Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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CARING PLACE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey in response to a complaint completed on November 15, 2019, it was determined that The Caring Place 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.

 Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and 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.
483.25(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 observations, review of clinical records and staff interviews, it was determined that the facility failed to follow physician orders to ensure fall precautions were in place for two of six residents reviewed (Residents R1 and R2).

Findings include:

Resident R1's clinical record revealed an admission date of 7/11/17, with diagnoses that included broken left leg, Alzheimer's disease, history of falling, high blood pressure, and anxiety.

Observation on 11/14/19, at 10:58 a.m. revealed Resident R1 sitting in a wheelchair with an extended back, with a chair alarm in place.

Observation on 11/15/19, from 9:30 a.m. to 11:30 a.m. revealed Resident R1 sitting in wheelchair with an extended back, with a chair alarm in place.

Resident R1's clinical record revealed a physician's order dated 11/07/19, for bed and chair alarms. A care plan entitled "risk for falls related to confusion" indicated that staff are to utilize an alarm on Resident R1's wheelchair when he/she is out of bed.

A facility investigation dated 11/12/19, relating to Resident R1 falling out of his/her wheelchair revealed that when Resident R1 was discovered kneeling on the floor, his/her chair alarm was not in place on the chair he/she had been seated in. A progress note dated 11/12/19, also indicated that staff did not ensure the physician ordered chair alarm was in place on the wheelchair that Resident R1 was sitting in.

During an interview on 11/14/19, at 2:35 p.m. Nurse Aide Employee E1 stated that he/she had not placed the chair alarm on the wheelchair prior to assisting Resident R1 with seating.

Resident R2's clinical record revealed an admission date of 1/07/19, with diagnoses that included repeated falls, dementia, muscle weakness, diabetes, and high blood pressure.

Observation on 11/15/19, at 9:55 a.m. revealed Resident R2 laying in bed with an alarming device in place and plugged in while in bed, fall mats in place, and the bed in low position.

Resident R2's clinical record revealed a physician's order dated 2/09/19, for a pad alarm to bed for resident safety. A care plan entitled "risk for falls related to recurrent falls and multiple attempts for self-transfer" indicated that staff are to apply a bed alarm to alert staff to attempts of the resident rising. A facility investigation dated 9/14/19, relating to Resident R2 being discovered sitting on the floor in the doorway of his/her bathroom, and bed alarm not sounding discovered that the bed alarm was not plugged in.

During an interview on 11/15/19, at approximately 12:30 p.m. the Nursing Home Administrator confirmed that physician ordered alarms are to be in place to help with resident safety.

28 Pa. Code 211.12(d)(1)(5) Nursing services

 Plan of Correction - To be completed: 01/02/2020

This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and The Caring Place reserves all rights to raise all possible contestations and defenses in any civil or criminal claim, action, or proceeding.
1.Resident R1 and R2 did not suffer an adverse affect from this process failure. Resident R1 and Resident R2's Medical Record was reviewed by the Interdisciplinary Team focusing on fall prevention and Chair/Bed Alarms. The Interdisciplinary team discussed the Root Cause Analysis and reviewed Resident R1, R2's interventions to prevent future process failures (chair/bed alarms) and falls. Resident R1 and R2's Physician and Responsible Party was contacted.
2. The Interdisciplinary Team (Assistant Director of Nursing and Director of Therapy) completed a house wide audit of all residents that have an order for bed/chair alarms for functionality. All alarms were found to be in good working order and in place per order.
3. The Interdisciplinary Team (Registered Nurse Supervisors or designee) will audit all residents that have bed/chair alarms for functionality daily times 3 weeks, weekly times 4 and monthly times 2. All data will be discussed at the monthly Quality Assurance Performance Improvement meeting. The Staff Development Coordinator will provide education to the nursing department related to F Tag 689 Free of Accident Hazards/Supervision/Devices Accidents.
4.The Interdisciplinary Team (Nursing Administration or Designee) will audit all residents that have orders for bed/chair alarms in our morning clinical meeting and will be evaluated ongoing per new orders. Residents with current orders for alarms will be reviewed monthly for 2 months. Any changes will be communicated with the residents physician, and responsible party. All data will be relayed to the Quality Assurance Performance Improvement monthly committee.
5.Plan of Correction will be completed by 1/2/2020

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