Nursing Investigation Results -

Pennsylvania Department of Health
WILLOWBROOKE COURT AT SOUTHAMPTON ESTATES
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WILLOWBROOKE COURT AT SOUTHAMPTON ESTATES
Inspection Results For:

There are  33 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.
WILLOWBROOKE COURT AT SOUTHAMPTON ESTATES - 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 and a complaint completed on February 15, 2019, it was determined that Willowbrooke Court at Southampton Estates was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirments for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
































 Plan of Correction:


483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by 483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:

Based on clinical record review, review of facility policy, observation and staff interview, it was determined that the facility failed to ensure that the interdisciplinary team assessed a resident's capabilities to self administer medications for one of one sampled resident who self administered medications. (Resident 357)

Findings include:

Review of facility policy entitled "Self-Administration of Medication", dated December 2018, revealed that the facility was to strive to ensure that the resident was properly prepared and clinically appropriate to self -administer medications. Staff was to complete a self-administration evaluation form to determine if the resident was able to self administer medications. The facility was to ensure that the physician's order and care plan reflected the residents ability to self administer medications. In addition, all medications to be self administered were to be stored in a locked medication drawer in the residents room or another designated area and the licensed nursing staff was to monitor parameters and lab values as needed.

Clinical record review revealed that Resident 357 was admitted to the facility on February 8, 2019, with diagnoses that included status post right knee replacement and a history of an upper respiratory infection. Observation on February 13, 2019, at 10:45 a.m., revealed that there was an Aerosol inhaler (Breo Elipta Aerosol) stored in an unlocked bathroom cabinet in the resident's bathroom. Resident 357stated that she was able to use the inhaler on her own. Further observation on February 14, 2019, at 10:00 a.m., and 12:35 p.m., revealed that the Aerosol inhaler was still stored in the unlocked cabinet. Review of the physician's orders revealed that on February 12, 2019, there was an order for staff to administer the Breo Aerosol powder daily for an upper respiratory infection. The order did not include instructions for the resident to be able to self administer the medication. There was no documented evidence that the facility completed the evaluation for the resident to be able to self administer medications, there was no physician's order or care plan for the resident to self administer and the medication was not stored in a locked area as per facility policy.

In an interview on February 15, 2019, at 11:35 a.m., the Director of Nursing stated that the facility had not completed an evaluation, care plan, physician's order nor had the medication stored as per facility policy for the resident to self administer the Aerosol inhaler.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/30/18






 Plan of Correction - To be completed: 03/08/2019

On February 13, 2019 after being notified of the medication and the resident's desire to self-administer. Nursing completed assessments and orders were completed per policy and presented to the survey team. Medication was secured in the resident's room.
Resident discharged the community on February 15, 2019.
Rounds were conducted to ensure that there are no unsecured medications in resident rooms. Any other residents that do have medications will be reviewed to ensure that we are operating in compliance with company policy and related regulation. Rounds completed February 28, 2019.
DON or designee will conduct education for all licensed nurses relating to Medication Self-Administration Policy and appropriate intervention to be implemented if resident non-compliance with policy. Education completed by February 28, 2019.

The Care Plan will reflect the resident choice to self-administer medications.

Residents will be asked, by the licensed nurses, upon move-in, if he/she self-administers any medication(s) or chooses to self-administer medications (if applicable).

NHA or designee will provide education relating to Medication Self-Administration and proper Storage of Medications at Resident Council Meetings.

NHA or designee will provide information on Medication Self-Administration and Storage of Medications to residents as part of the move-in process by March 8, 2019.
Weekly rounds will be completed for 3 months to ensure that there are no unsecured medications in resident rooms. Results will be reported to QAPI quarterly.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on observations and clinical record review, it was determined that the facility failed to ensure that a call bell was accessible to one of 26 sampled residents. (Resident 9)

Findings include:

Clinical record review revealed that Resident 9 had diagnoses that included dementia and osteoarthritis. The Minimum Data Set (MDS) assessment dated January 30, 2019, indicated that the resident was alert and able to express her needs. The MDS assessment indicated that the resident was totally dependent and required a two person assist for transfers and bed mobility. The current careplan revealed that the resident was to reach the call bell at all times and was instructed to use her call bell for assistance when needed. Observations on February 11, 2019 at 10:39 a.m.,1:30 p.m., and 1:46 p.m., revealed that the resident was in her wheelchair and that the call bell was out of her reach in the middle of her bed. Observation on February 13, 2019 at 11:30 a.m., revealed that Resident 9 was in her wheelchair and calling out for staff assistance. The call bell cord was secured to the side bed rail and was out of reach of the resident.

29 Pa Code 211.12 (d)(5) Nursing Services
Previously cited 5/4/18

















 Plan of Correction - To be completed: 03/08/2019

Preparation and/or execution of this plan of correction does not constitute
admission or agreement by the providers of the truth of the facts alleged or
conclusions set forth in the statement of deficiencies. The plan of
correction is prepared solely as a matter of compliance with federal and
state law.

A longer call bell cord was placed in the resident room to allow for easier access on February 25, 2019. Resident was again encouraged to push the button if any assistance is needed. Staff reeducated to remind the resident of the location of the call bell and to use as needed for staff assistance.

A full house audit will be completed by March 8, 2019 to ensure that all call bell cords are appropriate in length and that they are accessible to residents.

Community staff will be educated on the proper placement of call bells to be completed by March 8, 2019.

Random checks to be completed by evening supervisor on 5 rooms weekly x 4 weeks, then monthly x 2months to determine proper call bell placement. Audits will begin March 4, 2019. Results will be reported at QAPI quarterly.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on observation and clinical record review, it was determined that the facility failed to ensure that staff provided a resident with the required assistance to eat for one of 26 sampled residents. (Resident 91)

Clinical record review revealed that Resident 91 had a diagnosis of dementia without behavioral disturbance. Review of the Minimum Data Set assessment dated January 22, 2019 indicated that the resident had memory impairment and required physical assistance with eating. Review of the Care Area Assessment for the eating dated January 22, 2019, revealed that the resident requireed physical assistance to eat due to mental errors that includeed sequencing problems, incomplete performance and anxiety limitations. The intervention "provide cues, supervision and assistance as needed for all meals" was added to the Activities of Daily Living care plan under the "eating" heading on November 12th, 2018.

Observation during lunch on February 11, 2019 from 12:15PM to 12:47PM and February 13, 2019 from 12:12PM to 12:56PM, revealed Resident 91 was sleeping through the meal. Staff failed to attempt to wake the resident or provide eating assistance.

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 5/4/18









 Plan of Correction - To be completed: 03/08/2019

Nursing staff has been be educated on the importance of assisting Resident with meals and actively engaging her in conversation during meals. Education completed by February 28, 2019.

Professional nurses will ensure that staff are aware of residents that require assistance with meals.

DON or designee will observe meals in dining rooms 3x weekly x 4 weeks, then monthly x 2 months to determine if residents are assisted properly during meals. Results will be reported at QAPI.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and staff interview it was determined that the facility failed to notify a physician of a resident's refusal to take a medication in a timely manner for one of 26 sampled residents. (Resident 357)

Findings include:

Clinical record review revealed that Resident 357 was admitted to the facility on February 8, 2019, with diagnoses that included lymphocytic colitis (inflammation of the colon). Review of a nursing note dated February 8, 2019, revealed that the resident was alert and oriented and was able to clearly verbalize her needs to staff. On admission, a physician ordered for staff to administer a medication to treat the lymphocytic colitis (Budesonide ER every day). Review of the Medication Administration record for February 2019, revealed that the resident had refused the medication from February 9 through 13, 2019. There was no documented evidence that the physician was notified in a timely manner of the resident's refusal to take the medication. In an interview on February 15, 2019, the Director of Nursing confirmed that there was no documented evidence that the physician had been notified in a timely manner of the resident's refusal to take the medication.

CFR Quality of Care 483.25
Previously cited 3/30/18

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 3/30/18










 Plan of Correction - To be completed: 03/08/2019

Resident was seen by the physician on February 13, 2019. Physician was made aware of the refusal and addressed during the visit on February 13, 2019, noted in the visit note.
DON or designee has completed a full house audit to review non-administered medication and will address findings individually as appropriate. Audit completed February 27, 2019.
DON or ADON has educated nursing staff on the necessity of notifying the provider of resident refusal of medication and/or treatment in accordance with this requirement. Education completed by February 28, 2019.


DON or designee will review 5 Electronic Medication Administration Records (eMAR) per neighborhood 2x per week x4 weeks to ensure we are in compliance with this requirement. The results of these audits will be reported at QAPI quarterly.

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on clinical record review, review of facility policy, observation and interview, it was determined that the facility failed to ensure that pain medication was administered as per the resident's pain management program and physician's orders for one of two sampled residents who were on pain management. (Resident 357)

Findings include:

Review of the facility policy entitled "Pain Management" dated December 2018, revealed that staff was to strive to recognize when a resident was experiencing pain and the potential for pain, evaluate existing pain and causes and provide appropriate pain management consistent with the care plan and the resident's goals and preferences.

Clinical record review revealed that Resident 357 was admitted to the facility on February 8, 2019, with diagnoses that included a total right knee replacement, post op pain, osteoarthritis and a history of a right hip fracture. On admission, a physician ordered for staff to administer a medication for pain (Oxycodone) one tablet every four hours as needed for moderate pain on a pain scale (4-7) out of ten and two tablets every four hours as needed for severe pain on a pain scale of (8-10). Review of the care plan initiated February 10, 2019, revealed that the resident had acute pain status post right total knee replacement and the intervention was for staff to administer pain medication as per physician orders. Review of a nursing admission note dated February 8, 2019, indicated that the resident was alert and oriented and able to clearly verbalize her needs to staff.

Observation on February 13, 2019, at 10:45 a.m., revealed that LPN1 administered medications to Resident 357. At this time, the resident expressed that she had pain in her right knee and had not received any pain medication since "around 3:00 a.m., that same morning". LPN1 did not offer or administer any pain medication to the resident at this time. In an interview on the same day at 1:27 p.m., Resident 357 stated that she "now had severe pain in her right leg that was radiating up to her hip and that it hurt her when she walked". Review of the Medication Administration Record (MAR) for February 2019, revealed that the resident had last received the as needed pain medication Oxycodone at 4:18 a.m., on February 13, 2019; however, she did not receive any additional as needed pain medication as ordered by the physician until 1:27 p.m., for a pain level of 8. At that time, the resident then required the two tablets of the Oxycodone due to the severity level of her pain.

In an interview on February 15, 2019, at 9:30 a.m., the Director of Nursing stated that the resident had not received her as needed pain medication as ordered by the physician in a timely manner.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 3/30/18







 Plan of Correction - To be completed: 03/08/2019

Resident was discharged from community on 2/15/19.
DON provided reeducation on February 13, 2019 to the nurse responsible on the importance of pain management with a focus on timeliness of administration of pain medication. The Nursing team was reeducated on the Pain Management Policy with a focus on timeliness of administration of pain medication. Education completed February 28, 2019.

Residents receiving as needed (PRN) pain medication are being interviewed by the DON or designee to determine if they are receiving the requested pain medication in a timely manner. Interviews to be completed by March 8, 2019.

Random residents receiving as needed (PRN) pain medications will be interviewed by the DON or designee 3x per week on varying shifts x 4 weeks to ascertain if they feel their PRN pain medication was given timely in relation to the time of the request. Results will be presented at QAPI quarterly meeting.


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