Nursing Investigation Results -

Pennsylvania Department of Health
PAUL'S RUN
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PAUL'S RUN
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.
PAUL'S RUN - 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 an abbreviated survey in response to two reportable events, completed on February 19, 2019, it was determined that Paul's Run 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 as they relate to the health portion of the survey process.




 Plan of Correction:


483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan: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 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based upon clinical record review it was determined that a baseline care plan for a skin wound was not developed with 24 hours of admission for one of 27 residents reviewed (Resident R41).

Findings include:

Review of Resident R41's clinical record revealed the resident was admitted to the facility on December 26, 2018, with diagnosis to include non-displaced fracture of left second metatarsal bone (break in the long bone in the foot) due to a fall at home. The resident was non-weight bearing to left lower extremity and had a cast on.

Review of the acute care hospital's transfer paperwork that was sent to the facility for the resident's December 26, 2018, admission to the facility revealed " .. there is 5 by 3 centimeter blister on left dorsal foot which has popped. ..."

Further, review of Resident R41's clinical record revealed no documented evidence that a baseline care plan for the resident's blister on left dorsal foot was developed with 24 hours of admission.

Interview on February 15, 2019, at 11:15 a.m. with Employee E3, RN, where he confirmed that there was no documented evidence that a baseline care plan for the resident's blister on the left dorsal foot was developed within 24 hours of admission.

The facility failed to ensure that a baseline care plan for a skin wound was developed with 24 hours of admission


28 Pa. Code 201.18(b)(3) Management

28 pa. Code 211.12(c)(d)(1)(5) Nursing Services










































 Plan of Correction - To be completed: 03/10/2019

Staff education completed on 3/8/2019
RE:
Documentation received from the acute care setting and other transfers is reviewed during the admission process by the IDT
This process will be monitored by each shift supervisor (RN) and reported monthly at QA committee with 100% compliance achieved for 6 months and then continued quarterly

Information related to the resident's care is incorporated into the baseline care plan within 24 hrs. of admission. Baseline care plans are reviewed within 24 hrs of admission by the IDT each morning

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on clinical record reviews, as well as staff and resident interviews, it was determined that the facility failed to ensure that a resident with a skin wound received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of 27 residents reviewed (Resident 41).

Findings include:

Review of Resident R41's clinical record revealed the resident was admitted to the facility on December 26, 2018, with diagnosis to include non-displaced fracture of left second metatarsal bone (break in the long bone in the foot) due to a fall at home. The resident was non-weight bearing to left lower extremity and had a cast on.

Review of the acute care hospital's transfer paperwork that was sent to the facility for the resident's December 26, 2018, admission to the facility revealed " ... there is 5 by 3 centimeter blister on left dorsal foot which has popped...."

Resident R41's cast was removed on January 29, 2019, and the resident's new orders included weight bearing as tolerated in fracture boot (walking boot). Review of the resident's physician orders revealed an order dated January 30, 2019, to monitor skin integrity of left lower leg prior to placing cam boot on in AM and after removing cam boot (walking boot) in the evening. Review of Resident R41's treatment administration record revealed that facility staff had documented that the skin assessments were completed on the following dates: January 30, 31, February 1, 2, and 3, 2019.

Review of Resident R41's clinical record from December 26, 2019, to February 2, 2019, revealed no nursing documentation regarding the resident's dorsal foot blister that was noted on the acute care hospital's transfer information. Further, review of Resident R41's clinical record revealed a nurse progress note dated February 3, 2019, which revealed " ... CNA while doing care observed a soft black eschar (wound is covered with thick, dry, black dead tissue) on left heel measuring 5 cm x 4.5 cm. "

Interview on February 15, 2019, at 11:00 a.m. with Employee E3, RN, where he confirmed that the resident was admitted to the facility from an acute care hospital with a left dorsal foot blister which had popped. Employee E3, RN, confirmed that when the resident's left lower leg cast was removed on January 29, 2019, nursing staff failed to identify the blister on January 29, 30, 31, February 1, 2, and 3, 2019.

The facility failed to ensure that a resident with skin wound received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing

28 Pa. Code 211.5(f) Clinical records.

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

28 Pa. Code 211.12(d)(3) Nursing services.

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





 Plan of Correction - To be completed: 03/12/2019

Staff re-educated to perform thorough skin assessments especially post cast removals and other orthopedic consultations 2/20/2019 and ongoing

Competency and education for skin assessment and wound care for all licensed nurses started on 2/20/2019 and ongoing. Included in annual competency training.

Skin assessments and documentation of wound care monitored monthly to ensure compliance with skin assessments and wound care. Reported at monthly QA meetings by 7-3 RN Clinical Coordinator and DON. Goal is 100% compliance

483.40(b)(1) REQUIREMENT Treatment/Srvcs Mental/Psychoscial Concerns: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.
483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that-
483.40(b)(1)
A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;
Observations:


Based on the review of the clinical record and interviews with staff, it was determined that the facility failed to ensure that a resident who verbalized suicidal ideation received treatment and services for one out of twenty-three residents reviewed (Resident R89).

Findings include:

Review of the clinical record revealed that Resident R89 was admitted to the facility on December 26, 2018 with diagnoses that included, but not limited to, Major depressive disorder (feelings of sadness, low esteem, hopelessness) Repeated falls, Difficulty in walking, Fracture of the left femur (thigh bone), and the presence of a left artificial hip joint.

Review of the physician orders for February 2019 revealed a physician's order dated December 26, 2018, and every month thereafter, for the administration of the anti-depressant medication, Mirtazapine (15 milligram, give one tablet by mouth at bedtime) for Resident R89's diagnosis of Major depressive disorder.

Review of the nursing notes revealed a note written by the resident's attending physician on January 1, 2019 which stated that Resident R89 was seen by the physician after receiving a call from the resident's daughter regarding issues of pain control, nausea and depression. The note written by the resident's attending physician on January 1, 2019 also stated that "Patient verbalized desire to die. No intentions of hurting herself."

Review of the resident's clinical record and nursing notes did not reveal any documentation regarding the physician's discussion with the resident or the resident's daughter or any plan to monitor and assess Resident R89's psycho-social well-being.

During an interview with the unit manager (Employee E4) on February 19, 2019 at approximately 11:50 a.m. the note written by the physician on January 1, 2019 documenting the resident's suicidal ideation was reviewed. Employee E4, Unit Manger reported that the resident was on another floor during that time and that she was not aware of the resident's comment to the physician regarding a desire to die.

During an interview with the Registered Nursing Assessment Coordinator (Employee E5) on February 19, 2019 at approximately 11:50 a.m. the note written by the physician on January 1, 2019 documenting suicidal ideation was reviewed, and it was confirmed during this time by (Employee E5) that there was no indication in the resident's medical chart that the resident was monitored and assessed by staff after the physician was notified that Resident R89 verbalized suicidal ideation. It was also confirmed during this time, that there was no evidence that the resident was referred to a behavioral health professional, and no evidence that the resident's person-centered plan of care was reviewed and revised to address the resident's comments regarding her desire to die.

During an interview with the Social Services Coordinator (Employee E6) on February 19, 2019 at approximately 12:00 p.m. she reported that she was not aware that Resident R89 verbalized ta desire to die to the physican. Employee E6 also reported that she was the social worker for the resident during that time.

The facility failed to ensure that a resident who verbalized suicidal ideation received treatment and services.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services








 Plan of Correction - To be completed: 03/11/2019

The attending physician was educated that as a member of the IDT will communicate changes in resident's psycho-social well being and will write orders for care ad monitoring of resident with suicidal ideation. (2/20/2019)
Staff educated to recognize signs and symptoms of depression, withdrawal, PTSD, and suicidal ideation /and or passive wishes to die (2/25/2019 and as needed as well as annually.
Policy and Competency developed

All admissions are reviewed for any indication of suicidal ideation by the RN supervisor at time of admission. QA monitor to ensure that assessment is completed and alert documentation initiated for any resident expressing suicidal ideation whether active or passive and appropriate action initiated. Reported at QA meeting monthly by Director of Social Services with expectation of 100% compliance for 6 months and then monitored quarterly

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 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.
483.20(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 review of clinical records and staff interviews, it was determined that the facility failed to maintain and complete accurate documentation for one of 27 residents reviewed (Resident R32).

Findings include:

Review of Resident R32's clinical record revealed the resident was admitted on March 20, 2017, with a diagnosis to include seizure disorder (abnormal electrical activity in the brain).

Review of Resident R32's clinical record nurse progress notes revealed the resident had a fall on January 18, 2019, where the resident was found on the floor.

A request was made on February 15, 2019, at 2:30 p.m. for a facility investigation regarding the resident's fall on January 18, 2019.

Interview on February 19, 2019, at 9:00 a.m. with the administrator, where she stated that Resident R32 did not have a fall on January 18, 2019, and she stated that facility nursing staff had documented in the wrong clinical record regarding the fall.

The facility failed to maintain and complete accurate documentation


28 Pa. Code: 211.5(f)(g)(h) Clinical records.














 Plan of Correction - To be completed: 03/11/2019

Documentation competency developed and initiated on 2/25/2019 for all staff who document in the EMR/medical record. Education will be conducted annually and as needed.
Signage placed in each team room/nurses station to remind staff to select the correct resident before starting documentation (2/20/2019)

Monthly monitor established to review chart documentation for accuracy/ any errors in documentation. Items to be assessed are correct identification of resident, content, grammar and accuracy of progress note. Responsibility of DON. Monitor to be maintained monthly for 6 months and if 100% accuracy will continue quarterly


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