Nursing Investigation Results -

Pennsylvania Department of Health
CHRIST THE KING MANOR
Patient Care Inspection Results

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CHRIST THE KING MANOR
Inspection Results For:

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CHRIST THE KING MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a complaint survey completed on April 1, 2019, it was determined that Christ the King 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:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify a resident's representative about incidents, changes in medications, and/or changes in condition for one of 15 residents reviewed (Resident 4).

Findings include:

The facility's policy regarding changes in a resident's condition or status, dated August 29, 2018, indicated that the resident's representative would be notified about any changes in the resident's medical or mental condition, or status.

Quarterly Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs) for Resident 4, dated September 17 and December 14, 2018, as well as an annual MDS assessment dated March 6, 2019, indicated that the resident was confused. A Pennsylvania General Durable Power of Attorney (legal authorization for someone to make decisions for another person), signed May 12, 2015, indicated that Resident Family Member 1 was designated as the "Primary Agent" for Resident 4, and Resident Family Member 2 was designated as the "First Alternate Agent" in the event that the Primary Agent was unable to serve, unavailable, or refused to serve as the Primary Agent. Review of an undated "Skilled Nursing Facility face sheet" in Resident 4's electronic health record revealed that that Resident Family Member 2 was designated as the primary contact, and Resident Family Member 1 was designated as the second contact.

A facility incident note, dated October 25, 2018, indicated that Resident 4 fell while walking to the bathroom, and Resident Family Member 2 was notified about the incident, instead of Resident Family Member 1.

A nursing note for Resident 4, dated October 31, 2018, indicated that the physician reviewed laboratory results and ordered a decrease in a medication the resident received, and Resident Family Member 2 was notified about the change in medication, instead of Resident Family Member 1.

A nursing note for Resident 4, dated January 9, 2019, indicated that the physician was notified about a change in the resident's condition, resulting in physician's orders for the resident to be tested for influenza and to have a chest x-ray completed. The note indicated that Resident Family Member 2 was notified about the change in condition and the new orders, instead of Resident Family Member 1.

A physical therapy note for Resident 4, dated February 27, 2019, indicated that the resident was screened for the requirements for physical therapy, and the resident was to receive physical therapy for four weeks. There was no documented evidence that Resident Family Member 1 was notified about the orders for physical therapy.

A nursing note for Resident 4, dated March 7, 2019, indicated that the resident was having increased difficulty swallowing, and new orders were received for a speech therapy evaluation and treatment. There was no documented evidence that Resident Family Member 1 was notified about the orders for speech therapy.

A nursing note for Resident 4, dated March 11, 2019, at 12:08 p.m. indicated that the facility contacted Resident Family Member 2 related to a change in condition, instead of Resident Family Member 1.

A nursing note for Resident 4, dated March 13, 2019, indicated that the facility contacted Resident Family Member 2, instead of Resident Family Member 1, related to a possible hospice consultation.

Interviews with the Director of Nursing on April 1, 2019, at 1:20 p.m. and 4:00 p.m. confirmed that the Primary Agent should have been contacted regarding changes for Resident 4, and the face sheet in the resident's clinical record was incorrect. She confirmed that there was no documented evidence that Resident Family Member 1 was notified.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Previously cited 11/1/18.




 Plan of Correction - To be completed: 04/22/2019

1. The facility can not retroactively correct the deficiency as it relates to this resident.
2. All current residents' primary agents have been reviewed. All face sheet information has been updated to assure that the information is correct.
3. The therapy department has been educated on the necessity of calling primary agents at the start of therapy. Education on calling the primary agent was included to both therapy staff and nursing staff who notify families of changes. Documentation will now be completed by the therapists who contact the responsible parties regarding therapy.
Any changes to the primary agents will be made by only the Social Service department. Social service is also responsible for making updates to the facesheet and providing documentation.
4. Audits for responsible party notification for therapy compliance will be completed by the therapy manager. Audits for correct primary agent notification will be completed by the Director of Nursing or her designee. These audits will be done weekly for four weeks and monthly for two months. The results of these audits will be presented to the Quality Assurance Committee for review for 3 quarters.
5. Corrective action completion 4/22/19.


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