Nursing Investigation Results -

Pennsylvania Department of Health
PHILADELPHIA PROTESTANT HOME
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PHILADELPHIA PROTESTANT HOME
Inspection Results For:

There are  29 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
PHILADELPHIA PROTESTANT HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure Survey, Civil Rights Compliance Survey, and an Abbreviated survey in response to a reportable event completed on January 8, 2019, it was determined that Philadelphia Protestant Home 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 as they relate to the health portion of the survey process.



















 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based review of facility policy, clinical records and facility documentation and interviews with staff, it was determined that the facility failed to provide the necessary assistance to safely transfer one resident (Resident R28) and failed to provide the appropriate level of supervision during meals for another resident (Resident R 107), which resulted in actual harm related to a laceration and a burn for two of 28 residents reviewed (Resident R28 and R 107).

Findings include:

Review of facility policy, "Abuse, Neglect, Misappropriation of Property," dated last reviewed October 2018, revealed that "Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress."

Review of the clinical record for Resident R28 revealed a quarterly Minimum Data Set assessment (MDS- assessment of resident care needs) dated November 29, 2017 which indicated that the resident was severely cognitively impaired and required the physical assistance of two or more persons for transfers. Continued record review for Resident R28 revealed a physician's order dated December 8, 2017, which directed staff to "transfer with assist of two staff."

Review of facility documentation, submitted on December 27, 2017, revealed that Resident R28 was transferred on December 27, 2017, during morning care and sustained a laceration to her right leg which measured 3.5 cm (centimeters) by 2.2 cm by 2.5 cm. Resident R28 was subsequently sent to the hospital and received six sutures for the laceration. Review of the facility's investigation of this incident revealed that a nurse aide had transferred Resident R28 by herself and stated that when she made rounds the previous nurse aide had told her that the resident was a one person assist.

Interview on January 4, 2019, at 12:00 p.m. with the Nursing Home Administrator (NHA) confirmed that the nurse aide on December 27, 2017, did not follow orders for Resident R28 related to the need for the physical assistance of two staff persons for transfers which resulted in the resident receiving a laceration which required hospital treatment and six sutures.

The facility failed to provide the appropriate level of staff assistance while transferring Resident R28. Resident R28 sustained a laceration during the transfer which required a hospital evaluation and six sutures.

Review of facility policy, Hot Beverage Temperature Guidelines, dated reviewed October 22, 2018, revealed that "Hot beverages may pose a safety risk to residents even when the temperature, at the point of service, is within the 150-155 range. Facilities must ensure that these beverages are served in a "no risk" manner."

Review of Resident R 107's clinical record revealed that the resident was admitted to the facility on October 24, 2017, with diagnoses including, severe dementia (progressive brain disorder associated with confusion, memory loss and impaired reasoning), blindness and macular degeneration (eye disorder that may lead to blindness).

A review of the quarterly Minimum Data Set (MDS- an assessment tool used to determine resident care needs) completed on January 23, 2018, indicated that the resident's cognitive skills (an activity related to thinking, reasoning or remembering) for daily decision making was poor and moderately impaired. She required cueing (verbal directions) and supervision. Further review revealed that the resident required extensive assistance with one person physical assistance with eating.

Review Resident R 107's care plans dated November 2, 2017, revealed that the resident had macular degeneration (an eye disorder that may lead to blindness). The care plan further identifed that the resident was at risk for injuries due to poor vision and directed staff to observe the resident for safety. Additionally, the care plan indicated that the resident needed limited/extensive assist for activities of daily living because the resident was legally blind. The care plan further directed staff to assist the resident as needed while eating.

Review of information submitted by the facility, dated April 5, 2018, revealed that Resident
R107 had spilled soup on her lap while in the dining room at approximately 11:00 a.m. and had "one blister about the size of a quarter." The facility investigation revealed redness on the right thigh measured 7 cm x 12 cm and left thigh measured 6 cm x 3 cm (centimeters, length x width; 1 inch = approximately 2.5 centimeters). Further review of information submitted by the facility indicated that the resident's burns required daily treatments with Silvadene Cream (an antibiotic cream used in the treatment of second and third degree burns) for seven days.

Continued review of the information submitted by the facility revealed a witness statement written by Employee E6, Nursing Assistant, which stated that she "took the resident to the dining room and came out to get more residents. I got to the door I noticed she (Resident R 107) was screaming. "I burn myself its hot'." Additionally, Employee E6's statement indicated that the dietitian had given the cup of soup to the resident, which was still in the resident's hand. Employee E6 further indicated in the witness statement that the temperature of the soup served to Resident R 107 was 160 degrees Fahrenheit (F).

Review of Nurses' notes for Resident R 107 dated April 9, 2018, revealed a "blister noted on right thigh measuring 2 cm (centimeters) x 2.2 cm and 1.8 x 1.2 and on left thigh blister 1.7 x 1.2 cm."

A review of the Dining Services temperature audit form of the soup for April 5, 2018,
confirmed that the temperature of the soup was documented as 160 degrees Fahrenheit.

Interview with the Nursing Home Administrator (NHA) on January 7, 2017, at approximately 4:00 p.m. confirmed that the soup was placed near a visually impaired resident who required supervision during meals.

The facility failed to provide adequate supervision for one resident who sustained a burn to her right and left thighs from hot soup.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/17/17, 12/09/16

28 Pa. Code 201.18(b)(1) Management
Previously cited 11/17/17, 12/09/16

28 Pa. Code 201.18(b)(3) Management
Previously cited 11/17/17

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 211.10(d) Resident care policies
Previously cited 12/09/16

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 11/17/17, 12/09/16











 Plan of Correction - To be completed: 01/28/2019

1)Staff education to check CNA log on start of shift before assignment and check orders regarding assistance required and or any devices used for each resident. Staff to assure assist of 2 provided when indicated and ordered. Staff will be educated on abuse/neglect policy.
2)Each resident CNA log is a communication tool for staff and should be checked and signed at the beginning of the shift. All Care given is checked in ADLS IN Electronic medical records. Charge nurse or senior CNA will check for completion within the hour of the shift for completion. Charge nurse check will be a log sheet in front of each book to assure the check was completed. DON or designee will check compliance weekly times 4 weeks and then monthly.
3)Policy updated to serve Hot liquids within 145 to 155 range at point of service. Dietary staff are inserviced to hold hot liquid/soup until nursing staff is available to feed residents that require assistance. Nursing staff are inserviced to assure to provide assistance with hot soup/beverages. Nursing supervisor will do meal audit at each dining room at random to asure compliance. Report will be reviewed by DON/NHA weekly for 4 weeks and then monthly for 3 months.
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 review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to provide adequate supervision related a burn for one of 28 residents reviewed (Resident R 107).

Findings include:

A review of Resident R 107's clinical record revealed that the resident was admitted to the facility on October 24, 2017, with diagnoses that included severe dementia (progressive, irreversible loss of memory), blindness, macular degeneration (eye disorder that may lead to blindness) and generalized muscle weakness.

A review of the quarterly Minimum Data Set assessment (MDS) (an assessment tool used to determine resident care needs) completed on January 23, 2018, indicated the resident's cognitive skills (an activity related to thinking, reasoning or remembering) for daily decision making was poor and moderately impaired. She required cueing (giving encouragement and verbal directions) and supervision. Further review revealed that the resident was an extensive assistance with one person physical assist with eating.

A review of the resident's care plans dated November 2, 2017, revealed that Resident R 107 had macular degeneration and was at risk for injuries due to poor vision, and included an intervention to observe the resident for safety. An additional care plan revealed that the resident needed limited/extensive assist for activities of daily living because she was legally blind, with an intervention to assist resident as needed, related to eating.

Review of facility policy, Hot Beverage Temperature Guidelines, dated December 5, 2007 and reviewed October 22, 2018, revealed the policy to specifically cover coffee and hot water with no mention of soup. Further review revealed that "Hot beverages may pose a safety risk to residents even when the temperature, at the point of service, is within the 150-155 range. Facilities must ensure that these beverages are served in a "no risk" manner."

Review of information submitted by the facility, dated April 5, 2018, revealed that the resident spilled soup on her lap while in the dining room at approximately 11:00 a.m. and had "one blister about the size of a quarter." The facility investigation revealed redness on the right thigh measured 7 cm x 12 cm and left thigh measured 6 cm x 3 cm (centimeters, length x width; 1 inch = approximately 2.5 centimeters). It was indicated that the temperature of the soup was listed for that day was documented on the Dining Services temperature audit form at 160 degrees Fahrenheit (F). Further review indicated that temperature guidelines for soup, at point of service, was listed at 160 degrees F.

Nurses' notes, dated April 9, 2018, revealed a "blister noted on right thigh measuring 2 cm x 2.2 cm and 1.8 x 1.2 and on left thigh blister 1.7 x 1.2 cm."

Further review of the witness statement written by Employee E6, Nursing Assistant, revealed that she "took the resident to the dining room and came out to get more residents. I got to the door I noticed she was screaming. 'I burn myself its hot'." Further review of information submitted by the facility indicated that the resident's burns required daily treatments with Silvadene Cream (an antibiotic cream used in the treatment of second and third degree burns) for seven days.

Interview with the Nursing Home Administrator (NHA), on January 7, 2017, at approximately 4:00 p.m. revealed that soup was placed near a visually impaired resident who required supervision during meals.

The facility failed to provide adequate supervision for one resident who was visually impaired who sustained a burn to her right and left thigh from hot soup.

Free of Accident Hazards/Supervision/Devices
CFR(s): 483.25(d)(1)(2) - Previously cited 11/17/17, 12/09/16

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/17/17, 12/09/16

28 Pa. Code 201.18(b)(1) Management
Previously cited 11/17/17, 12/09/16

28 Pa. Code 201.18(b)(3) Management
Previously cited 11/17/17

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 211.10(d) Resident care policies
Previously cited 12/09/16

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 11/17/17, 12/09/16













 Plan of Correction - To be completed: 01/28/2019

Policy updated to serve Hot liquids within 145 to 155 range at point of service. Dietary staff are inserviced to hold hot liquid/soup until nursing staff is available to feed residents that require assistance. Nursing staff are inserviced to assure to provide assistance with hot soup/beverages. Nursing supervisor will do meal audit at each dining room at random to asure compliance. Report will be reviewed by DON/NHA weekly for 4 weeks and then monthly for 3 months.



483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observations and staff interviews, it was determined that the facility failed to maintain proper safe food storage practices in the Food and Nutrition Services department.

Findings include:

Observations during inspection of the Food and Nutrition Services department, accompanied by the Director of Dining Services, on January 3, 2019, at approximately 10:00 a.m. revealed foods that were not labeled and or dated in the walk in refrigerator. Observations included: a metal container of cottage cheese and stuffed chicken that were not labeled or dated. A container of beef, tuna fish and chicken were not labeled. A container of beets was not dated.

This was confirmed in an interview with the Director of Dining Services, on January 3, 2019, at approximately 10:15 a.m.

Food/Procurement,Store/Prepare/Serve-Sanitary
CFR(s): 483.60(i)(1)(2) - Previously cited 11/17/17

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/17/17, 12/09/16

28 Pa. Code 201.18(b)(1) Management
Previously cited 11/17/17, 12/09/16

28 Pa. Code 201.18(b)(3) Management
Previously cited 11/17/17



 Plan of Correction - To be completed: 01/28/2019

Staff has been inserviced that all items that are stored in the refrigerator must have the name of the item and the date. Signs are posted inside the refrigerator to remind staff regarding labeling.
Daily check by supervisor to assure all items are labeled.
483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to complete thorough investigations to identify and/or rule out neglect for one of 28 residents reviewed (Resident R28).

Findings include:

Review of facility policy, "Abuse, Neglect, Misappropriation of Property," dated last reviewed October 2018, revealed that "Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress." Continued review of the policy revealed that when an incident of neglect is found, an incident report must be filed, an investigation must be initiated immediately, and an electronic report (PB-22) including statements from all persons involved must be transmitted to the Pennsylvania Department of Health field office within five days of the conclusion of the investigation.

Clinical record review for Resident R28 revealed a quarterly Minimum Data Set assessment (MDS -an assessment of resident care needs), dated November 29, 2017, which indicated that the resident was severely cognitively impaired and required the physical assistance of two or more persons for transfers.

Review of facility documentation submitted on December 8, 2017, indicated that Resident R28 was sent to the hospital because of an injury/accident. The documentation revealed that the resident was transferred from her bed to her wheelchair by a nurse aide on December 8, 2017, during morning care and that Resident R28 sustained a laceration to her right lower leg while being transferred. Resident R28 was subsequently sent to the hospital and received ten sutures for the laceration. There was no further documentation available for review that indicated the size of the laceration. Review of the facility's investigation of this incident revealed that the nurse aide had transferred Resident R28 by herself and that this nurse aide was counseled for transferring the resident and causing a laceration that required treatment at the hospital. The counseling note also indicated interventions put in place to prevent further injury which included transferring the resident with the assistance of two staff members and using good transfer techniques.

Continued record review for Resident R28 revealed a physician's order, dated December 8, 2017, to "transfer with assist of two staff." Review of the December 2017 nurse aide care Kardex revealed that the above order was noted, implemented on December 9, 2017, and initialed every shift through December 31, 2017.

Review of facility documentation, submitted on December 27, 2017, indicated that Resident R28 was again sent to the hospital because of an injury/accident. The documentation revealed that the resident was transferred from her bed to her wheelchair on December 27, 2017, during morning care and sustained another laceration to her right leg which measured 3.5 cm (centimeters) by 2.2 cm by 2.5 cm. Resident R28 was subsequently sent to the hospital and received six sutures for the laceration. Review of the facility's investigation of this incident revealed that another nurse aide transferred Resident R28 by herself and stated that when she made rounds the previous nurse aide told her that the resident was a one person assist. The investigation further revealed that this nurse aide was disciplined for substandard work that resulted in the resident sustaining a laceration that required treatment at the hospital.

Interview on January 4, 2019, at 12:00 p.m. with the Nursing Home Administrator (NHA) confirmed that neither of the above incidents had been investigated to identify or rule out neglect. Additionally, the NHA confirmed that an electronic report (PB-22) including statements from all persons involved was not completed or transmitted to the Pennsylvania Department of Health as required.

The facility failed to complete thorough investigations to identify or rule out neglect for a resident who sustained two lacerations while being transferred by staff.

Investigate/Prevent/Correct Alleged Violation
CFR(s): 483.12(c)(2)-(4) - Previously cited 11/17/17

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/17/17, 12/09/16

28 Pa. Code 201.14(d) Responsibility of licensee

28 Pa. Code 201.18(b)(1) Management
Previously cited 11/17/17, 12/09/16

28 Pa. Code 201.18(b)(3) Management
Previously cited 11/17/17

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 211.5(f) Clinical records
Previously cited 12/09/16

28 Pa. Code 211.5(g) Clinical records

28 Pa. Code 211.10(d) Resident care policies
Previously cited 12/09/16










 Plan of Correction - To be completed: 01/28/2019

Incident reports will be reviewed every morning by IDT in stand up meeting, any non compliant incidents or incidents with injury will be investigated and ruled out for abuse or neglect. If founded will be reported as abuse/neglect per facility policy. Policy on accident incident investigation will be updated to reflect investigation protocol for incidents with major injury or non compliant issues.
DON or designee will monitor corrective action at the time of incident report review daily at stand up meeting.
NHA or designee will monitor compliance of complete review weekly when incident report are signed off.
Incidents with injuries and reported to DOH, its action plans and outcome of the plan of actions will be discussed at staff QA meeting and Board QA quarterlymeeting.
483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to develop and/or implement comprehensive care plans based on the residents' individual assessed needs related to transfers for three of 28 residents reviewed (Residents R59, R41, and R112).

Findings include:

Clinical record review for Resident R59 revealed a quarterly Minimum Data Set assessment (MDS- an assessment of resident care needs), dated November 14, 2018, which indicated that the resident was admitted to the facility on March 6, 2018, that the resident was moderately cognitively impaired and that the resident required the assistance of two or more persons for transfers. Continued clinical record review revealed a physician's order, dated March 6, 2018, for "two people transfers with all transfers." Review of Resident R59's care plan, dated last reviewed November 16, 2018, revealed that the resident was a risk for falls related to a left above the knee amputation with interventions including "Instruct/remind resident to call for assist with mobility/transfers as needed." There was no indication on the resident care plan that the resident required the assistance of two or more persons for transfers. Additionally, review of the resident's nurse aide care Kardex also revealed no indication of the resident's required need for two person assist with transfers.

Clinical record review for Resident R41 revealed an annual MDS, dated November 6, 2018, which indicated that the resident was moderately cognitively impaired and the resident required the assistance of two or more persons for transfers. Review of Resident R41's care plan, dated last reviewed November 7, 2018, revealed that the resident was at risk for falls with interventions including "Instruct/remind resident to call for assist with mobility/transfers as needed." There was no indication on the resident care plan that the resident required the assistance of two or more persons for transfers. Additionally, review of the resident's nurse aide care Kardex also revealed no indication of the resident's assessed need for the assistance of two or more persons for transfers.

Clinical record review for Resident R112 revealed a quarterly MDS, dated December 19, 2018, which indicated that the resident was moderately cognitively impaired and the resident required the assistance of two or more persons for transfers. Review of Resident R112's care plan, dated last reviewed December 20, 2018, revealed that the resident was at risk for falls and injuries with interventions including "Assist with all transfers." There was no indication on the resident care plan that the resident required the assistance of two or more persons for transfers. Additionally, review of the resident's nurse aide care Kardex also revealed no indication of the resident's assessed need for the assistance of two or more persons for transfers.

Interview with Employee E3, Licensed Practical Nurse, and Employee E4, Registered Nurse, on January 4, 2019, confirmed that Residents R59, R41, and R112's care plans did not indicate the residents' assessed needs or prescribed orders for the assistance of two or more persons for transfers. Employee E4 also confirmed that there was no information on the nurse aide care Kardexs to indicate that the residents required the assistance of two persons for transfers.

The facility failed to develop comprehensive care plans based on residents' assessed needs related to transfers.

28 Pa. Code 211.5(f) Clinical records
Previously cited 12/09/16

28 Pa. Code 211.11(c)(d) Resident care plan

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 11/17/17, 12/09/16









 Plan of Correction - To be completed: 01/28/2019

Facility is implementing new electronic care plans that are automatically triggered from the assessments. Care plans will be updated to show amount of assistance required for care if the order is obtained for 2 person assist. LNAC on care plan/ MDS review will assure this information has been updated accordingly on care plans, CNA log, MAR/TAR. In service licensed nursing staff on updating care plans and all logs as needed to reflect resident care with assist of 2. MDS coordinator will audit randomly to assure compliance.
Performance improvement plan (PIP)developed for monitoring compliance with updating care plan and is monitored by RNAC or designee. Results will be discussed and reported in quarterly Quality assurance meetings by DON or designee
483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on clinical record review, review of facility documentation and interviews with staff, it was determined that the facility failed to revise a care plan after a fall for one of 28 residents reviewed (Resident R41).

Findings include:

Clinical record review for Resident R41 revealed an annual Minimum Data Set assessment (MDS - assessment of resident care needs), dated November 6, 2018, which indicated that the resident was moderately cognitively impaired and required the assistance of two or more persons for transfers. Continued record review for Resident R41 revealed a nurse's note dated December 15, 2018, at 10:12 p.m. indicating that the resident was found on the floor next to her bed and that a bed alarm and safety mattress was ordered for safety.

Review of facility documentation dated December 15, 2018, revealed that the resident did not know how she fell. Per the documentation a plan of action was developed in response to the fall which included applying a bed alarm, placing a safety mattress on the floor and updating the resident's care plan.

Review of the physician's orders revealed orders dated December 15, 2018, for a bed alarm and a safety mattress on the floor. Two days later, on December 17, 2018, a chair alarm was also ordered.

Review of Resident R41's care plan dated last reviewed November 7, 2018, revealed that the resident is at risk for falls with interventions that included to observe the resident for safety and to keep the resident's bed in the lowest position. Interview on January 4, 2019, with Employee E3, Licensed Practical Nurse, and Employee E4, Registered Nurse, confirmed that Resident R41's care plan for falls was not updated after she fell on December 15, 2018, and did not include the physician prescribed interventions of the bed alarm, chair alarm and safety mats. Employee E4 also confirmed that the nurse aide care Kardex was not updated to include the bed alarm, chair alarm and safety mats.

Interview on January 7, 2019, at approximately 4:00 p.m. with the Nursing Home Administrator (NHA) confirmed that Resident R41's care plan for falls was not updated after she fell on December 15, 2018, and did not include the physician prescribed interventions of the bed alarm, chair alarm and safety mats. The NHA could not explain why the resident's care plan was not updated.

The facility failed to revise a care plan after a fall for one resident.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/17/17, 12/09/16

28 Pa. Code 201.18(b)(1) Management
Previously cited 11/17/17, 12/09/16

28 Pa. Code 201.18(b)(3) Management
Previously cited 11/17/17

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 11/17/17, 12/09/16









 Plan of Correction - To be completed: 01/28/2019

Care plans are updated as orders are initiated or changes to resident occur. Care plans for order changes will be added to 24 hour chart checks, Care plans will be reviewed when incident reports are reviewed every morning and updated as needed. Staff education on updating care plans with order changes and incidents will be completed.
DON will monitor daily at stand up meeting with review of Incident report that care plans are updated.
Performance improvement plan (PIP)developed for monitoring compliance with updating care plan and is monitored by RNAC or designee. Results will be discussed and reported in quarterly Quality assurance meetings by DON or designee

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