Nursing Investigation Results -

Pennsylvania Department of Health
CHANDLER HALL HEALTH SERVICES, INC.
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CHANDLER HALL HEALTH SERVICES, INC.
Inspection Results For:

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CHANDLER HALL HEALTH SERVICES, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on December 20, 2018, it was determined that Chandler Hall Health Services was not in compliance with the 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, related to the health portion of the survey process.





 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 policy, facility documentation, and hospital records and interviews with staff, it was determined that the facility failed to protect residents from neglect by not providing the necessary services for one of 18 residents reviewed which resulted in actual harm, related to multiple fractures which required surgical treatment and admission into an intensive care unit for one resident (Residents R16).

Findings include:

Review of facility policy "Abuse Prohibition," dated effective October 26, 2017, stated, "Each resident will be free from abuse." It further stated, "No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. Additionally, "investigation of injuries of unknown origin or suspicious injuries must be immediately investigated to rule out abuse."

Review of Resident R16's record revealed a Minimum Data Set (MDS- periodic assessment of resident needs) dated August 30, 2018, which indicated that Resident R16 was admitted to the facility on October 4, 2016, with diagnoses including, but not limited to, dementia (progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Parkinson's disease (progressive disorder of the nervous system that affects movement), high blood pressure and depression. The MDS further indicated that the resident was moderately cognitively impaired, required extensive assistance of one staff member for bed mobility, transfers, dressing, toileting, hygiene, used a walker or wheelchair for mobility and was frequently incontinent of bowel and bladder.

Review of facility documentation revealed that during morning care on September 28, 2018, Resident R16 was noted with a bruise on the left shoulder, complained of pain, had slurred speech and disorganized conversation. The physician was notified and ordered that the resident go to the emergency room.

Continued review of facility documentation revealed a written statement dated September 28, 2018, by Employee E5, nurse's aide, revealed that when she started helping Resident R16 get ready for breakfast the "resident was screaming it hurts, everything hurts," and that the "resident was not able to roll over side to side as she usually does, when getting washed (personal care and hygiene)." Employee E5 further stated, she "tried to help her sit by the side of the bed to stand," the Resident could not stand at all and she put the resident back to bed using a "complete lifting," and transferred the resident into the wheelchair. She removed the resident's pajama top and saw a bruise on her left shoulder. Additionally, Employee E5 stated, "She was screaming "it hurts while I was taking her top off and while I was putting her clothes on as well." The nurse was notified of the resident's bruising. While assisting the resident with her meal, Resident R16 told Employee E5 "I fell really hard out of bed."

Review of facility "Face to Face" documentation revealed that the nurse practioner had examined the resident on September 28, 2018, at 2:30 p.m. Upon examination of the left upper arm the resident was found to have purplish discoloration to the back of the arm, had pain with movement and had a weak hand grip, had slurred speech and did not follow commands. The resident was sent to the emergency room for further evaluation.

Review of hospital X-ray of left shoulder dated September 28, 2018, at 3:22 p.m. revealed diagnoses of comminuted (in pieces) displaced (bone not in alignment) angulated proximal humeral fracture (broken upper arm bone at shoulder). Further review of Resident R16's hospital records revealed a left hip X-ray dated September 28, 2018, at 7:41 p.m. which revealed an acute displaced and angulated left femoral neck fracture (left hip) and left inferior pubic ramus fracture (pelvis). Resident R16's hospital records further indicated that the resident had been admitted to the hospital on September 28, 2018, had required surgery to repair a left hip fracture and a left humerus fracture, had anemia which required a blood transfusion and had been subsequently admitted into the Intensive Care Unit.

Review of a written statement by Employee E4, nurse aide, on the 3:00 p.m. to 11:00 p.m. nursing shift on September 27, 2018, confirmed that "she had cared for the resident that evening. Employee E4 further stated that she had assisted the resident with dinner, returned her to her room after dinner at 6:00 p.m., assisted the resident to the bathroom, helped her to get cleaned up and ready for bed, placed her into bed, saw the resident again at 9:30 p.m. and changed her brief."

Continued review of facility documentation revealed a verbal statement obtained from the roommate of Resident R16 (Resident R27) on September 28, 2018, at 1:30 p.m. which noted that Resident R16 fell the night before in front Resident R27's television, that "someone came in and picked her up." Additionally, the facility investigation noted that it had been determined that Employee E4, nurse aide, had assisted Resident R16 using her walker out of the bathroom. Employee E4 had then instructed Resident R16 to walk to her bed (on the other side of the room), that the employee then exited the room, leaving the resident to walk back to her bed alone. When Employee E4 returned to the room, the resident was lying on the floor.

Review of documentation submitted by the facility related to Resident R16's fall in the evening of September 27, 2018, confirmed that the resident had been care planned for the assistance of one staff person for supervision while ambulating (walking) with a rolling walker (assistive device).

Interview with the Director of Nursing on December 19, 2018, at approximately 1:00 p.m. revealed that Employee E4 had put the resident into bed after she found her on the floor and did not report it and had been subsequently terminated.

The facility failed to provide the resident with the necessary staff assistance while ambulating, resulting in actual harm to the resident who fell. The resident sustained a fractured proximal humerus and a fractured hip as a result of the fall. The resident required surgical treatment for her injuries and a blood transfusion and was admitted into the intensive care unit as a result of her fall.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/08/16

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
Previously cited 12/08/16

28 Pa. Code 201.29(c) Resident rights

28 Pa. Code 201.29(j) Resident rights
Previously cited 12/08/16

28 Pa. Code 211.10(d) Resident care policies
Previously cited 12/08/16

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 12/08/16






























 Plan of Correction - To be completed: 02/04/2019

1. Identified staff was suspended pending an abuse investigation and was terminated from the facility for failure to maintain resident safety and follow the resident plan of care. A police report, report to Area Agencies on Aging and Pennsylvania Department of Health submitted at time of allegation. There have been no further incidents of potential abuse involving the identified resident.
2. All Incident Reports looking back 30 days were reviewed and no other findings of abuse or neglect identified. All Incident reports for all skin and falls are evaluated and screened to rule out abuse. Each Incident Report is prompted to ask questions at the time of the incident to determine if abuse/neglect was involved and, if so, the DON/NHA is made aware of findings and will initiate the investigation. The initial Incident Reports are reviewed at the charge nurse/supervisor level, then all Incident Reports are reviewed by DON/NHA for further action needed. All Incident reports that are potentially related to abuse will be reported.
3. Licensed and certified staff were educated at the time of the incident on Identifying and Preventing Dependent Adult Abuse and Neglect. Licensed and certified staff will be educated on the importance of following the resident plan of care.
4. Incident Reports are brought to daily Clinical Start Up meeting as they occur to ensure allegations of abuse/neglect are investigated per policy. Administrator/Designee will audit investigation reports weekly. Results of audits will be trended for patterns and will be reported to the QAPI committee for additional oversight and action.
5. Date certain 2/4/19

483.70(a)-(c) REQUIREMENT License/Comply w/ Fed/State/Locl Law/Prof Std:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.70(a) Licensure.
A facility must be licensed under applicable State and local law.

483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards.
The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

483.70(c) Relationship to Other HHS Regulations.
In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.
Observations:

Based on review of facility documentation, personnel records and interviews with staff, it was determined that the facility failed to provide evidence of annual inservice training for all facility staff as required by the Pennsylvania Department of Health.

Findings include:

Review of facility documentation did not provide evidence that the facility had conducted, at least annual inservice training, for all facility employed staff, at a minimal, in the areas of recognition and reporting suspected resident abuse, neglect, and misappropriation of resident property, infection prevention and control, fire prevention and safety, accident prevention, disaster preparedness, resident confidential information, resident psychosocial needs, care of residents with dementia, restorative nursing techniques,and resident rights, including personal property rights, privacy, and preservation of resident dignity. Further review of the documentation available did not provide the date of inservice education or evidence of the staff understanding and comprehension of the inservice training.

Interview with the Nursing Home Administrator on December 20, 2018, at approximately 4:00 p.m. confirmed that the facility had no documented evidence that it conducted all the required annual staff inservice trainings. The administrator further indicated that the facility had no documentation related to the trainings, their content or staff comprehension of the subject matter which was not accessible since it "was electronic."

The facility failed to provide training for all facility staff on the prevention of resident abuse, neglect, and misappropriation of funds as required by the Pennsylvania
Department of Health.

28 Pa. Code 201.14(a)Responsibility of licensee
Previously cited 12/08/16

28 Pa. Code 201.18(b)(3) Management
Previously cited 12/08/16

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 201.20(a)(c) Staff development


















 Plan of Correction - To be completed: 02/04/2019

1. Ensured all staff completed mandatory in-servicing.
2. All current staff were confirmed to be in compliance with mandatory in services. The interdisciplinary team will continue to identify training topics in monthly QAPI meeting that need in-person in-servicing.
3. All licensed staff to receive education on a continued monthly basis. Trends and identified focus will be reported to the campus Education committee to see if topics identified could benefit other departments.
4. Administrator to monitor compliance of all staff mandatory training completion monthly and report in QAPI Committee monthly.
5. Date certain 2/4/19

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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.
483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that the resident's wishes for Advance Directives (one's wishes on life-sustaining medical or surgical treatment), were reflected accurately in the clinical record for two of 18 resident records reviewed (Residents R32 and R37).

Findings include:

Review of the facility policy "Advance Directives," dated as revised July 2018, stated, the facility would "establish procedures for implementing resident rights regarding medical treatment and advance directives under state law," and would inquire "at the time of admission whether the resident being admitted had signed an advance directive, will document in the resident's medical record whether or not he or she has signed an advance medical directive, will ensure that a resident's treatment decisions which are consistent with state law will be honored, and will provide for the education of staff concerning advance directives." Under "Procedure," the policy stated that at the time of admission if an advance directive exists, that a copy would be provided to the facility in order to honor the resident's wishes.

Review of the clinical record for Resident R32 revealed that the resident was admitted to the facility on April 16, 2018, with diagnoses including hypertension (elevated blood pressure) and dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform every day activities). Review of an "Advance Directive for Health Care" signed by the Resident R32 and dated July 17, 2006, indicated that the resident "did not want cardiac resuscitation" - DNR (Do Not Resuscitate), and also indicated that the resident did not want mechanical respiration - no intubation (DNI - use of a tube or machine to help a person breathe). Review of the physician's orders for the resident "dated for December 20, 2018," and ordered with a start date of April 16, 2018, (resident's date of admission to the facility) revealed that the Code Status for Resident R32 was "DNR Form: DNR."

Interview with the Director of Nursing on December 20, 2018, at approximately 2:30 p.m. confirmed that the physcian's orders for Resident R32 did not accurately reflect the wishes of the resident for emergency care measures, as indicated on the resident's Advance Directive for Health form.

Review of the clinical record for Resident R37 revealed that the resident was admitted to the facility on November 30, 2018, with diagnoses including hypertension (elevated blood pressure) and generalized muscle weakness. Review of a POLST (Pennsylvania's Orders for Life Saving Treatment) form signed and dated by Resident R37's daughter on November 18, 2018, indicated DNR (Do Not Resuscitate) and no intubation (DNI - use of a tube or machine to help a person breathe). Review of the physician's orders for the resident "dated for December 20, 2018" and ordered with a start date of November 30, 2018, (resident's date of admission to the facility) revealed that the Code Status for Resident R37 was DNR.

Interview with the Director of Nursing on December 20, 2018, at approximately 2:30 p.m. confirmed that the physcian's orders for Resident R37 was DNR only and did not accurately reflect the wishes of the resident for emergency care measures, as indicated on the POLST form.

The facility failed to ensure accurate documentation was maintained regarding the resident's wishes for resuscitation upon life-threatening medical conditions.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/08/16

28 Pa. Code 201.18(b)(2) Management

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
Previously cited 12/08/16

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 201.29(j) Resident rights
Previously cited 12/08/16

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(d)(2) Nursing services

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 11/01/17, 12/08/16

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 12/08/16










 Plan of Correction - To be completed: 02/04/2019

1. Advance Directive orders updated in electronic medical record (EMR) for residents R32 and R37 based on their Advance Directive for Health Care and the POLST (Physician Orders for Life Saving Treatment).
2. Review of Resident charts conducted to ensure accurate Advanced Directive orders include DNI into the electronic medical record. Advance directives including order for DNI have been entered the EMR for current residents.
3. The EMR have been refined to accurately include order for Do Not Intubate (DNI). Licensed nursing staff will be reeducated on the elements of a complete Advanced Directive order and the importance of transcribing all resident advance directives information into the electronic medical record. Licensed nursing staff and Social Workers will be educated on the importance of a fully completed POLST form to ensure that the medical record is reflective of the resident's wishes.
4. Resident's code status will be reviewed on admission, with any change, and at least quarterly during care plan meetings with resident and family. Any variances identified will be immediately corrected and results from audits will be brought to the monthly QAPI x5months.
5. Date certain 2/4/19

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 the review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to ensure that residents were provided with adequate supervision to prevent an elopement for one of 16 residents reviewed (Resident R3).

Findings include:

Review of the facility policy related to resident elopement (leaving the facility without permission) dated as revised July 1, 2018, revealed that the purpose of the policy was to expediently find the resident/client and maintain his or her dignity and privacy.

Review of the clinical record for Resident R3 revealed diagnoses including, but not limited to, Alzheimer's disease (progressive brain disorder that causes memory loss and impaired, thinking), difficulty walking, anxiety disorder (feelings of persistent fear and worry), dysphagia (difficulty swallowing) and hypertension (high blood pressure). Continued review of the clinical record for Resident R3 revealed a quarterly Minimum Data Set (MDS- assessment of resident needs) Assessment completed on September 20, 2018, which indicated that the resident was severely cognitively impaired.

Review of the physician orders for Resident R3 revealed a physician's order dated June 4, 2017, and continued monthly thereafter, for nursing staff to check the function of the resident's wander guard (electronic bracelet that sets off an alarm to notify staff when a resident is within close proximity of the doors) two times a day. Review of the Treatment Administration Record (TAR) revealed that the resident's wander guard was scheduled for functional checks at 6:00 a.m. and 9:00 p.m. daily.

Review of facility documentation revealed that Resident R3 could not be located by facility staff on November 8, 2017. Continued review of the investigation revealed that the resident was last seen at 7:20 p.m., was reported missing by staff at 7:45 p.m. and was found at 20:00 (8:00 p.m.) in an enclosed playground deck near the dining room.

Review of the facility's investigation documentation revealed that the resident's wander guard bracelet did not work. Additionally, the investigation indicated that the doors that should have alarmed to notify staff that the resident was near the doors did not work. Continued review of the investigation identified the "Contributing Factors" of the elopement as the resident's defective wander guard bracelet and the failure of the equipment-door alarm.

Interview with the Director of Nursing on December 20, 2018, at approximately 5:33 p.m. confirmed that the facility did not have a formal policy developed for the use of a wander guard or a wander guard assessment (instrument designed to assess the risk of a resident wandering from the facility) tool developed. Further interview with the Director of Nursing on revealed that the facility had not developed a policy and/or guideline for the routine testing of the proper functioning of the door wander guard alarms.

Continued interview with the Director of Nursing revealed that the door alarms are checked by maintenance, but that the maintenance department does not keep documentation of when they completed the checks of the wander guard doors. The Director of Nursing confirmed that documentation could not be provided regarding the last time the wander guard doors were checked prior to the resident eloping on November 8, 2017.

The facility failed to ensure that residents were provided with adequate supervision to prevent an elopement, and that facility doors were tested to ensure proper functioning.

Free of Accident Hazards/Supervision/Devices
CFR(s): 483.25(d)(1)(2) - Previously cited 12/08/16

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/08/16

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
Previously cited 12/08/16

28 Pa. Code 207.2(a) Administrator's responsibility
Previously cited 12/08/16

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.10(d) Resident care policies
Previously cited 12/08/16

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 11/01/17, 12/08/16

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 12/08/16













 Plan of Correction - To be completed: 02/04/2019

1. At the time, the Wander Guard for resident R3 was checked and functioning. Resident is no longer considered a wandering risk and no longer needs a Wander Guard device. Resident's plan of care was comprehensively reviewed by the interdisciplinary team and no longer uses the Wander Guard device as he is no longer exit seeking.
2. Reviewed all current residents with Wander Guards and found that all devices are functioning properly and as expected and orders are entered properly. Facility will change batteries every other month on the fifteenth of the month on evening shift regardless if old battery is still working.
3. Nightly door checks on evening rounds done by the front desk, with a log kept in a binder at the desk. Any malfunctions will be escalated to the Director of Community Support and will inform the NHA to follow the Wander Guard malfunction policy and procedure. Nursing will continue to perform daily Wander Guard placement and function checks and every other monthly battery change on the devices.
4. Director of Community Support will provide the monthly log to the NHA to ensure the door inspections are being completed. NHA will review for inconsistencies and report to the QA committee to track for trends and review for any recommendations x 4 months. DON/designee to review monthly wander guards on residents are functioning and batteries have been changed. Findings will be reported to the Administrator monthly, results will be brought to monthly QAPI for x 4 months.
5. Date certain 2/4/19


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