Nursing Investigation Results -

Pennsylvania Department of Health
AVENTURA AT PROSPECT
Patient Care Inspection Results

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AVENTURA AT PROSPECT
Inspection Results For:

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AVENTURA AT PROSPECT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on May 13, 2019, it was determined that Aventura at Prospect Park 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 related to the health portion of the survey process.



 Plan of Correction:


483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of clinical records, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to complete a thorough investigation for an allegation of neglect for one of four residents reviewed (Resident R1).

Findings include:

The facility's policy "Abuse Protection," stated that the "facility shall have processes in place to include screening, training, prevention, protection, investigation, reporting and response to all allegations of potential or actual abuse and neglect."

Additionally it stated, "Regardless of how minor an accident or incident may be, including injuries of unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned." In addition "An investigation is implemented and witness statements are obtained."

Review of Resident R1's clinical record revealed the resident was readmitted to the facility on November 26, 2018, with a diagnosis to include osteoarthritis (A type of arthritis that occurs when flexible tissue at the ends of bones wears down) and psychosis (A mental disorder characterized by a disconnection from reality).

Review of Resident R1's clinical record revealed a progress note dated January 9, 2019, which revealed "I was left in bed from 3:30-5:30 and no one came to help me. I had to go to the bathroom and no one would come to help me. My call bell was on two hours and no one would come to help me OOB to the bathroom."

A request was made to the DON on May 13, 2019, at 12:45 p.m. for a facility investigation to rule out neglect regarding Resident R1's concerns. The DON confirmed the facility had no documented evidence that an investigation was conducted regarding Resident R1's above mentioned concerns.

The was no evidence available for review regarding the incidents or that a thorough investigation had been completed as required.

28 Pa. Code: 201.18(a)(b)(1)(3) Management
Previously cited 6/7/18

28 Pa. Code: 211.10(a)(c) Resident care policies
Previously cited 6/7/18

28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services
Previously cited 6/7/18






 Plan of Correction - To be completed: 06/13/2019

Resident R1 was given a bed bath at 4 pm and a skin check was performed at 430pm.

A random audit of residents was completed to ensure timely answering of call bells.

Nursing staff was reeducated on properly documenting resident concerns and reporting to the Administrator/DON or designee.

Call bell auditing will be performed 3 times a week x4 weeks Then monthly for x3

All concerns or complaints will be investigated and reviewed by the IDT.

Results of the outcomes will be reported to the QAPI committee monthly for review.


483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive 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(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of four residents (Resident R1).

Findings include:

Review of Resident R1's clinical record revealed the resident was readmitted to the facility on November 26, 2018, with a diagnosis to include osteoarthritis (A type of arthritis that occurs when flexible tissue at the ends of bones wears down) and psychosis (A mental disorder characterized by a disconnection from reality).

Review of Resident R1's clinical record revealed a progress note dated April 12, 2019, which revealed that the resident was diagnosed with scabies. Further, review of Resident R1's clinical record revealed a comprehensive care plan was not developed regarding the scabies (An itchy skin condition caused by a tiny, burrowing mite).

Interview on May 13, 2019, at 2:20 p.m. with the DON, where she confirmed the facilty did not develop a comprehensive care plan regarding the resident's diagnosed scabies

The facility failed to develop a comprehensive care plan for an identified medical diagnosis as required.

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 6/7/18.


















 Plan of Correction - To be completed: 06/13/2019

Resident's R1 careplan was updated.

All other careplans were reviewed no other careplans had any diagnosis of scabies or lice.

License Nursing Staff were reeducated on ensuring that any resident with a diagnosis of scabies or lice will have a careplan reflecting that diagnosis.

During clinical review any diagnosis of scabies or lice will be careplaned. Weekly audit of all diagnosis for scabies and lice will be performed X2 then monthly X2

Results of these audits will be presented to the QAPI committee for review.



211.1(b) LICENSURE Reportable diseases.:State only Deficiency.
(b) Cases of scabies and lice shall be reported to the appropriate Division of Nursing Care Facilities field office.
Observations:
Based on a review of facility documentation, medical records, interviews with administrative staff, and review of documentation submitted by the facility, it was determined that the facility failed to notify the Pennsylvania Department of Health of one occurrence of scabies for Resident R1.

Findings include:

Review of facility policy "Reporting Unusual Occurrences," dated February 2018, revealed the policy stated that unusual occurrences are reported by the facility as required by federal, state laws and local agencies. The guidelines stated that appropriate agencies will be notified by the administrator or Administrative designee, if the following events occur, which included an epidemic outbreak of any disease, prevalence of communicable disease to infestation of parasites or vectors.

Review of Resident R1's clinical record revealed the resident was readmitted to the facility on November 26, 2018, with a diagnosis to include osteoarthritis (A type of arthritis that occurs when flexible tissue at the ends of bones wears down) and psychosis (A mental disorder characterized by a disconnection from reality).

Review of Resident R1's clinical record revealed a progress note dated April 12, 2019, which revealed that the resident was diagnosed with scabies.

Interview with the Director of Nursing on May 13, 2019, at 2:30 p.m., revealed that the facility failed to report the resident's scabies, to the Pennsylvania Department of Health as required by regulations.




 Plan of Correction - To be completed: 06/13/2019

Resident's R1 diagnosis of Scabies was reported.

An audit of resident's diagnosis were completed and no other resident had a diagnosis of Scabies or Lice

Administrator/DON were inserviced on DOH reporting guidance.

An audit on any cases of scabies or lice will be performed weeklyx2 , then monthly x2.

Findings of any Diagnosis of Scabies and Lice will be reported to the QAPI committee for review


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