Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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MANORCARE HEALTH SERVICES-CARLISLE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Findings of an abbreviated survey in response to four complaints, completed on February 19, 2019, at Manorcare Health Services Carlisle, identified that the facility 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:

483.25(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.

Based on a review of facility documentation, clinical records, and interviews with staff it was determined that the facility failed to provide proper supervision and implement interventions to prevent an accident for one of seven residents reviewed (Resident 3), resulting in harm when the resident fell, receiving a fractured left hip.

Findings include:

Review of Resident 3's clinical record revealed diagnoses that included dementia (progressive, irreversible degenerative disease of the brain that decreases reality contact and daily functioning ability).

Review of Resident 3's significant change Minimum Data Set assessment (MDS-periodic assessment of resident needs) dated October 24, 2018, revealed, under functional status for activities of daily living for toileting, that Resident 3 required the extensive physical assistance of 2 + persons. Review of Resident 3's Kardex (a form used by staff to communicate important information on residents and provides a quick summary of individual resident needs) revealed that for safety "staff supervision when in bathroom" was listed.

Review of the facility's incident report dated December 21, 2018, and nursing progress notes dated the same day, revealed Resident 3 was being toileted by Nurse Aide (NA) 1 who had assisted her to the bathroom and then left. Resident 3 was subsequently found on the floor and complained of pain to left hip and leg. Physician and family were notified, and X-rays were ordered and revealed a left hip fracture. Resident was transferred to the hospital for further evaluation and treatment.

Review of facility investigation documentation included a telephone statement provided to the facility by NA 1 dated December 22, 2018, which stated, "I put her in the bathroom and took the wheelchair out of the room, put down 2 other residents and then I came back into the room, she was on the floor. Her wheelchair was back in the bathroom. I'm guessing she got up and put it back herself. I did know she shouldn't be left alone. I didn't check the Kardex."

During an interview on February 14, 2019, at 2:30 PM with the Nursing Home Administrator she stated her expectation is that the resident's care plan be followed and that the Kardex should be referred to and followed when providing care to residents.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 11/8/18, 12/8/17.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 11/8/18.

28 Pa. Code 201.18(b)(3) Management.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 12/8/17.

28 Pa. Code 201.29(a)(d) Resident rights.

28 Pa. Code 211.10(c) Resident care policies.
Previously cited 11/8/18.

28 Pa. Code 211.10(d) Resident care policies.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 12/8/17.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Previously cited 11/8/18, 12/8/17.

 Plan of Correction - To be completed: 03/20/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all state and federal regulations, this center has taken or will take the actions set forth in this plan of correction. The plan of correction constitutes the center's allegation of compliance. All alleged deficiencies cited have been or will be corrected by the dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. This plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designated to meet their interests and promote the highest practicable level of physical, mental, and psychosocial wellbeing.

Resident R3 no longer resides in the facility.

Other residents in similar situations or like residents (residents who have experienced a fall from 2/19/19 forward) will have their care plans reviewed and updated to provide proper supervision and interventions to prevent accidents. A comprehensive audit will be completed using the QAPI tool for residents who have had falls from 2/19/19 forward.

The facility will ensure that the problem does not reoccur by conducting directed in-servicing to licensed and non-licensed nursing staff on federal regulation F689 and the accompanying guidelines on regulatory requirements. During the ICP team meetings, the falls QAPI tool (a tool that reviews the date and time of falls, the investigation process, lists new interventions, and verifies that the care plan/kardex is updated) will be completed by the DON/designee to ensure the resident's environment remains as free of accident hazards as possible. The ICP team will discuss each individual resident's falls to ensure proper interventions are in place and that care plans are updated. Nursing staff will be in-serviced on checking the patient's kardex prior to providing care to ensure each resident's care plan is followed.

A falls QAPI audit will be completed randomly by the DON/designee, 5 per week x4 and 10 per month x3. The QAA committee will review for further audits as necessary.

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