Pittsburgh nursing home for veterans cited by state
A state-run nursing home for veterans in Lincoln-Lemington has been cited by state health officials for keeping a resident in restraints for more than five months without doing the required reviews to determine if they were necessary. When the review finally occurred, the restraints were removed.
According to the inspection report for the Southwestern Veterans Center on Highland Drive, only after the January state inspection was a reassessment made that showed the restraints were no longer needed.
Under state and federal regulations, reassessments for the use of restraints are required every 30 days.
“There are poor outcomes for individuals when restraints are used,” said Joseph Rodrigues, board member of the National Committee for the Prevention of Elder Abuse and the California State Nursing Home Ombudsman.
Citing physical and mental complications that can result from restraints, Rodrigues said, “Some facilities use restraints in place of adequate staff. Simply put, restraints are bad for residents.”
Joan Nissley, spokeswoman for the state Department of Military and Veterans Affairs, said that the plan of correction has been implemented and accepted by the state Health Department.
She said that all restraint orders at the facility had been reviewed for compliance with state and federal requirements.
“The Pennsylvania Department of Military and Veterans Affairs' No. 1 priority is ensuring that veterans and their spouses receive long-term care services in a safe, secure and caring environment,” Nissley said, adding that the inspection report showed “that no actual harm was done to any of our residents.”
According to the inspection report, a physician ordered restraints for the patient, identified as R9, on Sept. 8, but no monthly assessments were made afterward to determine whether lesser or no restraints would be appropriate.
“The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms,” the report states.
The veterans home, in a plan of correction filed after the inspection, stated that following a mid-January re-assessment “there was a determination made to discontinue the restrictive device.”
The resident had belts attached to his thighs, preventing him from lifting his legs.
The inspectors found a second patient, identified as R1, had been placed in restraints for nearly a year with only one required monthly re-assessment.
Inspectors said that he had been placed in a chair seatbelt restraint under a physician's order on Feb. 6, 2015. He still had the restraint when inspectors arrived in early January.
Those findings and others, including failure to properly secure pharmaceutical supplies, were included in the inspection report conducted to determine whether the facility met eligibility requirements for the Medicare and Medicaid programs.
The 246-bed nursing home is one of six state facilities for veterans run by the Department of Military and Veterans Affairs.
In its plan of correction, home officials said that they were establishing procedures to ensure that restraint orders were properly monitored. They agreed to set up a restraint device monitoring committee to oversee the re-assessments.
They reported that R9's family was notified of the decision to drop the use of the restraints.
In another major finding, inspectors discovered a failure to complete and maintain patient assessment records for more than half the records reviewed, according to the inspection report.
Health inspectors observed that medical carts loaded with drugs were left unlocked and unattended. Three of five carts were observed during the inspection without staff in attendance.
Other findings included failure to observe patients' rights to privacy and failing to safeguard patient records.
Walter F. Roche Jr. is a contributing writer.