Pavilion St Luke: Abuse Investigation Failures - PA
HAZLETON, PA - Federal inspectors documented serious failures in abuse investigation protocols at Pavilion at St Luke Village after discovering the facility did not properly investigate a physical assault between residents and failed to examine a dementia patient experiencing unexplained vaginal bleeding for potential abuse.
Assault Investigation Lacked Critical Witness Statements
The most concerning violation involved the facility's inadequate response to a July 9, 2024 incident where a cognitively impaired resident physically assaulted another resident in her own room. According to the federal inspection report, Resident 87, who had Alzheimer's disease, entered Resident 35's room uninvited, took personal property, and slapped the victim in the face when confronted about taking an orange.
Despite the seriousness of this physical assault, investigators found the facility's response fell far short of regulatory requirements. The nursing home failed to interview the staff member who first reported the incident to the supervising nurse - a critical oversight that left the investigation incomplete. This staff member had direct knowledge of the immediate aftermath and could have provided crucial testimony about what they observed or were told.
The RN Supervisor who conducted the investigation later admitted to inspectors that she had been alerted by a nurse aide who said the two residents "got into it," but the facility never documented this aide's statement. The supervisor also acknowledged that Resident 87 had been displaying increasingly aggressive behavior and "had the potential to hit someone if they told her no or tried to take something she wanted."
Pattern of Aggressive Behavior Ignored
The investigation revealed a troubling pattern that should have triggered more comprehensive protective measures. Staff confirmed that Resident 87 routinely entered other residents' rooms without permission, creating ongoing safety risks for vulnerable residents. The supervisor's acknowledgment that this resident was "becoming more agitated lately" with potential for violence should have prompted immediate intervention strategies beyond the minimal response documented.
When federal inspectors interviewed the victim on July 17, 2024, she confirmed the assault occurred exactly as she had reported. The alert and oriented resident expressed ongoing concerns, stating she didn't want Resident 87 entering her room because "she takes things and has the potential to become angry and hit her again." Despite these valid safety concerns from a cognitively intact resident, the facility's investigation concluded they could not substantiate the abuse due to "lack of corroborating evidence."
Dementia Patient's Unexplained Bleeding Never Investigated
Perhaps more disturbing was the facility's complete failure to investigate unexplained vaginal bleeding in a severely cognitively impaired resident as a potential sign of abuse. Resident 24, who suffered from severe dementia with a cognitive score indicating minimal mental function, experienced repeated episodes of vaginal bleeding over a month-long period without any investigation into whether abuse or mistreatment could be the cause.
The bleeding episodes began on June 13, 2024, when nursing staff discovered blood clots in the resident's brief. Despite the resident being on anticoagulant medication for a heart condition, which could explain some bleeding, federal regulations require facilities to investigate any injury of unknown origin in vulnerable residents who cannot communicate what happened to them.
Over the following weeks, the resident experienced multiple bleeding episodes: - June 14: Medication held due to bleeding - June 15: Pink blood found in brief - June 27: Moderate vaginal bleeding documented - July 5: Continued moderate bleeding - July 14: Blood in urine noted - July 15: Physician finally ordered gynecology consultation
Throughout this entire period, no physical examination was conducted to rule out abuse, despite the facility's own policy requiring such assessments. The resident's severe cognitive impairment meant she could not report if someone had harmed her, making the facility's investigation even more critical.
Retroactive Documentation Raises Additional Concerns
When federal inspectors questioned administrators on July 16, 2024, about the lack of abuse investigation for the bleeding, neither the Administrator nor Director of Nursing could provide any evidence that an examination had occurred. Both officials admitted no investigation was conducted to rule out abuse, neglect, or mistreatment as potential causes.
Only after inspectors raised these concerns did staff retroactively enter a note at 3:31 PM that day claiming a "head-to-toe assessment" had been performed with "no suspicious findings identified." This after-the-fact documentation, entered only in response to regulatory scrutiny, raises serious questions about the facility's commitment to resident protection and accurate record-keeping.
Facility Policy Violations
The facility's own Abuse, Neglect, Exploitation, and Misappropriation Policy, reviewed just two months before these incidents in May 2024, clearly mandates specific responses that were not followed. The policy states that any employee with knowledge of an injury of unknown source must report it immediately, but no later than two hours for serious injuries or 24 hours for other incidents.
The policy specifically defines physical abuse as including "hitting, slapping, punching, biting, and kicking" - exactly the type of assault that occurred between residents. It requires the abuse coordinator or designee to "take statements from the victim, the suspect, and all possible witnesses including all other employees in the vicinity." The facility's failure to interview the reporting staff member directly violated this requirement.
For unexplained injuries, the policy mandates that "residents will be evaluated for any signs of injury, including a physical exam and/or psychosocial assessment." No such evaluation occurred for the resident with unexplained bleeding until inspectors intervened.
Medical Risks of Investigation Failures
The facility's failures created serious medical risks for both residents involved. Physical assault between residents, particularly when one has dementia-related aggression, can result in fractures, head injuries, psychological trauma, and escalating violent behaviors if not properly addressed. The victim's ongoing fear and the perpetrator's continued access to other residents' rooms perpetuated an unsafe environment.
For the resident with unexplained vaginal bleeding, the failure to investigate potential abuse meant that if assault had occurred, it would have continued unchecked. Vaginal bleeding in elderly residents on anticoagulants requires careful evaluation to distinguish between medication side effects and trauma. Without proper examination, signs of sexual abuse, physical trauma, or other mistreatment could be missed entirely.
Anticoagulant medications like Pradaxa increase bleeding risk, but they don't typically cause spontaneous vaginal bleeding without an underlying cause. The repeated episodes over multiple weeks, combined with the eventual finding of blood in the urine, warranted immediate comprehensive investigation including pelvic examination and careful assessment for signs of trauma.
Regulatory Requirements and Industry Standards
Federal regulations are explicit about protecting vulnerable nursing home residents from abuse. Facilities must immediately investigate all allegations and injuries of unknown source, particularly in residents who cannot advocate for themselves. The investigation must be thorough, documented, and include physical examination when appropriate.
Industry standards recognize that residents with dementia face heightened abuse risk because they may be unable to report mistreatment or defend themselves. Best practices require enhanced monitoring, immediate investigation of any unexplained injuries or behavioral changes, and comprehensive documentation of all findings.
The facility's investigation failures violated multiple regulations including federal tag F610, which requires facilities to protect residents from abuse and thoroughly investigate all allegations. Pennsylvania state regulations under 28 Pa. Code also mandate proper investigation procedures and protection of resident rights.
Systemic Failures in Resident Protection
These incidents reveal systemic problems in how Pavilion at St Luke Village protects its most vulnerable residents. The facility houses individuals with severe cognitive impairments who depend entirely on staff vigilance for their safety. When a severely demented resident experiences unexplained bleeding for over a month without investigation, or when a physical assault doesn't trigger a complete investigation, the fundamental duty to protect residents has failed.
The Administrator's inability to provide any documentation of investigations when questioned by inspectors suggests these were not isolated oversights but rather indicators of a broader pattern of inadequate response to potential abuse. The facility's conclusion that they couldn't substantiate abuse due to "lack of corroborating evidence" - when they failed to interview available witnesses - demonstrates a fundamental misunderstanding of their investigatory obligations.
Federal inspectors ultimately cited the facility for failing to properly respond to and investigate potential abuse situations, documenting these as violations affecting multiple residents. While classified as "minimal harm or potential for actual harm," these failures could have masked serious abuse that might have continued without regulatory intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pavilion At St Luke Village, The from 2024-07-19 including all violations, facility responses, and corrective action plans.
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