Nursing Investigation Results -

Pennsylvania Department of Health
LUTHERAN COMMUNITY AT TELFORD
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LUTHERAN COMMUNITY AT TELFORD
Inspection Results For:

There are  32 surveys for this facility. Please select a date to view the survey results.

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LUTHERAN COMMUNITY AT TELFORD - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed April 26, 2018, it was determined that Lutheran Community At Telford, 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 as they relate to the Health portion of the survey process.




 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
483.25(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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate falls to determine if assessed safety measures were implemented and functional and that the Interdisciplinary Team (IDT) had been involved in the investigative process for three of nine sampled residents who had fallen. (Resident 30, 35, 42)

Findings include:

Review of the facility policy entitled "Accident and Incident Policy" dated May 30, 2018, revealed that the interdisciplinary team was to work with the resident to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing independence.

Clinical record review revealed that Resident 30 had diagnoses that included dementia, psychosis, muscle weakness and difficulty walking. The Minimum Data Set (MDS) assessment dated March 6, 2019, identified that the resident had cognitive impairment, required staff assistance for activities of daily living and had falls during the assessment period. The ongoing care plan dated December 10, 2018, identified the resident a high risk for falls and directed staff to implement a bed alarm safety device, offer a toileting plan for bathroom privileges, seating and positioning, an activity when in the lounge, frequent checks during morning naps and do not lock the wheel chair brakes to prevent mobility unless transferring. Review of the clinical record and other facility documentation revealed that from November 16, 2018 to March 11, 2019, the resident had eleven falls. Review of the fall on November 16, 2018 at 7:15 a.m., revealed that the resident was found on the floor after she had attempted toileting. There was no documentation to support that the facility had offered a toileting plan as indicated. Review of the falls on November 16, 2018 at 6:45 p.m., November 25, 2018 and December 22, 2018, revealed that the resident was found on the floor after leaning and positioning. The resident notified the facility of that concern to the facility but there was no documentation to support that seating and positioning had been addressed. Review of the fall on December 8, 2018, revealed that the resident fell forward out of the wheelchair after the brakes had been locked and limited her mobility. Review of two falls on December 20, 2018, revealed that the resident was found on the floor in the lounge but there was no clinical documentation to support that activities had been offered as indicated by the IDT. Review of three falls on December 27, 2018, January 3, 2019 and January 8, 2019, revealed that frequent checks as recommended by psychological services during morning naps had not been done as indicated. Lastly, review of the fall on March 11, 2019, revealed that the resident's bed alarm had not functioned to alert staff after the resident had fallen out of bed.

Clinical record review revealed that Resident 35 had diagnoses that included dementia, history of falls and muscle weakness. The MDS assessment dated March 12, 2019, identified that the resident had memory and decision making impairment, required staff assistance for activities of daily living and had falls during the assessment period. The ongoing care plan most recently reviewed on March 14, 2019, identified the resident at risk for falls and directed staff to implement safety interventions such as call bell in reach and supervision. Review of the clinical record and other facility documentation revealed that from December 18, 2018 to April 16, 2019, the resident had four falls. Review of the falls on January 29, 2019 and April 16, 2019, revealed that the resident was found sitting on the floor in her room but the facility had no investigation that identified that the resident had been supervised by staff. Review of the falls on December 18, 2018 and March 13, 2019, revealed that the resident's call bell had not been accessible.

Clinical record revealed that Resident 42 had diagnoses that included dementia, history of falls, muscle weakness and visual impairment. The MDS assessment dated March 20, 2019, identified that the resident was cognitively and visually impaired, required staff assistance for activities of daily living and had falls during the assessment period. The care plan most recently reviewed February 26, 2019, identified the resident was a high risk for falls and directed staff to implement safety interventions such as frequent checks, repositioning and staff supervision. Review of the clinical record and other facility documentation revealed that from November 2, 2018 to February 23, 2019, the resident had eleven falls. Review of the falls on November 2, 2018, November 10, 2018, November 15, 2018, November 25, 2018, November 29, 2018, December 4, 2018, December 9, 2018, January 20, 2019, February 20, 2019, and February 23, 2019, revealed that the resident was found on the floor but the facility had no investigation that identified that the resident had been supervised by staff, frequently checked or repositioned. There was no clinical documentation to support that the IDT investigative process reviewed ongoing preventative interventions for efficacy.

In an interview on April 26, 2019 at 9:30 a.m., the Director of Nursing confirmed that there was no documented evidence these interventions were implemented.

CFR 483.25(d)(1)(2) Accidents Hazards/Supervision/Devices
Previously cited 5/18/18

28a. Pa Code 211.12(d)(1)(3) Nursing services
Previously cited 5/18/18




 Plan of Correction - To be completed: 05/22/2019

Resident 30's dementia has increased to the point that the behaviors causing frequent falls in November and December have stabilized.

Resident 35: Documentation reflecting frequent checks that are performed will be added to the nurses' summary.

Resident 42: Documentation reflecting effectiveness of interventions will be added to the nurses' summary.

Alarms will be check for function as well as placement each shift and documented in the Emar.

Interventions initiated by IDT will be reviewed with direct care staff and evaluated for effectiveness. Care plans will be updated accordingly.

Monitored by DON or designee


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