Nursing Investigation Results -

Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LAKESIDE
Patient Care Inspection Results

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KADIMA REHABILITATION & NURSING AT LAKESIDE
Inspection Results For:

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KADIMA REHABILITATION & NURSING AT LAKESIDE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on April 11, 2019, it was determined that Kadima Rehabilitation and Nursing at Lakeside was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care 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.
Observations:

Based on review of clinical records and incident investigation and staff interview revealed that the facility failed to demonstrate that sufficient supervision was provided to prevent accidents for one resident (Resident CR1) out of five residents reviewed.


Findings include:

A review of the Resident CR1's clinical record revealed that the resident required the assistance of one person contact guard (one or more hands on the resident to provide assistance) with the use of a walker to ambulate.

A review of the facility investigation into an incident, revealed that Employee 1, a nursing assistant had ambulated the resident into the bathroom on September 5, 2018, at 7:56 a.m.

According to a statement completed by Employee 1, Resident CR1 was walking through the door from his room into the bathroom. Employee 1 alleged that the resident was holding onto his walker. Employee 1 further stated she was "guiding" Resident CR1 through the door. Employee 1 indicated that the resident took a few steps and then fell face first, hitting is head on the floor.

The resident was assessed and had sustained a laceration to the forehead and was unresponsive. The resident's head was bleeding, which was controlled with direct pressure. The resident's pulse oximetry (amount of oxygen in the blood) was 77%. Oxygen was applied and it rose to 82% and then 90%. The resident also had a skin tear to the left dorsal hand and his right arm was extended and stiff. He had abrasions to each knee.

Further review of the facility investigation into the incident, revealed that the incident was reviewed by the Director of Nursing Services who stated that the staff member was not able to "catch" the resident as he fell.

There was no documented evidence, however, that the facility had thoroughly evaluated the circumstances surrounding the resident's fall and Employee 1's account of the fall to determine if the required level of staff assistance had been provided.

The facility failed to assure that Employee 1 had provided Resident CR1 the planned level of contact guard physical assistance of one staff member with the use of a walker at the time of the incident.

Interview with both the Director of Nursing Services and Nursing Home Administrator on April 11, 2019 at 2:10 p.m., confirmed that they were unable to provide documented evidence, which demonstrated the thoroughness of the facility's investigation into the incident or additional information as neither had been employed at the facility at the time of the resident's fall.





28 Pa. Code: 211.12 (a)(c)(d)(1)(5) Nursing Services.
Previously cited: 3/18/19.









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

1. Employee 1 was re-interviewed by current Administration to clarify the level of assistance provided. Sufficient supervision was provided per POC.
2. A facility wide audit was conducted to ensure sufficient supervision was present for incidents occurring in the last 30 days.
3. The Director of Nursing was re-educated on the Incident and Accidents Policy. The NHA will review investigations following incident to ensure they are complete.
4. The NHA or designee will complete an audit of incident report investigations weekly x four weeks then monthly x two months to ensure sufficient supervision was present. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.


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