Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT ORANGEVILLE, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT ORANGEVILLE, THE
Inspection Results For:

There are  57 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT ORANGEVILLE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Revisit and Abbreviated Complaint Survey completed on April 30, 2019, it was determined that The Gardens at Orangeville corrected the federal deficiencies cited during the survey of March 5, 2019, but continued to be out of 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 a review of clinical records and a facility investigative report and staff interviews it was determined that the facility failed to promptly notify the resident's physician of a change in condition for one of 15 residents reviewed (Resident 78).

Findings include:

Review of Resident 78's clinical record revealed admission to the facility on April 10, 2013, with diagnoses including Alzheimer's and Dementia (Non-Alzheimer's dementia) disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).

A review of the resident's quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 78, dated February 1, 2019, revealed that the resident had short- and long-term memory impairment, was moderately cognitively impaired and dependent on staff for bed mobility, transfer, dressing and eating.

Further review of the resident's clinical record revealed nursing documentation dated April 2, 2019, at 3:51 a.m. indicating that nursing was called to Resident 78's bedside because the resident's upper left arm was bruised. The bruising encompassed the resident's upper left arm, including the axilla (a person's armpit). The nurse called the physician and received a new order for X-rays of Resident 78's left humerus (upper arm bone) and shoulder, which revealed a fracture involving the humeral neck.

A facility investigative report dated April 2, 2019, at 3:51 a.m. identified a purple bruise on Resident 78's left upper arm.

A review of Employee 1's (Nurse Aide) witness statement (undated), accompanying this investigative report, indicated that on Saturday March 30, 2019, around 10:00-11:00 a.m. staff went to check on Resident 78, and put her back in bed. The resident's left arm was "down by her side" and staff "didn't think anything of it". Around 1:30 staff went in to change her and reposition the resident and noticed resident's "hand seemed to be bent to the side and her arm was back down by her side." Employee 1 summoned Employee 2, Nurse Aide, who agreed "something wasn't right" with Resident 78. Employee 2 "went to our charge nurse to report that something wasn't right with resident's left arm". "I (Employee 1) stayed over 2nd shift and reported the same thing to that charge nurse".

A review of Employee 2 (Nurse Aide) witness statement dated April 2, 2019 stated "I was working 11:00 a.m. to 3:00 p.m. Employee 1 came and asked me to look at Resident 78's arm, that it seemed limp. I looked at it, agreed with her and reported it to Employee 3 (Licensed Practical Nurse-LPN) who was my charge nurse."

A review of Employee 3, LPN's witness statement dated April 2, 2019, revealed that "On March 30, 2019, CNA came to me and stated that Resident 78's left arm was flaccid and not contracted per normal." "Assessed left arm and was noted to be very flaccid without rigidity". "Will monitor same."

A review of Employee 4, RN (Registered Nurse)'s witness statement dated April 3, 2019, revealed that "Employee 1 asked me if Employee 3 passed along about her (Resident 78) arm being flaccid. Was not assessed during my shift."

There was no documented evidence at the time of the survey ending April 30, 2019, that the licensed nursing staff, Employee 3 (LPN) or Employee 4 (RN) had notified the physician regarding the change in condition of Resident 78's her left arm, when identified on March 30, 2019. The physician was notified until April 2, 2019.

During an interview April 30, 2019, at approximately 1:00 p.m. with the Director of Nursing confirmed that the facility's licensed nursing staff had not timely notified the physician of Resident 78's change in condition.




28 Pa. Code 211.5(f) Clinical Records
Previously cited 7/13/18, 3/5/19

28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services
Previously cited 7/13/18, 3/5/19















 Plan of Correction - To be completed: 05/17/2019

The physician was notified of the change in condition for resident 78 on April 2, 2019. Re-education provided to employee 3 and employee 4 on physician notification.

Review of 24 hour reports for the past 30 days to ensure any change in conditions have notification to the physician documented in the clinical record.

Licensed staff will be re-educated on physician notification with any change in condition of a resident.

Audit of 10% of clinical records will be completed by the DON/designee weekly x4 weeks, then monthly x2 to ensure any change in condition is updated to the physician. Results of audits to QA for review and recommendations.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:

Based on a review of clinical records and select facility investigation and staff interview, it was determined that the facility failed to assure that nursing services met professional standards of quality according to Title 49. Professional and Vocational Standards Chapter 21 State Board of Nursing by failing to demonstrate the timely implementation of nursing procedures and services in response to a resident's change in condition and that the licensed nurse and registered nurse documented complete and accurate findings related to a change in resident condition in the clinical record of one resident (Resident 78) out of 15 sampled residents.

Findings include:

According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (1) Collecting complete and ongoing data to determine nursing care needs. (2) Analyzes the health status of the individuals and families and compares the data with the norm when possible in determining nursing care needs. (4) Carries out nursing care actions which promote, maintain and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered.

According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145. (a) The licensed practical nurse (LPN) is prepared to function as a member of a health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and the patients health care team to seek guidance when: (iii) The patients condition deteriorates or there is a significant change in condition.

A review of Resident 78's clinical record revealed admission to the facility on April 10, 2013, with diagnoses including Alzheimer's and Dementia (Non-Alzheimer's dementia) disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).

A review of the resident's quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) dated February 1, 2019, indicated that the resident had short- and long-term memory impairment and was moderately cognitively impaired and dependent on staff for bed mobility, transfer, dressing and eating.

Further review of the resident's clinical record revealed nursing documentation dated April 2, 2019, at 3:51 a.m. indicating that nursing was called to Resident 78's bedside because the resident's upper left arm was bruised. The bruising encompassed the resident's upper left arm, including the axilla (a person's armpit). The nurse called the physician and received a new order for X-rays of Resident 78's left humerus (upper arm bone) and shoulder, which revealed a fracture involving the humeral neck.

A facility investigative report dated April 2, 2019, at 3:51 a.m. identified a purple bruise on Resident 78's left upper arm.

A review of Employee 1's (Nurse Aide) witness statement (undated), accompanying this investigative report, indicated that on Saturday March 30, 2019, around 10:00-11:00 a.m. staff went to check on Resident 78, and put her back in bed. The resident's left arm was "down by her side" and staff "didn't think anything of it". Around 1:30 staff went in to change her and reposition the resident and noticed resident's "hand seemed to be bent to the side and her arm was back down by her side." Employee 1 summoned Employee 2, Nurse Aide, who agreed "something wasn't right" with Resident 78. Employee 2 "went to our charge nurse to report that something wasn't right with resident's left arm". "I (Employee 1) stayed over 2nd shift and reported the same thing to that charge nurse".

A review of Employee 2 (Nurse Aide) witness statement dated April 2, 2019 stated "I was working 11:00 a.m. to 3:00 p.m. Employee 1 came and asked me to look at Resident 78's arm, that it seemed limp. I looked at it, agreed with her and reported it to Employee 3 (Licensed Practical Nurse-LPN) who was my charge nurse."

A review of Employee 3, LPN's witness statement dated April 2, 2019, revealed that "On March 30, 2019, CNA came to me and stated that Resident 78's left arm was flaccid and not contracted per normal." "Assessed left arm and was noted to be very flaccid without rigidity". "Will monitor same."

A review of Employee 4, RN (Registered Nurse)'s witness statement dated April 3, 2019, revealed that "Employee 1 asked me if Employee 3 passed along about her (Resident 78) arm being flaccid. Was not assessed during my shift."

The facility's licensed nursing staff failed to document the resident's new symptom (flaccid arm) in the resident's clinical record. The facility's licensed professional nursing staff failed to assess the resident in response to the nurse aide's report that the resident's arm was flaccid and document the results of this assessment in the resident's clinical record.

At the time of the survey ending April 30, 2019, there was no documented evidence of a complete/accurate accounting and progression of events or a complete/accurate nursing assessment of the resident's clinical status documented in the resident's clinical record in order to demonstrate that the appropriate nursing services were provided according to professional standards of practice by either Employee 3 (LPN), nor Employee 4 (RN) regarding her left arm till April 2, 2019.

During an interview April 30, 2019, at approximately 1:00 p.m. with the Director of Nursing confirmed that the facility's nursing staff had not documented or communicated timely with the physician regarding Resident 78's change in condition.




28 Pa. Code 211.5(f) Clinical Records
Previously cited 7/13/18, 3/5/19

28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing Services
Previously cited 7/13/18, 3/5/19

28 Pa. Code 201.29(a)(j) Resident rights
Previously cited



























 Plan of Correction - To be completed: 05/17/2019

The physician was notified of the change in condition for resident 78 on April 2, 2019. Re-education provided to employee 3 and employee 4 on complete and accurate assessment of a residents clinical status and documentation reflects this in this medical record.

Review of 24 hour reports for the past 30 days to ensure any change in conditions have a complete and accurate assessment of a residents clinical status and is reflected in the medical record with physician notification.

Licensed staff will be re-educated on ensuring a complete and accurate assessment for any change in condition for all residents and this is reflected in the medical record with physician notification.

Audit of 10% of clinical records will be completed by the DON/designee weekly x4 weeks, then monthly x2 to ensure any change in condition has an accurate and complete assessment documented and the medical record reflects physician notification. Results of audits to QA for review and recommendations.





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