Nursing Investigation Results -

Pennsylvania Department of Health
JOHN J KANE REGIONAL CENTER- SCOTT TOWNSHIP
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
JOHN J KANE REGIONAL CENTER- SCOTT TOWNSHIP
Inspection Results For:

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JOHN J KANE REGIONAL CENTER- SCOTT TOWNSHIP - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Findings of an Abbreviated Survey in response to an Incident, completed on February 27, 2019, determined that John J Kane Regional Center - Scott Township, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations, for the Health portion of the survey process.















 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 resident and staff interviews, it was determined that the facility failed to make certain that residents were free from neglect, which resulted in actual harm (a fractured tibia) for one of five residents reviewed (Resident R3).

Findings include:

The facility's policy "Lifting and Moving Residents, Mechanical Lift Transfers" last reviewed 1/19/19, indicated there must always be at least two staff members when using a mechanical lift (a device with a sling attached to a C shaped frame that lifts the resident mechanically) for transfers.

A review of the Admission Face Sheet indicated that Resident R3 was admitted to the facility on 3/29/17.

A review of the Annual Minimum Data Set assessment (MDS-a periodic assessment of care needs) dated 1/16/19, indicated that Resident R3 was re-admitted to the facility on 11/9/17, was cognitively intact (alert and oriented), and had current diagnoses that included atrial fibrillation (irregular heart beat), renal insufficiency (kidney failure), diabetes, dementia, and anxiety. The MDS also indicated Resident R3 transferred from surface to surface (bed to chair) with total dependence of two persons, did not walk in room or corridor, and required one person assist of locomotion on the unit (in wheelchair).

A review of the physician order dated 2/5/19, indicated Resident R3 utilizes a Hoyer (a type of mechanical lift) for transfers with assistance of two persons.

The plan of care dated 4/2/18, indicated Resident R3 required a mechanical lift for transfers due to immobility and to use two or more staff persons.

A review of the February 2019, Activities of Daily Living (ADL) care sheet indicated two people were to assist Resident R3 out of bed with a mechanical lift.

A review of the facility reported incident indicated that on 2/10/19, at 10:45 a.m. Nurse Aide (NA) Employee E7, was transferring Resident R3 via a Hoyer lift, without assistance of a second person, and the lift tipped, sending resident R3 to the floor.

A review of the X-Ray report dated 2/10/19, indicated that Resident R3 had a nondisplaced oblique (at an angle or diagonally) fracture of the left tibia (lower leg bone).

A review of a statement dated 2/10/19, and signed by NA Employee E7, indicated NA Employee E7 was aware that residents of the facility are to have assistance of two persons for a mechanical lift and "I know I should have waited."

A review of the facility's investigation of Resident R3's fall on 2/10/19, indicated NA Employee E7, failed to follow the physician order to have two staff persons present during the transfer with the mechanical lift.

A review of the physician order dated 2/14/19, indicated Resident R3 was to have oxycodone-acetaminophen 5/325 milligrams (mg) four times a day as needed for pain and to wear a knee immobilizer on the left knee.

A review of the February 2019 medication administration record revealed that prior to the fall Resident R3 received no oxycodone-acetaminophen pain medication. After the fall Resident R3 received oxycodone-acetaminophen twenty-one times for pain from 2/14/19 until 2/27/19.

During an interview on 2/27/19, at 10:20 a.m. Resident R3 indicated that they must keep their leg straight, have had increased pain from the left leg fracture and now takes a pain pill and that they are afraid of the mechanical lift which is used to get out of bed.

During an interview on 2/27/19, at 2:15 p.m. the Director of Nursing confirmed the facility failed to make certain that Resident R3 was free from neglect during a transfer from the bed to the chair which resulted in actual harm (left tibia fracture) to Resident R3.

The facility failed to make certain that Resident R3 was protected from neglect while transferring a resident from the bed to the chair.

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.
Previously cited 7/9/18.

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

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Previously cited 7/9/18.







 Plan of Correction - To be completed: 04/09/2019

This plan of correction constitutes my written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by state and federal law.
It is the policy of the facility to provide the necessary care and services to attain and maintain the highest practicable well-being of our residents in accordance with state and federal regulations.


It is the policy of this facility to educate staff upon hire, yearly and as needed regarding resident neglect and abuse and facility mechanical lift policy of two or more assist.

All residents requiring a mechanical lift for transfers were immediately reviewed by Nursing Supervisors to verify physician orders, plan of care and the (ADL's) Activity of Daily Living, nurse aide assignment sheet is reflective of resident transfer status of Hoyer lift with 2 assists.

Resident returned from hospital with left knee immobilizer, PT/OT consulted. Upon discharge from Occupational Therapy, new orders implemented, and care planned to reflect resident out of bed status with continuation of Hoyer lift transfer with assist of 2 to a wide recliner wheelchair with ROHO cushion and side lying wedge under bilateral lower extremities near ankles. Resident is currently being treated for pain with Percocet every six hours as needed and is to follow up with Orthopedics.







On 2/11/19 nursing conducted re-education to staff on Mechanical Lift Transfer, Policy N-L-30. Facility policy was reviewed and reinforced that there will be two or more staff members during a mechanical lift transfer per facility policy.

On 2/21/2019 and 3/12/19 Invacare representative conducted on-site re-training to nursing staff on the mechanical lifts.

A new QAPI is in effect as follows:

Assistant Director of Nursing (ADON)/Designee will conduct random observation audits weekly on 50 staff members for proper use of the mechanical lifts. Audits will be completed weekly until all nursing staff has been observed and 100 % compliance is obtained. Random observation audits will be conducted on 20 staff members monthly for the next 3 months to ensure proper techniques of mechanical lift is in 100% compliance. Assistant Director of Nursing (ADON)/Designee will address problems identified and take corrective action and report to DON immediately.

Director of Nursing (DON)/designee will monitor findings and report to Quality Assurance/Quality Improvement (QA/QI) for review and recommendations.
Director of Nursing (DON) will determine need for continued monitoring after 6 months of 100 % compliance.

Continued hands-on education will be conducted twice per year versus annually for reinforcement of mechanical lift transfer safety for one year.

Environmental Service Manager (ESM)/designee will complete an audit on all mechanical lifts to monitor that they are functioning properly.

Audits will be completed weekly for four weeks and then every other week for two months and then monthly for two months. Audits will be completed until 100% compliance. Any problems identified corrective action will be taken immediately and reported to the Nursing Home Administrator.

Environmental Service Manager (ESM) will monitor findings and report to Quality Assurance/Quality Improvement (QA/QI) for review and recommendations. Nursing Home Administrator will determine the need for continued monitoring after 6 months of 100% compliance.

Mechanical lifts are monitored on a monthly bases as part of the facilities routine ongoing preventative maintenance.

A monthly physical inspection to verify Mechanical lifts are functioning and operating properly has been ongoing and will continue to be conducted.

If the facility finds Mechanical lifts are not functioning they are removed from service and serviced.


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 resident and staff interviews, it was determined that the facility failed to provide adequate assistance during a transfer that resulted in actual harm (a fractured tibia) for one of five residents reviewed (Resident R3).

Findings include:

The facility's policy "Lifting and Moving Residents, Mechanical Lift Transfers" last reviewed 1/19/19, indicated there must always be at least two staff members when using a mechanical lift (a device with a sling attached to a C shaped frame that lifts the resident mechanically from point to point) for transfers.

A review of the Admission Face Sheet indicated that Resident R3 was admitted to the facility on 3/29/17.

A review of the Annual Minimum Data Set assessment (MDS- a resident assessment of care and screening) dated 1/16/19, indicated that Resident R3 was re-admitted to the facility on 11/9/17, was cognitively intact (alert and oriented), and had current diagnoses that included atrial fibrillation (irregular heart beat), renal insufficiency (kidney failure), diabetes, dementia and anxiety. The MDS also indicated Resident R3 transferred from surface to surface (bed to chair) with total dependence of two persons, did not walk in the room or the corridor, and required one person assist with locomotion on the unit (in wheelchair).

A review of the physician order dated 2/5/19, indicated Resident R3 utilizes a Hoyer (a type of mechanical lift) for transfers with assistance of two persons.

The plan of care dated 4/2/18, indicated Resident R3 required a mechanical lift for transfers due to immobility and to use two or more staff persons.

A review of the February 2019, Activities of Daily Living (ADL) care sheet indicated two people were to assist Resident R3 out of bed with a mechanical lift.

A review of the facility's reported incident indicated that on 2/10/19, at 10:45 a.m. a Nurse Aide (NA) Employee E7, was transferring Resident R3 via a Hoyer lift, without assistance of a second person, and the lift tipped, sending Resident R3 to the floor.

A review of the X-Ray report dated 2/10/19, indicated that Resident R3 had a nondisplaced oblique (a fracture at an angle or diagonally) fracture of the left tibia (lower leg bone).

A review of a statement dated 2/10/19, and signed by NA Employee E7, indicated NA Employee E7 was aware that residents of the facility are to have assistance of two persons for a mechanical lift.

A review of the facility's investigation of Resident R3's fall on 2/10/19, indicated NA Employee E7, failed to follow the physician order to have two staff persons present during the transfer with the mechanical lift.

A review of the physician order dated 2/14/19, indicated Resident R3 was to have oxycodone-acetaminophen 5/325 milligrams (mg) four times a day as needed for pain and to wear a knee immobilizer on the left knee.

A review of the February 2019, medication administration record revealed that prior to the fall Resident R3 received no oxycodone-acetaminophen pain medication. After the fall Resident R3 received oxycodone-acetaminophen for pain twenty-one times from 2/14/19 until 2/27/19.

During an interview on 2/27/19, at 10:20 a.m. Resident R3 indicated that they must keep their leg straight, have had increased pain from the left leg fracture and now take a pain pill, and they are afraid of the mechanical lift which is used to get out of bed.

During an interview on 2/27/19, at 2:15 p.m. the Director of Nursing confirmed the facility failed to make certain that Resident R3 was provided adequate assistance during a mechanical lift transfer which resulted in a fall and actual harm to the resident (left tibia fracture).

The facility failed to make certain that Resident R3 was provided adequate staff assistance during a mechanical lift transfer to prevent an accident resulting in harm.

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.
Previously cited 7/9/18.

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

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Previously cited 7/9/18.









 Plan of Correction - To be completed: 04/09/2019

A new QAPI is in effect as follows:

Environmental Service Manager (ESM)/designee must complete an audit on all mechanical lifts to monitor that they are functioning properly.

Audits will be completed weekly for four weeks and then every other week for two months and then monthly for two months. Audits will be completed until 100% compliance. Any problems identified corrective action will be taken immediately and reported to the Nursing Home Administrator.

Environmental Service Manager (ESM) will monitor findings and report to Quality Assurance/Quality Improvement (QA/QI) for review and recommendations. Nursing Home Administrator will determine the need for continue monitoring after 6 months of compliance.


Mechanical lifts are monitored on a monthly bases as part of the facilities routine ongoing preventative maintenance.

A monthly physical inspection to verify Mechanical lifts are functioning and operating properly has been ongoing and will continue to be conducted.

If the facility finds Mechanical lifts are not functioning they are removed from service and serviced.


On 2/11/19 nursing conducted re-education to staff on Mechanical Lift Transfer, Policy N-L-30. Facility policy was reviewed and reinforced that there will be two or more staff members during a mechanical lift transfer per facility policy.

On 2/21/2019 and 3/12/19 Invacare representative conducted on-site re-training to nursing staff on the mechanical lifts.

Assistant Director of Nursing (ADON)/Designee will conduct random observation audits weekly on 50 staff members for proper use of the mechanical lifts. Audits will be completed weekly until all nursing staff has been observed and 100 % compliance is obtained. Random observation audits will be conducted on 20 staff members monthly for the next 3 months to ensure proper techniques of mechanical lift is in 100% compliance.
Assistant Director of Nursing (ADON)/designee will address problems identified and take corrective action and report to Director of Nursing (DON) immediately.

Continued hands-on education will be conducted twice per year versus annually for reinforcement of mechanical lift transfer safety for one year.

Director of Nursing (DON)/designee will monitor findings and report to Quality Assurance/Quality (QA/QI) Improvement for review and recommendations. Director of Nursing (DON) will determine need for continued monitoring after 6 months of 100 % compliance.




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