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 February 22, 2019, it was determined that Pleasant Valley Manor was not in compliance with the following requirements of 42 Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 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 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.
483.10(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 interviews with residents, visiting family members and staff and a review of grievances lodged with the facility it was was determined that the facility failed to provide care in an environment, which promotes each resident's quality of life by failing to respond timely to residents' request for assistance as reported by nine residents and one family member on behalf of the resident out of 14 interviewed (Residents 67, 56, 54, 53, 102, 103, 81, 110, 86, and 44).

Findings include:

Interview with Resident 67 on February 22, 2019, at 10:30 a.m. revealed that the resident stated that she has waited 25 minutes or longer, at times, for staff to respond to her call bell and provide needed assistance. The resident stated that these delays may occur at any time of day and during any tour of duty.

Interview with Resident 56 on February 22, 2019 at 10:45 a.m. revealed that the resident stated that she feels that there is not enough staff to respond to residents' needs timely. The resident stated that she usually waits more than 15 minutes for staff to answer her call bell when she needs assistance.

Interview with Resident 54 on February 22, 2019, at 10:55 a.m. revealed that the resident stated that she consistently waits at least 20 minutes for staff to answer her call bell. The resident also stated that she is smoker, but is afraid to go outside to smoke. The resident explained that staff take her outside to smoke and the resident smokes outside independently. However, when she is ready to come back inside, on a few occassions, "it took a long time" for staff to come back outside and get her to assist her back inside the facility.

Interview with Resident 53 on February 22, 2019, at 11:00 a.m. revealed that the resident stated that he waits at least 20 minutes for staff to answer his call bell and the resident feels that the facility "could use more staff."

Interview with Resident 102 on February 22, 2019 at 11:15 a.m. revealed that the resident stated that she experiences long waits for staff to respond to her call bell and believes the facility needs more staff to meet residents' needs timely. The resident further stated that about two weeks ago she waited over 4 hours to be changed after having a bowel movement. The resident stated that she rang the call bell numerous times, but staff would come into the resident's room, turn off the call bell and inform the resident that they were "getting her nurse aide." However, the nurse aide never came into the resident's room to provide the needed care. A review of grievances lodged with the facility revealed that the resident filed a grievance with the facility on February 4, 2019, regarding this incident.

Interview with Resident 103's family member on February 22, 2019, at 11:20 a.m. the resident's family member stated that he had observed occassions during which Resident 103 waits over 15 minutes for staff to answer the resident's call bell. The family member stated that he had activated the call bell himself to request care for the resident and stated that he observed delays of more than 15 minutes to respond to the resident's call bell and provide needed assistance.

During interview with Resident 81 on February 22, 2019 at 11:30 a.m., the resident stated that she has only been in the facility about 2 weeks, but there have been a few times during the resident's short stay when she has waited up to 30 minutes for staff to answer her call bell.

Interview with Resident 110 on February 22, 2019, at 12:10 p.m. revealed that the resident stated that, at times, the delays in staff response to the call bell are more than 15 minutes.

Interview with Resident 86 on February 22, 2019, at 12:30 p.m. revealed that the resident stated that she has experienced long waits for staff to respond to her call bell. The resident stated that she has "waited up to an hour for help."

Interview with Resident 44 on February 22, 2019, at 12:50 p.m. revealed that the resident stated that she feels that the facility "needs more staff." The resident stated that she waits more than 20 minutes for staff to answer her all bell and the long waits may occur at any time of day and during any shift of nursing duty.

During interview with the Director of Nursing on February 22, 2019 at 2:00 p.m. the DON acknowledged that residents have complaints regarding untimely call bell response and lengthy delays in meeting their needs for assistance, which is negatively affecting the residents quality of life in the facility.



28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services
Previously cited: 8/17/18

28 Pa. Code 201.29 (j) Resident Rights
Previously cited: 8/17/18

28 Pa. Code 201.18 (e)(1)(2)(3)(6) Management
Previously cited: 8/17/18




 Plan of Correction - To be completed: 03/22/2019


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 550
- Resident 81 was discharged home on 2/28/19. Interviews were conducted with residents 67, 56, 54, 53, 102, 103, 110, 86, 44, and family for 103 regarding timely call bell response to resident's request for assistance.
- Cognitive residents were interviewed throughout the facility regarding timely call bell responses.
- The Resident call bell policy was updated and revised. The Staff educator will educate PVM staff and on-site providers on the policy revisions.
- Social Services/Unit Manager/designee will conduct an audit reflecting call bell compliance all shifts 3 times a weeks for 4 weeks, then weekly for 4 weeks, then monthly for 1 month. Variances will be addressed as identified. Results will be reported to the QAPI committee for review.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on a review of clinical records and resident incident reports and staff interview, it was determined that the facility failed to maintain complete and accurate records for one of 15 resident's sampled (Resident 71).

Findings include:

A review of Resident 71's clinical record revealed that the resident was admitted to the facility on January 25, 2015, and had current diagnoses to include spinal stenosis (condition where spinal column narrows and compresses the spinal cord), migraines (A severe throbbing pain, generally experienced on one side of the head), and a C1 (neck) vertebra fracture.

Nursing progress notes dated December 23, 2018, at 11:25 p.m. revealed that a registered nurse received notice from the hospital that Resident 71 was being transferred to a different hospital for a C1 fracture. The resident returned to the facility on December 26, 2018.

However, nursing progress notes dated December 27, 2018, at 1:57 p.m. revealed that the resident was a re-admit with a diagnosis of a fractured C4, neck collar in place, and her vital signs are stable.

Nursing progress notes dated December 27, 2018, at 6:27 p.m. revealed that the resident was a re-admit alert and verbally responsive, with a diagnosis of a fractured C2, neck brace left in place.

Nursing progress notes dated December 28, 2018, at 3:04 a.m. revealed that the resident is a re-admit with a diagnosis of a C2 fracture. Cervical collar in place. Nursing progress notes dated January 2, 2019 at 11:22 p.m., indicated that the resident is a re-admit with a fractured C2.

Nursing progress notes dated December 28, 2018, at 11:22 p.m., December 29, 2018, at 8:30 a.m., December 30, 2018, at 10:10 a.m., December 31, 2018, at 1:13 p.m. December 31, 2018, at 8:15 p.m. January 1, 2019, at 8:00 a.m. January 1, 2019 at 12:58 p.m. January 1, 2019 at 10:46 p.m., January 2, 2019 at 3:59 a.m., indicated the resident was readmitted with a fractured C4

A review of the facility investigation and facility information dated December 23, 2018, both indicated that the resident incurred a C1 fracture.

Interview with the Director of Nursing on February 22, 2019 at 11:30 a.m. confirmed that the resident had sustained a C1 fracture and that nursing staff had erroneously documented both C2 and C4 fractures in their progress notes.

Progress notes dated January 18, 2019, at 6:25 a.m. indicated that the IDCP (interdisciplinary care plan) committee met to discuss the resident's incident. The investigation revealed that the resident had a history of falls and has a bed pad alarm. Resident 71 has a left bedside floor mat, chair pad alarm, and clip tab to chair. The note also addressed a fall the resident had incurred from a Broda chair and no injuries indicated at the time of the fall; but 6 to 7 hours later the resident complained of neck pain and was sent to the hospital for evaluation.

Review of a facility investigation and facility information dated January 18, 2019, both indicated that resident had a fall, but during the late morning early afternoon, occurring after the entry noted January 18, 2019, at 6:25 AM.

Interview with the Director of Nursing on February 22, 2019, at 11:30 a.m. revealed that the progress note on January 18, 2019 at 6:25 a.m. was referring to the incident that occurred on December 23, 2018. However, the entry dated January 18, 2019, failed to identify the date the incident being discussed had occurred, December 23, 2018.

Progress notes dated January 18, 2019, at 8:07 a.m. revealed that the resident was awake most of the night, screaming, yelling. The resident's neck brace was in place. Nursing noted that the resident was climbing out of bed and climbing out of her chair. Nursing administered Tylenol to the resident, which was noted to be ineffective. The resident was repositioned several times, but still uncomfortable. The physician was made aware and new order for Tramadol (a narcotic pain medication) was obtained. However, the Tramadol was discontinued as the result of the resident's allergy to Morphine.

Progress notes dated January 18, 2019, at 12:05 p.m. indicated that the resident was in bed, with the neck brace in place, yelling and crying and unable to explain why. Nursing shift report was received from previous shift of duty indicating that the resident had not slept last night. The physician was made aware and a new order to transfer the to the hospital for further evaluation was given. The resident left the facility via stretcher with two ambulance attendants to the hospital.

Nursing progress notes dated January 18, 2019 at 12:55 p.m. indicated that during the shift, the resident began screaming inconsolably. The resident was unable to verbalize her needs and would just state "I don't feel good." Nursing noted that the resident was redirected, given fluids and pain medication, but all interventions were ineffective. The resident continued to scream. The resident stated " I want to go to my room." The resident was placed in bed and then found on the floor out of the bed on the floor mat. Resident 71 continued screaming and showing signs of restlessness. Three staff members placed the resident back in bed. The physician was notified and an order was received to transfer the resident to the hospital.

Progress notes on January 18, 2019 at 1:17 p.m. indicated that the resident continued to scream. Resident stated " I want to go to my room". The resident was placed in bed and then found on the floor out of the bed on the floor mat. Resident 71 continued screaming and showing signs of restlessness, she then was placed back in bed by three staff members and the physician was notified and an order was received to transfer the resident to the hospital.

Nursing notes dated January 18, 2019, and timed at 12:05 p.m. indicated that the resident had been transferred to the hospital. However, nursing notes on January 18, 2019, timed at 12:55 p.m. and January 18, 2019, at 1:17 p.m. both indicated that the resident was still present in the facility at those times.

Interview with the Director of Nursing on February 22, 2019 at 11:30 a.m. she confirmed that Progress notes on January 18, 2019 at 12:55 p.m. and 1:17 p.m. failed to accurately reflect the resident's location at that time.



28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.
Previously cited: 8/17/18

28 Pa. Code 211.5 (f) Clinical records.
Previously cited: 8/17/18




 Plan of Correction - To be completed: 03/22/2019

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 842
- Documentation related to injury of Resident 71 will be corrected by licensed staff to ensure accuracy.
- Facility will ensure clinical record documentation is complete and accurately reflects resident status.
- The Staff educator will educate licensed staff in documenting complete and accurate resident clinical records.
- The Medical Records/designee will conduct audits on 5% of the clinical records weekly x 4 weeks then every two weeks for 1 month then 5% monthly for 1 month. Variances will be addressed as identified. Results of the audits will be reported to the QAPI committee for review.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 a review of clinical records and resident incident reports and staff interview, it was determined that the facility failed to sufficiently supervise a resident during known periods of restless and unsafe behaviors to prevent a fall for one resident out of 15 sampled (Resident 71).

Findings include:

A review of Resident 71's clinical record revealed that the resident was admitted to the facility on January 25, 2015, and had current diagnoses to include spinal stenosis (a condition where spinal column narrows and compresses the spinal cord), migraines (severe throbbing pain, generally experienced on one side of the head) and a C1 (neck) vertebra fracture.

Progress notes dated January 18, 2019, at 8:07 a.m. revealed that the resident had been awake most of the night, screaming, yelling. The resident's neck brace was in place. The resident was climbing out of bed while in bed and climbing out of her chair. This entry noted that Resident 71 was medicated with Tylenol, which was ineffective. The resident was repositioned several times, but remained uncomfortable. The physician was made aware and new order for Tramadol (a narcotic pain medication) was obtained. However, this physician order was discontinued when the resident's allergy to morphine was noted. Nursing noted that staff would continue to monitor the resident.

Progress notes dated January 18, 2019, at 12:05 p.m. revealed that the resident was noted to be yelling and crying and unable to explain why. The nursing report received from previous shift indicated that the resident had not slept last night.

Progress notes dated January 18, 2019 at 12:55 p.m. indicated that during the nursing shift, the resident began screaming inconsolably. The resident was unable to verbalize her needs and would just state "I don't feel good." Nursing noted that all interventions were ineffective.

Progress notes dated January 18, 2019, at 1:17 p.m. revealed that the resident continued to scream. The resident was placed in bed and then found on the floor out of the bed on the floor mat. Resident 71 continued screaming and showing signs of restlessness. The resident was then placed back in bed by three staff members. The physician was notified and an order was received to transfer the resident to the hospital.

Review of the facility's incident investigation dated January 18, 2019, at 12:39 p.m. noted that the resident rolled out of bed and was found on the floor out of the bed on the floor mat.

Nursing staff was aware, through shift report, that the resident had been awake most of the night, screaming, yelling, climbing out the bed and chair, demonstrating restless unsafe behaviors, but failed to provide sufficient staff supervision at the level and frequency required to meet this resident's safety needs and prevent a fall.

Interview with the Director of Nursing on February 22, 2019, at 2:00 p.m. confirmed that the facility failed to provide adequate supervision of Resident 71 in response to the resident's displays of restless behavior resulting in the resident's fall on January 18, 2019, during the 7 AM to 3 PM shift


28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services
Previously cited: 8/17/18











 Plan of Correction - To be completed: 03/22/2019

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
- Resident 71 is currently stable with no signs of restlessness or unsafe behavior.
- Facility will provide sufficient individualized supervision of residents with known signs of restless behavior to prevent unsafe behaviors.
- The Staff educator will educate licensed staff the importance of maintaining sufficient supervision of residents with known restless behavior and include documentation to support that individualized supervision.
- Audits will be conducted to monitor residents with documented known restless behaviors to ensure that they receive sufficient supervision to maintain safety. Unit Manager/designee will conduct the audit 5 times a week for 2 weeks, then 3 times a week for 2 weeks, then weekly for 1 month. Variances with be addressed as identified. Results of the audit will be reported to the QAPI committee for review.

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 a review of clinical records and staff interview it was determined that the facility failed to manage one resident's pain in a timely manner (Resident 71) out of 15 sampled residents.

Findings include:

A review of Resident 71's clinical record revealed that the resident was admitted to the facility on January 25, 2015, and had current diagnoses to include spinal stenosis (a condition where spinal column narrows and compresses the spinal cord), migraines (severe throbbing pain, generally experienced on one side of the head) and a C1 (neck) vertebra fracture.

Progress notes dated January 18, 2019, at 8:07 a.m. revealed that the resident had been awake most of the night, screaming, yelling. The resident's neck brace was in place. The resident was climbing out of bed while in bed and climbing out of her chair. This entry noted that Resident 71 was medicated with Tylenol, which was ineffective. The resident was repositioned several times, but remained uncomfortable. The physician was made aware and new order for Tramadol (a narcotic pain medication) was obtained. However, this physician order was discontinued when the resident's allergy to morphine was noted. Nursing noted that staff would continue to monitor the resident.

Progress notes dated January 18, 2019, at 12:05 p.m. revealed that the resident was noted to be yelling and crying and unable to explain why. The nursing report received from previous shift indicated that the resident had not slept last night.

Progress notes dated January 18, 2019 at 12:55 p.m. indicated that during the nursing shift, the resident began screaming inconsolably. The resident was unable to verbalize her needs and would just state "I don't feel good." Nursing noted that all interventions were ineffective.

Progress notes dated January 18, 2019, at 1:17 p.m. revealed that the resident continued to scream. The resident was placed in bed and then found on the floor out of the bed on the floor mat. Resident 71 continued screaming and showing signs of restlessness. The resident was then placed back in bed by three staff members. The physician was notified and an order was received to transfer the resident to the hospital.

There was no documented evidence that the facility had consulted with the physician regarding the resident's pain management following the discontinuation of Tramadol due to the resident's noted morphine medication allergy. The facility failed to demonstrate timely and effective pain management for this resident.

Interview with the Director of Nursing on February 22, 2019 at 2:00 p.m. confirmed that the physician was not consulted for potential alternate pain medication and the resident had been displaying symptoms of pain during the previous 11 PM to 7 AM shfit and majority of 7 AM to 3 PM shift on January 18, 2019, prior to be transported to the hospital.



28. Pa Code: 211.12 (a)(d)(1)(3)(5) Nursing services
Previously cited: 8/17/18





 Plan of Correction - To be completed: 03/22/2019

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 697
- Resident 71 is currently on an effective pain management regimen.
- The Unit Manager/designees will interview/ residents with a pain management program to ensure that there is timely and effective pain management.
- The Staff educator will educate staff on signs and symptoms of pain, pain evaluation, assessment, and timeliness of interventions. Residents exhibiting signs of will pain will be assessed for the most appropriate pain intervention based on the pain scales.
- Audits will be conducted by the Unit managers on residents communicating an ineffective response to their pain 5 times a week for 4 weeks, then 3 times a week for 2 weeks, then weekly for 1 month. Variances will be addressed as identified. Results of the audit will be reported to the QAPI committee for review.


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