Nursing Investigation Results -

Pennsylvania Department of Health
RIVERWOODS
Patient Care Inspection Results

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RIVERWOODS
Inspection Results For:

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RIVERWOODS - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Revisit Survey and Complaint Investigation, completed on June 4, 2019, it was determined that Riverwoods corrected the deficiencies identified during the survey of April 18, 2019, but continued to be out of compliance from the survey ending April 5, 2019, 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(j)(1)-(4) REQUIREMENT Grievances: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.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on resident and staff interview, grievance log review, and review of facility documentation of call bell response times, it was determined that the facility failed to resolve resident grievances related to call bell response times for three of five nursing units (300 Hall: Resident 25; 400 Hall: Resident 39; and 500 Hall: Resident 94).

Findings include:

Review of the facility's plan of correction for the survey ending April 5, 2019, revealed that the facility developed plans of correction, which included quality assurance components to assure that the facility maintained corrections regarding call bell response grievances.

Review of the facility grievance log for May and June 2019 revealed two concerns related to call bell response for Resident 94 (dated May 16, 2019) and Resident 39 (dated May 30, 2019).

Interview with Resident 25 on June 4, 2019, at 12:00 PM revealed that she can wait up to two hours for staff to respond to her call bell at least once or twice a week.

Review of a call bell activity report for 15 days dated from May 21, 2019, to June 4, 2019, revealed the following lengthy call bell response times for Resident 25:

May 21, 2019, at 7:29 AM, 46 minutes and 11 seconds
May 24, 2019, at 7:30 AM, 43 minutes and two seconds
May 25, 2019, at 7:25 AM, 62 minutes and 37 seconds
May 27, 2019, at 7:15 AM, 36 minutes and nine seconds
May 29, 2019, at 7:28 AM, 73 minutes and 25 seconds
June 4, 2019, at 7:36 AM, 31 minutes and 47 seconds

This survey identified repeat deficiencies concerning Resident Rights regarding resolving resident grievances.

Interview with the Nursing Home Administrator and Director of Nursing on June 4, 2019, at 3:30 PM reviewed the above findings.

483.10(j)(1)-(4) Resident rights
Previously cited deficiency 4/5/19

28 Pa. Code: 201.14(a) Responsibility of licensee
Previously cited deficiency 4/5/19

28 Pa. Code: 201.18(b)(3) Management
Previously cited deficiency 4/5/19


 Plan of Correction - To be completed: 06/11/2019

- Resident 25's call bell will be answered in an appropriate amount of time to meet the resident's needs.
- All resident call bells will be answered in an appropriate amount of time to meet all resident needs.
- DON/Designee will run weekly call bell reports for all resident rooms and report at QAPI meetings.

-Social Worker will follow up with each resident grievance for resolution within 1 week of grievance date to assure resident is satisfied with outcome.
- Social worker will track outcomes and report at QAPI meetings.

-Residents 25,39, and 94 call bells will be answered timely.

- LPN charge nurses will receive 5 minute call bell alerts on all units.

RN Supervisors will receive 10 minute call bell alerts for each unit

DON/ADON will receive 20 minute call bell alerts for each unit.

NHA will receive 30 minute call bell alerts for each unit.

483.24(c)(2)(i)(ii)(A)-(D) REQUIREMENT Qualifications of Activity Professional: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.
483.24(c)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who-
(i) Is licensed or registered, if applicable, by the State in which practicing; and
(ii) Is:
(A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or
(B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or
(C) Is a qualified occupational therapist or occupational therapy assistant; or
(D) Has completed a training course approved by the State.
Observations:

Based on staff and resident interview and review of activity documentation, it was determined that the facility failed to ensure that the activities program was directed by a qualified professional (Employee 1, Resident 63).

Findings include:

Interview with Resident 63 on June 4, 2019, at 10:54 AM revealed that, in her opinion, the activity program at the facility has not improved since the annual standard survey (ending April 5, 2019) identified deficient practice. Resident 63 stated that she asked activities staff to resume the game "Tabletop Hopscotch" (game similar to bingo in which the player rolls dice and puts a marker on that number on a drawn hopscotch board); however, was told by the activities staff that they did not know where the papers with the drawn hopscotch board were.

Interview with the Nursing Home Administrator on June 4, 2019, at 3:15 PM revealed that the facility hired an activity director, but she has not started employment. She is not expected to start until June 19, 2019. The Nursing Home Administrator revealed that Employee 1 (activity director at another facility) was overseeing the facility's activity program.

There was no indication that Employee 1 was directing the development, implementation, supervision, and ongoing evaluation of the activities program. Interview with the Nursing Home Administrator confirmed that Employee 1 was only in the building one day since the facility's correction date.

483.24(c)(2) Qualifications of Activity Professional
Previously cited deficiency 4/5/19

28 Pa. Code 201.18(b)(3)(e)(2)(6) Management
Previously cited 4/5/19

28 Pa. Code 201.19 Personnel policies and procedures
Previously cited 4/5/19


 Plan of Correction - To be completed: 06/19/2019

- Qualified Activity professional from sister facility was present in the building on 5/14/19, 5/23/19, 5/31/19, and 6/6/19. During these visits the care plans, MDS assessments, goals, monthly documentation as well as activity observations on each unit were conducted. Will continue weekly visits and training until new activity Director is proficient with activity schedules, calendars, mds, care planning.


- A qualified activity director was hired fulltime by the facility and is scheduled to start employment on June 19th, 2019.
483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:

Based on review of select facility policies and procedures, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident's right to participate in significant daily activities per her preference for one of 14 residents reviewed (Resident 63).

Findings include:

Interview with Resident 63 on June 4, 2019, at 10:54 AM revealed that she was required to remain in her room for several days when her roommate was diagnosed with C. difficile (Clostridium-difficile, bacterial infection that causes inflammation of the colon that results in watery diarrhea and fever). Resident 63 indicated that she could not leave her room for meals, bathing, activities, or her "daily walk" (restorative nursing program, RNP, for ambulation), during that time. Resident 63 indicated that she never exhibited signs or symptoms of C. difficile.

Clinical record review for Resident 63 revealed nursing documentation dated April 11, 2019, at 10:33 PM that assessed Resident 63 as having no loose stools but remained on contact precautions due to her roommate's diagnosis of C. difficile.

Nursing documentation dated April 15, 2019, at 3:24 PM again assessed Resident 63 as having no loose stools; however, Resident 63 received a bed bath for care instead of a shower as she resided in a room designated as requiring contact precautions.

Review of daily nurse aide charting for Resident 63 confirmed that staff failed to complete her restorative nursing program for ambulation from April 13 through 16, 2019.

Review of the facility policy entitled, "Clostridium Difficile," last reviewed without changes on December 21, 2018, revealed that residents with diarrhea caused by C. difficile should be in private rooms or in the same room with other residents with C. difficile. If neither of the above rooming situations is available, contact the Infection Control Practitioner or other designee to review the specific resident situation to determine if a semi-private room with a low risk roommate is acceptable. Isolation may be discontinued once active treatment has been completed and the resident remains without loose stools for at least 72 hours.

The facility policy did not indicate that anyone other than the resident who is diagnosed with C. difficile should be quarantined under isolation precautions.

Interview with the Director of Nursing and the Nursing Home Administrator on June 4, 2019, at 3:30 PM confirmed that some staff were under the impression that Resident 63 could not leave her room due to her roommate's diagnosis of C. difficile and implemented contact precautions for Resident 63. The interview confirmed that Resident 63 was not permitted to leave her room for meals, RNP programs, activities, or showering, for at least six days. The interview confirmed that there was no medical justification for Resident 63 to have isolation precaution restrictions as she was never diagnosed with C. difficile.

The facility failed to allow Resident 63 to participate in her typical daily activities as she chose without medical justification.

28 Pa. Code 211.10(d) Resident care policies
Previously cited 4/5/19

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 4/5/19


 Plan of Correction - To be completed: 06/10/2019

-To ensure that all residents rights of choice the infection control RN provided education facility wide to nursing staff on isolation precautions policy and procedure for residents who share a room on 6/6/19 and 6/7/19.

-Resident #63 was informed that staff education was provided. Resident #63 received education on her rights to choice such as activities, walking program and bathing schedule by the social worker on 6/10/2019.

-Residents right to choice will be addressed at the next resident council meeting.

- Social Services will track resident choice concerns and report at QAPI

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