Harmar nursing home penalized for fatal fall

The state Health Department has downgraded HarmarVillage Care Center to a provisional license due to a bathroom fall resulting in the death of one of the nursing home’s residents this year.

The incident occurred Feb. 15 when a resident with a history of falls was not sufficiently monitored by staff at the 130-bed facility in Harmar, according to a report by state inspectors. The resident died two days later.

The Health Department does not identify individuals harmed in such cases, but the Allegheny County Medical Examiner’s Office confirmed Tuesday that HarmarVillage resident Dolores Cerutti, 83, died Feb. 17 at UPMC Presbyterian as a result of head injuries.

A six-month provisional license is designed to put a nursing home under closer scrutiny by state regulators than a standard 12-month operating license. Civil fines often accompany licensing downgrades, though no monetary penalty has yet been announced against HarmarVillage. A Health Department spokeswoman said one is still possible because the department often acts more quickly on licensing actions than fines.

Officials from neither HarmarVillage nor its parent company, Grane Healthcare Co. of O’Hara, returned calls seeking comment.

Conditions in Grane’s 11 nursing homes — seven of which are in the Pittsburgh area — came under criticism in a lawsuit filed against the chain in November by the Pennsylvania Attorney General’s Office. The suit cited numerous care problems in the facilities, based on state inspections over the years and interviews with former staff.

Attorney General Josh Shapiro withdrew the Commonwealth Court suit against Grane last week, however, in the wake of a court ruling that went against the state in a similar case against the Golden Living Centers chain. The latter case has been appealed to state Supreme Court, and a spokesman for the attorney general said Tuesday that legal procedures enable the case against Grane to be refiled “at a later point if we deem it appropriate to do so.”

In the HarmarVillage case, which occurred after the lawsuit was filed against Grane, the state report noted the death of a resident who was “a high risk for falls due to an unsteady gait, visual disturbances, seizure disorder and bladder dysfunction.” To avoid potential injury, she was supposed to be supervised by someone “in proximity to the bathroom door” when she used the toilet.

The report said that when the resident used the bathroom early on the morning of Feb. 15, “the nurse aide was outside of the bathroom when the resident began to fall and was unable to reach the resident to prevent the fall.” The aide was turning off a bed alarm at the time, and the resident suffered injuries diagnosed at the hospital as including multiple fractures and bleeding that affected the brain.

The report said the aide stated to nursing home inspectors “that he was not aware of the order to not leave the resident in the bathroom.” In a required response to the state to show that it would avoid similar incidents, HarmarVillage indicated that all direct care staff would undergo new training related to fall intervention and a new data system would be used to keep employees aware of all residents’ level of fall risk.

Gary Rotstein: grotstein@post-gazette.com or 412-263-1255.


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