Nursing Investigation Results -

Pennsylvania Department of Health
WAYNE WOODLANDS MANOR
Patient Care Inspection Results

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Severity Designations

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

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

Based on an Abbreviated Complaint and Revisit Survey completed on June 12, 2019, it was determined that Wayne Woodlands Manor failed to correct the deficiencies identified during the survey of April 11, 2019, and continued to be out of 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observation of the medication room supplement refrigerator and the resident pantry and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for microbial growth in food, which increased the risk of food-borne illness.

Findings include:

Observation of the medication storage room on June 11, 2019, at approximately 11:00 AM revealed undated pitchers of orange juice and cranberry juice and one 6 ounce container of a Nutritional Juice Drink (a nutritional beverage supplement which is purchased frozen) with no thaw or discard date (according to the manufacturer label should be discarded 14 days after thawing).

Observation of the resident pantry on June 12, 2019, at 10:00 AM revealed three, 4 ounce Mighty Shakes (a nutritional beverage supplement which is purchased frozen), with no thaw or discard date (according to the manufacturer label should be discarded 14 days after thawing).

Interview with the food and nutrition services director on June 12, 2019, at approximately 9:30 AM confirmed that all juices and supplements were to be labeled and dated.

483.60 Food and nutrition services
Continuing deficiency from 4/11/19

28 Pa. Code 207.2(a) Administrator's responsibility
Continuing deficiency from 4/11/19

28 Pa Code 211.6(c) Dietary services
Continuing deficiency from 4/11/19

28 Pa Code 211.12 (c)(d)(1) Nursing Services
Continuing deficiency from 4/11/19











 Plan of Correction - To be completed: 06/25/2019

Dietary service to monitor dates on all juices and mighty shakes prior to distribution to nursing department. Nursing department will check dates prior to distribution to residents.
Education to all nursing and dietary staff.
Daily audits will be completed by both departments.
Report to Q/A x 2

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 observation, a review of clinical records and resident incident reports and staff interview, it was determined the facility failed to provide necessary supervision and implement planned assistance devices to prevent repeat falls for two of 12 sampled residents (Residents 37 and 78).

Findings include:

A review of the clinical record revealed Resident 37 had diagnoses, which included Alzheimer's disease. Review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 4, 2019, revealed that Resident 37 was severely cognitively impaired and required staff assistance for activities of daily living including transfers and locomotion (how resident moves between locations).

Review of a facility Incident Report dated May 24, 2019, at 6:43 PM revealed that Resident 37 placed her feet down on the floor during staff transport (in a wheelchair) from the resident's room to the shower room. The resident fell from the wheelchair and landed on the floor. The planned intervention to prevent future falls was the use of legrests to the resident's wheelchair when transporting the resident.

Observation on June 11, 2019, at approximately 10:00 AM revealed Employee 1 (nurse aide) transporting Resident 37 in a wheelchair in the hallway located outside the resident's room without legrests on the wheelchair as planned following the resident's fall on May 24, 2019. Interview with Employee 1 at the time of the observation confirmed that legrests were to be used when transporting the resident in the wheelchair.

A review of the clinical record revealed Resident 78 had diagnoses, which included dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning).

Review of Resident 78's quarterly MDS Assessment dated March 19, 2019, indicated that the resident had highly impaired vision, was severely cognitively impaired and required staff assistance activities of daily living, which included transfers, ambulation, and toileting.

Review of a facility Incident Report dated June 8, 2019, at 5:25 AM revealed that Resident 78 was found on the floor in front of the bathroom door in the resident's room. The Incident Report revealed that the last time the resident was observed and toileted was at 2:00 AM (3 hours and 25 minutes prior to the fall). The new planned intervention was safety checks every 30 minutes for seven days.

Review of Resident 78's documented safety checks revealed that on June 9, 2019, safety checks were not conducted between the hours of 3:15 PM and 11:00 PM. Safety check documentation revealed that on June 10, 2019, safety checks were not completed between the hours of 2:45 PM and 11:00 PM.

Interview with the director of nursing (DON) on June 12, 2019, at approximately 11:30 AM confirmed the lack of documented evidence of the consistent provision of planned staff supervision to prevent future falls for Resident 78.

483.25 (d)(2) Adequate supervision and assistance devices to prevent accidents.
Continuing deficiency from 4/11/19

28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services
Continuing deficiency from 4/11/19





 Plan of Correction - To be completed: 06/25/2019

Therapy to review all residents for use of leg rests.
Resident 37 use of leg rests has been re-assessed by therapy.
Visual reminders will be placed on the w/c for all residents using leg rests for transport only.
All staff will be inserviced r/t all above matters.
Education for all staff r/t fall prevention interventions.
Care plans will be updated.
Daily audits will be completed for compliance of same.
Will report to Q/A x 2.
Visual reminders will be placed on the w/c for all residents using leg rests for transport only.
All staff will be inserviced r/t all above matters
Audits will be conducted on all residents who are on safety checks as well as Resident 78.

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