Nursing Investigation Results -

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

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GARDENS AT TUNKHANNOCK, THE
Inspection Results For:

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

Based on an abbreviated incident survey completed on February 20, 2019, it was determined that The Gardens at Tunkhannock was not in compliance with the following requirements of 42 CFR 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 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on a review of clinical records and staff interviews it was revealed that the facility failed to timely identify and act upon a change in resident condition, including signs and symptoms of a serious head injury, to assure the resident received timely and necessary treatment and prompt medical intervention at the level required for a serious head injury for one resident out of three sampled (Resident CR1).


Findings included:

A review of the clinical record review revealed that Resident CR1 was 68 years old and admitted to the facility from the hospital on May 16, 2013, with diagnoses, which included cerebral infarction (is an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), seizure disorder, schizophrenia (mental disorder), anxiety disorder and macular degeneration (a progressive vision problem which leads to blindness).

An Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to identify resident care needs) dated November 7, 2018, indicated that the resident was cognitively intact and required the assistance of one person for transfers between surfaces, was not steady moving from a seated position to a standing position and had a history of falls.

Current physician orders dated February 2019, included the medication Plavix (an antiplatelet medication, that helps prevent red blood cells from clumping together; a noted side effect of this medication is increased risk for bleeding) 75 mg (milligram) daily for cerebral artery occlusion (blood clot causing a blockage resulting in a stroke) initially ordered August 4, 2018.

A review of the resident's February 2019 medication administration record dated February 2019, revealed that Resident CR1 received the Plavix 75 mg daily from February 1st through 4th, 2019.

Further review of the resident's clinical record revealed that Resident CR1 was under the care of a neurologist related to his seizure disorder.

A review of a facility investigation report dated February 2, 2019, at 8:45 PM revealed that Resident CR1 fell while in the shower room. The resident was lying on his right side with his head on a ceramic base, a raised block attached to the end of the bath tub. The report indicated that the shower room floor was wet and this resident had ambulation, balance and vision impairment.

The resident's physician and responsible party were notified and neuro checks (tests used to assess an individual's neurological functions and level of consciousness in order determine whether or not an individual is functioning properly and reacting appropriately to the tests being performed) were initiated. The resident had no apparent injuries noted at that time.

Nursing documentation dated February 3, 2019, revealed no indication of any neurological changes for this resident.

On February 4, 2019, at 10:00 AM nursing contacted the resident's attending physician to report a change in the resident's treatment status and to request therapy services and a change from transfer assistance of one staff member to two staff. The nursing documentation did not include any further information on the details relayed to the physician regarding the resident's need for a change in treatment status.

Nursing documentation dated February 4, 2019, at 10:03 AM revealed that nurse aides made the licensed nurse aware that Resident CR1 had a change in condition. The entry indicated that the resident was unable to sit up on the edge of the bed. Nursing noted that the facility was awaiting a return call from the physician to clear him (the resident) for physical therapy.

A nurses note dated February 4, 2019, at 2:59 PM indicated that the licensed nurse placed a telephone call to neurology and was awaiting a return call from same. The entry did not indicate why the neurologist was called.

An additional nursing assessment dated February 4, 2019, at 9:11 PM indicated that Resident CR1 had poor verbalizations (not speaking clearly) during the 3:00 PM to 11:00 PM shift, was incontinent of urine (the resident had been identified as continent or urine prior to this change) and tremors were noted while performing a neurological exam. The resident displayed right sided weakness, more than baseline, he was unable to transfer without extensive assistance of 2 staff and had increased lethargy.

Nursing documentation, a change in condition assessment, dated February 4, 2019, at 9:11 PM indicated that nursing staff had assessed Resident CR1 and noted decline in his condition. The attending physician was contacted and directed nursing to call the resident's neurologist. The neurologist was contacted and ordered that the facility send the resident to the hospital for evaluation. The resident was sent to the hospital at that time.

There was no documented evidence at the time of the survey ending February 20, 2019, that the facility had timely acted upon the resident's signs of neurological decline. The resident had a history of cerebral infarcts and stroke, was receiving Plavix and had struck his head during a fall on February 2, 2019. Nursing documentation revealed that this resident was exhibiting signs of a neurological decline February 4, 2019 at 10 AM, but the resident was not sent to the hospital until 9:12 PM on February 4, 2019.

Interview with the Director of Nursing during the survey ending February 20, 2019, confirmed that the resident was not sent to the hospital until approximately 11 hours after the noted change in the resident's condition. The resident was diagnosed with a subdural hematoma (a collection of blood outside the brain. Subdural hematomas are usually caused by severe head injuries. The bleeding and increased pressure on the brain from a subdural hematoma can be life-threatening), required a craniotomy (the surgical removal of part of the bone from the skull to expose the brain) and was admitted to the intensive care unit at the hospital.


28 Pa Code 211.12(a)(c) Nursing services
Previously cited 11/30/18, 12/27/17, 10/27/17

28 Pa Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 11/30/18, 10/27/17






























 Plan of Correction - To be completed: 03/27/2019

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1.CR1 has since been discharged from the facility.

2.This was an isolated incident and there was no other residents identified in the facility to be at risk, for the same area of concern. There have been no further incidents of the same nature.

3.Licensed staff were in-serviced/educated on timely documentation and depicting actual times in nursing progress notes to ensure a clear concise picture of when care occurs. Facility protocol following any accidents/incidents with actual or suspected head injuries, and who are on anticoagulation therapy, has been re-evaluated and in addition to Neuro checks, an RN assessment will be done Q4H x 2 days then Q Shift x 3 days. MD will be made aware of any changes of condition to ensure prompt care is rendered, as it occurs.

4.DNS/Designee will do Audits of accidents/incidents x 3 months, to identify residents with actual/suspected head injuries and ensure facility protocol is being followed. Audit Results will be reported and reviewed by the QAPI committee monthly x 3 months to ensure compliance.

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 observations, review of clinical records, facility event summary reports and information submitted by the facility and staff interview, it was determined that the facility failed to maintain an environment free of potential accident hazards to prevent a fall with serious head injury for one resident out of three residents reviewed (Resident CR1).

Findings include:

A review of the clinical record review revealed that Resident CR1 was 68 years old and admitted to the facility from the hospital on May 16, 2013, with diagnoses, which included cerebral infarction (is an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), seizure disorder, schizophrenia (mental disorder), anxiety disorder and macular degeneration (a progressive vision problem which leads to blindness).

An Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to identify resident care needs) dated November 7, 2018, indicated that the resident was cognitively intact and required the assistance of one person for transfers between surfaces, was not steady moving from a seated position to a standing position and had a history of falls

The resident was identified at risk for falls due to abnormality of gait, vertigo (dizziness), legal blindness and seizures as per his care plan initially dated January 21, 2014. The only planned approaches included to encourage the resident to transfer and change positions slowly and to alert the staff member if he feels his "legs give out."

A review of a hospital history and physical report dated July 30, 2018, revealed that the resident had a past medical history of a fall with fractured ribs at the facility. The report stated that Resident CR1 stated at that time that his "legs gave out" and he fell from a standing position onto the floor.

Current physician orders dated February 2019, included the medication Plavix (an antiplatelet medication, that helps prevent red blood cells from clumping together; a noted side effect of this medication is increased risk for bleeding) 75 mg (milligram) daily for cerebral artery occlusion (blood clot causing a blockage resulting in a stroke) initially ordered August 4, 2018.

A review of the resident's February 2019 medication administration record dated February 2019, revealed that Resident CR1 received the Plavix 75 mg daily from February 1st through 4th, 2019.

Further review of the resident's clinical record revealed that Resident CR1 was under the care of a neurologist related to his seizure disorder.

A review of a facility investigation report dated February 2, 2019, at 8:45 PM revealed that Resident CR1 fell while in the shower room. The resident was lying on his right side with his head on a ceramic, raised block attached to the end of the bath tub. The report indicated that the shower room floor was wet and this resident had ambulation, balance and vision impairment.

A post fall analysis of the February 2, 2019, fall indicated that Resident CR1 had a history of falls and had bare feet at the time of the fall.

A review of a witness statement dated February 2, 2019 (no time indicated) revealed that, Employee 1 (nurse aide) stated "I took Resident CR1 into the shower room, stood him up to transfer him into the shower chair. While I was helping him to turn around, he had lost his balance and grabbed a hold of the shower bed, which began to roll towards him. He fell straight back onto the floor, hitting his head against the green tub. This was at 8:45 PM."

The facility notified the resident's physician and responsible party. Neuro checks (tests used to assess an individuals neurological functions and level of consciousness in order determine whether or not an individual is functioning properly and reacting appropriately to the tests being performed) were initiated. No apparent injuries were noted at that time.

Nursing documentation dated February 2, 2019, at 8:45 PM indicated that the resident was lying on the floor in the resident's shower room. The resident was lying on his right side with knees bent. The resident's head was resting on a ceramic block next to the tub. The resident was awake and alert and able to move his extremities. It was noted that Resident CR1 was partially clothed, but he had no socks or shoes on. The tile floor was wet from a prior shower. Immediate interventions put into place at the time of the incident included a change in his assistance level of assistance to two persons for transfers until he was assessed by physical therapy. Documentation indicated that no injuries were noted at the time.

A tour of the resident shower room during the survey ending February 20, 2019, at approximately 10:00 AM revealed that there was a large changing area next to the shower with sufficient space to transfer a resident without obstacles. However, the location where Employee 1 had attempted to transfer Resident CR1 from the wheelchair to the shower chair, was located directly inside the door of the shower area. Lining the far wall in this area was the ceramic bathtub with a large ceramic pedestal (on the floor) at the end of the tub on which the resident struck his head. This space was large enough to accommodate a wheelchair, but there was a shower bed along with another ceramic bathtub in the immediate vicinity. Employee 1 failed to ensure that the area was free of potential accident hazards, including the wet floor and shower bed, prior to transferring Resident CR1 from the wheelchair.

On February 4, 2019, at 10:00 AM nursing contacted the resident's attending physician to report a change in the resident's treatment status and to request therapy services and a change from transfer assistance of one staff member to two staff.

Nursing documentation dated February 4, 2019, at 10:03 AM revealed that nurse aides made the licensed nurse aware that Resident CR1's had a change in condition. The entry indicated that the resident was unable to sit up on the edge of the bed. Nursing noted that the facility was awaiting a return call from the physician to clear him (the resident) for physical therapy.

A nurses note dated February 4, 2019, at 2:59 PM indicated that the licensed nurse placed a telephone call to neurology and was awaiting a return call from same.

An additional nursing assessment dated February 4, 2019, at 9:11 PM indicated that Resident CR1 had poor verbalizations (not speaking clearly) during the 3:00 PM to 11:00 PM shift, was incontinent of urine (the resident had been identified as continent or urine prior to this change) and tremors were noted while performing a neurological exam. The resident displayed right sided weakness, more than baseline, he was unable to transfer without extensive assistance of two staff and had increased lethargy.

Nursing documentation, a change in condition assessment, dated February 4, 2019, at 9:11 PM indicated that nursing staff had assessed Resident CR1 and noted decline in his condition. The attending physician was contacted and directed nursing to call the resident's neurologist. The neurologist was contacted and ordered that the facility send the resident to the hospital for evaluation. The resident was sent to the hospital at that time.

A review of hospital documentation dated February 4, 2019, at 11:21 PM included a CT scan of the head (computer tomography, scan of the head is a diagnostic tool used to create detailed pictures of the skull, brain, paranasal sinuses, and eye sockets) indicated that he had (1) a large subdural (between the layers of the brain) collection of blood. These findings were noted as critical.

A review of a subsequent CT scan of the head dated February 5, 2019, at 8:51 AM indicated that the resident still had the bleeding area in his brain and a noted midline shift [the collection of blood pressing on the brain, causing a midline shift of the brain (midline shift occurs when something pushes this natural center line of the brain to the right or to the left. It is a concerning sign after head trauma. Since a midline shift happens due to bleeding and pressure, the amount of bleeding, the location of damage, and the overall level of pressure experienced by the brain are all important considerations]. Again, these findings were noted to be critical.

The resident was sent from the emergency department to a speciality care unit for further care. An additional CT scan of the head was performed and the resident was transferred to the intensive care unit. The surgeon drilled 2 burr holes (a surgical operation in which a bone flap is temporarily removed from the skull to access the brain and a hole surgically created to remove collection of blood) at the resident's bedside to evacuate the blood collection in order to relieve the pressure on his brain tissue. Drains were placed to allow any collected blood to flow out. The resident was initially a surgical risk due to his medication Plavix, so the burr hole evacuation procedure was completed at his bedside.

On February 10, 2019, the resident had surgery to remove the remainder of the collected blood in his head. After surgery, the resident was returned to the intensive care unit.

The facility failed to ensure that the resident, identified at risk for falls, was transferred in a manner and environment that was free of potential accident hazards to prevent this fall with serious head injury requiring hospitalization and surgical intervention.

Interview with the Director of Nursing (DON) on February 20, 2019, at approximately 12:30 PM confirmed that accident hazards were present in the shower room at the time of Resident CR1's transfer and subsequent fall.

Refer F684

483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices
Previously cited 11/30/18

28 Pa Code 211.12(a)(c) Nursing services
Previously cited 11/30/18, 12/27/17, 10/27/17

28 Pa Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 11/30/18, 10/27/17






































 Plan of Correction - To be completed: 03/27/2019

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1.CR1 has since been discharged from the facility.

2.To ensure safety of current residents; a walk-through of showers and resident care areas was conducted by DON and ED, to identify any obvious potential hazards and they were addressed immediately.


3.Licensed staff were in-serviced/re-educated on Hazardous areas, devices, and equipment as per policy, specifically observing the environment for possible hazards prior to transferring and/or assisting with ADLs.


4.DNS/Designee will do 10 random audits weekly x 4 weeks then monthly x 2. Audits will be conducted during shower times and in resident care areas, to ensure safe transfers and ADLs are being done free of potential hazards. Audit Results will be reported and reviewed by the QAPI committee monthly x 3 months to ensure compliance.



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