Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT SCRANTON, THE
Patient Care Inspection Results

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GARDENS AT SCRANTON, THE
Inspection Results For:

There are  119 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT SCRANTON, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint survey completed on February 6, 2019, it was determined that The Gardens at Scranton was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on a review of clinical records, select facility policy and facility documentation and resident and staff interviews it was determined that the facility failed to timely and thoroughly investigate the potential neglect of a resident to prevent further neglect during an investigation as evidenced by one resident out of eight residents reviewed (Resident CR1).

Findings include:

A review of facility policy entitled Abuse Reporting and Investigation, revised July 2018, revealed all reports of suspected or alleged abuse (mental, physical, sexual, involuntary seclusion or misappropriation of resident property), neglect or exploitation. Injuries of unknown origin will be investigated to rule out potential abuse. The role of the individual conducting the investigation will review the resident's medical record to determine events leading up to the incident, interview the person reporting the incident and interview any witnesses to the incident. Interview the resident and staff members on all shifts who have had contact with the resident during the period of alleged incident. Interview the resident's roommate, family and visitors. Review all events leading up to the alleged incident. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the staff member and have him/her sign and date it.

A review of the clinical record revealed that Resident CR1 was a 58 year old resident admitted to the facility on January 31, 2019, for physical therapy due to being unsteady on his feet. The resident's diagnoses included cirrhosis (hepatic/liver failure). The resident was noted to be a current smoker and cognitively intact. Upon admission, the facility did not identify this resident to be at risk for elopement. Facility documentation indicated that the resident ambulated independently, but according to the facilty's assessment dated January 31, 2019, had a balance problem while standing or walking.

A review of information dated February 4, 2019, at 12 noon submitted by the facility revealed that Resident CR1 eloped from the facility. The resident left the facility at approximately 12 noon. The resident was reportedly last seen at 11:30 AM during medication pass. The facility was unaware the resident had left the facility until it was noted at 12 noon that the resident was not in his room, his belongings were gone and a note was found stating that he would be back Thursday or Friday to sign anything needed. The facility called the resident and the resident stated that he left the building as others (not identified) were coming in the building at the ambulance entrance.

A report of the event provided by the facility dated February 4, 2019, revealed that the report was written at 3:31 PM by the ADON (assistant director of nursing) and noted "11:30 AM RN gave resident (Resident CR1) his ordered medications. At 12:00 noon, resident not in room. Room checked. Note found. Resident left phone number. It was his mother's number. Call placed to number. Resident returned call. I called a friend for a ride to my mothers. I have meds at home."

There were no written statements accompanying the facility's report at the time of survey on February 6, 2019 at 5:00 PM. There was no documented evidence that the facility had attempted to identify the individuals, potential staff, that allowed the resident to leave the building through the ambulance entrance at approximately 12 noon on February 4, 2019. The facility failed to demonstrate prompt efforts to investigate the circumstances surrounding Resident CR1's elopement to ensure that immediate corrective actions were taken to rectify the contributing factors to prevent further elopements.

A review of the resident's clinical record revealed that the first documented entry regarding Resident CR1's elopement from the facility was dated February 4, 2019, at 2:56 PM, which indicated that the social worker, Employee 2, stated that the resident left the facility "against medical advice -AMA." Employee 2 noted that she contacted the resident's son as well as his mother, with whom the resident resides, along with the Area Agency on Aging in the resident's local area (Sullivan County New York) .

Interview with Employee 2 at 4:30 PM on February 6, 2019, revealed that Employee 3, a second social worker, had made Employee 2 aware that Resident CR1 left the facility.

There was no documentation in the resident's clinical record by Employee 3 at the time of the survey ending February 6, 2019.

Nursing documentation dated February 4, 2019, at 3:00 PM written by the RN Supervisor Employee 4, indicated "charge nurse made aware of resident leaving AMA without signing release for AMA. He left a note on the bed for social services. Discharged AMA."

Employee 1, the RN, who last observed the resident present in the facility on February 4, 2019, was interviewed on February 6, 2019, at 5:00 PM. Employee 1 stated that he gave the resident his Lactulose at 11:30 AM because the resident asked for it; Employee 1 then went back to the resident's room "about 12:15 PM" and the resident was not there. Employee 1 stated that the facility did not request that he write a witness statement. He stated that Employee 3 (social services) made the DON (director of nursing) aware that the resident was missing. Employee 1 stated it was about an hour later when he was made aware that the resident wrote a note. He did not know where the note was found, but that it was given to Employee 3 because it was addressed to him. Employee 1 stated that Employee 4, the 3:00 PM to 11:00 PM RN stated that she would "write a note." Employee 1 was the last staff member to see the resident prior to the resident's elopement, but as of February 6, 2019, at 5 PM, the facility had yet to request that Employee 1 write a statement as part of an investigation into Resident CR1's elopement.

Interview with Employee 3 on February 6, 2019, at 5:10 PM , revealed that on Monday February 4, 2019, the therapy department informed him, that a friend was picking Resident CR1 up on Monday February 4, 2019. Employee 3 stated that he had spoken to the resident earlier in the day on February 4, 2019, and the resident had agreed to stay until Wednesday February 6, 2019. Employee 3 stated that he went to the resident's room after 12:15 PM on February 4, 2019, and the resident was not in his room. Employee 3 asked Employee 1 where the resident was and he stated he "did not know." Employee 3 stated that he searched for the resident and made the DON aware that the resident was missing. Employee 3 stated that he d he went outside through the ambulance exit and looked to "see if there was any movement outside." Employee 3 further stated between that between 12:30 PM and 1:00 PM, a nurse aide, Employee 5, found a note in the resident's room and gave it to him, the note read; "had to go today. Sorry, I will be back at (local hospital) Thursday or Friday for lab work should you need anything signed. Thanks for your help. Too much time sitting idle. Thanks again (Resident CR1)." The resident's mother's phone number was also noted on the letter.

Telephone interview with the resident on February 6, 2019 at 5:17 PM, revealed that Resident CR1 stated that he made staff aware when he was admitted to the facility that he did not want to stay in the facility. He stated there was not enough therapy provided to him and he mostly sat around all day. He stated that Employee 3 almost convinced him to stay until Wednesday February 6th, but his friend came in the main entrance and came up to the third floor to get him on February 4, 2019, around noon. Resident CR1 stated that he packed his belonging (socks, jeans, underwear) in a tote bag and he and his friend walked down to first floor. He stated he knew that staff would need to key the code on the exit door in order for them to exit the building, but he stated that facility "staff was bringing in food and he grabbed the door before it closed." He stated that it was about noon when he and his friend left the building. He stated his mother contacted him about an hour or so after he left the building to let him know the facility was looking for him. He spoke to the facility staff about 3:30 PM, on February 4, 2019, when he finally arrived at home.

The facility failed to immediately act upon the potential neglect of Resident CR1 and the potential that facility staff entering the facility with food may have allowed the resident to leave the facility without staff knowledge.

Interview with facility administrative and corporate staff on February 6, 2019, revealed that the facility did not immediately consider the Resident CR1 leaving the facility without staff knowledge on February 4, 2019, as an elopement because "he left a note" and that it was only two days since the resident had left the facility and an investigation had not been completed.

The facility did not promptly determine how the resident had exited the facility and confirm which he exit he had used and if staff had witnessed the resident leave. The facility did not interview any staff that may have been entering or exiting the building at the time the resident and his friend left the building at approximately 12 PM on February 4, 2019. The facility was unaware of the resident's whereabouts and inattentive to this resident's activities. and location during his stay and failed to provide safe and appropriate services to this resident. The facility did not conduct a timely and thorough investigation to rule out neglect of this resident when the facility was unaware of his whereabouts, the circumstances within the facility surrounding the resident's elopement, including the knowledge of staff and other potential witnesses and the specific exit used by the resident to immediately rectify and risk factors for future elopements.



28 Pa. Code 201.14(a) Responsibility of Licensee
Previously cited 10/19/18

28 Pa. Code 201.18 (a)(b)(1)(3)(e)(1) Management
Continuing deficiency of 1/12/19
Previously cited 10/19/18

28 Pa. Code 201.29(a)(d) Resident Rights

28 Pa. Code 211.5(f) Clinical Records
Previously cited 10/19/18

28 Pa. Code:211.12 (a)(c)(d)(1)(5) Nursing services
Continuing deficiency of 1/12/19
Previously cited 10/19/18











 Plan of Correction - To be completed: 03/05/2019


1. Resident CR1 discharged from facility.
2. An investigation into Resident CR1' s elopement will be completed and documented per facility policy.
3. NHA will educate Interdisciplinary Team on policy and procedure for abuse and elopement investigations. NHA/designee will implement the review of incident reports in IDT meeting to ensure an investigation has been initiated and completed timely accordingly based on the nature of the incident.
4. NHA/designee will audit Abuse reports and/or elopement reports to ensure that and investigation was completed and written statements have been obtained. Audits will be weekly for four weeks then monthly for 2 months
5. Audits will be submitted to QAPI for review.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on a review of clinical records, select facility policy and documentation, observations and interviews with residents and staff it was determined that the facility failed to provide sufficient supervision to prevent an elopement and unsafe behavior by a resident with exit seeking behavior and failed to carry out established procedures for locating a missing resident as evidenced by two residents out of eight reviewed (Resident CR1 and Resident 4.

Findings Include:

A review of the facility's policy entitled elopement dated as reviewed January 2019 indicated that in the event a resident is identified as missing or has left the premises the facility will do the following: The charge nurse will initiate a search on the unit to determine if the resident is in another location and or determine if the resident is out on an authorized leave of absence or pass. If the resident is unable to be located the charge nurse will notify the nursing supervisor or designee that the facility cannot locate the resident. The nursing supervisor is to notify the other units. Each unit should conduct a search for the resident. The nursing supervisor shall assign staff members to search non-resident areas and the facility perimeter. If the resident is not located in 10 minutes the DON (director of nursing) will be notified for possible elopement. The DON will assign staff members to conduct a search of the surrounding community. The resident's responsible party and physician will be notified of potential elopement.

A review of the clinical record revealed that Resident CR1 was a 58 year old resident admitted to the facility on January 31, 2019, for physical therapy due to being unsteady on his feet. The resident's diagnoses included cirrhosis (hepatic/liver failure). The resident was noted to be a current smoker and cognitively intact. Upon admission, the facility did not identify this resident to be at risk for elopement. Facility documentation indicated that the resident ambulated independently, but according to the facilty's assessment dated January 31, 2019, had a balance problem while standing or walking.

A review of information dated February 4, 2019, at 12 noon submitted by the facility revealed that Resident CR1 eloped from the facility. The resident left the facility at approximately 12 noon. The resident was reportedly last seen at 11:30 AM during medication pass. The facility was unaware the resident had left the facility until it was noted at 12 noon that the resident was not in his room, his belongings were gone and a note was found stating that he would be back Thursday or Friday to sign anything needed. The facility called the resident and the resident stated that he left the building as others (not identified) were coming in the building at the ambulance entrance.

According to the facility documentation dated February 4, 2019, and telephone interviews with staff and Resident CR1 on February 6, 2019, the resident left the building with his friend at approximately 12:00 PM on February 4, 2019. The facility was unaware of the resident's location until approximately 1:00 PM on February 4, 2019, when a note from the resident was found with his mother's telephone number. The facility tried to contact the resident with the numbers listed for the resident, but received no answer. At approximately 1:30 PM on February 4, 2019, the DON contacted the resident's mother who stated that the resident was on his way home (Catskills, NY).

The resident stated via telephone interview on February 6, 2019, at 5:17 PM that he exited a door when staff was entering the facility, carrying food. The resident stated that he grabbed the door before it closed. The facility contacted his mother, who was unaware he was no longer at the facility. The resident did state that his mother called him about an hour after he left the facility to let him know they were looking for him. The facility made contact with the resident himself at 3:00 PM on February 4, 2019.

The facility facility to implement their elopement policy or conduct a thorough investigation to determine how the resident was able to exit the building without staff aware knowledge.

Interviews with the NHA and DON on February 6, 2019, at 7:00 PM revealed that these administrative staff members did not believe that Resident CR1's elopement was a concern because the resident was cognitively intact and once they made contact with him (3:00 PM on February 4, 2019) they made sure he had his medications at home and put him in contact with a home health agency where he resided.

At the time of the survey ending February 6, 2019, the facility was unable to identify the door through which the resident had exited the facility or efforts to identify the individuals entering the facility at the time the resident exited to rectify an accident hazards and staff practices, which allowed the resident to leave the facility without staff knowledge .

The facility did not conduct any interviews to determine who had entered the facility, reportedly carrying food, at the time the resident exited on February 4, 2019, at approximately 12 noon. The corporate director of clinical services stated during interview on February 6, 2019, that "the resident was capable, we can't keep him here" and "staff cannot know everyone in the building."

This resident resided on third floor and stated during interview on February 6, 2019, that he had exited the building on the first floor.

The facility failed to demonstrate that effective and necessary supervision of Resident CR1 to ensure knowledge of the resident's whereabouts and activities to maintain the resident's safety.

A review of the clinical record revealed that Resident 4 was admitted to the facility on January 31, 2019, and was identified at risk for elopement. A wanderguard was placed on the resident, (a device which would lock the elevator doors if the resident attempted to enter the elevator and would lock and alarm doors if the resident went near a door with a wanderguard sensor).

Observation conducted on February 6, 2019, at 4:30 PM on the third floor revealed that Resident 4 was not in his room or in the dining room. Interview with Employee 6, LPN, regarding Resident 4's whereabouts revealed that Employee 6 stated that "he is around he was looking for his socks." Employee 6 assisted in locating the resident who was at the end of the hallway (farthest distance from his room), in the lounge, self-propelling in his wheelchair. The resident was confused and was unable to state where he was, but stated that he could leave the facility, stating "I would just go down the steps." The resident was observed to continue to self-propel in his wheelchair up and down the hallway.

Observation revealed that at approximately 5:50 PM on February 6, 2019, the fire alarm sounded and a Code Red was called (alerting staff of possible fire due to fire alarm activation).

After the facility determined it was a false alarm and reported that "a resident pulled the fire alarm." Interview with Employee 6 at 6:15 PM on February 6, 2019, revealed that Resident 4 was self-propelling in his wheelchair in the hallway on third floor, entered the dining room and pulled the fire alarm, which was located next to the stairwell. The facility failed to demonstrate adequate supervision of Resident 4.


483.25(d) Accidents
Previously cited 10/19/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/19/18

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services

28 Pa. Code 201.18(b)(1)(e)(1) Management
Previously cited 10/19/18
Previously cited 02/06/15, 03/10/16, 05/18/17

28 Pa. Code 211.10 (a)(c)(d) Resident care policies




 Plan of Correction - To be completed: 03/05/2019


1. Resident CR1 discharged from facility. Resident 4s behaviors will be monitored and reviewed in IDT meeting and interventions will be developed accordingly.
2. The NHA and DON will review the facility's Elopement policy. Facility will implement elopement drills. Residents with reported unsafe behaviors in the last two weeks will be reviewed in IDT to develop plans accordingly.
3. The NHA/designee will re-educate staff on the policy and procedure for Elopement. An elopement drill will be conducted weekly for 4 weeks and monthly thereafter.
4. The NHA/designee will audit elopement drill completion weekly for 4 weeks and then monthly for 2 months. The NHA/designee will audit residents with reported unsafe behaviors weekly for 4 then monthly for 2 months.
5. Audits will be submitted to QAPI for review.

211.12(c) LICENSURE Nursing services.:State only Deficiency.
(c) The director of nursing services shall have, in writing, administrative authority, responsibility and accountability for the functions and activities of the nursing service staff, and shall serve only one facility in this capacity.
Observations:

Based on interviews and review of job descriptions it was determined the facility failed to ensure the director of nursing was accountable for the activities of the nursing staff.

Findings include:

A review of the facility job description for the DON (director of nursing) dated January 1, 2019, indicated the job functions of the DON are as follows:

The DON will organize and direct nursing administration, nursing services and resident care developing, organizing, implementing, evaluating and directing the day to day functions of the Nursing Service Department its programs and activities,

Complete incident reports and follow up on reports,

Knowledge of company goals, objectives, policies, procedures, and federal, state and local regulations,

Assure adequate 24-hour nursing coverage in facility each day,

Ensures a safe environment.

According to facility documentation dated February 4, 2019, Resident CR1 eloped from the facility between 11:30 AM and 12:00 PM on February 4, 2019. The facility was unaware that the resident had left the facility until some time after 12 noon on February 4, 2019, when a note was found. The facility was unaware of the resident's whereabouts until his mother was contacted at approximately 1:30 PM and stated that the resident was on his way back to his residence (Catskills, NY). The facility spoke to the resident via telephone at 3:00 PM on February 4, 2019.

Facility documentation dated February 4, 2019, prior to 3:00 PM that the resident had left the facility against medical advice.

The DON failed to follow facility protocol for a missing resident and failed to obtain statements from staff and potential witnesses as part of complete and timely investigation into the resident's elopement. The DON was unable to verify how the resident had exited the facility or demonstrate efforts to identify possible staff entering the facility who allowed the resident to exit as the resident stated that "staff coming in with food" left the door open for him to exit.

The DON failed to follow facilty policy for elopement, maintain a safe environment and ensure proper investigation into the elopement of a resident to ensure other residents were not at risk.




 Plan of Correction - To be completed: 03/01/2019

1. Resident CR1 discharged from facility.
2. The NHA and DON will review the facility's Elopement policy. The facility will implement elopement drills.
3. The NHA will re-educate the DON on the abuse investigation policy and the elopement policy. DON/designee will review investigation reports in IDT meeting to insure they are completed accordingly. An Elopement Drill will be completed weekly for 4 weeks and monthly thereafter.
4. The NHA/designee will audit elopement drill completion and investigation reports weekly for 4 weeks and then monthly for 2 months.
5. Audits will be submitted to QAPI for review.

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:

Based on a review of nursing time schedules it was determined the facility failed to provide the minimum number of general nursing care hours to each resident in a 24-hour period on one of 2 days reviewed.

The findings include:

A review of nursing time schedules revealed that the facility failed to provide 2.7 hours of general nursing care to each resident in a 24-hour period. On February 6, 2019, only 2.69 hours were provided.

The facility failed to meet the minimum 2.7 hours of direct nursing care for each resident for a 24 hour period.





 Plan of Correction - To be completed: 03/01/2019

1. The facility will insure it is providing the required number of nursing care for each resident.
2. The nursing schedule will be reviewed by the DON/designee to insure adequate staffing is in place. A review of deployment sheets daily to insure adequate staffing.
3. The RN supervisors will be re-educated on the timely notification to the DON/designee of changes in staffing that directly impact nursing hour per patient day.
4. The NHA/designee will audit the nursing per patient (NHPPD) weekly for 4 weeks then monthly for 2 months.
5. Audits will be submitted to QAPI for review.


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