Nursing Investigation Results -

Pennsylvania Department of Health
PINECREST MANOR
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PINECREST MANOR
Inspection Results For:

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PINECREST MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure Survey, and Civil Rights Compliance Survey completed on November 16, 2018, it was determined that Pinecrest Manor was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.






 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on review of clinical records, facility documentation and policy and procedures, and interviews with residents and staff, it was determined that the facility failed to ensure that residents were free from neglect during transfers for two of 24 residents reviewed (Residents R35 and R122), resulting in actual harm to Resident R122 who sustained a fall that resulted in the dislocating of their left hip prosthesis. This deficiency is cited as past non-compliance (Resident R122).

Findings include:

The facility policy related to abuse, dated May 31, 2018, defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

The facility policy titled, "Transfer Status," dated 05/31/18, indicated that all residents would be evaluated by therapy to determine a transfer status, the transfer evaluation would be entered in the electronic health record and care plan, and posted in the closet of the resident's room. The policy further indicated that all staff involved in a resident transfer would review the transfer process posted in the resident's closet prior to transferring the resident.

Resident R35's clinical record revealed that Resident R35 was severely cognitively impaired, admitted to the facility on January 23, 2014, and had current diagnoses including, but not limited to: osteoporosis, brain injury, Alzheimer's Disease and heart failure.

Resident R35's clinical record included a physician order dated December 8, 2017, for a "total lifter for all transfers," and an Activities of Daily Living care plan indicating the use of a total lift for all transfers.

Facility documentation, dated December 12, 2017, revealed that on December 12, 2017, at 4:30 p.m. during an investigation regarding a fracture of the left femur on Resident R35, Nurse Assistant (NA) Employee E9 had gotten Resident R35 out of bed by himself/herself. Resident R35 did not show any signs of pain at the time of the improper transfer and propelled them self around facility as per usual. Also, the investigation revealed that NA Employee E11, assisted NA Employee E9 transferring Resident R35 back into bed. Resident R35 had an increase in pain on December 13, 2017, at approximately 5:00 a.m. An x-ray report of the left hip obtained following the increase in pain on December 13, 2017, revealed a left femoral neck fracture. The family was made aware and the decision not to treat was made. A physcian's progress note dated December 23, 2017, revealed that given Resident R35's comorbidities, advanced age, and Alzheimer's Disease that surgical intervention for the fractured femur was not warranted.

Facility documentation related to the event, dated December 12, 2017, at 4:30 p.m. revealed that NA Employee E9 stated that he/she transferred Resident R35 from the bed without assisstance and without difficulty, also stated that Resident R35 did not complain of pain or show signs of pain at any time. Documentation also indicated that NA Employee E11 indicated that he/she assisted Resident R35 back to bed without a lift when called in to assist NA Employee E9.

Facility documentation dated December 14, 2017, reflected that the facility substantiated the allegation of neglect of Resident R35 by NA Employees E9 and E11. Documentation also revealed that the cause of Resident R35's left femur fracture was not determined.

During an interview on November 15, 2018, at 2:02 p.m. the Nursing Home Administrator and the Director of Nusing confirmed that NA Employees E9 and E11, transferred Resident R35 on December 12, 2017, without the use of a total lift, failed to look at the physician ordered transfer status posted in Resident R35's closet prior to the transfer which indicated the use of a total lift for all transfers. They also confirmed that the cause of Resident R35's left femoral neck fracture was not determined.

Resident R122's clinical record revealed that Resident R122 was alert and oriented, admitted to the facility on August 23, 2016, and had current diagnoses that included: diabetes, fibromyalgia (generalized muscle pain), a history of lung cancer, and a fractured left hip surgically repaired on August 20, 2018.

During an interview on November 13, 2018, at 2:51 p.m. Resident R122 stated that "several months ago" he/she sustained a fall and broke his/her hip, stating, "it was my own fault." Resident R122 then stated that several weeks after the fall, two nursing assistants [Nursing Assistants (NA) Employee E4 and NA Employee E5] transferred him/her "wrong" resulting in being lowered to the floor and injuring the previously fractured/repaired hip. Resident R122 stated, "I'm suffering from it . . I think it's worse than it was."

Facility documentation, dated September 8, 2018, revealed that on September 8, 2018, at 3:30 p.m. NA Employee E4 and NA Employee E5, during the process of transferring Resident R122 from a reclining chair in his/her room to a wheeled toilet chair, the resident's legs "gave out" and Resident R122 was "assisted" to the floor. The documentation indicated Resident R122 complained of pain in the left hip following the event, with both knees "adducted" (positioned toward the midline of the body). An x-ray report of the left hip obtained following the event on 09/08/18, revealed that Resident R122's left hip prosthesis (artificial joint) was "dislocated superiorly" (out of the joint space toward the upper part of the body). Resident R122 was transferred to the hospital for surgical repair.

Facility documentation related to the event, dated September 8, 2018, at 4:00 p.m. revealed that NA Employee E4 stated that he/she attempted to stand Resident R22 from a chair, with the assistance of NA Employee E5 when Resident R122 "turned to dead weight and started pulling towards the floor . . . just lowered him/her to the floor." The documentation further indicated that NA Employee E4 "asked her (Resident R122) how he/she was transferred" because he/she has not transferred Resident R122 since surgery. Documentation also indicated that NA Employee E5 indicated that he/she "wasn't familiar with many transfer statuses" of residents on Resident R122's hallway when called in to assist NA Employee E4.

Facility documentation related to the event dated September 8, 2018, further indicated that Licensed Practical Nurse (LPN) Employee E6 was called to the room by NA Employees E4 and E5 to find Resident R122 sitting on the floor, complaining of pain in the left hip at a level of ten, on a scale of one to ten with ten being the most severe. Upon asking NA Employees E4 and E5 regarding Resident R122's transfer status, the employees stated, "assist of two." LPN Employee E6, upon referencing the transfer status documented in Resident R122's closet, indicated the transfer assessment revealed "stand up lift for all transfers."

Resident R122's clinical record included a physician order dated August 30, 2018, for a "stand up lifter for transfer, watch hip precaution in stand-up lift" and an Activities of Daily Living care plan indicating the use of a stand-up lift for all transfers.

Physician documentation dated October 1, 2018, indicated that Resident R122 was evaluated following the hip fracture dislocation of September 8, 2018, and that Resident R122 has low level pain in the left hip every day, worse when he/she moves, that the pain had escalated somewhat and was directly located over the lateral hip (left) and described as "jaggy" and radiating to the knee.

Facility documentation dated September 13, 2018, reflected that the facility substantiated the allegation of neglect of Resident R122 by NA Employees E4 and E5 related to an improper transfer.

During an interview on November 15, 2018, at 2:02 p.m. the Nursing Home Administrator and Director of Nursing confirmed that NA Employees E4 and E5 improperly transferred Resident R122 on September 8, 2018, neglecting to reference the physician ordered transfer status posted in Resident R122's closet prior to the transfer which indicated the use of a stand-up lift for all transfers, resulting in Resident R122 being lowered to the floor resulting in harm to the resident of a dislocated left hip.

This deficiency is cited as past non-compliance.

On September 8, 2018, the facility initiated a plan of correction to address the substantiated allegation of neglect during Resident R122's transfer that included the following: termination of NA Employee E4; re-education of NA Employee E5 by the facility clinical educator on September 21, 2018, prior to return to the clinical setting, in the safe transfer of residents per physician order and facility policy; re-education of clinical nursing staff by the Director of Nursing on September 17, 2018, and September 18, 2018, in safe transfer methods per facility policy and physician order; the implementation of a minimum of 10 random, unannounced transfer observations of residents on all units per week beginning September 24, 2018, and ending the week of October 28, 2018, for a total of 202 observations with no evidence of non-compliance with safe transfer methods.

Documentation provided by the facility during an interview on November 15, 2018, at 3:30 p.m. with the NHA and DON confirmed that the facility had achieved compliance with safe transfers as indicated by Quality Assurance review at this time and will continue to monitor on a random basis.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 09/14/17, 10/21/16

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 09/14/17

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29(c) Resident rights

28 Pa. Code 211.10(d) Resident care policies
Previously cited 10/21/16

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 09/14/17, 10/21/16


















 Plan of Correction - To be completed: 12/07/2018

Past noncompliance: no plan of correction required.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 resident and staff interviews, review of clinical records, facility documentation and policy and procedures, it was determined that the facility failed to ensure that one of two residents reviewed (Resident R122) was transferred by an assistive device as ordered by the physician resulting in actual harm. This deficiency is cited as past non-compliance


Findings include:

The facility policy titled, "Transfer Status," dated May 31, 2018, indicated that all residents would be evaluated by therapy to determine a transfer status, the transfer evaluation entered in the electronic health record and care plan, and posted in the closet of the resident's room. The policy further indicated that all staff involved in a resident transfer will review the transfer process posted in the resident's closet prior to transferring the resident.

Resident R122's clinical record revealed that Resident R122 was alert and oriented, admitted to the facility on August 23, 2016, and had current diagnoses including, but not limited to: diabetes, fibromyalgia (generalized muscle pain), a history of lung cancer, and a fractured left hip surgically repaired on August 20, 2018.

During an interview on November 13, 2018, at 2:51 p.m. Resident R122 stated that "several months ago" he/she sustained a fall and broke his/her hip, stating, "it was my own fault." Resident R122 then stated that following that several weeks after the fall, two nursing assistants [Nursing Assistants (NA) Employee E4 and NA Employee E5] transferred him/her "wrong" resulting in being lowered to the floor and injuring the previously fractured/repaired hip. Resident R122 stated, "I'm suffering from it . . I think it's worse than it was."

Facility documentation dated September 8, 2018, revealed that on September 8, 2018, at 3:30 p.m. NA Employee E4 and NA Employee E5, during the process of transferring Resident R122 from a reclining chair in his/her room to a wheeled toilet chair, the resident's legs "gave out" and Resident R122 was "assisted" to the floor. The documentation indicated Resident R122 complained of pain in the left hip following the event, with both knees "adducted" (positioned toward the midline of the body). An x-ray report of the left hip obtained following the event on September 8, 2018, revealed that Resident R122's left hip prosthesis (artificial joint) was "dislocated superiorly" (out of the joint space toward the upper part of the body) and Resident R122 transferred to the hospital for surgical repair.

Facility documentation related to the event dated September 8, 2018, at 4:00 p.m. revealed that NA Employee E4 stated that he/she attempted to stand Resident R22 from a chair, with the assistance of NA Employee E5 when Resident R122 "turned to dead weight and started pulling towards the floor . . . just lowered him/her to the floor." The documentation further indicated that NA Employee E4 "asked her (Resident R122) how he/she was transferred" because he/she hadn't transferred Resident R122 since surgery. Documentation also indicated that NA Employee E5 indicated that he/she "wasn't familiar with many transfer statuses" of residents on Resident R122's hallway when called in to assist NA Employee E4.

Facility documentation related to the event dated September 8, 2018, further indicated that Licensed Practical Nurse (LPN) Employee E6 was called to the room by NA Employees E4 and E5 to find Resident R122 sitting on the floor, complaining of pain in the left hip at a level of ten, on a scale of one to ten with ten being the most severe . Upon asking NA Employees E4 and E5 regarding Resident R122's transfer status, the employees stated, "assist of two." LPN Employee E6, upon referencing the transfer status documented in Resident R122's closet, indicated the transfer assessment revealed "stand up lift for all transfers."

Resident R122's clinical record included a physician's order dated August 30, 2018, for a "stand up lifter for transfer, watch hip precaution in stand-up lift" and an Activities of Daily Living care plan indicating the use of a stand-up lift for all transfers.

Physician documentation dated October 1, 2018, indicated that Resident R122 was evaluated following the hip fracture dislocation of September 8, 2018, and that Resident R122 had low level pain in the left hip every day, worse when he/she moves, that the pain had escalated somewhat and was directly located over the lateral hip (left) and described as "jaggy" and radiating to the knee.

During an interview on November 15, 2018, at 2:02 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed that the facility failed to ensure that Resident R121 was safely transferred per physician's order and care plan, resulting in actual harm of a dislocated hip.

This deficiency is cited as past non-compliance.

On September 8, 2018, the facility initiated plan of correction to address the substantiated allegation of neglect during Resident R122's transfer that included the following: termination of NA Employee E4; re-education of NA Employee E5 by the facility clinical educator on September 21, 2018, prior to return to the clinical setting, in the safe transfer of residents per physician order and facility policy; re-education of clinical nursing staff by the Director of Nursing on September 17, 2018, and September 18, 2018, in safe transfer methods per facility policy and physician order; the implementation of a minimum of 10 random, unannounced transfer observations of residents on all units per week beginning September 24, 2018, and ending the week of October 28, 2018, for a total of 202 observations with no evidence of non-compliance with safe transfer methods.

Documentation provided by the facility during an interview on November 15, 2018, at 3:30 p.m. with the NHA and the DON confirmed that the facility had achieved compliance with safe transfers as indicated by Quality Assurance review at this time and will continue to monitor on a random basis.


28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 09/14/17, 10/21/16

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 09/14/17

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29(c) Resident rights

28 Pa. Code 211.10(d) Resident care policies
Previously cited 10/21/16

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 09/14/17, 10/21/16



























 Plan of Correction - To be completed: 12/07/2018

Past noncompliance: no plan of correction required.
483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:


Based on resident and staff interviews, review of clinical records, facility policies and procedures, and facility documentation, it was determined that the facility failed to implement its abuse policy for one of two residents reviewed (Resident R78).

Findings include:

The facility policy titled, "Abuse Prevention - Protection of Resident during Investigation," dated May 31, 2018, defined verbal abuse as "any oral, written or gestured language that includes disparaging (of little worth) and derogatory (critical and disrespectful) terms to residents within their hearing distance to describe resident regardless of their age, ability to comprehend or disability. The policy further indicated any allegation of abuse must be reported to the Registered Nurse (RN) Supervisor who then reports the allegation to the Director of Nursing (DON) and the Nursing Home Administrator (NHA). Any employee accused of participating in the alleged abuse, according to the policy, will be immediately suspended until the findings of the investigation have been reviewed by the NHA.

Resident R78's clinical record revealed an admission date of June 26, 2015, current diagnoses that included: a spinal cord injury with paraplegia (paralysis of lower body), chronic (long standing) pain, and obesity, and that Resident R78 was alert and oriented.

During an interview on November 14, 2018, at 9:08 a.m. Resident R78 indicated that Nursing Assistant (NA) Employee E7, while providing incontinence care on May 15, 2018, with the assistance of NA Employee E8, stated that he/she didn't want to provide the care and that Resident R78 ought to have a catheter and colostomy so staff didn't have to provide care so frequently.

Facility documentation dated May 15, 2018, indicated that NA Employee E8 reported that at approximately 9:00 p.m. while assisting with incontinence care, NA Employee E7 told Resident R78 that "we should put a colostomy and catheter on you - we can't be coming in here every five minutes and cleaning you up or giving you the urinal." Upon Resident R78 responding that his/her condition wasn't NA Employee E7's business, NA Employee E7 called Resident R78 a "f-cking f-ggot" and told Resident R78 to shut his/her mouth or "I will punch you."

Facility documentation related to the May 15, 2018, event, indicated that the allegation of verbal abuse was reported to Licensed Practical Nurse (LPN) Employee E9 by 9:30 p.m. who then reported the allegation to Registered Nurse (RN) Supervisor Employee E10. NA Employee E8's statement regarding the event, reflected that Employee E7 was still functioning in the clinical setting at 10: 45 p.m. Facility documentation and staff statements lacked evidence that NA Employee E7 was removed from the clinical area in response to the reported allegation of verbal abuse and reflected that the NHA and the DON were not notified of the allegation of abuse until the following day.

During an interview on November 15, 2018, at 9:40 a.m. the NHA confirmed that the facility failed to implement their abuse policy by not notifying the NHA and the DON in a timely manner and by not sending NA Employee E7 home at the time the allegation of abuse was reported.

28 Pa. Code 201.14(a) Responsibility of Licensee
Previously cited 09/14/17, 10/21/16

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 09/14/17

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29(c) Resident rights

28 Pa. Code 211.10(d) Resident care policies
Previously cited 10/21/16

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 09/14/17, 10/21/16






















 Plan of Correction - To be completed: 01/04/2019

1. Social Services provided emotional support to resident at time of incident. Registered Nurse Supervisor involved, educated on facility abuse policy and procedure at time of incident.

2. All Registered Nurse Managers and Supervisors were educated on facility abuse policy and procedure at time of incident.


3. Staff will be reeducated on abuse policy.
NHA and DON phone numbers provided to staff in the event they feel the incident is not being reported or investigated timely.

4. Audits will be completed by NHA and DON by interviewing staff on proper procedure for reporting suspected abuse. 10 audits will be completed weekly for 4 weeks and monthly thereafter. Results will be reported to the Quality Assurance Performance Improvement Committee.

5. Corrective action date is January 4, 2019.


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