Nursing Investigation Results -

Pennsylvania Department of Health
PAVILION AT SAINT LUKE VILLAGE, THE
Patient Care Inspection Results

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PAVILION AT SAINT LUKE VILLAGE, THE
Inspection Results For:

There are  68 surveys for this facility. Please select a date to view the survey results.

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PAVILION AT SAINT LUKE VILLAGE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated complaint survey completed on April 22, 2019, it was determined that The Pavilion at St. Luke Village was not in compliance with the following requirements of 42 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 affects more than a limited 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. This deficiency was not found to be throughout this facility.
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 a review of clinical records and select resident incident reports and staff interviews it was determined that the facility to implement measures planned to deter repeated falls and failed to revise those approaches that proved ineffective in preventing accidents/falls for one resident out of seven sampled (Resident 14).

Findings included:


A review of the clinical record revealed Resident 14, was 90 years old and admitted to the facility on January 3, 2019, with altered mental status, difficulty walking, and atherosclerosis cardiovascular disease (The inside of an artery narrows due to the build up of plaque limiting the flow of oxygen-rich blood to parts of the body.)

A review of Resident 14's Admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 10, 2019, indicated that the resident had a BIMS (Brief Interview for Mental Status which indicates how well you are functioning cognitively) score of 3 ( a score of 0-7 indicates severe cognitive impairment).

A review of a resident incident report dated March 4, 2019, revealed that at 6:00 PM the resident's tab alarm sounded and staff found the resident on the floor in the hall, on her knees in front of the wheelchair. Following this fall, the facility updated the resident's care plan to provide activity for redirection for repeat wandering to no specific place. The facility did not identify the resident's preferred activities of those of interest that may be used in an attempt to redirect the resident.

A resident incident report dated March 11, 2019, revealed that Resident 14 was wandering aimlessly. The resident was found on the floor, between two beds, in another resident's room yelling. There was no documented evidence that the facility had implemented the planned intervention of diversional activities to redirect the wandering behavior and/or the resident's response to the activities attempted/provided. No new interventions were added to the resident's care plan after this fall.

A resident incident report dated March 16, 2019, revealed that at 9:45 PM Resident 14 was found sitting on floor in doorway to her bedroom. The resident's roommate rang her call bell to alert staff that the resident was on the floor. Resident 14's bed alarm was ringing, in the low sound position, and was not heard by the staff until they entered the room. A witness statement from Employee 2, a nurse aide, indicated that she had checked that the alarm was on the bed, but not that it was set on the loud position.

A review of an incident report dated March 17, 2019, revealed that at 11:30 AM Resident 14 was heard yelling at another resident. Resident 14 was found sitting on the floor in the doorway of her bedroom. Nursing progress note indicate that the resident was agitated. The bed alarm was sounding, but not loud enough for staff to hear it in the hall. The resident had a fall the prior day, March 16, 2019, under similar circumstances during which the facility staff was unable to hear the alarm. The facility failed to promptly rectify the issue with the volume of the resident's personal safety alarms to prevent recurrence.

A review of an incident report dated March 27, 2019, revealed at 4:00 PM Resident 14 was swinging her fists at another resident, leaning forward in her wheelchair. Resident 14 slipped forward out of her chair and fell on her buttocks on the floor in front of nursing station. The facility noted that the resident was self-propelling in the halls prior to the incident. There was no documented evidence of that the facility had implemented the diversional activities to redirect the resident's wandering as planned following the incident on March 4, 2019, or that the facility had developed alternative or revised approaches to maintain the resident's safety related to the resident's wandering behavior. Following this incident, the resident's care plan and nursing progress notes indicated the intervention of 15-minute checks of the resident and 1:1 staff observation of the resident during increased periods of agitation.

An incident report dated April 1, 2019, revealed at 1:15 PM Resident 14 was standing in Hall D on the second floor and lowered herself to the floor. The resident stated that she wanted to shut the air conditioner off. It was noted that the resident was self-propelling through the halls prior to the incident. There was no documented evidence that the facility had implemented effective safety and supervisory measures to maintain this resident's.

An incident report dated April 13, 2019, revealed that the resident had increased behaviors at 3:00 PM. It was noted that the resident was disrobing, screaming at staff and peers that she was going to kill them. It was noted at 5:55 PM that the resident had increased behaviors after dinner yelling out "I want to kill you. " Resident 14 fell out of the wheelchair onto floor by sliding herself out of her wheelchair. The facility failed to demonstrate the provision of increased staff supervision (1:1) during periods of increased agitation as noted following the incident on March 27, 2019. .

A review of the resident's current care plan dated February 15, 2019 and revised on April 1, 2019, revealed that the resident had incurred falls at the facility and planned interventions included 15-minute checks. There are no documented evidence that the facility had conducted every 15-minute checks of the resident after April 16, 2019, as care planned for the resident's safety.

An interview with the Director of Nursing and Nursing Home Administrator on April 22, 2019, at approximately 3:30 PM confirmed there was no documented evidence that the facility had implemented the safety interventions identified and care planned to prevent accidents for this resident with known unsafe behaviors and repeated falls.


28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services

28 Pa. Code 211.11(d) Resident care plan




 Plan of Correction - To be completed: 05/30/2019

Preparation and submission of this
plan of correction does not
constitute an admission or
agreement by the provider of the
truth of the facts alleged or
correctness of the conclusions set
forth on the statement of
deficiencies, the plan of correction is
prepared and submitted solely
because of the requirements under
State and Federal law.
This Plan of Correction will serve
asthe Facility's allegation of
substantial compliance.


1. Resident #14's Care plan was revised to include interventions to help to prevent falls


2. Residents who have had a fall in last 60 days will be reviewed for preventative intervention and implementation.
Any issues identified will be corrected immediately.


3. Incident and accidents will be reviewed at morning meeting to ensure preventative interventions are in place and to revise ineffective approaches. Nursing staff will be educated on fall prevention and care plans to maintain and update with intervention.


4. Audit care plans of residents with Incident and Accident reports to assure proper interventions are in place and documented on the care plans.
Results of audits will be presented at QAPI.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on a review of clinical records, select facility policies and employee personnel files and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the necessary competencies and skills to accurately provide physician ordered care, necessary nursing care and timely consistent monitoring of a resident's colostomy for adequate function, to prevent infection and skin impairment for one of seven residents reviewed (Resident CR1).

Findings included:

A review of Resident CR1's clinical record revealed admission to the facility on February 13, 2019, with a colostomy related to a malignant neoplasm of the transverse colon. Further review of the resident's clinical record revealed no indication of any skin issues around the colostomy/stoma site upon the resident's admission to the facility. The resident did have a midline (vertical cut made in the abdomen to allow access for a surgical procedure) surgical area upon admission. On March 2, 2019, the area measured 10 cm length x 2 cm width and 1 cm in depth. There was a small amount of odorless serous drainage pink/red in color. The area was described as macerated. A treatment of wet gauze wrapped with normal saline solution pack distal 1/3 of incision and cover with 4 x 4 dressings and Abdominal gauze pads, tape window and change twice daily.

According to review of nursing progress notes the resident's colostomy was changed on February 16, 2019, and February 27, 2019, for leakage. On February 23, 24, 2019 the colostomy bag and wafer had to be changed because they were loose.

On February 28, 2019, the resident was seen for a follow-up consultation for the resident's colostomy. A review of the request for consultation sheet, revealed that the resident's surgical incision at the colostomy site was extremely excoriated around the ostomy site. It was described as difficult to keep sealed with loose bowel movement leaking into the original incision site. The surgeon response was that the facility needed to "snap the ostomy bag together better."

A review of the resident's clinical record revealed no documented evidence that the area was excoriated around the colostomy site or that any interventions were in place to address the problem.

On March 5, 2019, however, there was a physician telephone order to apply duoderm closely surrounding the stoma site under the wafer. A review of the resident's March 2019 treatment administration records revealed no evidence that this physician order had been carried out.

When interviewed at 2:15 p.m., Employee 3 (Registered Nurse) stated it was facility policy to apply barrier cream as a routine part of ostomy care.

A review of the facility policy for Ostomy Care-Stoma Care last revised by the facility on September 5, 2017, revealed that "after the areas around the stoma was cleansed. Skin barrier was to be applied around the stoma, any skin treatment order was to be completed at the time and skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of adhesives or used to prepare surrounding ostomy sites) "as needed" could be utilized." Employye 1 confirmed the physician order from March 5, 2019, and the absence of documented evidence that it had been implemented by nursing staff. Employee 1 was unaware that the physician order had not been carried out prior to surveyor inquiry.

Clinical record documentation revealed that on March 6, 2019, there was increased drainage, described as thick green purulent, noted from the resident's abdominal incision. A physician order to culture the wound drainage to the abdominal incision area was obtained on March 7, 2019. The drainage tested positive for methicillin resistance staphylococcus aureus.

A review of a non-pressure skin condition record completed for the resident dated March 10, 2019, (first indication that the facility had measured and described the area for tracking purposes) revealed that the impaired area to the resident's colostomy site was noted to be "not present on admission." The area was noted to be excoriated and measured 15 cm x 10 cm.

On March 7, 2019, and March 15, 2019, according to review of nursing progress notes, the stoma to the resident's colostomy was described as red, with no drainage to the area.

The area to the resident's surgical site/ abdomen was measured on March 13, 2019, and revealed that the area measured 10 cm x 2 cm x 2 cm depth with a large amount of green drainage.

According to review of the resident's non-pressure skin condition record dated March 17, 2019, the area to the resident's colostomy remained 15 cm x 10 cm, but was now described as a red macerated moisture associated skin disorder.

On March 21, 2019, the resident was seen for a post-operative visit. The resident's son accompanied the resident and told the surgeon that the facility was having difficulty with the seal on the ostomy and that it was continually leaking into the midline incision. When the surgeon examined the ostomy site he determined that it was functioning, but had a poor seal on the wafer at the site of the incision. The surgeon's plan was to discuss ostomy care with a wound care ostomy nurse at the hospital to explore outpatient services that the facility could use to improve the fit of the ostomy device.

The resident's clinical record revealed a physician order was received on March 22, 2019, for a consultation between facility staff and an Ostomy nurse, which was completed via telephone. Following this consultation, orders were received to dust the ostomy site irritated skin with stoma powder on all raw areas, brush off lightly with gloved finger so as not to cake powder. Pat with non sting skin prep or skin prep. Subsequently the resident was transferred out to the hospital on March 26, 2019.

When interviewed at 2:15 p.m. Employee 3, RN stated that the facility was having a very difficult time getting the resident's colostomy to stop leaking. She stated that the issue became so extensive they had utilized briefs on the resident, although the resident was continent of urine. Employee 3 stated that the problem had improved after the Ostomy nurse had provided guidance to facility nursing staff and orders via the telephone related to care of the device to prevent leakage. Once the resident returned to the facility following his admission to the hospital on March 26, 2019, the resident's skin and the seal of the resident's colostomy had improved as had the leakage.

According to review of the facility's Colostomy, Ileostomy and Nephrostomy Care Competency Checklist, competencies were completed for both licensed practical nurses and registered nurses at the facility in January 2019.

A review of the competencies revealed that the competency review was related to routine changing and care of the device. However, this review did not address any issues/complications which might arise, related to the use of the device including seal, leakage, possible skin irritation and infection control during leakage.



28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services
Previously cited: 1/31/19,10/26/18,9/9/18


28 Pa. Code 211.5(f)(g) Clinical records
Previously cited: 10/26/18,9/9/18,7/24/18.6/4/18.

28 Pa. Code 201.20(a)(d) Staff Development

28 Pa. Code 201.19 Personnel policies and procedures






 Plan of Correction - To be completed: 05/30/2019

1. Resident CR1 no longer resides in the facility.


2. Residents with colostomies will have their stoma sites assessed for any skin issues and if found will be reported to physician for follow up care as ordered.


3. Residents with ostomies will be reviewed at Wound Meeting to discuss and address any issues/complications that may arise.
Staff will be educated on the P&P for ostomy care and will include reporting and follow up for issues and complications that may arise including leakage, skin irritation and infection control.
Competencies for ostomy care will be revised to include identification and treatment of issues that may arise.


4. An audit of residents with ostomies will be completed with attention to condition, treatment, Physician orders and documentation.
The results of the audits will be presented to QAPI.


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