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Everyone must assure that safety comes first at our nursing homes

Intelligencer Journal - 1/4/2020


“Two residents at separate Lancaster County nursing homes died after workers at each facility violated patient transfer policies, according to reports from the Pennsylvania Department of Health,” LNP’s Heather Stauffer reported Monday. The Department of Health says the incidents took place Aug. 1 at Lancashire Hall and Sept. 8 at Mennonite Home Communities.

For those who might have missed this awful news in the midst of a distraction-filled holiday week, we want to reiterate some of Stauffer’s reporting.

First, to state that a facility “violated patient transfer policies” means, more precisely, that these residents died — as confirmed by the coroner — of “traumatic neck injuries after falling while being transferred by one worker instead of the required two,” Stauffer reported.

Residents at 2 Lancaster County nursing homes die after workers violate patient transfer policies: reports

This defies safety protocol. It defies belief.

We count on staffers in nursing homes — staffers looking after our loved ones during their most vulnerable years — to follow proper procedures. As made plain by Stauffer’s reporting, their adherence to those procedures is critical.

Further, we count on the state Department of Health to monitor nursing homes to ensure, as much as possible, that proper procedures are being taught, reinforced and followed.

Proper prevention is so much better than the heartbreak of reacting afterward to tragedy.

In the fatality in August at Lancashire Hall, “(The) resident fell shortly after 7 a.m., according to the report, which also says the nurse aide transferring the resident committed another violation by not notifying a nurse of the incident. The report says the nurse aide instead claimed the resident was found in bed bleeding from the forehead,” Stauffer reported.

Neither the state nor Lancashire Hall indicates the consequences for the employee. Beyond the failure to follow protocol, the apparent attempt to cover up the violation is immoral, even ghastly.

In the other Lancaster County fatality, the one that took place in September at Mennonite Home Communities, staff responded immediately — that is to say, appropriately — but the resident died an hour after falling.

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“A statement by the Mennonite Home in response to LNP’s request for comment described the situation as ‘an unfortunate and isolated incident due to the conduct of an employee who was terminated following a thorough investigation,’ ” Stauffer reported.

Even an “isolated incident” is not acceptable when the safety of vulnerable residents is at stake.

Some credit is due, though. As Stauffer reported, the Mennonite Home said a follow-up survey the state conducted Dec. 19 validated that the home had successfully implemented the approved plan of correction, which included education and audits.

So that’s all we know regarding the specifics of those two local violations that resulted in deaths last summer. And it would be difficult and perhaps unfair to extrapolate anything further.

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In the bigger picture, nursing home safety and oversight are issues we have touched on repeatedly in this space.

In 2015, we found it “appalling” that the state Department of Health did not issue a single financial penalty against a Pennsylvania nursing home in 2012. The agency downplayed the severity and scope of many violations and errors during that period.

But the state department has made good progress in the past half-decade. By March 2019, we praised the news (odd as it might seem) that state nursing homes were being fined more frequently for violations found during inspections. The rising use of sanctions and the creation of a public database on homes were meant to effect change.

We further wrote: “The state Department of Health seems to be making strides in its oversight of nursing homes, and we hope that continues. We praise its transparency, which allows for those who have loved ones in facilities or are assessing facilities for potential future use to have as much solid information as possible at hand. ... We would like to see a faster turnaround on some violation reports. And we question whether the current fine structure is working; it’s a question we hope the Department of Health is asking internally, too.”

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We believe those are still fair questions to raise.

And we believe it’s fair to ask whether administrators at our local nursing homes are doing everything they can to promote safe working and living environments. That especially means having sufficient staffing levels, so there never is any question of whether two people are available to handle a patient transfer.

These are not mere best business practices. They can be matters of life and death. As was proven tragically not once, but twice, last summer in Lancaster County.


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