Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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

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Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Revisit survey completed on April 10, 2019, it was determined that Renaissance Healthcare and Rehabilitation Center, corrected the deficiencies identified during the survey of February 7, 2019, had a newly identified deficiency identified and 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 related to the health portion of the survey process.

 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 observations of resident care, clinical record reviews, interviews with residents and staff, and the review of facility policies and procedures, it was determined that for one of fourteen residents reviewed, the facility failed to provide adequate supervision, staff assistance and assistive devices to ensure an environment that was free of accident hazards. The lack of supervision, assistance and assistive devices caused an incident of actual harm for Resident R8 (Resident R8).

Findings include:

The facility policies related to safety with hot beverages indicated that beverages were to be served at a palatable temperature while maintaining appropriate practices for resident safety. The policy indicated that hot liquids were to be served in the proper container, lids were to be removed at the point of service to the resident, except those identified as an adaptive feeding device and all coffee equipment must be in a secure area or under constant visual surveillance by staff.

The comprehensive assessment MDS (an assessment of care needs) dated February 12, 2019, for Resident R8 indicated that this resident had severely impaired vision (no vision or sees only light, colors or shapes: eyes do not appear to follow objects). The BIMS (a brief screener that aids in detecting cognitive impairment) score for Resident R8 revealed that this resident was cognitively intact. The assessment also indicated that the functional status of Resident R8 for eating (how the resident eats and drinks regardless of skill) was extensive assistance of one person physical assist for eating.

The occupational therapist evaluated Resident R8 on February 25, 2019. The evaluation indicated that Resident R8 required a two handled cup with lid and straw, food placed in bowls and regular utensils for all meals with supervision.

The speech language pathologist evaluated Resident R8 on March 19, 2019 and indicated that this resident required full feeding assistance during meals.

There was no person centered care plan developed and documented related to Resdient R8's functional abilities/level of assistance and supervision needed for eating. This lack of person centered care plan development and implementation was confirmed during an interview with the director of nursing, Employee E2, at 2:00 p.m., on April 10, 2019.

Nursing progress notes and physician progress notes for March 25, 2019 indicated that Resdient R8 sustained a burn on the anterior chest, after a hot liquid spill.

There was no documentation to indicate that this resident was provided a two handled cup with lid and straw as assessed by the occupational therapist for the eating/drinking and safety needs of this resident. There was no documentation to indicate that Resident R8 was provided adequate supervision and one person physical assistance with eating and drinking as assessed by the occupational therapist and the speech language pathologist, to meet this resident's care needs for eating and drinking.

An interview with Resdient R8 at 2:30 p.m., on April 10, 2019 revealed that the resident was given a cup of coffee on March 25, 2019. The resident reported that he screamed when the incident happened, because the scalding, with the hot beverage was painful.

An interview with the registered nurse responsible for the care of Resident R8 on March 25, 2019 revealed that during this interview at 3:00 p.m., on April 10, 2019, that the registered nurse was not in the dining room at the time the incident happened. The registered nurse reported being in the hallway outside the dining room and went into the dining room to assess the resdient's skin condition.

The facility failed to indicate how Resident R8 obtained a cup of hot coffee in the dining room on March 25, 2019. This was confirmed during an interview with the nursing home administrator at 3:30 p.m., on April 10, 2019.

The wound care specialist evaluated Resdient R8 on March 29, 2019 and diagnosed the resident with trauma having a full thickness ulceration of the chest 23.0 by 36 cm measurement. Wound base localized area 70% fluid filled blister. A third degree burn was a burn that has penetrated the epidermis and dermis and extended into the subcutaneous fat of the hypodermis. On April 5, 2019 the wound specialist documented the anterior chest wall as a full thickness wound, measuring 20cm by 34cm by .1 cm area.

An observation of Resident R8's anterior chest at 2:30 p.m. on April 10, 2019 revealed an ulceration on the chest wall. The registered nurse, Employee E6, who was present during this observation and reported that Resident R8 was being treated with silvadene and xerofoam every day and that the anterior chest was then covered with ABD pad and ABD binder.

The facility failed to ensure a safe environment for Resident R8. The resident was not provided with adequate supervision, physical assistance, and assistive devices to prevent accidents, and this lack of care resulted in actual harm to Resident R8.

28 PA. Code: 201.18(a)(b)(1)(3) Management

28 PA. Code: 211.10(a)(b)(c)(d) Resident care policies

28 PA. Code: 211.11(a)(b)(c)(d) Resident care plan

28 PA. Code: 211.12(c)(d)(1)(3)(5) Nursing services

 Plan of Correction - To be completed: 04/29/2019

Resident R8 has had no further incidents as a result of the assistive device not being in place.
DON or designee will review the last 30 days of Incident Reports to ensure that no incident occurred as a result of an assistive device with meals not being in place.
Staff will be re-inserviced on the following policies: Assistive Devices and Equipment, Safety and Supervision of Residents, and Accidents and Incidents- Investigating and Reporting. DON or designee will review incident reports weekly to ensure that no incident occurred as a result of an assistive device with meals not being in place.
DON or designee will audit current residents who require assistive devices with meals and weekly thereafter for 3 months. This audit will include that a physician order is in place for the assistive device, care plan is in place for the assistive device and the assistive device is present with meals. DON or designee will randomly audit residents with assistive devices to ensure adequate supervision is present if needed weekly for 3 months. Results of the audits will be forwarded to the QAPI Committee for review and additional recommendations.

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