Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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

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ALLIED SERVICES SKILLED NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit and abbreviated complaint survey completed on September 25, 2019, it was determined that Allied Services Skilled Nursing Center corrected the federal deficiency cited during the survey of September 4, 2019, but 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(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Based on review of clinical records and select facility investigative reports and resident and staff interviews it was determined the facility failed to provide necessary staff assistance as planned and utilize safe technique during a transfer from the wheelchair to bed, to prevent an accident resulting in a fractured leg for one out of five residents reviewed (Resident 267).

Findings include:

A review of the clinical record revealed that Resident 267 was admitted to the hospital on September 6, 2019, from her apartment with difficulty walking. The resident was then admitted to the facility on September 11, 2019, from the hospital with a diagnosis of left lower extremity cellulitis (is a common, potentially serious bacterial skin infection. Cellulitis appears as a swollen, red area of skin that feels hot and tender. It can spread rapidly to other parts of the body), and muscle weakness, abnormality of gait (difficulty walking) osteoarthritis (sometimes called degenerative joint disease or "wear and tear" arthritis, osteoarthritis (OA) is the most common chronic condition of the joints. It occurs when the cartilage or cushion between joints breaks down leading to pain, stiffness and swelling).

A review of Resident 267's most recent MDS (minimum data set-standardized assessment process conducted at periodic intervals to assess resident care needs) Assessment dated September 18, 2019, revealed that the resident required extensive assistance of two staff members for transfers which includes moving between surfaces including to or from bed, wheelchair or chair. The resident was unable to move from a seating to standing position without assistance. The resident was cognitively intact with a BIMS score of 15 (brief interview for mental status-a tool to assess cognitive function - a score of 13-15 indicates intact cognition).

A review of the resident's bedside Kardex (information card utilized by nurse aides which is a quick reference to the specific needs of each resident) conducted during the survey of indicated that the resident required assistance of two persons for transferring from one surface to another and was non ambulatory. The resident utilized a brace (hinged knee orthosis- a brace to limit movement of knee and may reduce pain and pressure of arthritis) to her left leg when out of bed and to be removed when in bed and for hygiene.

A review of information dated September 23, 2019, submitted by the facility indicated that on September 21, 2019, "Capable resident, Resident 267 (Age 83), admitted to facility on 9/11/2019 with Dx: Cellulitis of the Left Lower Limb. On 9/22/19 resident complained of pain in her left lower leg. An RN assessment was completed, resident was medicated for pain, and MD was notified with orders noted for Keflex and an X-ray of the left leg. X-Ray result revealed osteoporosis and a fracture to LLE. Resident indicated she did not have an accident or a fall. MD was notified with orders noted to consult orthopedics. Resident and Representative were updated."

On September 23, 2019, the State Survey Agency received an allegation that a staff member was transferring Resident 267 into bed on September 21, 2019, during which the resident sustained a fracture (break) to her left lower leg.

A review of the facility's variance report dated September 22, 2019, at 3:13 AM written by the registered nurse (RN) supervisor, Employee 1, which indicated that upon rounds the licensed practical nurse (LPN) Employee 2 noticed that resident's left lower leg was red, swollen and warm to touch, with pain of a "7" on a scale of 1-10 with 10 being the worst amount of pain tolerable. A lump on the resident's leg was later noted on September 22, 2019. On September 22, 2019, the physician was called and was ordered to have an X-ray of the left leg and was placed on an antibiotic for the possibility of cellulitis."

An X-ray of the resident's left leg was obtained at 11:00 AM on September 22, 2019. At 12:23 p.m. on September 22, 2019, the X-ray results revealed proximal tibia/fibula (both bones of lower leg) fracture.

A physician order was noted at that time to to consult the orthopedic physician and apply an ACE wrap (an elastic bandage used to decrease swelling and protect contused joints and limit mobility) was applied to her left lower leg.

A review of the facility's variance report and interview with Employee 2, LPN, conducted on September 25, 2019, at 3:30 PM revealed that this nurse had written a statement for the facility, as part of their review of the incident, indicating that she was in the resident's room at 9:00 PM on September 21, 2019 discussing other care issues. Employee 2 stated during a telephone interview on September 25, 2019 at 3:30 p.m. that she was at the nurses station getting report from the other staff nurses around "eight-ish" on September 21, 2019. She stated that Employee 3, a nurse aide, informed her that Resident 267 wanted to see a nurse because "she pops all over." Employee 2 stated she "didn't think anything of it" because she was not understanding what the aide meant by "popping all over." Employee 2 stated she spoke to the resident at 9:00 PM on September 21, 2019, about another issue. Employee 2 stated that the resident was already in bed at that time and did not convey concerns to her at this time.

Employee 2 stated she was making rounds around midnight on September 21, 2019, (into the early morning hours of September 22, 2019) and saw Resident 267's light on in the resident's room, which was unusual. Employee 2 stated that she looked into the resident's room and the bed covers were off the resident exposing the resident's left leg and observed the resident was rubbing her leg. Employee 2 saw that the resident's leg was red, swollen, and warm to touch. Employee 2 thought it was cellulitis and applied ice and administered Tylenol to the resident. Employee 2 stated that she asked the resident what happened., and the resident stated she was "not sure." Employee 2 stated that she was not concerned how it happened because she stated she was "sure it was cellulitis" due to the fact the resident was admitted to the facility with cellulitis of her left leg. Employee 2 further stated that around 1:45 a.m. on September 22, 2019, she went back to check on the resident's leg and noticed a bump. Employee 2 then called the supervisor who contacted the physician and an order was received to obtain an X-ray and start Keflex, an antibiotic for what was potentially cellulitis.

A review of a typed nurse aide statement by Employee 3, the nurse aide, obtained by the facility on September 22, 2019, not time noted, indicated that Employee 3 had showered the resident on the evening of September 21, 2019 (no time indicated). Employee 3 stated that she brought the resident back to her room, got her dressed in the bathroom and placed the resident's wheelchair next to her bed. Employee 3 stated that the resident was talking about laundry. Employee 3 stated "she (Resident 267) just started to stand up. Before I could finish, she started to transfer herself to the bed. I stepped close to her and held on to her so she would not fall. After she scooted herself over to the bed, she stated the resident stated, she heard a pop, 'but I pop all over.' She stated she was having some discomfort in her left leg. After she was comfortable in the bed I went and told the nurse about her saying she heard a pop."

Multiple attempts were made to interview Employee 3 at the time of the survey ending September 25, 2019. The employee was not working at the time of this survey and the employee did not return telephone calls placed to her in attempt to interview the employee by phone.

The resident was seen by the orthopedic surgeon on September 23, 2019, and returned to the facility with a long leg cast in place and orders for no weight bearing on the left leg.

An interview with the resident on September 25, 2019, at 10:05 a.m. verified that Employee 3 gave her a shower on the evening of September 21, 2019. When she (the resident) returned to her room via wheelchair, she wanted to be placed in bed on the right side of her bed. However, Employee took her to the left side of the resident's bed. The resident stated that she "had to hang on to the bedside table." Resident 267 stated that Employee 3 "swung her into bed." The resident stated at the she heard a very loud "pop." During this interview the resident stated that she did not write a statement for the facility as part of the facility's incident review nor did any facility staff member question her about what happened on that evening when her leg was fractured. The resident stated that the nurse aide (Employee 3) "was supposed to tell the nurse what happened that she heard a "pop."

The facility provided a type written statement dated September 23, 2019, no time identified, which reportedly had been signed by Resident 267 when the resident was interviewed regarding her injury. This typed statement, allegedly signed by the resident noted "I didn't have any accident or fall. No one hit me or did anything to hurt me. I have had many problems with my left leg. Ever since I had a hysterectomy, I have had bone trouble, I know I have osteoporosis. I have felt for a long time I am going to have a broken bone sooner or later. I am not in a lot of pain, I can lift my leg and it doesn't hurt. I slept good last night".

This typed written statement varied from the account the resident reported to the surveyor on September 25, 2019. The written statement was reviewed with this resident along with her signature during the survey on September 25, 2019, at 11 AM. The resident stated that she did not provide that statement and it "was not her signature." The resident proceeded to demonstrate her signature to the survey and signed her signature underneath the signature on the typed statement. The resident's signature was not similar to the signature signed on the statement. A review of the resident's clinical record also revealed notations of the resident's signature on admission paperwork, which were consistent with the signature written in the surveyor's presence and inconsistent with the signature noted on the facility's typed written statement.

The resident's account of the incident and her injury also differed from Employee 3's account of the incident according to the Employee 3's typed written statement.

At 1:00 p.m. on September 25, 2019, the NHA and director of nursing (DON) accompanied by the surveyor, with the resident's permission, interviewed the resident regarding her account of the injury she sustained and incident of September 21, 2019. During this interview Resident 267 repeated the account she had provided to the surveyor earlier that morning. The resident stated that after her shower that evening, Employee 3, the nurse aide, "put me in bed on the left side of my bed, I usually go into bed on the right side since it is easier" for her. The resident further stated that she had to stand up and hold on to the furniture (bedside table) and Employee 3 "swung her around" and sat her on the bed. The resident stated, "I wanted to tell her it did not move (left leg), but she twirled me around and I sat on the bed and I heard a loud, loud pop." The resident confirmed that it was only Employee 3 assisting her with the transfer. The resident stated that she does require two persons for transfers because she has difficultly moving her left leg. The resident was shown her statement (typed written statement) and her signature during this inteviews. The resident confirmed that this was not her statement nor her signature. She then signed below the signature on the statement and it differed from the signature on the paper, in the presence of the NHA, DON and surveyor. The signature she signed in front of the surveyor, DON and NHA was comparable to documentation in her clinical record.

After the interview with the resident on September 25, 2019. the NHA stated "ooh, that sounded like a different story."

During interview with the DON on September 25, 2019, at 1:20 PM he stated that he had spoke to resident, but she did not tell him what happened. The DON stated that he typed out the statement and sent it back to the nursing unit. The DON did not address the resident's signature on the statement during this interview.

During a follow-up interview with the resident after the DON and NHA left the room on September 25, 2019 at 1:30 p.m. the resident verified that the DON did come to her room after the fracture was confirmed. The resident stated that "he (DON) just stood in front of me for a few minutes and asked me if I had pain, he did not ask me any of those other questions."

There was no evidence that Employee 3 had attempted to summon the assistance of another staff member, as planned and necessary for the resident's transfer after the resident's shower on the evening of September 21, 2019.

Employee 3 provided care to Resident 267 without the assistance of another staff member as the resident required and the resident sustained a fractured leg.

The facility failed to ensure that the resident was consistently provided the assessed level of staff assistance necessary to safely perform transfers. The facility further failed to thoroughly and accurately investigate the resident's injury to identify potential causative factors to plan the resident's care and prevent similar incidents and injury to the resident.

28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing Services.
Continuing deficiency of 9/4/19
Previously cited 4/18/19, 6/13/19, 2/21/19, 10/26/18

 Plan of Correction - To be completed: 10/10/2019

1. Resident 267 will be provided the necessary level of assistance, as care planned, for transfers at all times. Resident 267 will have any injury thoroughly investigated to identify causative factors and to prevent further injury. Employee 3 has been counseled related to providing assistance as care planned.

2. An audit will be completed for residents who require the assistance of two staff members for transfers to ensure that the plan of care is being consistently implemented. An audit will be completed to ensure that resident injuries are thoroughly investigated to identify causative factors and to prevent further injury.

3. Nursing staff will be educated to follow the plan of care for any residents who require the assistance of two staff members for transfers. Professional nursing staff will be in-serviced on the facility policy Incident Report & Investigation.

4. Audits will be completed daily by the DON, or designee, on sampled residents, to ensure that the care plan for residents who require the assistance of two staff members for transfers is being consistently implemented. Audits will be completed five days a week by the DON, or designee, to ensure that resident injuries are thoroughly investigated to identify causative factors and to prevent further injury. These audits will be completed for two weeks and then will be reevaluated by the Quality Assurance Committee.

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