Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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WILLOWS OF PRESBYTERIAN SENIORCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to four complaints completed on May 3, 2019, it was determined that Willows of Presbyterian Senior Care 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 for the Health portion of the survey process.

 Plan of Correction:

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.
Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to follow physician orders to obtain weights for one of six residents (Resident R1) and failed to follow the plan of care to verify a significant weight loss for one of six residents (Resident R2).

Findings include:

The facility policy entitled "Weights" dated 11/1/18, indicated that if a resident has experienced a five pound weight change, a re-weigh will take place within 24 hours."

The clinical face sheet indicated that Resident R1 was admitted to the facility on 3/25/18, with diagnoses that included congestive heart failure, localized edema (swelling from fluid), and chronic kidney disease. A physician progress note dated 1/16/19, indicated these diagnoses remained current.

Review of a physician order dated 9/24/18, indicated that Resident R1 was to be weighed daily and the physician was to be notified of a weight gain of 2 pounds in one day.

Review of the Resident Weight Tracking Report indicated that Resident R1 did not have weights obtained on 1/11/19, 1/18/19, 1/19/19, 1/23/19, 1/25/19, 1/16/19, 1/27/19, 2/6/19, 2/10/19, 2/11/19, 2/12/19, 2/13/19, 2/14/19, 2/24/19, 2/25/19, 2/17/19, 2/18/19, 3/1/19, 3/5/19, 3/7/19, 3/8/19, 3/10/19, 3/17/19, 3/18/19, 3/21/19, 3/22/19, 4/1/19, 4/2/19.

During an interview on 5/2/19, at 11:30 a.m. Unit Manager Employee E1 confirmed that staff failed to obtain daily weights on Resident R1 as ordered by the physician.

The clinical face sheet indicated that Resident R2 was admitted to the facility on 10/2/18, with diagnoses that included repeated falls and anemia. A physician progress note dated 5/1/19, indicated these diagnoses remained current.

Review of the Care Plan dated 4/5/19, indicated that Resident R2 needed to be re-weighed at scheduled intervals and a 5 pound weight change was to be verified with a re-weight.

Review of the Resident Weight Tracking Report indicated that Resident R2 had weight of 155.8 pounds on 3/11/19, and a weight of 143.3 pounds on 4/2/19, a loss of 12.5 pounds.

During an interview on 5/3/19, at 3:00 p.m. the Nursing Home Administrator confirmed that no re-weigh had been obtained for Resident R2 to confirm the 12.5 pound weight loss.

28 Pa. Code: 211.10(c) Resident care policies.

28 Pa. Code: 211.12(d)(1(5) Nursing services.

 Plan of Correction - To be completed: 05/28/2019

This Plan of Correction constitutes my written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
Resident R1's record was reviewed. The order for daily weights was discontinued and replaced with an order for weekly weights on 5/9/19. The weekly weights have been completed as ordered. Family and MD were notified of the findings.
Resident R2's weights were reviewed. There was a routine monthly weight obtained on 5/1/19, and a reweight was obtained 5/8 to verify that gain. Family and MD were notified.
The facility has determined that all residents have the potential to be affected.
The policy and process for obtaining weights was reviewed and revised. An inventory of the number of scales was taken. The scales were inspected to ensure they were in working order and recalibrated if needed. The Director of Nursing educated the nursing staff on the policy for obtaining and recording daily weights and reweights. The nursing staff were also notified of new visuals that will make it easier to see who needs to be weighed.
The Director of Nursing, or designee, will conduct a whole house audit on all residents requiring daily weights and reweights to ensure completion and appropriateness of the need for daily weights. The Director of Nursing and management team have reviewed the process by which weights are obtained and have applied LEAN methodology to the process, using a large daily worksheet as a visual so that all team members can see the weights ordered and still needed.
The nursing management team and dietitians will audit to ensure daily weights and reweights are completed five (5) times per week for 4 weeks.
This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

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