Pennsylvania Department of Health
CARING PLACE, THE
Patient Care Inspection Results

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CARING PLACE, THE
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 Complaint Survey completed on 2/8/2024, 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:


483.12(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 facility policy and clinical records, and staff interviews, it was determined that the facility failed to fully investigate an injury of unknown origin in a timely manner for one of one residents reviewed (Resident R1).

Findings include:

Review of facility policy entitled "Incidents and Accident Reports, Resident" dated 9/2023, revealed "An incident report is completed whenever there is an occurrence ...," "The following is a list of the types of occurrences for which an incident report is prepared ... Injury of unknown origin" and "Those incidents requiring investigation ... will be reported to the Administrator and Director of Nursing ..."

Review of Resident R1's clinical record revealed an admission date of 11/16/23, with diagnoses that included hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), hypertension (high blood pressure), and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone).

Review of Resident R1's nursing documentation revealed a progress note dated 12/12/23, that identified he/she was seen by his/her physician and a new order was given from his/her physician for x-rays of left shoulder, left humerus, and left foot and deformity.

Further review of Resident R1's nursing documentation revealed a progress note dated 12/13/23, that indicated x-ray results were received by the facility. Physician was updated on Resident R1's acute fracture of the fifth metatarsal (foot bone between the ankle and toe) and gave an order to have Resident R1 seen by an orthopedic physician (a physician that specializes in bone care).

Review of Resident R1's care plan revealed a care plan dated 12/14/23, for left foot fracture related to previous fall.

Review of a Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 12/15/23, section J 1800 indicated Resident R1 had not had any falls since admission/reentry.

Review of facility incident report for December 2023, revealed no evidence that Resident R1 had any type of incident.

Review of Resident R1's clinical record lacked evidence that an investigation was started or completed, regarding the identified of the fracture of the fifth metatarsal. Further review of clinical record lacked evidence of interviews from staff present at the time of the incident or handwritten statements from staff.

During an interview on 2/8/2024, at 11:46 a.m. the Nursing Home Administrator (NHA) confirmed that there was no investigation started or completed on Resident R1's injury of unknown origin. NHA also confirmed that the injury of unknown origin should have been investigated.

28 Pa. Code 201.14(a) Responsibility of licensee

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




 Plan of Correction - To be completed: 03/05/2024

Resident R1 identified to have injury of unknown origin that was not investigated in a timely manner. Resident R 1 was discharged home from facility on 1-30-2024. The Caring Place cannot retroactively correct this finding.
Whole house audit was completed on 2-12-2024 on residents who resided in the home from 11-16-2023 to present to insure that the policy for incident and accident reporting is being followed. All clinical progress notes were reviewed by the NHA and DON to ensure policies and procedures are being followed. Ongoing audits of progress notes, incident reports and 24-hour report will be reviewed by NHA, DON, and IDT to ensure that Incident and Accident policy is being followed 5 times a week for 2 weeks, then weekly for 2 weeks. Audits initiated on 2-12-2024. NHA and DON will review the investigation on all incidents and accidents to ensure that a good faith investigation has been completed to rule out or substantiate abuse or neglect. This is an ongoing audit indefinitely conducted at morning clinical meeting.
Staff in all departments completed in-service education on 2-9-2024 on the policy and procedure for reporting incidents and accidents and injuries of unknown origin. Nursing staff was educated on 2-9-2024 regarding the process of completing an incident report and investigation. Additionally, all department managers were trained in how to conduct a thorough investigation on 2-12-2024.
Quality Assurance/Performance Improvement Committee meetings for any further recommendations to achieve and maintain compliance. Any identified areas of concern will result in further quality process review as applicable. Feedback and follow up will be provided to staff at the time of discovery for any variances found.

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