Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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

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AVALON PLACE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to an incident and a complaint completed on April 22, 2019, it was determined that Avalon Place 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(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.
Based on clinical record review and staff interview, it was determined that the facility failed to make certain a resident was provided adequate supervision to prevent a fall for one of three residents (Resident R1).

Findings include:

A review of the admission record indicated Resident R1 was admitted to the facility on 4/9/19, and had current diagnoses that included a history of falls, high blood pressure and high cholesterol.

A review Resident R1's physician order that was not signed or dated, indicated the resident was an assist with 2 staff for transfers.

A review of Resident R1's nurses note dated 4/10/19, at 2:00 a.m., indicated Nurse Aide (NA) Employee E1 was ambulating the resident to the bathroom. Resident fell backward striking his head and back on the tray table.

A review of Resident R1's incident/accident report dated 4/10/19, indicated NA Employee E1 walked resident to bathroom without a second staff to assist.

A review of NA Employee E1's witness statement dated 4/10/19, indicated "I did not ask for another assist."

A review of a physician's order dated 4/10/19, indicated to send Resident R1 to the emergency department for an evaluation.

A review of the hospital physical examination dated 4/10/19, indicated Resident R1 was diagnosed with a subdural hematoma (bleeding inside the head from injury) and had 3 staples to the back of his head.

During an interview on 4/12/19, at 10:25 a.m. the Nursing Home Administrator confirmed NA Employee E1 failed to provided adequate assistance to prevent Resident R1's fall.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 10/5/18 and 2/1/19.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 10/5/18 and 2/1/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 2/1/19.

 Plan of Correction - To be completed: 05/29/2019

Cited resident R1 continues to be a two person assist per physician order. Employee E1 was re-educated on proper transfer status of residents.
The Kardex for residents requiring assistance for transfer were reviewed to ensure proper transfer status was in place.
The Director of Nursing/Designee will reeducate the Licensed nursing staff and CNA's on following proper transfer status.
The Director of Nursing/Designee will audit resident transfers with 2-person assist as ordered weekly for 5 residents for 4 weeks and 20 per month for 2 months. Audits will be submitted to QAPI for review and follow-up recommendations.

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