Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT EAST MOUNTAIN, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GARDENS AT EAST MOUNTAIN, THE
Inspection Results For:
There are 78 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.


GARDENS AT EAST MOUNTAIN, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated complaint survey completed on January 22, 2020, it was determined that The Gardens at East Mountain, 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.

Observations:

Based on a review of clinical records and select facility incident investigations and resident and staff interviews, it was determined that the facility failed to provide sufficient staff assistance and utilize safe technique and/or necessary assistance devices during transfers to prevent a fall with serious injury, a fractured femur, for one resident out of five sampled (Resident CR4).

Findings include:

A review of Resident CR4's clinical record revealed he had diagnoses, which included cerebral infarct (is an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) with hemiplegia and hemiparesis of the left side (hemiplegia means paralysis of one side of the body - hemiparesis means a slight paralysis or weakness on one side of the body) muscle weakness and Parkinson's Disease (disorder of the central nervous system that affects movement, often including tremors).

The resident's quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 24, 2019, indicated that the resident's cognition was intact with a score of 15/15 of BIMS assessment (Brief interview for mental status - a tool to assess cognitive function). The resident's weight was documented as 255 pounds.

A review of the resident's MDS Assessments of transfer status dated March 14, 2019, (quarterly); June 6, 2019, (quarterly); September 24, 2019 (quarterly); November 24, 2019, (annual); and December 24, 2019, (quarterly) revealed that each indicated that the resident required extensive assistance of two person physical assistance for transfers.

A review of the resident's clinical record revealed that upon admission to the facility on November 16, 2018, the resident was assessed for the use of a mechanical lift for safe transfers.

A review of this assessment dated November 16, 2018, revealed that the resident required the use of a "bariatric lift" (Heavy-duty patient lifts are especially designed to accommodate users who are of greater than average weight and require assistance in transferring from their beds to their wheelchairs or from wheelchairs to the toilet, bath or back into bed for transfers).

There were no further assessments regarding the resident's need for a mechanical lift for transfers upon review of the resident's clinical record conducted at the time of the survey ending January 22, 2020.

Interview with the occupational therapist on January 22, 2020, at 2:05 p.m., revealed that lift assessments are conducted upon a resident's admission and if a resident's transfer status changes.

Further review of the resident's clinical record revealed that the resident was referred to occupational therapy services on December 11, 2019, related to pain in his left shoulder.
The occupational therapy evaluation dated December 11, 2019, revealed that the goal was to have the resident display a decrease in pain with movement to allow for activities of daily living participation and to increase right upper extremity strength to assist with "stand up lift transfers." During this evaluation, the resident's past history was obtained and it was determined that prior to his admission to the facility, he had resided in another skilled nursing facility, and required moderate transfer assistance of two persons for transfers and ambulation.

Review of the OT assessment summary revealed that the therapist's clinical impression was that the resident required the stand-up lift for bed to wheelchair transfers. The resident additionally had informed the therapist that he utilized the stand-up lift for transfers to the commode.

The occupational therapy discharge summary dated January 6, 2019, noted that resident's use and assistance with stand-up lift transfers.

An occupational therapy discharge summary dated June 28, 2019, revealed that the resident received occupational therapy services from June 1, 2019, to June 30, 2019, to assist the resident with repositioning himself in the wheelchair without assistance.

A review of the OT assessment and summary of skilled services section, revealed that the equipment that was utilized prior to the onset of the current problem requiring therapy, included the use of the stand-up lift.

A review of the occupational therapy evaluation and plan of treatment revealed that the functional skills assessment-activities of daily living section, revealed that the resident required "assistance in the areas of bathing/transfers." It was further determined that these areas would not be addressed during treatment, as the resident was presenting with no change in function in that area.

According to review of a nursing progress note, dated as a late entry by Employee 1, RN, on January 7, 2020, at 15:35 [3:35 PMfor January 6, 2020, at 13:15 [1:15 PM], revealed that she was called to the resident's room to assess the resident due to a resident fall. Employee 1 documented that Employee 2, nurse aide, stated that he was transferring the resident from the bed to the chair, when the (wheel) chair moved, and he had to "lower the resident to the floor."

A review of the incident report dated January 6, 2020, revealed that "approx 1 hr later resident reported to charge nurse he was experiencing pain in left hip/leg area. Call placed to PA (physician assistant); orders received to obtain x-ray of the left leg and hip."

The X-ray was completed and the results received at 8:45 PM on January 6, 2020, revealing a suspected undisplaced fracture of the left femur (thigh bone). The resident was admitted to the hospital on Janaury 7, 2020, with a minimal non-displaced (the bone cracks either part or all of the way through, but does move and maintains its proper alignment) fracture base of left femoral neck (femoral neck fracture is one type of hip fracture. This injury occurs just below the ball of the ball-and-socket hip joint, the region of the thigh bone called the femoral neck. A femoral neck fracture disconnects the ball from the rest of the thigh bone (femur)).

A review of the statement completed by Employee 2 regarding the incident dated January 7, 2020, revealed that he stated that he proceeded to get the resident ready for the "morning shift" and "the resident was then washed up and dressed for the morning." Employee 2 stated "I placed the resident's sneakers on his feet as part of the procedure. I then proceeded to get the resident ready for transfer. I pulled the wheelchair next to the bed. The brakes were locked on the chair." I proceeded to transfer. The chair kicked back from the resident. I proceeded to place the resident on the floor. I was in front of the resident and lowered him to the floor."

Employee 3, LPN (Licensed Practical Nurse), was called to the resident's room after the incident. He stated that the nurse aide, Employee 2, providing the resident's morning care stated that he was transferring the resident and the wheelchair shifted and the resident was placed on the floor.

There was no documented evidence that the facility had interviewed Resident CR4, who was assessed as cognitively intact, to obtain the resident's account of the incident. The Director of Nursing confirmed during interview at 2 PM on Janaury 22, 2020, that the resident had not been interviewed regarding his fall during transfer.

A review of the resident's care plan and Kardex (working tool used by direct care staff identifying each resident's specific needs for daily care and assistance level) conducted during the survey ending January 22, 2020, revealed that Employee 1, RN, had revised the resident's comprehensive care plan on January 7, 2020, and Kardex to indicate that the resident was a transfer assist of one person. Prior to that date (January 7, 2020), there was no transfer status identified on the resident's care plan or Kardex.

When interviewed on January 22, 2020, at 2:20 p.m., the Director of Nursing Services confirmed that the resident's transfer status was not part of the resident's plan of care or identified on the Kardex prior to the incident on January 7, 2020. The DON stated that transfer status was "left up to the resident" since he was cognitively intact and it was based on his perception of his strength that day. The DON stated that the nursing staff relied on communicating this information to each other by "word of mouth."

The facility was unable to provide an assessment of the resident's transfer status at the time of, or prior to the incident of January 6, 2020. The facility was unable to provide documented evidence of what information had been used to update his comprehensive plan of care and Kardex on January 7, 2020, to a transfer assist of one. The resident had consistently triggered during MDS assessments process, as an assist of two. It was documented in therapy notes that the resident consistenly said that he utilized the sit to stand lift and therapy had been working to strengthen his ability to continue to do so. The only lift assessment completed by the facility determined the resident required the use of a bariatric lift.

An interview was conducted with Resident CR4 on January 28, 2020, at 3:18 PM following his admission to another skilled nursing facility after his hospital stay for treatment of the fracture. A review of the resident's admission MDS Assessment dated January 20, 2020, revealed that the resident was cognitively intact with a BIMS score of 13.

When interviewed at 3:18 PM on Janaury 28 2020, the resident confirmed that he had fallen on January 6, 2020, during morning care. The resident estimated the fall to have occurred at approximately 7:30 a.m. that morning and was able to identify the caregiver (Employee 2) involved. The resident stated that Employee 2 had been assigned to him in the past, and had always used another caregiver for transfers, but on that date had transferred him by himself. The resident wasn't aware of the reason Employee 2 transferred without the assistance of another person on that morning. The resident stated that "the only thing I can think of is he was trying to be a hero." He stated that the facility staff consistently used the sit to stand lift or a transfer assistance of two during his stay at the facility. The resident stated that he had been transferred in this manner since admission to the facility and prior to his admission in November 2018. The resident stated it was necessary to use two persons to transfer, due to his left sided weakness, size and lack of strength in his arms and legs. The resident stated that he was recently having pain in his left shoulder, for which he was receiving therapy and which was causing an additional issue with his activities of daily living status at the time of his fall with fracture. The resident confirmed that the use of the sit to stand lift or transfer status of two was not a new intervention. The resident stated that he would never ask staff to transfer him without the assistance of a second person.

The resident explained to the surveyor how Employee 2, put his one arm around his right side(the resident demonstrated his chest area) and they walked towards the wheelchair. The resident added that the locks on the wheelchair were not activated. He stated that he was not sure if he or Employee 2, bumped the chair or lost their footing, but they "both," went down on the floor. The resident stated that he played many sports in his lifetime, some of them contact sports, but never did he "take a fall or a hit that caused so much pain upon impact." The resident stated that he is now in constant pain and has not been able to tolerate getting out of bed. His goal now he stated, is to control his pain to participate in therapy. The resident confirmed that no one at the facility had interviewed him regarding the incident despite the extended time period from the time of incident (approximated 7:20 a.m) up to his transfer to the hospital, which he recalled was about 8:30 p.m. on January 6, 2020.

The facility failed to assure that staff used sufficient staff assistance and/or necessary assistance device and safe technique to prevent this fall with serious injury and pain to Resident CR4.

483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
Previously cited: 6/21/19.

28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services.
Previously cited: 6/21/19, 2/16/19

28 Pa. Code 211.11(d)(e) Resident care plan

Plan of Correction - To be completed: 02/26/2020

Unable to correct for resident CR4 has been discharged.

Current residents will be reviewed to ensure that the appropriate transfer status is documented in the residents' care plan and Care Kardex.

Residents transfer status will be assessed on admission, and with significant changes. Transfer status or changes will be communicated to nursing to ensure orders for status and assistive devices are obtained and documented in the clinical record. Nursing and Therapy staff will receive education on importance of communication for changes in residents' transfer status or equipment. Direct care staff will be educated on the importance of following ordered transfer status and equipment to prevent injury or accidents with resident.

Random audits will be performed at the morning clinical meeting with IDT members to monitor orders are current, documented in clinical record and communicated to staff. The results of the audits will be reviewed by the QAPI committee to determine the need for further audits, education and/or recommendations.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:

Based on review of clinical records and select incident reports and resident and family interviews, it was determined that the facility failed to timely notify the resident's identified primary family contact of the resident's fall at the facility with subsequent serious injury for one (Resident CR4) out of five residents reviewed.

Findings include:

A review of the clinical record and incident report Resident CR4 had a fall at the facility on January 6, 2020, which according to statements completed by Employees 2 and 3 occurred during provision of morning care on that date. Employee 2 and 3 failed to provide an actual or approximated time of the incident and the specific time of the of fall was not noted in resident's clinical record documentation or on the facility investigation into the incident. According to the incident report the resident's daughter was notified of the resident's fall at 12:52 PM on January 6, 2020.

An interview was conducted with Resident CR4 on January 28, 2020, at 3:18 PM following his admission to another skilled nursing facility, after his hospital stay, for treatment of the fracture. A review of the resident's admission MDS Assessment dated January 20, 2020, revealed that the resident was cognitively intact with a BIMS score of 13.

When interviewed at 3:18 PM on Janaury 28 2020, the resident confirmed that he had fallen on January 6, 2020, during morning care. The resident estimated the fall to have occurred at approximately 7:30 a.m. that morning, and was able to detail the circumstances and identify the caregiver involved(Employee 2) by name. The resident stated that he began to have severe pain around lunch time and told the nurse. The resident confirmed that he had an XRAY and was transferred to the hospital once the results were received, which he recalled was about 8:30 p.m. on January 6, 2020.

The resident acknowledged that he was responsible for himself and able to exercise his rights, but always had expressed to the facility that he wanted his primary contact, his daughter, notified of anything regarding his care. The resident stated,"even if I did something so small as to bump my elbow on the door, I would want her to be made aware." The resident stated as far as he knew, the facility had notified his daughter of changes in his condition in the past.

The resident's daughter (primary contact) was interviewed by phone on January 27, 2020, at 4:50 p.m. She confirmed that the facility had contacted her in the past about changes in her father's condition and were aware these were his wishes. She stated that she was notified by the facility at approximately 1:30 p.m., on January 6, 2020, that her father had been lowered to the floor, was complaining of pain and was having an XRAY. She stated that she then spoke with her father who told her he had fallen at approximately 7:00 a.m. that morning. The resident's daughter stated that he had not been notified of the resident's fall prior to 1:30 PM of the resident's fall. She stated that she never heard from the facility again and called the facility and was told her father had a fracture and had an order to be sent out to the hospital for treatment.

A review of documentation in the resident's clinical record and the facility investigation into the incident, revealed there was no documented evidence that the facility had promptly notified the resident's daughter, as the resident desired, of the resident's fall, serious injury and transfer to the hospital.

28 Pa. Code: 211.12 (a)(c)(d)(1)(3)(5)Nursing Services.
Previously cited 6/21/19, 2/16/19.

.

Plan of Correction - To be completed: 02/26/2020

Corrections does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

Unable to correct for resident CR4 has been discharged.

Residents who have been identified with an Incident/Accident in last 14 days will be reviewed for timely notification of primary family contact/RP with the actual or approximated time of the incident is recorded in the medical record or the facility investigation.

Licensed nursing staff will be educated on the importance of timely notification of RP/family members with their responsibility for documenting the actual or approximated time of the incident in resident's clinical record or facility investigation reports.

Random audits will be performed of Incidents of facility investigation at the morning clinical meeting with IDT members to ensure timely documentation of RP notification is present with the actual or approximated time of the incident in resident's clinical record or facility investigation reports. The results of the audits will be reviewed by the QAPI committee to determine the need for further audits, education and/or recommendations.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:
Based on review of clinical records and resident interview, it was determined the facility failed to maintain accurate clinical records, consistent with professional standards and practices, for one of five sampled residents (Resident CR4).

Findings include:

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties.

According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

A review of the clinical record Resident CR4 revealed admission to the facility on November 16, 2018, with diagnosis which, cerebral infarct (is an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) with hemiplegia and hemiparesis of the left side (hemiplegia means paralysis of one side of the body - hemiparesis means a slight paralysis or weakness on one side of the body) muscle weakness and Parkinson's Disease (disorder of the central nervous system that affects movement, often including tremors).

Nursing documentation dated January 7, 2020, at 15:35 (3:35 PM) entered as a late entry for January 6, 2020, at 13:15 (1:15 PM) by Employee 1, RN (registered nurse), indicated that she was called to Resident CR4's room by Employee 3 (a Licensed Practical Nurse) after the resident was "lowered to the floor," by Employee 2, a nurse aide, after a transfer attempt.

Employee 1 documented that the resident denied any injuries at the time, his legs were equal in length with no external rotation. The resident was assisted back to bed with the hoyer lift and denied pain. Neuro checks were within normal limits for the resident.

A review of the statement completed by Employee 2 regarding the incident dated January 7, 2020, revealed that he stated that he proceeded to get the resident ready for the "morning shift" and "the resident was then washed up and dressed for the morning." Employee 2 stated "I placed the resident's sneakers on his feet as part of the procedure. I then proceeded to get the resident ready for transfer. I pulled the wheelchair next to the bed. The brakes were locked on the chair." I proceeded to transfer. The chair kicked back from the resident. I proceeded to place the resident on the floor. I was in front of the resident and lowered him to the floor."

According to review of Employee 3's statement, he was called to the resident's room after the incident. He stated that the nurse aide, Employee 2, who was providing the resident's morning care, stated that he was transferring the resident and the wheelchair shifted, and the resident was placed on the floor. He stated an assessment was completed by the Registered Nurse supervisor on the shift (identified as Employee 1) and the resident offered no complaints of pain or discomfort. The resident was lifted back to bed with the hoyer lift. He stated that "later on, around lunch time" the resident complained of leg and hip pain.

Review of the resident's clinical record revealed that Employee 3 documented on January 6, 2020, at 15:16 (3:16 PM) that he was called to the resident's room by an aide who alleged that the resident had to be lowered to the floor after the resident's wheelchair "rolled back." The resident then offered complaints of left hip and leg pain.

A review of the facility investigation into the incident revealed Employee 3 documented that the incident occurred on January 6, 2020, at 12:52 PM.

The investigative report revealed no reference to an amended time, which would reflect that the incident had occurred much earlier based on the statements from Employee 2 and Employee 3.

Employee 4, RN, documented on January 6, 2020 at 15:19 (3:19 PM), that she was assessing the resident post fall. The nurse documented that the resident had complaints of pain to the left back and hip area with guarding to the left side. A review of Employee 4's statement, conducted on January 30, 2020, revealed that she assessed the resident after Employee 3 told her the resident was complaining of pain.

The x-ray was completed and the results received at 8:45 PM on January 6, 2020, revealing that a suspected undisplaced fracture of the left femur (thigh bone). The resident was admitted to the hospital on Janaury 7, 2020, with a minimal non-displaced (the bone cracks either part or all of the way through, but does move and maintains its proper alignment) fracture base of left femoral neck (femoral neck fracture is one type of hip fracture. This injury occurs just below the ball of the ball-and-socket hip joint, the region of the thigh bone called the femoral neck. A femoral neck fracture disconnects the ball from the rest of the thigh bone (femur).

On January 7, 2020, the Director of Nursing Services electronically reported to the State Survey Agency, that on January 6, 2020, at approximately 1:00 p.m. the resident was involved in this transfer incident and was transferred to the hospital.

An interview was conducted with Resident CR4 on January 28, 2020, at 3:18 PM following his admission to another skilled nursing facility, after his hospital stay, for treatment of the fracture. A review of the resident's admission MDS Assessment dated January 20, 2020, revealed that the resident was cognitively intact with a BIMS score of 13.

When interviewed at 3:18 PM on Janaury 28 2020, the resident confirmed that he had fallen on January 6, 2020, during morning care. The resident estimated the fall to have occurred at approximately 7:30 a.m. that morning, and was able to detail the circumstances and identify the caregiver involved(Employee 2) by name. The resident stated that he began to have severe pain around lunch time and told the nurse. The resident confirmed that he had an XRAY and was transferred to the hospital once the results were received, which he recalled was about 8:30 p.m. on January 6, 2020.

The facility failed to ensure that the resident's clinical record accurately reflected the care and services provided to the resident. The licensed nurses failed to document the accurate time of the incident in both the clinical record and facility investigation into the incident to provide an accurate time line of the occurrence and the timeliness of the care and services provided to the resident after the fall with serious injury.

28 Pa. Code 211.5 (f)(g)(h) Clinical records.
Previously cited: 6/21/19, 2/16/19.

28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services.
Previously cited:6/21/19,2/16/19.

Plan of Correction - To be completed: 02/26/2020

Unable to correct for resident CR4 has been discharged. Unable to retroactively document.

Residents' clinical records will be reviewed to ensure the clinical record accurately reflects the care provided to the resident involving Incidents and Accidents with the actual or approximated time of the incident recorded in the medical record or the facility investigation.

Residents' clinical records will be reviewed at the morning clinical meeting to ensure the clinical record accurately reflects the care provided to the resident involving Incidents and Accidents with the actual or approximated time of the incident recorded in the medical record or the facility investigation. Licensed nursing staff will receive education on their responsibility for accurate and timely documentation as directed per PA code Professional/Vocational standards and principles of documentation.

Random audits will be conducted in the morning clinical meeting with IDT members on nursing documentation to ensure residents clinical record accurately reflects care and services provided in a timely manner with the actual or approximated time of the incident. The results of the audits will be reviewed by the QAPI committee to determine the need for further audits, education and/or recommendations.

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