Nursing Investigation Results -

Pennsylvania Department of Health
PLEASANT VALLEY MANOR, INC./ MONROE COUNTY HOME
Patient Care Inspection Results

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PLEASANT VALLEY MANOR, INC./ MONROE COUNTY HOME
Inspection Results For:

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PLEASANT VALLEY MANOR, INC./ MONROE COUNTY HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on May 22, 2019, it was determined that Pleasant Valley Manor,Inc. 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.



 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 observations, a review of clinical records and resident incident/accident reports and staff and resident interview, it was determined that the facility failed to identify a resident's increased unsafe behaviors and provide adequate staff supervision to maintain the resident's safety, failed to implement effective measures to prevent elopement by one resident (Resident 1), failed to identify risk factors and implement applicable preventive interventions following an incident to prevent recurrence and/or failed to consistently utilize planned safety interventions for one resident (Resident 11) out of six reviewed.

Findings include:

A review of Resident 1's clinical record revealed that the facility assessed the resident's risk of wandering/exit seeking behaviors on February 15, 2019. At that time, the facility determined that the risk's risk of elopement from the facility was low.

Review of the resident's most recent MDS Assessment (minimum data set - a standardized assessment completed at periodic intervals to plan resident care) dated February 23, 2019(quarterly) revealed that the resident was severely cognitively impaired with a BIMS (Brief interview for mental status - a tool to assess cognitive function) score of 2.

Nursing noted that the resident was combative and confused on March 3, 3019. It was noted that the resident was at the nurses station stating that she wanted to go home and make dinner. Staff attempted to redirect the resident, but as not successful according to the documentation.

Progress notes revealed that on April 1, 2019, during the 11 PM to 7 AM shift, the resident was combative for the entire shift. The resident was described as yelling and attempting to hit staff. The resident believed the staff had her baby and she was going to call the police.

Staff documented at 09:22 a.m. on April 1, 2019, that the resident was roaming around the facility aimlessly, attempting to go home because she left her baby home alone. The resident became very aggressive with attempts to redirect her and asked the staff to release her seatbelt so she could go home. Staff documented that the resident attempted several times to get up from her chair. The resident was yelling at the staff and other residents.

According to review of interdisciplinary progress notes completed on April 1, 2019, at 11:00 a.m., the resident's behaviors were increasing and she hit one of the nurses. The resident told the staff she was not staying because she needed to get home to her eight month old baby .

A review of the facility investigation into an incident dated April 1, 2019, revealed that at 11:15 a.m., Employee 1 (nursing assistant) was leaving the facility to go outdoors to smoke. According to her statement, as she exited the door, she saw Resident 1 heading down the driveway to the main traffic road in front of the facility. Employee 1 stated that she "ran" down the driveway and called the resident's name. The resident ignored her and continued down the driveway. Employee 1 stated she caught up to the resident just as she reached the end of the driveway.

According to review of the facility investigation into the incident, Employee 3 (registered nurse) documented that the resident had been behind the nurses station "hitting" her at 11:00 a.m. and was found outside the facility at 11:15 a.m.

Employee 2's statement (nursing assistant assigned to the resident at the time of the elopement) alleged she had seen the resident at 7:15 a.m. and expressed no awareness of the resident's behaviors or the possible need to increase supervision of the resident.

Employee 4 (licensed practical nurse) stated the resident had been sitting at the nurses station 15 minutes prior to the incident. Employee 4 did not note any awareness of the resident's whereabouts until the resident was found outdoors.

When the facility investigated the incident, it was determined that the resident's wanderguard (device which signals an alarm/locks door when passing near it) read "low battery." It was determined that since the device did not function as it was designed to (signal/lock) the resident was able to leave the facility undetected.

The facility failed to Resident 1 was adequately supervised to prevent an elopement.

A review of Resident 11's annual MDS Assessment dated March 18, 2019, revealed that the resident was severely cognitively impaired with a BIMS score of 7 and required assistance of staff for eating.

According to review of the resident's clinical record the resident was in her room having lunch on March 11, 2019. At approximately 11:45 a.m. the resident pulled her lunch tray towards herself spilling her cup of tea on to her right upper thigh. The resident had not been sitting in an upright position at the time.

A review of the facility's investigation into the incident dated March 11, 2019, revealed that Resident 11 was in her room seated in a Broda chair. Employee 7 (nursing assistant) provided her lunch tray. At approximately 11:45 a.m. Employee 8 (nursing assistant) heard a noise in the resident's room and discovered the resident with her lunch meal tray on her lap. The resident had spilled hot tea on her lap. The facility's investigation determined that the resident was seated in her chair, reclined at the time of the incident. The facility concluded that the resident would be evaluated for a 2 handled covered cup for all liquids and that the resident was to be in an upright position for meals.

Observation conducted on May 22, 2019, at approximately 12:05 p.m. revealed that Resident 11 was observed lying flat in bed with her lunch tray in front of her on the rolling bed side table. At 12:10 p.m. Employee 6 (nursing assistant) was observed to enter resident's room and subsequently exit, without making any adjustments to the resident's position in bed.

Observation at approximately 12:20 p.m. revealed that Employee 5 (Licensed Practical Nurse) confirmed that Resident 11 was lying flat in her bed with her lunch tray in front of her. The resident not in an upright position for the meal as planned following the incident on March 11, 2019.

When interviewed on May 22, 2019 at approximately 2:40 p.m. the director of nursing (DON) verified that Resident 11 should have been in an upright position for meals and was unable to explain why staff had not repositioned as required for the resident's safety.

Resident 11's most recent MDS Assessment dated March 18, 2019, also revealed that this severely cognitively impaired resident required the assistance of two staff members for transfer.

A review of the resident's comprehensive plan of care last revised by the facility on May 17, 2019, revealed that the resident was identified at risk for impaired skin integrity on February 3, 2016. Interventions planned on September 25, 2017, included the application of dermasavers to bilateral full leg and upper extremities. The care plan noted that the devices utilized by the resident, including the shaft portion of the bedside table, (planned 10/31/16) and bilateral leg rests (9/25/17) were to be padded to prevent injury related to the resident's fragile skin, history of falls and poor safety awareness. On February 3, 2016, and revised on June 23, 2017, the facility planned interventions noted on the resident's comprehensive care plan, to use caution during transfers and with bed mobility, to prevent the resident from striking her arms, legs or hands against any sharp or hard surface.

A review of the facility investigation into an incident revealed that on May 26, 2019, Employees 9 and 10 (nursing assistants) were preparing Resident 11 for a bath in the common bathroom.

A review of statements completed by Employees 9 and 10 as part of the facility's incident investigation revealed that the resident's derma sleeves (fabric sleeves utilized to prevent skin injuries for resident's with fragile skin) were removed along with the resident's clothing in preparation for bathing.

According to the statement completed by Employee 9, Resident 11 was not cooperating and they (Employees 9 and 10) decided to utilize the sit to stand lift (requires the resident to participate in the lift by following directions and holding on to handle to successfully transfer).
Employee 9 stated she was behind the resident's chair and the sit to stand lift and Employee 10 was retrieving the shower chair. Employee 9 was in the process of using the remote to aid in lifting the resident when she noted the resident had taken her hands off the handles of the lift. Employee 9 stated that the resident's arms were sliding against the straps of the sling and she attempted to lower the resident to the floor from behind, due to her awareness of the resident's fragile skin. The resident fell to the ground, hit her head on the shower chair and sustained a a laceration to the right occipital area. The resident also sustained an extensive skin tear to the right arm measuring from the wrist, to above the elbow.

A review of interdisciplinary progress notes revealed that the resident was anxious and continued to "grab" at the affected area to the right arm, which caused further injury to the area.

A review of the resident's clinical record revealed no indication that the resident had been assessed for the safe use of the sit to stand lift. There was no documented evidence that the facility had determined that the resident possessed both the cognitive ability to follow directions and had demonstrated the physical ability to participate in a safe transfer using the sit to stand lift.

The resident had a known history of falls, poor safety awareness and fragile skin with specific interventions planned to prevent falls/injuries, but the facility staff failed to consistently implement the resident's care plan to prevent injury to the resident's fragile skin.


483.25(d)(10 Accidents
Previously cited:2/22/19, 8/17/18.

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services.
Previously cited: 2/22/19, 8/17/18.

28 Pa. Code 211.11(d) Resident care plan











 Plan of Correction - To be completed: 06/21/2019


Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.


F Tag 689
- Wandering Risk Scale was completed for Resident 1. The wanderguard was checked and is functioning effectively. Safety measures are in place to prevent elopement. No increased unsafe behaviors have been identified.

- Resident 11's risk factors have been identified and safety interventions are in place.

- Facility will reassess residents with unsafe and exit-seeking behaviors, complete another elopement assessment and care plan to prevent elopement, and will implement effective measures to prevent elopement.

- Planned safety interventions will be implemented following an incident to prevent reoccurrence.

- Elopement policy was reviewed and revised. Staff Educator will re-educate staff on the elopement procedure and following the plan of care for residents.

- Audits will be conducted by Unit Manager/designee on 5 incidents for compliance weekly times 4 weeks, then 3 incidents weekly times 2 weeks, then 8 incidents times 1 month. Variances will be addressed as identified. Results will be reported to QAPI committee for review.

- Audits will be conducted by Unit Manager/designee on residents identified with elopement bracelets for functionality weekly times 4 weeks, then biweekly times 2 weeks, then monthly times 2 months. Variances will be addressed as identified. Results will be reported to QAPI committee for review.

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Chemical Restraints: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) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:

Based on observations and clinical record review it was determined that the facility failed to ensure that residents were free of chemical restraints for one (Resident 1) out of six residents reviewed.

Findings include:

A review of Resident 1's clinical record revealed that on March 2, 2019, the resident was restless, screaming and attempting to hit staff. The staff offered the resident a snack, back massage and wheeled the resident around the unit, but the resident's behaviors continued. Physician's order was received for Ativan Gel 0.5 mg/ml (an antianxiety medication) every eight hours as needed for a duration of seven days for anxiety and a psychiatric evaluation.

A review of nursing progress notes revealed that the resident was combative during the 11 PM to 7 AM shift on April 1, 2019. Staff described the resident as yelling and trying to hit staff as the resident believed the staff stole her baby.

During the 7 AM to 3 PM on April 1, 2019, the resident was roaming the hallways attempting to go home to look for her baby according to nursing documentation. The resident became aggressive with staff redirection. At 11:15 a.m., the resident left the facility undetected by the staff. The resident's attending physician was contacted and ordered Ativan gel 0.5 mg every eight hours as needed for anxiety. 15 minute checks and then one to one observations were also ordered.

It was noted that on April 2, 2019, the resident was involved in an altercation with two other residents.

A physician order was noted on April 2, 2019, to change the Ativan gel from 0.5 mg every eight hours for anxiety to Ativan 1 mg every eight hours for anxiety. Seroquel 25 mg (an antipsychotic drug used to treat certain mental/mood conditions such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) at bedtime was added to the resident's medication regimen.

Potential side effects of both Ativan and Seroquel are drowsiness and tiredness.

Further review of the resident's clinical record revealed that the interdisciplinary team met on April 11, 2019, to discuss the resident's behaviors and incidents of resident to resident aggression. However, no additional non-pharmacological interventions were devised or implemented at that time to manage or mitigate the resident's behaviors.

A review of interdisciplinary progress notes dated April 21, 2019, revealed that the resident was involved in a resident to resident altercation, in which she was the victim.

A physician order was noted to change the resident's to Ativan 1 mg twice daily and the Seroquel was changed to 25 mg twice daily on April 22, 2019.

A review of progress notes revealed that the resident's evening medications were held on April 27, 2019, because the resident was asleep/lethargic the entire shift.

On April 30, 2019, staff noted that the resident was very sleepy, unable to take evening medications or follow directions. All medications were held and despite encouragement the resident could not wake up to eat her eveing meal.

On May 2, 2019, all the resident's medications were held because the resident was lethargic/sleepy on the 3 PM to 11 PM shift. On May 5, 2019, staff documented at 16:41 (4:41 PM) that the resident remained asleep, was unable to comply with taking medications and refused meals. At 21:43 (9:43 PM) staff documented that all medications were held because the resident was lethargic/asleep and refused meals.

On May 8, 2019, the resident's Ativan was held on the 3 PM to 11 PM shift, because the resident was asleep. Progress notes noted during the 3 PM to 11 PM shift on May 12, 2019, revealed that the resident was asleep the entire shift without waking up. She was unable to take her ordered medications or eat her meal as each time she opened her eyes she immediately closed them.

There was no indication that the facility had developed and consistently attempted individualized alternative interventions to manage or mitigate the resident's anxious/agitated behaviors, even after the resident displayed potential adverse side effects of psychoactive drug use, which negatively affected her activities of daily living. The facility staff administered the psychotropic drugs, Ativan and Seroquel to most readily control the resident's behavior with the least amount of staff effort.


28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing Services
previously cited: 2/22/19, 8/17/18

28 Pa. Code 211.8 (b) Use of restraints


28 Pa. Code 211.9(a)(1) Pharmacy services


28 Pa. Code 211.2(a) Physician Services













.







 Plan of Correction - To be completed: 06/21/2019

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

F Tag 605
- Resident 1 was seen and evaluated by psych and medications were reviewed. GDR was done. Resident 1 has no further episodes of agitation or exit seeking. Her condition is stable.

- Residents receiving psychotropic medications will be assessed to ensure they are not chemically restrained.

- Staff Educator will re-educate licensed staff to identify changes in behaviors of residents using psychotropic medications. The focus being on a decrease in activities of daily living, and implement individualized alternative interventions to manage the resident's behavior.

- Audits will be conducted by Manager/designee of 5 residents using psychotropic medications weekly times 4 weeks, then 5 residents weekly times 2 weeks, then 5 residents monthly times 2 months.
Variances will be addressed as identified. Results will be reported to QAPI committee for review.

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 clinical record review, observations and staff interview it was determined that the facility failed to provide services necessary to maintain adequate personal hygiene and/or grooming of residents dependent on staff for assistance with these activities of daily living for one out of six residents reviewed (Resident 11).

Findings include:

A review of Resident 11's annual MDS Assessment (Minimum Data Set-a federally mandated standardized assessment process completed periodically to plan resident care) dated March 18, 2019, revealed that the resident had severely impaired cognition and required extensive assistance of staff for transfers, dressing, and personal hygiene.

Observations conducted on May 22, 2019, at approximately 10:45 a.m., and again at approximately 2:05 p.m. revealed a brown substance beneath the fingernails of Resident 11's right hand.

When interviewed on May 22, 2019 at approximately 2:40 p.m. with the Director of Nursing (DON) verified that Resident 11 needed staff assistance with dressing, grooming and personal hygiene services. The DON confirmed that the nursing staff members are to assist the resident with these activities of daily living, but was unable to explain why nail care was not provided to Resident 11 to maintain adequate personal grooming.


28 Pa Code 211.12 (a)(c)(d)(1)(3)(4)(5) Nursing services.
Previously cited 2/22/19, 8/17/18






 Plan of Correction - To be completed: 06/21/2019

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.


F Tag 677
- Resident 11 received nail care and is maintaining adequate personal grooming.

- Residents dependent on staff assistance with grooming and/or personal hygiene will receive and be maintained with adequate personal grooming provided by staff.

- Policy on personal hygiene/grooming was reviewed and revised. Nail care is provided with showers.

- Staff Educator will provide education to nursing staff regarding policy to ensure personal hygiene is adequate. Licensed staff will focus on nail care during weekly skin evaluation.

- Audits will conducted by licensed staff/designee for 10 residents weekly times 4 weeks, then 10 residents times 2 weeks, then 10 residents times 1 month. Variances will be addressed as identified. Results will be reported to QAPI committee for review.





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