Failure to Investigate Incident Involving Resident's Spouse
Penalty
Summary
Heritage Ridge Senior Living at Johnstown was found to be non-compliant with federal and state regulations due to a failure to conduct a thorough investigation following an incident involving a resident. The incident involved a cognitively intact resident with dementia, who required extensive assistance with daily care needs. The resident's spouse attempted to remove her from the facility, made threats towards staff, and the police were called to de-escalate the situation. Despite the severity of the incident, the facility did not conduct a thorough investigation as required by their policy. Interviews with facility staff revealed a lack of awareness regarding the necessity of an investigation when a family member is involved in such incidents. The Director of Nursing and the Nursing Home Administrator both indicated they were unaware that an investigation was needed. The Administrator had signed a document barring the resident's spouse from the property but did not initiate an investigation into the incident. This oversight led to the facility's failure to meet the requirements for investigating, preventing, and correcting alleged violations as outlined in 42 CFR Part 483 and the 28 PA Code.
Plan Of Correction
Investigation and incident report completed for incident occurring on 03/20/2025 for resident #2. Residents who receive care and services at the facility have the potential to be affected. Director of Nursing was educated by the Administrator on the when to investigate and initiate an incident report in reference to family members/visitors and when police come into the facility to investigate an incident. The Administrator or designee will audit and review incident reports to ensure the necessary investigation is completed. Audits will be conducted as follows: 1.) Up to 5 records will be reviewed daily for 4 weeks. 2.) Then up to 10 records will be reviewed monthly for 2 months. Results of the audits will be provided by the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.