Nursing Investigation Results -

Pennsylvania Department of Health
LUTHER CREST NURSING FACILITY
Patient Care Inspection Results

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LUTHER CREST NURSING FACILITY
Inspection Results For:

There are  42 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
LUTHER CREST NURSING FACILITY - 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 March 28, 2019, it was determined that Luther Crest Nursing Facility, 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.


 Plan of Correction:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on policy review, observation, and interviews, it was determined that the facility failed to accommodate resident needs during meal times for one of fifteen sampled residents, respond to call bell alerts for six of fifteen sampled residents, and did not post a schedule of snacks times for residents on two of four nursing units. (Resident 15, 25, 28, 31, 32) (North unit, East unit)

Findings include:

In an interview on March 26, 2019, at 11:30 a.m., Resident 28 stated that it takes a long time for staff to answer call bells, especially in the evening hours.

During a tour of the South nursing unit, on March 26, 2019, at 1:10 p.m., Resident 25's responsible party was observed requesting assistance from nursing staff to toilet her mother. The staff answered stating "she will have to wait because we are still passing meal trays."

In an interview on March 26, 2019, at 1:10 p.m., Resident 25's responsible party reported that she activated the call bell button at approximately 1:00 p.m. A staff member responded, turned off the call bell, and said she said she would get someone to help toilet her mother. The resident was not toileted by staff until 1:22 p.m.

In a resident group interview on March 27, 2019, at 10:45 a.m., Residents 15, 31, and 48 reported concerns regarding lack of call bell response by staff, especially during the night shift, and reported staff do not consistently offer evening snacks.

A review of a facility policy entitled "Frequency of Meals", dated November 13,2018, indicated that a schedule of snacks times shall be posted in resident areas. A tour of the North and East nursing units, on March 28, 2019, at 12:30 p.m., did not reveal any posted schedules for snacks.


28 Pa. Code 201.29(j) Resident's rights.















 Plan of Correction - To be completed: 05/17/2019

R 13 Care plan was updated with current bed mobility status per therapy screen

Incidents and new interventions will be reviewed to ensure that care plan is updated.

Staff education will be completed by DON / designee to educate on care planning interventions related to incidents that occur.

Incidents will be reviewed by the interdisciplinary team to ensure that interventions are care planned. Audits will be done daily X 5, weekly X 3, monthly X 2 by DON / designee to ensure compliance. Audits will be reviewed at monthly QAPI X 3
483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on clinical record review, staff interview, and review of facility documentation, it was determined that the facility failed to revise and implement care plan interventions for one of 15 sampled residents. (Resident 13)

Findings include:

Clinical record review revealed that Resident 13 had diagnoses that included fall with fractures, muscle weakness, and immobility. The Minimum Data Set assessment dated January 16, 2019, revealed that the resident was an extensive assist of two staff for bed mobility. A physical therapy discharge summary dated January 22, 2019, revealed that the resident was also a maximal assist with bed mobility. Review of an event on January 5, 2019, revealed that the resident had a fall and the facility's follow-up action was to revise the care plan for two staff to assist with bed mobility. Review of the current care plan dated January 6, 2019, revealed that there had not been a revision to implement the use of two staff assistance with bed mobility as indicated.

In an interview on March 28, 2019, at 10:45 a.m., the Director of Nursing stated the facility failed to revise the resident care plan for bed mobility.


28 Pa. Code 211.12(d)(5) Nursing services.















 Plan of Correction - To be completed: 05/17/2019

Snack times were posted after survey. Policy has now been revised - requirement for snack time to be posted was removed from facility policy.

Education will be provided to staff regarding the deficiency and expectations for improved customer service.

Staff education will be completed by DON / designee to educate on HS snacks to be offered, call bell response time and how to prioritize care needs.

Random call bell audits will be done by DON / designee daily X 7, weekly X 3 then monthly X 2. Results of the audits will be reported at monthly QAPI meeting X 3.

Snack report will be audited by DON / designee daily X 5, weekly X 3 then monthly X 2. Results of audits will be reported at the monthly QAPI meeting X 3.




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