Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-KINGSTON
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MANORCARE HEALTH SERVICES-KINGSTON
Inspection Results For:

There are  114 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.
MANORCARE HEALTH SERVICES-KINGSTON - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated complaint survey completed on April 16, 2019, it was determined that Manorcare Healthservices Kingston 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:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
483.12 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 on review of clinical records and observations, it was revealed that the facility failed to identify resident's risk for abuse related to resident behaviors and devise and implement measures necessary, including sufficient staff supervision, to protect the resident and other residents from abuse and physical harm, for two residents out of (Resident 4 and 5) of 11 residents sampled.



Findings include:

A review of Resident 4's clinical record revealed she had a diagnosis of dementia without behavioral symptoms, adjustment disorder with mixed anxiety and depression, compounded with her inability to communicate in English.

A review of the resident's most recent MDS (minimum data set - standardized data collection assessment tool conducted periodically to identify resident care needs) Assessment dated February 3, 2019, revealed that the resident's BIMS (brief interview for mental status - a tool to assess cognitive function) could not be completed due to her inability to participate in English.

Further review of the resident's clincal record revealed that the resident had a long history of wandering in common areas of the facility and in and out of resident rooms. As a result of this wandering, the resident was involved in various altercations with peers.

On September 18, 2016, the resident wandered into another resident's room and received a skin tear as the other resident attempted to direct her out of the room.

While wandering in the hallway on March 22, 2017, the resident was pushed by another resident and sustained a fractured left femur.

According to review of the resident's clinical record on October 18, 2018, Resident 4 wandered into Resident 5's room. Resident 4 was able to gain access to Resident 5's door by going under the velcro stop sign strip, which had been placed across the door to deter wandering residents from entering the room. Resident 5 pushed Resident 4 and she landed on her buttocks.

On January 11, 2019, Resident 4 wandered into Resident CR8's room. Resident CR8 attempted to redirect the resident and she became combative and he pushed her and she fell.

A review of the resident's clinical record revealed that she wandered into Resident 5's room again on January 12, 2019. Resident 5 pushed Resident 4, but Resident 4 did not fall.

According to a review of a facility investigation into an incident and Resident 4's clinical record, revealed that on March 18, 2019 at 9:23 p.m., the resident was found on her back in another resident's room (Room D-15.) Blood was noted to the back of the resident's head. The resident was sent to the emergency department and returned with two staples to the back of her head.

A review of the facility investigation into the incident, revealed that they could not determine how the incident happened as the resident was not able to participate in the assessment.

There was no indication that the facility's investigation had determined if there were any other resident' in the room at the time of the incident and if they were involved in the resident's fall.

On March 26, 2019, staff documented that the staples had been removed from Resident 4's head.

A review of a facility investigation into an incident and a corresponding Pennsylvania Bulletin 22 (Report form for investigation of alleged abuse, neglect and misappropriation of property,) initiated by the facility on April 3, 2019, revealed that Resident 4 wandered into Resident 5's room again. Staff members heard Resident 5 yelling. As staff entered Resident 5's room, they witnessed Resident 5 push Resident 4. Resident 4 was observed falling to her buttocks and hitting her head on the side of the bathroom door. The resident sustained a 1 cm laceration to her head.

Subsequent to this incident, the facility planned to place a velcro stop sign across Resident 5's door to prevent Resident 4 from entering, despite Resident 4's past history of entering the room beneath the sign.

Observations conducted throughout the day of the survey, April 16, 2019, revealed that a velcro stop sign was hanging to the left side of Resident 5's door, but was not in use.

A review of Resident 4's most recent comprehensive plan of care with a target date of May 14, 2019, identified the resident's behaviors of wandering and pacing, but failed to identify the resident's history of wandering and intrusive behaviors and the risk of abuse related to Resident 4's behaviors and response to those behaviors from other residents. The facility did not develop and implement individualized interventions to protect the resident from abuse.

Resident 11, who resides on the same unit as Resident 5, was interviewed at 2:00 p.m. on April 16, 2019. Resident 11 stated that he did not mind Resident 4 coming into his room because "she was harmless and did not know any better." Resident 11, stated however, that Resident 5 becomes angry when Resident 4 wanders into Resident 5's room, and calls her "awful names." Resident 11 stated that he had approached Resident 5 about how inappropriate it was to call a lady those types of names. Resident 11 stated that this led to he and Resident 5 having a verbal altercation.

A review of Resident 5's clinical record revealed the resident's last MDS Assessment was completed on February 2, 2019. The resident's BIMS was assessed at 12, indicating that the resident was moderately cognitively impaired.

According to review of nursing documentation dated March 10, 2019, and March 11, 2019, Resident 5 was yelling for staff assistance as another resident had wandered into his room.

Staff documented on March 17, 2019, that Resident 5 was verbally abusive towards a female resident singing outside his room.

A review of nursing documentation dated March 20, 2019, revealed that another resident was in the doorway of Resident 5's room and Resident 5 was yelling "you c**t get your ass out of here."

Resident 5 was yelling for a supervisor on March 21, 2019, because a resident was singing in the hallway, according to nursing documentation.

On March 24, 2019, staff documented that Resdient 5 was yelling out for a supervisor. When the supervisor arrived he started screaming to "get this wh**e out of here and go sing somewhere else," referring to a resident singing in the hallway by Resident 5's room. Resident 5 stated "if she comes into my room I will cut her into bloody pieces." The staff member documented that she was unable to speak over the resident because he (Resident 5) was yelling so loudly.

According to documentation dated March 26, 2019, Resident 5 was yelling at residents passing by his room. On March 25, 2019, staff documented Resident 5 was "yelling and cursing" at a resident that walked into his room. Resident 5 stated "the next time she comes in my room I will hit her in the face."

A review of documentation dated April 3, 2019, revealed that the nursing supervisor heard yelling and went into Resident 5's room to find Resident 4 lying on the floor by Resident 5' bed. Resident 5 was attempting to walk back to where Resident 4 was lying, was stopped by a staff member. Resident 5 was yelling to "get that wh**e out of here." As the staff was attempting to tell the resident he could not touch another resident he continued to yell and ignore the nurse's instructions.

According to review of Resident 5's clinical record, he displayed numerous instances of inappropriate behaviors. On April 9, 2019, staff documented that the resident was yelling at another resident because she was singing outside his door.

According to documentation, on April 6, 2019, the resident was "yelling profanities in his room using vulgar expletives, saying,"I will kill every one of you "c**ts!", and "you think that I harmed that little Russian lady?! (Resident 4) You haven't seen nothing, yet!"

A review of Resident 5's comprehensive plan of care revealed that a "stop sign to doorway to deter wandering residents at all times" was initiated on January 12, 2019, as the only intervention related to intrusive behaviors by other residents, although this intervention and proved ineffective as a resident entered the room below the sign. This resident's care plan was updated on April 4, 2019, with no additional interventions added or revised.

Observations conducted at 3:05 p.m. on April 16, 2019, revealed that Resident 4 wandered into Resident 13's room. Resident 13 verbally asked Resident 4 (who does not speak English) to leave and when she did not, Resident 13 took her hands to lead Resident 4 out of her room. Resident 4 began resisting and pulling her hands away. Resident 13 began raising her voice for her to leave. The surveyor requested staff assistance as staff at the nurses station, two doors down from the resident's room, were unaware of the incident.


483.12(a)(1)Free from abuse.
Previously cited 2/9/19,7/9/18


28 Pa. Code 201.18(e)(1) Management
Previously cited:2/9/19,11/19/18,10/16/18,7/9/18,4/17/18.

28 Pa. Code 201.29(a)(c) Resident Rights
Previously cited: 2/9/19,11/19/18,7/9/18.

28 Pa. Code 211.12(a) Nursing Services
Previously cited 2/9/19,11/19/18,7/9/18,4/17/18.

28 Pa. Code 211.12(c) Nursing Services
Previously cited: 2/9/19,11/19/18,7/9/18,4/17/18.

28 Pa. Code 211.12(d)(1) Nursing Services
Previously cited: 2/9/19,11/19/18,7/9/18,4/17/18.

28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited: 2/9/19,11/19/18,7/9/18,4/17/18.
.










 Plan of Correction - To be completed: 05/28/2019

1. Resident's 4 and 5 have had their plan of care reviewed and interventions updated to protect them from abuse.
2. Utilizing the Investigation QAPI tool incidents reports over the past 30 days will be reviewed to identify any other residents who need additional interventions to maintain an environment free of abuse.
3. Staff will be educated using the focus on f tag 600 Free from Abuse and Neglect
4. Random audits of incident reports will be completed to ensure interventions are in place and effective to prevent abuse. Results of the audits will be completed for 8 weeks and reported to QA for further evaluation.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
483.35(a) Sufficient Staff.
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)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on observations, clinical record and incident investigation review and resident interviews it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely quality of care, services and supervision to maintain the physical and mental well-being of the residents in the facility.

Findings include:


Observations conducted during the day of the survey of April 16, 2019, revealed that Resident 8 was seated in the hallway in front of his room, positioned next to the handrails. He was seated in a reclined Broda chair with a cushion to the seat. The resident was observed to continually slide down in the chair or bend at the waist as if to stand up, while verbalizing he was sliding/falling. Various staff members were observed to reposition or redirect the resident to sit down throughout the day, with the resident displaying this behavior repeatedly.


During observations st 12:30 p.m., on April 16, 2019, the surveyor observed the resident lying on his back on the floor, in front of the Broda chair in the hallway. Staff members remarked to the nurse assessing the resident, that he had been displaying these behaviors for "awhile."


Observation of Resident 8 at 4:20 p.m. on April 16, 2019, revealed that he was seated by the nurses station in the Broda chair next to the wall/handrails. The Broda chair was reclined and a heavy straight back chair with arm rests was observed placed in the opposite direction of the chair. The resident's legs were observed to be partially on the reclined portion of the chair and the bottom of his legs and feet on the straight back chair. This position impeded the resident's ability to get up and out as the positioning of the two chairs were preventing his freedom of movement.

A review of the resident's clinical record revealed no indication that this seating arrangement, which physically restrained the resident, had been assessed for its safety, appropriateness and necessity in treating the resident's medical symptoms and had not been implemented solely for staff convenience to most readily control the resident's behaviors with the least amount of staff effort.

Observations on the D hall at 12:05 p.m. on April 16, 2019, revealed that a blister pack of Amiodarone 400 mg (antiarrythmia drug) was on top of the medication a hemostats (surgical clamp). These potentially hazardous items were accessible to residents observed wandering in the area. There was no staff supervision in the area and wandering residents were observed in the area.

Observations conducted at 3:15 p.m. on April 16, 2019, revealed that a male resident was ambulating Resident 15, hand in hand out of room 5, located to the side of the nurses station.) This resident stated that residents frequently ambulate in and out of his and other resident rooms, but Resident 15 "was not a problem like some of the other residents who wander."

A review of Resident 4's clinical record revealed she had diagnoses of dementia without behavioral symptoms, adjustment disorder with mixed anxiety and depression, compounded with her inability to communicate in English.

Review of the resident's clincal record revealed that the resident had a long history of wandering in common areas of the facility and in and out of resident rooms. As a result of this wandering, the resident was involved in various altercations with peers. A review of these altercations revealed that some led to physical abuse of the resident (October 18, 2018, January 11, 2019, Januray 12, 2019, March 18, 2019 and April 3, 2019).

According to a review of a facility investigation into an incident and Resident 4's clinical record, on March 18, 2019 at 9:23 p.m., the resident was found on her back after she had wandered into another resident's room (Room D-15.) Blood was noted to the back of the Resident 4's head. The resident was sent to the emergency department and returned with two staples to the back of her head.

Resident 11, who resides on the same unit as Resident 5, was interviewed at 2:00 p.m. on April 16, 2019. According to review of this resident's most recent MDS Assessment dated 2/9/19 his BIMS was 15. Resident 11 stated that he did not mind Resident 4 coming into his room because "she was harmless and did not know any better." The resident stated, however, that there was currently not enough staff to adequately supervise residents or provide timely care to residents. Resident 11 stated that the man across the hall (identified as Resident 5) becomes very angry and threatening, using foul language, when residents wander near or into his room.

A review of Resident 5's clinical record confirmed the account reported by Resident 11. According to review of Resident 5's clinical record he was verbally abusive to residents singing outside the room on March 17, 20, 21, 24, 25, 26, and April 9, 2019.

A review of a facility investigation into an incident and a corresponding Pennsylvania Bulletin 22 (Report form for investigation of alleged abuse, neglect and misappropriation of property,) initiated by the facility on April 3, 2019, revealed that Resident 4 wandered into Resident 5's room again. Staff members heard Resident 5 yelling. As staff entered Resident 5's room, they witnessed Resident 5 push Resident 4. Resident 4 was observed falling to her buttocks and hitting her head on the side of the bathroom door. The resident sustained a 1 cm laceration to her head.

According to documentation, on April 6, 2019, the staff responded when resident 5 was "yelling profanities in his room using vulgar expletives, saying,"I will kill every one of you "c**ts!", and "you think that I harmed that little Russian lady?! (Resident 4) You haven't seen nothing, yet!"

Staff were aware of Resident 4's history of wandering and incidents of resident to resident physical abuse as well as Resident 5's intolerance and threats to his peers, but the facility did not sufficiently supervise these residents to prevent these resident to resident altercations and subsequent resident injuries.

Observations conducted at 3:05 p.m. on April 16, 2019, revealed that Resident 4 wandered into Resident 13's room. Resident 13 verbally asked Resident 4 (who does not speak English) to leave and when she did not, Resident 13 took her hands to lead Resident 4 out of her room. Resident 4 began resisting and pulling her hands away. Resident 13 began raising her voice for her to leave. The surveyor requested staff assistance as staff at the nurses station, two doors down from the resident's room, were unaware of the incident.

Resident 12 was observed wandering about her unit hallways throughout the day of the survey and into the resident room across the hallway from her's at 3:25 p.m. on April 16, 2019. A staff member walking by the resident's room, was observed to notice the resident and direct her out of the other resident's room.

When interviewed at 2:40 p.m., Resident 6, whose most recent MDS Assessment was conducted on 2/14/19, revealed that Resident 6's cognition was intact (BIMS 15). The resident stated that the facility was not adequately staffed to provide necessary and timely care. The resident stated that the facility had recently hired more nursing assistants, but the 7 AM to 3 PM shift was still unable to provide needed assistance to residents and care in a timely manner.




28 Pa. Code 211.12(a) Nursing services
Previously cited. 2/9/19,11/19/18,10/16/18,7/9/18,4/17/18

28 Pa. Code 211.12(c) Nursing services
Previously cited. 2/9/19,11/19/19,7/9/18,4/17/18

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited. 2/9/19,11/19/18,7/9/18,4/17/18.

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited. 2/9/19,11/19/18,7/9/18,4/17/18.

28 Pa. Code 201.18(e)(1) Management
Previously cited: 2/9/19, 11/19/18, 7/9/18.

28 Pa. Code 201.18(e)(3)(6) Management
.






 Plan of Correction - To be completed: 05/28/2019

1. The facility will maintain sufficient nursing staff to provide timely quality of care, services and supervision to maintain the physical and mental well being of our residents.
2. Staffing patterns have been reviewed and deployed as needed to meet the needs of the residents
3. The nursing management staff will be educated on Focus on F-tag 725 Sufficient Nursing staff and staffing patterns. Staffing patterns will be reviewed daily and staff adjusted based upon the needs of the units
4. A weekly staffing summary will be presented to QA for review and modification based upon the changing needs of the residents


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 observations, review of clinical records and facility investigations into incidents and interviews with residents and staff, it was determined that the facility failed to maintain the environment free of accident hazards, provide timely supervision and appropriate safety interventions, based on each resident's clinical condition and individual preferences, to prevent accidents. The facility further failed to fully evaluate the circumstances surrounding resident incidents, to effectively plan preventative measures necessary to promote resident safety as evidenced by two (Residents 8 and 13 ) out of 11 residents sampled.



Findings include:

Observations conducted during the day of the survey, April 16, 2019, revealed that Resident 8 was seated in the hallway in front of his room, positioned next to the handrails. He was seated in a reclined Broda chair with a cushion to the seat. The resident was observed to continually slide down in the chair or bend at the waist as if to stand up, while verbalizing he was sliding/falling. Staff members were observed to reposition or seat the resident down back down in the chair throughout the day, with the resident continuing this behavior repeatedly.

A review of the resident's comprehensive plan of care dated/last revised by the facility December 8, 2018, revealed that he was to use a Broda chair with bilateral leg rests.

During observations conducted on April 16, 2019, at 12:30 p.m., the resident was observed lying on his back on the floor, in front of the Broda chair in the hallway. Staff members remarked to the nurse assessing the resident, that he had been displaying these behaviors for "awhile."

Subsequent to this incident, the resident was observed in the hallway in the reclined Broda chair continuing similar behavior throughout the afternoon of April 16, 2019.

A review of documentation in the resident's clinical record from February 2019 through April 16, 2019, revealed that staff repeatedly documented that the resident was sliding himself down in his chair. It was documented that this was determined to be "intentional behavior."

A review of a Therapy Discharge Communication dated December 26, 2018, revealed that the resident required a Broda chair for seating, but did not specify the position, of a reclined chair. The resident's continued to display behaviors of sliding, but there was no indication the resident's seating position had been assessed to ascertain its continued appropriateness and safety.

Resident 6 approached the surveyor at 2:40 PM on April 16, 2019, to complain that she had sustained a fall in the shower due to what she felt was the unsafe use of a shower chair, which did not safely support the resident. The resident alleged that the shower chair was too high and when she went to step down the floor was slippery and she fell. Resident 6 stated that administration was aware of her concerns regarding the height of the chair. A review of the resident most recent MDS Assessment dated February 4, 2019, revealed that the resident's cognition was intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognition, a score of 13-15 indicates intact cognition).

A review of a facility investigation into Resident 6's fall revealed that the staff member providing the resident's shower on April 9, 2019, stated that the floor had appeared "oily" and she used a towel to dry the floor, but the condition did not improve. The resident reached for her cane and the staff member reached for the resident's wheelchair and the resident slipped. Following the incident the facility determined that the resident's slippers were worn on the bottom. There was no indication that the facility had evaluated the size/height of the shower chair during its investigation.

The facility failed to demonstrate that all hazards were eliminated to assure the resident's safety and prevent falls.

Observations completed on the D hall at 12:05 p.m. on April 16, 2019, revealed that a blister packet of Amiodarone 400 mg (used to treat certain types of serious (possibly fatal) irregular heartbeat (such as persistent ventricular fibrillation/tachycardia). It is used to restore normal heart rhythm and maintain a regular, steady heartbeat) was on top of the medication cart along with a hemostat (a surgical tool used in many surgical procedures to control bleeding).

There was no staff supervision observed in the area at this time and wandering residents were observed in the area of these accident hazards


28 Pa. Code 211.12(a) Nursing services
Previously cited. 2/9/19,11/19/18,10/16/18,7/9/18,4/17/18

28 Pa. Code 211.12(c) Nursing services
Previously cited. 2/9/19,11/19/19,7/9/18,4/17/18

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited. 2/9/19,11/19/18,7/9/18,4/17/18.

28 Pa. Code: 211.12(d)(3)(5) Nursing Services
Previously cited: 2/9/19, 7/9/19/, 4/17/18.










 Plan of Correction - To be completed: 05/28/2019

1. Resident 8 seating has been evaluated by therapy, Resident #6 has been reviewed by therapy and recommendations for shower chair implemented, and the identified medication has been accounted for and secured.
2. An audit of falls over last 30 days will be completed utilizing the Falls QAPI tool to identify any additional interventions needed to maintain an environment free of hazards as much as possible. Med pass observations will be completed on licensed nurses focusing on cart safety/security
3. Staff will be educated using the focus on f tag 689 Free of Accidents and Hazards.
4. Random audits will be completed weekly for 8 weeks to ensure interventions are effective to promote resident safety. Results of the audits will be reported to QA for further evaluation.

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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.
483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

483.12
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)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:

Based on observations and review of clinical records it was determined the facility failed to assure that one resident out of 11 sampled was free from a physical restraint imposed for the purpose of staff convenience and without evidence the restraint was required to treat the resident's medical symptoms for one out of 11 residents sampled( Resident 8.)

Findings include:

Observations conducted during the survey April 16, 2019, revealed that Resident 8 was seated in the hallway in front of his room, positioned next to the handrails. He was seated in a reclined Broda chair with a cushion to the seat. The resident was observed to continually slide down in the chair or bend at the waist as if to stand up, while verbalizing that he was sliding/falling. Staff members were observed to repeatedly reposition or seat the resident down throughout the day of the survey, with the resident repeating this behavior continually.

During surveyor observations at 12:30 p.m., on April 16, 2019, the resident was observed lying on his back on the floor in front of the Broda chair. Staff members remarked to the nurse assessing the resident, that he had been displaying these behaviors for "awhile."

Following the above observation at 12:30 PM on April 16, 2019, the resident was observed in the hallway seated in the reclined Broda chair continuing to display similar behavior throughout the afternoon hours.

A review of the resident's clinical record documentation dated from February 2019 through April 16, 2019, revealed that staff consistently documented that the resident was sliding himself down in his chair. Staff documented that this was determined to be "intentional behavior."

Further observation of the resident at 4:20 p.m. on April 16, 2019, revealed that he was seated by the nurses station in the Broda chair next to the wall/handrails. The Broda chair was reclined and a heavy straight back chair with arm rests was observed placed in the opposite direction of the chair. The resident's legs were observed to be partially on the reclined portion of the chair and the bottom of his legs and feet on the straight back chair. This position impeded the resident's ability to get up and out as the positioning of the two chairs were preventing his freedom of movement.

A review of the resident's clinical record revealed no indication that this seating arrangement, which physically restrained the resident, had been assessed for its safety, appropriateness and necessity in treating the resident's medical symptoms and had not been implemented solely for staff convenience to most readily control the resident's behaviors with the least amount of staff effort.




Refer F725

28 Pa. Code 201.29 (j) Resident Rights.

28 Pa. Code 211.8 (a)(d)(e) Use of Restraints.

28 Pa. Code 211.12(a) Nursing services
Previously cited. 2/9/19,11/19/18,10/16/18,7/9/18,4/17/18

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited. 2/9/19,11/19/18,7/9/18,4/17/18.

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited. 2/9/19,11/19/18,7/9/18,4/17/18.









 Plan of Correction - To be completed: 05/28/2019

1. Resident 8 seating has been evaluated by therapy
2. A comprehensive audit using the Physical Restraint QAPI audit tool will be completed to ensure residents are free from physical restraint unless required to treat the resident's medical symptoms.
3. Nursing staff will be educated using the focus on f tag 604 Right to be Free of Physical Restraints.
4. Random audits will be completed weekly x 8 weeks to ensure interventions do not physically restraint residents unless required to treat the resident's medical symptoms. . Results of the audits will be reported to the QA committee

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observations conducted all nursing units and resident interviews it was determined that the facility failed to maintain clean, comfortable and homelike environment for residents including Residents 8, 10, 14, 16.

Findings include:

Observation conducted on April 16, 2019, revealed that Resident 10 was observed seated in a Broda chair throughout the day of the survey. The chair cushion was observed soiled with dried stains and liquids

Resident 8 was observed seated in a Broda chair in the hallway throughout the day of the survey. The chair cushion was observed to be heavily soiled with dried stains.

Resident 14 was observed seated in a Broda chair in the the hallway from 1:45 p.m. to 3:45 p.m. The chair's surface was ripped and soiled with dried substances.

A pole used for an enteral tube feeding in room 105 was soiled with dried white stains on the base.

Resident 16's overbed table was observed soiled with a dried pink substance.

A set of support bars/handrails were observed in the tub in room 118 with cob webs on them.






28 Pa. Code: 201.29(j)(k) Resident Rights.
Previously cited: 2/9/19,11/19/18,10/16/18.


28 Pa. Code 207.2(a) Administrator's responsibility






 Plan of Correction - To be completed: 05/28/2019

1. The identified chairs, tube feeding pole, overbed table, and handrails have been cleaned and repaired.
2. A comprehensive audit will be completed using the Environmental Observation QAPI tool to identify and correct any like residents equipment issues
3. Environmental services supervisor will develop cleaning schedules to include resident equipment. Maintenance will be contacted to repair equipment as needed.
4. Environmental services supervisor/designee will complete random audits of resident equipment for cleanliness and good repair 3x week for 8 weeks, results will be reported to QA committee for further evaluation. .


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