Lutheran Home at Hollidaysburg

In the surveyor’s words

From the most serious findings on record at Lutheran Home at Hollidaysburg, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 25, 2024

  Based on review of facility policies, investigative reports, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by the failure to transfer a resident properly, resulting in a fractured arm for one of three residents (Resident 2) reviewed. This deficiency was cited as past noncompliance. Findings include: The facility's policy on freedom from abuse, neglect, misappropriation of property, exploitation and other suspicious crimes or events, dated January 11, 2024, indicated that each resident had the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; misappropriation of property; and involuntary seclusion. […]

• Actual harm, isolatedF600Oct 12, 2023

  Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 24 residents reviewed (Resident 3), resulting in the resident suffering mental anguish. Findings include: The facility's abuse policy, dated January 11, 2023, indicated that each resident had the right to be free from verbal, sexual, physical, and mental abuse; corporate punishment; misappropriation of property; and involuntary seclusion. […]

• Actual harm, isolatedF689Jul 6, 2022

  Based on review of policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to develop fall/injury prevention interventions for residents who were at risk for falls for one of eight residents reviewed (Resident 8), resulting in a fall with fracture. Findings include: The facility's policy regarding falls, dated May 19, 2022, indicated that the facility was to provide an immediate, appropriate assessment and treatment of a resident following a fall. Immediately after the fall, a team consisting of the nurse aide, licensed practical nurse, and registered nurse was to meet to attempt to determine how the fall occurred. The team was to discuss the need for interventions to prevent additional falls. […]

• Actual harm, isolatedF658Apr 1, 2021

  Based on review of the Pennsylvania Nurse Practice Act, facility policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident was assessed after a change in condition for one of 4 residents reviewed (Resident 1), resulting in a delay in sending the resident to the hospital for a serious medical condition. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote,… […]

• No harm, potential for more than minimal, patternF623Sep 12, 2024

  Based on clinical record reviews and staff interviews, it was determined the facility failed to provide clearly documented reasons for facility-initiated transfers to the hospital to the resident and resident's representative in language and manner that could be easily understood for five of 25 residents reviewed (Residents 8, 18, 35, 42, 47). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated August 4, 2024, revealed that the resident was cognitively intact, was independent with personal hygiene care needs, and had diagnosis that included dementia. A nurse's note for Resident 8, dated January 17, 2024, revealed that the resident had a fall in her bathroom and complained of right hip pain. […]