Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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PATRIOT, A CHOICE COMMUNITY THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on April 13, 2019, it was determined that The Patriot, A Choice Community 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.

 Plan of Correction:

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with oxygen therapy as ordered by the physician for one of seven residents reviewed (Resident 1).

Findings include:

The facility's policy regarding oxygen administration, dated March 11, 2019, indicated that the facility would provide oxygen to residents as ordered by the physician.

A care plan for Resident 1, dated May 10, 2017, revealed that the resident had chronic obstructive pulmonary disease (COPD - lung disease that makes breathing difficult) and was on continous oxygen therapy, which was to be administered per physician's orders. Physician's orders for Resident 1, dated September 11, 2018, included an order for the resident to receive continuous oxygen at a flow rate of 3 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils).

Observations of Resident 1 on April 13, 2019, at 9:30 a.m. and 12:15 p.m. revealed that the resident was in a wheelchair using an oxygen concentrator that was set at a flow rate of 2 liters per minute.

Interview with Registered Nurse 1 on April 13, 2019, at 12:20 p.m. confirmed that Resident 1 was ordered to receive oxygen at a flow rate of 3 liters per minute, not 2 liters per minute.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 6/22/19, 4/12/18.

 Plan of Correction - To be completed: 04/29/2019

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community's written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

1. Resident R1's oxygen flow was immediately adjusted to reflect the ordered flow rate of 3 liters/minute following this observation. A Registered Nurse assessed R1's respiratory status and R1 was noted to be free of any negative effect from this observation. The physician was notified of the observation and no additional orders were given.

2. Residents with oxygen orders were audited immediately following this observation to assure that oxygen was delivered at the physician ordered flow rate by the Director of Nursing/designee.

3. Licensed nursing staff will be re-educated by the Director of Nursing, Staffing Education Coordinator, or designee related to assuring that residents with physician orders for oxygen are receiving therapy at the ordered flow rate. Stickers with individual resident ordered liter flow have been placed on oxygen concentrators for staff reference to assure oxygen is delivered at ordered flow rate.

4. Oxygen flow rates will be audited to assure that residents with physician orders for oxygen therapy are receiving oxygen therapy per order daily x 2 weeks, weekly x 2 weeks, then monthly x 2 months by the Director of Nursing / designee. The audit results will be reviewed with the Quality Assurance Performance Improvement Committee.

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