Nursing Investigation Results -

Pennsylvania Department of Health
QUALITY LIFE SERVICES - SUGAR CREEK
Patient Care Inspection Results

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QUALITY LIFE SERVICES - SUGAR CREEK
Inspection Results For:

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QUALITY LIFE SERVICES - SUGAR CREEK - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to two complaints completed on May 15, 2019, it was determined that Quality Life Services - Sugar Creek 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:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:
Based on review of facility policies, clinical records and facility documents, and staff interview, it was determined that the facility failed to make certain that residents are free from neglect, which resulted in actual harm (fractured ankle and fibula/calf bone) for one of eight residents (Resident R1).

Findings include:

The facility policy "Resident Protection from Abuse, Neglect or Exploitation" last revised on 9/12/18, indicated that neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

A review of the Admission Face Sheet indicated that Resident R1 was admitted to the facility on 4/5/16. A review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 1/31/19, indicated that Resident R1 was re-admitted to the facility on 5/17/17, and had current diagnoses that included mild intellectual disabilities, dementia with behavioral disturbance, bipolar disorder (disorder characterized by extreme mood swings from depressive lows to manic or high energy highs), anxiety, and foot drop of the left foot (impaired ability to raise toes or raise the foot from the ankle).

A review of the initial physician order dated 9/27/18, and continued on her monthly recapitulation (restatement) orders dated 5/2/19, indicated that Resident R1 was to be out of bed to an evolution wheelchair ( a high back chair that promotes self-mobility) with standard leg rests for transport in and out of the facility.

A review of the facility incident report indicated that on 5/2/19, at 3:30 p. m. Nurse Aide Employee E1 was pushing Resident R1 in her wheelchair to the dining room, when LPN Employee E2 alerted her to stop as her left foot was bent underneath her wheelchair.

A review of the mobile x-ray report dated 5/2/19, indicated that Resident R1 had an acute medial malleolar (middle ankle) fracture. A review of the hospital x-ray report dated 5/3/19, indicated an acute nondisplaced bimalleolar fracture (occurring on the side and middle) of the ankle and an acute Weber A fracture (near the ankle) of the distal (end nearest the foot) fibula (the smaller of the two calf bones).

A review of the statement dated 5/3/19, and signed by NA Employee E1, indicated that NA Employee E1 was aware that residents' feet are to be on the wheelchair leg rests during transport.

A review of the facility's investigation of Resident R1's incident on 5/2/19, indicated that NA Employee E1 failed to follow the physician order to utilize leg rests during transport in the facility.

A review of the physician order dated 5/3/19, indicated that Resident R1 was to have a CAM (controlled ankle movement) boot on at all times and is not to bear weight on her left leg. She had an order to change her transfer status to mechanical lift with assist of two staff. She also has an order for oxycodone-acetaminophen 5/325 milligrams (mg) every six hours as needed for pain.

A review of the April and May 2019 medication administration records revealed that Resident R1 did not have an order for oxycodone-acetaminophen 5/325 mg until after the fracture to her ankle and fibula on 5/3/19. She has received 14 doses for pain from 5/3/19 through 5/15/19.

During an interview on 5/15/19, at 2:15 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that Resident R1 was free from neglect during transport to the dining room which resulted in actual harm (acute nondisplaced bimalleolar left ankle fracture and acute Weber A fracture of the left distal fibula) to Resident R1.

28 Pa. Code: 201.14 (a) Responsibility of licensee.

28 Pa. Code: 201.18 (b) (1) (3) (e) (1) Management.

28 Pa. Code: 201.29 (d) Resident rights.

28 Pa. Code: 211.10 (c) (d) Resident care policies.

28 Pa. Code: 211.12 (d) (1) (2) (3) (5) Nursing services.





 Plan of Correction - To be completed: 06/04/2019

Quality Life Services Sugar Creek has adopted internal processes as part of our on-going commitment to provide quality care to the residents we serve. The attached information contains Quality Life Services Sugar Creek's Plan of Correction which we are submitting in response to specific deficiencies identified by the Pennsylvania Department of Health and is required for purposes of our facility's licensure and certification. The information and responses contained in our Plan of Correction are consistent with our own quality improvement efforts and should not be construed as an admission of or agreement with the deficiencies cited in the Department's findings. This Plan of Correction is not an admission of wrongdoing on the part of Quality Life Services Sugar Creek.

On 5/3/19 R1 was ordered elevated leg rests when out of bed in wheelchair.
E1 was educated 1:1 on wheelchair safety by the Director of Nursing during the investigation of the incident that occurred on 5/2/19. Director of Nursing and Assistant Director of Nursing will provide re-education to the direct staff on the facility's policy on abuse and neglect. Copies of the facility's abuse and neglect policy and procedure training has been reviewed for training completeness for all staff by the Administrator. Abuse and neglect training audit will be reviewed at the next QAPI meeting in June 2019. Abuse and neglect training will continue for new hires and annually. Residents will be screened quarterly by the therapy department for the residents need of leg rest and their plan of care will be updated with changes. **DON or designee will visually audit residents to ensure leg rest are being used: Nursing will audit (10) residents five times a week x four weeks that leg rests are on wheelchairs prior to resident transport. Completed audits results will be reviewed through QAPI process
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 review of facility policies, clinical records and facility documents, and staff interview, it was determined that the facility failed to provide physician ordered assistive devices which resulted in actual harm (fractured ankle and fibula/calf bone) for one of eight residents (Resident R1).

Findings include:

A review of the Admission Face Sheet indicated that Resident R1 was admitted to the facility on 4/5/16. A review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 1/31/19, indicated that Resident R1 was re-admitted to the facility on 5/17/17, and had current diagnoses that included mild intellectual disabilities, dementia with behavioral disturbance, bipolar disorder (disorder characterized by extreme mood swings from depressive lows to manic or high energy highs), anxiety, and foot drop of the left foot (impaired ability to raise toes or raise the foot from the ankle).

A review of the initial physician order dated 9/27/18, and continued on her monthly recapitulation (restatement) orders dated 5/2/19, indicated that Resident R1 was to be out of bed to an evolution wheelchair ( a high back chair that promotes self-mobility) with standard leg rests for transport in and out of the facility.

A review of the facility incident report indicated that on 5/2/19, at 3:30 p. m. Nurse Aide Employee E1 was pushing Resident R1 in her wheelchair to the dining room, when LPN Employee E2 alerted her to stop as her left foot was bent underneath her wheelchair.

A review of the mobile x-ray report dated 5/2/19, indicated that Resident R1 had an acute medial malleolar (middle ankle) fracture. A review of the hospital x-ray report dated 5/3/19, indicated an acute nondisplaced bimalleolar fracture (occurring on the side and middle) of the ankle and an acute Weber A fracture (near the ankle) of the distal (end nearest the foot) fibula (the smaller of the two calf bones).

A review of the statement dated 5/3/19, and signed by NA Employee E1, indicated that NA Employee E1 was aware that residents' feet are to be on the wheelchair leg rests during transport.

A review of the facility's investigation of Resident R1's incident on 5/2/19, indicated that NA Employee E1 failed to follow the physician order to utilize leg rests during transport in the facility.

A review of the physician order dated 5/3/19, indicated that Resident R1 was to have a CAM (controlled ankle movement) boot on at all times and is not to bear weight on her left leg. She had an order to change her transfer status to a mechanical lift with assist of two staff. She also has an order for oxycodone-acetaminophen 5/325 milligrams (mg) every six hours as needed for pain.

A review of the April and May 2019 medication administration records revealed that Resident R1 did not have an order for oxycodone-acetaminophen 5/325 mg until after the fracture to her ankle and fibula on 5/3/19. She has received 14 doses for pain from 5/3/19 through 5/15/19.

During an interview on 5/15/19, at 2:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide physician ordered assistive devices for Resident R1 which resulted in actual harm (acute nondisplaced bimalleolar left ankle fracture and acute Weber A fracture of the left distal fibula) to Resident R1.

28 Pa. Code: 201.14 (a) Responsibility of licensee.
Previously cited 7/28/17.

28 Pa. Code: 201.18 (b) (1) (3) (e) (1) Management.

28 Pa. Code: 201.29 (d) Resident rights.

28 Pa. Code: 211.10 (c) (d) Resident care policies.

28 Pa. Code: 211.12 (d) (1) (2) (3) (5) Nursing services.


 Plan of Correction - To be completed: 06/03/2019

On 5/3/19 R1 was ordered elevated leg rests when out of bed in wheelchair. Audit was completed by the Director of Nursing, Assistant Director of Nursing and Therapy Manager to ensure residents who do not self-propel in a wheelchair have leg rests on and in use during transport. E1 was educated 1:1 on wheelchair safety by the Director of Nursing during the investigation of the incident that occurred on 5/2/19. Staff were also educated on wheelchair safety at that time. Director of Nursing and Assistant Director of Nursing provided re-education to staff on wheelchair safety during resident transport. Administrator provided education to residents' family/responsible party to use leg rests on wheelchairs when transporting residents in and outside of the facility via email and letters. Residents will be screened quarterly and as needed for therapy which would include wheel chair positioning and to identify need for leg rests. Director of Nursing or designee will visually inspect residents in their wheelchair that require leg rest prior to transport monitor. Nursing will audit (10) residents five times a week x four weeks that leg rests are on wheelchairs prior to resident transport. Completed audits results will be reviewed through QAPI process.

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