Nursing Investigation Results -

Pennsylvania Department of Health
CARBONDALE NURSING & REHABILITATION CENTER
Patient Care Inspection Results

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CARBONDALE NURSING & REHABILITATION CENTER
Inspection Results For:

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CARBONDALE NURSING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on February 26, 2019, it was determined the Carbondale Nursing and Rehabilitation Center 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:


483.25(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 a review of clinical records, select facility investigation reports, documentation submitted by the facility and staff interviews, it was determined that the facility failed to maintain a resident's environment free of potential accident hazards, that increased the risk for injury from a fall during which the resident sustained a fractured wrist, and failed to provide necessary staff supervision for one resident who exited the facility without staff knowledge for two of three residents reviewed (Resident 2 and Resident 3).

Findings include:

A review of the clinical record of Resident 2 revealed admission to the facility on May 8, 2018, with diagnoses to include dementia (group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbances abnormalities of gait and mobility (difficulty walking), history of broken left wrist and a history of falls.

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 8, 2019, revealed the resident was severely cognitively impaired, with a BIMS score of 3 (brief interview for mental status - a tool to assess cognitive function; a score of 0-7 indicates severe cognitive impairment). The resident required extensive staff assistance of two persons for transfers and bed mobility. The resident required extensive assistance of one person for ambulation in her room and toileting. The resident had a history of falls and was identified to be at high risk for falls.

Nursing documentation dated January 2, 2019, at 10:24 AM indicated that the resident was having increased difficulty with transfers and complained of severe pain in her back and right knee pain. X-rays were ordered and compression fractures of T 11-T12 vertebrae (last two vertebrae of the thoracic or longest region of the spine) were identified. The facility determined that the resident would benefit from the use of a commode (a chair with a chamber pot) for toileting at her bedside so staff did not have to transfer her into the bathroom. The resident's care plan was updated on January 2, 2019, indicating that staff were to place the commode for toileting in her room, away from her bedside.

Nursing documentation dated January 12, 2019, at 9:35 PM indicated that the resident was found kneeling in the doorway of Room 102 (the resident resided in room 202) leaning at the foot of the bed. The resident did not sustain any injuries.

Nursing documentation of February 2, 2019, at 8:30 PM revealed that the resident had a bruise to her left inner calf measuring 7 cm x 3 cm. Nursing documentation of February 6, 2019, at 4:45 PM revealed that the resident had a bruise to her right great toe. The facility was unable to determine the origins of these bruises.

A review of a facility incident report dated February 10, 2019, at 5:15 AM indicated that the resident's bed alarm was sounding. As Employee 5, Licensed Practical Nurse (LPN), entered the resident's room, she observed the resident attempting to sit on the commode, which was at the resident's bedside. The resident missed the commode and fell to the floor putting her left arm out to break her fall. The resident's left wrist was noted to be swollen and the bone was exposed. The area was bleeding. The resident was noted to be in severe pain and she could not tolerate having the site cleansed. The resident was admitted to the hospital on this date with a severely displaced radially acute fracture involving the distal ulna (broken both bones of the left wrist, the ulna and the radius).

The resident required surgery, which involved an open reduction (involves the implementation of implants to guide the healing process of a bone, as well as the open reduction, or setting, of the bone. Open reduction refers to open surgery to set bones, as is necessary for some fractures) with removal of previous hardware from prior fracture and implantation of a plate and screws (medical devices to keep the bones together). The resident returned to the facility on February 12, 2019, with a cast to her left arm.

Upon return to the facility, the facility noted that the commode was to be placed away from the resident to decrease the resident's attempts to transfer independently.

On February 11, 2019, therapy discontinued the use of the commode. A fall mat alarm was in place to alert staff of self transfering.

Interview with the Director of Nursing (DON) on February 26, 2019, at 12:42 PM revealed that the resident would try to get up to use the bathroom herself so a commode was ordered (January 2, 2019) at nursing request. During an interview on February 26, 2019, at 1:31 PM the DON stated that the commode remained positioned on the right side of the resident's bed, since she always exited the bed on the right side. The DON stated that it was never intended that the resident independently use the bedside commode without staff assistance, but the commode was left at the resident's bedside.

The facility initiated the use of the bedside commode due to the resident's difficulties and discomfort during ambulation to the bathroom for toileting, but failed to remove the commode from the resident's bedside when not in use to deter independent transfer and toileting attempts by the resident. The facility failed to implement the resident's care plan dated January 2, 2019, indicating that staff were to place the commode for toileting in her room, away from her bedside.

The facility failed to maintain a safe environment to discourage unsafe acts and prevent falls for this resident by failing to remove the resident's access to the bedside commode when unsupervised or assisted by staff.

A review of the clinical record revealed that Resident 3 was admitted to the facility on November 23, 2018, with diagnoses of depression and Parkinson's disease (a progressive neurological disease).

An admission Minimum Data Set assessment dated November 30, 2018, indicated that the resident was cognitively intact with a BIMS of 13 and was independent for ambulation with her rollator walker. The resident was not identified at risk for elopement.

A review of a facility incident investigation report dated January 14, 2019, at 2:00 PM revealed that Resident 2 was observed to be unattended outside the facility on the sidewalk. The resident stated that when she got to the front door of the facility, a man was coming in and the door was open so she walked out. The resident stated that her cardiologist told her to take short walks so she put her coat on and started walking with her walker. Employee 6, the Director of Rehabilitation Services noticed her outside of the building at approximately 1:40 PM and went outside to escort the resident back inside the facility. Employee 7, a physical therapist indicated that she had observed this resident in her room at approximately 1:35 PM No one observed the resident exit the front door of the building.

Interview with this resident on February 26, 2019, at approximately 10:45 AM revealed that her cardiologist told her to walk so she put her coat on and she went outside that day because she was "going to the fair."

Observations conducted on February 26, 2019, at 11:00 AM revealed that facility's front door was locked and must be opened by a staff member at the front desk. On the day the resident exited the facility, a staff member released the door lock for the visitor to enter the building. However, staff failed to identify that Resident 3 had exited the building when the door was unlocked to allow the visitor to enter.

Further review of the facility incident report indicated that staff were educated when allowing someone to exit or enter the building, that they are to monitor the door to verify that residents do not exit the building. The facility also identified that Resident 3 was now at risk for elopement.

During an interview at 3:00 PM on February 26, 2019, regarding staff supervision and the resident's ability to exit the building without staff knowledge, the Nursing Home Administrator (NHA) stated that "the resident was not out of the facility that long!"

The facility failed to ensure that staff sufficiently supervised residents' activities to ensure awareness of the residents' whereabouts.

28 Pa. Code 201.29(a) Resident Rights.
Previously cited 6/14/18

28 Pa. Code 211.12(a)(c)(d)(5) Nursing services
Previously cited 6/14/18, 4/12/18, 9/12/17, 7/28/17

28 Pa Code 211.12(d)(3) Nursing services.
Previously cited 6/14/18, 9/12/17, 7/28/17






 Plan of Correction - To be completed: 04/08/2019

Resident 2's care plan dated 1/2/19 stated "resident may have bedside commode for toileting @ bedside."
Resident 2's care plan was adjusted on 2/11/19 to state "resident may have commode for toileting in room away from bedside"
Resident 3 has been educated on signing out of the facility when she would like to go for a walk.
Current residents with orders for bedside commodes will be reviewed to ensure the commode is safe to be left bedside. Current residents with falls will be reviewed during change in status to ensure residents care plans were followed. Current residents that are capable will be educated on the sign out process, to allow staff to sufficiently supervise their whereabouts.
The NPE or designee will re-inservice staff on the Incident and Accident policy and following care plan interventions and the elopement policy. Receptionist will be re-inserviced on monitoring for potential residents exiting when unlocking the front doors.
The Unit Managers or designees will conduct weekly audits of incidents due to falls to ensure care plans continue to being followed and a safe environment is maintained. The Unit Managers or designees will conduct weekly audits to ensure that staff sufficiently supervise resident's activities to ensure awareness of the resident's whereabouts. Results of the audits will be presented at the monthly QI meetings for review and/or recommendations.

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 for one of three residents reviewed (Resident 1).

Findings include:

A review of the facility policy entitled Abuse Prohibition dated as reviewed by the facility on July 1, 2018 indicated that the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation for all residents.

The facility will implement an abuse prohibition policy through the following which include but are not limited to, identification of possible incidents or allegations which need investigation, investigation of incidents and allegations and reporting incidents and allegations. The facility defines 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 policy further stated staff will identify events that may constitute abuse and notify the supervisor immediately. The employee alleged to have committed the act of abuse would be immediately removed from duty pending investigation. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the facility will report the allegation. An investigation will be initiated within 24 hours of an allegation that focuses on whether abuse or neglect occurred and to what extent, clincal examination for injuries. The investigation will be thoroughly documented and ensure documentation of witnesses.

A review of the clinical record of Resident 1 revealed that the resident was admitted to the facility on August 21, 2018, with diagnoses, which included muscle weakness, difficulty walking, abnormal posture and foot drop (a weakening of the muscles that allow for flexing of the ankle and toes, this condition causes the individual to drag the front of the foot while walking).

A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 30, 2018, indicated that the resident required extensive assistance of two persons for transfers, which included how the resident moves between surfaces and required extensive assistance with two persons for toileting, that included using the bathroom, bedpan or commode. The resident was assessed as cognitively intact with a BIMS (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) score of 14.

Interview with Resident 1 on February 26, 2019, at approximately 10:00 AM revealed that a few weeks ago, Employee 1, a nurse aide, left the resident on the bed pain for "two hours." The resident stated that she said she could not reach her call bell to ring for help from staff so she telephoned her daughter, who contacted the facility and then had to wait until someone came to get her off the bedpan.

On February 26, 2019, at 11:00 AM the surveyor requested the facility's investigation into the potential neglect of Resident 1 by Employee 1. However, it was determined that no investigation had been completed nor had the allegation been reported to the State Survey Agency. The facility had determined that Employee 1 left the building during the employee's shift of nursing duty on January 3, 2019, (the date of the alleged neglect of Resident 1), which was against facility policy.

During an interview with Employee 1, nurse aide, on February 26, 2019, at 11:35 AM the employee stated that on January 3, 2019, she worked 6:00 PM until 10:00 PM on the A wing nursing unit on which Resident 1 resided. Employee 1 stated that she was assisting nurse aides and had no designated resident assignment. Employee 1 confirmed that she placed Resident 1 on the bed pan with the assistance of a sit to stand lift (mechanical equipment for resident to stand and be assisted to bed). Employee 1 stated that the resident refused to use the bedside commode and wanted to be put back to bed to use the bedpan. Employee 1 stated that she put the call bell over the bedrail, but admitted "it must have fallen" and the resident may not have been able to reach it. Employee 1 alleged that she told Employee 2, a nurse aide, that Resident 1 was on the bedpan and then left the building by car for personal reasons. Employee 1 stated she did not know what time she placed Resident 1 on the bedpan, but she stated she only left the building for about "15 minutes."

A review of Employee 1's statement was dated as written on January 3, 2019, but the Director of Nursing stated during an interview on February 26, 2019, at 12:00PM, that she requested that Employee 1 write a statement on February 26, 2019, the date of the survey. The employee's statement indicated that she put the resident on the bedpan because she refused to be toileted. Employee 1 stated that she put the call bell over the bed rail. Employee 1 also stated the resident was on the telephone with her family. Employee 1 noted that she told Employee 2 that Resident 1 was on the bedpan; then Employee 1 left the facility and when she returned Resident 1 was off the bedpan.

An interview with the Registered Nurse (RN) Supervisor, Employee 3, on February 26, 2019, at 12:00 PM, who was on duty on the evening of January 3, 2019, revealed that she did not initiate an investigation to determine how long the resident was left on the bedpan. Employee 3 stated that she did check the resident for any injuries, but was unable to provide documented evidence of this assessment. Employee 3 stated that "I just did a PIP \ on Employee 1."

A review of the PIP dated January 3, 2019, indicated that Employee 1 left the facility without notifying the supervisor, charge nurse or fellow nurse aides. Employee 3 also noted that she observed Employee 1 entering the building (did not indicate at what time) and Employee 1 told her that she left the facility and drove to the store. Employee 3 informed Employee 1 that she was not allowed to the leave the facility. Employee 3 indicated on Employee 1's PIP that employees are not allowed to leave the facility without permission and she left her residents without coverage, which may be considered abandonment and could cause great risk to residents.

Further interview with Employee 3 on February 26, 2019, at 12:10 PM regarding the time Employee 1 had returned to the building or estimation as to how long the employee was gone, Employee 3 stated that she did not know. Employee 3 also confirmed that there was no documentation of an assessment of the resident or an investigation to rule out neglect. Employee 3 stated she was not aware if the resident's daughter called the facility on that evening as the resident had stated.

An interview with the Employee 4, (RN-former Director of Nursing (DON) on February 26, 2019, at 12:53 PM revealed that on January 4, 2019, she checked the resident's skin because the incident was reported to her from the prior shift. She stated the resident had no injury, but was unable to provide documented evidence that any skin checks had been conducted or that an investigation was conducted. Employee 4 confirmed no staff or resident statements were obtained. The facility failed to obtain a statement from Employee 2, the nurse aide whom Employee 1 had allegedly informed that she was leaving the building. The facility was unable to state how long the resident was left on the bedpan and without the use of her call bell. Employee 4 stated that she was unaware if the resident's family called to alert staff of Resident 1 being left on the bed pan. Employee 4 stated that she evaluated call bell placement to determine if they can be attached to the beds to ensure a resident was able to reach them when in need.

Multiple telephone calls during the survey ending February 26, 2019, and again following the survey on February 28, 2019, were placed to Employee 2, the nurse aide Employee 1 had identified as being aware that Employee 1 was leaving the building while Resident 1 was on the bed pan to determine if he was made aware of Employee 1 leaving the building and leaving Resident 1 on the bedpan. As of March 5, 2019, Employee 2 had not returned any phone messages.

Interview with the resident's daughter on March 1, 2019, at 9:33 AM revealed that she confirmed that she spoke with her mother on that night (January 3, 2019). She stated that her mother told her that she had been left on the bedpan for two hours. The resident's daughter stated she called the facility to tell them her mother needed assistance to be removed from the bedpan. The resident stated that the facility staff apologized and told her it would not happen again.

Interview with the current facility DON on February 26, 2019, at 1:30 PM confirmed that the facility failed to timely and thoroughly investigate this incident to rule out neglect of Resident 1. The facility was unable to provide documentation of a nursing assessment of the resident for any skin impairments/injury as the result of the extended period of time the resident had remained on the bed pan. The facility failed to conduct interviews with residents and staff in an attempt to ascertain how long the resident was left on the bedpan or how long Employee 1 was out of the building. The facility failed to confirm with Employee 2, that Employee 1, had informed him that she was leaving the building.

28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 201.18(e)(1) Management
Previously cited 6/14/18, 7/28/17

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

28 Pa. Code 211.5(f)(h) Clinical Records
Previously cited 4/12/18, 1/16/18, 7/28/17

28 Pa. Code 211.12(a)(c)(d)(5) Nursing services
Previously cited 6/14/18, 4/12/18, 9/12/17, 7/28/17

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 4/12/18, 9/12/17, 7/28/17













 Plan of Correction - To be completed: 04/08/2019

An investigation of the alleged incident will be completed and reported to the DOH. Resident 1 sustained no injury related to the alleged incident.
Employee #1 was counselled on the facility policy of employee breaks, and the abuse policy. Registered nurse Supervisor has been re-inserviced on the abuse policy and investigation requirements.
A thorough investigation will be conducted to rule out neglect on any current residents that have abuse related incidents.
The Management staff will be re-inserviced on the abuse policy and procedure and incident and accident policy and procedure.
The DON or Designee will conduct weekly audits of potential abuse incidents to ensure a thorough investigation was completed, and reported to the DOH . Results of the audits will be presented at the monthly QAPI meetings for review and/or recommendations.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to maintain complete and accurate professional nursing documentation in the clinical record of one of three residents reviewed (Resident 1).

Findings include:

A review of the clinical record of Resident 1 revealed that the resident was admitted to the facility on August 21, 2018, with diagnoses which included muscle weakness, difficulty walking, abnormal posture and foot drop (a weakening of the muscles that allow for flexing of the ankle and toes, this condition causes the individual to drag the front of the foot while walking).

A quarterly Minimum Data Set (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 30, 2018, indicated that the resident required extensive assistance of two persons for transfers, which include how the resident moves between surfaces and extensive assistance with two persons for toileting, that included using the bathroom, bedpan or commode. The resident was cognitively intact with a BIMS (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) score of 14.

Upon interview with Resident 1 on February 26, 2019, at approximately 10:00 AM the resident stated that a few weeks ago Employee 1 left her on the bed pan for "two hours." The resident stated that her call bell was out of reach and she was unable to ring for staff assistance. The resident stated that she called her daughter and asked that her daughter call the facility to tell them that the resident needed help. The resident stated that after calling her daughter she had to wait for staff to come and get her off the bedpan.

Interviews with the Director of Nursing (DON) and former DON Employee 4 on February 26, 2019, at 12:00 PM revealed that the facility had determined that Employee 1 left the facility during her shift on the evening of January 3, 2019, after placing Resident 1 on the bed pan. The DON and Employee 4 stated that they interviewed the resident and assessed the resident for injury. However, there was no documentation in the resident's clinical record regarding this interview or the nursing assessment.

An interview with the DON on February 26, 2019, at 2:00 PM confirmed there was no documentation in the resident's clinical record that nursing staff had assessed the resident for any injuries after determining that Employee 1 had left Resident 1 on the bed pan for an unspecified amount of time.

Cross refer F610

483.70(i)(1)-(5) Resident Records-Identifiable Information
Previously cited 4/12/18

28 Pa. Code 211.5(f)(h) Clinical records
Previously cited 4/12/18, 1/16/18, 7/28/17

28 Pa. Code 211.12(a)(c)(d)(5) Nursing services
Previously cited 6/14/18, 4/12/18, 9/12/17, 7/28/17

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 4/12/18, 9/12/17, 7/28/17






 Plan of Correction - To be completed: 04/08/2019

Resident 1 was assessed for injuries at the time of the incident by the nurse and had no injuries.
Current residents with incidents will be reviewed during change ins status meeting to ensure an assessment for potential injury has been completed and documented in the clinical record.
Licensed staff will be re-inserviced on the Documentation policy and procedure.
The NPE or designee will conduct weekly audits of residents with incidents to ensure that an assessment for potential injury was completed and documented in the medical record. Results of the audits will be presented at the monthly QAPI meetings for review and/or recommendations.


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