Nursing Investigation Results -

Pennsylvania Department of Health
SENA KEAN MANOR
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SENA KEAN MANOR
Inspection Results For:

There are  69 surveys for this facility. Please select a date to view the survey results.

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SENA KEAN MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on January 10, 2019, it was determined that Sena Kean Manor 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:


483.21(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 review of clinical records and staff interviews, it was determined that the facility failed to develop and/or update individualized care plans for one of 26 residents (Resident R104).

Findings include:

Resident R104's clinical record revealed an admission date of 8/05/2015, with diagnoses including but not limited to dementia, type 2 diabetes, hypertension (high blood pressure), acute respiratory failure, and major depression.

A physician's order dated 11/05/18, included oxygen therapy at two liters per minute (rate of delivery of oxygen) through nasal cannula (tubing with prongs that enters the nose to deliver oxygen) as needed (prn) for shortness of breath (SOB).

Observations on 1/07/19, at 4:33 p.m.; on 1/08/19, at 1:44 p.m.; and on 1/09/19, at 11:27 a.m. revealed Resident R104 lying in bed, the oxygen tubing was draped on top of his/her ears with the nasal cannula in his/her nose.

There was no evidence in the clinical record of a care plan regarding oxygen therapy prn.

Resident R104's physician's order dated 12/18/18, directed the application of "spot duoderm [type of treatment for wounds] to top of right ear as needed for soilage or dislodgement AND every evening shift every Tuesday, Friday for wound care." He/she was noted to have a tan dressing inch in diameter on the top of his/her right ear to address the wound.

There was no evidence of a care plan to address the pressure ulcer wound on his/her ear.

During an interview on 1/9/19, at 2:30 p.m. the Director of Nursing confirmed that Resident R104 did not have a care plan for oxygen therapy or the pressure ulcer on his/her ear.

28 Pa. Code 211.11(a)(c)(d) Resident care plan

28 Pa Code 211.12(d)(3)(5) Nursing Services
Previously cited 3/20/18







 Plan of Correction - To be completed: 02/28/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

Resident R104's care plan was updated at the time of the survey. All other care plans for residents with orders for oxygen have been audited at this time as well.

Resident R104's care plan and order were updated at the time of the survey to reflect the resolution of the wound and an order was obtained to apply the spot duoderm to top post right ear for preventative measures and the care plan updated accordingly. All other care plans for residents with wound care orders have been audited at this time as well.

Licensed staff will be re-educated to the facility policy related to care plans with an emphasis on updating care plans according to newly obtained/updated physician orders.

Random, 50%, audits of oxygen and wound care care plans will be conducted by the Director of Nursing/Designee weekly for four (4) weeks then monthly for three (3) months.

Audit findings will be reported to the Quality Assurance Committee and recommendations will be made as appropriate as indicated.

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 observations, review of clinical records and facility policy and staff interviews, it was determined that the facility failed to appropriately provide pressure ulcer treatments for one of 28 residents reviewed (Resident R104).

Findings include:

Resident R104's clinical record revealed an admission date of 8/05/2015, with diagnoses including but not limited to dementia, type 2 diabetes, hypertension (high blood pressure), acute respiratory failure, and major depression.

A facility policy titled "Oxygen Therapy/ Pulse Oximetry," last reviewed 1/3/19, revealed "to place oxy-ears or other padding on tubing where the tubing lies against skin behind the ears."

Observations on 1/07/19, at 4:33 p.m.; 1/08/19, at 1:44 p.m.; and on 1/09/19, at 11:27 a.m. revealed Resident R104 lying in bed, with the oxygen tubing draped on top of his/her ears with the nasal cannula (tubing with prongs that enters the nose to deliver oxygen) in his/her nose.

There was no padding on the ear for the tubing to rest on for the top of his/her ears to protect the skin.


28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 3/20/18









 Plan of Correction - To be completed: 02/28/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

Resident R104's oxygen tubing was padded at the time of the survey. All other residents with oxygen tubing have been checked for padding at this time as well.

Resident R104's orders and care plan have also been updated to include using padding (a spot duoderm) on the resident's ear to protect the skin.

Licensed staff will be re-educated to the facility policy "Oxygen Therapy/Pulse Oximetry" with emphasis on placing oxy-ears or other padding on tubing where the tubing lies against skin behind the ears.

Random, 50%, audits of oxygen tubing will be conducted to ensure the use of padding where the tubing lies against the skin behind the ears by the Director of Nursing/Designee weekly for four (4) weeks then monthly for three (3) months.

Audit findings will be reported to the Quality Assurance Committee and recommendations will be made as appropriate as indicated.

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.
Observations:

Based on observations, review of clinical records and staff interview, it was determined that the facility failed to provide respiratory services according to physician orders for one of 26 residents reviewed (Resident R104).


Findings include:

Resident R104's clinical record revealed an admission date of 8/05/2015, with diagnoses including but not limited to dementia, type 2 diabetes, hypertension (high blood pressure), acute respiratory failure, and major depression.

Facility policy titled "Oxygen Therapy/Pulse Oximetry," directed checking the rate (liters per minute) of delivery of oxygen at least every shift and as needed (prn).

A physician order dated 11/5/18, included an order to administer oxygen at two liters per minute via a nasal cannula (tubing with prongs that enters the nose to deliver oxygen) prn for shortness of breath.

Observations on 1/8/19, at 1:44 p.m. and on 1/9/19, at 11:22 a.m. revealed Resident R104 lying in bed, with the oxygen tubing draped on top of his/her ears with the nasal cannula in his/her nose. The oxygen concentrator (a machine that takes surrounding air to supply an oxygen rich stream) was identified with the oxygen administration level set at 1.5 liters per minute.

During an interview on 1/9/18, at 11:27 a.m. Licensed Practical Nurse Employee E2 confirmed that Resident R104's oxygen delivery rate was not set correctly at the ordered administration rate of two liters per minute.


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

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 3/20/18









 Plan of Correction - To be completed: 02/28/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

Resident R104's oxygen was set to 2.0 liters per minute at the time of the survey. All other residents with oxygen orders were audited at this time as well.

All licensed staff will be re-educated to the facility policy "Oxygen Therapy/Pulse Oximetry" with emphasis on checking the rate of delivery of oxygen at least every shift and as needed.

Random, 50%, audits of oxygen delivery rates for residents ordered oxygen will be conducted by the Director of Nursing/Designee weekly for four (4) weeks then monthly for three (3) months.

Audit findings will be reported to the Quality Assurance Committee and recommendations will be made as appropriate as indicated.

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 reportable facility incidents, clinical records and staff interviews, it was determined that the facility failed to adequately document in the clinical record regarding an incident that occurred and failed to document regarding assessment of a wound and application of a wound treatment and the administration of oxygen for two of 28 residents reviewed (Residents R54 and R104).

Findings include:

The clinical record indicated that Resident R54 was admitted to the facility on 3/11/15, with diagnosis including, but not limited to high blood pressure, lymphedema (swelling of legs and arms), anxiety, and constipation.

Review of information dated 12/14/18, submitted by the facility revealed that on 12/13/18, at 2:00 a.m. Registered Nurse (RN) Employee E4 administered a soaps suds enema (injecting fluid into the lower bowel by way of rectum to relieve constipation) as physician ordered to Resident R54. Per the information submitted and RN Employee E4's statement, he/she inadvertently failed to remove the blue cap off the tubing prior to inserting the tube into Resident R54's rectum. As a result, upon removal of the tubing from the rectum, the blue cap had remained inside Resident R54's rectum. RN Employee E4 removed the cap from Resident R54's rectum at the time of discovery.

Clinical record progress note dated 12/13/18, at 2:44 a.m. revealed that RN Employee E4 documented "Resident in bed with eyes closed. No complaints of pain or discomfort voiced or noted. Resident currently undergoing a soaps suds enema every hour due to constipation. Resident is tolerating well. At this time there have not been any results." Further review of the progress notes between the time of the incident and 12/15/18, at 6:40 p.m. revealed no evidence of documentation concerning the incident described above or that the physician was made aware of the incident.

During an interview on 1/9/19, at 12:30 p.m. RN Employee E3 indicated that RN Employee E5 reported the incident to Resident R54's primary physician on 12/14/18, at which time the physician ordered for Resident R54 to go to the emergency room (ER).

Clinical record progress notes for 12/14/18, at 8:07 a.m. and 12/14/18, at 4:49 p.m. completed by RN Employee E5 lacked documented evidence of the physician being notified of the incident that occurred and also had no evidence of documentation by the physician regarding the incident. Review of the ER report from 12/14/18, revealed that Resident R54 attended the ER per physician orders for abdominal distension and constipation. The ER report did not indicate awareness of the facility incident.

During an interview on 1/9/19, at 12:48 p.m. the Director of Nursing confirmed that there was a lack of clinical record documentation regarding the actual incident that occurred, to include physician notification of the incident and that the ER was also aware of the incident.



Resident R104's clinical record revealed an admission date of 8/05/2015, with diagnoses including but not limited to dementia, type 2 diabetes, hypertension (high blood pressure), acute respiratory failure, and major depression.

Facility policy "Oxygen Therapy/Pulse Oximetry," directed checking the rate of delivery of oxygen (liters per minute) at least every shift and as needed (prn) and for all oxygen orders to be transcribed in the Medication Administration Record (MAR).

A physician's order dated 11/5/18, for Resident R104 included to administer oxygen at two liters per minute via a nasal cannula (tubing with prongs that enters the nose to deliver oxygen) as needed for shortness of breath.

Observations on 1/8/19, at 1:44 p.m., and on 1/9/19, at 11:22 a.m. revealed Resident R104 lying in bed, the oxygen tubing was draped on top of his/her ears with the nasal cannula in his/her nose.

Resident R104's January 2019 MAR did not identify the oxygen order to enable staff to document assessment of his/her respiratory status and any corresponding oxygen application/use.

During an interview on 1/10/19, at 11:00 a.m. the Assistant Director of Nursing confirmed that the clinical record lacked documentation regarding Resident R104's respiratory status and the administration of oxygen.


A nurse's note dated 12/18/18, documented that Resident R104 had an open area on top of his/her right ear from the oxygen tubing. A physician's order dated 12/18/18, directed the application of "spot duoderm [a type of treatment for a wound] to top of right ear as needed for soilage or dislodgement AND every evening shift every Tuesday, Friday for wound care."

Resident R104's clinical record revealed that there was no documentation regarding wound care to include a wound assessment or for the application of the duoderm from 12/18/18 to 12/31/18, a period of 13 days.

During an interview on 1/10/19, at 10:30 a.m. the Wound Nurse Employee E1 confirmed that Resident R104's wound had not been assessed and there was no corresponding documentation regarding the treatment application.

28 Pa. Code 201.18(a)(1) Management
Previously cited 3/20/18

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 3/20/18

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












 Plan of Correction - To be completed: 02/28/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

Resident R54's physician has been notified of the incident occurring 12/13/2018 and documentation of the incident has been completed.

Resident R104's MAR was updated at the time of the survey to enable staff to document assessment of resident respiratory status and corresponding oxygen application/use. All other residents MAR's have been audited for documentation of respiratory status assessment and corresponding oxygen application/use.

Resident R104's wound was assessed at the time of the survey. The wound was found to have been resolved and documentation of the findings was completed. All residents with wounds have been checked for proper assessment and application of the ordered treatment.

Licensed staff have been re-educated on the facility policy regarding documentation and physician notification of resident incidents.

Licensed staff have been re-educated on the facility policy "Oxygen Therapy/Pulse Oximetry" with emphasis on checking the rate of delivery of oxygen at least every shift and as needed as well as transcribing all oxygen orders in the MAR for all residents receiving oxygen therapy.

Licensed staff have been re-educated to the facility policy regarding resident wounds with emphasis on wound assessment documentation as well as documentation regarding the application of the wound treatment.

100% audits of all new incidents will be conducted by the Director of Nursing/Designee for proper documentation and physician notification. Audits will be completed weekly for four (4) weeks then monthly for three (3) months.

Audit findings will be reported to the Quality Assurance Committee and recommendations will be made as appropriate as indicated.

Random, 50%, audits of respiratory status and oxygen application documentation will be conducted by the Director of Nursing/Designee weekly for four (4) weeks then monthly for three (3) months.

Audit findings will be reported to the Quality Assurance Committee and recommendations will be made as appropriate as indicated.

Random, 50%, audits of resident wound assessments documentation and wound treatments documentation will be conducted by the Director of Nursing/Designee weekly for four (4) weeks then monthly for three (3) months.

Audit findings will be reported to the Quality Assurance Committee and recommendations will be made as appropriate as indicated.


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