care.
The report on the Chester County facility cites multiple cases of patients falling and sustaining injuries because staffers did not assist them as ordered in their medical records.
The facility "failed to ensure that adequate monitoring, supervision and implementation of interventions were provided to prevent falls and injuries," the report states.
A female resident was found to have suffered a hip fracture when staffers responded to her calls for help on March 18 of this year.
"Resident was ambulating unassisted and with no supervision," the report states.
Another patient's fall resulted in multiple areas of bleeding on the brain.
"The licensed staff failed to follow the resident's plan of care," the report states.
Yet another patient suffered a head laceration from a fall in January. That same patient suffered from falls on May 30, Aug. 17 and Aug. 24, the report states.
Another patient diagnosed with hypertension and dementia had five falls between April and October of this year.
"The facility failed to provide resident B7 with appropriate supervision during ambulation to prevent falls," the inspectors reported.
Other deficiencies reported at the Chester county facility included failing to properly store medications and discard expired medications.
In several cases the inspectors found that staffers failed to inform the patients' physicians when tests were missed or adverse test results had been recorded.
There were medication errors including the case of a patient who had ear drops mistakenly placed in the eye.
The report on the Hollidaysburg home included details of patients being transported on wheelchairs without leg rests, thus placing them at risk for injuries.
One patient was observed with his legs bouncing up and down while being taken out of the dining area.
The report states that the facility had failed to perform an assessment to determine "if it was safe" to transport the patients in wheelchairs without leg rests.
In an October case, the inspectors found that staffers failed to thoroughly investigate the cause of bruising on a patient's arm.
Another patient who required oxygen was observed with an empty tank.
In February a patient was discovered with two pairs of scissors impaled on his abdomen. The inspectors noted that a day before that discovery a strong odor had been detected in the patient's room but it was not reported or investigated.
"When areas of concern are identified, we take immediate action to address and rectify them, with a continued focus on the safety and care of residents," Nissley said, noting that all six homes are fully licensed.
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