Nursing Investigation Results -

Pennsylvania Department of Health
LGAR HEALTH & REHABILITATION CTR
Patient Care Inspection Results

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LGAR HEALTH & REHABILITATION CTR
Inspection Results For:

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LGAR HEALTH & REHABILITATION CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated Survey in response to a complaint completed on March 5, 2019, it was determined that LGAR Health and Rehabilitation 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:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify the resident representative for a change in condition for four of six residents (Resident R1,R2, R3, and R4).

Findings included:

A review of facility policy "Change in Resident Status/Condition" last reviewed 7/18/18, indicated the facility will notify the representative of changes in the resident ' s medical/mental condition.

A review of the clinical record revealed Resident R1 was admitted to the facility on 1/16/19, and has a diagnosis that includes dementia.

A review of the clinical notes indicated that on 1/13/19, Resident R1 was had a new instance of skin breakdown on her left heel, and a new order for betadine to be applied.

A review of wound care provider documentation completed by the Certified Registered Nurse Practitioner indicated that Resident R1 was seen by their practice on 2/14/19.

A review of the clinical record did not include documentation that a resident representative was notified of Resident R1's skin breakdown and subsequent provider visit.

A review of the clinical record revealed Resident R2 was admitted to the facility on 11/21/18, and has a diagnosis that includes dementia.

A review of the January 2019 Incident/Accident Log indicated that on 1/3/19, between 09:00 a.m. and 10:00 a.m. and on 1/30/19, between 10:00 a.m. and 11:00 a.m. Resident R2 was found on the floor.

A review of the clinical record did not include documentation that a resident representative was notified of Resident R2 being found on the floor on 1/3/19, and on 1/30/19.

A review of the clinical record revealed Resident R3 was admitted to the facility on 5/23/16, and has a diagnosis that includes dementia.

A review of the January 2019 Incident/Accident Log indicated that on 1/16/19, between 04:00 p.m. and 5:00 p.m. Resident R3 was treated at the facility for a skin tear of unknown origin.

A review of the clinical record did not include documentation that a resident representative was notified of Resident R3's skin tear.

A review of the clinical record revealed Resident R4 was admitted to the facility on 12/13/17, and has a diagnosis that includes dementia.

A review of the February 2019 Incident/Accident Log indicated that on 2/6/19, between 10:00 p.m. and 11:00 p.m. Resident R4 was treated at the facility for a bruise of unknown origin.

A review of the clinical record did not include documentation that a resident representative was notified of Resident R4's was notified of bruise of unknown origin.

During an interview on 3/5/18, at 6:15 p.m. the Nursing Home Administrator (NHA) confirmed that documentation did not include notification of family or other representatives for Residents R1, R2, R3, and R4.

28 Pa. Code 201.14(a) Responsibility of Licensee.


 Plan of Correction - To be completed: 04/15/2019

The Director of Nursing (DON) will conduct and document an in-service for licensed nursing staff of need to notify resident's responsible party with any change of condition. The DON or designee will then complete random chart audits (based on information discussed in morning report regarding changes in resident condition) for 25% of residents with changes on a weekly basis for four weeks, then 10% of residents with changes on a monthly basis for 2 months. Any issues identified will be addressed at time of audit. Results of these audits will be presented and discussed at quarterly QA meeting. For residents R1, R2, and R3 the responsible parties have been updated on resident condition. Resident R4 already had a note on 2/6/19 that states family was notified of a new bruise.

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