Nursing Investigation Results -

Pennsylvania Department of Health
WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER
Patient Care Inspection Results

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WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER
Inspection Results For:

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WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint and incident survey completed on February 20, 2020, it was determined that Windber Woods Senior Living and Rehabilitation Center 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:


483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.10(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:


Based on clinical record reviews, and resident and staff interviews, it was determined that the facility failed to honor a resident's right to make decisions regarding aspects of the their lives that were important to them for one of three residents reviewed (Resident 3).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 9, 2020, revealed that the resident was cognitively intact, could understand and be understood, received nutrition via a gastrostomy tube (tube surgically inserted through the abdomen into the stomach), and had diagnoses that included tongue, mouth and throat cancer with severe protein-calorie malnutrition. The resident's care plan, dated January 6, 2020, indicated that he was at risk for aspiration (inhaling food or foreign matter into the lungs) due to throat cancer, and that his nutritional needs would be met via the gastrostomy tube. Physician's orders for Resident 3, dated January 3, 2020, indicated that he was to have nothing by mouth (NPO). The resident's weight record revealed that he weighed 87.8 pounds on admission.

A nursing note for Resident 3, dated January 6, 2020, at 3:30 p.m. revealed that the resident communicated via pen and paper, asking for hot tea and a dinner tray. The nurse explained to the resident that he could not have anything by mouth and that this was the doctor's orders. "Nothing by Mouth" signs were posted to the closet and bedside table.

A nursing note for Resident 3, dated January 6, 2020, at 4:52 p.m. revealed that the resident called the nurse to his room multiple times that shift, asking why he could not have a dinner tray or food. The resident was given lemon swabs for his mouth and it was explained to him multiple times that he cannot have anything by mouth and that is the doctor's order.

A late entry activity note for Resident 3, dated January 10, 2020, at 11:54 a.m. revealed that an "Interview for Preferences for Customary Routine and Activities" was conducted with the resident on January 9, 2020, and he indicated that although it was important to him, he did not have a choice to have snacks.

A nursing note for Resident 3, dated January 10, 2020, at 2:21 p.m. revealed that the resident was alert and oriented to self, made his needs known by writing them, and was ambulating (walking) to the sink in the room and drinking tap water. Teaching was provided and the note indicated that the resident only gets agitated and walks away.

A nursing note for Resident 3, dated January 14, 2020, at 6:54 a.m. revealed that the resident was non-compliant with treatment and care. He was observed several times standing at the sink and attempting to get a drink of water. Education was provided, and the resident expressed understanding, but continued to defy physician's orders. The resident was also observed disconnecting his tube feeding and allowing it to run into the garbage can. Education on the tube feeding was provided, and the resident expressed understanding but continued to do so.

A nursing note for Resident 3, dated January 15, 2020, at 2:04 a.m. revealed that he refused to have his tube feeding put up and shook his head no when the nurse went to hang up the feeding. The resident was alert and oriented to person, place and time, and able to make all needs known by writing or facial expressions.

A nursing note for Resident 3, dated January 15, 2020, at 8:01 p.m. revealed that staff found two apples, half of an orange, and two cups of water at the resident's bedside. The resident was informed that he cannot be taking anything by mouth and all items were removed from the room.

A nursing note for Resident 3, dated January 17, 2020, at 10:04 a.m. revealed that the resident was sitting on the edge of his bed, had removed his tube feeding prior to the 10:00 a.m. order, and refused for the feeding to be run. The note indicated that the resident was alert and oriented.

A nursing note for Resident 3, dated January 20, 2020, at 6:06 a.m. revealed that the resident continued with non-compliant behavior. The resident disconnects his feeding tube and allows to infuse into the garbage can, as well as refuses oxygen and seeks out cups in order to drink from the sink. Attempts were made on several occasions to educate the resident and he pushed the nurse away or put his fingers in his ears and closed his eyes.

A nursing note for Resident 3, dated January 27, 2020, at 2:31 p.m. revealed that the resident was noted taking food from his roommate's tray when the roommate was finished with his meal. The registered nurse was notified.

A statement of "Diet Noncompliance" form, dated January 28, 2020, and signed by the physician and Resident 3, indicated that the resident was aware of all of the risks associated with going against medical advice in this matter. He assumed all risks in connection with this refusal, to hold harmless the facility, its agents, employees, directors and representatives from any and all claims, liability or damages resulting from the refusal to comply with the recommendations.

A dietary note for Resident 3, dated January 30, 2020, at 11:17 a.m. revealed that the resident signed a non-compliance with diet form on January 28, 2020, acknowledging his risk of aspiration/choking by not following his NPO diet order. His wife was aware and was bringing in foods for him to consume while she was visiting. The note indicated, "Reinforced our staff is not to give resident food. We discussed this at his care plan meeting as well."

A nursing note for Resident 3, dated February 19, 2020, at 11:45 p.m. revealed that the resident was awake and alert, refused to have his gastrostomy tube flushed per orders, showed no signs or symptoms of respiratory distress, and had no complaints at that time. He asked for food and was again educated that he is strictly NPO and receives tube feedings as ordered.

A nursing note for Resident 3, dated February 20, 2020, at 7:34 a.m. revealed that upon approaching the resident, one whole, peeled hard-boiled egg was noted on his stand. The nurse questioned the resident regarding how/where he got the egg, and on his communication board he told the nurse that he got it at the "ground floor cafeteria." Staff reported that the resident is ambulatory and leaves the nursing unit via the elevator at times. The nurse educated the resident that he was not to eat any food unless it was given by his wife and in the presence of his wife.

There was no documented evidence that Resident 3's choice to eat food by mouth was honored by the facility and its nursing and dietary staff.

An interview with Resident 3 on February 20, 2020, at 2:25 p.m. confirmed that he misses food and wants to be able to eat but is not allowed to have anything at all by mouth.

An interview with the Director of Nursing on February 20, 2020, at 3:50 p.m. confirmed that even though Resident 3 signed a waiver acknowledging his risk of aspiration/choking, he was still not permitted to eat or drink anything, and the facility would not provide him with anything to eat or drink by mouth.

28 Pa. Code 201.29(j) Resident rights.



 Plan of Correction - To be completed: 03/10/2020

- Resident #3 is being provided with pleasure food during meals per his preference. Resident remains alert and able to make his needs known. The resident and his wife were educated regarding the risks of aspiration up to and including death.
- Resident was evaluated by speech therapy to determine the least restrictive diet, despite his physician's order to maintain NPO (nothing by mouth) status.
- Resident is currently satisfied with pleasure trays.
Nursing will continue to monitor his respiratory status and notify the physician regarding any clinical changes.
- Residents with current orders for NPO have the potential to be affected by the deficient practice.
DON (Director of Nursing)/Designee completed audits of residents with NPO orders, which revealed no other residents were affected.
DON/Human Resource shall provide an in-service to staff, all new employees, and agency personnel regarding Resident's Rights to ensure that an alert and oriented resident's preferences and personal choices are honored, despite education on risks and potentially negative outcomes
- DON/Designee shall perform random audits of residents with NPO orders daily x 5 days, weekly x 4 weeks then monthly x 2 or until compliance is met, to ensure that resident rights, preferences and personal choices are being honored.
Results from audits shall be submitted to the Quality Assurance Performance improvement committee for review and addressed as needed.

483.50(a)(2)(i)(ii) REQUIREMENT Lab Srvcs Physician Order/Notify of Results:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.
Observations:


Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the ordering practitioner was notified about abnormal laboratory results for one of three residents reviewed (Resident 2).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 7, 2020, revealed that the resident was cognitively impaired and required extensive assistance for daily care tasks. The resident's care plan, dated May 1, 2018, revealed that she had episodes of confusion with behavioral changes.

A nursing note for Resident 2, dated January 26, 2020, at 1:51 p.m. revealed that the resident was visibly upset and stated that she wanted to die. Redirection was effective and the resident's family did not want the resident sent to a geriatric psychiatry facility at that time. The nurse stated that the resident would be monitored closely, the staff would be made aware of her behavior, and if she could not be redirected she would need to be sent out.

A nursing note for Resident 2, dated January 27, 2020, at 11:37 a.m. revealed that the nurse had a phone conversation with the resident's family member, who thought that she might have a urinary tract infection. A urine sample was to be obtained. A nursing note, dated January 27, 2020, at 2:22 p.m. revealed that the nurse spoke with another family member regarding the resident's behavior on January 26, 2020, and the family member was concerned that the resident may have a urinary tract infection and stated that the last time the resident "got this way" she had an infection. An order was obtained per the family's request for a urinalysis, culture and sensitivity (UA, C&S - urine test to determine if an infection is present and which antibiotics would be effective for treating it) due to a change in mental status, and the UA, C&S was transported to the lab on January 27, 2020.

There was no documented evidence that the physician was notified about the results of the urine tests obtained for Resident 2.

A nursing note for Resident 2, dated February 6, 2020, at 2:48 p.m. revealed that the resident was seen by a counseling agency that day. She was very agitated and aggressive, and stated that she wanted to die. A nursing note dated February 6, 2020, at 3:55 p.m. revealed that the physician was notified and the resident was sent to the emergency room for evaluation of suicidal ideations.

Interview the Director of Nursing on February 20, 2020, at 3:30 p.m. confirmed that Resident 2's urine sample was collected and sent to the laboratory on January 27, 2020, but when the final result was faxed to the facility on January 29, 2020, it was placed in the wrong bin and was not presented to the physician. The final result for Resident 2's urine culture was positive for a urinary tract infection. The Director of Nursing confirmed that the physician should have been notified about the lab results on January 29, 2020.

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




 Plan of Correction - To be completed: 03/10/2020

- Resident #2's Urinary Tract Infection was treated with antibiotics.
Resident #2 is currently free from signs and symptoms of infection
- Residents with current orders and pending results for Urinalysis, Culture & Sensitivity (UA C&S) have the potential to be affected by the deficient practice.
- Director of Nursing (DON)/Designee have completed audits of orders related to UA, C&S results and revealed no other residents were affected.
Lab binders will be provided
- DON/Designee shall provide nurses, new nursing personnel, and agency staff an in-service regarding UA, C&S orders, following up with results, notifying the physician, and obtaining orders to implement as needed.
Lab sheets of labs obtained for the day will be created and placed on each nursing unit to be monitored by staff nurses to ensure follow up of lab results
DON/Designee shall perform random UA, C&S audits daily x 5 days, then weekly x 4 then monthly x 2, or until compliance is met, to ensure results are received and relayed to the physician

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Chemical Restraints:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free of chemical restraints that were not required to treat the resident's medical symptoms for one of three residents reviewed (Resident 3).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 9, 2020, revealed that the resident was cognitively intact, could understand and be understood, received nutrition via a gastrostomy tube (tube surgically inserted through the abdomen into the stomach), and had diagnoses that included tongue, mouth and throat cancer with severe protein-calorie malnutrition. Physician's orders for Resident 3, dated January 3, 2020, included and order for the resident to receive 15 milligrams (mg) of Morphine Sulfate (a narcotic pain medication) through the gastrostomy tube every four hours as needed for severe pain.

Nursing notes for Resident 3, dated January 6, 10, 14, 15, 20 and 27, 2020, revealed that the resident was alert and oriented and either requested food, was found with food, and/or was getting water to drink from the tap. The notes indicated that the resident was told that he could not have anything by mouth.

During a facility audit of Resident 3's medications on February 14, 2020, at 7:00 a.m., it was determined that staff administered 15 mg of Morphine Sulfate during the night shift on January 31 and February 2, 3, 4, 5, 6, 7, 10, 11, 13 and 14, 2020, with documentation of "severe pain." An interview with Resident 3 by Registered Nurse 1 on February 14, 2020, revealed the resident indicated that he has never asked for Morphine because he did not know that he had an order for it, and he was never asked by a nurse if he needed anything for pain. Upon further investigation, it was determined that the same nurse, Registered Nurse 2, administered every dose of Morphine to Resident 3 on those dates.

An interview with Registered Nurse 2 by the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing on February 14, 2020, at 7:00 a.m. revealed that Registered Nurse 2 gave Resident 3 the Morphine every night because he was up all night wandering and going through other residents' things, and she was aware that it was a chemical restraint.

28 Pa. Code 211.2(a) Physician services.

28 Pa. Code 211.8(b) Use of restraints.

28 Pa. Code 211.9(a)(1) Pharmacy services.

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



 Plan of Correction - To be completed: 03/05/2020

- Resident # 3 is not chemically restrained.
- Based on nursing documentation and staff interviews, resident # 3 did not experience any adverse effects from receiving morphine, nor was he observed to be more lethargic or unable to perform his usual daily routines.
Registered Nurse (RN) #2 is no longer employed in the facility as of 2/17/2020.
- Residents with current orders for Morphine tablets had the potential to be affected by RN #2's deficient practice.
- Residents that exhibit wandering behaviors on the unit where RN #2 was working had the potential to be affected by this deficient practice.
DON/Designee completed an audit of residents with Morphine tablet orders and residents that exhibit wandering behaviors on the unit where RN #2 worked, which revealed no other residents were affected.
DON/Designee shall provide the nurses, new staff nurses and agency personnel an in-service regarding the proper administration of Morphine, that includes following the physician's order and indication for use, and how morphine administration that is not required to treat the resident's medical symptoms is considered a chemical restraint
- DON/Designee shall perform random audits of residents with current orders for morphine tablets and exhibit wandering behaviors daily x 5 days, weekly x 4 weeks then monthly x 2 months or until compliance is met, to ensure that morphine tablets are properly administered as per the physician's order and indication for use.
Results from audits shall be submitted to Quality Assurance Performance Improvement Committee for review and addressed as needed.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed to meet each resident's care needs for one of three residents reviewed (Resident 3).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 9, 2020, revealed that the resident was cognitively intact and had diagnoses that included respiratory failure requiring a tracheostomy (a surgical hole in the neck used to help with breathing); tongue, mouth and throat cancer; severe protein-calorie malnutrition requiring a gastrostomy tube (a tube surgically inserted into the stomach for nutritional needs). The assessment also revealed that the resident indicated that he felt down/depressed and felt bad about himself nearly every day. A nursing note for Resident 3, dated January 6, 2020, at 3:30 p.m. revealed that the resident communicated via pen and paper.

There was no documented evidence that care plans were developed to address Resident 3's care needs related to having a tracheostomy, a unique communication need, and a depressed mood.

Interview with the Director of Nursing on February 20, 2020, at 3:25 p.m. confirmed that care plans to address Resident 3's tracheostomy, communication deficit, and depressed mood were not developed and should have been.

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

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





 Plan of Correction - To be completed: 03/10/2020

- Resident #3 currently has care plans in place to address specific needs related to having a tracheostomy; potential for communication deficit; and a depressed mood.
- Resident #3 continues to receive appropriate care and did not have adverse effects related to not having specific care plans developed.
- Resident #3 has current physician orders to manage and maintain his tracheostomy patent and care has been ongoing in order to meet his needs as appropriate per standards of nursing practice.
- Resident #3 has been provided a communication board since initial admission and continues to utilize a dry-erase board to write and make his more complex needs known, or performs head nods and hand gestures for more simple interactions.
- Resident #3 will be followed by mental health services as needed to address his depressed mood and initiate therapy as appropriate, while staff continues to monitor any changes in mood and behavior.

- Residents currently residing in the facility with specific care needs related to having a tracheostomy, a unique communication need, and depressed mood have the potential to be affected by the deficient practice.
- Director of Nursing (DON)/Designee have completed an audit of residents with a tracheostomy and results revealed no other resident was affected.
- DON/Designee have completed an audit of residents with unique communication needs requiring the use of communication boards and results revealed no other resident was affected.
DON/Designee have completed an audit of residents with depressed moods based on Minimum Data Set assessments and results revealed no other residents were affected.

DON/Designee shall provide nurses,including new nursing staff and agency nurses an in-service on developing and implementing a resident-centered comprehensive care plan, which also includes addressing specific care needs related to having a tracheostomy, a unique communication need, and depressed mood.

- DON/Designee shall perform random audits on residents' care plans daily x 5 days, then weekly x 4 weeks and monthly x 2 or until compliance is met, to ensure that the residents' comprehensive plan of care include specific care needs related to a tracheostomy, a unique communication need, and depressed mood.
Results from audits shall be submitted to Quality Assurance Performance Improvement for review and addressed as needed


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