Nursing Investigation Results -

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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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.

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:

§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:

§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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