Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT BLUE RIDGE, THE
Patient Care Inspection Results

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GARDENS AT BLUE RIDGE, THE
Inspection Results For:

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GARDENS AT BLUE RIDGE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Revisit Survey completed on February 12, 2020, it was determined that The Gardens at Blue Ridge did not correct all the federal deficiencies cited during the abbreviated complaint survey ending January 3, 2020, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities.




 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.
Observations:


Based on review of clinical records, incident reports, observations and interviews with residents and staff , it was determined that the facility failed to implement appropriate interventions based on individual resident needs to promote resident safety and prevent falls for three of eight sampled residents with falls (Resident 3, 6 and 8).

Findings include:

Review of the facility's plan of correction stated that staff will be in-serviced on ensuring that residents that sustain falls have care plan interventions implemented post fall. All nursing staff will be educated on F689. The facility will conduct random observations of residents that have sustained a fall weekly x 4 then monthly x 2 to ensure that interventions have been implemented post fall.

Review of Resident 3's clinical record revealed diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).

Further review of Resident 3's clinical record revealed that he had a fall on February 2, 2020. Review of Resident 3's fall report revealed that he was calling for help from his room and was observed lying on the floor beside his bed. The immediate action taken was to add side mattress wedges to bed. Review of Resident 3's current care plan revealed an intervention, dated February 2, 2020, for side mattress wedges to bed while in bed.

Observation on February 12, 2020, at 1:40 PM revealed Resident 3 in bed but no side mattress wedges were in place.

On February 12, 2020, at 2:12 PM the Director of Nursing (DON) was made aware that Resident 3 did not have side mattress wedges in place while he was in bed, per his care plan. During an interview with the DON at 2:44 PM he stated that the wedges were now in place.

Review of the clinical record for Resident 6 revealed diagnoses including hemiparesis (weakness on one side of the body) and cerebral infarction (also known as a stroke) (refers to damage to tissues in the brain).
Review of a fall report dated February 8, 2020 at 5:00 PM, revealed that Resident 6 was found on the floor next to his bed. Further review of the fall report it was noted by staff that Resident 6's bed does not lock.
During an interview with the Nursing Home Administrator on February 12, 2020 at 2:44 PM he stated that maintenance adjusted the brake on the bed. The facility was unable to provide a specific work order to indicate that the brake on the bed was fixed.
On February 11, 2020 at 7:25 PM, Resident 6 had another fall. Review of the fall report revealed that he was found on the floor beside his bed. The resident said at the time of the fall that he was trying to transfer from the wheelchair to the bed when the bed slid away from him prompting the fall. A nursing note dated February 11, 2020 at 7:25 PM stated that the nurse was called to resident's room. The resident was seen lying on the floor beside the bed. The nurse noted that the bed was in the locked position but was able to move/slide. The resident was encouraged to use the call light when he needed help. The note stated "bed needs to be changed d/t [due to] not locking when in lowest potion; DON [Director of Nursing] made aware". The new intervention put into place to prevent future falls was a neurological consult.
During an interview with the Director of Nursing on February 12, 2020 at 12:20 PM he denied knowing that there was anything wrong with Resident 6's bed.
On February 12, 2020 at 1:49 PM, the surveyor was able to easily move/slide the bed when it was in the locked position. The resident was interviewed and confirmed that the bed doesn't lock and he had falls trying to get into bed because the bed slides.
Additional assessment of Resident 6's bed on February 12, 2020 at 2:00 PM with the Nursing Home Administrator (NHA) he confirmed that the bed did not lock properly and that he ordered new beds.
On February 12, 2020 at 2:44 PM, the NHA stated that the housekeeping supervisor replaced two pieces on Resident 6's bed and the bed now locks and does not move.

Review of the clinical record for Resident 8 revealed diagnoses that included dementia (memory loss and difficulty with thinking, problem-solving or language) and lung cancer.
Review of a fall report for Resident 8 revealed that she had a fall on February 5, 2020 at 10:45 PM. Resident 8's roommate called for help when the resident fell out of bed. Resident 8 stated that she was rolling in bed and rolled out.

The intervention initiated after the fall was to consult PT/OT (physical therapy/ occupational therapy). The resident was already on PT/OT caseload from February 1, 2020 through March 1, 2020.

During an interview with the Director of Nursing on February 12, 2020 at 3:05 PM he acknowledged that the resident was already receiving PT/OT at the time of the fall.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.











 Plan of Correction - To be completed: 02/20/2020

- Resident #3 has had their mattress replaced.
- Resident #6 has had their bed replaced.
- Resident 8 had a new mattress added as the care plan intervention.
- Residents with falls are at risk for this alleged deficient practice. These residents will have appropriate care plan interventions implemented based on their specific needs. A house-wide audit of residents sustaining a fall has been completed to ensure that care plan interventions have been implemented post fall.
- Licensed staff will be in-serviced on ensuring that residents that sustain falls have appropriate care plan interventions implemented based on their specific needs.
- The DNS/designee will conduct 5 random observations of residents that have sustained a fall, weekly x 4 and then monthly x2 or until substantial compliance has been achieved to ensure that that appropriate interventions have been implemented post fall. Results of audits will be submitted to the Quality Assurance Committee monthly for further recommendations.



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